95%. Occasionally coughing , minimal\\n secretions\\n Action:\\n RT placed on humidified air. CPAP trial started at 0600\\n Response:\\n Able to suction intermittently for mod amts thin, tan secretions.\\n Currently maintaining sat at 97% on CPAP with improved HR and more\\n comfortable appearance.\\n Plan:\\n Obtain abg. Sxn prn, iv abx/tamilflu\\n Wife telephoned in for an update twice on this shift. She will be in\\n to visit in the am.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 658432,\n \"text\": \"Clinician: Attending\\n Wife updated in full and clinical course of concern discussed--we have\\n evolution of worsening fever, rising WBC count and worsening\\n hypotension. We have influenza and S. Aureus in pulmonary secretions\\n to explain evolution of ARDS and respiratory failure, however--on\\n optimal antibiotic therapy we have raised a concern for additional\\n infectious source and are pursuing CT scan to evaluate. Agreed to have\\n her call at end of day for update on progress or decline of the day.\\n Total time spent: 30 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658481,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Norepi shut off at 1800 last evening. Continues on Linezolid and\\n cefipime IV.\\n Pt remains intubated on low dose sedation, fent and versed drips.\\n Remained on AC overnight with the plan to switch to PSV in AM.\\n Plan for cardiac echo today. Pt may also go to IR for drainage of\\n pleural effusions.\\n Pt\\ns wife is contact person and has been updated by team overnight. She\\n wants to speak to Attending today before any invasive procedures are\\n done. Visitors are limited to a few people written on a paper at the\\n front desk. She was upset that his co-workers were let in to visit on\\n .\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remains on the vent. ARDS protocol with low tidal volumes\\n maintained. Lungs diminished at both bases. Clear breath sounds right\\n upper lobe and coarse rhonchi on the left upper lobe. Suctioned for\\n thick white secretions.\\n Action:\\n Seems to be requiring less suctioning tonight than previously\\n described. Suctioned orally and nasally for large amts secretions.\\n Response:\\n Stable ABG on the AC overnight.\\n Plan:\\n Plan to switch to PSV in AM. Will need to repeat ABG omce on PSV for\\n one hour.\\n Sepsis without organ dysfunction\\n Assessment:\\n Remains off norepinephrine with goal MAP>60 most of the night. UO\\n adequatevia foley. CVP 13-14.\\n Action:\\n Continues on antibiotics, Cefipime and Linezolid as ordered.\\n Response:\\n Pt with low grade fever overnight. Given Tylenol once as pt had been\\n cultured in past 24hr.\\n Plan:\\n Will need to be cultured if spikes temp again. Follow vital signs\\n closely and try to keep pt off pressors if possible.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658581,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n T max 102.3 oral, appeared to have aspirated his tube feedings, LS\\n clear in the apices, bronchial on the L base and diminished in the R\\n base, he has been coughing through the day, his sputum is thick and\\n yellow. Remains off of pressors.\\n Action:\\n Sputum sent for clx and leginella, his tube feedings were stopped for\\n now due to his aspiration. His sputum is MSSA so the linazolid was\\n d/ced and he is now on naffcillin, he will need Tamaflu for 2 more\\n days. He had a thoracentesis done, they removed ~600cc of serous fluid\\n and this was sent for clx and chemistries. He was changed back to A/C\\n since his resp rate was in the 30s and it was felt that he needed to\\n rest.\\n Response:\\n Cont to cough despite an increase in his sedation, yellow secreations,\\n febrile, WBC still elevated.\\n Plan:\\n Cont to follow temp, high aspiration risk - will need to discuss food\\n in the near future, 2 more days of Tamaflu after today, f/u with clx\\n results.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains vented, conts to cough frequently, suctioned for thick yellow\\n sputum\\n Action:\\n Changed to A/C from PSV due to his resp rate of 30\\n Response:\\n Plan:\\n Cont to follow, wean the vent as he tolerates, f/u on clx\\n Sepsis without organ dysfunction\\n Assessment:\\n His BP has remained stable today, he conts off of pressors, T max\\n 102.3, his u/o is ~ 40cc/hr\\n Action:\\n He had a thorocentesis done today, his sputum his MSSA so he is on\\n nafcillian and off of linezolid\\n Response:\\n Stable BP but still febrile\\n Plan:\\n f/u on clx results, follow temp curve\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658776,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 7\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Crackles\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt has coughing spasms when sedation is decreased\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: AM RSBI-94. Started on MDI Albuterol Q4PRN\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658166,\n \"text\": \"FULL CODE\\n CC: Respiratory failure influenza B/PNA\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt febrile to 101.7, BP\\ns declining, CVP=5. u/o WNL, pt arouses to\\n voice and follows commands\\n Action:\\n Pan cultured, NS 1L bolus x2 with minimal improvement in BP. Started on\\n Levophed, initially .1mcg, Tylenol 650mg x1\\n Response:\\n Able to wean levo to .02mcg for several hours, finally to off at\\n 05:30. ABP current =104/47. T=\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 657985,\n \"text\": \"This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenze B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is intubated on vent in AC mode settings 500X18X60%X8. He is sedated\\n well on fentanyl 50mcg/versed 1mg/hr. Suctioned for moderate amts thin\\n yellow secretions.\\n Action:\\n fiO2 was 70% but decreased to 60% when ABG showed pO2 of 109. Fentanyl\\n decreased to 40mcg when pt hypotensive but back up to 50mcg/hr when he\\n became tachypneic and hypertensive after turning.\\n Response:\\n Pt slept quietly all night, no desating, no restlessness,\\n Plan:\\n Wean vent and sedation slowly as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 100.8ax. SBP in the 70\\ns at beginning of shift.\\n Action:\\n IVF bolus of NS 1L given X1 over an hour.\\n Response:\\n SBP remained >100 the rest of the night.\\n Plan:\\n Monitor vs, temp and give NS bolus prn SBP <80.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658280,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp. failure, and is now being treated for\\n influenza/ARDS.\\n Events:\\n Spiked to 102.5 (no cultures as pt was pan cultured on )\\n 1 L NS bolus hypotension\\n Restarted on levophed\\n TF initiated\\n RUQ US to rule out cholecystitis\\n K of 3.5 repleted w/ 40mgq PO K\\n Sepsis without organ dysfunction\\n Assessment:\\n T max 102.5, hypotensive to 80\\ns systolic, no growth to date in all\\n BCs.\\n Action:\\n ID consulted\\n Response:\\n No increase in antimicrobial coverage\\n Plan:\\n Monitor hemodynamic status and support as necessary w/ pressor and\\n volume\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\\n secretions.\\n Action:\\n Multiple vent changes made, remains on CPAP as pts own rate and volumes\\n coincide w/ ARDS net protocol\\n Response:\\n ABGs remain largely unchanged PaO2 slightly improved, pt continues to\\n deny any SOB\\n Plan:\\n Cont to monitor resp status and wean vent support as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658273,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for\\n influenza/ARDS.\\n Events:\\n Spiked to 102.5 (no cultures as pt was pan cultured on )\\n K of 3.5 repleted w/ 40mgq PO K\\n 1 L NS bolus hypotension\\n Restarted on levophed\\n TF initiated\\n RUQ US to rule out\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658274,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for\\n influenza/ARDS.\\n Events:\\n Spiked to 102.5 (no cultures as pt was pan cultured on )\\n K of 3.5 repleted w/ 40mgq PO K\\n 1 L NS bolus hypotension\\n Restarted on levophed\\n TF initiated\\n RUQ US to rule out cholecystites\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 102.5, hypotensive to 80\\ns systolic, no growth to date in all BCs.\\n Action:\\n ID consulted\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658420,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 4\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt remains on CPAP/PSV, no changes made this shift.\\n Assessment of breathing comfort: No claim of dyspnea\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n CT\\n 1400\\n pt vomitted contrast, orally suctioned for copious amounts of think\\n yellow secretions.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658576,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 5\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Tube Type\\n ETT:\\n Position: 26 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Bronchial\\n Secretions\\n Sputum color / consistency: Yellow / Thin\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt increasingly more tachypneic this AM, switched back to A/C\\n ventilation to rest w/ PIP/Pplat = 22/19, ETT advanced per CXR and ICU\\n team.\\n Assessment of breathing comfort: No claim of dyspnea\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: continue to attempt to wean as tolerated.\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658717,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 26 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 26 cmH2O\\n Cuff volume: 8 mL / Air\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Bronchial\\n Comments:\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously, Abnormal trigger\\n efforts (efforts during inspiratory)\\n Dysynchrony assessment: Frequent alarms (High pressure, High min.\\n ventilation)\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658769,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Sepsis without organ dysfunction\\n Assessment:\\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\\n 80s-100. Spiked fecer to 101.3. This AM K 3.7 and Ph 2.5\\n Action:\\n Given 500 cc NS bolus, given Tylenol 0nce, 2 sets of bld cx, urine cx,\\n and stool cx sent. Continued on antibiotics as ordered. KCL 20 meq IV\\n given.\\n Response:\\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\\n above 10.\\n Plan:\\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\\n ordered, bolus fluids as needed. Monitor lytes and replete as needed,\\n Ph to be repleted.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\\n at upper lobes and diminished at bases. Was observed to be very\\n restless and trying to jump out of bed.\\n Action:\\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\\n increased to 4 mg/hr.\\n Response:\\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\\n strong productive cough.\\n Plan:\\n Wean vent as tolerated, suction frequently PRN.\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 658909,\n \"text\": \"Progress Note:\\n This worker met with Ms. who reported having had a\\nmelt down\\n last night,\\n apparently precipitated by talking with one of the\\n residents re her husband\\ns current medical status, which she is now\\n feeling may be terminal. She spoke with her parents this AM and\\n suggested that they might want to come to ; they live in\\n . Although there have been two previous major medical\\n events\\nhis BMT and ICU admission in AZ\\nshe seems to be feeling that\\n this admission is the most foreboding because doctors cannot identify\\n the source of her husband's infection. Ms. said that her sons\\n still do not want to come to the , but she is beginning to wonder\\n if she should insist. Friends and family members (sisters and\\n sister-in-law) are providing support. She was able to contact her\\n husband\\ns business associates whom she reports are fine with their not\\n being paid at this time.\\n Assessment:\\n Although clearly and understandably stressed, Ms. appeared more\\n in control this AM than she reported being last night. Pt is anxious to\\n speak with Dr. for further medical information and status.\\n Plan:\\n 1. This worker will continue to meet with pt for support during\\n Mr. \\ns stay in the .\\n Page \\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-01-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 657904,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 69.9 None\\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: Suctioned / None\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: pt intubated this am for impending resp failure and hypoxia.\\n fio2 has been slowly weaned throughout the shift and currently remains\\n at 70%\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658153,\n \"text\": \"FULL CODE\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658154,\n \"text\": \"FULL CODE\\n CC: Respiratory failure influenza B/PNA\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658635,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fent and versed drips. Remained\\n on AC overnight.\\n Sepsis without organ dysfunction\\n Assessment:\\n BP started dropping to 80s then to high 70s, UO 30-40 cc/hr, CVP 13-14.\\n Action:\\n Levophed resumed at 0.01 mcg.kg/min, continues on antibiotics as\\n ordered.\\n Response:\\n Pt with low grade fever overnight. T max 100.1, given Tylenol once as\\n pt had been cultured (urine and sputum) within the past 24hrs.\\n Plan:\\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\\n ordered, wean levophed off as tolerated.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is sedated and intubated on AC for ARDS. Lung sounds rhonchi at\\n upper lobes and diminished at bases..\\n Action:\\n Suctioned frequently for thick yellowish secretions. Remains on\\n Fentanyl 50 mcg/hr and versed 2 mg/hr.\\n Response:\\n Present vent setting AC 20, 400, 50%, PEEP 8.\\n Plan:\\n Wean vent as tolerated, suction PRN.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658570,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n T max 101 oral, appeared to have aspirated his tube feedings, LS clear\\n in the apices, bronchial on the L base and diminished in the R base, he\\n has been coughing through the day, his sputum is thick and yellow.\\n Remains off of pressors.\\n Action:\\n Sputum sent for clx and leginella, his tube feedings were stopped for\\n now due to his aspiration. His sputum is MSSA so the linazolid was\\n d/ced and he is now on naffcillin, he will need Tamaflu for 2 more\\n days. He had a thoracentesis done, they removed ~600cc of serous fluid\\n and this was sent for clx and chemistries. He was changed back to A/C\\n since his rate was in the 30s and it was felt that he needed to rest.\\n Response:\\n Cont to cough despite an increase in his sedation, yellow secreations,\\n febrile, WBC still elevated.\\n Plan:\\n Cont to follow temp, high aspiration risk - will need to discuss food\\n in the near future, 2 more days of Tamaflu after today, f/u with clx\\n results.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658713,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n T max 100.5, conts to have a lg amount of secretions friom his ETT and\\n the back of his mouth\\n Action:\\n Conts on abx, started on afrin for a sinusits, conts with frequent\\n coughing and suctioning, given versed and fent boluses to try and stop\\n the coughing\\n Response:\\n Still conts to cough, no high spike today\\n Plan:\\n Cont abx, follow temp, flx if spikes, afrin for 3 days.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains on A/C, conts to have frequent coughing spells\\n Action:\\n His FI02 was decreased to 40%, we tried to decrease his PEEP to 5 but\\n he started to cough and desaturated\\n Response:\\n 02 SAT has been in the mid 90s, his PEEP was put back up to 8\\n Plan:\\n Cont to try and wean the vent as he tolerates\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt had one episode of hypotension to the 80s after a fent and vesed\\n bolus, CVP 8 at that time, it was 12 earlier in the day, u/o has been\\n 30-70cc/hr of amber colored urine, t max 100.5.\\n Action:\\n Given a 500cc NS bolus\\n Response:\\n His BP did come back up to the 90s-100s\\n Plan:\\n Cont to follow VS, u/o, temp curve, cont abx\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658908,\n \"text\": \"Chief Complaint: This is a 53 year-old male with a history of hodkin's\\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\\n pneumonia, S. aureus superinfections, and ARDS.\\n 24 Hour Events:\\n FEVER - 101.4\\nF - 04:00 PM\\n \\n -Weaned Fi02 from 50->40%\\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\\n not given\\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\\n contrast (unable to obtain peripheral access). However, there is no\\n change in size of multiple regions of consolidation bilaterally.\\n Further, there is no change in distribution and appearance of\\n air-bronchograms that would suggest a change in the underlying\\n consolidation, or the presence of a new space-occupying lesion.\\n Persistent pleural effusions\\n -RUQ U/S done\\n -spoke to his wife about how mr. was doing. She was very\\n anxious.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Linezolid - 12:35 PM\\n Cefipime - 06:56 PM\\n Nafcillin - 10:32 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 04:44 PM\\n Fentanyl - 10:51 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.6\\nC (97.8\\n HR: 88 (77 - 107) bpm\\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\\n RR: 24 (20 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 18 (10 - 24)mmHg\\n Total In:\\n 5,336 mL\\n 499 mL\\n PO:\\n TF:\\n IVF:\\n 3,176 mL\\n 170 mL\\n Blood products:\\n Total out:\\n 1,400 mL\\n 620 mL\\n Urine:\\n 1,400 mL\\n 620 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,936 mL\\n -121 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 652 (652 - 652) mL\\n RR (Set): 20\\n RR (Spontaneous): 1\\n PEEP: 8 cmH2O\\n FiO2: 40%\\n RSBI: 47\\n PIP: 22 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 96%\\n ABG: ///25/\\n Ve: 9.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 623 K/uL\\n 7.7 g/dL\\n 131 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 23 mg/dL\\n 102 mEq/L\\n 134 mEq/L\\n 23.9 %\\n 25.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n Plt\\n 293\\n 334\\n 439\\n \\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n TCO2\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n 151\\n 131\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\\n and oxygenation stable on AC settings. He is on day 8 of\\n antimicrobial therapy with cefepime, he received six days of\\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\\n was stopped and nafcillin started (now day 4) after his staph was\\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\\n re-expansion after the procedure, suggesting that it is freely\\n flowing. FiO2 40% from 50%.\\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\\n instead of ARDS so will attempt PS today\\n - Has completed course of oseltamavir\\n - continue nafcillin but can d/c cefepime considering no clear source\\n of GNR infection\\n - F/U cultures\\n - diuresis with lasix drip today to decrease total body fluid and\\n maximize chance of successful extubation\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\\n drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin and saline nasal washes for sinus disease\\n - Continue nafcillin\\n - consider pulling central line, particularly if any blood cx are\\n positive\\n - F/U cultures and culture if spikes\\n - F/U ID reccs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Attempted to place\\n Duboff in post-pyloric position but appears to remain in the stomach\\n despite raglan and mechanical manipulation. Will consult radiology\\n regarding advancing tube.\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU until respiratory status improves\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:54 PM 42 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: hep sc, PPI\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659028,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659127,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\\n following commands, writing on paper to communicate. T max 100.1po.\\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\\n abd and back appears improved micu md staff who saw this pt\\n yesterday.\\n Action:\\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\\n scant amts thick yellow sputum, small amts blood tinged sputum in back\\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\\n pending.\\n Response:\\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\\n extubated today. ett retaped and repositioned to left side of mouth at\\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\\n and versed drips restarted and titrated up to comfort but pt still\\n easily arousable and following commands. Continues to diurese well\\n approx 3.9 liters negative since mn. 7 liters + los. Cvp approx .\\n Plan:\\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\\n around 4. Follow up with 5pm lab results and replete lytes prn.\\n Continue to monitor rash on abd and back.\\n Sepsis without organ dysfunction\\n Assessment:\\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\\n Also + influenza.\\n Action:\\n Continues with iv nafcillin\\n Response:\\n Remains with low grade temp, currently afebrile.\\n Plan:\\n Continue nafcillin, follow up with bld culture results. Monitor temps.\\n Social: pt\\ns wife up to visit pt in late am and most of day.pt\\ns wife\\n spoke with Dr. re: pt\\ns update and plan of care. Pt\\ns twin sons\\n and also visited in the early evening. Pt\\ns requested\\n to also speak with Dr. for an update. Dr. spoke to them\\n to give them an update, but they requested an update from Dr. .\\n Dr. paged Dr. and plan is for Dr. to speak to pt\\n later this evening after 7:30pm. Wife and are visiting\\n in room and waiting room. social worker has been following wife\\n and pt for support and spoke to them yesterday. Wife declined need to\\n speak to today. continue to provide emotional support to\\n pt/family prn.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-01-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658102,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a possible PNA.\\n Events:\\n No growth to date on BCs, sputum or urine cultures\\n Multiple vent changes made currently on\\nARDS net\\n settings\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS clear upper lobes dimished @ bases, suctioned for scant amounts thin\\n yellow secretions, lightly sedated on fent/midaz and denies any\\n subjective SOB\\n Action:\\n Multiple vent changes made, placed on ARDs settings some question\\n of a worsening chest film, FI02 weaned to 50%\\n Response:\\n Most recent ABG on 50% is pending @ this time, appears comfortable w/\\n vent, maintaing sats 97- 100%\\n Plan:\\n Cont to monitor resp status and wean vent as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n WBC count stable @ 12, Temp 100\\n 100.9, hemodynamically stable, BUN/CR\\n are within normal limits however U/O ~30cc/hr\\n Action:\\n Remains on cefepime/linezolid/\\n Response:\\n All vital signs within normal limits\\n Plan:\\n Monitor hemodynamic status, cont broad spectrum abx and , \\n require maintainence fluids.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 658254,\n \"text\": \"Clinician: Attending\\n wife in for visit. She was updated in full on his clinical\\n course with ARDS secondary to influenza +/- bacterial superinfection\\n leading to hypoxemic respiratory failure. In addition he has\\n intermittent hypotension and concern for acalculous cholecystitis and\\n antibiotic resistant bacteria leading to sepsis.\\n All questions were answered and plans for visit with her twin sons\\n ) were made.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658574,\n \"text\": \"Chief Complaint: Respiratory failure, ARDS\\n 24 Hour Events:\\n - FEVER - 101.1\\nF - 09:00 PM\\n -OFF PRESSORS at 6:00 pm\\n -CT torso w/o abcess or drainable collection\\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\\n -Thoracentesis deferred as minimal fluid on echo\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 12:30 AM\\n Cefipime - 05:56 AM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.4\\nC (101.1\\n Tcurrent: 37.4\\nC (99.3\\n HR: 75 (75 - 117) bpm\\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\\n RR: 19 (16 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (13 - 334)mmHg\\n Total In:\\n 1,855 mL\\n 941 mL\\n PO:\\n TF:\\n 917 mL\\n 382 mL\\n IVF:\\n 878 mL\\n 514 mL\\n Blood products:\\n Total out:\\n 1,520 mL\\n 218 mL\\n Urine:\\n 1,520 mL\\n 218 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 335 mL\\n 723 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 370 (370 - 542) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 100\\n PIP: 17 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 26.7 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.42/41/85./25/1\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 170\\n Physical Examination\\n General Appearance: Thin\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : few)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 439 K/uL\\n 8.3 g/dL\\n 149 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 104 mEq/L\\n 133 mEq/L\\n 26.3 %\\n 19.2 K/uL\\n [image002.jpg]\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n Plt\\n 293\\n 334\\n 439\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n TCO2\\n 25\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL, ALT\\n 70*, AST 75*, AP 385*, LDH 176, T Bil 0.8\\n Imaging:\\n CT Torso:\\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\\n greater\\n than right, with scattered patchy opacities seen medially within the\\n upper lobes. Interval increase in bilateral pleural effusions, now\\n moderate.\\n 2. Prominence of the esophagus, which is diffusely filled with oral\\n contrast\\n material, consistent with extensive gastroesophageal reflux disease.\\n Given the degree of contrast reflux into the esophagus, which is\\n marked, the patient is felt to be a very high risk for aspiration.\\n 3. No acute inflammatory process or abnormal fluid collection is seen\\n in the\\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\\n fluid.\\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\\n Microbiology: Sputum:\\n : Culture with coag + staph\\n Gram stain (-)\\n : Culture preliminary negative, gram\\n stain (-)\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\\n known influenza B as well as staph aureus in sputums. Presumably, flu\\n with bacterial superinfection is the etiology of his ARDS. The patient\\n was on AC overnight but was switched back to CPAP this AM. Since then,\\n he has been pulling lower tidal volumes than previously (<400) and more\\n tachypneic. We will place him back on AC to decrease work of breathing\\n while we continue to treat his pneumonia and support him through his\\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\\n and oseltamavir.\\n -F/U cultures, obtain viral cultures per ID recommendation\\n - Continue current antimicrobials pending culture data\\n -IP will attempt to perform diagnostic thoracentesis today as ICU team\\n unable to safely do at bedside\\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though this should be\\n appropriately covered by his antibiotics.\\n -Continue linezolid/cefepime/oseltamavir pending culture data\\n -obtain pleural fluid to rule out complicated effusion\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE today to evaluate for effusion/tamponade\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: Pt with noted aspiration event this AM, presumably due to\\n history of irradiation, we will hold tube feeds for now and swallow\\n study once extubated.\\n 6) Access: 2 PIVs; right IJ\\n 7) PPx: hep sc, PPI\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658632,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fent and versed drips. Remained\\n on AC overnight.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remains on the vent. ARDS protocol with low tidal volumes\\n maintained. Lungs diminished at both bases. Clear breath sounds right\\n upper lobe and coarse rhonchi on the left upper lobe. Suctioned for\\n thick white secretions.\\n Action:\\n Seems to be requiring less suctioning tonight than previously\\n described. Suctioned orally and nasally for large amts secretions.\\n Response:\\n Stable ABG on the AC overnight.\\n Plan:\\n Plan to switch to PSV in AM. Will need to repeat ABG omce on PSV for\\n one hour.\\n Sepsis without organ dysfunction\\n Assessment:\\n Remains off norepinephrine with goal MAP>60 most of the night. UO\\n adequatevia foley. CVP 13-14.\\n Action:\\n Continues on antibiotics, Cefipime and Linezolid as ordered.\\n Response:\\n Pt with low grade fever overnight. Given Tylenol once as pt had been\\n cultured in past 24hr.\\n Plan:\\n Will need to be cultured if spikes temp again. Follow vital signs\\n closely and try to keep pt off pressors if possible.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658896,\n \"text\": \"Chief Complaint: This is a 53 year-old male with a history of hodkin's\\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\\n pneumonia, S. aureus superinfections, and ARDS.\\n 24 Hour Events:\\n FEVER - 101.4\\nF - 04:00 PM\\n \\n -Weaned Fi02 from 50->40%\\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\\n not given\\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\\n contrast (unable to obtain peripheral access). However, there is no\\n change in size of multiple regions of consolidation bilaterally.\\n Further, there is no change in distribution and appearance of\\n air-bronchograms that would suggest a change in the underlying\\n consolidation, or the presence of a new space-occupying lesion.\\n Persistent pleural effusions\\n -RUQ U/S done\\n -spoke to his wife about how mr. was doing. She was very\\n anxious.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Linezolid - 12:35 PM\\n Cefipime - 06:56 PM\\n Nafcillin - 10:32 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 04:44 PM\\n Fentanyl - 10:51 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.6\\nC (97.8\\n HR: 88 (77 - 107) bpm\\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\\n RR: 24 (20 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 18 (10 - 24)mmHg\\n Total In:\\n 5,336 mL\\n 499 mL\\n PO:\\n TF:\\n IVF:\\n 3,176 mL\\n 170 mL\\n Blood products:\\n Total out:\\n 1,400 mL\\n 620 mL\\n Urine:\\n 1,400 mL\\n 620 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,936 mL\\n -121 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 652 (652 - 652) mL\\n RR (Set): 20\\n RR (Spontaneous): 1\\n PEEP: 8 cmH2O\\n FiO2: 40%\\n RSBI: 47\\n PIP: 22 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 96%\\n ABG: ///25/\\n Ve: 9.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 623 K/uL\\n 7.7 g/dL\\n 131 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 23 mg/dL\\n 102 mEq/L\\n 134 mEq/L\\n 23.9 %\\n 25.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n Plt\\n 293\\n 334\\n 439\\n \\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n TCO2\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n 151\\n 131\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\\n aureus superinfections, and ARDS.\\n #) Hypoxic Respiratory failure/Influenza Pneumonia with secondary\\n bacterial pneumonia: The patient was initially intubated for hypoxic\\n respiratory failure. Has known influenza B as well as staph aureus in\\n sputums presumably causing ARDS. Ventilation and oxygenation stable on\\n AC settings. He is on day 7 of antimicrobial therapy with cefepime,\\n he received six days of vancomycin/linezolid, he is on day six of\\n oseltamavir. His linezolid was stopped and nafcillin started after his\\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\\n and lung reexpansion after the procedure would suggest this is freely\\n flowing.\\n -F/U cultures\\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\\n duration of nafcillin therapy in this very sick patient with ID who is\\n following\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though this should be\\n appropriately covered by his antibiotics. Hypotension presumably due\\n to continued SIRs driving process (active infection vs ARDS).\\n -Afrin and saline nasal washes for sinus disease\\n -Continue nafcillin/cefepime/oseltamavir pending culture data\\n -F/U cultures and culture if spikes\\n -F/U ID reccs\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\\n history of irradiation, nevertheless he needs nutrition. We will speak\\n to GI re: post-pyloric feeding tube and start PPN in the interim.\\n 6) Access: 2 PIVs; right IJ\\n 7) PPx: hep sc, PPI\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:54 PM 42 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: hep sc, PPI\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-01-31 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658140,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 69.9 None\\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt remains intubated on full vent support. O2 sat remained\\n stable through the night on 50%. Plan to wean 02 and ventilatory\\n support as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658712,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n T max 100.5, conts to have a lg amount of secretions friom his ETT and\\n the back of his mouth\\n Action:\\n Conts on abx, started on afrin for a sinusits, conts with frequent\\n suctioning\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659661,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n CNS: Remains alert and oriented x3 and can get out of bed with the\\n assist of persons. Complained that he was having difficulty\\n sleeping and was given a one time dose of lorazepam 1mg IV with good\\n effect.\\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\\n seeing that he has been aggressively Diuresed. Has maintained\\n normotensive blood pressures ranging SBP 110\\n 130\\ns. Right double\\n lumen basilic PICC placed yesterday evening and OK for use. Central\\n line D/c\\nd this am without difficulty and occlusive dsg to site at\\n present.\\n RESP: Continues on 3l/min with sats in the mid to upper 90\\ns. Denies\\n any SOB or DOE. LS clear with minimally diminished bases.\\n GU: Remains with urinary catheter and with good output. See flow chart\\n for numbers.\\n GI: Dobhoff now in stomach. Noted that it was longer than previously.\\n KUB done and confirmed in stomach. TF ok to go and continues at\\n 10cc/hr. tolerated diet as recommended last pm without difficulty. Will\\n re-evaluated to today. Had a small soft BM last pm.\\n INTEG: Skin remains unremarkable at this time.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659490,\n \"text\": \"Chief Complaint: PNA, s/p resp failure\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 10:10 AM\\n ARTERIAL LINE - STOP 04:00 PM\\n -extubated in a.m. and did well\\n -was c/o nausea intermittently -> concerning for opiate or benzo\\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\\n iv prn.\\n Allergies:\\n Cefepime\\n Rash;\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:32 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 07:45 AM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Lorazepam (Ativan) - 01:30 AM\\n Fentanyl - 01:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 35.9\\nC (96.7\\n HR: 94 (91 - 114) bpm\\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\\n RR: 24 (14 - 40) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (12 - 18)mmHg\\n Total In:\\n 1,308 mL\\n 288 mL\\n PO:\\n TF:\\n 13 mL\\n IVF:\\n 547 mL\\n 228 mL\\n Blood products:\\n Total out:\\n 5,035 mL\\n 1,100 mL\\n Urine:\\n 5,035 mL\\n 1,100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,727 mL\\n -813 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: PSV/SBT\\n Vt (Spontaneous): 730 (730 - 730) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 0 cmH2O\\n FiO2: 50%\\n SpO2: 96%\\n ABG: ///23/\\n Ve: 12.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : L\\n >R base)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 896 K/uL\\n 7.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.5 mEq/L\\n 21 mg/dL\\n 103 mEq/L\\n 136 mEq/L\\n 24.5 %\\n 22.0 K/uL\\n [image002.jpg]\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n WBC\\n 24.7\\n 25.6\\n 26.7\\n 23.6\\n 22.0\\n Hct\\n 24.9\\n 23.9\\n 23.9\\n 24.7\\n 24.5\\n Plt\\n 81\\n 896\\n Cr\\n 1.0\\n 0.8\\n 0.7\\n 0.8\\n 0.8\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n Glucose\\n 151\\n 131\\n 144\\n 135\\n 128\\n 115\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659491,\n \"text\": \"Chief Complaint: PNA, s/p resp failure\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 10:10 AM\\n ARTERIAL LINE - STOP 04:00 PM\\n -extubated in a.m. and did well\\n -was c/o nausea intermittently -> concerning for opiate or benzo\\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\\n iv prn.\\n Allergies:\\n Cefepime\\n Rash;\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:32 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 07:45 AM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Lorazepam (Ativan) - 01:30 AM\\n Fentanyl - 01:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 35.9\\nC (96.7\\n HR: 94 (91 - 114) bpm\\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\\n RR: 24 (14 - 40) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (12 - 18)mmHg\\n Total In:\\n 1,308 mL\\n 288 mL\\n PO:\\n TF:\\n 13 mL\\n IVF:\\n 547 mL\\n 228 mL\\n Blood products:\\n Total out:\\n 5,035 mL\\n 1,100 mL\\n Urine:\\n 5,035 mL\\n 1,100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,727 mL\\n -813 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: PSV/SBT\\n Vt (Spontaneous): 730 (730 - 730) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 0 cmH2O\\n FiO2: 50%\\n SpO2: 96%\\n ABG: ///23/\\n Ve: 12.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : L\\n >R base)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 896 K/uL\\n 7.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.5 mEq/L\\n 21 mg/dL\\n 103 mEq/L\\n 136 mEq/L\\n 24.5 %\\n 22.0 K/uL\\n [image002.jpg]\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n WBC\\n 24.7\\n 25.6\\n 26.7\\n 23.6\\n 22.0\\n Hct\\n 24.9\\n 23.9\\n 23.9\\n 24.7\\n 24.5\\n Plt\\n 81\\n 896\\n Cr\\n 1.0\\n 0.8\\n 0.7\\n 0.8\\n 0.8\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n Glucose\\n 151\\n 131\\n 144\\n 135\\n 128\\n 115\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. FiO2 40% and on PS 5/5 but\\n blood gas this noon 7.52/41/64. This am, did well on SBT (although had\\n some mucous plugging around 7a).\\n - Has completed course of oseltamavir\\n - continue nafcillin day 6 today- plan for 14 D course\\n - F/U cultures\\n - extubate this am. Will start Incentive spirometry\\n -monitor diuresis and consider bolus lasix PRN. D/c diamox\\n -will need speech and swallow eval but will hold off until tomorrow\\n -of note, since pt has been on fent/versed for sedation for >1wk, may\\n have benzo withdrawl. Will consided valium or versed PRN\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 14 D course\\n - consider pulling central line if any blood cx are positive. Keep now\\n for TPN. If stable tomorrow, will likely pull CVL.\\n - F/U cultures and culture if spikes\\n - F/U ID recs- they rec thoracentesis but do not think this is\\n medically necessary for now.\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Will restart TF today after extubation. Cont TPN for today\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659605,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Received pt on 4l/m nc with rr in the high 20\\ns to low 30\\ns. lungs\\n essentially clear on auscultation with crackles bil at the bases. Neg\\n fluid balance for this shift. Wbc has dropped to 22.\\n Action:\\n Fluid balance followed closely as well as his hemodynamics. Pt using\\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\\n Receiving nafcillin as ordered . resp status monitored closely. Speech\\n and swallow study completed. Physical therapy has been consulted. Tube\\n fdgs restarted via dobhoff tube since pt\\ns nutritional status is most\\n certainly not adequate. Oob to chair with assist of 2 and tolerated\\n activity well. Ic consulted to place picc line since infectious dx\\n consult team is recommending 21 day course of nafcillin. Post\\n completion of speech andswallow study diet advancedto low sodium/heart\\n healthy soft consistency , thin liqs ensure pudding with ea. Meal\\n give all pills via dobhoff\\n Response:\\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\\n and for los pos 1.6 liters.\\n Plan:\\n Will maintain aspiration precautions. Continue to follow fluid balance\\n and resp status. Follow culture data. Pt to have picc line placed for\\n 21 day course of nafcillin and once access is obtained will then d/cri\\n j triple lumen. Increase pt\\ns level of activity as he tolerates. If\\n stable overnoc will transfer to medical floor bed tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659755,\n \"text\": \"Chief Complaint: s/p resp failure\\n 24 Hour Events:\\n PICC LINE - START 09:29 PM\\n MULTI LUMEN - STOP 06:00 AM\\n -PICC placed and IJ d'c'd\\n -KUB checked to evaluate dobhoff\\n -speech and swallow bedside eval passed with pt cleared to take thin\\n liquids and MOIST soft solids.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientCefepime\\n Rash;\\n Last dose of Antibiotics:\\n Nafcillin - 04:55 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 03:42 PM\\n Lorazepam (Ativan) - 01:10 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\\n occassional nausea. Tolerated dinner last night well.\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (99\\n Tcurrent: 37\\nC (98.6\\n HR: 93 (92 - 109) bpm\\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\\n RR: 26 (22 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 14 (11 - 15)mmHg\\n Total In:\\n 1,693 mL\\n 243 mL\\n PO:\\n 960 mL\\n TF:\\n 83 mL\\n 72 mL\\n IVF:\\n 590 mL\\n 172 mL\\n Blood products:\\n Total out:\\n 3,330 mL\\n 800 mL\\n Urine:\\n 3,330 mL\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,637 mL\\n -557 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: 7.48/31/74/23/0\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n at left base )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 948 K/uL\\n 8.2 g/dL\\n 113 mg/dL\\n 1.0 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 17 mg/dL\\n 105 mEq/L\\n 136 mEq/L\\n 25.3 %\\n 20.4 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n 08:09 AM\\n 03:27 AM\\n WBC\\n 26.7\\n 23.6\\n 22.0\\n 20.4\\n Hct\\n 23.9\\n 24.7\\n 24.5\\n 25.3\\n Plt\\n 48\\n Cr\\n 0.7\\n 0.8\\n 0.8\\n 1.0\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n 24\\n Glucose\\n 144\\n 135\\n 128\\n 115\\n 113\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\\n mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. Successfully extubated \\n - Has completed course of oseltamavir\\n - continue nafcillin - plan for 21 D course today abx from when\\n linezolid was started \\n -monitor diuresis and consider bolus lasix PRN.\\n - speech and swallow eval clears for meds, thin liquids and soft\\n solids PO\\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\\n consider fentanyl or ativan PRN\\n -Incentive spirometry,\\n -PT consulted\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam. WBC now trending down to 22\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 21 D course\\n -PICC in place for ABX\\n - F/U ID recs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: regular, soft diet\\n #) Access: PICC in place\\n #) PPx: hep sc, PPI\\n #) Dispo: c/o floor today\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n PICC Line - 09:29 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659461,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Obtained pt on NC 3L, reports breathing is comfortable, productive\\n cough, crackles at bases, using IS frequently without queing, pt with\\n generalized edema, had been on lasix gtt prior to extubation, now\\n autodiuresing, pt reporting abd pain and nausea at times\\n Action:\\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\\n with HO ? scale overnight, monitoring for signs of withdrawal\\n overnight, no scale ordered, adm fent and ativan x2 with good\\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\\n Response:\\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\\n continues to have nausea and abd pain at times though no other signs of\\n withdrawl\\n Plan:\\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 659754,\n \"text\": \"Chief Complaint: s/p resp failure\\n 24 Hour Events:\\n PICC LINE - START 09:29 PM\\n MULTI LUMEN - STOP 06:00 AM\\n -PICC placed and IJ d'c'd\\n -KUB checked to evaluate dobhoff\\n -speech and swallow bedside eval passed with pt cleared to take thin\\n liquids and MOIST soft solids.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientCefepime\\n Rash;\\n Last dose of Antibiotics:\\n Nafcillin - 04:55 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 03:42 PM\\n Lorazepam (Ativan) - 01:10 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\\n occassional nausea. Tolerated dinner last night well.\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (99\\n Tcurrent: 37\\nC (98.6\\n HR: 93 (92 - 109) bpm\\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\\n RR: 26 (22 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 14 (11 - 15)mmHg\\n Total In:\\n 1,693 mL\\n 243 mL\\n PO:\\n 960 mL\\n TF:\\n 83 mL\\n 72 mL\\n IVF:\\n 590 mL\\n 172 mL\\n Blood products:\\n Total out:\\n 3,330 mL\\n 800 mL\\n Urine:\\n 3,330 mL\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,637 mL\\n -557 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: 7.48/31/74/23/0\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n at left base )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 948 K/uL\\n 8.2 g/dL\\n 113 mg/dL\\n 1.0 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 17 mg/dL\\n 105 mEq/L\\n 136 mEq/L\\n 25.3 %\\n 20.4 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n 08:09 AM\\n 03:27 AM\\n WBC\\n 26.7\\n 23.6\\n 22.0\\n 20.4\\n Hct\\n 23.9\\n 24.7\\n 24.5\\n 25.3\\n Plt\\n 48\\n Cr\\n 0.7\\n 0.8\\n 0.8\\n 1.0\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n 24\\n Glucose\\n 144\\n 135\\n 128\\n 115\\n 113\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\\n mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. Successfully extubated \\n - Has completed course of oseltamavir\\n - continue nafcillin - plan for 21 D course today abx from when\\n linezolid was started \\n -monitor diuresis and consider bolus lasix PRN.\\n - speech and swallow eval today\\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\\n consider fentanyl or ativan PRN\\n -Incentive spirometry,\\n -PT today and OOB to chair\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam. WBC now trending down to 22\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 21 D course\\n -pull CVL today if can get PICC\\n - F/U ID recs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Getting s/s today. If passes, d/c TF\\n #) Access: 2 PIVs; right IJ\\n trying to get PICC today\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now- consider PM c/o\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n PICC Line - 09:29 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\\n c/b MSSA pneumonia. Much improved, tolerating POs, OOB, PICC placed,\\n passed S+S.\\n Exam notable for Tm 99.2 BP 110/65 HR 95 RR 24-30 with sat 97 on RA.\\n TBB -1L/8h. Few rales. RRR s1s2. Soft +BS. Trace edema. Labs notable\\n for WBC 23K, HCT 24, K+ 4.5, Cr 1.0. CXR B ASD, stable to sl worse.\\n Agree with plan to discontinue low dose lasix given slight bump in\\n creatinine. Will continue naf for MSSA pneumonia x 12/21 days total via\\n PICC. Will mobilize OOB to chair and continue PT consult. Wean oxygen\\n to off, ADAT, may need to d/c tube if it remains clogged. Above d/w\\n wife and PCP. of plan as outlined above.\\n Total time: 35 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659419,\n \"text\": \"Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Obtained pt on NC 3L, reports breathing is comfortable, productive\\n cough, crackles at bases, using IS frequently without queing, pt with\\n generalized edema, had been on lasix gtt prior to extubation, now\\n autodiuresing, pt reporting abd pain and nausea at times\\n Action:\\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\\n with HO ? scale overnight, monitoring for signs of withdrawal\\n overnight, no scale ordered, adm fent and ativan x2 with good\\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\\n Response:\\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\\n continues to have nausea and abd pain at times though no other signs of\\n withdrawl\\n Plan:\\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659420,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Obtained pt on NC 3L, reports breathing is comfortable, productive\\n cough, crackles at bases, using IS frequently without queing, pt with\\n generalized edema, had been on lasix gtt prior to extubation, now\\n autodiuresing, pt reporting abd pain and nausea at times\\n Action:\\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\\n with HO ? scale overnight, monitoring for signs of withdrawal\\n overnight, no scale ordered, adm fent and ativan x2 with good\\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\\n Response:\\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\\n continues to have nausea and abd pain at times though no other signs of\\n withdrawl\\n Plan:\\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658318,\n \"text\": \"FULL CODE\\n CC: Respiratory failure influenza B/PNA\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt febrile to 101.7, BP\\ns declining, CVP=5. u/o WNL, pt arouses to\\n voice and follows commands\\n Action:\\n Pan cultured, NS 1L bolus x2 with minimal improvement in BP. Started on\\n Levophed, initially .1mcg, Tylenol 650mg x1\\n Response:\\n Able to wean levo to .02mcg for several hours, to off at 05:30 but ABP\\n slowly drifting down. T=98.9\\n Plan:\\n Monitor fever curve, maintain CVP~12, IV abx, pressor support prn.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Assumed care of patient on CMV 50%/400/24/8. LS clear upper, dim at\\n bases but maintaining sat >95%. Occasionally coughing , minimal\\n secretions\\n Action:\\n RT placed on humidified air. CPAP trial started at 0600\\n Response:\\n Able to suction intermittently for mod amts thin, tan secretions.\\n Currently maintaining sat at 97% on CPAP with improved HR and more\\n comfortable appearance.\\n Plan:\\n Obtain abg. Sxn prn, iv abx/tamilflu\\n Wife telephoned in for an update twice on this shift. She will be in\\n to visit in the am.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658319,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Events:\\n No growth to date on BCs, sputum or urine cultures\\n Multiple vent changes made currently on\\nARDS net\\n settings\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt. spiked temp again yesterday, however, has continued with low-grade\\n temp throughout this shift. No growth to date in all BCs, urine and\\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\\n weaned throughout the shift.\\n Action:\\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\\n Response:\\n Pt. remains with low-grade temp. Hemodynamically stable throughout\\n shift.\\n Plan:\\n Monitor hemodynamic status and support as necessary w/ pressor and\\n volume. Continue antibiotics as ordered/\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\\n secretions. Remains on vent.\\n Action:\\n Multiple vent changes made, remains on CPAP as pts own rate and volumes\\n coincide w/ ARDS net protocol\\n Response:\\n ABGs remain largely unchanged PaO2 slightly improved, pt continues to\\n deny any SOB\\n Plan:\\n Cont to monitor resp status and wean vent support as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 658375,\n \"text\": \"Chief Complaint: Respiratory Failure\\n Sepsis\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n FEVER - 102.5\\nF - 12:00 PM\\n ID Consult--Flagyl added\\n RUQ U/S with no evidence of cholecystitis\\n fevers persist\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 11:01 PM\\n Cefipime - 04:50 AM\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:16 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 11:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.2\\nC (102.5\\n Tcurrent: 37.2\\nC (99\\n HR: 92 (75 - 100) bpm\\n BP: 137/59(82) {89/45(60) - 172/88(118)} mmHg\\n RR: 22 (15 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 334 (4 - 334)mmHg\\n Total In:\\n 2,942 mL\\n 752 mL\\n PO:\\n TF:\\n 167 mL\\n 389 mL\\n IVF:\\n 2,445 mL\\n 303 mL\\n Blood products:\\n Total out:\\n 1,615 mL\\n 640 mL\\n Urine:\\n 1,615 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,327 mL\\n 112 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 460 (435 - 465) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 20\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 76\\n PIP: 19 cmH2O\\n SpO2: 98%\\n ABG: 7.38/40/94./24/0\\n Ve: 8.6 L/min\\n PaO2 / FiO2: 188\\n Physical Examination\\n General Appearance: Well nourished\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\\n (Breath Sounds: Diminished: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: 1+, Left: 1+\\n Skin: Not assessed\\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.8 g/dL\\n 334 K/uL\\n 112 mg/dL\\n 0.8 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 103 mEq/L\\n 133 mEq/L\\n 26.6 %\\n 20.4 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 11:32 PM\\n 03:19 AM\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n WBC\\n 12.3\\n 15.8\\n 20.4\\n Hct\\n 28.9\\n 28.1\\n 26.6\\n Plt\\n \\n Cr\\n 1.0\\n 0.9\\n 0.8\\n TCO2\\n 24\\n 21\\n 25\\n 23\\n 24\\n 23\\n 25\\n Glucose\\n 96\\n 122\\n 112\\n Other labs: PT / PTT / INR:13.5/35.5/1.2, ALT / AST:67/64, Alk Phos / T\\n Bili:381/0.9, Amylase / Lipase:/13, Differential-Neuts:85.9 %,\\n Lymph:5.3 %, Mono:8.1 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\\n Imaging: CXR__ETT and IJ catheter in good position. He does have\\n persistent and significant bilateral plural effusions and likely\\n consolidations\\n Microbiology: Sputum-\\n --S. Aureus\\n Assessment and Plan\\n 53 yo male with admission with influenza with a history of Hodgkin\\n Disease and now subsequently complicated by ARDS and hypoxemic\\n respiratory failure now complicated by persistent sepsis. He has\\n continued good tolerance of PSV support with FIO2 wean oxygenation has\\n remained reasonably stable. The issue has been one of continued fevers\\n and hypotension despite antibiotics in place. In addition he has had\\n significant rise in WBC count all arguing for untreated bacterial\\n infection, although, cultures have been negative to date. LFT's have\\n improved in this setting and may be consistent with mild intrahepatic\\n cholestasis.\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n -Cefepime/Linezolid\\n -He has GPC\\ns noted in sputum and suggestion of S. Aureus involving\\n pulmonary\\n -Continue with ABX and raise issue of alternative coverage based up on\\n culture and imaging findings.\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n -would favor return to A/C support to maintain adequate ventilatory\\n support if worsening\\n -return to A/C support if need for further imaging needed as with\\n increased sedation will be needed\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n -Levophed continues\\n -WBC is rising and persistent fevers seen\\n -Concern for possible empyema and pulmonary cavitary lesions\\n -Catheter placed in the setting of fevers and fevers have continued\\n -No cultures positive\\n -Sinusitis is somewhat unilikely as is relatively early in course but\\n is possible\\n -Pulmonary abscess is possible and of concern\\n -U/S negative but intra-abdominal source is possible with focal\\n collection\\n -DVT is possible but will be evaluated with LENI\\n -ECHO to eval for possible\\n -No evidence of rash\\nwill follow up on diff and consider possible drug\\n fever\\n -Will pursue further interventions as indicated based upon findings\\n -No change in ABX and will pursue evaluation given hypotension, fever,\\n despite antibiotics Rx\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 10:23 AM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 06:27 AM\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 70 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658827,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt conts to have a fever, t max has been 100.4, LS coarse throughout,\\n suctioning tan sputum from his ETT, he has been coughing less today.\\n Action:\\n To have a chest CT\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658511,\n \"text\": \"Chief Complaint: Respiratory failure, ARDS\\n 24 Hour Events:\\n FEVER - 101.1\\nF - 09:00 PM\\n -CT torso showed mildly decreased dense bilateral lower lobe\\n consolidation, increase in bilateral pleural effusions, significant\\n contrast reflux in esophagus concerning for high aspiration risk, but\\n not abscess.\\n -CT sinus wet read is paranasal sinus dz though cannot differentiate\\n infection from tissue thickening\\n -Patient prepped for bedside diagnostic thoracentesis but bedside\\n ultrasound demonstrated less fluid than seen on CT so tap deferred\\n -didn't get ECHO b/c of scheduling problem but should get on \\n -kept on PS but put on AC for and kept on that overnight;\\n put back on PS at 10/8 at 4a.m. and ABG written for 7a.m.\\n -pressors stopped at 6pm\\n -ID reccs -> cont oseltamavir, linezolid, cefepime; check sputum cx,\\n sputum viral cx, legionella cx; send cx from TLC and peripherally if\\n spikes\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 12:30 AM\\n Cefipime - 05:56 AM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.4\\nC (101.1\\n Tcurrent: 37.4\\nC (99.3\\n HR: 75 (75 - 117) bpm\\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\\n RR: 19 (16 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (13 - 334)mmHg\\n Total In:\\n 1,855 mL\\n 941 mL\\n PO:\\n TF:\\n 917 mL\\n 382 mL\\n IVF:\\n 878 mL\\n 514 mL\\n Blood products:\\n Total out:\\n 1,520 mL\\n 218 mL\\n Urine:\\n 1,520 mL\\n 218 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 335 mL\\n 723 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 370 (370 - 542) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 100\\n PIP: 17 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 26.7 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.42/41/85./25/1\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 170\\n Physical Examination\\n General Appearance: Thin\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : few)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 439 K/uL\\n 8.3 g/dL\\n 149 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 104 mEq/L\\n 133 mEq/L\\n 26.3 %\\n 19.2 K/uL\\n [image002.jpg]\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n Plt\\n 293\\n 334\\n 439\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n TCO2\\n 25\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\\n Imaging: CT Torso:\\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\\n greater\\n than right, with scattered patchy opacities seen medially within the\\n upper lobes. Interval increase in bilateral pleural effusions, now\\n moderate.\\n 2. Prominence of the esophagus, which is diffusely filled with oral\\n contrast\\n material, consistent with extensive gastroesophageal reflux disease.\\n Given the degree of contrast reflux into the esophagus, which is\\n marked, the patient is felt to be a very high risk for aspiration.\\n 3. No acute inflammatory process or abnormal fluid collection is seen\\n in the\\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\\n fluid.\\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\\n Microbiology: Sputum:\\n : Culture with coag + staph\\n Gram stain (-)\\n : Culture preliminary negative, gram\\n stain (-)\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\\n to infectious process/ ARDS. Patient with known influenza and with\\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\\n likely flu but given staph aureus in respiratory culture there is\\n evidence for bacterial superinfection. He is continuing to maintain\\n good ventilation and adequate oxygenation on pressure support.\\n Potentially concerning to allow ARDS patient off protocol due to\\n ability to exceed low lung volumes but he seems more comfortable on PS\\n and tidal volumes are relatively low (450-475) decreasing concern for\\n barotrauma.\\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\\n -F/U cultures\\n - Continue oseltamavir for influenza B\\n 2) SIRS/ Hypotension/Fevers: This patient\\ns fever is not as concerning\\n in and of itself given influenza can often cause persistent fever.\\n Still, with persistent white count and his leukocytosis recurring it is\\n very concerning that we are not adequately covering an infectious\\n process. Blood cultures remain negative and RUQ U/S not suggestive of\\n choleycystitis. Major concern now if for a drainable collection as his\\n broad spectrum antibiotics should cover most common organisms.\\n -Continue current antimicrobial regimen\\n -CT scan of torso and sinuses looking for possible closed space\\n infection and to better evaluate possible effusions vs atelectasis in\\n lungs\\n -Echo to evaluate for other causes of hypotension give patient has hx\\n of pericarditis and could potentially have some restrictive pathology\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE per above\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: NPO for now, given potential for prolonged intubation will\\n initiate nutrtition consult to start tube feeds\\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\\n appropriately sited on follow up scans)\\n 7) PPx: hep sc, ppi as outpt\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin, LMW Heparin\\n Stress ulcer:\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 658454,\n \"text\": \"Clinician: Attending\\n With ultrasound patient does have clear pleural effusion. We were,\\n unable, however--to identify a pocket > 2.5 cm in depth despite\\n multiple attempts at positioning to allow safe thoracentesis needle\\n passage.\\n Given concerns for risk of thoracentesis and pneumothorax in the\\n setting of significant lung disease and ARDS will defer for IP\\n evaluation for attmpt.\\n Total time spent: 10 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 658537,\n \"text\": \"Chief Complaint: ARDS\\n SEPSIS\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n FEVER - 101.1\\nF - 09:00 PM\\n -Pressors weaned to off yesterday\\n -Patient wtih A/C support overnight and return to PSV support this\\n morning\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 12:30 AM\\n Cefipime - 09:53 AM\\n Infusions:\\n Fentanyl - 35 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 AM\\n Midazolam (Versed) - 09:30 AM\\n Fentanyl - 09:45 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Genitourinary: Foley\\n Flowsheet Data as of 10:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.4\\nC (101.1\\n Tcurrent: 37.9\\nC (100.3\\n HR: 86 (75 - 117) bpm\\n BP: 138/65(86) {85/46(60) - 198/111(140)} mmHg\\n RR: 28 (16 - 33) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 12 (12 - 332)mmHg\\n Total In:\\n 1,855 mL\\n 1,265 mL\\n PO:\\n TF:\\n 917 mL\\n 514 mL\\n IVF:\\n 878 mL\\n 661 mL\\n Blood products:\\n Total out:\\n 1,520 mL\\n 378 mL\\n Urine:\\n 1,520 mL\\n 378 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 335 mL\\n 887 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 400 (400 - 542) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 28\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 100\\n PIP: 17 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 26.7 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.42/41/85./25/1\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 170\\n Physical Examination\\n General Appearance: Thin\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\\n (Breath Sounds: Diminished: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 8.3 g/dL\\n 439 K/uL\\n 149 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 104 mEq/L\\n 133 mEq/L\\n 26.3 %\\n 19.2 K/uL\\n [image002.jpg]\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n Plt\\n 293\\n 334\\n 439\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n TCO2\\n 25\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n Other labs: PT / PTT / INR:13.1/35.9/1.1, ALT / AST:70/75, Alk Phos / T\\n Bili:385/0.8, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:176 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\\n Fluid analysis / Other labs: AG-4\\n Imaging: CT--Inrease in bilateral pleural effusions, no abdominal\\n process to suggest focus of infection.\\n CT Sinus---Mild thickening of Mucosa\\n CXR-\\n ETT at 8 cm above carina\\n OGT past diaphragm\\n CVL in good position\\n Improved bilateral pleural effusions\\n Microbiology: -_Sputum-Staph\\n -GS--Pending\\n Assessment and Plan\\n 53 yo male with admission with influenza and S. Aureus pnumonia\\n complicated by ARDS and with persistent fevers at 7 days into course\\n search for alternative sources has been extensive but unrevealing to\\n date. His bilateral effusions appear to have diminished slightly. He\\n has minimal sinusitis.\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n -Cefepime/Linezolid\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)-Concern for possible\\n aspiration event and will need to confirm that ETT is in good position.\\n -Advance ETT this morning 3 cm\\n -Continue with A/C mode of support this morning\\n -Maintain adequate PEEP\\n SEPSIS WITHOUT ORGAN DYSFUNCTION-\\n -Continue with Cefepime/Linezolid\\n ICU Care\\n Nutrition: NPO given concern for aspiration\\nwith \\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments: Wife updated in full in regards to plan for\\n the day and the slight improvement from yesterday to today.\\n Explanation of thoracentesis procedure provided in detail and timing\\n for intervention with IP supervision today in the setting of difficult\\n to identify safe pocket for thoracentesis.\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 48 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658614,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 6\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 26 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Comments\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658517,\n \"text\": \"Chief Complaint: Respiratory failure, ARDS\\n 24 Hour Events:\\n - FEVER - 101.1\\nF - 09:00 PM\\n -OFF PRESSORS at 6:00 pm\\n -CT torso w/o abcess or drainable collection\\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\\n -Thoracentesis deferred as minimal fluid on echo\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 12:30 AM\\n Cefipime - 05:56 AM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.4\\nC (101.1\\n Tcurrent: 37.4\\nC (99.3\\n HR: 75 (75 - 117) bpm\\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\\n RR: 19 (16 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (13 - 334)mmHg\\n Total In:\\n 1,855 mL\\n 941 mL\\n PO:\\n TF:\\n 917 mL\\n 382 mL\\n IVF:\\n 878 mL\\n 514 mL\\n Blood products:\\n Total out:\\n 1,520 mL\\n 218 mL\\n Urine:\\n 1,520 mL\\n 218 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 335 mL\\n 723 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 370 (370 - 542) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 100\\n PIP: 17 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 26.7 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.42/41/85./25/1\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 170\\n Physical Examination\\n General Appearance: Thin\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : few)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 439 K/uL\\n 8.3 g/dL\\n 149 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 104 mEq/L\\n 133 mEq/L\\n 26.3 %\\n 19.2 K/uL\\n [image002.jpg]\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n Plt\\n 293\\n 334\\n 439\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n TCO2\\n 25\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\\n Imaging:\\n CT Torso:\\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\\n greater\\n than right, with scattered patchy opacities seen medially within the\\n upper lobes. Interval increase in bilateral pleural effusions, now\\n moderate.\\n 2. Prominence of the esophagus, which is diffusely filled with oral\\n contrast\\n material, consistent with extensive gastroesophageal reflux disease.\\n Given the degree of contrast reflux into the esophagus, which is\\n marked, the patient is felt to be a very high risk for aspiration.\\n 3. No acute inflammatory process or abnormal fluid collection is seen\\n in the\\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\\n fluid.\\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\\n Microbiology: Sputum:\\n : Culture with coag + staph\\n Gram stain (-)\\n : Culture preliminary negative, gram\\n stain (-)\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\\n to infectious process/ ARDS. Patient with known influenza and with\\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\\n likely flu but given staph aureus in respiratory culture there is\\n evidence for bacterial superinfection. He is continuing to maintain\\n good ventilation and adequate oxygenation on pressure support.\\n Potentially concerning to allow ARDS patient off protocol due to\\n ability to exceed low lung volumes but he seems more comfortable on PS\\n and tidal volumes are relatively low (450-475) decreasing concern for\\n barotrauma.\\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\\n -F/U cultures\\n - Continue oseltamavir for influenza B\\n 2) SIRS/ Hypotension/Fevers: This patient\\ns fever is not as concerning\\n in and of itself given influenza can often cause persistent fever.\\n Still, with persistent white count and his leukocytosis recurring it is\\n very concerning that we are not adequately covering an infectious\\n process. Blood cultures remain negative and RUQ U/S not suggestive of\\n choleycystitis. Major concern now if for a drainable collection as his\\n broad spectrum antibiotics should cover most common organisms.\\n -Continue current antimicrobial regimen\\n -CT scan of torso and sinuses looking for possible closed space\\n infection and to better evaluate possible effusions vs atelectasis n\\n lungs\\n -Echo to evaluate for other causes of hypotension give patient has hx\\n of pericarditis and could potentially have some restrictive pathology\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE per above\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: NPO for now, given potential for prolonged intubation will\\n initiate nutrtition consult to start tube feeds\\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\\n appropriately sited on follow up scans)\\n 7) PPx: hep sc, ppi as outpt\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658688,\n \"text\": \"Chief Complaint: Hypoxic respiratory failure\\n 24 Hour Events:\\n THORACENTESIS - At 12:36 PM\\n FEVER - 102.3\\nF - 04:00 PM\\n -Restarted on norepinephrine overnight for hypotension\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Metronidazole - 12:20 PM\\n Linezolid - 12:35 PM\\n Nafcillin - 04:12 AM\\n Cefipime - 06:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 02:43 PM\\n Fentanyl - 02:44 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.1\\nC (102.3\\n Tcurrent: 37.8\\nC (100\\n HR: 90 (72 - 113) bpm\\n BP: 124/87(100) {79/44(56) - 161/87(100)} mmHg\\n RR: 22 (19 - 31) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 13 (11 - 23)mmHg\\n Total In:\\n 2,076 mL\\n 344 mL\\n PO:\\n TF:\\n 514 mL\\n IVF:\\n 1,383 mL\\n 344 mL\\n Blood products:\\n Total out:\\n 818 mL\\n 360 mL\\n Urine:\\n 818 mL\\n 360 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,258 mL\\n -16 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 23 cmH2O\\n Plateau: 21 cmH2O\\n Compliance: 31.5 cmH2O/mL\\n SpO2: 96%\\n ABG: ///24/\\n Ve: 7.5 L/min\\n Physical Examination\\n General Appearance: Thin, ill appearing\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : at apices, Diminished: more diminished on\\n right)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: 1+, Left: 1+\\n Skin: Not assessed\\n Neurologic: Responds to: verbal stimuli, Movement: purposeful\\n Labs / Radiology\\n 509 K/uL\\n 8.1 g/dL\\n 118 mg/dL\\n 0.8 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 100 mEq/L\\n 131 mEq/L\\n 24.7 %\\n 22.4 K/uL\\n [image002.jpg]\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n Plt\\n 293\\n 334\\n 439\\n 509\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n TCO2\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:84/80, Alk Phos / T\\n Bili:419/1.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:193 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Fluid analysis / Other labs: Pleural fluid:\\n WBC 6900*\\n -PMN 68* -Lymphs 1* -Monos 0-Eos 3*-Mesos 13*-Macros 15*\\n RBC 2275*\\n Imaging: CXR from :\\n IMPRESSION: Persistent bibasilar retrocardiac opacities, which may be\\n due to pneumonia in the appropriate clinical setting. Bilateral areas\\n of radiation fibrosis in the upper lobes without change.\\n Microbiology: GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n NO MICROORGANISMS SEEN.\\n RESPIRATORY CULTURE (Final ):\\n OROPHARYNGEAL FLORA ABSENT.\\n STAPH AUREUS COAG +. SPARSE GROWTH.\\n Staphylococcus species may develop resistance during prolonged\\n therapy with quinolones. Therefore, isolates that are initially\\n susceptible may become resistant within three to four days after\\n initiation of therapy. Testing of repeat isolates may be\\n warranted.\\n SENSITIVITIES: MIC expressed in MCG/ML\\n _________________________________________________________\\n STAPH AUREUS COAG +\\n |\\n CLINDAMYCIN----------- =>8 R\\n ERYTHROMYCIN---------- =>8 R\\n GENTAMICIN------------ <=0.5 S\\n LEVOFLOXACIN---------- 0.25 S\\n OXACILLIN------------- 0.5 S\\n TRIMETHOPRIM/SULFA---- <=0.5 S\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\\n aureus superinfections, and ARDS.\\n 1) Respiratory failure/Influenza Pneumonia with secondary bacterial\\n pneumonia: The patient was initially intubated for hypoxic respiratory\\n failure. Has known influenza B as well as staph aureus in sputums\\n presumably causing ARDS. Ventilation and oxygenation stable on AC\\n settings. He is on day 7 of antimicrobial therapy with cefepime, he\\n received six days of vancomycin/linezolid, he is on day six of\\n oseltamavir. His linezolid was stopped and nafcillin started after his\\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\\n and lung reexpansion after the procedure would suggest this is freely\\n flowing.\\n -F/U cultures\\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\\n duration of nafcillin therapy in this very sick patient with ID who is\\n following\\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though this should be\\n appropriately covered by his antibiotics. Hypotension presumably due\\n to continued SIRs driving process (active infection vs ARDS).\\n -Afrin and saline nasal washes for sinus disease\\n -Continue nafcillin/cefepime/oseltamavir pending culture data\\n -F/U cultures and culture if spikes\\n -F/U ID reccs\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\\n history of irradiation, nevertheless he needs nutrition. We will speak\\n to GI re: post-pyloric feeding tube and start PPN in the interim.\\n 6) Access: 2 PIVs; right IJ\\n 7) PPx: hep sc, PPI\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n ICU \\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658994,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 9\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning; Comments: Plan to extubate\\n Comments: rsbi 74\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658947,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n T max 100.4, coarse LS on the L, conts on Nafcillian, he has developed\\n a rash on his abd and back, he has yellow sputum from his ETT and a lg\\n amount of secretions from the back of his throat. He is more alert\\n today, writing, though somewhat illegibly, able to tell us some of his\\n needs. He is 13 liters pos.\\n Action:\\n Placed on PSV 5 PEEP 8, his PEEP was decreased to 5 this afternoon,\\n started on a lasix gtt, weaned his fent to 75 mcg/hr and his midaz to 4\\n mg/hr\\n Response:\\n Tolerating the PSV, he had had > 1 liter off from the lasix so far, his\\n CVP was 18-20 this morning and now it is and his BP has been stable\\n in the 110-120s this afternoon.\\n Plan:\\n Let him stay on PSV overnight if he tolerates this, cont with the lasix\\n gtt as his BP and CVP allow, follow his lytes, follow his rash\\n there\\n is concern that the rash is from the nafacillin but this is a good\\n antibiotic for his staph pneumonia, cont to wean the fent and versed.\\n He went to radiology this afternoon to place a NG tube in his\\n jejunum, the was done, he will be able to be started on TF this\\n evening, his TPN will cont until his TF is up to his goal.\\n His wife was very anxious today, she spent much of the morning and\\n part of the afternoon here, she did feel better after talking to the\\n attending, and is relieved to hear that he is doing better. His\\n parents will be in to see him tomorrow.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658677,\n \"text\": \"Chief Complaint: Hypoxic respiratory failure\\n 24 Hour Events:\\n THORACENTESIS - At 12:36 PM\\n FEVER - 102.3\\nF - 04:00 PM\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Metronidazole - 12:20 PM\\n Linezolid - 12:35 PM\\n Nafcillin - 04:12 AM\\n Cefipime - 06:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 02:43 PM\\n Fentanyl - 02:44 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.1\\nC (102.3\\n Tcurrent: 37.8\\nC (100\\n HR: 90 (72 - 113) bpm\\n BP: 124/87(100) {79/44(56) - 161/87(100)} mmHg\\n RR: 22 (19 - 31) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 13 (11 - 23)mmHg\\n Total In:\\n 2,076 mL\\n 344 mL\\n PO:\\n TF:\\n 514 mL\\n IVF:\\n 1,383 mL\\n 344 mL\\n Blood products:\\n Total out:\\n 818 mL\\n 360 mL\\n Urine:\\n 818 mL\\n 360 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,258 mL\\n -16 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI Deferred: No Spon Resp\\n PIP: 23 cmH2O\\n Plateau: 21 cmH2O\\n Compliance: 31.5 cmH2O/mL\\n SpO2: 96%\\n ABG: ///24/\\n Ve: 7.5 L/min\\n Physical Examination\\n General Appearance: Thin, ill appearing\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : at apices, Diminished: more diminished on\\n right)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: 1+, Left: 1+\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 509 K/uL\\n 8.1 g/dL\\n 118 mg/dL\\n 0.8 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 20 mg/dL\\n 100 mEq/L\\n 131 mEq/L\\n 24.7 %\\n 22.4 K/uL\\n [image002.jpg]\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n Plt\\n 293\\n 334\\n 439\\n 509\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n TCO2\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:84/80, Alk Phos / T\\n Bili:419/1.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:193 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Fluid analysis / Other labs: Pleural fluid:\\n WBC 6900*\\n -PMN 68*\\n -Lymphs 1*\\n -Monos 0\\n -Eos 3*\\n -Mesos 13*\\n -Macros 15*\\n RBC 2275*\\n Imaging: CXR from :\\n IMPRESSION: Persistent bibasilar retrocardiac opacities, which may be\\n due to pneumonia in the appropriate clinical setting. Bilateral areas\\n of radiation\\n fibrosis in the upper lobes without change.\\n Microbiology: GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n NO MICROORGANISMS SEEN.\\n RESPIRATORY CULTURE (Final ):\\n OROPHARYNGEAL FLORA ABSENT.\\n STAPH AUREUS COAG +. SPARSE GROWTH.\\n Staphylococcus species may develop resistance during prolonged\\n therapy with quinolones. Therefore, isolates that are\\n initially\\n susceptible may become resistant within three to four days\\n after\\n initiation of therapy. Testing of repeat isolates may be\\n warranted.\\n SENSITIVITIES: MIC expressed in MCG/ML\\n _________________________________________________________\\n STAPH AUREUS COAG +\\n |\\n CLINDAMYCIN----------- =>8 R\\n ERYTHROMYCIN---------- =>8 R\\n GENTAMICIN------------ <=0.5 S\\n LEVOFLOXACIN---------- 0.25 S\\n OXACILLIN------------- 0.5 S\\n TRIMETHOPRIM/SULFA---- <=0.5 S\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\\n known influenza B as well as staph aureus in sputums. Presumably, flu\\n with bacterial superinfection is the etiology of his ARDS. The patient\\n was on AC overnight but was switched back to CPAP this AM. Since then,\\n he has been pulling lower tidal volumes than previously (<400) and more\\n tachypneic. We will place him back on AC to decrease work of breathing\\n while we continue to treat his pneumonia and support him through his\\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\\n and oseltamavir.\\n -F/U cultures, obtain viral cultures per ID recommendation\\n - Continue current antimicrobials pending culture data\\n -IP will attempt to perform diagnostic thoracentesis today as ICU team\\n unable to safely do at bedside\\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though this should be\\n appropriately covered by his antibiotics.\\n -Continue linezolid/cefepime/oseltamavir pending culture data\\n -obtain pleural fluid to rule out complicated effusion\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE today to evaluate for effusion/tamponade\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: Pt with noted aspiration event this AM, presumably due to\\n history of irradiation, we will hold tube feeds for now and swallow\\n study once extubated.\\n 6) Access: 2 PIVs; right IJ\\n 7) PPx: hep sc, PPI\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658746,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Sepsis without organ dysfunction\\n Assessment:\\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\\n 80s-100. Spiked fecer to 101.3.\\n Action:\\n Given 500 cc NS bolus, given Tylenol 0nce, 2 sets of bld cx, urine cx,\\n and stool cx sent. continued on antibiotics as ordered.\\n Response:\\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\\n above 12.\\n Plan:\\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\\n ordered, bolus fluids as needed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\\n at upper lobes and diminished at bases. Was observed to be very\\n restless and trying to jump out of bed.\\n Action:\\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\\n increased to 4 mg/hr.\\n Response:\\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\\n strong productive cough.\\n Plan:\\n Wean vent as tolerated, suction frequently PRN.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 659103,\n \"text\": \"Chief Complaint: resp failure\\n 24 Hour Events:\\n Family meeting with Dr. and re: pt's course and\\n prognosis. Very helpful for wife to hear positive steps we are taking\\n with him.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:23 PM\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 75 mcg/hour\\n Other ICU medications:\\n Fentanyl - 03:22 PM\\n Lansoprazole (Prevacid) - 07:44 AM\\n Heparin Sodium (Prophylaxis) - 07:44 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: pt denies Pain, nausea. States has some mild SOB\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 88 (85 - 121) bpm\\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\\n RR: 19 (19 - 35) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 8 (6 - 22)mmHg\\n Total In:\\n 1,897 mL\\n 512 mL\\n PO:\\n TF:\\n IVF:\\n 889 mL\\n 184 mL\\n Blood products:\\n Total out:\\n 4,615 mL\\n 1,810 mL\\n Urine:\\n 4,615 mL\\n 1,810 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,718 mL\\n -1,298 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 388 (347 - 453) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 74\\n PIP: 11 cmH2O\\n SpO2: 100%\\n ABG: 7.44/40/76./31/2\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 190\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n slight at bases)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 714 K/uL\\n 7.8 g/dL\\n 144 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 17 mg/dL\\n 98 mEq/L\\n 136 mEq/L\\n 23.9 %\\n 26.7 K/uL\\n [image002.jpg]\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n WBC\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n 26.7\\n Hct\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n 23.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 28\\n 28\\n 28\\n Glucose\\n 112\\n 149\\n 118\\n 151\\n 131\\n 144\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. FiO2 40% today and on PS 5/5\\n but blood gas this noon 7.52/41/64\\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\\n instead of ARDS. Trying to wean PS daily but did not tolerate today.\\n Will try again tomorrow.\\n - Has completed course of oseltamavir\\n - continue nafcillin day 5 today\\n - F/U cultures\\n - lasix gtt stopped today contraction alkylosis. Consider lasix\\n boluses for CVP >4. Started Diamox 500 TID \\n -added cefepime to allergy list given likely elevation LFT\\ns with this.\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin\\n - consider pulling central line if any blood cx are positive. Keep now\\n for TPN\\n - F/U cultures and culture if spikes\\n - F/U ID reccs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Will give TF until early am for possible am extubation\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU until respiratory status improves\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:42 PM 42 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\\n c/b MSSA pneumonia. Improving with lasix, fevers and rash decreasing.\\n Exam notable for Tm 100.4 BP 118/58 HR 90 RR 24 with sat 96 on PSV 5/5,\\n 7.52/37/70 -3+L/24h. Rash on anterior chest improved, lungs clearer.\\n RRR s1s2. Soft +BS. Trace edema. Labs notable for WBC 26K, HCT 23, K+\\n 3.6, Cr 0.7. CXR .\\n Agree with plan to continue PSV, lasix gtt and diamox for component of\\n metabolic alkalosis while transitioning to bolus sedation. SBT now;\\n appears close to extubation. Will continue naf for MSSA pneumonia x 14\\n days total. Fever / rash better, will add cefepime to allergy list.\\n +BM, will continue TPN and initiate Doboff feeds if not extubated.\\n Above d/w wife and PCP. of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 15:25 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 659575,\n \"text\": \"Chief Complaint: PNA, s/p resp failure\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 10:10 AM\\n ARTERIAL LINE - STOP 04:00 PM\\n -extubated in a.m. and did well\\n -was c/o nausea intermittently -> concerning for opiate or benzo\\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\\n iv prn.\\n Allergies:\\n Cefepime\\n Rash;\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:32 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 07:45 AM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Lorazepam (Ativan) - 01:30 AM\\n Fentanyl - 01:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 35.9\\nC (96.7\\n HR: 94 (91 - 114) bpm\\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\\n RR: 24 (14 - 40) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (12 - 18)mmHg\\n Total In:\\n 1,308 mL\\n 288 mL\\n PO:\\n TF:\\n 13 mL\\n IVF:\\n 547 mL\\n 228 mL\\n Blood products:\\n Total out:\\n 5,035 mL\\n 1,100 mL\\n Urine:\\n 5,035 mL\\n 1,100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,727 mL\\n -813 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: PSV/SBT\\n Vt (Spontaneous): 730 (730 - 730) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 0 cmH2O\\n FiO2: 50%\\n SpO2: 96%\\n ABG: ///23/\\n Ve: 12.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: crackles :\\n L >R base)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 896 K/uL\\n 7.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.5 mEq/L\\n 21 mg/dL\\n 103 mEq/L\\n 136 mEq/L\\n 24.5 %\\n 22.0 K/uL\\n [image002.jpg]\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n WBC\\n 24.7\\n 25.6\\n 26.7\\n 23.6\\n 22.0\\n Hct\\n 24.9\\n 23.9\\n 23.9\\n 24.7\\n 24.5\\n Plt\\n 81\\n 896\\n Cr\\n 1.0\\n 0.8\\n 0.7\\n 0.8\\n 0.8\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n Glucose\\n 151\\n 131\\n 144\\n 135\\n 128\\n 115\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. Successfully extubated \\n - Has completed course of oseltamavir\\n - continue nafcillin - plan for 21 D course today abx from when\\n linezolid was started \\n -monitor diuresis and consider bolus lasix PRN.\\n - speech and swallow eval today\\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\\n consider fentanyl or ativan PRN\\n -Incentive spirometry,\\n -PT today and OOB to chair\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam. WBC now trending down to 22\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 21 D course\\n -pull CVL today if can get PICC\\n - F/U ID recs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Getting s/s today. If passes, d/c TF\\n #) Access: 2 PIVs; right IJ\\n trying to get PICC today\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now- consider PM c/o\\n #) Comm: With wife\\n ICU \\n Nutrition: diet pending speech and swallow eval today\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor possibly in afternoon\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\\n c/b MSSA pneumonia. Extubated yesterday, on NC but still tachypnic.\\n Exam notable for Tm 99.2 BP 110/65 HR 95 RR 24-30 with sat 93 on 4L NC.\\n TBB -1.5L/8h. Scattered rales. RRR s1s2. Soft +BS. Trace edema. Labs\\n notable for WBC 23K, HCT 24, K+ 4.5, Cr 0.8. CXR B ASD, stable to sl\\n worse.\\n Agree with plan to continue lasix bolus PRN for goal negative and CVP\\n <4. Will continue naf for MSSA pneumonia x 12/21 days total. Will d/c\\n CVL and place PICC for duration of therapy. Will mobilize OOB to chair\\n and get PT consult. Wean oxygen to off, S+S eval, ADAT post evaluation.\\n Given recent benzo/narcotic use, will continue low dose ativan and\\n fentanyl PRN. Will continue TPN and initiate Doboff feeds today. Above\\n d/w wife and PCP. of plan as outlined above.\\n Total time: 35 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:03 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658801,\n \"text\": \"Chief Complaint: This is a 53 year-old male with a history of hodkin's\\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\\n pneumonia, S. aureus superinfections, and ARDS.\\n 24 Hour Events:\\n BLOOD CULTURED - At 10:03 PM\\n 2 sets of bld cx\\n URINE CULTURE - At 10:03 PM\\n STOOL CULTURE - At 02:45 AM\\n - ID rec to d/c cefepime but keeping for now as pt not clinically\\n improving\\n -Tried to place doppoff but first ended up in lungs. In stomach on\\n second try. Will monitor to see if it can move post pyloric over the\\n next day or so to safely start tube feeds\\n - Afrin and NS nasal washes started for 3 days duration\\n - No new cx data\\n -Attempted to wean FiO2 but unable and remains on 50%\\n - blood and urine cx ordered around 10p for T 101\\n - Pt coughing throughout day and intermittently bolused with sedatives.\\n - Bolused 500cc in afternoon for low BP. Map again low 60's in evening\\n sedation.\\n - PPN ordered\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Linezolid - 12:35 PM\\n Nafcillin - 04:04 AM\\n Cefipime - 06:00 AM\\n Infusions:\\n Fentanyl - 75 mcg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 04:37 PM\\n Fentanyl - 10:07 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.8\\nC (100.1\\n HR: 75 (71 - 122) bpm\\n BP: 93/54(67) {71/45(55) - 191/86(121)} mmHg\\n RR: 21 (20 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 11 (8 - 34)mmHg\\n Total In:\\n 1,648 mL\\n 1,934 mL\\n PO:\\n TF:\\n IVF:\\n 1,528 mL\\n 1,884 mL\\n Blood products:\\n Total out:\\n 1,080 mL\\n 110 mL\\n Urine:\\n 1,080 mL\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 568 mL\\n 1,824 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 283 (283 - 283) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 94\\n PIP: 18 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 34.8 cmH2O/mL\\n SpO2: 98%\\n ABG: ///24/\\n Ve: 8.6 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 519 K/uL\\n 7.9 g/dL\\n 151 mg/dL\\n 1.0 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 23 mg/dL\\n 103 mEq/L\\n 135 mEq/L\\n 24.9 %\\n 24.7 K/uL\\n [image002.jpg]\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n Plt\\n 293\\n 334\\n 439\\n 509\\n 519\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n TCO2\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n 151\\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:66/54, Alk Phos / T\\n Bili:326/1.2, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:170 IU/L, Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\\n aureus superinfections, and ARDS.\\n 1) Respiratory failure/Influenza Pneumonia with secondary bacterial\\n pneumonia: The patient was initially intubated for hypoxic respiratory\\n failure. Has known influenza B as well as staph aureus in sputums\\n presumably causing ARDS. Ventilation and oxygenation stable on AC\\n settings. He is on day 7 of antimicrobial therapy with cefepime, he\\n received six days of vancomycin/linezolid, he is on day six of\\n oseltamavir. His linezolid was stopped and nafcillin started after his\\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\\n and lung reexpansion after the procedure would suggest this is freely\\n flowing.\\n -F/U cultures\\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\\n duration of nafcillin therapy in this very sick patient with ID who is\\n following\\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though this should be\\n appropriately covered by his antibiotics. Hypotension presumably due\\n to continued SIRs driving process (active infection vs ARDS).\\n -Afrin and saline nasal washes for sinus disease\\n -Continue nafcillin/cefepime/oseltamavir pending culture data\\n -F/U cultures and culture if spikes\\n -F/U ID reccs\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\\n history of irradiation, nevertheless he needs nutrition. We will speak\\n to GI re: post-pyloric feeding tube and start PPN in the interim.\\n 6) Access: 2 PIVs; right IJ\\n 7) PPx: hep sc, PPI\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n ICU \\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 658815,\n \"text\": \"Chief Complaint: Respiratory Failure\\n ARDS\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n BLOOD CULTURED - At 10:03 PM\\n 2 sets of bld cx\\n URINE CULTURE - At 10:03 PM\\n STOOL CULTURE - At 02:45 AM\\n History obtained from Patient, Family / Friend\\n Allergies:\\n Known Drug Allergies\\n Last dose of Antibiotics:\\n Linezolid - 12:35 PM\\n Cefipime - 06:00 AM\\n Nafcillin - 10:08 AM\\n Infusions:\\n Fentanyl - 75 mcg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 04:37 PM\\n Fentanyl - 10:07 PM\\n Heparin Sodium (Prophylaxis) - 08:13 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fever\\n Flowsheet Data as of 11:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.8\\n HR: 87 (71 - 122) bpm\\n BP: 110/61(77) {71/45(55) - 191/86(121)} mmHg\\n RR: 24 (20 - 30) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 13 (8 - 34)mmHg\\n Total In:\\n 1,648 mL\\n 2,680 mL\\n PO:\\n TF:\\n IVF:\\n 1,528 mL\\n 2,043 mL\\n Blood products:\\n Total out:\\n 1,080 mL\\n 390 mL\\n Urine:\\n 1,080 mL\\n 390 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 568 mL\\n 2,290 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 283 (283 - 283) mL\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 94\\n PIP: 18 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 34.8 cmH2O/mL\\n SpO2: 98%\\n ABG: ///24/\\n Ve: 8.6 L/min\\n Physical Examination\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\\n (Breath Sounds: Diminished: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Trace, Left: 1+\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 7.9 g/dL\\n 519 K/uL\\n 151 mg/dL\\n 1.0 mg/dL\\n 24 mEq/L\\n 3.7 mEq/L\\n 23 mg/dL\\n 103 mEq/L\\n 135 mEq/L\\n 24.9 %\\n 24.7 K/uL\\n [image002.jpg]\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n Plt\\n 293\\n 334\\n 439\\n 509\\n 519\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n TCO2\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n 151\\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:66/54, Alk Phos / T\\n Bili:326/1.2, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:170 IU/L, Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Imaging: CXR--ETT at 5cm, CVL in good position, OGT in stomach\\n Assessment and Plan\\n 53 yo male admit with influenza B and MSSA superinfection with severe\\n hypoxemic respiratory failure and ARDS. He has had extensive\\n evaluation for alternative source of infection and WBC count elevation\\n but has been unrevealing to date. In this setting have had continued\\n elevation in WBC count but has been able to maintain pressure off\\n pressors.\\n 1)Respiratory Failure-_Acute-\\n -Will continue with A/C support and lung protective strategy for\\n ventilation\\n -Wean FIO2 as possible today\\n -Maintain PEEP and only move to wean if able to maintain stable PO2 at\\n decreased PEEP\\n -Tamiflu\\n 2) PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)-\\n -Nafcillin/Cefepime continuing\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\nConcerning continued rise in WBC\\n count.\\n -C. Diff is of concern\\n -Evidence of alternative source not clearly seen\\n -Will need to consider ID input\\n -Cefepime/Nafcillin/Taimflu continuing\\n -CT for chest as concern for necrotizing abscess is of concern\\n -If unrevealing would consider line changes as next intervention if\\n persistent fever, leukocytosis seen\\n -Will pre-hydrate with fluids and Mucomyst\\n ICU Care\\n Nutrition:\\n Peripheral Parenteral Nutrition - 07:45 AM 166 mL/hour\\n today\\nwe have OGT inplace and are looking for post pyloric feeding\\n given significant risk of recurrent aspiration events. If unable to\\n achieve with placement and Reglan will have to ask IR for assistance in\\n achieving adequate positioning\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659096,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\\n following commands, writing on paper to communicate. T max 100.1po.\\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\\n abd and back appears improved micu md staff who saw this pt\\n yesterday.\\n Action:\\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\\n scant amts thick yellow sputum, small amts blood tinged sputum in back\\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\\n pending.\\n Response:\\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\\n extubated today. ett retaped and repositioned to left side of mouth at\\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\\n and versed drips restarted and titrated up to comfort but pt still\\n easily arousable and following commands.\\n Plan:\\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\\n around 4. Follow up with 5pm lab results and replete lytes prn.\\n Continue to monitor rash on abd and back.\\n Sepsis without organ dysfunction\\n Assessment:\\n T max 100.1po. sbp stable in 100s-140s.\\n Action:\\n Continues with iv nafcillin\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659099,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\\n following commands, writing on paper to communicate. T max 100.1po.\\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\\n abd and back appears improved micu md staff who saw this pt\\n yesterday.\\n Action:\\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\\n scant amts thick yellow sputum, small amts blood tinged sputum in back\\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\\n pending.\\n Response:\\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\\n extubated today. ett retaped and repositioned to left side of mouth at\\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\\n and versed drips restarted and titrated up to comfort but pt still\\n easily arousable and following commands.\\n Plan:\\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\\n around 4. Follow up with 5pm lab results and replete lytes prn.\\n Continue to monitor rash on abd and back.\\n Sepsis without organ dysfunction\\n Assessment:\\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\\n Also + infuluenza.\\n Action:\\n Continues with iv nafcillin\\n Response:\\n Remains with low grade temp, currently afebrile.\\n Plan:\\n Continue nafcillin, follow up with bld culture results. Monitor temps.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659101,\n \"text\": \"Chief Complaint: resp failure\\n 24 Hour Events:\\n Family meeting with Dr. and re: pt's course and\\n prognosis. Very helpful for wife to hear positive steps we are taking\\n with him.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:23 PM\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 75 mcg/hour\\n Other ICU medications:\\n Fentanyl - 03:22 PM\\n Lansoprazole (Prevacid) - 07:44 AM\\n Heparin Sodium (Prophylaxis) - 07:44 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: pt denies Pain, nausea. States has some mild SOB\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 88 (85 - 121) bpm\\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\\n RR: 19 (19 - 35) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 8 (6 - 22)mmHg\\n Total In:\\n 1,897 mL\\n 512 mL\\n PO:\\n TF:\\n IVF:\\n 889 mL\\n 184 mL\\n Blood products:\\n Total out:\\n 4,615 mL\\n 1,810 mL\\n Urine:\\n 4,615 mL\\n 1,810 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,718 mL\\n -1,298 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 388 (347 - 453) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 74\\n PIP: 11 cmH2O\\n SpO2: 100%\\n ABG: 7.44/40/76./31/2\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 190\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n slight at bases)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 714 K/uL\\n 7.8 g/dL\\n 144 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 17 mg/dL\\n 98 mEq/L\\n 136 mEq/L\\n 23.9 %\\n 26.7 K/uL\\n [image002.jpg]\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n WBC\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n 26.7\\n Hct\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n 23.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 28\\n 28\\n 28\\n Glucose\\n 112\\n 149\\n 118\\n 151\\n 131\\n 144\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. FiO2 40% today and on PS 5/5\\n but blood gas this noon 7.52/41/64\\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\\n instead of ARDS. Trying to wean PS daily but did not tolerate today.\\n Will try again tomorrow.\\n - Has completed course of oseltamavir\\n - continue nafcillin day 5 today\\n - F/U cultures\\n - lasix gtt stopped today contraction alkylosis. Consider lasix\\n boluses for CVP >4. Started Diamox 500 TID \\n -added cefepime to allergy list given likely elevation LFT\\ns with this.\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin\\n - consider pulling central line if any blood cx are positive. Keep now\\n for TPN\\n - F/U cultures and culture if spikes\\n - F/U ID reccs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Will give TF until early am for possible am extubation\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU until respiratory status improves\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:42 PM 42 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659556,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Received pt on 4l/m nc with rr in the high 20\\ns to low 30\\ns. lungs\\n essentially clear on auscultation with crackles bil at the bases. Neg\\n fluid balance for this shift. Wbc has dropped to 22.\\n Action:\\n Fluid balance followed closely as well as his hemodynamics. Pt using\\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\\n Receiving nafcillin as ordered . resp status monitored closely. Speech\\n and swallow study completed. Physical therapy has been consulted. Tube\\n fdgs restarted via dobhoff tube since pt\\ns nutritional status is most\\n certainly not adequate. Oob to chair with assist of 2 and tolerated\\n activity well. Ic consulted to place picc line since infectious dx\\n consult team is recommending 21 day course of nafcillin.\\n Response:\\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\\n and for los pos 1.6 liters.\\n Plan:\\n Will maintain aspiration precautions. Continue to follow fluid balance\\n and resp status. Follow culture data. Pt to have picc line placed for\\n 21 day course of nafcillin and once access is obtained will then d/cri\\n j triple lumen. Increase pt\\ns level of activity as he tolerates. If\\n stable overnoc will transfer to medical floor bed tomorrow.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Bedside Swallow Evaluation\",\n \"row_id\": 659561,\n \"text\": \"TITLE: Bedside Swallow Evaluation\\n Patient was seen for bedside swallow evaluation. Please see full\\n evaluation in OMR or paper chart for details and recommendations.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 659571,\n \"text\": \"Objective\\n Pertinent medications: Noted.\\n Labs:\\n Value\\n Date\\n Glucose\\n 115 mg/dL\\n 04:20 AM\\n Glucose Finger Stick\\n 144\\n 06:00 PM\\n BUN\\n 21 mg/dL\\n 04:20 AM\\n Creatinine\\n 0.8 mg/dL\\n 02:50 AM\\n Sodium\\n 136 mEq/L\\n 04:20 AM\\n Potassium\\n 4.5 mEq/L\\n 04:20 AM\\n Chloride\\n 103 mEq/L\\n 04:20 AM\\n TCO2\\n 23 mEq/L\\n 04:20 AM\\n PO2 (arterial)\\n 74 mm Hg\\n 08:09 AM\\n PCO2 (arterial)\\n 31 mm Hg\\n 08:09 AM\\n pH (arterial)\\n 7.48 units\\n 08:09 AM\\n pH (urine)\\n 6.0 units\\n 09:54 PM\\n CO2 (Calc) arterial\\n 24 mEq/L\\n 08:09 AM\\n Albumin\\n 2.4 g/dL\\n 03:19 AM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 02:50 AM\\n Phosphorus\\n 3.4 mg/dL\\n 02:50 AM\\n Magnesium\\n 2.6 mg/dL\\n 04:20 AM\\n ALT\\n 46 IU/L\\n 04:20 AM\\n Alkaline Phosphate\\n 282 IU/L\\n 04:20 AM\\n AST\\n 39 IU/L\\n 04:20 AM\\n Total Bilirubin\\n 0.6 mg/dL\\n 04:20 AM\\n WBC\\n 22.0 K/uL\\n 04:20 AM\\n Hgb\\n 7.7 g/dL\\n 04:20 AM\\n Hematocrit\\n 24.5 %\\n 04:20 AM\\n Current diet order / nutrition support: Regular/Soft/Thin with Ensure\\n Pudding TID\\n TF: Replete with Fiber at goal 75mL/hr via PPFT.\\n Assessment of Nutritional Status/Plan:\\n Specifics:\\n Passed swallow eval today. TF started & currently at 10mL/hr. Recommend\\n continue with TF until able to tolerate adequate po intake. Adjust free\\n water flushes per hydration. Monitor & replete lytes PRN. Will adjust\\n TF goal rate per po intake.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659573,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Received pt on 4l/m nc with rr in the high 20\\ns to low 30\\ns. lungs\\n essentially clear on auscultation with crackles bil at the bases. Neg\\n fluid balance for this shift. Wbc has dropped to 22.\\n Action:\\n Fluid balance followed closely as well as his hemodynamics. Pt using\\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\\n Receiving nafcillin as ordered . resp status monitored closely. Speech\\n and swallow study completed. Physical therapy has been consulted. Tube\\n fdgs restarted via dobhoff tube since pt\\ns nutritional status is most\\n certainly not adequate. Oob to chair with assist of 2 and tolerated\\n activity well. Ic consulted to place picc line since infectious dx\\n consult team is recommending 21 day course of nafcillin. Post\\n completion of speech andswallow study diet advancedto low sodium/heart\\n healthy soft consistency , thin liqs ensure pudding with ea. Meal\\n give all pills via dobhoff\\n Response:\\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\\n and for los pos 1.6 liters.\\n Plan:\\n Will maintain aspiration precautions. Continue to follow fluid balance\\n and resp status. Follow culture data. Pt to have picc line placed for\\n 21 day course of nafcillin and once access is obtained will then d/cri\\n j triple lumen. Increase pt\\ns level of activity as he tolerates. If\\n stable overnoc will transfer to medical floor bed tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658646,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fent and versed drips. Remained\\n on AC overnight.\\n Sepsis without organ dysfunction\\n Assessment:\\n BP started dropping to 80s then to high 70s, UO 30-40 cc/hr, CVP 13-14.\\n Action:\\n Levophed resumed at 0.01 mcg.kg/min then weaned down to 0.001, then\\n stopped at 0630, continues on antibiotics as ordered.\\n Response:\\n Pt with low grade fever overnight. T max 100.1, given Tylenol once as\\n pt had been cultured (urine and sputum) within the past 24hrs.\\n Plan:\\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\\n ordered, wean levophed off as tolerated.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is sedated and intubated on AC for ARDS. Lung sounds rhonchi at\\n upper lobes and diminished at bases..\\n Action:\\n Suctioned frequently for thick yellowish secretions. Remains on\\n Fentanyl 50 mcg/hr and versed 2 mg/hr.\\n Response:\\n Present vent setting AC 20, 400, 50%, PEEP 8.\\n Plan:\\n Wean vent as tolerated, suction PRN.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658784,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Sepsis without organ dysfunction\\n Assessment:\\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\\n 80s-100. Spiked fecer to 101.3. This AM K 3.7 and Ph 2.5\\n Action:\\n Given 500 cc NS bolus x3, given Tylenol 0nce, 2 sets of bld cx, urine\\n cx, and stool cx sent. Continued on antibiotics as ordered. KCL 20 meq\\n IV given and Neutraphos will be given.\\n Response:\\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\\n above 10.\\n Plan:\\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\\n ordered, bolus fluids as needed. Monitor lytes and replete as needed,\\n Ph to be repleted.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\\n at upper lobes and diminished at bases. Was observed to be very\\n restless and trying to jump out of bed.\\n Action:\\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\\n increased to 4 mg/hr.\\n Response:\\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\\n strong productive cough.\\n Plan:\\n Wean vent as tolerated, suction frequently PRN.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 658939,\n \"text\": \"Chief Complaint: This is a 53 year-old male with a history of hodkin's\\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\\n pneumonia, S. aureus superinfections, and ARDS.\\n 24 Hour Events:\\n FEVER - 101.4\\nF - 04:00 PM\\n \\n -Weaned Fi02 from 50->40%\\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\\n not given\\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\\n contrast (unable to obtain peripheral access). However, there is no\\n change in size of multiple regions of consolidation bilaterally.\\n Further, there is no change in distribution and appearance of\\n air-bronchograms that would suggest a change in the underlying\\n consolidation, or the presence of a new space-occupying lesion.\\n Persistent pleural effusions\\n -RUQ U/S done\\n -spoke to his wife about how mr. was doing. She was very\\n anxious.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Linezolid - 12:35 PM\\n Cefipime - 06:56 PM\\n Nafcillin - 10:32 PM\\n Infusions:\\n Midazolam (Versed) - 5 mg/hour\\n Fentanyl - 100 mcg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 04:44 PM\\n Fentanyl - 10:51 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.6\\nC (101.4\\n Tcurrent: 36.6\\nC (97.8\\n HR: 88 (77 - 107) bpm\\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\\n RR: 24 (20 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 18 (10 - 24)mmHg\\n Total In:\\n 5,336 mL\\n 499 mL\\n PO:\\n TF:\\n IVF:\\n 3,176 mL\\n 170 mL\\n Blood products:\\n Total out:\\n 1,400 mL\\n 620 mL\\n Urine:\\n 1,400 mL\\n 620 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,936 mL\\n -121 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 400 (400 - 400) mL\\n Vt (Spontaneous): 652 (652 - 652) mL\\n RR (Set): 20\\n RR (Spontaneous): 1\\n PEEP: 8 cmH2O\\n FiO2: 40%\\n RSBI: 47\\n PIP: 22 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 40 cmH2O/mL\\n SpO2: 96%\\n ABG: ///25/\\n Ve: 9.1 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 623 K/uL\\n 7.7 g/dL\\n 131 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 23 mg/dL\\n 102 mEq/L\\n 134 mEq/L\\n 23.9 %\\n 25.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n Plt\\n 293\\n 334\\n 439\\n \\n Cr\\n 0.9\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n TCO2\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n 118\\n 151\\n 131\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\\n and oxygenation stable on AC settings. He is on day 8 of\\n antimicrobial therapy with cefepime, he received six days of\\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\\n was stopped and nafcillin started (now day 4) after his staph was\\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\\n re-expansion after the procedure, suggesting that it is freely\\n flowing. FiO2 40% from 50%.\\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\\n instead of ARDS so will attempt PS today\\n - Has completed course of oseltamavir\\n - continue nafcillin but can d/c cefepime considering no clear source\\n of GNR infection\\n - F/U cultures\\n - diuresis with lasix drip today to decrease total body fluid and\\n maximize chance of successful extubation\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\\n drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin and saline nasal washes for sinus disease\\n - Continue nafcillin\\n - consider pulling central line, particularly if any blood cx are\\n positive\\n - F/U cultures and culture if spikes\\n - F/U ID reccs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Attempted to place\\n Duboff in post-pyloric position but appears to remain in the stomach\\n despite raglan and mechanical manipulation. Will consult radiology\\n regarding advancing tube.\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU until respiratory status improves\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:54 PM 42 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: hep sc, PPI\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\\n c/b MSSA pneumonia. CT chest\\n Exam notable for Tm 101.4 BP 118/58 HR 90 RR 24 with sat 96 on 400x24\\n 0.4 PEEP 8. Rash on anterior chest. Labs notable for WBC 25K, HCT 23,\\n K+ 3.6, Cr 0.8. CT with dependent ASD, effusions.\\n Agree with plan to transition to PSV and initiate gentle diuresis with\\n lasix gtt while weaning sedation. Will d/c cefepime and continue naf\\n for now. Will check cultures, diff, eos, amylase and lipase for ongoing\\n fevers. +BM, will continue TPN and d/w IR re advancing Doboff. Case d/w\\n wife and PCP in detail x50min. Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 100 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:38 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659206,\n \"text\": \"Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Patient with CAP and know influenza B, currently being treated with\\n Nafcillin MSSA growth. Did suffer hypoxic respiratory failure on\\n this admission with subsequent intubation.\\n Action:\\n Remains mechanically ventilated on PS 5/5 with sedation of fent/midaz\\n at 50mg and 2mg respectively. Sedation has been weaned from fent/midaz\\n 75/3 to previously mentioned settings. Suctioned for small amount of\\n thick pale yellow secretions with strong cough. He is s/p thoracentesis\\n with exudative effusion and lung re-expansion.\\n Response:\\n Tolerating vent settings well and will probably be extubated this am.\\n Remains afebrile during shift, WBC trending down slowly now 23.6.\\n Plan:\\n Continue with antibiotic management as ordered f/u labs and cultures.\\n Has been NPO since midnight Tube feeding off as ordered. TPN in\\n progress. Does have a h/s of NHL with esophageal strictures so Dobhuff\\n was placed on \\n Started on diamox for metabolic alkalosis. Now s/p Lasix infusion for\\n fluid excess more than 9l. Infusion stopped yesterday eventing with\\n patient maintaining CVP greater than 14mmHg throughout the shift. No\\n further diuresing done overnight, has maintained adequate urinary\\n output.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659682,\n \"text\": \"Chief Complaint: s/p resp failure\\n 24 Hour Events:\\n PICC LINE - START 09:29 PM\\n MULTI LUMEN - STOP 06:00 AM\\n -PICC placed and IJ d'c'd\\n -KUB checked to evaluate dobhoff\\n -speech and swallow bedside eval passed with pt cleared to take thin\\n liquids and MOIST soft solids.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientCefepime\\n Rash;\\n Last dose of Antibiotics:\\n Nafcillin - 04:55 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 03:42 PM\\n Lorazepam (Ativan) - 01:10 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\\n occassional nausea. Tolerated dinner last night well.\\n Flowsheet Data as of 07:23 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (99\\n Tcurrent: 37\\nC (98.6\\n HR: 93 (92 - 109) bpm\\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\\n RR: 26 (22 - 36) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 14 (11 - 15)mmHg\\n Total In:\\n 1,693 mL\\n 243 mL\\n PO:\\n 960 mL\\n TF:\\n 83 mL\\n 72 mL\\n IVF:\\n 590 mL\\n 172 mL\\n Blood products:\\n Total out:\\n 3,330 mL\\n 800 mL\\n Urine:\\n 3,330 mL\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,637 mL\\n -557 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: 7.48/31/74/23/0\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n at left base )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 948 K/uL\\n 8.2 g/dL\\n 113 mg/dL\\n 1.0 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 17 mg/dL\\n 105 mEq/L\\n 136 mEq/L\\n 25.3 %\\n 20.4 K/uL\\n [image002.jpg]\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n 08:09 AM\\n 03:27 AM\\n WBC\\n 26.7\\n 23.6\\n 22.0\\n 20.4\\n Hct\\n 23.9\\n 24.7\\n 24.5\\n 25.3\\n Plt\\n 48\\n Cr\\n 0.7\\n 0.8\\n 0.8\\n 1.0\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n 24\\n Glucose\\n 144\\n 135\\n 128\\n 115\\n 113\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\\n mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. Successfully extubated \\n - Has completed course of oseltamavir\\n - continue nafcillin - plan for 21 D course today abx from when\\n linezolid was started \\n -monitor diuresis and consider bolus lasix PRN.\\n - speech and swallow eval today\\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\\n consider fentanyl or ativan PRN\\n -Incentive spirometry,\\n -PT today and OOB to chair\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam. WBC now trending down to 22\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 21 D course\\n -pull CVL today if can get PICC\\n - F/U ID recs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Getting s/s today. If passes, d/c TF\\n #) Access: 2 PIVs; right IJ\\n trying to get PICC today\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now- consider PM c/o\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n PICC Line - 09:29 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 659712,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n CNS: Remains alert and oriented x3 and can get out of bed with the\\n assist of persons. Complained that he was having difficulty\\n sleeping and was given a one time dose of lorazepam 1mg IV with good\\n effect.\\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\\n seeing that he has been aggressively Diuresed. Has maintained\\n normotensive blood pressures ranging SBP 110\\n 130\\ns. Right double\\n lumen basilic PICC placed yesterday evening and OK for use. Central\\n line D/c\\nd this am without difficulty and occlusive dsg to site at\\n present.\\n RESP: Continues on 3l/min with sats in the mid to upper 90\\ns. Denies\\n any SOB or DOE. LS clear with minimally diminished bases.\\n GU: Remains with urinary catheter and with good output. See flow chart\\n for numbers.\\n GI: Dobhoff fdg tube clooged this am without successful attempts to\\n unclog with sodium bicarb and viokase. Pt tolerating heart healthy soft\\n moist diet with good appetite. Will crush pt\\ns pills and administer\\n with pureed ood such as applesauce. Will follow pt\\ns nutritionl intake\\n and if poor will reinsert dobhoff fdgtube for nutritional support\\n Demographics\\n Attending MD:\\n F.\\n Admit diagnosis:\\n FEVER\\n Code status:\\n Full code\\n Height:\\n 71 Inch\\n Admission weight:\\n 71 kg\\n Daily weight:\\n Allergies/Reactions:\\n Cefepime\\n Rash;\\n Precautions: Droplet\\n PMH:\\n CV-PMH:\\n Additional history: pericarditis, pericardial effusion,myelodysplasia.\\n GERD, high cholestrol,hypothyroidism\\n Surgery / Procedure and date: s/p BMT in for myelodysplasia\\n s/p splenectomy in \\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:131\\n D:68\\n Temperature:\\n 98.8\\n Arterial BP:\\n S:99\\n D:62\\n Respiratory rate:\\n 34 insp/min\\n Heart Rate:\\n 102 bpm\\n Heart rhythm:\\n ST (Sinus Tachycardia)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 94% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 303 mL\\n 24h total out:\\n 980 mL\\n Pertinent Lab Results:\\n Sodium:\\n 136 mEq/L\\n 03:27 AM\\n Potassium:\\n 4.2 mEq/L\\n 03:27 AM\\n Chloride:\\n 105 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 17 mg/dL\\n 03:27 AM\\n Creatinine:\\n 1.0 mg/dL\\n 03:27 AM\\n Glucose:\\n 113 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 25.3 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 144\\n 06:00 PM\\n Valuables / Signature\\n Patient valuables: blackberry\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: no\\n Transferred from: 410\\n Transferred to: 1165 \\n Date & time of Transfer: \\n INTEG: Skin remains unremarkable at this time.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659713,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n CNS: Remains alert and oriented x3 and can get out of bed with the\\n assist of persons. Complained that he was having difficulty\\n sleeping and was given a one time dose of lorazepam 1mg IV with good\\n effect.\\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\\n seeing that he has been aggressively Diuresed. Has maintained\\n normotensive blood pressures ranging SBP 110\\n 130\\ns. Right double\\n lumen basilic PICC placed yesterday evening and OK for use. Central\\n line D/c\\nd this am without difficulty and occlusive dsg to site at\\n present.\\n RESP: Continues on 3l/min with sats in the mid to upper 90\\ns. Denies\\n any SOB or DOE. LS clear with minimally diminished bases.\\n GU: Remains with urinary catheter and with good output. See flow chart\\n for numbers.\\n GI: Dobhoff fdg tube clooged this am without successful attempts to\\n unclog with sodium bicarb and viokase. Pt tolerating heart healthy soft\\n moist diet with good appetite. Will crush pt\\ns pills and administer\\n with pureed ood such as applesauce. Will follow pt\\ns nutritionl intake\\n and if poor will reinsert dobhoff fdgtube for nutritional support\\n Demographics\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 658858,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Bronchial\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment: Vigorous inspiratory efforts, Frequent alarms\\n (High rate, High min. ventilation)\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Reduce PEEP as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n CT\\n 1730\\n no complications\\n Bedside Procedures:\\n Comments:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2181-02-05 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 658921,\n \"text\": \"Objective\\n Pertinent medications: Noted.\\n Labs:\\n Value\\n Date\\n Glucose\\n 131 mg/dL\\n 04:17 AM\\n BUN\\n 23 mg/dL\\n 04:17 AM\\n Creatinine\\n 0.8 mg/dL\\n 04:17 AM\\n Sodium\\n 134 mEq/L\\n 04:17 AM\\n Potassium\\n 3.6 mEq/L\\n 04:17 AM\\n Chloride\\n 102 mEq/L\\n 04:17 AM\\n TCO2\\n 25 mEq/L\\n 04:17 AM\\n PO2 (arterial)\\n 76. mm Hg\\n 12:05 PM\\n PCO2 (arterial)\\n 40 mm Hg\\n 12:05 PM\\n pH (arterial)\\n 7.44 units\\n 12:05 PM\\n pH (urine)\\n 6.0 units\\n 09:54 PM\\n CO2 (Calc) arterial\\n 28 mEq/L\\n 12:05 PM\\n Albumin\\n 2.4 g/dL\\n 03:19 AM\\n Calcium non-ionized\\n 7.5 mg/dL\\n 04:17 AM\\n Phosphorus\\n 2.7 mg/dL\\n 04:17 AM\\n Magnesium\\n 2.4 mg/dL\\n 04:17 AM\\n ALT\\n 57 IU/L\\n 04:17 AM\\n Alkaline Phosphate\\n 276 IU/L\\n 04:17 AM\\n AST\\n 47 IU/L\\n 04:17 AM\\n Total Bilirubin\\n 0.5 mg/dL\\n 04:17 AM\\n WBC\\n 25.6 K/uL\\n 04:17 AM\\n Hgb\\n 7.7 g/dL\\n 04:17 AM\\n Hematocrit\\n 23.9 %\\n 04:17 AM\\n Current diet order / nutrition support: NPO/TPN: Day /Starter STD w/\\n nonstd lytes ()\\n Assessment of Nutritional Status\\n Specifics:\\n On TPN now d/t aspiration event & inability to advance dobhoff as PPFT\\n pending IR c/s for placement. ? if patient with an obstruction or a\\n stricture at lower stomach. Please check triglyceride as lipids in TPN\\n is contraindicated if >400mg/dl. Start RISS to assess glucose\\n tolerance.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Consider KUB to R/O obstruction\\n 2. TPN today: 1500mL(200g Dex/105g AA/35g Fat) with nonstd lytes\\n in mEq: 50 NaCl, 55 NaPO4, 30 KCl, 30 KAc, 5 MgSO4, 10 CaGlu, 15 units\\n insulin.\\n 3. Start RISS; check FSBG Q 6hrs\\n 4. Check Triglycerides with am labs\\n 5. check chem. 10 daily\\n 6. Advance toward goal TPN per FSBG: Goal TPN: 1750mL(298g\\n Dex/105g AA/35g Fat)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659300,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt initially intubated for hypoxic resp failure. Has known influenza\\n bas well as a secondary bacterial pneumonia from staph aureus in\\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\\n for mssa that grew . thoracentesis to r lung shwed exudative\\n effusion and lung re-expansion after procedure.tolerated spontaneous\\n breathing trial after aggressive diuresis initially with lasix gtt and\\n then with diamox. Post extubation pt c/o nausea.pt has been on\\n fentanyul/versed gtts for > 1 week and concern is that pt may be\\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\\n with rhonchi bil on auscultation and crackles at the bases.\\n Action:\\n Fluid balance followed closely. Pt extubated this am and then able to\\n be weaned to 4l/m nc. Diamox d/c\\nd. pt medicated with 4 mg iv zofran\\n with no relief. Was then given 10 mg ivp compazine with no effect. With\\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Reps\\n status monitored closely. Pt kept npo for now in the setting of\\n continued nausea but will have speech and swallow study in the am if\\n stable overnoc from resp standpoint.\\n Response:\\n Successful extubation with pt tolerating minimal amts of supplemental\\n o2. pt still having adequate hourly uo off lasix and Fentanyl gtts.\\n Pt\\ns flid alnce neg 1.7 liters for 23 hrs but still overall positive\\n for los.\\n Plan:\\n Continue to follow fluid balance and bolus with lasix as needed.\\n Continue to monitor resp status closely and if pt has increasing resp\\n distress notify medical team. Administer nafcillin as ordered.\\n Continue to moitor fro signs if narcotic/benzo withdrawal and medicate\\n with ativan and Fentanyl as needed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659545,\n \"text\": \"Chief Complaint: PNA, s/p resp failure\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 10:10 AM\\n ARTERIAL LINE - STOP 04:00 PM\\n -extubated in a.m. and did well\\n -was c/o nausea intermittently -> concerning for opiate or benzo\\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\\n iv prn.\\n Allergies:\\n Cefepime\\n Rash;\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:32 AM\\n Infusions:\\n Other ICU medications:\\n Midazolam (Versed) - 07:45 AM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Lorazepam (Ativan) - 01:30 AM\\n Fentanyl - 01:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 35.9\\nC (96.7\\n HR: 94 (91 - 114) bpm\\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\\n RR: 24 (14 - 40) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (12 - 18)mmHg\\n Total In:\\n 1,308 mL\\n 288 mL\\n PO:\\n TF:\\n 13 mL\\n IVF:\\n 547 mL\\n 228 mL\\n Blood products:\\n Total out:\\n 5,035 mL\\n 1,100 mL\\n Urine:\\n 5,035 mL\\n 1,100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,727 mL\\n -813 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: PSV/SBT\\n Vt (Spontaneous): 730 (730 - 730) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 0 cmH2O\\n FiO2: 50%\\n SpO2: 96%\\n ABG: ///23/\\n Ve: 12.1 L/min\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: crackles :\\n L >R base)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 896 K/uL\\n 7.7 g/dL\\n 115 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.5 mEq/L\\n 21 mg/dL\\n 103 mEq/L\\n 136 mEq/L\\n 24.5 %\\n 22.0 K/uL\\n [image002.jpg]\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n 04:20 AM\\n WBC\\n 24.7\\n 25.6\\n 26.7\\n 23.6\\n 22.0\\n Hct\\n 24.9\\n 23.9\\n 23.9\\n 24.7\\n 24.5\\n Plt\\n 81\\n 896\\n Cr\\n 1.0\\n 0.8\\n 0.7\\n 0.8\\n 0.8\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n Glucose\\n 151\\n 131\\n 144\\n 135\\n 128\\n 115\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. Successfully extubated \\n - Has completed course of oseltamavir\\n - continue nafcillin - plan for 21 D course today abx from when\\n linezolid was started \\n -monitor diuresis and consider bolus lasix PRN.\\n - speech and swallow eval today\\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\\n consider fentanyl or ativan PRN\\n -Incentive spirometry,\\n -PT today and OOB to chair\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam. WBC now trending down to 22\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 21 D course\\n -pull CVL today if can get PICC\\n - F/U ID recs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Getting s/s today. If passes, d/c TF\\n #) Access: 2 PIVs; right IJ\\n trying to get PICC today\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now- consider PM c/o\\n #) Comm: With wife\\n ICU \\n Nutrition: diet pending speech and swallow eval today\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor possibly in afternoon\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659550,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 659194,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 10\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 25 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: plan to extubate in am\\n Comments: rsbi 71\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659045,\n \"text\": \"Chief Complaint: resp failure\\n 24 Hour Events:\\n Family meeting with Dr. and re: pt's course and\\n prognosis. Very helpful for wife to hear positive steps we are taking\\n with him.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:23 PM\\n Infusions:\\n Furosemide (Lasix) - 2 mg/hour\\n Midazolam (Versed) - 4 mg/hour\\n Fentanyl - 75 mcg/hour\\n Other ICU medications:\\n Fentanyl - 03:22 PM\\n Lansoprazole (Prevacid) - 07:44 AM\\n Heparin Sodium (Prophylaxis) - 07:44 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: pt denies Pain, nausea. States has some mild SOB\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.7\\nC (98.1\\n HR: 88 (85 - 121) bpm\\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\\n RR: 19 (19 - 35) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 8 (6 - 22)mmHg\\n Total In:\\n 1,897 mL\\n 512 mL\\n PO:\\n TF:\\n IVF:\\n 889 mL\\n 184 mL\\n Blood products:\\n Total out:\\n 4,615 mL\\n 1,810 mL\\n Urine:\\n 4,615 mL\\n 1,810 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,718 mL\\n -1,298 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 388 (347 - 453) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 74\\n PIP: 11 cmH2O\\n SpO2: 100%\\n ABG: 7.44/40/76./31/2\\n Ve: 7.5 L/min\\n PaO2 / FiO2: 190\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n slight at bases)\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 714 K/uL\\n 7.8 g/dL\\n 144 mg/dL\\n 0.7 mg/dL\\n 31 mEq/L\\n 3.6 mEq/L\\n 17 mg/dL\\n 98 mEq/L\\n 136 mEq/L\\n 23.9 %\\n 26.7 K/uL\\n [image002.jpg]\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n WBC\\n 20.4\\n 19.2\\n 22.4\\n 24.7\\n 25.6\\n 26.7\\n Hct\\n 26.6\\n 26.3\\n 24.7\\n 24.9\\n 23.9\\n 23.9\\n Plt\\n \\n Cr\\n 0.8\\n 0.9\\n 0.8\\n 1.0\\n 0.8\\n 0.7\\n TCO2\\n 25\\n 28\\n 28\\n 28\\n Glucose\\n 112\\n 149\\n 118\\n 151\\n 131\\n 144\\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\\n and oxygenation stable on AC settings. He is on day 8 of\\n antimicrobial therapy with cefepime, he received six days of\\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\\n was stopped and nafcillin started (now day 4) after his staph was\\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\\n re-expansion after the procedure, suggesting that it is freely\\n flowing. FiO2 40% from 50%.\\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\\n instead of ARDS so will attempt PS today\\n - Has completed course of oseltamavir\\n - continue nafcillin but can d/c cefepime considering no clear source\\n of GNR infection\\n - F/U cultures\\n - diuresis with lasix drip today to decrease total body fluid and\\n maximize chance of successful extubation\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\\n drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin and saline nasal washes for sinus disease\\n - Continue nafcillin\\n - consider pulling central line, particularly if any blood cx are\\n positive\\n - F/U cultures and culture if spikes\\n - F/U ID reccs\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to reveal\\n a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Attempted to place\\n Duboff in post-pyloric position but appears to remain in the stomach\\n despite raglan and mechanical manipulation. Will consult radiology\\n regarding advancing tube.\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU until respiratory status improves\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:42 PM 42 mL/hour\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659295,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt initially intubated for hypoxic resp failure. Has known influenza\\n bas well as a secondary bacterial pneumonia from staph aureus in\\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\\n for mssa that grew . thoracentesis to r lung shwed exudative\\n effusion and lung re-expansion after procedure.tolerated spontaneous\\n breathing trial after aggressive diuresis initially with lasix gtt and\\n then with diamox. Post extubation pt c/o nausea\\n Action:\\n Fluid balance followed closely. Pt extubated this am and then able to\\n be weaned to 4l/m nc. Diamox d/c\\nd. pt medicated with 4 mg iv zofran.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659297,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt initially intubated for hypoxic resp failure. Has known influenza\\n bas well as a secondary bacterial pneumonia from staph aureus in\\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\\n for mssa that grew . thoracentesis to r lung shwed exudative\\n effusion and lung re-expansion after procedure.tolerated spontaneous\\n breathing trial after aggressive diuresis initially with lasix gtt and\\n then with diamox. Post extubation pt c/o nausea.pt has been on\\n fentanyul/versed gtts for > 1 week and concern is that pt may be\\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\\n with rhonchi bil on auscultation and crackles at the bases.\\n Action:\\n Fluid balance followed closely. Pt extubated this am and then able to\\n be weaned to 4l/m nc. Diamox d/c\\nd. pt medicated with 4 mg iv zofran\\n with no relief. Was then given 10 mg ivp compazine with no effect. With\\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Reps\\n status monitored closely. Pt kept npo for now in the setting of\\n continued nausea but will have speech and swallow study in the am if\\n stable overnoc from resp standpoint.\\n Response:\\n Successful extubation with pt toleratinf min\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658419,\n \"text\": \"Chief Complaint: Hypoxia/ARDS\\n 24 Hour Events:\\n FEVER - 102.5\\nF - 12:00 PM\\n -put back on Levo in afternoon hypotension then weaned back in\\n evening - on 0.1 at 9p\\n - ID consulted- d/c azithro and flagyl. ? Rpt Chest CT possibly in a\\n couple days. Still on linezolid, cefepime, tamiflu, course still to be\\n determined\\n - TF were started per nutrition recs\\n -d/c statin elevated LFTs\\n -lipase 13\\n -f/u on RUQ u/s - prelims are mildly distended gallbladder with sludge,\\n no secondary signs of cholecystitis, no ductal dilation, right pleural\\n effusion\\n -bowel regimen ordered\\n -EKG and pulsus checked - no sign of pericardial disease - no TTE\\n -Vent on PS with FiO2 50%\\n -Fungal Blood culture ordered\\n - BNP 574\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 10:00 AM\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 11:01 PM\\n Cefipime - 04:50 AM\\n Infusions:\\n Fentanyl - 50 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Norepinephrine - 0.02 mcg/Kg/min\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:09 AM\\n Heparin Sodium (Prophylaxis) - 11:02 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 39.2\\nC (102.5\\n Tcurrent: 37.7\\nC (99.8\\n HR: 92 (75 - 106) bpm\\n BP: 111/49(67) {89/45(60) - 172/88(118)} mmHg\\n RR: 23 (15 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 12 (4 - 14)mmHg\\n Total In:\\n 2,942 mL\\n 487 mL\\n PO:\\n TF:\\n 167 mL\\n 246 mL\\n IVF:\\n 2,445 mL\\n 241 mL\\n Blood products:\\n Total out:\\n 1,615 mL\\n 440 mL\\n Urine:\\n 1,615 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,327 mL\\n 47 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 465 (435 - 465) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 76\\n PIP: 19 cmH2O\\n SpO2: 99%\\n ABG: 7.38/40/94./24/0\\n Ve: 8.7 L/min\\n PaO2 / FiO2: 188\\n Physical Examination\\n General Appearance: Thin, appears unwell\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : , Crackles : scattered)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 334 K/uL\\n 8.8 g/dL\\n 112 mg/dL\\n 0.8 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 103 mEq/L\\n 133 mEq/L\\n 26.6 %\\n 20.4 K/uL\\n [image002.jpg]\\n 03:08 PM\\n 11:32 PM\\n 03:19 AM\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n WBC\\n 12.3\\n 15.8\\n 20.4\\n Hct\\n 28.9\\n 28.1\\n 26.6\\n Plt\\n \\n Cr\\n 1.0\\n 0.9\\n 0.8\\n TCO2\\n 24\\n 21\\n 25\\n 23\\n 24\\n 23\\n 25\\n Glucose\\n 96\\n 122\\n 112\\n Other labs: PT / PTT / INR:13.5/35.5/1.2, ALT / AST:67/64, Alk Phos / T\\n Bili:381/0.9, Amylase / Lipase:/13, Differential-Neuts:85.9 %,\\n Lymph:5.3 %, Mono:8.1 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\\n RUQ U/S: Sludge but no pericholeycystic fluid.\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\\n to infectious process/ ARDS. Patient with known influenza and with\\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\\n likely flu but given staph aureus in respiratory culture there is\\n evidence for bacterial superinfection. He is continuing to maintain\\n good ventilation and adequate oxygenation on pressure support.\\n Potentially concerning to allow ARDS patient off protocol due to\\n ability to exceed low lung volumes but he seems more comfortable on PS\\n and tidal volumes are relatively low (450-475) decreasing concern for\\n barotrauma.\\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\\n -F/U cultures\\n - Continue oseltamavir for influenza B\\n 2) SIRS/ Hypotension/Fevers: This patient\\ns fever is not as concerning\\n in and of itself given influenza can often cause persistent fever.\\n Still, with persistent white count and his leukocytosis recurring it is\\n very concerning that we are not adequately covering an infectious\\n process. Blood cultures remain negative and RUQ U/S not suggestive of\\n choleycystitis. Major concern now if for a drainable collection as his\\n broad spectrum antibiotics should cover most common organisms.\\n -Continue current antimicrobial regimen\\n -CT scan of torso and sinuses looking for possible closed space\\n infection and to better evaluate possible effusions vs atelectasis in\\n lungs\\n -Echo to evaluate for other causes of hypotension give patient has hx\\n of pericarditis and could potentially have some restrictive pathology\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE per above\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: NPO for now, given potential for prolonged intubation will\\n initiate nutrtition consult to start tube feeds\\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\\n appropriately sited on follow up scans)\\n 7) PPx: hep sc, ppi as outpt\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n ICU \\n Nutrition:\\n Replete with Fiber (Full) - 04:15 AM 40 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 06:27 AM\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SC heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, mouth care\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659035,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Remained afebrile overnight. LS clear throughout conts on Nafcillian,\\n he has developed a rash on his abd and back, he has yellow sputum from\\n his ETT and a lg amount of secretions from the back of his throat. He\\n is more alert today, writing, though somewhat illegibly, able to tell\\n us some of his needs. He is 13 liters pos.\\n Action:\\n Placed on PSV 5 PEEP 8, his PEEP was decreased to 5 last evening,\\n started on a lasix gtt secondary to positive fluid status. Continues on\\n sedation fent/midaz at 75mg and 4mg respectively.\\n Response:\\n Tolerating the PSV with any distress overnight. Diuresing well on lasix\\n gtt at 2mg/hr, his CVP is 14-16mmHgand maintaing SBP greater than 120\\n throughout. Unable to tell whether rash has gotten any worse since I\\n have nothing to compare with. However, it is diffuse.\\n Plan:\\n Cont with the lasix gtt as his BP and CVP allow, follow his lytes,\\n follow his rash\\n there is concern that the rash is from the nafacillin\\n but this is a good antibiotic for his staph pneumonia, cont to wean the\\n fent and versed.\\n Went to radiology in afternoon of a NG tube in his\\n jejunum. Order for TF written, however unable to start feed last pm\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659188,\n \"text\": \"Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Patient with CAP and know influenza B, currently being treated with\\n Nafcillin MSSA growth. Did suffer hypoxic respiratory failure on\\n this admission with subsequent intubation.\\n Action:\\n Remains mechanically ventilated on PS 5/5 with sedation of fent/midaz\\n at 50mg and 2mg respectively. Sedation has been weaned from fent/midaz\\n 75/3 to previously mentioned settings. Suctioned for small amount of\\n thick pale yellow secretions with strong cough. He is s/p thoracentesis\\n with exudative effusion and lung re-expansion.\\n Response:\\n Tolerating vent settings well and will probably be extubated this am.\\n Remains afebrile during shift, WBC trending down slowly now 23.6.\\n Plan:\\n Continue with antibiotic management as ordered f/u labs and cultures.\\n Has been NPO since midnight Tube feeding off as ordered. TPN in\\n progress. Does have a h/s of NHL with esophageal strictures so Dobhuff\\n was placed on \\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658327,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Events:\\n No growth to date on BCs, sputum or urine cultures\\n Multiple vent changes made currently on\\nARDS net\\n settings\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt. spiked temp again yesterday, however, has continued with low-grade\\n temp throughout this shift. No growth to date in all BCs, urine and\\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\\n weaned throughout the shift. Was able to wean gtt off for most of shift\\n but BP slowly dropped. Back on at 0400.\\n Action:\\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\\n Levophed gtt on to maintain MAP >60.\\n Response:\\n Pt. remains with low-grade temp. SBP high 90\\ns to 130\\ns. Good UO.\\n Plan:\\n Monitor hemodynamic status and support as necessary w/ pressor and\\n volume. Continue antibiotics as ordered/\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\\n secretions. Remains on vent. CPAP 50%/. Last gas 7.38/40/94. Sats\\n >97%. Sedated on fent/versed.\\n Action:\\n Pt. kept on CPAP as pts own rate and volumes coincide w/ ARDS net\\n protocol. Suctioned Q4h and prn.\\n Response:\\n Pt. remains stable on these vent settings. Also appears comfortable on\\n sedation. Does arouse easily and nod head to questions asked.\\n Plan:\\n Cont to monitor resp status and wean vent support as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659137,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\\n remains intubated on low dose sedation, fentanyl and versed drips.\\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\\n following commands, writing on paper to communicate. T max 100.1po.\\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\\n abd and back appears improved micu md staff who saw this pt\\n yesterday.\\n Action:\\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\\n scant amts thick yellow sputum, small amts blood tinged sputum in back\\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\\n pending.\\n Response:\\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\\n extubated today. ett retaped and repositioned to left side of mouth at\\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\\n and versed drips restarted and titrated up to comfort but pt still\\n easily arousable and following commands. Continues to diurese well\\n approx 3.9 liters negative since mn. 7 liters + los. Cvp approx .\\n Plan:\\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\\n around 4. Follow up with 5pm lab results and replete lytes prn.\\n Continue to monitor rash on abd and back.\\n Sepsis without organ dysfunction\\n Assessment:\\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\\n Also + influenza.\\n Action:\\n Continues with iv nafcillin\\n Response:\\n Remains with low grade temp, currently afebrile.\\n Plan:\\n Continue nafcillin, follow up with bld culture results. Monitor temps.\\n Social: pt\\ns wife up to visit pt in late am and most of day.pt\\ns wife\\n spoke with Dr. re: pt\\ns update and plan of care. Pt\\ns twin sons\\n and also visited in the early evening. Pt\\ns requested\\n to also speak with Dr. for an update. Dr. spoke to them\\n to give them an update, but they requested an update from Dr. .\\n Dr. paged Dr. and plan is for Dr. to speak to pt\\n later this evening after 7:30pm. Wife and are visiting\\n in room and waiting room. social worker has been following wife\\n and pt for support and spoke to them yesterday. Wife declined need to\\n speak to today. continue to provide emotional support to\\n pt/family prn.\\n ------ Protected Section ------\\n Pt receiving tpn via tlcl and tube feedings replete with fiber via\\n dobhoff ngtube confirmed to be postpyloric by radiology yesterday\\n . tube feeding started at 14:30 at 10cc/hr and increased to\\n 20cc/hr at 18:30. continue to increase rate by 10ml q4hr. stop feedings\\n in am in prep for possible extubation tomorrow.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 18:27 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659293,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 659265,\n \"text\": \"Chief Complaint: resp failure\\n 24 Hour Events:\\n - pt failed. ABG 7.52/41/64\\n -resumed TF until midnight.\\n -lasix gtt turned off in afternoon as CVP down to 4\\n - diamox TID started\\n -KCL repleted\\n -TPN reordered\\n -Afrin d/c'd\\n -added cefepime to allergy list given rash\\n - plan for extubation during rounds in am. Respiratory aware.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientCefepime\\n Rash;\\n Last dose of Antibiotics:\\n Cefipime - 08:30 AM\\n Nafcillin - 04:15 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 07:44 AM\\n Heparin Sodium (Prophylaxis) - 03:46 PM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Pt very anxious having trouble breathing with ?\\n muscous plug this am. Denies pain.\\n Flowsheet Data as of 07:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.1\\nC (98.8\\n HR: 104 (81 - 116) bpm\\n BP: 148/70(98) {99/49(65) - 175/86(117)} mmHg\\n RR: 22 (18 - 31) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 19 (4 - 19)mmHg\\n Total In:\\n 2,153 mL\\n 522 mL\\n PO:\\n TF:\\n 150 mL\\n 13 mL\\n IVF:\\n 979 mL\\n 207 mL\\n Blood products:\\n Total out:\\n 6,100 mL\\n 1,255 mL\\n Urine:\\n 6,100 mL\\n 1,255 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,947 mL\\n -733 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 711 (289 - 711) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 71\\n PIP: 11 cmH2O\\n SpO2: 96%\\n ABG: 7.42/36/60/24/0\\n Ve: 14.4 L/min\\n PaO2 / FiO2: 150\\n Physical Examination\\n General Appearance: Thin, Anxious\\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Trace, Left: Trace\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\\n Labs / Radiology\\n 781 K/uL\\n 7.9 g/dL\\n 128 mg/dL\\n 0.8 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 20 mg/dL\\n 101 mEq/L\\n 133 mEq/L\\n 24.7 %\\n 23.6 K/uL\\n [image002.jpg]\\n 04:29 AM\\n 02:36 AM\\n 04:17 AM\\n 12:05 PM\\n 03:05 AM\\n 08:23 AM\\n 12:58 PM\\n 04:13 PM\\n 02:50 AM\\n 06:12 AM\\n WBC\\n 22.4\\n 24.7\\n 25.6\\n 26.7\\n 23.6\\n Hct\\n 24.7\\n 24.9\\n 23.9\\n 23.9\\n 24.7\\n Plt\\n 14\\n 781\\n Cr\\n 0.8\\n 1.0\\n 0.8\\n 0.7\\n 0.8\\n 0.8\\n TCO2\\n 28\\n 31\\n 35\\n 24\\n Glucose\\n 118\\n 151\\n 131\\n 144\\n 135\\n 128\\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:54/50, Alk Phos / T\\n Bili:299/0.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:233 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\\n aureus superinfections.\\n #) Hypoxic Respiratory failure: He was initially intubated for\\n hypoxic respiratory failure. Has known influenza B as well as\\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\\n changed to Nafcillin when MSSA grew . Thoracentesis showed\\n exudative effusion and lung re-expansion after the procedure,\\n suggesting that it is freely flowing. FiO2 40% and on PS 5/5 but\\n blood gas this noon 7.52/41/64. This am, did well on (although had\\n some mucous plugging around 7a).\\n - Has completed course of oseltamavir\\n - continue nafcillin day 6 today- plan for 14 D course\\n - F/U cultures\\n - extubate this am. Will start Incentive spirometry\\n -monitor diuresis and consider bolus lasix PRN. D/c diamox\\n -will need speech and swallow eval but will hold off until tomorrow\\n -of note, since pt has been on fent/versed for sedation for >1wk, may\\n have benzo withdrawl. Will consided valium or versed PRN\\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\\n also had known source of infection. No longer requiring pressors.\\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\\n a drainable abscess. The presumed etiology of his fevers is pneumonia\\n and possibly sinusitis vs cholecystitis, but no clear source on CT\\n torso and sinus. Repeated CT chest on but no evidence of abscess\\n on exam.\\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\\n disease\\n - Continue nafcillin for 14 D course\\n - consider pulling central line if any blood cx are positive. Keep now\\n for TPN. If stable tomorrow, will likely pull CVL.\\n - F/U cultures and culture if spikes\\n - F/U ID recs- they rec thoracentesis but do not think this is\\n medically necessary for now.\\n #) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Echo failed to\\n reveal a pericardial effusion.\\n #) Hypothyroidism: Continue home levothyroxine.\\n #) FEN: Pt with noted aspiration event on , presumably due to\\n history of irradiation and esophageal stricture. Has Doppoff in place\\n now. Will restart TF today after extubation. Cont TPN for today\\n #) Access: 2 PIVs; right IJ\\n #) PPx: hep sc, PPI\\n #) Dispo: ICU for now\\n #) Comm: With wife\\n ICU \\n Nutrition:\\n TPN without Lipids - 06:01 PM 42 mL/hour\\n Restart TF today after extubation\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659278,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658471,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Norepi shut off at 1800 last evening. Continues on Linezolid and\\n cefipime IV.\\n Pt remains intubated on low dose sedation, fent and versed drips.\\n Remained on AC overnight with the plan to switch to PSV in AM.\\n Plan for cardiac echo today. Pt may also go to IR for drainage of\\n pleural effusions.\\n Pt\\ns wife is contact person and has been updated by team overnight. She\\n wants to speak to Attending today before any invasive procedures are\\n done. Visitors are limited to a few people written on a paper at the\\n front desk. She was upset that his co-workers were let in to visit on\\n .\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 658556,\n \"text\": \"Chief Complaint: Respiratory failure, ARDS\\n 24 Hour Events:\\n - FEVER - 101.1\\nF - 09:00 PM\\n -OFF PRESSORS at 6:00 pm\\n -CT torso w/o abcess or drainable collection\\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\\n -Thoracentesis deferred as minimal fluid on echo\\n Patient unable to provide history: intubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Azithromycin - 08:56 PM\\n Metronidazole - 12:20 PM\\n Linezolid - 12:30 AM\\n Cefipime - 05:56 AM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.4\\nC (101.1\\n Tcurrent: 37.4\\nC (99.3\\n HR: 75 (75 - 117) bpm\\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\\n RR: 19 (16 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 71 Inch\\n CVP: 16 (13 - 334)mmHg\\n Total In:\\n 1,855 mL\\n 941 mL\\n PO:\\n TF:\\n 917 mL\\n 382 mL\\n IVF:\\n 878 mL\\n 514 mL\\n Blood products:\\n Total out:\\n 1,520 mL\\n 218 mL\\n Urine:\\n 1,520 mL\\n 218 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 335 mL\\n 723 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 400 (400 - 500) mL\\n Vt (Spontaneous): 370 (370 - 542) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 0\\n PEEP: 8 cmH2O\\n FiO2: 50%\\n RSBI: 100\\n PIP: 17 cmH2O\\n Plateau: 23 cmH2O\\n Compliance: 26.7 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.42/41/85./25/1\\n Ve: 8.9 L/min\\n PaO2 / FiO2: 170\\n Physical Examination\\n General Appearance: Thin\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : few)\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 439 K/uL\\n 8.3 g/dL\\n 149 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 19 mg/dL\\n 104 mEq/L\\n 133 mEq/L\\n 26.3 %\\n 19.2 K/uL\\n [image002.jpg]\\n 04:01 AM\\n 01:00 PM\\n 04:13 PM\\n 03:59 AM\\n 07:11 AM\\n 12:36 PM\\n 03:42 AM\\n 02:27 AM\\n 04:03 AM\\n 06:25 AM\\n WBC\\n 15.8\\n 20.4\\n 19.2\\n Hct\\n 28.1\\n 26.6\\n 26.3\\n Plt\\n 293\\n 334\\n 439\\n Cr\\n 0.9\\n 0.8\\n 0.9\\n TCO2\\n 25\\n 23\\n 24\\n 23\\n 25\\n 28\\n 28\\n Glucose\\n 122\\n 112\\n 149\\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL, ALT\\n 70*, AST 75*, AP 385*, LDH 176, T Bil 0.8\\n Imaging:\\n CT Torso:\\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\\n greater\\n than right, with scattered patchy opacities seen medially within the\\n upper lobes. Interval increase in bilateral pleural effusions, now\\n moderate.\\n 2. Prominence of the esophagus, which is diffusely filled with oral\\n contrast\\n material, consistent with extensive gastroesophageal reflux disease.\\n Given the degree of contrast reflux into the esophagus, which is\\n marked, the patient is felt to be a very high risk for aspiration.\\n 3. No acute inflammatory process or abnormal fluid collection is seen\\n in the\\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\\n fluid.\\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\\n Microbiology: Sputum:\\n : Culture with coag + staph\\n Gram stain (-)\\n : Culture preliminary negative, gram\\n stain (-)\\n Assessment and Plan\\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\\n worsening hypoxia and respiratory distress and CT concerning for\\n multilobar PNA.\\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\\n known influenza B as well as staph aureus in sputums. Presumably, flu\\n with bacterial superinfection is the etiology of his ARDS. The patient\\n was on AC overnight but was switched back to CPAP this AM. Since then,\\n he has been pulling lower tidal volumes than previously (<400) and more\\n tachypneic. We will place him back on AC to decrease work of breathing\\n while we continue to treat his pneumonia and support him through his\\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\\n and oseltamavir.\\n -F/U cultures, obtain viral cultures per ID recommendation\\n - Continue current antimicrobials pending culture data\\n -IP will attempt to perform diagnostic thoracentesis today as couldn\\n be done at bedside.\\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\\n space infection or a drainable abcess. The presumed etiology of his\\n fevers is pneumonia and possibly sinusitis though his\\n -Continue current antimicrobial regimen\\n -CT scan of torso and sinuses looking for possible closed space\\n infection and to better evaluate possible effusions vs atelectasis n\\n lungs\\n -Echo to evaluate for other causes of hypotension give patient has hx\\n of pericarditis and could potentially have some restrictive pathology\\n 3) Hx of Hodgkin\\ns Lymphoma/pericardial disease: Particularly given\\n current concern for effusion there is a possibility of post radiation\\n serositis in the chest or possibility of effusion.\\n -TTE per above\\n 4) Hypothyroidism: Continue home levothyroxine.\\n 5) FEN: NPO for now, given potential for prolonged intubation will\\n initiate nutrtition consult to start tube feeds\\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\\n appropriately sited on follow up scans)\\n 7) PPx: hep sc, ppi as outpt\\n 8 Code: FULL (confirmed with patient)\\n 8) Dispo: ICU until respiratory status improves\\n 9) Comm: With wife\\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 09:05 AM\\n Arterial Line - 09:30 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 659338,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 78 None\\n Ideal tidal volume: mL/kg\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Crackles\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Plug\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Comments: Pt extubated this shift to 50% cool aerosol with good cuff\\n leak noted. PT coughing and raising most secretions on own. Pt now\\n wearing 3L NC with spo2 99-100%. Incentive spirometer at bedside and\\n encouraged pt to use device every hr W/A. Will cont to follow as\\n needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 659341,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic respiratory failure, and is now being treated for\\n influenza and a probable PNA with SEPSIS.\\n Sputum growth to date positive for s. aureus. Pt also +influenza.\\n Pneumonia, bacterial, community acquired (CAP)\\n Assessment:\\n Pt initially intubated for hypoxic resp failure. Has known influenza\\n bas well as a secondary bacterial pneumonia from staph aureus in\\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\\n for mssa that grew . thoracentesis to r lung showed exudative\\n effusion and lung re-expansion after procedure. tolerated spontaneous\\n breathing trial after aggressive diuresis initially with lasix gtt and\\n then with diamox. Post extubation pt c/o nausea.pt had been on\\n fentanyul/versed gtts for > 1 week and concern is that pt may be\\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\\n with rhonchi bil on auscultation and crackles at the bases.\\n Action:\\n Fluid balance followed closely. Pt extubated this am and then able to\\n be weaned to 4l/m nc. Diamox d/c\\nd. pt medicated with 4 mg iv zofran\\n with no relief. Was then given 10 mg ivp compazine with no effect. With\\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Resp\\n status monitored closely. Pt kept npo for now in the setting of\\n continued nausea but will have speech and swallow study in the am if\\n stable overnoc from resp standpoint.\\n Response:\\n Successful extubation with pt tolerating minimal amts of supplemental\\n o2. pt still having adequate hourly uo off lasix gtt and diamox. Pt\\ns fluid balance neg 2.9 liters for 24 hrs but still overall positive\\n for los.\\n Plan:\\n Continue to follow fluid balance and bolus with lasix as needed.\\n Continue to monitor resp status closely and if pt has increasing resp\\n distress notify medical team. Administer nafcillin as ordered.\\n Continue to monitor for signs of narcotic/benzo withdrawal and\\n medicate with ativan and Fentanyl as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658317,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Events:\\n No growth to date on BCs, sputum or urine cultures\\n Multiple vent changes made currently on\\nARDS net\\n settings\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2181-02-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 658320,\n \"text\": \"53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\\n who presented w/ influenza B and worsening hypoxia. Intubated on\\n for hypoxic resp failure, and is now being treated for influenza\\n as well as a probable PNA with SEPSIS.\\n Events:\\n No growth to date on BCs, sputum or urine cultures\\n Multiple vent changes made currently on\\nARDS net\\n settings\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt. spiked temp again yesterday, however, has continued with low-grade\\n temp throughout this shift. No growth to date in all BCs, urine and\\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\\n weaned throughout the shift.\\n Action:\\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\\n Response:\\n Pt. remains with low-grade temp. Hemodynamically stable throughout\\n shift.\\n Plan:\\n Monitor hemodynamic status and support as necessary w/ pressor and\\n volume. Continue antibiotics as ordered/\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\\n secretions. Remains on vent. CPAP 50%/. Last gas 7.38/40/94. Sats\\n >97%. Sedated on fent/versed.\\n Action:\\n Pt. kept on CPAP as pts own rate and volumes coincide w/ ARDS net\\n protocol. Suctioned Q4h and prn.\\n Response:\\n Pt. remains stable on these vent settings. Also appears comfortable on\\n sedation. Does arouse easily and nod head to questions asked.\\n Plan:\\n Cont to monitor resp status and wean vent support as tolerated.\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2181-02-02 00:00:00.000\",\n \"description\": \"Social Work Admission Note\",\n \"row_id\": 658544,\n \"text\": \"Family Information\\n Next of : , (Wife)\\n Health Proxy appointed: Yes - But NO copy of signed proxy form in\\n medical record\\n Family Spokesperson designated: , (Wife) Phone:\\n ; Other Phone: \\n Communication or visitation restriction: Restriction on visitors. \\n wife has given nursing a list of people who can see him.\\n Patient Information:\\n Previous living situation: Home w/ others\\n Previous level of functioning: Independent\\n Previous or other hospital admissions: First admission; he\\n was last hospitalized in AZ approximately two years with what his wife\\n reports as similar symptoms.\\n Past psychiatric history: None known.\\n Past addictions history: None known.\\n Employment status: Employed\\n Legal involvement: None known.\\n Mandated Reporting Information:\\n Additional Information:\\n Patient / Family Assessment: This worker met with pt's wife in response\\n to RN concerns about her level of stress. Her 53 y/o husband was\\n admitted with what had initially been flu symptoms. Recently, one of\\n her 18 y/o twin sons had the flu is apparently concerned that he might\\n have caused his father's illness. At this time, they have not seen the\\n pt, nor does their mother want them to see him unless they are pushing\\n the\\n Clergy Contact:\\n Communication with Team:\\n Plan / Follow up:\\n\"\n }\n]"}}},{"rowIdx":24972,"cells":{"subject_id":{"kind":"number","value":9364,"string":"9,364"},"hadm_id":{"kind":"number","value":150732,"string":"150,732"},"target_text":{"kind":"string","value":"53 y/o male with ESLD due to Hep C/ETOH cirrhosis and HCC now with diuretic resistant ascites who presents for liver transplant. Of note he was called in several times previously over the last few weeks. He was taken to the OR on by Drs and who performed an orthotopic liver transplant with duct-to-duct anastomosis. The patient tolerated the procedure well and was transferred to the SICU, stable, intubated. He received protocol induction immunosuppression which included Solumedrol, and Cellcept, and started Prograf on pos op day 1. He was extubated on POD 1. In the post op period he required transfusion of 5 units RBCs and 3 units platelets. Over the course of the hospitalization the platelet count increased and the HCT remained stable. He was transferred out of the SICU on POD 3. evaluation of the liver revealed normal vasculature except the right hepatic artery. This was possibly a technical difficulty due to large abdominal size. A repeat U/S done on showed all patent vasculature including the RHA. There was some concern due to velocities in the main portal vein ranging from 109 to 149 cm/sec, which was similar to the previous study. An MR was initially suggestive of a Portal Vein stenosis and the patient was initiated on a heparin drip. Portal venography was performed on showing discrepancy in size between the native and donor portal veins with relative stenosis, but no significant pressure gradient across the anastomosis. No interventions were performed after discussion with Dr. . Drain Bili measured on was 8.1. The patient had one remaining JP at the time of this test which was putting out about 1-1.2 liters of ascitic fluid tinged with bile daily. Liver enzymes (AST and ALT) which had briefly elevated at the time of the portal venography trended back to normal. Alk phos remained slightly elevated in addition to serum bilirubin of 5.9. On , an ERCP was performed for concern for bile leak as the JP bili was 25.7. This revealed biliary narrowing at the site of duct to duct anastomosis. No extravasation of contrast was noted - high pressure cholangiogram was not obtained given recent transplant. A biliary sphincterotomy was performed and a biliary stent was inserted. Recommendations included repeating an ERCP in 2 months. LFTs trended down and the JP drainage decreased. A CT without iv contrast was performed on to assess for a perihepatic collection. A collection was noted and this was drained in CT for 260cc of serosanguinous fluid. A pigtail drain was left in place. Culture of this fluid was negative. The perihepatic drain and JP were left in place at time of discharge from the hospital. VNA services were arranged to assist with this at home. The JP drainage was ~700-1400cc/day. On (pod 9), the apex area of the incision was opened due to inadequete approximation of the incision and fluid noted at the site. A gram stain and culture were submitted and he was started on Ancef. Gram stain had 1+pmns without growth on the culture. Two 2x2 gauzes were placed at the apex. Immunosuppression consited of cellcept, prednisone and prograf titrated to 2mg . consult was obtain for assist with insulin management of hyperglycemia. Initially, he was on an insulin drip in the SICU, but this was switched to humalog sliding scale and glargine insulin. He did well with insulin teaching and experienced no low blood sugars. He was ambulatory, vital signs were stable and he was tolerating a regular diet when discharged home."},"extractive_notes_summ":{"kind":"string","value":"TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were obtained, including dynamic imaging performed prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. Pre- procedural non-contrast scan of the abdomen was performed, again demonstrating a perihepatic fluid collection. AP chest radiograph compared to shows replacement of the right IJ central venous catheter, which terminates at the confluence of the superior vena cava and brachiocephalic vein. IMPRESSION: Normal post-operative appearance of liver transplant without patent vasculature. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Unchanged small right pleural effusion and mild atelectasis of the right lung base. MRI OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is status post liver transplant. DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal vein are patent with hepatopetal flow. The stenosis is located 2.1 cm from the portal vein branch into the right and left portal veins, and 2.1 cm from the portosplenic confluence. The remaining hepatic vasculature is patent. (Over) 4:37 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # CT GUIDANCE DRAINAGE Reason: NEEDS TO BE DRAINED. 4:37 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # CT GUIDANCE DRAINAGE Reason: NEEDS TO BE DRAINED. A newly inserted Swan-Ganz catheter over the right internal jugular vein is in standard position. The hepatic veins and inferior vena cava are patent. The right middle and left hepatic veins as well as the inferior vena cava are patent with normal waveforms. The main, left, and right hepatic arteries are patent with normal waveforms. Small right pleural effusion and ascites as described. The bladder, distal ureters, the rectum, and sigmoid colon are normal. No (Over) 11:14 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess for fluid collection or abscesses Admitting Diagnosis: END STAGE LIVER FAILURE FINAL REPORT (Cont) abscess cavity or hematoma. COMPARISON: Liver Doppler ultrasound . The impression should state normal postoperative appearance of the liver transplant with patent vasculature and no evidence of biliary ductal dilatation. IMPRESSION: Discrepancy in size between the native and donor portal veins with relative stenosis, but no significant pressure gradient across the anastomosis. The imaged aorta is of normal caliber. Placed on A/C, ABG slight resp. Resp Care,Pt. PT WEANED OFF OF NEO. JP'S PATENT - MOD AMT OF SEROUS DRAINAGE OUT. MD aware.ENDO: BS elevated. HOLDING HEPARIN PER DR. . CONDITION UPDATEVSS. Wean from neo gtt as tolerated. SICU NN: SEE CAREVUE FOR SPECIFICS. Dr. and Dr. notified of values. U/O ADEQUATE (SEE FLOWSHEETS). ENC IS, C/DB. WEANED OFF PPF. SVO2 AND CO WITHIN PT BASELINE. CONDITION UPDATEPT A/O X3. Turn/reposition as tolerated ? AFEBRILE. See carevue. Pt denies nausea. Medial JP and Lateral JP both patent and draining sanquinous fluild. RSR. Sinus rhythm. Sinus rhythm. Sinus rhythm. LUNGS CTA BILAT. U/O QS VIA FOLEY. BP WNL ON LOPRESSOR ATC. MD aware. POSSIBLE O.R. See carevue for details. IF HCT DROPS. + BS. REPEAT HCT 28.8. ADVANCED TO CLR DIET TODAY. USING IS.CV: NSR HR 70-80. PA PRESSURES UNCHANGED FROM PT BASELINE. admitted from OR intubated #8ET.BS equal. Sinus rhythm and occasional ventricular ectopy. TWO JP'S WITH SMALL AMT SEROSANG OUTPUT. RN admission noteSee Carevue for data & specifics. TOL CLEAR LIQUIDS. Pt able to cough up secretions. PO'S WELL. CVP 3-7. VSS. P.M. HCT PENDING. CVP 4-10. LS clear bilaterally,decreased at bases. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES. LUNGS CLEAR, DIMINISHED AT BASES. PAP 37-28/25. FOLEY ADEQUATE URINE OUTPUT. ORIG SURGICAL INCISION INTACT - MOD S/S DRAINAGE NOTED. LOWGRADE TEMP. Pt HCT stable at present, continue to follow HCTs.GI-Pt NPO, ok for sips with meds. SVO2 76-80. ABD OBESE. ABD OBESE. JP'S PUTTING OUT MIN SEROUS DRAINAGE, MOD AMT OF SEROUS DRAINAGE NOTED AROUND INSERTION SITE. PATIENT ALERT AND ORIENTED X 3. OOB today. LOW GRADE TEMP, PRESENTLY TEMP 98.8. PAIN/COMFORT. 4L NC. Wean from vent to extubate. ENCOURAGE TURN/COUGH/DEEP BREATHE. PROVIDE EMOTIONAL SUPPORT TO PT. FOLLOW PA NUMBERS. CO 7.8-12. SICU TEAM AND TRANSPLANT TEAMS AWARE. Currently 110s. NOT WEDGING SECONDARY TO LOW PLTS. CVP readings remain low 0-2 ?accuracy of readings. ? PA NUMBERS ACCEPTABLE; PAS 37 TO 45, CO 10 TO 14. PT WEANED SUCCESSFULLY TO CPAP - EXTUBATED AT 18:00 W/O INCIDENT. MONITORING HCT AND LFTS.GI: OBESE ABDOMEN. CVP CONT TO BE LOW HOWEVER PRESSURE LABILE, 3 -10. PT GIVEN 1UNIT OF PRBC'S THIS AM PER DR. ORDERS. SBP 140-160. MONITOR DRAIN OUTPUT. Compared tothe previous tracing of ventricular ectopy is absent. MAE EQUALLY. Non-diagnostic Q waves in leads II, III and aVF. 7pm-7am Nursing NoteSee CareVue for objective data and trends:NEURO-Pt alert and oriented X 3, follows commands appropriately.RESP-LS are coarse to clear and diminished at bases. Non-specific ST-T wavechanges. change PA line over to central IV access. JP X2 DRAINING AROUND INSERTION SITE, SM AMTS SER/SANG IN JP BULBS. O2 SAT ACCEPTABLE ON 4L NP. Abdomen is obese with positive bowel sounds. AS SHIFT PROGRESSED CVP DECREASING, PA READINGS LOWER, PT GIVEN MULT FLUID BOLUSES W/ MOD EFFECT MD'S ORDERS. Monitor recalibrated and now in 70s. MOD AMT OF SUCTIONING FOR THICK TAN SECRETIONS."},"n_notes":{"kind":"number","value":29,"string":"29"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2139-08-10 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1021204,"text":" 10:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: blood flow\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o liver transplant\n REASON FOR THIS EXAMINATION:\n blood flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 5:26 PM\n No flow identified in the right hepatic artery otherwise patent vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with recent liver transplant.\n\n COMPARISON: Liver Doppler ultrasound .\n\n FINDINGS: The liver shows no focal or textural abnormality. There is no\n biliary dilatation and the common duct measures 0.5 cm. There is no ascites\n seen and no perihepatic collections are identified.\n\n DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal\n vein are patent with hepatopetal flow. Appropriate waveforms are identified\n in the main hepatic artery and the left hepatic artery. No flow was\n documented in the right hepatic artery but this may be due to technical\n factors. Appropriate flow is seen in the IVC and the hepatic veins.\n\n IMPRESSION:\n 1. No flow detected in the right hepatic artery. This finding may be due to\n technical difficulties. A repeat ultrasound is suggested. The remaining\n hepatic vasculature is patent.\n 2. No biliary dilatation. No fluid collection is identified.\n\n These findings were discussed with Dr. .\n\n\n"},{"category":"Radiology","chartdate":"2139-08-10 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1021205,"text":", J. SICU-A 10:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: blood flow\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o liver transplant\n REASON FOR THIS EXAMINATION:\n blood flow\n ______________________________________________________________________________\n PFI REPORT\n No flow identified in the right hepatic artery otherwise patent vasculature.\n\n\n"},{"category":"Radiology","chartdate":"2139-08-14 00:00:00.000","description":"MRI ABDOMEN W/O & W/CONTRAST","row_id":1021985,"text":" 3:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess liver transplant vasculature specifically the portal\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: MAGNEVIST Amt: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTS. US showed high portal vein velocity. Unable to get CTA given\n iodine allergy\n REASON FOR THIS EXAMINATION:\n assess liver transplant vasculature specifically the portal vein\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant on for hepatitis C/HCC\n cirrhosis. Elevated LFTs. Ultrasound demonstrated high portal vein velocity.\n Iodine allergy. Assess liver transplant vasculature, specifically portal\n vein.\n\n COMPARISON: Liver ultrasound and Doppler of .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were\n obtained, including dynamic imaging performed prior to, during, and after the\n uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\n Multiplanar 2D and 3D reformatted images and subtraction images were generated\n and reviewed on an independent workstation.\n\n MRI OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is status post\n liver transplant. The hepatic artery is patent, with patency of branches in\n the right and left lobes of the liver seen. The portal vein is patent,\n however, there is a severe stricture at the presumed anastomotic site, where\n the portal vein passes just posterior to the hepatic artery crossing\n anteriorly. This finding is perhaps best demonstrated on reformatted images\n (series 282, image 25). Proximal and distal to this severe focal stenosis,\n the portal venous caliber is normal to large. The hepatic veins and inferior\n vena cava are patent.\n\n No focal liver lesions are seen. There is no intra- or extra-hepatic biliary\n ductal dilatation. A choledochocholedocho anastomosis is seen (4:19). The\n spleen is large, measuring 18.9 cm in craniocaudad dimension. There is a\n wedge-shaped infarct measuring 2.5 cm in the posterior aspect of the spleen,\n and a second possible 7-mm infarct in the anterior spleen. The pancreas and\n adrenal glands are unremarkable. The kidneys enhance symmetrically and\n excrete normally. There is a 1-cm cyst in the interpolar region of the right\n kidney.\n\n The imaged aorta is of normal caliber. No lymphadenopathy is appreciated.\n There is a small right pleural effusion and small amounts of ascites within\n the abdomen. There are couple of foci of fluid within the abdomen for which\n followup will be necessary to determine if these are static or dynamic\n collections. One such focus of fluid measures 2.5 cm posterior to the spleen.\n Another such collection is medial to the native IVC, measuring 3.7 x 2.1 cm.\n (Over)\n\n 3:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess liver transplant vasculature specifically the portal\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: MAGNEVIST Amt: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar reformatted images were essential in the delineation of the portal\n venous stenosis and other findings described.\n\n IMPRESSION:\n\n 1. Severe portal vein stenosis, likely at the anastomosis. The stenosis is\n located 2.1 cm from the portal vein branch into the right and left portal\n veins, and 2.1 cm from the portosplenic confluence.\n\n 2. Patent hepatic artery and hepatic veins.\n\n 3. Splenomegaly with two small probable splenic infarcts.\n\n 4. Small right pleural effusion and ascites as described.\n\n Findings were discussed with Dr. on the surgical service at the\n conclusion of the exam.\n\n"},{"category":"Radiology","chartdate":"2139-08-14 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1021906,"text":", J. FA10 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please assess liver transplant arterial/venous flow, assess\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n please assess liver transplant arterial/venous flow, assess for ductal\n dilatation\n ______________________________________________________________________________\n PFI REPORT\n Patent hepatic vasculature including the right hepatic artery. No biliary\n ductal dilation.\n\n\n"},{"category":"Radiology","chartdate":"2139-08-14 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1021905,"text":" 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please assess liver transplant arterial/venous flow, assess\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n please assess liver transplant arterial/venous flow, assess for ductal\n dilatation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn FRI 4:33 PM\n Patent hepatic vasculature including the right hepatic artery. No biliary\n ductal dilation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man status post liver transplant on for\n hepatitis C/HCC cirrhosis, now with elevated LFTs.\n\n COMPARISON: Doppler ultrasound from .\n\n FINDINGS: No hepatic parenchymal abnormalities are appreciated. There are no\n perihepatic fluid collections. There is no biliary ductal dilation.\n\n The main, right anterior, right posterior and left portal veins are patent\n with appropriate waveforms. Velocities in the main portal vein range from 109\n to 149 cm/sec, similar to the previous study. The right middle and left\n hepatic veins as well as the inferior vena cava are patent with normal\n waveforms. The main, left, and right hepatic arteries are patent with normal\n waveforms.\n\n IMPRESSION:\n 1. Patent hepatic vasculature, including the right hepatic artery, which was\n not seen on the prior study.\n\n 2. No evidence of biliary ductal dilation.\n\n\n"},{"category":"Radiology","chartdate":"2139-08-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1021401,"text":" 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: catheter location\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p rewiring of cvl\n REASON FOR THIS EXAMINATION:\n catheter location\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg TUE 2:52 PM\n Replacement of right IJ central venous catheter, which terminates at the\n confluence of the SVC and brachiocephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 53-year-old male status post rewiring of central venous\n line. Evaluate catheter location.\n\n AP chest radiograph compared to shows replacement of the right IJ\n central venous catheter, which terminates at the confluence of the superior\n vena cava and brachiocephalic vein. There is no pneumothorax. Since the last\n exam, the patient has been extubated. Small right pleural effusion is\n slightly increased in size. The cardiomediastinal contour is unchanged. Post-\n surgical changes related to median sternotomy and CABG are present.\n\n"},{"category":"Radiology","chartdate":"2139-08-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1021402,"text":", J. SICU-A 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: catheter location\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p rewiring of cvl\n REASON FOR THIS EXAMINATION:\n catheter location\n ______________________________________________________________________________\n PFI REPORT\n Replacement of right IJ central venous catheter, which terminates at the\n confluence of the SVC and brachiocephalic vein.\n\n"},{"category":"Radiology","chartdate":"2139-08-20 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1022889,"text":" 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant, continues with large volume drain output\n REASON FOR THIS EXAMINATION:\n assess for fluid collection or abscesses\n CONTRAINDICATIONS for IV CONTRAST:\n iodine allergy\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:49 PM\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\n fluid characteristics. No hematoma or abscess.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with liver transplant and continued large volume\n drain output. Please evaluate for fluid collection or abscess.\n\n Comparison is made to the MR of the abdomen performed on .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis after administration of the oral contrast. No IV contrast was used.\n Sagittal and coronal reformatted images were then obtained.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Unchanged small right pleural effusion\n and mild atelectasis of the right lung base.\n\n There is a new large fluid collection at the gastrohepatic ligament measuring\n 10.2 x 5.8 cm, which based on its Hounsfield units (4 ) is relatively simple\n fluid rather than being a hematoma or abcess. No hematocrit effect is noted\n within this collection. The surgical clips are noted adjacent to the IVC and\n the portal vein. The patient is status post liver transplant. The drain\n anterior to the right lobe of the liver terminates in the right lower quadrant\n area. The biliary drain is also in place.\n\n The enlarged spleen measures 18 cm. Multiple dilated tortuous vessels are not\n adjacent to the spleen suggesting the presence of varicosities setting of\n portal hypertension. Small amount of fluid is noted in both anterior pararenal\n spaces and perihepatic and perisplenic spaces and in the pelvis. The adrenal\n glands, kidneys, and pancreas have normal appearance. The stomach, duodenum\n and loops of small bowel and large bowel have normal appearance.\n\n The bladder, distal ureters, the rectum, and sigmoid colon are normal. Small\n amount of fluid is noted within the pelvis. No pathologically enlarged\n pelvic, inguinal, mesenteric, or retroperitoneum nodes are noted. The aorta is\n moderately calcified with no aneurysm or stenosis.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Enlarging 10.2 x 5.8 cm fluid collection in the gastrohepatic ligament. No\n (Over)\n\n 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n abscess cavity or hematoma.\n\n 2. Status post liver transplant with signs of prior portal hypertension with\n splenomegaly and multiple perisplenic collaterals.\n\n 3. Small amount of fluid in perihepatic, perisplenic spaces and within the\n pelvis.\n\n Findings were discussed with Dr at the time of dictataion.\n\n"},{"category":"Radiology","chartdate":"2139-08-20 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1022890,"text":", J. FA10 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant, continues with large volume drain output\n REASON FOR THIS EXAMINATION:\n assess for fluid collection or abscesses\n CONTRAINDICATIONS for IV CONTRAST:\n iodine allergy\n ______________________________________________________________________________\n PFI REPORT\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\n fluid characteristics. No hematoma or abscess.\n\n"},{"category":"Radiology","chartdate":"2139-08-07 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1020840,"text":" 3:14 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE LIVER FAILURE\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with HCV cirrhosis to undergo transplant today\n REASON FOR THIS EXAMINATION:\n For Pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Preoperative evaluation.\n\n COMPARISON: .\n\n IMPRESSION: No relevant changes as compared to the previous examination.\n Mild cardiomegaly, without overhydration. No pleural effusion, no focal\n parenchymal opacity suggestive of pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2139-08-08 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1020885,"text":" 4:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new r ij cvl/paline\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with liver txp\n REASON FOR THIS EXAMINATION:\n new r ij cvl/paline\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant.\n\n COMPARISON: .\n\n FINDINGS: Status post liver transplant. There is a newly inserted\n endotracheal tube located 4 cm above the carina. A newly inserted Swan-Ganz\n catheter over the right internal jugular vein is in standard position. The\n course of the catheter is unremarkable, there are no signs of complications,\n no evidence of pneumothorax. A small pneumothorax, however, is seen in the\n left lung. The apical gap of the pneumothorax averages 8-10 mm. There are no\n signs of tension. Except for small areas of retrocardiac atelectasis, there\n are no other parenchymal abnormalities. The size of the cardiac silhouette is\n unchanged. No pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2139-08-08 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1020906,"text":" 7:45 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: SP LIVER TX EVAL FOR FLOW\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM\n\n There is a transcription error in the impression. The impression should state\n normal postoperative appearance of the liver transplant with patent\n vasculature and no evidence of biliary ductal dilatation.\n\n\n\n 7:45 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: SP LIVER TX EVAL FOR FLOW\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man pod 0 s/p liver txp\n REASON FOR THIS EXAMINATION:\n please assess vasculature / flow / biliary tree doppler\n ______________________________________________________________________________\n FINAL REPORT\n LIVER, GALLBLADDER ULTRASOUND\n\n INDICATION: 53-year-old man post-liver transplant.\n\n The liver transplant appears unremarkable, without evidence of peritransplant\n fluid collection. There is no intrahepatic biliary ductal dilatation.\n\n Doppler examination demonstrates normal color flow and waveforms in the\n hepatic arteries, veins and portal veins, as well as IVC.\n\n Common duct measures 5 mm.\n\n IMPRESSION: Normal post-operative appearance of liver transplant without\n patent vasculature.\n\n Findings were discussed with Dr. at 3 p.m. on .\n\n\n"},{"category":"Radiology","chartdate":"2139-08-19 00:00:00.000","description":"ERCP BILIARY&PANCREAS BY GI UNIT","row_id":1022987,"text":" 12:27 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLTX, with bile leak.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: Patient is a 53-year-old male status post liver\n transplant, presenting with biliary leak status post ERCP , for review\n of ERCP images.\n\n EXAMINATION: 33 single spot fluoroscopic images from ERCP reviewed.\n\n FINDINGS: 33 single spot fluoroscopic images obtained by gastroenterologist\n without radiologist present reviewed. Surgical hardware from liver transplant\n noted in fluoroscopic images. There is a 10-mm long single smooth stricture\n present in the middle third of the common bile duct, likely at the site of the\n duct-to-duct anastomosis. There is some mild post-obstructive dilitation of\n the biliary tree. The visualized biliary tree is otherwise unremarkable. There\n is interval placement of a common bile duct biliary stent.\n\n IMPRESSION: Common bile duct stricture at site of anastomosis status post\n stenting.\n\n Please refer to ERCP report on for full report, findings, and\n recommendations.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2139-08-15 00:00:00.000","description":"PERC PORTAL VEIN CATH","row_id":1022099,"text":" 12:01 PM\n PORTAL VENOGRAPHY Clip # \n Reason: Pt needs portal stent for stenosis\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: VISAPAQUE Amt: 80\n ********************************* CPT Codes ********************************\n * PERC PORTAL VEIN CATH INJ SINUS TRACT, THERAPUTIC *\n * -51 MULTI-PROCEDURE SAME DAY PERC TRANHEP PORTOGRAPHY WITH *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant with rising bili, CT showing stenosis at\n portal anastomosis.\n REASON FOR THIS EXAMINATION:\n Pt needs portal stent for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n PORTOGRAM WITH PRESSURES\n\n INDICATION: Seven days after liver transplant with increasing LFTs and\n suggestion of a portal venous anastomosis stenosis by MRV.\n\n Details of the procedure and possible complications were explained to the\n patient and informed consent was obtained.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist,\n was present for the entire procedure.\n\n TECHNIQUE AND FINDINGS: Using sterile technique, local anesthesia and\n conscious sedation, the peripheral portal branch in the right lobe of the\n liver was accessed with a 21-gauge needle and an Accustick sheath was placed\n over the wire using Seldinger technique. The catheter and the wire were then\n placed through the sheath and advanced into the splenic vein under\n fluoroscopic guidance. Portogram was performed in several projections. A\n pressure gradient was then measured across the portal vein anastomosis. There\n is some discrepancy in size of the donor and native portal veins with relative\n stenosis at their anastomosis, which is not hemodynamically significant. There\n is a very brisk flow through the anastomosis and the pressure gradient across\n the anastomosis was 3 mmHg.\n\n The findings were discussed with Dr. and it was decided not to perform\n any interventions at this time. The catheter was removed. The liver\n parenchymal tract was embolized with two Gelfoam pledgets through the sheath\n and the sheath removed.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Discrepancy in size between the native and donor portal veins\n with relative stenosis, but no significant pressure gradient across the\n anastomosis. No interventions performed after discussion with Dr. .\n\n\n (Over)\n\n 12:01 PM\n PORTAL VENOGRAPHY Clip # \n Reason: Pt needs portal stent for stenosis\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: VISAPAQUE Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"},{"category":"Radiology","chartdate":"2139-08-20 00:00:00.000","description":"CT PERITINEAL DRAIN EXCLUDING APPENDICEAL","row_id":1022948,"text":" 4:37 PM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ********************************* CPT Codes ********************************\n * CT PERITINEAL DRAIN EXCLUDING APPEND -79 UNRELATED PROCEDURE/SERVICE DURI *\n * CT GUIDANCE DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant and now with a new subhepatic fluid\n collection\n REASON FOR THIS EXAMINATION:\n NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE. SEND SAMPLE FOR\n GRAM STAIN AND CULTURE AND FOR TOTAL BILI\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man status post liver transplant, now with new\n subhepatic fluid collection.\n\n PROCEDURE:\n The risks, benefits, and alternatives, including intravenous moderate\n sedation, were explained to the patient who gave her an informed consent.\n\n A pre-procedural timeout was performed using two patient identifiers.\n\n The patient received intravenous moderate sedation (150 mcg of fentanyl, 3 mg\n of Versed), during the procedure. There was continuous monitoring by\n radiology nursing staff for a total intra-service time of 35 minutes.\n\n Pre- procedural non-contrast scan of the abdomen was performed, again\n demonstrating a perihepatic fluid collection. After review of the scan, a\n suitable site for catheter placement was chosen. The overlying skin was\n prepped and draped in usual sterile fashion. 10% lidocaine was given in the\n subcutaneous tissues as local anesthetic. Under CT guidance, an 8 French\n catheter was advanced into the collection. Approximately 260 cc of\n serosanguineous fluid was aspirated. The catheter was connected to a drainage\n bag and securely fastened to the skin using a StatLock device. A sterile\n dressing was applied. The patient tolerated the procedure, without immediate\n post-procedural complications.\n\n Samples were sent to the lab for bilirubin and amylase as well as gram stain\n and culture.\n\n Dr. , the attending physician, present for and performed the\n entire procedure.\n\n IMPRESSION: Successful placement of catheter into perihepatic fluid\n collection.\n\n\n (Over)\n\n 4:37 PM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"ECG","chartdate":"2139-08-09 00:00:00.000","description":"Report","row_id":134749,"text":"Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2139-08-08 00:00:00.000","description":"Report","row_id":134750,"text":"Sinus rhythm. Small non-diagnostic Q waves in the inferolateral leads.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof there is no significant diagnostic change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2139-08-04 00:00:00.000","description":"Report","row_id":134751,"text":"Sinus rhythm. Non-diagnostic Q waves in leads II, III and aVF. Compared to\nthe previous tracing of ventricular ectopy is absent. Otherwise,\nno diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2139-08-03 00:00:00.000","description":"Report","row_id":134752,"text":"Sinus rhythm and occasional ventricular ectopy. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the recording is of\nimproved technical quality. Otherwise, no diagnostic interim change.\n\n"},{"category":"Nursing/other","chartdate":"2139-08-08 00:00:00.000","description":"Report","row_id":1385972,"text":"CONDITION UPDATE\nVSS. LOWGRADE TEMP. AS SHIFT PROGRESSED CVP DECREASING, PA READINGS LOWER, PT GIVEN MULT FLUID BOLUSES W/ MOD EFFECT MD'S ORDERS. PT WEANED OFF OF NEO. WEANED OFF PPF. LUNGS COARSE THROUGHOUT. MOD AMT OF SUCTIONING FOR THICK TAN SECRETIONS. ABD OBESE. NO BOWEL SOUNDS AUSCULTATED. ORIG SURGICAL INCISION INTACT - MOD S/S DRAINAGE NOTED. JP'S PATENT - MOD AMT OF SEROUS DRAINAGE OUT. U/O ADEQUATE (SEE FLOWSHEETS). PT WEANED SUCCESSFULLY TO CPAP - EXTUBATED AT 18:00 W/O INCIDENT. PT REMAINS ON INSULIN DRIP - BSUGARS SOMEWHAT LABILE - INSULIN PROTOCOL FOLLOWED. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE W/ EFFECT.\nCONT CURRENT ICU CARE AND ASSESSMENTS. MONITOR FOR S/S OF BLEEDING/INFECTION/REJECTION. AGGRESSIVE PULMONARY TOILET. PAIN MANAGEMENT. PT AND FAMILY TEACHING.\n"},{"category":"Nursing/other","chartdate":"2139-08-09 00:00:00.000","description":"Report","row_id":1385973,"text":"7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt alert and oriented X 3, follows commands appropriately.\nRESP-LS are coarse to clear and diminished at bases. Pt able to cough up secretions. Pt weaned to nasal cannula at 6 liters O2 and pt's pox 96-98%.\nCV/Heme-Pt's HR 90s, NSR. CVP readings remain low 0-2 ?accuracy of readings. Pt given 2 units PRBC and 1 unit of platelets for HCT of 24.1 and PLTs 50. BPs running 110's/50s initially and now up to 130s/60s after transfusion. PA pressures low at start of shift but improved post transfusions as well Cardiac output trended up from 7 to during blood transfusion, Dr. aware of elevated C.O.(see flowsheet for specifics) Awaiting lab results post transfusion.\nGI-abdomen is obese, bowel sounds heard on auscultation. Pt taking small sips of water without difficulty. Pt denies nausea. No bowel movement overnight.\nGU-urine icteric in color, putting out 35-60cc of urine per hour.\nENDO-insulin drip continues-Blood sugars running 104-130s.\nPLAN-plan to change out PA catheter line today if pt remians stable. Monitor labs closely, follow HCT and platelet levels. Turn/reposition as tolerated ? OOB today. Monitor urine output closely.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2139-08-10 00:00:00.000","description":"Report","row_id":1385976,"text":"7pm-7am nursing note\nsee CareVue for objective data and trends:\nNeuro-pt is alert and oriented X 3, MAE, follows commands appropriately.\nResp-Pt on 4 liters via NC and maintaining pox at 96-98%. LS clear bilaterally,decreased at bases. Pt with productive cough, bringing up small amounts of white sputum.\nCV/heme-Pt HR 70s-80s in NSR. Pt BP 130s-140s/60s. PA pressures running 30-40s/. CVP 3-7. Pt HCT stable at present, continue to follow HCTs.\nGI-Pt NPO, ok for sips with meds. Abdomen is obese with positive bowel sounds. Pt c/o abdominal discomfort and getting morphine 2mg for pain with fair effect. Abdomen with surgical dressing and medial and lateral JP drains.\nGU-Pt urine output at has been >100cc/hr.\nPLAN-Follow HCTs, if HCT drops Dr. to consider pt going back to OR to explore abdomen. Follow LFTs as well as pt's levels have been trending up. ? change PA line over to central IV access.\n\n"},{"category":"Nursing/other","chartdate":"2139-08-10 00:00:00.000","description":"Report","row_id":1385977,"text":"NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: A&OX3. MAE, WEAK. C/O INCISIONAL PAIN, RECIEVING 2MG MORPHINE W/EFFECT.\nRESP: SAT'S 97-99% 4L NC. LUNGS CLEAR, DIMINISHED AT BASES. PRODUCTIVE COUGH BRINGING UP SCANT/SMALL AMTS THICK WHITE SECRETIONS, USING YANKEUR APPROPRIATELY. USING IS.\nCV: NSR HR 70-80. SBP 140-160. CVP 4-10. RECIEVED 1UNIT PLATELETTES IN AM, GOAL TO MAINTAIN PLT LEVEL >50. SWAN TO REMAIN IN PER DR WHO SPOKE W/TRANSPLANT TEAM, AWARE THAT NUMBERS VARY GREATLY AT TIMES. PAP 37-28/25. SVO2 76-80. CO 7.8-12. MONITORING HCT AND LFTS.\nGI: OBESE ABDOMEN. + BS. NO BM. ADVANCED TO CLR DIET TODAY. PO'S WELL. LIVER US DONE AT BS, ORDERED TO MONITOR AV FLOW.\nENDO: INSULIN GTT, TITRATING ACCORDING TO SCALE.\nGU: FOLEY PATENT, ADEQUATE CYU.\nSKIN: TRANSPLANT INCISION C/D/I. JP X2 DRAINING AROUND INSERTION SITE, SM AMTS SER/SANG IN JP BULBS. ECCYMOSIS AROUND SWAN-GANZ SITE ON NECK, TEAMS AWARE; ALSO SM AREA OF ECCYMOSIS NOTED ON LEFT SIDE OF NECK AS WELL.\nSOCIAL: FAMILY INTO VISIT. SISTER AND NEPHEW CALLED.\n\nPOC: MONITOR HCT, LFT'S. PLT >50. FOLLOW PA NUMBERS. ENC IS, C/DB. MONITOR DRAIN OUTPUT. PAIN/COMFORT. PROVIDE EMOTIONAL SUPPORT TO PT. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2139-08-09 00:00:00.000","description":"Report","row_id":1385974,"text":"addendum to 7p-7am nursing note\nPt's repeat HCT, post 2 units of PRBCs only bumped to 25 (from 24.1) Dr aware. Pt given an additional 2 units PRBCs and an additional unit of platelets. Subsequent HCT level came back at 26.5 and platelets at 55. Dr. and Dr. notified of values. Further plan pending.\n"},{"category":"Nursing/other","chartdate":"2139-08-09 00:00:00.000","description":"Report","row_id":1385975,"text":"CONDITION UPDATE\nPT A/O X3. VSS. LOW GRADE TEMP, PRESENTLY TEMP 98.8. SBP 102 TO 136. PA NUMBERS ACCEPTABLE; PAS 37 TO 45, CO 10 TO 14. CVP CONT TO BE LOW HOWEVER PRESSURE LABILE, 3 -10. SICU TEAM AND TRANSPLANT TEAMS AWARE. PT GIVEN 1UNIT OF PRBC'S THIS AM PER DR. ORDERS. REPEAT HCT 28.8. P.M. HCT PENDING. LUNGS CTA BILAT. O2 SAT ACCEPTABLE ON 4L NP. ABD OBESE. SURGICAL DRSG - OLD S/S STAINING. JP'S PUTTING OUT MIN SEROUS DRAINAGE, MOD AMT OF SEROUS DRAINAGE NOTED AROUND INSERTION SITE. U/O QS VIA FOLEY. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE MD'S ORDERS W/ EFFECT. CONT ON INSULIN DRIP.\nMONITOR FOR S/S OF BLEEDING. SERIAL LABS AS ORDERED. MONITOR FOR S/S OF INFECTION. ENCOURAGE TURN/COUGH/DEEP BREATHE. PAIN MANAGEMENT. PT/FAMILY TEACHING. POSSIBLE O.R. IF HCT DROPS.\n"},{"category":"Nursing/other","chartdate":"2139-08-08 00:00:00.000","description":"Report","row_id":1385969,"text":"Resp Care,\nPt. admitted from OR intubated #8ET.BS equal. Placed on A/C, ABG slight resp. acidosis. See carevue. No RSBI due to OR procedure.\n"},{"category":"Nursing/other","chartdate":"2139-08-08 00:00:00.000","description":"Report","row_id":1385970,"text":"RN admission note\nSee Carevue for data & specifics. See chart and FHP for HPI and medical history.\n\n53 yo male with hx of HCV/ETOH cirrhosis and hepatocellular carcinoma was received from the OR s/p liver transplant. No complications during case, per OR report.\n\nNEURO: pt sedated on ppf, MAE, does not follow commands, open eyes to loud stimuli, withdraws to pain, PERRL. Pt appeared to be in pain as assessed by vital signs and grimace. IV morphine given with positive result.\n\nCV: ST in 130s when arrived. Currently 110s. No ectopy. Episodes of hypotension to 70s systolic, 500 cc bolus x 1 given and neo gtt started, currently at 0.6 , MD aware. SV02 initially in 40s and 30s. MD aware. Monitor recalibrated and now in 70s. Wedge not done d/t elevated INR. CVP 6-8.\n\nRESP: Ventilated on AC. Initially put on 50% Fi02 but PA02 low, so increased to 100% then weaned to 70% and 50% with ABGs improving with each vent change.\n\nGI: NGT to suction, draining bilious fluid. Medial JP and Lateral JP both patent and draining sanquinous fluild. Abdominal dsg intact.\n\nGU: Foley draining clear urine but output slowly decreasing. MD aware.\n\nENDO: BS elevated. Insulin gtt started.\n\nSOCIAL: Nephew called for an update.\n\nPLAN: Continue to monitor VS closely. Monitor lab values closely and tx abnormal values as ordered. Wean from neo gtt as tolerated. Wean from vent to extubate.\n"},{"category":"Nursing/other","chartdate":"2139-08-08 00:00:00.000","description":"Report","row_id":1385971,"text":"resp care - Pt was extubated without incident and placed on cool aerosol. See carevue for details.\n"},{"category":"Nursing/other","chartdate":"2139-08-11 00:00:00.000","description":"Report","row_id":1385978,"text":"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT ALERT AND ORIENTED X 3. MAE EQUALLY. NO NEURO DEFICITS. 4L NC. LUNGS CLEAR. RSR. BP WNL ON LOPRESSOR ATC. AFEBRILE. CCO SWAN IN PLACE VIA CATHETER. PA PRESSURES UNCHANGED FROM PT BASELINE. NOT WEDGING SECONDARY TO LOW PLTS. SVO2 AND CO WITHIN PT BASELINE. STRONG PEDAL PULSES PALPABLE. LARGE OBESE ABDOMEN, SOFT, WITH BOWEL SOUNDS PRESENT, HYPOACTIVE AT TIMES. TOL CLEAR LIQUIDS. INCISION WITH DSD , NO DRAINAGE. TWO JP'S WITH SMALL AMT SEROSANG OUTPUT. FOLEY ADEQUATE URINE OUTPUT. MORPHINE SULFATE FOR PAIN. PNEUMO BOOTS. HOLDING HEPARIN PER DR. . PLAN: FOLLOW HCT'S AND PLTS, ?DC SWAN AND CHANGE TO CVL OVER WIRE TODAY, ?DC RICC LINE, MONITOR HEPATIC FUNCTION, IMMUNOSUPRESSIVES AS ORDERED, ?OOB, PAIN CONTROL.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-10 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1021204,\n \"text\": \" 10:23 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOP ABD/PEL LIMITED\\n Reason: blood flow\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with h/o liver transplant\\n REASON FOR THIS EXAMINATION:\\n blood flow\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 5:26 PM\\n No flow identified in the right hepatic artery otherwise patent vasculature.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man with recent liver transplant.\\n\\n COMPARISON: Liver Doppler ultrasound .\\n\\n FINDINGS: The liver shows no focal or textural abnormality. There is no\\n biliary dilatation and the common duct measures 0.5 cm. There is no ascites\\n seen and no perihepatic collections are identified.\\n\\n DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal\\n vein are patent with hepatopetal flow. Appropriate waveforms are identified\\n in the main hepatic artery and the left hepatic artery. No flow was\\n documented in the right hepatic artery but this may be due to technical\\n factors. Appropriate flow is seen in the IVC and the hepatic veins.\\n\\n IMPRESSION:\\n 1. No flow detected in the right hepatic artery. This finding may be due to\\n technical difficulties. A repeat ultrasound is suggested. The remaining\\n hepatic vasculature is patent.\\n 2. No biliary dilatation. No fluid collection is identified.\\n\\n These findings were discussed with Dr. .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-10 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1021205,\n \"text\": \", J. SICU-A 10:23 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOP ABD/PEL LIMITED\\n Reason: blood flow\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with h/o liver transplant\\n REASON FOR THIS EXAMINATION:\\n blood flow\\n ______________________________________________________________________________\\n PFI REPORT\\n No flow identified in the right hepatic artery otherwise patent vasculature.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-14 00:00:00.000\",\n \"description\": \"MRI ABDOMEN W/O & W/CONTRAST\",\n \"row_id\": 1021985,\n \"text\": \" 3:28 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: assess liver transplant vasculature specifically the portal\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n Contrast: MAGNEVIST Amt: 25\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\\n elevated LFTS. US showed high portal vein velocity. Unable to get CTA given\\n iodine allergy\\n REASON FOR THIS EXAMINATION:\\n assess liver transplant vasculature specifically the portal vein\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post liver transplant on for hepatitis C/HCC\\n cirrhosis. Elevated LFTs. Ultrasound demonstrated high portal vein velocity.\\n Iodine allergy. Assess liver transplant vasculature, specifically portal\\n vein.\\n\\n COMPARISON: Liver ultrasound and Doppler of .\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were\\n obtained, including dynamic imaging performed prior to, during, and after the\\n uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\\n Multiplanar 2D and 3D reformatted images and subtraction images were generated\\n and reviewed on an independent workstation.\\n\\n MRI OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is status post\\n liver transplant. The hepatic artery is patent, with patency of branches in\\n the right and left lobes of the liver seen. The portal vein is patent,\\n however, there is a severe stricture at the presumed anastomotic site, where\\n the portal vein passes just posterior to the hepatic artery crossing\\n anteriorly. This finding is perhaps best demonstrated on reformatted images\\n (series 282, image 25). Proximal and distal to this severe focal stenosis,\\n the portal venous caliber is normal to large. The hepatic veins and inferior\\n vena cava are patent.\\n\\n No focal liver lesions are seen. There is no intra- or extra-hepatic biliary\\n ductal dilatation. A choledochocholedocho anastomosis is seen (4:19). The\\n spleen is large, measuring 18.9 cm in craniocaudad dimension. There is a\\n wedge-shaped infarct measuring 2.5 cm in the posterior aspect of the spleen,\\n and a second possible 7-mm infarct in the anterior spleen. The pancreas and\\n adrenal glands are unremarkable. The kidneys enhance symmetrically and\\n excrete normally. There is a 1-cm cyst in the interpolar region of the right\\n kidney.\\n\\n The imaged aorta is of normal caliber. No lymphadenopathy is appreciated.\\n There is a small right pleural effusion and small amounts of ascites within\\n the abdomen. There are couple of foci of fluid within the abdomen for which\\n followup will be necessary to determine if these are static or dynamic\\n collections. One such focus of fluid measures 2.5 cm posterior to the spleen.\\n Another such collection is medial to the native IVC, measuring 3.7 x 2.1 cm.\\n (Over)\\n\\n 3:28 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: assess liver transplant vasculature specifically the portal\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n Contrast: MAGNEVIST Amt: 25\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Multiplanar reformatted images were essential in the delineation of the portal\\n venous stenosis and other findings described.\\n\\n IMPRESSION:\\n\\n 1. Severe portal vein stenosis, likely at the anastomosis. The stenosis is\\n located 2.1 cm from the portal vein branch into the right and left portal\\n veins, and 2.1 cm from the portosplenic confluence.\\n\\n 2. Patent hepatic artery and hepatic veins.\\n\\n 3. Splenomegaly with two small probable splenic infarcts.\\n\\n 4. Small right pleural effusion and ascites as described.\\n\\n Findings were discussed with Dr. on the surgical service at the\\n conclusion of the exam.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-14 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1021906,\n \"text\": \", J. FA10 8:28 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please assess liver transplant arterial/venous flow, assess\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\\n elevated LFTs\\n REASON FOR THIS EXAMINATION:\\n please assess liver transplant arterial/venous flow, assess for ductal\\n dilatation\\n ______________________________________________________________________________\\n PFI REPORT\\n Patent hepatic vasculature including the right hepatic artery. No biliary\\n ductal dilation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-14 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1021905,\n \"text\": \" 8:28 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please assess liver transplant arterial/venous flow, assess\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\\n elevated LFTs\\n REASON FOR THIS EXAMINATION:\\n please assess liver transplant arterial/venous flow, assess for ductal\\n dilatation\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn FRI 4:33 PM\\n Patent hepatic vasculature including the right hepatic artery. No biliary\\n ductal dilation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man status post liver transplant on for\\n hepatitis C/HCC cirrhosis, now with elevated LFTs.\\n\\n COMPARISON: Doppler ultrasound from .\\n\\n FINDINGS: No hepatic parenchymal abnormalities are appreciated. There are no\\n perihepatic fluid collections. There is no biliary ductal dilation.\\n\\n The main, right anterior, right posterior and left portal veins are patent\\n with appropriate waveforms. Velocities in the main portal vein range from 109\\n to 149 cm/sec, similar to the previous study. The right middle and left\\n hepatic veins as well as the inferior vena cava are patent with normal\\n waveforms. The main, left, and right hepatic arteries are patent with normal\\n waveforms.\\n\\n IMPRESSION:\\n 1. Patent hepatic vasculature, including the right hepatic artery, which was\\n not seen on the prior study.\\n\\n 2. No evidence of biliary ductal dilation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1021401,\n \"text\": \" 11:09 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: catheter location\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p rewiring of cvl\\n REASON FOR THIS EXAMINATION:\\n catheter location\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg TUE 2:52 PM\\n Replacement of right IJ central venous catheter, which terminates at the\\n confluence of the SVC and brachiocephalic vein.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 53-year-old male status post rewiring of central venous\\n line. Evaluate catheter location.\\n\\n AP chest radiograph compared to shows replacement of the right IJ\\n central venous catheter, which terminates at the confluence of the superior\\n vena cava and brachiocephalic vein. There is no pneumothorax. Since the last\\n exam, the patient has been extubated. Small right pleural effusion is\\n slightly increased in size. The cardiomediastinal contour is unchanged. Post-\\n surgical changes related to median sternotomy and CABG are present.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1021402,\n \"text\": \", J. SICU-A 11:09 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: catheter location\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p rewiring of cvl\\n REASON FOR THIS EXAMINATION:\\n catheter location\\n ______________________________________________________________________________\\n PFI REPORT\\n Replacement of right IJ central venous catheter, which terminates at the\\n confluence of the SVC and brachiocephalic vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-20 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1022889,\n \"text\": \" 11:14 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for fluid collection or abscesses\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant, continues with large volume drain output\\n REASON FOR THIS EXAMINATION:\\n assess for fluid collection or abscesses\\n CONTRAINDICATIONS for IV CONTRAST:\\n iodine allergy\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:49 PM\\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\\n fluid characteristics. No hematoma or abscess.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man with liver transplant and continued large volume\\n drain output. Please evaluate for fluid collection or abscess.\\n\\n Comparison is made to the MR of the abdomen performed on .\\n\\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\\n symphysis after administration of the oral contrast. No IV contrast was used.\\n Sagittal and coronal reformatted images were then obtained.\\n\\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Unchanged small right pleural effusion\\n and mild atelectasis of the right lung base.\\n\\n There is a new large fluid collection at the gastrohepatic ligament measuring\\n 10.2 x 5.8 cm, which based on its Hounsfield units (4 ) is relatively simple\\n fluid rather than being a hematoma or abcess. No hematocrit effect is noted\\n within this collection. The surgical clips are noted adjacent to the IVC and\\n the portal vein. The patient is status post liver transplant. The drain\\n anterior to the right lobe of the liver terminates in the right lower quadrant\\n area. The biliary drain is also in place.\\n\\n The enlarged spleen measures 18 cm. Multiple dilated tortuous vessels are not\\n adjacent to the spleen suggesting the presence of varicosities setting of\\n portal hypertension. Small amount of fluid is noted in both anterior pararenal\\n spaces and perihepatic and perisplenic spaces and in the pelvis. The adrenal\\n glands, kidneys, and pancreas have normal appearance. The stomach, duodenum\\n and loops of small bowel and large bowel have normal appearance.\\n\\n The bladder, distal ureters, the rectum, and sigmoid colon are normal. Small\\n amount of fluid is noted within the pelvis. No pathologically enlarged\\n pelvic, inguinal, mesenteric, or retroperitoneum nodes are noted. The aorta is\\n moderately calcified with no aneurysm or stenosis.\\n\\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\\n\\n IMPRESSION:\\n 1. Enlarging 10.2 x 5.8 cm fluid collection in the gastrohepatic ligament. No\\n (Over)\\n\\n 11:14 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for fluid collection or abscesses\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n abscess cavity or hematoma.\\n\\n 2. Status post liver transplant with signs of prior portal hypertension with\\n splenomegaly and multiple perisplenic collaterals.\\n\\n 3. Small amount of fluid in perihepatic, perisplenic spaces and within the\\n pelvis.\\n\\n Findings were discussed with Dr at the time of dictataion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-20 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1022890,\n \"text\": \", J. FA10 11:14 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for fluid collection or abscesses\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant, continues with large volume drain output\\n REASON FOR THIS EXAMINATION:\\n assess for fluid collection or abscesses\\n CONTRAINDICATIONS for IV CONTRAST:\\n iodine allergy\\n ______________________________________________________________________________\\n PFI REPORT\\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\\n fluid characteristics. No hematoma or abscess.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-07 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1020840,\n \"text\": \" 3:14 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: END STAGE LIVER FAILURE\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with HCV cirrhosis to undergo transplant today\\n REASON FOR THIS EXAMINATION:\\n For Pre-op eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Preoperative evaluation.\\n\\n COMPARISON: .\\n\\n IMPRESSION: No relevant changes as compared to the previous examination.\\n Mild cardiomegaly, without overhydration. No pleural effusion, no focal\\n parenchymal opacity suggestive of pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1020885,\n \"text\": \" 4:31 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: new r ij cvl/paline\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with liver txp\\n REASON FOR THIS EXAMINATION:\\n new r ij cvl/paline\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post liver transplant.\\n\\n COMPARISON: .\\n\\n FINDINGS: Status post liver transplant. There is a newly inserted\\n endotracheal tube located 4 cm above the carina. A newly inserted Swan-Ganz\\n catheter over the right internal jugular vein is in standard position. The\\n course of the catheter is unremarkable, there are no signs of complications,\\n no evidence of pneumothorax. A small pneumothorax, however, is seen in the\\n left lung. The apical gap of the pneumothorax averages 8-10 mm. There are no\\n signs of tension. Except for small areas of retrocardiac atelectasis, there\\n are no other parenchymal abnormalities. The size of the cardiac silhouette is\\n unchanged. No pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1020906,\n \"text\": \" 7:45 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \\n Reason: SP LIVER TX EVAL FOR FLOW\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM\\n\\n There is a transcription error in the impression. The impression should state\\n normal postoperative appearance of the liver transplant with patent\\n vasculature and no evidence of biliary ductal dilatation.\\n\\n\\n\\n 7:45 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOP ABD/PEL LIMITED\\n Reason: SP LIVER TX EVAL FOR FLOW\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man pod 0 s/p liver txp\\n REASON FOR THIS EXAMINATION:\\n please assess vasculature / flow / biliary tree doppler\\n ______________________________________________________________________________\\n FINAL REPORT\\n LIVER, GALLBLADDER ULTRASOUND\\n\\n INDICATION: 53-year-old man post-liver transplant.\\n\\n The liver transplant appears unremarkable, without evidence of peritransplant\\n fluid collection. There is no intrahepatic biliary ductal dilatation.\\n\\n Doppler examination demonstrates normal color flow and waveforms in the\\n hepatic arteries, veins and portal veins, as well as IVC.\\n\\n Common duct measures 5 mm.\\n\\n IMPRESSION: Normal post-operative appearance of liver transplant without\\n patent vasculature.\\n\\n Findings were discussed with Dr. at 3 p.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-19 00:00:00.000\",\n \"description\": \"ERCP BILIARY&PANCREAS BY GI UNIT\",\n \"row_id\": 1022987,\n \"text\": \" 12:27 AM\\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \\n Reason: Please review ERCP images done \\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p OLTX, with bile leak.\\n REASON FOR THIS EXAMINATION:\\n Please review ERCP images done \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR EXAM: Patient is a 53-year-old male status post liver\\n transplant, presenting with biliary leak status post ERCP , for review\\n of ERCP images.\\n\\n EXAMINATION: 33 single spot fluoroscopic images from ERCP reviewed.\\n\\n FINDINGS: 33 single spot fluoroscopic images obtained by gastroenterologist\\n without radiologist present reviewed. Surgical hardware from liver transplant\\n noted in fluoroscopic images. There is a 10-mm long single smooth stricture\\n present in the middle third of the common bile duct, likely at the site of the\\n duct-to-duct anastomosis. There is some mild post-obstructive dilitation of\\n the biliary tree. The visualized biliary tree is otherwise unremarkable. There\\n is interval placement of a common bile duct biliary stent.\\n\\n IMPRESSION: Common bile duct stricture at site of anastomosis status post\\n stenting.\\n\\n Please refer to ERCP report on for full report, findings, and\\n recommendations.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-15 00:00:00.000\",\n \"description\": \"PERC PORTAL VEIN CATH\",\n \"row_id\": 1022099,\n \"text\": \" 12:01 PM\\n PORTAL VENOGRAPHY Clip # \\n Reason: Pt needs portal stent for stenosis\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n Contrast: VISAPAQUE Amt: 80\\n ********************************* CPT Codes ********************************\\n * PERC PORTAL VEIN CATH INJ SINUS TRACT, THERAPUTIC *\\n * -51 MULTI-PROCEDURE SAME DAY PERC TRANHEP PORTOGRAPHY WITH *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant with rising bili, CT showing stenosis at\\n portal anastomosis.\\n REASON FOR THIS EXAMINATION:\\n Pt needs portal stent for stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTOGRAM WITH PRESSURES\\n\\n INDICATION: Seven days after liver transplant with increasing LFTs and\\n suggestion of a portal venous anastomosis stenosis by MRV.\\n\\n Details of the procedure and possible complications were explained to the\\n patient and informed consent was obtained.\\n\\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist,\\n was present for the entire procedure.\\n\\n TECHNIQUE AND FINDINGS: Using sterile technique, local anesthesia and\\n conscious sedation, the peripheral portal branch in the right lobe of the\\n liver was accessed with a 21-gauge needle and an Accustick sheath was placed\\n over the wire using Seldinger technique. The catheter and the wire were then\\n placed through the sheath and advanced into the splenic vein under\\n fluoroscopic guidance. Portogram was performed in several projections. A\\n pressure gradient was then measured across the portal vein anastomosis. There\\n is some discrepancy in size of the donor and native portal veins with relative\\n stenosis at their anastomosis, which is not hemodynamically significant. There\\n is a very brisk flow through the anastomosis and the pressure gradient across\\n the anastomosis was 3 mmHg.\\n\\n The findings were discussed with Dr. and it was decided not to perform\\n any interventions at this time. The catheter was removed. The liver\\n parenchymal tract was embolized with two Gelfoam pledgets through the sheath\\n and the sheath removed.\\n\\n The patient tolerated the procedure well. There were no immediate\\n complications.\\n\\n IMPRESSION: Discrepancy in size between the native and donor portal veins\\n with relative stenosis, but no significant pressure gradient across the\\n anastomosis. No interventions performed after discussion with Dr. .\\n\\n\\n (Over)\\n\\n 12:01 PM\\n PORTAL VENOGRAPHY Clip # \\n Reason: Pt needs portal stent for stenosis\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n Contrast: VISAPAQUE Amt: 80\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2139-08-20 00:00:00.000\",\n \"description\": \"CT PERITINEAL DRAIN EXCLUDING APPENDICEAL\",\n \"row_id\": 1022948,\n \"text\": \" 4:37 PM\\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \\n CT GUIDANCE DRAINAGE\\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ********************************* CPT Codes ********************************\\n * CT PERITINEAL DRAIN EXCLUDING APPEND -79 UNRELATED PROCEDURE/SERVICE DURI *\\n * CT GUIDANCE DRAINAGE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p liver transplant and now with a new subhepatic fluid\\n collection\\n REASON FOR THIS EXAMINATION:\\n NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE. SEND SAMPLE FOR\\n GRAM STAIN AND CULTURE AND FOR TOTAL BILI\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man status post liver transplant, now with new\\n subhepatic fluid collection.\\n\\n PROCEDURE:\\n The risks, benefits, and alternatives, including intravenous moderate\\n sedation, were explained to the patient who gave her an informed consent.\\n\\n A pre-procedural timeout was performed using two patient identifiers.\\n\\n The patient received intravenous moderate sedation (150 mcg of fentanyl, 3 mg\\n of Versed), during the procedure. There was continuous monitoring by\\n radiology nursing staff for a total intra-service time of 35 minutes.\\n\\n Pre- procedural non-contrast scan of the abdomen was performed, again\\n demonstrating a perihepatic fluid collection. After review of the scan, a\\n suitable site for catheter placement was chosen. The overlying skin was\\n prepped and draped in usual sterile fashion. 10% lidocaine was given in the\\n subcutaneous tissues as local anesthetic. Under CT guidance, an 8 French\\n catheter was advanced into the collection. Approximately 260 cc of\\n serosanguineous fluid was aspirated. The catheter was connected to a drainage\\n bag and securely fastened to the skin using a StatLock device. A sterile\\n dressing was applied. The patient tolerated the procedure, without immediate\\n post-procedural complications.\\n\\n Samples were sent to the lab for bilirubin and amylase as well as gram stain\\n and culture.\\n\\n Dr. , the attending physician, present for and performed the\\n entire procedure.\\n\\n IMPRESSION: Successful placement of catheter into perihepatic fluid\\n collection.\\n\\n\\n (Over)\\n\\n 4:37 PM\\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \\n CT GUIDANCE DRAINAGE\\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\\n Admitting Diagnosis: END STAGE LIVER FAILURE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134749,\n \"text\": \"Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\\nchange.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134750,\n \"text\": \"Sinus rhythm. Small non-diagnostic Q waves in the inferolateral leads.\\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\\nof there is no significant diagnostic change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134751,\n \"text\": \"Sinus rhythm. Non-diagnostic Q waves in leads II, III and aVF. Compared to\\nthe previous tracing of ventricular ectopy is absent. Otherwise,\\nno diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134752,\n \"text\": \"Sinus rhythm and occasional ventricular ectopy. Non-specific ST-T wave\\nchanges. Compared to the previous tracing of the recording is of\\nimproved technical quality. Otherwise, no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385972,\n \"text\": \"CONDITION UPDATE\\nVSS. LOWGRADE TEMP. AS SHIFT PROGRESSED CVP DECREASING, PA READINGS LOWER, PT GIVEN MULT FLUID BOLUSES W/ MOD EFFECT MD'S ORDERS. PT WEANED OFF OF NEO. WEANED OFF PPF. LUNGS COARSE THROUGHOUT. MOD AMT OF SUCTIONING FOR THICK TAN SECRETIONS. ABD OBESE. NO BOWEL SOUNDS AUSCULTATED. ORIG SURGICAL INCISION INTACT - MOD S/S DRAINAGE NOTED. JP'S PATENT - MOD AMT OF SEROUS DRAINAGE OUT. U/O ADEQUATE (SEE FLOWSHEETS). PT WEANED SUCCESSFULLY TO CPAP - EXTUBATED AT 18:00 W/O INCIDENT. PT REMAINS ON INSULIN DRIP - BSUGARS SOMEWHAT LABILE - INSULIN PROTOCOL FOLLOWED. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE W/ EFFECT.\\nCONT CURRENT ICU CARE AND ASSESSMENTS. MONITOR FOR S/S OF BLEEDING/INFECTION/REJECTION. AGGRESSIVE PULMONARY TOILET. PAIN MANAGEMENT. PT AND FAMILY TEACHING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385973,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objective data and trends:\\nNEURO-Pt alert and oriented X 3, follows commands appropriately.\\nRESP-LS are coarse to clear and diminished at bases. Pt able to cough up secretions. Pt weaned to nasal cannula at 6 liters O2 and pt's pox 96-98%.\\nCV/Heme-Pt's HR 90s, NSR. CVP readings remain low 0-2 ?accuracy of readings. Pt given 2 units PRBC and 1 unit of platelets for HCT of 24.1 and PLTs 50. BPs running 110's/50s initially and now up to 130s/60s after transfusion. PA pressures low at start of shift but improved post transfusions as well Cardiac output trended up from 7 to during blood transfusion, Dr. aware of elevated C.O.(see flowsheet for specifics) Awaiting lab results post transfusion.\\nGI-abdomen is obese, bowel sounds heard on auscultation. Pt taking small sips of water without difficulty. Pt denies nausea. No bowel movement overnight.\\nGU-urine icteric in color, putting out 35-60cc of urine per hour.\\nENDO-insulin drip continues-Blood sugars running 104-130s.\\nPLAN-plan to change out PA catheter line today if pt remians stable. Monitor labs closely, follow HCT and platelet levels. Turn/reposition as tolerated ? OOB today. Monitor urine output closely.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385976,\n \"text\": \"7pm-7am nursing note\\nsee CareVue for objective data and trends:\\nNeuro-pt is alert and oriented X 3, MAE, follows commands appropriately.\\nResp-Pt on 4 liters via NC and maintaining pox at 96-98%. LS clear bilaterally,decreased at bases. Pt with productive cough, bringing up small amounts of white sputum.\\nCV/heme-Pt HR 70s-80s in NSR. Pt BP 130s-140s/60s. PA pressures running 30-40s/. CVP 3-7. Pt HCT stable at present, continue to follow HCTs.\\nGI-Pt NPO, ok for sips with meds. Abdomen is obese with positive bowel sounds. Pt c/o abdominal discomfort and getting morphine 2mg for pain with fair effect. Abdomen with surgical dressing and medial and lateral JP drains.\\nGU-Pt urine output at has been >100cc/hr.\\nPLAN-Follow HCTs, if HCT drops Dr. to consider pt going back to OR to explore abdomen. Follow LFTs as well as pt's levels have been trending up. ? change PA line over to central IV access.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385977,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nSEE CAREVUE FOR DETAILS.\\n\\nNEURO: A&OX3. MAE, WEAK. C/O INCISIONAL PAIN, RECIEVING 2MG MORPHINE W/EFFECT.\\nRESP: SAT'S 97-99% 4L NC. LUNGS CLEAR, DIMINISHED AT BASES. PRODUCTIVE COUGH BRINGING UP SCANT/SMALL AMTS THICK WHITE SECRETIONS, USING YANKEUR APPROPRIATELY. USING IS.\\nCV: NSR HR 70-80. SBP 140-160. CVP 4-10. RECIEVED 1UNIT PLATELETTES IN AM, GOAL TO MAINTAIN PLT LEVEL >50. SWAN TO REMAIN IN PER DR WHO SPOKE W/TRANSPLANT TEAM, AWARE THAT NUMBERS VARY GREATLY AT TIMES. PAP 37-28/25. SVO2 76-80. CO 7.8-12. MONITORING HCT AND LFTS.\\nGI: OBESE ABDOMEN. + BS. NO BM. ADVANCED TO CLR DIET TODAY. PO'S WELL. LIVER US DONE AT BS, ORDERED TO MONITOR AV FLOW.\\nENDO: INSULIN GTT, TITRATING ACCORDING TO SCALE.\\nGU: FOLEY PATENT, ADEQUATE CYU.\\nSKIN: TRANSPLANT INCISION C/D/I. JP X2 DRAINING AROUND INSERTION SITE, SM AMTS SER/SANG IN JP BULBS. ECCYMOSIS AROUND SWAN-GANZ SITE ON NECK, TEAMS AWARE; ALSO SM AREA OF ECCYMOSIS NOTED ON LEFT SIDE OF NECK AS WELL.\\nSOCIAL: FAMILY INTO VISIT. SISTER AND NEPHEW CALLED.\\n\\nPOC: MONITOR HCT, LFT'S. PLT >50. FOLLOW PA NUMBERS. ENC IS, C/DB. MONITOR DRAIN OUTPUT. PAIN/COMFORT. PROVIDE EMOTIONAL SUPPORT TO PT. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385974,\n \"text\": \"addendum to 7p-7am nursing note\\nPt's repeat HCT, post 2 units of PRBCs only bumped to 25 (from 24.1) Dr aware. Pt given an additional 2 units PRBCs and an additional unit of platelets. Subsequent HCT level came back at 26.5 and platelets at 55. Dr. and Dr. notified of values. Further plan pending.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385975,\n \"text\": \"CONDITION UPDATE\\nPT A/O X3. VSS. LOW GRADE TEMP, PRESENTLY TEMP 98.8. SBP 102 TO 136. PA NUMBERS ACCEPTABLE; PAS 37 TO 45, CO 10 TO 14. CVP CONT TO BE LOW HOWEVER PRESSURE LABILE, 3 -10. SICU TEAM AND TRANSPLANT TEAMS AWARE. PT GIVEN 1UNIT OF PRBC'S THIS AM PER DR. ORDERS. REPEAT HCT 28.8. P.M. HCT PENDING. LUNGS CTA BILAT. O2 SAT ACCEPTABLE ON 4L NP. ABD OBESE. SURGICAL DRSG - OLD S/S STAINING. JP'S PUTTING OUT MIN SEROUS DRAINAGE, MOD AMT OF SEROUS DRAINAGE NOTED AROUND INSERTION SITE. U/O QS VIA FOLEY. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE MD'S ORDERS W/ EFFECT. CONT ON INSULIN DRIP.\\nMONITOR FOR S/S OF BLEEDING. SERIAL LABS AS ORDERED. MONITOR FOR S/S OF INFECTION. ENCOURAGE TURN/COUGH/DEEP BREATHE. PAIN MANAGEMENT. PT/FAMILY TEACHING. POSSIBLE O.R. IF HCT DROPS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385969,\n \"text\": \"Resp Care,\\nPt. admitted from OR intubated #8ET.BS equal. Placed on A/C, ABG slight resp. acidosis. See carevue. No RSBI due to OR procedure.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385970,\n \"text\": \"RN admission note\\nSee Carevue for data & specifics. See chart and FHP for HPI and medical history.\\n\\n53 yo male with hx of HCV/ETOH cirrhosis and hepatocellular carcinoma was received from the OR s/p liver transplant. No complications during case, per OR report.\\n\\nNEURO: pt sedated on ppf, MAE, does not follow commands, open eyes to loud stimuli, withdraws to pain, PERRL. Pt appeared to be in pain as assessed by vital signs and grimace. IV morphine given with positive result.\\n\\nCV: ST in 130s when arrived. Currently 110s. No ectopy. Episodes of hypotension to 70s systolic, 500 cc bolus x 1 given and neo gtt started, currently at 0.6 , MD aware. SV02 initially in 40s and 30s. MD aware. Monitor recalibrated and now in 70s. Wedge not done d/t elevated INR. CVP 6-8.\\n\\nRESP: Ventilated on AC. Initially put on 50% Fi02 but PA02 low, so increased to 100% then weaned to 70% and 50% with ABGs improving with each vent change.\\n\\nGI: NGT to suction, draining bilious fluid. Medial JP and Lateral JP both patent and draining sanquinous fluild. Abdominal dsg intact.\\n\\nGU: Foley draining clear urine but output slowly decreasing. MD aware.\\n\\nENDO: BS elevated. Insulin gtt started.\\n\\nSOCIAL: Nephew called for an update.\\n\\nPLAN: Continue to monitor VS closely. Monitor lab values closely and tx abnormal values as ordered. Wean from neo gtt as tolerated. Wean from vent to extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385971,\n \"text\": \"resp care - Pt was extubated without incident and placed on cool aerosol. See carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-08-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1385978,\n \"text\": \"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT ALERT AND ORIENTED X 3. MAE EQUALLY. NO NEURO DEFICITS. 4L NC. LUNGS CLEAR. RSR. BP WNL ON LOPRESSOR ATC. AFEBRILE. CCO SWAN IN PLACE VIA CATHETER. PA PRESSURES UNCHANGED FROM PT BASELINE. NOT WEDGING SECONDARY TO LOW PLTS. SVO2 AND CO WITHIN PT BASELINE. STRONG PEDAL PULSES PALPABLE. LARGE OBESE ABDOMEN, SOFT, WITH BOWEL SOUNDS PRESENT, HYPOACTIVE AT TIMES. TOL CLEAR LIQUIDS. INCISION WITH DSD , NO DRAINAGE. TWO JP'S WITH SMALL AMT SEROSANG OUTPUT. FOLEY ADEQUATE URINE OUTPUT. MORPHINE SULFATE FOR PAIN. PNEUMO BOOTS. HOLDING HEPARIN PER DR. . PLAN: FOLLOW HCT'S AND PLTS, ?DC SWAN AND CHANGE TO CVL OVER WIRE TODAY, ?DC RICC LINE, MONITOR HEPATIC FUNCTION, IMMUNOSUPRESSIVES AS ORDERED, ?OOB, PAIN CONTROL.\\n\"\n }\n]"}}},{"rowIdx":24973,"cells":{"subject_id":{"kind":"number","value":56960,"string":"56,960"},"hadm_id":{"kind":"number","value":149518,"string":"149,518"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"Right bundle-branch block.Non-specific ST-T wave changes. Right axis deviation. Sinus tachycardia with right bundle-branch block and secondary ST-T waveabnormalities. Compared to the previous tracing of right axis deviation is new. Sinus tachycardia."},"n_notes":{"kind":"number","value":2,"string":"2"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2118-03-21 00:00:00.000","description":"Report","row_id":222251,"text":"Sinus tachycardia with right bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"},{"category":"ECG","chartdate":"2118-03-21 00:00:00.000","description":"Report","row_id":222250,"text":"Sinus tachycardia. Right axis deviation. Right bundle-branch block.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nright axis deviation is new.\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2118-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222251,\n \"text\": \"Sinus tachycardia with right bundle-branch block and secondary ST-T wave\\nabnormalities. Compared to the previous tracing of no diagnostic\\ninterval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2118-03-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 222250,\n \"text\": \"Sinus tachycardia. Right axis deviation. Right bundle-branch block.\\nNon-specific ST-T wave changes. Compared to the previous tracing of \\nright axis deviation is new.\\n\\n\"\n }\n]"}}},{"rowIdx":24974,"cells":{"subject_id":{"kind":"number","value":11505,"string":"11,505"},"hadm_id":{"kind":"number","value":106933,"string":"106,933"},"target_text":{"kind":"string","value":"1)Chemical pneumonitis due to chlorine. Pt presented to ED with unresponsiveness and was intubated for airway protection and difficulty breathing. A toxicology consult was obtained and pt was treated with a course of steroids as per their recommendations. After 5 days of mechanical ventillation pt was extubated without difficulty. There was a minor component of reactive airway disease and so pt was given tiotropium and Advair. Because he has no history of COPD and was previously without respiratory compromise, tiotropium was discontinued. As he continued to have mild wheeze, Advair was continued with instrution to discontinue after one more week. 2)Possible aspiration pneumonia in addition to pneumonitis: On arrival to the MICU, there was concern that the pt may have developed an aspiration pneumonia in the setting of decreased consciousness. He was treated with 7 day course of antibiotics."},"extractive_notes_summ":{"kind":"string","value":"BS rhonchi, occ wheeze; no change with MDI's. Trivial mitral regurgitation is seen. LS dimished throughout, exp wheeze resolved throughout shift w/ administration of albuterol/Qvar. Normal ascending aortadiameter. There is a trivial/physiologicpericardial effusion. recieving antibx. Denies any discomfort.Resp: Remains on Time Cycled Pressure Controled Ventilation, PEEP dropped from 12 to 10, RR 28 -30. a febrile and continued on ceftriaxone iv. Compared to the previous tracing of nosignificant diagnostic change.TRACING #1 Neb treatment given.Cv: 1st degree av block, without any ectopy, SBP 110-120's, monitoring via lt radial aline. now suctioning increased tan thin sputum.+temp. resp careremains intubated/vented in spontaneous mode. BS clear upper and diminished at the bases. Left ventricular function.Height: (in) 68Weight (lb): 170BSA (m2): 1.91 m2BP (mm Hg): 167/59HR (bpm): 67Status: InpatientDate/Time: at 14:56Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. psv weaned to however pt with pronounced insp/expir wheezing and active exhalation. No other significant events.Review of Systems:Neuro: Lightly sedated on propofol, arouse to voice, able to track and follows commands. Suctioned for moderate-copious amounts of thin tan secretions.GU/GI: NPO, abd firm/nt/nd, +BS, -BM, patent foley draining >75cc clear yellow (occasional clots).Access: 18G R AC, 18 G L hand, L a-line, all ports flush appropriately.Plan: Cont to monitor/maintain heme/resp status. No c/o discomfort.CV: 1st deg AV block (PR .23), w/ no appreciable ventricular ectopy, art waveform dampened unable to get accurate pressure even with repositioning NBP 120's -140s. Lung sounds bilat I/E wheeze R>L with bibasilar rales; mod th off white sput. RESPIRATORY CARE:Pt remains intubated, vent supported. The mitral valve leaflets are mildlythickened. Please refer to carevue for objective data.Resp: Intubated 7.5 ETT 22 @ lip, Remains on 40% 12PS PEEP 5, RR 27-32, wheeze's persist despite albuterol/qvar nebs. Wean vent support, re-evaluate possibility of extubation in AM. Borderline first degree A-V block. Surface ecco performed @ bedside. Resp Care Note:Pt received from West ER intub with OETT and placed on mech vent as per Carevue. Please refer to carevue for objective data.GU/GI: NPO, abd firm/NT/ND, +BS, Patent foley draining >100cc/hr, urine became pink after pt recieved heparin SC/plavix po and has since resolved. Rest overnight, wean vent support and extubate @ earliest opportunity. Team does not suspect low airway compliance r/t Chlorine gas inhalation, as CXR inidicative for RUL infiltrates (probable aspiration).CV: 1st deg AV block (PR .23), no appreciable ventricular ectopy, ABP 120's-140 systolic. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Tricuspid valve not well visualized.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Suboptimal image quality. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded. new sepsis.Continue to monitor respiratory and hemodynamic status. BS's diminished, sxing thick pale tan secretions. Plan to continue weaning vent support as pt can tolerate. BS tight with insp and expir wheezes. RESP: BS'S RHONCHEROUS THROUGHOUT AND SOME WHEEZING NOTED EARLIER. LAST ABG WAS BETTER.GI: TO BE STARTED ON TF'INGS. BS coarse wheezes, MDI's as ordered. UPDATED.PLAN: RECHECK ABG'S AND K+ LATER D/T DIURESIS. GIVEN ATIVAN 1MG AND FENT 100MCQS IVP X1, BUT PT. BP IMPROVED WITH SEDATION.ID: CONT. TRIES TO REACH FOR TUBE.EARLIER ABLE TO WRITE AND ALERT AND MOUTHING WORDS.CV: HYPERTENSIVE TO 160'S WITH AGITATION. tube feeds d/ced. DOES REQUIRE AN OCCASS BOLUS. NSG.NOTES 1900-0700HRSA case of chloride gas inhalation,intubated and ventillated.Neuro:Sedated with propofol 22.6mcg/kg/hr which titrated to 15.07mcg as pt sedated well and HR remains 42-50/min.responding to call and pain.easily arousable.Resp:Intubated and ventillated,mode CPAP+PS,PEEP 5,Psupp 12,fio2 50%.blood gas done 7.4/43/150/2/28.suctioned small thick yellow secretions.sats >95% RR 10-16/min.coarse on auscultation.CVS:HR 42-50/min when sleeping and >50's when awake.Sinus brady.no PVC'noted.BP 120-145/40-68 MM OF HG.GI/GU:Abdomen soft ,bowel sounds present, sump OGT in place,started on feed Nutren pulmonary 10 ml/hr and then advanced to 20ml/hr after 4 hours,feed started as MD and orders to be put in.nil residue.on foley cath,UO adequate ,clear yellow urine.Integu:skin impaired,blister on left upper leg ,open to air.both hands restrained,circulation adequate.pulse present.T max 97.bath given and repositioned.all hygenic needs attended.IV access:two PIV'S ;one on each hand,patent,dressing intact.site looks clean.A line on Left radial,patent,BP monitoring.dressing ,pressure kit and saline changed.Endo:on sliding scale insulin.Social:no family visit or phone call this shift.full codePlan:wean off .advance tube feed if tolerating to acheieve goal rate of 40ml/hr. Resp Care,Pt. goal for today to diurese and wean to extubate.neuro: pt very alet and able to write messages on 15 mcg/kg/hr propofol. extubated at 1630 with improved gag off propophol. BS's coarse with, exp wheezes. PLACED ON PS OF , BUT AFTER HRS PT. LS range from exp wheezes to course throughout. but urine output only 20-30cc/hr Plan; cont to support as pt is very bronchospastic, inhalers as ordered. failed wean of psv earlier with increased wheezing,and access muscle use. GU; foley in place and draining well. SUCTIONED FOR COPIOUS TO MOD. Post extubation vitals HR 67, BP 156/80, RR 19 and non labored, SpO2 95 % on 0.5 via OFM. able to cough and talk and oriented x3. IPS wean as tol. ABG showed pH 7.26/55/, trouble with rising PIP's during fluid bolus, changed over to PCV Peep of 12cm,inspiratory pressure of 37, generating TV 400-480cc minute ventilation of 9liters/min. on D5w @ 180cc/hr. resp careremains intubated/vented in spontaneous mode. ABG slightly improve to pH 7.28. bronchodilators q4 and q2 as needed. remains intubated overnoc on IPS 12. BOTH HAVE IMPROVED WITH DIURESIS. hypernatremia tx with d5w at 75 cc/hr as pt is npo for extubation and flushes of 50 cc/q4h held.resp: secretions ranging yellow to white frothy and blood tinged.pt coughing. c/w frequent secretions although less tan than yesterday. AMTS OF THICK YELLOW SECRETIONS Q1-2HRS. 88 yr old pt post chlorine inhalation. may need to repeat lytes this pm. ID: hypothermic to 95 orally, placed on bair hugger, blood culture x1 urine sent."},"n_notes":{"kind":"number","value":24,"string":"24"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2175-08-03 00:00:00.000","description":"Report","row_id":99933,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 167/59\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 14:56\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Aortic valve not well seen. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nSuboptimal image quality. The left atrium is normal in size. Left ventricular\nwall thickness, cavity size, and systolic function are normal (LVEF>55%). Due\nto suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. There is no ventricular septal defect. Right ventricular\nchamber size and free wall motion are normal. The aortic valve is not well\nseen. There is no aortic valve stenosis. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. There is a trivial/physiologic\npericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2175-08-01 00:00:00.000","description":"Report","row_id":283073,"text":"Sinus rhythm. Borderline first degree A-V block. ST junctional depressions\nwhich are non-specific. Compared to the previous tracing of no\nsignificant diagnostic change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2175-08-02 00:00:00.000","description":"Report","row_id":283072,"text":"Baseline artifact. Sinus bradycardia. Compared to tracing #1 no significant\ndiagnostic change.\nTRACING #2\n\n"},{"category":"Nursing/other","chartdate":"2175-08-03 00:00:00.000","description":"Report","row_id":1413155,"text":"RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Weaned vent support from PCV to AC without event. BS's diminished, sxing thick pale tan secretions. Administering MDI's as ordered, see flowsheet for times and further pt data. Plan to continue weaning vent support as pt can tolerate. Will follow.\n"},{"category":"Nursing/other","chartdate":"2175-08-03 00:00:00.000","description":"Report","row_id":1413156,"text":"NPN M/SICU ICU DAY 2 (0700 -1900)\n\nEvents: Failed SBT this AM, became wheezy throughout all lung fields tachypneic, Co2 rose, pt tongued out OG tube which was replaced & confirmed by cxr, PS increased from to PS 12 PEEP 5, propofol restarted. Abx tx started. Surface ecco performed @ bedside. Pt rested comfortably for remainder of shift.\n\nReview of Systems;\n\nNeuro: Lightly sedated on propofol, opens eyes and nods head appropriately to questions, able to track and follow commands, MAE. No c/o discomfort.\n\nCV: 1st deg AV block (PR .23), w/ no appreciable ventricular ectopy, art waveform dampened unable to get accurate pressure even with repositioning NBP 120's -140s. Tmax 99.2. Please refer to carevue for objective data.\n\nResp: Intubated 7.5 ETT 22 @ lip, Remains on 40% 12PS PEEP 5, RR 27-32, wheeze's persist despite albuterol/qvar nebs. Suctioned for moderate-copious amounts of thin tan secretions.\n\nGU/GI: NPO, abd firm/nt/nd, +BS, -BM, patent foley draining >75cc clear yellow (occasional clots).\n\nAccess: 18G R AC, 18 G L hand, L a-line, all ports flush appropriately.\n\nPlan: Cont to monitor/maintain heme/resp status. Wean vent support, re-evaluate possibility of extubation in AM. Cont abx tx. Update family on POC as it develops.\n"},{"category":"Nursing/other","chartdate":"2175-08-03 00:00:00.000","description":"Report","row_id":1413157,"text":"resp care\nremains intubated/vented in spontaneous mode. psv weaned to however pt with pronounced insp/expir wheezing and active exhalation. increased to , given combivent q4h and receiving inhaled steroid . now suctioning increased tan thin sputum.+temp. wheezing persists but pt denies any sob. unable to wean despite good rsbi, increased wheezing and sputum production.\n"},{"category":"Nursing/other","chartdate":"2175-08-04 00:00:00.000","description":"Report","row_id":1413158,"text":"Nursing progress notes (0410)\nReview carevue for all other additional data\n\nAllergy: Iodine, iodine containing\ncode: full\n\n88 yo male with h/o CAD,s/p CABG, HTN and multiple urologic procedure,admitted to MICU with episode of unresponsives in seting of chlorine exposure and respiratory disress, pneumonia and failed SBT on . No significant events overnight.\n\nNeuro: Lightly sedated with propofol and increased the dose to 22mic/kg/min to keep him comfortable with ETT.Eyes opens spontaneously and following commands. Bilateral wrist restraints are in place for safety.\n\nResp: Vent mode changed to A/C to rest overnight, and plan to wean sedation and to do RSBI and SBT in am. Bilateral lung sounds coarse and exp wheeze, copius secreation with suction. Neb treatment given.\n\nCv: 1st degree av block, without any ectopy, SBP 110-120's, monitoring via lt radial aline. a febrile and continued on ceftriaxone iv. AM labs pending.\n\nGu/Gi: NPO, abd firm, BS present and no BM this shift. UO 30-120ml/hr via foley's catheter.\n\nSkin: Intact\nsocial; no call from family overnight\n\nPlan: wean sedation, SBT and ?possible extubation, patient with increased secreation and exp wheeze. ? to start TF if no extubation today. monitor temp curves and labs and continue antibiotics.\nEmotional support to patient and family and routine ICU care.\n"},{"category":"Nursing/other","chartdate":"2175-08-02 00:00:00.000","description":"Report","row_id":1413151,"text":"Resp Care Note:\n\nPt received from West ER intub with OETT and placed on mech vent as per Carevue. Lung sounds bilat I/E wheeze R>L with bibasilar rales; mod th off white sput. MDI given as per order and with good result. Pt initially with elevated PIPs. Attempted decreasing Vt and increase rate which resulted in autoPeep switched to PCV which resulted in lower PIP. Most recent ABG show slow improvement, may require more vent \"tweaking\" to optimize gas exchange today. Cont mech vent support/bronchodilators/inhaled steroids.\n"},{"category":"Nursing/other","chartdate":"2175-08-02 00:00:00.000","description":"Report","row_id":1413152,"text":"NPN M/SICU ICU day 1 (0700 - 1900)\n\nEvents: A-line placed, Hypothermia/hypotension resloved, propofol weaned to 20mcg/kg/min from 45. PCP updated on current status. No other significant events.\n\nReview of Systems:\n\nNeuro: Lightly sedated on propofol, arouse to voice, able to track and follows commands. MAE. PEARL. Denies any discomfort.\n\nResp: Remains on Time Cycled Pressure Controled Ventilation, PEEP dropped from 12 to 10, RR 28 -30. Most recent ABG 7.36/41/121. LS dimished throughout, exp wheeze resolved throughout shift w/ administration of albuterol/Qvar. Team does not suspect low airway compliance r/t Chlorine gas inhalation, as CXR inidicative for RUL infiltrates (probable aspiration).\n\nCV: 1st deg AV block (PR .23), no appreciable ventricular ectopy, ABP 120's-140 systolic. T-max 99.9 not currently on prophylactic abx (team aware of rising temp). Please refer to carevue for objective data.\n\nGU/GI: NPO, abd firm/NT/ND, +BS, Patent foley draining >100cc/hr, urine became pink after pt recieved heparin SC/plavix po and has since resolved. Fluid Status +2.2 liters for LOS.\n\nAccess: 18G R AC, 18 G L hand, L radial A-line all ports flush appropriately.\n\nPlan: Monitor/maintain heme/resp status. Rest overnight, wean vent support and extubate @ earliest opportunity. Monitor rising temp, possible initiation of abx therapy. Update pt on POC as it develops.\n"},{"category":"Nursing/other","chartdate":"2175-08-02 00:00:00.000","description":"Report","row_id":1413153,"text":"BS rhonchi, occ wheeze; no change with MDI's. Able to wean PEEP to 10 and will continue to wean as tolerated. Slight temp, ? new sepsis.\nContinue to monitor respiratory and hemodynamic status.\n"},{"category":"Nursing/other","chartdate":"2175-08-03 00:00:00.000","description":"Report","row_id":1413154,"text":"MICU Nursing Progress Note\n Respiratory: intubated and vented with settings of PCV PEEP 10cm, TV range 450-500cc RR 30, FIO240% this am weaned to A/C 450 x 20 breaths and 10cm PEEP ABG 7,38/44/99 will cont to wean with hopes of extubating this am. suctioned q3-4 hr for thick pink to tan sputum spec sent for culture. BS clear upper and diminished at the bases.\n Cardiac: HR 58-64 1st degree block. BP stable 110-120/60's\n neuro: sedated on propofol at 20mcg/kg/hr pt will respond to his name will answer to yes/no questions with nodding of head. is following commands. MAE, helping with turning in bed.\n GU foley in place, occasional clots passed, urine from yellow to pink.\n GI: NPO, abd firm with hypoactive BS, no stool,\n ID: low grade temp most of night, fully cultured, not on any antibx awaiting cultures..\n Plan: cont with vent wean as tolerated, extubate if possible. follow temp and awaiting culture results.\n"},{"category":"Nursing/other","chartdate":"2175-08-06 00:00:00.000","description":"Report","row_id":1413169,"text":"uneventful day:\n\nneuro: A&O x3 weak but oob to chair and commode with 1 assist .\n\ncard: d/ced a line. sys bp 130-165. nr 50' with sleep and up to 70 nsr no ectopy\n\nresp: pt progressed from 50% face tent to 3l nc. resp status improved with IS. copius amts yellow sputum. recieving antibx. pt developes wheeze with exertion and has good response to inhalers and uses inhalers at home\n\ngi: hem neg lg bm on commode. good appetite. this am pt seemed to have more congested cough after taking po liquids and does better with soft foods.\n\ngu: bun 25 creat 1.5 and output adequate. hx kidney stones.\n\nskin: noted blister on lt lower back to have skin test for poss herpes\nand sseveral scratch marks on back\n\nplan: prob call out soon. resp monitoring and increase strength\n"},{"category":"Nursing/other","chartdate":"2175-08-07 00:00:00.000","description":"Report","row_id":1413170,"text":"NPN 1900 - 0700\n\nNEURO: AXOX3, PLEASANT AND COOPERTIVE. NO C/O\n\nRESP: LOOSE COUGH W/ YELLOW SECRETIONS.ON 4 L NC , DOE MAINT SATS 96-99%\n\nC/V: SR -ST NO ECOTPY BP STABLE.\n\nF/E/N: UO ~ 50-60CC HR TOL PO'S.NO STOOL OVERNOC.\n\nPLAN: BE C/O TO FLOOR TODAY IF REMAINS STABLE\n"},{"category":"Nursing/other","chartdate":"2175-08-02 00:00:00.000","description":"Report","row_id":1413150,"text":"MICU Nursing Progress Note\n pt is an 88y/o gentleman who had been working on a leak near pool filter in small enclosed room,family found pt to be confused and heavy smell of chlorine gas.. placed in shower and pt became unresponsive\nEMT's called, in the ew pt was unresponsive, intubated for airway precautions.\n Respiratory: intubated on the vent with settings of A/C 450cc x 18 PEEP of 12cm. ABG showed pH 7.26/55/, trouble with rising PIP's during fluid bolus, changed over to PCV Peep of 12cm,inspiratory pressure of 37, generating TV 400-480cc minute ventilation of 9liters/min. RR 30. ABG slightly improve to pH 7.28. BS tight with insp and expir wheezes. on albuterol and added comivent inhaler cont to have wheezes and diminished bs throughout all lung fields.\n Cardiac: HR 50's SB, no VEA, BP has ranged from low of 86 to high of 100/ did receive one fluid bolus of LR 500cc ... ?poor complaince after fluid bolus.\n Electrolytes: serum calcium 5.7 repleted. magnesium 1.7, sodium 149, will treat with 2liters of free water. on D5w @ 180cc/hr.\n ID: hypothermic to 95 orally, placed on bair hugger, blood culture x1 urine sent. not on antibx at present.\n GU; foley in place and draining well. but urine output only 20-30cc/hr\n Plan; cont to support as pt is very bronchospastic, inhalers as ordered. pt is hypothermic,bradycardic,hypotensive, ?thyroid labs.\n"},{"category":"Nursing/other","chartdate":"2175-08-04 00:00:00.000","description":"Report","row_id":1413159,"text":"RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Rested overnight on AC. BS's coarse with, exp wheezes. Administering MDI's as ordered. Sxing copious yellow secretions. RSBI=88 this am. See flowsheet for further pt data. Will follow.\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413165,"text":"88 yr old pt post chlorine inhalation. goal for today to diurese and wean to extubate.\n\nneuro: pt very alet and able to write messages on 15 mcg/kg/hr propofol. increased to 9 cc= 16+ mcg/kg/min for pt attempting to pull on et tube and biting et tube. ablo to MAE and good ROM.\n\ncard: hr drops to 40's with sleep but up when aroused. range 45-60 /min no pvcs notedbp 130-160 sys range. lasix 40 mg given at 1200 to diurese with good response at 1330 1000 cc+ output. just prior to lasix output dropped off to 20 cc/hr. hypernatremia tx with d5w at 75 cc/hr as pt is npo for extubation and flushes of 50 cc/q4h held.\n\nresp: secretions ranging yellow to white frothy and blood tinged.\npt coughing. LS range from exp wheezes to course throughout. blood gas after lasix is good except o2 80%. on 50% o2.\n\ngi/gu no bm today tube feeding off at 1200 for poss extubation . tolerated 20 cc/ hr and md requested 50 cc h2o flush q 4h but did not order. bs present. foley urine slightly brown tinged ? medication effects. GAG reflex is poor and will need to eval with propophol turned off prior to extubation\n\nskin NO breakdown,\n\niv access: 1 PIV both \n\nsocial: family called on phone and updated.\n\nendo: covered glucose as ordered, day 3 of 4 steroids administration.\n\nplan: poss extubate if gag and gas ok. resume tf if not extubated\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413166,"text":"Respiratory Care\nPt extubated today at 1630. Post extubation vitals HR 67, BP 156/80, RR 19 and non labored, SpO2 95 % on 0.5 via OFM. No stridor was noted and lung sounds had slight exp wheeze in the RUL and clear else where. Pt has a strong cough and is able to speak. Will continue to follow pt.\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413167,"text":"extubated at 1630 with improved gag off propophol. able to cough and talk and oriented x3. cxr post done as soft tissue swelling on lt neck noted post extubation. tube feeds d/ced. pt had 2400 cc response to lasix given at 1200 and vital are stable. may need to repeat lytes this pm.\n"},{"category":"Nursing/other","chartdate":"2175-08-06 00:00:00.000","description":"Report","row_id":1413168,"text":"NPN 1900-0700\nNeuro: Alert, oriented x3, denied any pain or discomfort.\n\nResp: Breathing regularly on FT 50%, RR 18-28, Sat 95-100%, LS CTA, coughing and expectorating moderate amount of thick yellowish secretions, which he spits in the kidney basin and sometimes suctioned by yanker, CPT done frequently, receiving resp. puffs.\n\nCV: SB-NSR HR 57-69, BP 119-159/59-104, with A-line and 2 PIV lines on ceftriaxone IV.\n\nGI/GU: NPO, yet tolerated meds with little water very well, abdomen soft, BS present, no BM during the night, with Foley cath drained adequate U/O.\n\nInteg: T max 98.2, covered with 2 units Humalogue insulin for FS 125 as per sliding scale.\n\nSocial: Full code, no contact from family over night.\n\nPlan: Monitor respiratory status and wean O2 as tolerated, perform CPT and continie resp tx, continue antibiotics, monitor FS and cover with insulin per sliding scale, consider nutrition, if stable, possible C/O of ICU.\n"},{"category":"Nursing/other","chartdate":"2175-08-04 00:00:00.000","description":"Report","row_id":1413160,"text":"RESP: BS'S RHONCHEROUS THROUGHOUT AND SOME WHEEZING NOTED EARLIER. SUCTIONED FOR COPIOUS TO MOD. AMTS OF THICK YELLOW SECRETIONS Q1-2HRS. SECRETIONS HAVE DECREASED SINCE GIVING HIM LASIX. DESATED SEVERAL TIMES REQUIRING UPPING HIS FIO2 TO 50%. PLACED ON PS OF , BUT AFTER HRS PT. DECOMPENSATED AND PLACED BACK TO WHERE HE REMAINS. LAST ABG WAS BETTER.\nGI: TO BE STARTED ON TF'INGS. PASSING FLATUS. NO STOOL.\nRENAL: GIVEN 40MG LASIX IVP WITH EXCELLENT DIURESIS.\nENDOC: NA 147 K+ 4.8 THIS AM. BOTH HAVE IMPROVED WITH DIURESIS. SSI INSULIN GIVEN.\nNEURO: PROPOFOL OFF FOR A BRIEF PERIOD DURING PS TRIAL. GIVEN ATIVAN 1MG AND FENT 100MCQS IVP X1, BUT PT. BECAME MORE AGITATED AND PROPOFOL BACK ON. DOES REQUIRE AN OCCASS BOLUS. PT. TRIES TO REACH FOR TUBE.\nEARLIER ABLE TO WRITE AND ALERT AND MOUTHING WORDS.\nCV: HYPERTENSIVE TO 160'S WITH AGITATION. BP IMPROVED WITH SEDATION.\nID: CONT. ON ANTIBIOTICS. AFEBRILE.\nACCESS: NEW IV PLACED IN LEFT ANTECUB.\nSOCIAL: WIFE IN BY HO'S. SON ALSO IN AS WELL AS HIS PCP. UPDATED.\nPLAN: RECHECK ABG'S AND K+ LATER D/T DIURESIS. CONT. ON PS.\n"},{"category":"Nursing/other","chartdate":"2175-08-04 00:00:00.000","description":"Report","row_id":1413161,"text":"resp care\nremains intubated/vented in spontaneous mode. failed wean of psv earlier with increased wheezing,and access muscle use. c/w frequent secretions although less tan than yesterday. bronchodilators q4 and q2 as needed. reassess daily for wean.\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413162,"text":"blister on Left lower back present,open to air.\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413163,"text":"NSG.NOTES 1900-0700HRS\n\nA case of chloride gas inhalation,intubated and ventillated.\n\nNeuro:Sedated with propofol 22.6mcg/kg/hr which titrated to 15.07mcg as pt sedated well and HR remains 42-50/min.responding to call and pain.easily arousable.\n\nResp:Intubated and ventillated,mode CPAP+PS,PEEP 5,Psupp 12,fio2 50%.blood gas done 7.4/43/150/2/28.suctioned small thick yellow secretions.sats >95% RR 10-16/min.coarse on auscultation.\n\nCVS:HR 42-50/min when sleeping and >50's when awake.Sinus brady.no PVC'noted.BP 120-145/40-68 MM OF HG.\n\nGI/GU:Abdomen soft ,bowel sounds present, sump OGT in place,started on feed Nutren pulmonary 10 ml/hr and then advanced to 20ml/hr after 4 hours,feed started as MD and orders to be put in.nil residue.\non foley cath,UO adequate ,clear yellow urine.\n\nIntegu:skin impaired,blister on left upper leg ,open to air.both hands restrained,circulation adequate.pulse present.T max 97.bath given and repositioned.all hygenic needs attended.\n\nIV access:two PIV'S ;one on each hand,patent,dressing intact.site looks clean.A line on Left radial,patent,BP monitoring.dressing ,pressure kit and saline changed.\n\nEndo:on sliding scale insulin.\n\nSocial:no family visit or phone call this shift.full code\n\nPlan:wean off .advance tube feed if tolerating to acheieve goal rate of 40ml/hr.\n\n\n"},{"category":"Nursing/other","chartdate":"2175-08-05 00:00:00.000","description":"Report","row_id":1413164,"text":"Resp Care,\nPt. remains intubated overnoc on IPS 12. VT 500 RR 18. BS coarse wheezes, MDI's as ordered. Suctioned for moderate amount thick yellow sputum. ABG acceptable, RSBI 52 this am. Cont. IPS wean as tol.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2175-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 99933,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Left ventricular function.\\nHeight: (in) 68\\nWeight (lb): 170\\nBSA (m2): 1.91 m2\\nBP (mm Hg): 167/59\\nHR (bpm): 67\\nStatus: Inpatient\\nDate/Time: at 14:56\\nTest: Portable TTE (Complete)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\\ncannot be fully excluded. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Aortic valve not well seen. No AS.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\\npattern c/w impaired relaxation.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nSuboptimal image quality. The left atrium is normal in size. Left ventricular\\nwall thickness, cavity size, and systolic function are normal (LVEF>55%). Due\\nto suboptimal technical quality, a focal wall motion abnormality cannot be\\nfully excluded. There is no ventricular septal defect. Right ventricular\\nchamber size and free wall motion are normal. The aortic valve is not well\\nseen. There is no aortic valve stenosis. The mitral valve leaflets are mildly\\nthickened. Trivial mitral regurgitation is seen. The left ventricular inflow\\npattern suggests impaired relaxation. There is a trivial/physiologic\\npericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283073,\n \"text\": \"Sinus rhythm. Borderline first degree A-V block. ST junctional depressions\\nwhich are non-specific. Compared to the previous tracing of no\\nsignificant diagnostic change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2175-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283072,\n \"text\": \"Baseline artifact. Sinus bradycardia. Compared to tracing #1 no significant\\ndiagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413155,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains intubated, vent supported. Weaned vent support from PCV to AC without event. BS's diminished, sxing thick pale tan secretions. Administering MDI's as ordered, see flowsheet for times and further pt data. Plan to continue weaning vent support as pt can tolerate. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413156,\n \"text\": \"NPN M/SICU ICU DAY 2 (0700 -1900)\\n\\nEvents: Failed SBT this AM, became wheezy throughout all lung fields tachypneic, Co2 rose, pt tongued out OG tube which was replaced & confirmed by cxr, PS increased from to PS 12 PEEP 5, propofol restarted. Abx tx started. Surface ecco performed @ bedside. Pt rested comfortably for remainder of shift.\\n\\nReview of Systems;\\n\\nNeuro: Lightly sedated on propofol, opens eyes and nods head appropriately to questions, able to track and follow commands, MAE. No c/o discomfort.\\n\\nCV: 1st deg AV block (PR .23), w/ no appreciable ventricular ectopy, art waveform dampened unable to get accurate pressure even with repositioning NBP 120's -140s. Tmax 99.2. Please refer to carevue for objective data.\\n\\nResp: Intubated 7.5 ETT 22 @ lip, Remains on 40% 12PS PEEP 5, RR 27-32, wheeze's persist despite albuterol/qvar nebs. Suctioned for moderate-copious amounts of thin tan secretions.\\n\\nGU/GI: NPO, abd firm/nt/nd, +BS, -BM, patent foley draining >75cc clear yellow (occasional clots).\\n\\nAccess: 18G R AC, 18 G L hand, L a-line, all ports flush appropriately.\\n\\nPlan: Cont to monitor/maintain heme/resp status. Wean vent support, re-evaluate possibility of extubation in AM. Cont abx tx. Update family on POC as it develops.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413157,\n \"text\": \"resp care\\nremains intubated/vented in spontaneous mode. psv weaned to however pt with pronounced insp/expir wheezing and active exhalation. increased to , given combivent q4h and receiving inhaled steroid . now suctioning increased tan thin sputum.+temp. wheezing persists but pt denies any sob. unable to wean despite good rsbi, increased wheezing and sputum production.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413158,\n \"text\": \"Nursing progress notes (0410)\\nReview carevue for all other additional data\\n\\nAllergy: Iodine, iodine containing\\ncode: full\\n\\n88 yo male with h/o CAD,s/p CABG, HTN and multiple urologic procedure,admitted to MICU with episode of unresponsives in seting of chlorine exposure and respiratory disress, pneumonia and failed SBT on . No significant events overnight.\\n\\nNeuro: Lightly sedated with propofol and increased the dose to 22mic/kg/min to keep him comfortable with ETT.Eyes opens spontaneously and following commands. Bilateral wrist restraints are in place for safety.\\n\\nResp: Vent mode changed to A/C to rest overnight, and plan to wean sedation and to do RSBI and SBT in am. Bilateral lung sounds coarse and exp wheeze, copius secreation with suction. Neb treatment given.\\n\\nCv: 1st degree av block, without any ectopy, SBP 110-120's, monitoring via lt radial aline. a febrile and continued on ceftriaxone iv. AM labs pending.\\n\\nGu/Gi: NPO, abd firm, BS present and no BM this shift. UO 30-120ml/hr via foley's catheter.\\n\\nSkin: Intact\\nsocial; no call from family overnight\\n\\nPlan: wean sedation, SBT and ?possible extubation, patient with increased secreation and exp wheeze. ? to start TF if no extubation today. monitor temp curves and labs and continue antibiotics.\\nEmotional support to patient and family and routine ICU care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413151,\n \"text\": \"Resp Care Note:\\n\\nPt received from West ER intub with OETT and placed on mech vent as per Carevue. Lung sounds bilat I/E wheeze R>L with bibasilar rales; mod th off white sput. MDI given as per order and with good result. Pt initially with elevated PIPs. Attempted decreasing Vt and increase rate which resulted in autoPeep switched to PCV which resulted in lower PIP. Most recent ABG show slow improvement, may require more vent \\\"tweaking\\\" to optimize gas exchange today. Cont mech vent support/bronchodilators/inhaled steroids.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413152,\n \"text\": \"NPN M/SICU ICU day 1 (0700 - 1900)\\n\\nEvents: A-line placed, Hypothermia/hypotension resloved, propofol weaned to 20mcg/kg/min from 45. PCP updated on current status. No other significant events.\\n\\nReview of Systems:\\n\\nNeuro: Lightly sedated on propofol, arouse to voice, able to track and follows commands. MAE. PEARL. Denies any discomfort.\\n\\nResp: Remains on Time Cycled Pressure Controled Ventilation, PEEP dropped from 12 to 10, RR 28 -30. Most recent ABG 7.36/41/121. LS dimished throughout, exp wheeze resolved throughout shift w/ administration of albuterol/Qvar. Team does not suspect low airway compliance r/t Chlorine gas inhalation, as CXR inidicative for RUL infiltrates (probable aspiration).\\n\\nCV: 1st deg AV block (PR .23), no appreciable ventricular ectopy, ABP 120's-140 systolic. T-max 99.9 not currently on prophylactic abx (team aware of rising temp). Please refer to carevue for objective data.\\n\\nGU/GI: NPO, abd firm/NT/ND, +BS, Patent foley draining >100cc/hr, urine became pink after pt recieved heparin SC/plavix po and has since resolved. Fluid Status +2.2 liters for LOS.\\n\\nAccess: 18G R AC, 18 G L hand, L radial A-line all ports flush appropriately.\\n\\nPlan: Monitor/maintain heme/resp status. Rest overnight, wean vent support and extubate @ earliest opportunity. Monitor rising temp, possible initiation of abx therapy. Update pt on POC as it develops.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413153,\n \"text\": \"BS rhonchi, occ wheeze; no change with MDI's. Able to wean PEEP to 10 and will continue to wean as tolerated. Slight temp, ? new sepsis.\\nContinue to monitor respiratory and hemodynamic status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413154,\n \"text\": \"MICU Nursing Progress Note\\n Respiratory: intubated and vented with settings of PCV PEEP 10cm, TV range 450-500cc RR 30, FIO240% this am weaned to A/C 450 x 20 breaths and 10cm PEEP ABG 7,38/44/99 will cont to wean with hopes of extubating this am. suctioned q3-4 hr for thick pink to tan sputum spec sent for culture. BS clear upper and diminished at the bases.\\n Cardiac: HR 58-64 1st degree block. BP stable 110-120/60's\\n neuro: sedated on propofol at 20mcg/kg/hr pt will respond to his name will answer to yes/no questions with nodding of head. is following commands. MAE, helping with turning in bed.\\n GU foley in place, occasional clots passed, urine from yellow to pink.\\n GI: NPO, abd firm with hypoactive BS, no stool,\\n ID: low grade temp most of night, fully cultured, not on any antibx awaiting cultures..\\n Plan: cont with vent wean as tolerated, extubate if possible. follow temp and awaiting culture results.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413169,\n \"text\": \"uneventful day:\\n\\nneuro: A&O x3 weak but oob to chair and commode with 1 assist .\\n\\ncard: d/ced a line. sys bp 130-165. nr 50' with sleep and up to 70 nsr no ectopy\\n\\nresp: pt progressed from 50% face tent to 3l nc. resp status improved with IS. copius amts yellow sputum. recieving antibx. pt developes wheeze with exertion and has good response to inhalers and uses inhalers at home\\n\\ngi: hem neg lg bm on commode. good appetite. this am pt seemed to have more congested cough after taking po liquids and does better with soft foods.\\n\\ngu: bun 25 creat 1.5 and output adequate. hx kidney stones.\\n\\nskin: noted blister on lt lower back to have skin test for poss herpes\\nand sseveral scratch marks on back\\n\\nplan: prob call out soon. resp monitoring and increase strength\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413170,\n \"text\": \"NPN 1900 - 0700\\n\\nNEURO: AXOX3, PLEASANT AND COOPERTIVE. NO C/O\\n\\nRESP: LOOSE COUGH W/ YELLOW SECRETIONS.ON 4 L NC , DOE MAINT SATS 96-99%\\n\\nC/V: SR -ST NO ECOTPY BP STABLE.\\n\\nF/E/N: UO ~ 50-60CC HR TOL PO'S.NO STOOL OVERNOC.\\n\\nPLAN: BE C/O TO FLOOR TODAY IF REMAINS STABLE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413150,\n \"text\": \"MICU Nursing Progress Note\\n pt is an 88y/o gentleman who had been working on a leak near pool filter in small enclosed room,family found pt to be confused and heavy smell of chlorine gas.. placed in shower and pt became unresponsive\\nEMT's called, in the ew pt was unresponsive, intubated for airway precautions.\\n Respiratory: intubated on the vent with settings of A/C 450cc x 18 PEEP of 12cm. ABG showed pH 7.26/55/, trouble with rising PIP's during fluid bolus, changed over to PCV Peep of 12cm,inspiratory pressure of 37, generating TV 400-480cc minute ventilation of 9liters/min. RR 30. ABG slightly improve to pH 7.28. BS tight with insp and expir wheezes. on albuterol and added comivent inhaler cont to have wheezes and diminished bs throughout all lung fields.\\n Cardiac: HR 50's SB, no VEA, BP has ranged from low of 86 to high of 100/ did receive one fluid bolus of LR 500cc ... ?poor complaince after fluid bolus.\\n Electrolytes: serum calcium 5.7 repleted. magnesium 1.7, sodium 149, will treat with 2liters of free water. on D5w @ 180cc/hr.\\n ID: hypothermic to 95 orally, placed on bair hugger, blood culture x1 urine sent. not on antibx at present.\\n GU; foley in place and draining well. but urine output only 20-30cc/hr\\n Plan; cont to support as pt is very bronchospastic, inhalers as ordered. pt is hypothermic,bradycardic,hypotensive, ?thyroid labs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413159,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains intubated, vent supported. Rested overnight on AC. BS's coarse with, exp wheezes. Administering MDI's as ordered. Sxing copious yellow secretions. RSBI=88 this am. See flowsheet for further pt data. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413165,\n \"text\": \"88 yr old pt post chlorine inhalation. goal for today to diurese and wean to extubate.\\n\\nneuro: pt very alet and able to write messages on 15 mcg/kg/hr propofol. increased to 9 cc= 16+ mcg/kg/min for pt attempting to pull on et tube and biting et tube. ablo to MAE and good ROM.\\n\\ncard: hr drops to 40's with sleep but up when aroused. range 45-60 /min no pvcs notedbp 130-160 sys range. lasix 40 mg given at 1200 to diurese with good response at 1330 1000 cc+ output. just prior to lasix output dropped off to 20 cc/hr. hypernatremia tx with d5w at 75 cc/hr as pt is npo for extubation and flushes of 50 cc/q4h held.\\n\\nresp: secretions ranging yellow to white frothy and blood tinged.\\npt coughing. LS range from exp wheezes to course throughout. blood gas after lasix is good except o2 80%. on 50% o2.\\n\\ngi/gu no bm today tube feeding off at 1200 for poss extubation . tolerated 20 cc/ hr and md requested 50 cc h2o flush q 4h but did not order. bs present. foley urine slightly brown tinged ? medication effects. GAG reflex is poor and will need to eval with propophol turned off prior to extubation\\n\\nskin NO breakdown,\\n\\niv access: 1 PIV both \\n\\nsocial: family called on phone and updated.\\n\\nendo: covered glucose as ordered, day 3 of 4 steroids administration.\\n\\nplan: poss extubate if gag and gas ok. resume tf if not extubated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413166,\n \"text\": \"Respiratory Care\\nPt extubated today at 1630. Post extubation vitals HR 67, BP 156/80, RR 19 and non labored, SpO2 95 % on 0.5 via OFM. No stridor was noted and lung sounds had slight exp wheeze in the RUL and clear else where. Pt has a strong cough and is able to speak. Will continue to follow pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413167,\n \"text\": \"extubated at 1630 with improved gag off propophol. able to cough and talk and oriented x3. cxr post done as soft tissue swelling on lt neck noted post extubation. tube feeds d/ced. pt had 2400 cc response to lasix given at 1200 and vital are stable. may need to repeat lytes this pm.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413168,\n \"text\": \"NPN 1900-0700\\nNeuro: Alert, oriented x3, denied any pain or discomfort.\\n\\nResp: Breathing regularly on FT 50%, RR 18-28, Sat 95-100%, LS CTA, coughing and expectorating moderate amount of thick yellowish secretions, which he spits in the kidney basin and sometimes suctioned by yanker, CPT done frequently, receiving resp. puffs.\\n\\nCV: SB-NSR HR 57-69, BP 119-159/59-104, with A-line and 2 PIV lines on ceftriaxone IV.\\n\\nGI/GU: NPO, yet tolerated meds with little water very well, abdomen soft, BS present, no BM during the night, with Foley cath drained adequate U/O.\\n\\nInteg: T max 98.2, covered with 2 units Humalogue insulin for FS 125 as per sliding scale.\\n\\nSocial: Full code, no contact from family over night.\\n\\nPlan: Monitor respiratory status and wean O2 as tolerated, perform CPT and continie resp tx, continue antibiotics, monitor FS and cover with insulin per sliding scale, consider nutrition, if stable, possible C/O of ICU.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413160,\n \"text\": \"RESP: BS'S RHONCHEROUS THROUGHOUT AND SOME WHEEZING NOTED EARLIER. SUCTIONED FOR COPIOUS TO MOD. AMTS OF THICK YELLOW SECRETIONS Q1-2HRS. SECRETIONS HAVE DECREASED SINCE GIVING HIM LASIX. DESATED SEVERAL TIMES REQUIRING UPPING HIS FIO2 TO 50%. PLACED ON PS OF , BUT AFTER HRS PT. DECOMPENSATED AND PLACED BACK TO WHERE HE REMAINS. LAST ABG WAS BETTER.\\nGI: TO BE STARTED ON TF'INGS. PASSING FLATUS. NO STOOL.\\nRENAL: GIVEN 40MG LASIX IVP WITH EXCELLENT DIURESIS.\\nENDOC: NA 147 K+ 4.8 THIS AM. BOTH HAVE IMPROVED WITH DIURESIS. SSI INSULIN GIVEN.\\nNEURO: PROPOFOL OFF FOR A BRIEF PERIOD DURING PS TRIAL. GIVEN ATIVAN 1MG AND FENT 100MCQS IVP X1, BUT PT. BECAME MORE AGITATED AND PROPOFOL BACK ON. DOES REQUIRE AN OCCASS BOLUS. PT. TRIES TO REACH FOR TUBE.\\nEARLIER ABLE TO WRITE AND ALERT AND MOUTHING WORDS.\\nCV: HYPERTENSIVE TO 160'S WITH AGITATION. BP IMPROVED WITH SEDATION.\\nID: CONT. ON ANTIBIOTICS. AFEBRILE.\\nACCESS: NEW IV PLACED IN LEFT ANTECUB.\\nSOCIAL: WIFE IN BY HO'S. SON ALSO IN AS WELL AS HIS PCP. UPDATED.\\nPLAN: RECHECK ABG'S AND K+ LATER D/T DIURESIS. CONT. ON PS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413161,\n \"text\": \"resp care\\nremains intubated/vented in spontaneous mode. failed wean of psv earlier with increased wheezing,and access muscle use. c/w frequent secretions although less tan than yesterday. bronchodilators q4 and q2 as needed. reassess daily for wean.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413162,\n \"text\": \"blister on Left lower back present,open to air.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413163,\n \"text\": \"NSG.NOTES 1900-0700HRS\\n\\nA case of chloride gas inhalation,intubated and ventillated.\\n\\nNeuro:Sedated with propofol 22.6mcg/kg/hr which titrated to 15.07mcg as pt sedated well and HR remains 42-50/min.responding to call and pain.easily arousable.\\n\\nResp:Intubated and ventillated,mode CPAP+PS,PEEP 5,Psupp 12,fio2 50%.blood gas done 7.4/43/150/2/28.suctioned small thick yellow secretions.sats >95% RR 10-16/min.coarse on auscultation.\\n\\nCVS:HR 42-50/min when sleeping and >50's when awake.Sinus brady.no PVC'noted.BP 120-145/40-68 MM OF HG.\\n\\nGI/GU:Abdomen soft ,bowel sounds present, sump OGT in place,started on feed Nutren pulmonary 10 ml/hr and then advanced to 20ml/hr after 4 hours,feed started as MD and orders to be put in.nil residue.\\non foley cath,UO adequate ,clear yellow urine.\\n\\nIntegu:skin impaired,blister on left upper leg ,open to air.both hands restrained,circulation adequate.pulse present.T max 97.bath given and repositioned.all hygenic needs attended.\\n\\nIV access:two PIV'S ;one on each hand,patent,dressing intact.site looks clean.A line on Left radial,patent,BP monitoring.dressing ,pressure kit and saline changed.\\n\\nEndo:on sliding scale insulin.\\n\\nSocial:no family visit or phone call this shift.full code\\n\\nPlan:wean off .advance tube feed if tolerating to acheieve goal rate of 40ml/hr.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2175-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1413164,\n \"text\": \"Resp Care,\\nPt. remains intubated overnoc on IPS 12. VT 500 RR 18. BS coarse wheezes, MDI's as ordered. Suctioned for moderate amount thick yellow sputum. ABG acceptable, RSBI 52 this am. Cont. IPS wean as tol.\\n\"\n }\n]"}}},{"rowIdx":24975,"cells":{"subject_id":{"kind":"number","value":25210,"string":"25,210"},"hadm_id":{"kind":"number","value":197950,"string":"197,950"},"target_text":{"kind":"string","value":"The patient is an 82-year-old woman with a history of nonischemic cardiomyopathy, CHF, who presents to the CCU status post an episode of V tach, status post multiple shocks that were unable to resolve the V tach, status post EP study without inducibility of the rhythm, although the patient was found to have an infra HIS block resulting in a DDD pacer being placed. The patient received boluses of Amiodarone 150 mg times one and was loaded on IV Amiodarone for the V tach. 1. CARDIOLOGY: Rhythm/V tach: After the load of 1 mg per minute and vagal bang down broke into normal sinus rhythm. The Amiodarone was initially decreased to 0.5 mg per minute. She was converted to Amiodarone 400 mg p.o. q.d. and the Amiodarone was discontinued after the patient had been loaded sufficiently. The patient was started on low-dose of beta blocker 25 p.o. b.i.d. The patient had a run of sustained V tach on at approximately 4:00 p.m. and was given IV 2.5 Lopressor and the rhythm spontaneously reverted back to normal sinus rhythm. She had a 50 plus beat run of V tach at 8:55 a.m. on , again nonsymptomatic and then the ectopy tended to decrease, having three to four beats of NSVT on and four beats on . The Lopressor was converted to Toprol XL 50 mg q.d. at discharge. Of note, the patient received Amiodarone 400 mg b.i.d. for one week and then was transitioned to 400 q.d."},"extractive_notes_summ":{"kind":"string","value":"Mild tricuspid [1+]regurgitation is seen. Left ventricular function.Height: (in) 62Weight (lb): 143BSA (m2): 1.66 m2BP (mm Hg): 103/41HR (bpm): 73Status: InpatientDate/Time: at 16:02Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Right ventricular systolic functionappears depressed.AORTA: The aortic root is normal in diameter. CARDIAC ECHO DONE WITH (-) EFFUSION AND TAMPONADE. There is mild mitral annular calcification. Abd soft distended, +BS, -BM.GU: Pt has f/c with marginal u/o. PATIENT/TEST INFORMATION:Indication: r/o effusion.BP (mm Hg): 105/71HR (bpm): 75Status: InpatientDate/Time: at 06:06Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Left ventricular wall thicknesses are normal. R fem hematoma ecchymotic, but stable. TRANSCUTANEOUS PADS LEFT IN PLACE. Left ventricular wall thicknesses arenormal. ABD SOFT WITH (+) BSS. +BruitResp: Pt on 2L via NC, BS clear in upper airway, fine rales in bases. The heart size is at the upper limits of normal. Pt on 2Lnc with sats 95-98.GI=abd soft and slightly distended. There are focal calcificationsin the aortic root.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolichypertension. The leftventricular cavity is moderately dilated. \"O-MS: A/O/X/3. Radial pulses 3+ and equal bilat. Tolerating Lopressor dose. Right ventricular systolic functionappears depressed. There is nomitral valve prolapse. PA AND LATERAL CHEST: Permanent pacemaker is present, with leads terminating in the right atrium and right ventricle. Probable sinus rhythm with ventricular pacing witha typical precordial progression for right ventricular pacing. Biapical thickening is noted. RIGHT GROIN SITE ECCYMOTIC WITH HEMATOMA. The left ventricular cavity isdilated. The left ventricular cavity is moderately dilated. There is no significant mitral stenosis.Moderate to severe (3+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The aortic valve leaflets (3) are mildly thickened but notstenotic. Hematoma Right fem/groin.Lungs= normal resp with no SOB. Acatheter or pacing wire is seen in the right atrium and/or right ventricle.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. DENIES SOB.GU/GI: FOLEY IN PLACE. (+)CSM. PULSES 2+ PALPABLE THROUGHOUT. Ventricular tachycardia. Since the previous tracing of nosignificant change. Right groin stable with no noted expansion.Anticipate call out to floor, refer to transfer note for detailed note. pedal pulses 1+ bilat. There is systolic anterior motion of the mitral valveleaflets. Since the previous tracing of nosignificant change.TRACING #2 LYTES WNLS. COLOR PALE AND DIAPHORETIC. The right common, superficial and deep femoral arteries are patent, and the peak velocities at these levels are 97, 91 and 88 cm/sec, respectively. Right AC perph iv patent, left lower arm perph iv patent. Rightventricular chamber size is normal. Rightventricular chamber size is normal. The leftventricular cavity is dilated. cough intact. Moderate to severe (3+) mitral regurgitation is seen. (+)BRUIT. pt taking po amio and metoprolol. IMPRESSION: Satisfactory positioning of pacemaker. There is mild pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. Follow-up duplex ultrasonographic examination showed absence of flow in the pseudoaneurysm and normal patency and waveforms in the right common femoral artery. SINCE ADMISSION PT 3LS(+). Pacer rhythmventricular premature complexSince last ECG, no significant change BP STABLE AND PT ALERT. pt reports positive flatus. GIVEN SMALL SIP OF H2O OVERNIGHT.ID: AFBERILE. There is systolic anterior motionof the mitral valve leaflets. DDD PACER PLACED SUCCESFULLY BUT UNABLE TO REPRODUCE VT. PT LATER ADMITTED TO FLOOR WHERE DOING FINE UNTIL AROUND MN WHEN PT WHEN INTO VT WITH A RATE OF 170S TO 200S. Small pleural effusions are evident bilaterally. Thetricuspid valve supporting structures are normal. OLIGURIC. 7p-11pNeuro= pt A&O x3. There is severe global left ventricularhypokinesis.MITRAL VALVE: The mitral valve leaflets are mildly thickened.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Conclusions:Left ventricular wall thicknesses are normal. Pt c/o pain in L shoulder secondary to pacer placement, relieved with percocet.Cardiac: Pt remains AV paced with occ , pt had 8 beat run of NSVT; pt able to feel palpatations with VT. Pts HR 60's-70's BP in low 100's sys, with MAP >60. PREVIOULSY EXPANDING ON FLOORS BUT SINCE HAS BEEN STABLE. There is severeglobal left ventricular hypokinesis (ejection fraction approximately 20percent). CONCLUSION: Right groin pseudoaneurysm, with circulating portion measuring 1.2 x 1.6 cm, and connected to the higher portion of the right common femoral artery through a narrow neck. The needle was removed. There is severe global left ventricular hypokinesis. BUN/CREAT 24/0.9. IMPRESSION: Appropriately positioned pacing leads. CONCLUSION: 1. OBEYS AND FOLLOW COMMANDS APPROPRIATELY.MAES ON BED.CV: ARRIVING IN VT. BP DOWN INTO 80S POST AMIO LOAD FROM 100S SYS. Compared to the previous tracing no significant change.TRACING #3 The tricuspidvalve leaflets are mildly thickened. Sinus rhythm with ventricular pacing. The mitral valve leaflets are mildly thickened. APPEARING GREY AND SWEATY AGAIN. BP TREATED W/ 250CC BOLUS AND REPSONDANT. Informed consent was obtained and the right groin was sterilely prepped. A superficial hematoma is seen, located anteriorly to the right common femoral artery, with a circulating portion measured at 1.23 x 1.59 cm. SINCE BPS 90S TO 100S AND HR 60S TO 70S AVPACED. CKS ELEVATED IN 900S.RESP: LS WITH BIBASILAR CRACKLES. The mitral valveleaflets are mildly thickened. There is severe global leftventricular hypokinesis. (-) FOR PULSES PARADOX. This circulating hematoma or pseudoaneurysm is connected to the higher portion of the right common femoral artery through a narrow neck that shows to-and-fro flow pattern. grips strong and equal bilat. pt follows commands.CV=pt continues to be AV paced, Rate 70s-80s with frequent pvc's. PACER SITE CDI. LATER TOWARDS MORNING BP SPONTANEOUSLY DROPPING INTO 60S. A-V sequential paced rhythm. There ismild thickening of the mitral valve chordae. Pt amio gtt dc'd and started on po amio, and a low dose lopressor to help prevent VT. Pt has defib at bedside."},"n_notes":{"kind":"number","value":18,"string":"18"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2140-03-04 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":787606,"text":" 9:00 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: check lead placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new pacemaker\n REASON FOR THIS EXAMINATION:\n check lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check lead placement, new pace maker.\n\n SINGLE VIEW CHEST: A left sided pace maker power pack is in place and the\n dual chamber pacing leads are in appropriate position. The heart size is at\n the upper limits of normal. No infiltrates identified and there are no\n pleural effusions. The question of prominence of the upper zone vessels may\n be due to technical factors.\n\n IMPRESSION: Appropriately positioned pacing leads.\n\n\n"},{"category":"Radiology","chartdate":"2140-03-04 00:00:00.000","description":"ART DUP EXT LO UNI;F/U","row_id":787649,"text":" 2:57 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: RT GROIN BRUIT S/P EP STUDY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right groin bruit in an 82-year-old woman with recent cardiac\n catheterization for electrophysiologic study.\n\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\n examinations were performed at the level of the arteries and veins of the\n right groin.\n\n A superficial hematoma is seen, located anteriorly to the right common femoral\n artery, with a circulating portion measured at 1.23 x 1.59 cm. This\n circulating hematoma or pseudoaneurysm is connected to the higher portion of\n the right common femoral artery through a narrow neck that shows to-and-fro\n flow pattern.\n The right common, superficial and deep femoral arteries are patent, and the\n peak velocities at these levels are 97, 91 and 88 cm/sec, respectively.\n\n CONCLUSION: Right groin pseudoaneurysm, with circulating portion measuring 1.2\n x 1.6 cm, and connected to the higher portion of the right common femoral\n artery through a narrow neck.\n Close surveillance is recommended, with follow-up color Doppler ultrasound\n examination scheduled in three days from now.\n\n"},{"category":"Radiology","chartdate":"2140-03-08 00:00:00.000","description":"CHEST (PA & LAT)","row_id":787872,"text":" 8:31 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pacemaker\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new pacemaker\n\n REASON FOR THIS EXAMINATION:\n eval pacemaker\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pacemaker placement.\n\n PA AND LATERAL CHEST: Permanent pacemaker is present, with leads terminating\n in the right atrium and right ventricle. No pneumothorax is identified.\n\n The heart is enlarged, and there is upper zone vascular redistribution.\n Numerous thickened septal lines are present. Small pleural effusions are\n evident bilaterally. Biapical thickening is noted.\n\n IMPRESSION: Satisfactory positioning of pacemaker.\n\n Congestive heart failure pattern with interstitial edema.\n\n"},{"category":"Radiology","chartdate":"2140-03-07 00:00:00.000","description":"ART DUP EXT LO UNI;F/U","row_id":787804,"text":" 1:53 PM\n ART DUP EXT LO UNI;F/U; THROMBIN INJ PSEUDOANERYSM RIGHT Clip # \n GUID FOR PSEUDOANUREYSM (INJECTION)\n Reason: evaluate pseudoaneurysm on R, please compare to previous stu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with rt groin bruit s/p ep study\n\n REASON FOR THIS EXAMINATION:\n evaluate pseudoaneurysm on R, please compare to previous study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Surveillance of a right common femoral artery pseudoaneurysm post\n cardiac catheterization.\n\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\n examinations was performed at the level of the arteries and veins of the right\n groin.\n\n The pseudoaneurysm is still present, with flow circulating within it, and its\n dimensions are slightly increased as compared to three days ago (1.87 x 2.25\n cm today).\n\n Decision was made to occlude the pseudoaneurysm by percutaneous thrombin\n injection. Informed consent was obtained and the right groin was sterilely\n prepped. Under real-time ultrasound and color Doppler guidance, a 21 gauge\n needle was advanced until its tip reached the pseudoaneurysm. 400 units of\n thrombin were injected, resulting in immediate cessation of flow within the\n pseudoaneurym. The needle was removed.\n\n Follow-up duplex ultrasonographic examination showed absence of flow in the\n pseudoaneurysm and normal patency and waveforms in the right common femoral\n artery.\n\n CONCLUSION:\n 1. Follow-up examination of a right common femoral artery pseudoaneurysm,\n with mild increase in diameter since three days ago.\n 2. Successful occlusion of this aneurysm by percutaneous injection of 400\n units of thrombin under color Doppler ultrasound guidance.\n\n"},{"category":"Nursing/other","chartdate":"2140-03-05 00:00:00.000","description":"Report","row_id":1591252,"text":"CCU Nursing Progress Note 1900-0700: Stable VT arres\nVSS overnight. Unevenfut night. Complaining of right shoulder pain at inscional site. Given 2 percs for pain with good effect. Sleeping most of night. Tolerating Lopressor dose. Right groin stable with no noted expansion.\n\nAnticipate call out to floor, refer to transfer note for detailed note.\n"},{"category":"Nursing/other","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":1591249,"text":"CCU NURSING PROGRESS NOTE 1900-0700: VT\nHPI: IN BREIF 82 YO WHO PRESENTED ON IN STABLE VT AT OSH. AFTER MANY ATTEMPTS OF CARDIOVERSION PT CONVERTING AFTER AMIO LOAD TO NSR WITH BBB AND AV CONDUCTION DELAY. ON TRANSFERED TO EPS LAB FOR PACER PLACEMENT AND POSSIBLE ABLATION. DDD PACER PLACED SUCCESFULLY BUT UNABLE TO REPRODUCE VT. PT LATER ADMITTED TO FLOOR WHERE DOING FINE UNTIL AROUND MN WHEN PT WHEN INTO VT WITH A RATE OF 170S TO 200S. BP STABLE AND PT ALERT. NOT CV AT TIME. AMIO LOAD STARTED AND TRANSFERED TO CCU.\n\nSEE FHP FOR ALLERGIES AND PMH\n\nS-\"I FEEL HOT AND SWEATY.\"\n\nO-MS: A/O/X/3. VERY PLEASANT. OBEYS AND FOLLOW COMMANDS APPROPRIATELY.\nMAES ON BED.\n\nCV: ARRIVING IN VT. BP DOWN INTO 80S POST AMIO LOAD FROM 100S SYS. COLOR PALE AND DIAPHORETIC. GTT STARTED AT 1230 AT 1MG/MIN. BP TREATED W/ 250CC BOLUS AND REPSONDANT. PT SELF CONVERTING 15MIN POST CONTINUOUS INFUSION. LATER TOWARDS MORNING BP SPONTANEOUSLY DROPPING INTO 60S. APPEARING GREY AND SWEATY AGAIN. STATES NOT \"FEELING WELL.\"\nTOTAL OF 3 250CC NS BOLUSES GIVEN BEFORE PT RESPONDING. (-) FOR PULSES PARADOX. CARDIAC ECHO DONE WITH (-) EFFUSION AND TAMPONADE. SINCE BPS 90S TO 100S AND HR 60S TO 70S AVPACED. OCCASIONAL PVCS. LYTES WNLS. RIGHT GROIN SITE ECCYMOTIC WITH HEMATOMA. PREVIOULSY EXPANDING ON FLOORS BUT SINCE HAS BEEN STABLE. AREA SOFT. (+)BRUIT. PULSES 2+ PALPABLE THROUGHOUT. (+)CSM. AMIO GTT AT 1MG/MIN TILL FURTHER NOTICE THIS AM. LEFT GROIN CDI WITH NO HEMATOMA OR ECCYMOSIS. TRANSCUTANEOUS PADS LEFT IN PLACE. PACER SITE CDI. SLING REMOVED AND PT INSTRUCTED TO KEEP ARM IN PLACE. CKS ELEVATED IN 900S.\n\nRESP: LS WITH BIBASILAR CRACKLES. O2SATS 94-96% ON 3LNP. DENIES SOB.\n\nGU/GI: FOLEY IN PLACE. OLIGURIC. HUO 15-20CC/HR. URINE YELLOW AND SLIGHTLY CONCENTRATED. CCU TEAM AWARE. BUN/CREAT 24/0.9. SINCE ADMISSION PT 3LS(+). ABD SOFT WITH (+) BSS. NPO. GIVEN SMALL SIP OF H2O OVERNIGHT.\n\nID: AFBERILE. NO ISSUES. CONTINUE KEFZOL TIMES FOUR DOSES POST PACER.\n\nSOC: LIVES ALONE WITH VERY SUPPORTIVE SIGNIFICANT OTHER. HAS ONE SON WHO LIVE IN MA. FAMILY AND SO NOT AWARE EVENTS OVERNIGHT. PT WANTING TO WAIT TILL MORNING TO NOTIFY.\n\nA/P:S/P EPS WITH STABLE VT ARREST\nU/S OF RIGHT GROIN TODAY\nPOSSIBLE FORMAL CARDIAC ECHO\nPOSSIBLE RETURN TO EPS LAB\n\n"},{"category":"Nursing/other","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":1591250,"text":"CCU Nursing Progress Note\nNeuro: Pt A&O x3. Pt remains on bedrest secondary to R fem hematoma. Pt able to be at 30 degree angle. Pt c/o pain in L shoulder secondary to pacer placement, relieved with percocet.\n\nCardiac: Pt remains AV paced with occ , pt had 8 beat run of NSVT; pt able to feel palpatations with VT. Pts HR 60's-70's BP in low 100's sys, with MAP >60. Pt amio gtt dc'd and started on po amio, and a low dose lopressor to help prevent VT. Pt has defib at bedside. R fem hematoma ecchymotic, but stable. +Bruit\n\nResp: Pt on 2L via NC, BS clear in upper airway, fine rales in bases. O2 sat 98%.\n\nGI: Pt tolerating cardiac/low Na diet. Abd soft distended, +BS, -BM.\n\nGU: Pt has f/c with marginal u/o. Amber in color.\n\nID: Afebrile on cefzolin x4 s/p pacer placement.\n\nPt due to have echo and R fem ultrasound.\n"},{"category":"Nursing/other","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":1591251,"text":"7p-11p\nNeuro= pt A&O x3. PERRLA at 3mm. grips strong and equal bilat. pt follows commands.\n\nCV=pt continues to be AV paced, Rate 70s-80s with frequent pvc's. pt taking po amio and metoprolol. Radial pulses 3+ and equal bilat. pedal pulses 1+ bilat. Right AC perph iv patent, left lower arm perph iv patent. Hematoma Right fem/groin.\n\nLungs= normal resp with no SOB. clear throughout. cough intact. Pt on 2Lnc with sats 95-98.\n\nGI=abd soft and slightly distended. bowel sounds hypoactive in all four quadrants. pt reports positive flatus. Pt reports last bm was and she normally has one to two bm's per day.\n\nGU=clear yellow urine via foley cathetar. Amts greater than 50cc per hour.\n\nendo= no issues.\n\nID= pt afebrile.\n\nsoc= pt states \"i'm lonely, I haven't been able to talk with my family today.\" pt has one son, grandchildren and en. Pt has significant other of 5 years. This RN remained in room to chat with pt for 45 min at which time pt stated \"I feel better now.\"\n\nPlan=continue to monitor HR. Possible transfer to floor tomorrow.\n"},{"category":"Echo","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":71985,"text":"PATIENT/TEST INFORMATION:\nIndication: Dilated cardiomyopathy. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 143\nBSA (m2): 1.66 m2\nBP (mm Hg): 103/41\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 16:02\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis. There is no resting left ventricular outflow tract\nobstruction. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. There is systolic anterior motion\nof the mitral valve leaflets. There is no significant mitral stenosis.\nModerate to severe (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\ntricuspid valve supporting structures are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. There is severe\nglobal left ventricular hypokinesis (ejection fraction approximately 20\npercent). No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed. The aortic valve leaflets (3) are mildly thickened but not\nstenotic. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. There is systolic anterior motion of the mitral valve\nleaflets. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"},{"category":"Echo","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":71986,"text":"PATIENT/TEST INFORMATION:\nIndication: r/o effusion.\nBP (mm Hg): 105/71\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 06:06\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is dilated. There is severe global left ventricular\nhypokinesis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\ndilated. There is severe global left ventricular hypokinesis. The mitral valve\nleaflets are mildly thickened. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2140-03-09 00:00:00.000","description":"Report","row_id":179478,"text":"A-V sequential paced rhythm. Since the previous tracing of no\nsignificant change.\n\n"},{"category":"ECG","chartdate":"2140-03-09 00:00:00.000","description":"Report","row_id":179479,"text":"Pacer rhythm\nventricular premature complex\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2140-03-05 00:00:00.000","description":"Report","row_id":179704,"text":"Technically difficult study. Probable sinus rhythm with ventricular pacing with\na typical precordial progression for right ventricular pacing. Since the\nprevious tracing of the heart rate is faster.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":179705,"text":"Paced rhythm. Compared to the previous tracing no significant change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":179706,"text":"Paced rhythm. Compared to the previous tracing paced rhythm is new.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2140-03-04 00:00:00.000","description":"Report","row_id":179707,"text":"Ventricular tachycardia. Lead V6 unsuitable for analysis. No previous tracing\navailable for comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2140-03-08 00:00:00.000","description":"Report","row_id":179702,"text":"Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2140-03-06 00:00:00.000","description":"Report","row_id":179703,"text":"Sinus rhythm with ventricular pacing. Since the previous tracing of no\nsignificant change.\nTRACING #2\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 787606,\n \"text\": \" 9:00 AM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: check lead placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with new pacemaker\\n REASON FOR THIS EXAMINATION:\\n check lead placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Check lead placement, new pace maker.\\n\\n SINGLE VIEW CHEST: A left sided pace maker power pack is in place and the\\n dual chamber pacing leads are in appropriate position. The heart size is at\\n the upper limits of normal. No infiltrates identified and there are no\\n pleural effusions. The question of prominence of the upper zone vessels may\\n be due to technical factors.\\n\\n IMPRESSION: Appropriately positioned pacing leads.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"ART DUP EXT LO UNI;F/U\",\n \"row_id\": 787649,\n \"text\": \" 2:57 PM\\n ART DUP EXT LO UNI;F/U Clip # \\n Reason: RT GROIN BRUIT S/P EP STUDY\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right groin bruit in an 82-year-old woman with recent cardiac\\n catheterization for electrophysiologic study.\\n\\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\\n examinations were performed at the level of the arteries and veins of the\\n right groin.\\n\\n A superficial hematoma is seen, located anteriorly to the right common femoral\\n artery, with a circulating portion measured at 1.23 x 1.59 cm. This\\n circulating hematoma or pseudoaneurysm is connected to the higher portion of\\n the right common femoral artery through a narrow neck that shows to-and-fro\\n flow pattern.\\n The right common, superficial and deep femoral arteries are patent, and the\\n peak velocities at these levels are 97, 91 and 88 cm/sec, respectively.\\n\\n CONCLUSION: Right groin pseudoaneurysm, with circulating portion measuring 1.2\\n x 1.6 cm, and connected to the higher portion of the right common femoral\\n artery through a narrow neck.\\n Close surveillance is recommended, with follow-up color Doppler ultrasound\\n examination scheduled in three days from now.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-03-08 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 787872,\n \"text\": \" 8:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval pacemaker\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with new pacemaker\\n\\n REASON FOR THIS EXAMINATION:\\n eval pacemaker\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Pacemaker placement.\\n\\n PA AND LATERAL CHEST: Permanent pacemaker is present, with leads terminating\\n in the right atrium and right ventricle. No pneumothorax is identified.\\n\\n The heart is enlarged, and there is upper zone vascular redistribution.\\n Numerous thickened septal lines are present. Small pleural effusions are\\n evident bilaterally. Biapical thickening is noted.\\n\\n IMPRESSION: Satisfactory positioning of pacemaker.\\n\\n Congestive heart failure pattern with interstitial edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-03-07 00:00:00.000\",\n \"description\": \"ART DUP EXT LO UNI;F/U\",\n \"row_id\": 787804,\n \"text\": \" 1:53 PM\\n ART DUP EXT LO UNI;F/U; THROMBIN INJ PSEUDOANERYSM RIGHT Clip # \\n GUID FOR PSEUDOANUREYSM (INJECTION)\\n Reason: evaluate pseudoaneurysm on R, please compare to previous stu\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with rt groin bruit s/p ep study\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate pseudoaneurysm on R, please compare to previous study\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Surveillance of a right common femoral artery pseudoaneurysm post\\n cardiac catheterization.\\n\\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\\n examinations was performed at the level of the arteries and veins of the right\\n groin.\\n\\n The pseudoaneurysm is still present, with flow circulating within it, and its\\n dimensions are slightly increased as compared to three days ago (1.87 x 2.25\\n cm today).\\n\\n Decision was made to occlude the pseudoaneurysm by percutaneous thrombin\\n injection. Informed consent was obtained and the right groin was sterilely\\n prepped. Under real-time ultrasound and color Doppler guidance, a 21 gauge\\n needle was advanced until its tip reached the pseudoaneurysm. 400 units of\\n thrombin were injected, resulting in immediate cessation of flow within the\\n pseudoaneurym. The needle was removed.\\n\\n Follow-up duplex ultrasonographic examination showed absence of flow in the\\n pseudoaneurysm and normal patency and waveforms in the right common femoral\\n artery.\\n\\n CONCLUSION:\\n 1. Follow-up examination of a right common femoral artery pseudoaneurysm,\\n with mild increase in diameter since three days ago.\\n 2. Successful occlusion of this aneurysm by percutaneous injection of 400\\n units of thrombin under color Doppler ultrasound guidance.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591252,\n \"text\": \"CCU Nursing Progress Note 1900-0700: Stable VT arres\\nVSS overnight. Unevenfut night. Complaining of right shoulder pain at inscional site. Given 2 percs for pain with good effect. Sleeping most of night. Tolerating Lopressor dose. Right groin stable with no noted expansion.\\n\\nAnticipate call out to floor, refer to transfer note for detailed note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591249,\n \"text\": \"CCU NURSING PROGRESS NOTE 1900-0700: VT\\nHPI: IN BREIF 82 YO WHO PRESENTED ON IN STABLE VT AT OSH. AFTER MANY ATTEMPTS OF CARDIOVERSION PT CONVERTING AFTER AMIO LOAD TO NSR WITH BBB AND AV CONDUCTION DELAY. ON TRANSFERED TO EPS LAB FOR PACER PLACEMENT AND POSSIBLE ABLATION. DDD PACER PLACED SUCCESFULLY BUT UNABLE TO REPRODUCE VT. PT LATER ADMITTED TO FLOOR WHERE DOING FINE UNTIL AROUND MN WHEN PT WHEN INTO VT WITH A RATE OF 170S TO 200S. BP STABLE AND PT ALERT. NOT CV AT TIME. AMIO LOAD STARTED AND TRANSFERED TO CCU.\\n\\nSEE FHP FOR ALLERGIES AND PMH\\n\\nS-\\\"I FEEL HOT AND SWEATY.\\\"\\n\\nO-MS: A/O/X/3. VERY PLEASANT. OBEYS AND FOLLOW COMMANDS APPROPRIATELY.\\nMAES ON BED.\\n\\nCV: ARRIVING IN VT. BP DOWN INTO 80S POST AMIO LOAD FROM 100S SYS. COLOR PALE AND DIAPHORETIC. GTT STARTED AT 1230 AT 1MG/MIN. BP TREATED W/ 250CC BOLUS AND REPSONDANT. PT SELF CONVERTING 15MIN POST CONTINUOUS INFUSION. LATER TOWARDS MORNING BP SPONTANEOUSLY DROPPING INTO 60S. APPEARING GREY AND SWEATY AGAIN. STATES NOT \\\"FEELING WELL.\\\"\\nTOTAL OF 3 250CC NS BOLUSES GIVEN BEFORE PT RESPONDING. (-) FOR PULSES PARADOX. CARDIAC ECHO DONE WITH (-) EFFUSION AND TAMPONADE. SINCE BPS 90S TO 100S AND HR 60S TO 70S AVPACED. OCCASIONAL PVCS. LYTES WNLS. RIGHT GROIN SITE ECCYMOTIC WITH HEMATOMA. PREVIOULSY EXPANDING ON FLOORS BUT SINCE HAS BEEN STABLE. AREA SOFT. (+)BRUIT. PULSES 2+ PALPABLE THROUGHOUT. (+)CSM. AMIO GTT AT 1MG/MIN TILL FURTHER NOTICE THIS AM. LEFT GROIN CDI WITH NO HEMATOMA OR ECCYMOSIS. TRANSCUTANEOUS PADS LEFT IN PLACE. PACER SITE CDI. SLING REMOVED AND PT INSTRUCTED TO KEEP ARM IN PLACE. CKS ELEVATED IN 900S.\\n\\nRESP: LS WITH BIBASILAR CRACKLES. O2SATS 94-96% ON 3LNP. DENIES SOB.\\n\\nGU/GI: FOLEY IN PLACE. OLIGURIC. HUO 15-20CC/HR. URINE YELLOW AND SLIGHTLY CONCENTRATED. CCU TEAM AWARE. BUN/CREAT 24/0.9. SINCE ADMISSION PT 3LS(+). ABD SOFT WITH (+) BSS. NPO. GIVEN SMALL SIP OF H2O OVERNIGHT.\\n\\nID: AFBERILE. NO ISSUES. CONTINUE KEFZOL TIMES FOUR DOSES POST PACER.\\n\\nSOC: LIVES ALONE WITH VERY SUPPORTIVE SIGNIFICANT OTHER. HAS ONE SON WHO LIVE IN MA. FAMILY AND SO NOT AWARE EVENTS OVERNIGHT. PT WANTING TO WAIT TILL MORNING TO NOTIFY.\\n\\nA/P:S/P EPS WITH STABLE VT ARREST\\nU/S OF RIGHT GROIN TODAY\\nPOSSIBLE FORMAL CARDIAC ECHO\\nPOSSIBLE RETURN TO EPS LAB\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591250,\n \"text\": \"CCU Nursing Progress Note\\nNeuro: Pt A&O x3. Pt remains on bedrest secondary to R fem hematoma. Pt able to be at 30 degree angle. Pt c/o pain in L shoulder secondary to pacer placement, relieved with percocet.\\n\\nCardiac: Pt remains AV paced with occ , pt had 8 beat run of NSVT; pt able to feel palpatations with VT. Pts HR 60's-70's BP in low 100's sys, with MAP >60. Pt amio gtt dc'd and started on po amio, and a low dose lopressor to help prevent VT. Pt has defib at bedside. R fem hematoma ecchymotic, but stable. +Bruit\\n\\nResp: Pt on 2L via NC, BS clear in upper airway, fine rales in bases. O2 sat 98%.\\n\\nGI: Pt tolerating cardiac/low Na diet. Abd soft distended, +BS, -BM.\\n\\nGU: Pt has f/c with marginal u/o. Amber in color.\\n\\nID: Afebrile on cefzolin x4 s/p pacer placement.\\n\\nPt due to have echo and R fem ultrasound.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1591251,\n \"text\": \"7p-11p\\nNeuro= pt A&O x3. PERRLA at 3mm. grips strong and equal bilat. pt follows commands.\\n\\nCV=pt continues to be AV paced, Rate 70s-80s with frequent pvc's. pt taking po amio and metoprolol. Radial pulses 3+ and equal bilat. pedal pulses 1+ bilat. Right AC perph iv patent, left lower arm perph iv patent. Hematoma Right fem/groin.\\n\\nLungs= normal resp with no SOB. clear throughout. cough intact. Pt on 2Lnc with sats 95-98.\\n\\nGI=abd soft and slightly distended. bowel sounds hypoactive in all four quadrants. pt reports positive flatus. Pt reports last bm was and she normally has one to two bm's per day.\\n\\nGU=clear yellow urine via foley cathetar. Amts greater than 50cc per hour.\\n\\nendo= no issues.\\n\\nID= pt afebrile.\\n\\nsoc= pt states \\\"i'm lonely, I haven't been able to talk with my family today.\\\" pt has one son, grandchildren and en. Pt has significant other of 5 years. This RN remained in room to chat with pt for 45 min at which time pt stated \\\"I feel better now.\\\"\\n\\nPlan=continue to monitor HR. Possible transfer to floor tomorrow.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 71985,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Dilated cardiomyopathy. Left ventricular function.\\nHeight: (in) 62\\nWeight (lb): 143\\nBSA (m2): 1.66 m2\\nBP (mm Hg): 103/41\\nHR (bpm): 73\\nStatus: Inpatient\\nDate/Time: at 16:02\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is mildly dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\\n\\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\\nventricular cavity is moderately dilated. There is severe global left\\nventricular hypokinesis. There is no resting left ventricular outflow tract\\nobstruction. No masses or thrombi are seen in the left ventricle.\\n\\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\\nventricular chamber size is normal. Right ventricular systolic function\\nappears depressed.\\n\\nAORTA: The aortic root is normal in diameter. There are focal calcifications\\nin the aortic root.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\\nstenotic.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\\nmitral valve prolapse. There is mild mitral annular calcification. There is\\nmild thickening of the mitral valve chordae. There is systolic anterior motion\\nof the mitral valve leaflets. There is no significant mitral stenosis.\\nModerate to severe (3+) mitral regurgitation is seen.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\\ntricuspid valve supporting structures are normal. Mild tricuspid [1+]\\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity is moderately dilated. There is severe\\nglobal left ventricular hypokinesis (ejection fraction approximately 20\\npercent). No masses or thrombi are seen in the left ventricle. Right\\nventricular chamber size is normal. Right ventricular systolic function\\nappears depressed. The aortic valve leaflets (3) are mildly thickened but not\\nstenotic. The mitral valve leaflets are mildly thickened. There is no mitral\\nvalve prolapse. There is systolic anterior motion of the mitral valve\\nleaflets. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 71986,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: r/o effusion.\\nBP (mm Hg): 105/71\\nHR (bpm): 75\\nStatus: Inpatient\\nDate/Time: at 06:06\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\\nventricular cavity is dilated. There is severe global left ventricular\\nhypokinesis.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\\n\\nConclusions:\\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\\ndilated. There is severe global left ventricular hypokinesis. The mitral valve\\nleaflets are mildly thickened. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179478,\n \"text\": \"A-V sequential paced rhythm. Since the previous tracing of no\\nsignificant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179479,\n \"text\": \"Pacer rhythm\\nventricular premature complex\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179704,\n \"text\": \"Technically difficult study. Probable sinus rhythm with ventricular pacing with\\na typical precordial progression for right ventricular pacing. Since the\\nprevious tracing of the heart rate is faster.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179705,\n \"text\": \"Paced rhythm. Compared to the previous tracing no significant change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179706,\n \"text\": \"Paced rhythm. Compared to the previous tracing paced rhythm is new.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179707,\n \"text\": \"Ventricular tachycardia. Lead V6 unsuitable for analysis. No previous tracing\\navailable for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179702,\n \"text\": \"Regular ventricular pacing\\nPacemaker rhythm - no further analysis\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 179703,\n \"text\": \"Sinus rhythm with ventricular pacing. Since the previous tracing of no\\nsignificant change.\\nTRACING #2\\n\\n\"\n }\n]"}}},{"rowIdx":24976,"cells":{"subject_id":{"kind":"number","value":21576,"string":"21,576"},"hadm_id":{"kind":"number","value":171549,"string":"171,549"},"target_text":{"kind":"string","value":"1. NEURO: CT imaging showed limited sinus disease, but marked diffuse cerebral edema. The neurological exam was remarkably non-focal. The question of edema secondary to infection (although she did not look toxic and had a negative Brudzinski) was addressed, as well as venous sinus thrombosis (secondary to a sinus infection), and metastatic processes. Neurosurgery was consulted in case intervention became necessary, and the patient was admitted to the ICU with neurochecks q 1 hr. Her HAART therapy on admission was continued with the addition of ampicillin, and urine, sputum, and blood cx's were sent. The patient was started on decadron 6q4, and ID was consulted. On , the patient continued to have frontal and parietal signs, along with papilledema. MRI revealed diffuse T2 signal abnormality and 8mm downward displacement of cerebellar tonsils. IV decadron continued at 6Q6. Patient's headache improved significantly on decadron, and she was ultimately transferred to the general neurology floor on . Given the high level of concern for CNS infection, and after discussion with ID and neurosurgery, it was decided that an LP was necessary. A repeat MRI was performed first, and showed no progression of edema and no change in the level of the cerebellar tonsils. Ms. to the procedure, and the LP on revealed OP 30, 11 wbc (lympho) 0 rbc protein 50 glucose 96. Crypto negative, HSV negative. Gram stain was negative for bacteria or poly's. CSF bacterial and fungal cultures were negative. Pending CSF labs include: EEE, WNV, AFB culture. CSF viral load was 1350 despite peripheral load of 424. There was some concern that this represented HIV meningoencephalitis, but was not thought to be a definite explanation for her cerebral edema. The Infectious Disease team has been closely involved with her case, as well as her PCP . and Dr. . During the course of the admission Ms. neurologic exam remained non-focal, with some mild difficulties with executive function. Her repeat MRI on showed improvement in the edema and white matter changes. Her decadron was slowly weaned so that she was off the medication by . See below for details of ID tests that were performed. Ultimately, no definitive etiology was found for her cerebral edema, although it is suspected to have been infectious in nature (HIV versus other infection). 2. ID: Infectious disease consulted while patient in the emergency room. Following tests were sent on : HCV Ab, Cryptococcal Ag negative, VZV IgG positive, CMV IgG positive and IgM negative, EBV IgG positive and IgM negative, Toxo Ab negative, Lyme serology negative, RPR negative, Mycoplasma Ab negative for acute infection. Pending studies include WNV serology, EEE serology. Ophthalmology was consulted on and found no evidence of CMV, toxoplasmosis, PC choroidopathy, or lymphoma. Due to concern for HIV mengingoencephalitis, her HAART therapy was adjusted to include medications with better CNS penetration. Her new regimen included tenofovir 300 mg daily, abacavir 600 mg po daily, lamivudine 300 mg daily, and kaletra 3 caps . Abacavir has a risk of rash but this did not occur during the admission. She was diagnosed with oral thrush on and began a 2 week course of diflucan. Ms. had a wbc of 9 on admission, wbc of 17 on the day of LP, and peak wbc of 28.5 on , all with neutrophilia. The pattern was that her wbc rose as expected after initiation of steroids, but continued to rise after steroid taper. She had multiple cultures of blood and urine sent, all of which were negative, and chest x-rays were negative as well. She was never febrile. No clear source for the wbc could be identified, ultimately, but it has been coming down to a most recent level of 23.5 on . 3. PSYCH: Unfortunately, although Ms. had been doing quite well neurologically after her steroid wean, she became progressively more anxious and agitated during the weekend of , and by the morning of was reporting hearing voices, obsessing about the Bible, and wandering about agitatedly. She said she had not slept at all the night before. Psychiatry was consulted and thought this could be related to a steroid psychosis, although its coincidence with the wean of the steroids was a bit atypical. The patient had no prior history of psychiatric illness, except some mild depression. Her agitation improved during the course of the day on , and she slept through the night after receiving Seroquel 50 mg. On Ms. was much calmer, although she was still a bit guarded and suspicious. A repeat MRI was obtained to ensure that her behavioral changes were not related to herniation with injury to basal forebrain structures, but the MRI was actually improved. On the morning of Ms. again became acutely psychotic, now reporting that she heard a voice commanding her to harm herself, randomly calling relatives and telling them \"you're Satan\", and repeatedly shouting for . She attempted to leave the hospital and a \"Code Purple\" was called, as the patient was in danger of harming herself. She was moved to a private room near the nurses' station with security posted outside her room. Over the course of the morning she calmed down but was refusing all medications. Her psychosis seemed to wax and wane over the course of the day. An EEG was obtained due to concern for temporal lobe epilepsy and revealed no epileptiform activity. She was placed on Seroquel 100 mg qHS, which she refused. The Psychiatry team was consulted and were closely involved with her care during the day. It was decided that she would be safest on an inpatient psychiatric (med-psych preferably given her complex history), and arrangements for transfer were begun. However, there was significant difficulty in finding a bed for her either at or at or . Given her complicated prior medical issues, we felt it most important that she remain here if possible. She calmed down significantly and was much more lucid later in the day, and hence she remained on the neurology floor for another day. On she was quite calm and seemed to be doing well during the day, but that night she awoke with nightmares and began walking outside her room and screaming. Due to concern about safety of other patients a Code Purple was called and she was briefly placed in restraints. By the morning she was again more calm and lucid, but understood that for her safety it would be necessary for her to move to the psychiatry service."},"extractive_notes_summ":{"kind":"string","value":"Sinus rhythm with sinus arrhythmiaProminent U waves suggested - are nonspecific and baseline artifact in leadsV1-V3 makes assessment difficultOtherwise probably normal ECGNo previous tracing available for comparison Nevertheless, the findings are likely in part due to cerebral/cerebellar edema. FINDINGS: The sagittal sinus, straight sinus, transverse sinus, and vein of are all show normal signal without evidence of thrombosis. The left posterior (Over) 8:04 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # MRA BRAIN W/O CONTRAST Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel Contrast: MAGNEVIST Amt: 14 FINAL REPORT (Cont) inferior cerebellar artery is not visualized. SYMPTOMS PERSISTED AND PT CAME TO ED , TREATED WITH COMPAZINE, PERCOCET AND IVF AND D/C HOME. This is likely secondary to cerebellar edema, and though the amount has progressed since the prior MR of the cervical spine from , the supracerebellar cistern remains patent. FINDINGS: The distal right vertebral artery is diminutive, and largely ends at the posterior inferior cerebellar artery on the right. Assess for herniation or venous thrombosis. PT DENIES CHEST PAIN, DIZZINESS, SOB. PT EMPIRICALLY STARTED ON ACYCLOVIR, CEFTRIAXONE AND DECADRON. Diffuse sulcal narrowing without shift of normally midline structures. Both superior cerebellar and anterior inferior cerebellar arteries are visualized and are normal in caliber. HEAD CT DONE SHOWED CEREBRAL EDEMA (UNKNOWN ETIOLOGY SEE RADIOLOGY REPORT FOR FULL DETAILS), MRI ALSO COMPLETED (RESULTS REMAIN PENDING). SYMPTOMS WORSENED AND PT RETURNED TO ED . PT DENIES SOB.GI/GU: ABD SOFT, NONTENDER + BOWEL SOUNDS. Both internal jugular veins are patent. Both internal carotid arteries demonstrate normal signal and caliber. LUNGS CTA WITH NON PRODUCTIVE COUGH. Both anterior cerebral and middle cerebral arteries proximally are normal in caliber without aneurysmal dilatation. PT TREATED FOR SINUSITIS WITH LEVOQUIN AND ZOMIG FOR MIGRAINES. This is increased since the limited assessment on the cervical spine MR , but the supracerebellar cistern remains visible. Diffuse abnormal T2 signal within the white matter and some areas of matter, associated with sulcal effacement. MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: There is downward protrusion of the cerebellar tonsils, measuring approximately 8 mm. The majority of the sulci over both cerebral convexities are effaced but both lateral ventricles are likely normal in size. A form of reversible leukoencephalopathy is also possible. Both posterior cerebral arteries are normal in caliber without aneurysmal dilatation. MRV: No definite evidence of venous sinus thrombosis. Headache, nausea, vomiting, and abnormal CT scan with evidence of intracranial edema. The right posterior communicating artery is normal. PT DENIES N/V. The basilar artery is slightly small, but otherwise, unremarkable. TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the brain including diffusion-weighted imaging, before and following administration of gadolinium. PRESENTED TO WITH C/O N/V, HA, DIZZINESS, MALAISE X 12 DAYS. Imaging findings are most consistent with brain edema that may be related to an infectious or inflammatory condition, although, clinical correlation is necessary. FINAL REPORT INDICATIONS: HIV. Worsening downward displacement of cerebellar tonsils. The greatest abnormality is located within white matter, but there is also blurring and indistinction of matter margins, most pronounced in the right frontal lobe. Assessment of the T2 and FLAIR sequences shows large areas of abnormal T2 signal hyperintensity within both frontal lobes, both parietal lobes, and both temporal lobes. The anterior communicating artery is not definitely visualized. + PROTECTIVE REFLEXES, PT C/O HA TREATED WITH TYLENOL 650 MG PO. Normal MRA and MRV. MICU NURSING ADMIT NOTE:SEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.38 Y.O. PT SEEN IN CLINIC ON WITH SIMILAR SYMPTOMS, SINUS TENDERNESS, FEVER AND NASAL DRAINAGE. PT SENT TO MICU FOR FURTHER MANAGEMENT.NEURO: PT ALERT, ORIENTED X 3. PT VOIDING IN COMMODE + MENSTRUAL CYCLE.ENDOCRINE: CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI AS ORDERED.ID: PT WITH X 2. COMPARISON: MRI of the cervical spine from . 8:04 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # MRA BRAIN W/O CONTRAST Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel Contrast: MAGNEVIST Amt: 14 MEDICAL CONDITION: 38 year old woman with HIV and HA, nausea, vomiting; REASON FOR THIS EXAMINATION: eval: abn CT with edema, ?herniation; please do mra/v as well to r/o venous sinus thrombosis WET READ: MRSg FRI 12:01 AM Diffuse T2/FLAIR hyperintensity in subcortical white matter. - EDEMA + PULSES.PULM: PT REMAINS ON RA SATS 95-100%. Findings are not typical for PML, though it is possible. PUPILS EQUAL/REACTIVE. Meningitis also cannot be excluded. PT REPORTS A SUPPORTIVE FAMILY.PLAN: FOLLOW CULTURES, CONT IV DECADRON, CONT ANTIBIOTICS, CONT FREQUENT NEURO CHECKS, CONT BEDREST RESTRICTIONS, FOLLOW VIRAL STUDIES, WILL CONT TO MONITOR. BLOOD AND URINE CULTURES PENDING. ALSO GIVEN MORPHINE 4 MG FOR C/O HA. PT REMAINS ON Q 1 HOUR NEURO CHECKS AND BEDREST.CV: TMAX 99.5 BP 110-140/50-70 HR 80-90 NSR NO ECTOPY NOTED. Differential diagnosis includes HIV encephalopathy, viral encephalitis such as CMV, PML, other infectious etiology."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2107-10-07 00:00:00.000","description":"Report","row_id":1545815,"text":"MICU NURSING ADMIT NOTE:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\n38 Y.O. FEMALE WITH HIV DX (CD4 555)AND MIGRAINES DX . PRESENTED TO WITH C/O N/V, HA, DIZZINESS, MALAISE X 12 DAYS. PT SEEN IN CLINIC ON WITH SIMILAR SYMPTOMS, SINUS TENDERNESS, FEVER AND NASAL DRAINAGE. PT TREATED FOR SINUSITIS WITH LEVOQUIN AND ZOMIG FOR MIGRAINES. SYMPTOMS PERSISTED AND PT CAME TO ED , TREATED WITH COMPAZINE, PERCOCET AND IVF AND D/C HOME. SYMPTOMS WORSENED AND PT RETURNED TO ED . HEAD CT DONE SHOWED CEREBRAL EDEMA (UNKNOWN ETIOLOGY SEE RADIOLOGY REPORT FOR FULL DETAILS), MRI ALSO COMPLETED (RESULTS REMAIN PENDING). BLOOD AND URINE CULTURES SENT. PT EMPIRICALLY STARTED ON ACYCLOVIR, CEFTRIAXONE AND DECADRON. ALSO GIVEN MORPHINE 4 MG FOR C/O HA. PT BEING FOLLOWED BY ID AND SEVERAL VIRAL STUDY LABS SENT OUT PER ID REQUEST. PT SENT TO MICU FOR FURTHER MANAGEMENT.\n\nNEURO: PT ALERT, ORIENTED X 3. PUPILS EQUAL/REACTIVE. MAE. FOLLOWS COMMANDS. + PROTECTIVE REFLEXES, PT C/O HA TREATED WITH TYLENOL 650 MG PO. PT REMAINS ON Q 1 HOUR NEURO CHECKS AND BEDREST.\n\nCV: TMAX 99.5 BP 110-140/50-70 HR 80-90 NSR NO ECTOPY NOTED. PT DENIES CHEST PAIN, DIZZINESS, SOB. - EDEMA + PULSES.\n\nPULM: PT REMAINS ON RA SATS 95-100%. LUNGS CTA WITH NON PRODUCTIVE COUGH. PT DENIES SOB.\n\nGI/GU: ABD SOFT, NONTENDER + BOWEL SOUNDS. TOLERATING POs WITHOUT DIFFICULTY. PT DENIES N/V. - BM OVERNIGHT. PT VOIDING IN COMMODE + MENSTRUAL CYCLE.\n\nENDOCRINE: CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI AS ORDERED.\n\nID: PT WITH X 2. BLOOD AND URINE CULTURES PENDING. ID FOLLOWING PATIENT ALL VIRAL STUDIES PENDING. PT REMAINS ON AMPICILLIN, ACYCLOVIR, CEFTRIAXONE, AND ANTIRETROVIRAL MEDS.\n\nSOCIAL: PT CURRENTLY LIVES WITH SON'S FATHER AND SON WHO HAS CP AND IS HIV +, ALSO HAS A DAUGHTER THAT IS IN COLLEGE. PT MOTHER AND FATHER IN TO SEE PATIENT. PT REPORTS A SUPPORTIVE FAMILY.\n\nPLAN: FOLLOW CULTURES, CONT IV DECADRON, CONT ANTIBIOTICS, CONT FREQUENT NEURO CHECKS, CONT BEDREST RESTRICTIONS, FOLLOW VIRAL STUDIES, WILL CONT TO MONITOR.\n"},{"category":"Nursing/other","chartdate":"2107-10-07 00:00:00.000","description":"Report","row_id":1545816,"text":"see nsg transfer note\n"},{"category":"Radiology","chartdate":"2107-10-06 00:00:00.000","description":"MRA BRAIN W/O CONTRAST","row_id":885877,"text":" 8:04 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with HIV and HA, nausea, vomiting;\n REASON FOR THIS EXAMINATION:\n eval: abn CT with edema, ?herniation; please do mra/v as well to r/o venous\n sinus thrombosis\n ______________________________________________________________________________\n WET READ: MRSg FRI 12:01 AM\n Diffuse T2/FLAIR hyperintensity in subcortical white matter. No abnormal\n enhancement identified in these areas, and no abnormal meningeal enhancement\n or extraaxial fluid collections are identified. Diffuse sulcal narrowing\n without shift of normally midline structures. No hydrocephalus. MRV: No\n definite evidence of venous sinus thrombosis.\n\n Differential diagnosis includes HIV encephalopathy, viral encephalitis such as\n CMV, PML, other infectious etiology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: HIV. Headache, nausea, vomiting, and abnormal CT scan with\n evidence of intracranial edema. Assess for herniation or venous thrombosis.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the brain including\n diffusion-weighted imaging, before and following administration of gadolinium.\n\n COMPARISON: MRI of the cervical spine from .\n\n MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: There is downward protrusion of\n the cerebellar tonsils, measuring approximately 8 mm. This is increased since\n the limited assessment on the cervical spine MR , but the\n supracerebellar cistern remains visible. Nevertheless, the findings are\n likely in part due to cerebral/cerebellar edema. Assessment of the T2 and\n FLAIR sequences shows large areas of abnormal T2 signal hyperintensity within\n both frontal lobes, both parietal lobes, and both temporal lobes. The\n greatest abnormality is located within white matter, but there is also\n blurring and indistinction of matter margins, most pronounced in the\n right frontal lobe. There are no areas of abnormal enhancement within the\n brain parenchyma or leptomeninges. No signal abnormality is seen on\n diffusion-weighted imaging. There is no evidence of intracranial hemorrhage.\n The majority of the sulci over both cerebral convexities are effaced but both\n lateral ventricles are likely normal in size.\n\n BRAIN MRA:\n\n TECHNIQUE: 3D time-of-flight imaging of the circle of and its major\n branches with multiplanar reconstructions.\n\n FINDINGS: The distal right vertebral artery is diminutive, and largely ends\n at the posterior inferior cerebellar artery on the right. The left posterior\n (Over)\n\n 8:04 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inferior cerebellar artery is not visualized. Both superior cerebellar and\n anterior inferior cerebellar arteries are visualized and are normal in\n caliber. The basilar artery is slightly small, but otherwise, unremarkable.\n Both posterior cerebral arteries are normal in caliber without aneurysmal\n dilatation. The right posterior communicating artery is normal. The left is\n not definitely visualized. Both internal carotid arteries demonstrate normal\n signal and caliber. Both anterior cerebral and middle cerebral arteries\n proximally are normal in caliber without aneurysmal dilatation. The anterior\n communicating artery is not definitely visualized.\n\n MRV OF THE BRAIN:\n\n TECHNIQUE: Sagittal 2D time-of-flight imaging through the brain and venous\n sinuses.\n\n FINDINGS: The sagittal sinus, straight sinus, transverse sinus, and vein of\n are all show normal signal without evidence of thrombosis. Both\n internal jugular veins are patent.\n\n IMPRESSION:\n 1. Diffuse abnormal T2 signal within the white matter and some areas of \n matter, associated with sulcal effacement. Imaging findings are most\n consistent with brain edema that may be related to an infectious or\n inflammatory condition, although, clinical correlation is necessary. A form of\n reversible leukoencephalopathy is also possible. Findings are not typical for\n PML, though it is possible. Meningitis also cannot be excluded.\n 2. Worsening downward displacement of cerebellar tonsils. This is likely\n secondary to cerebellar edema, and though the amount has progressed since the\n prior MR of the cervical spine from , the supracerebellar cistern\n remains patent.\n 3. Normal MRA and MRV.\n\n Results were discussed with Dr. at 11:50 a.m. on .\n\n\n"},{"category":"ECG","chartdate":"2107-10-10 00:00:00.000","description":"Report","row_id":258761,"text":"Sinus rhythm with sinus arrhythmia\nProminent U waves suggested - are nonspecific and baseline artifact in leads\nV1-V3 makes assessment difficult\nOtherwise probably normal ECG\nNo previous tracing available for comparison\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1545815,\n \"text\": \"MICU NURSING ADMIT NOTE:\\n\\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\\n\\n38 Y.O. FEMALE WITH HIV DX (CD4 555)AND MIGRAINES DX . PRESENTED TO WITH C/O N/V, HA, DIZZINESS, MALAISE X 12 DAYS. PT SEEN IN CLINIC ON WITH SIMILAR SYMPTOMS, SINUS TENDERNESS, FEVER AND NASAL DRAINAGE. PT TREATED FOR SINUSITIS WITH LEVOQUIN AND ZOMIG FOR MIGRAINES. SYMPTOMS PERSISTED AND PT CAME TO ED , TREATED WITH COMPAZINE, PERCOCET AND IVF AND D/C HOME. SYMPTOMS WORSENED AND PT RETURNED TO ED . HEAD CT DONE SHOWED CEREBRAL EDEMA (UNKNOWN ETIOLOGY SEE RADIOLOGY REPORT FOR FULL DETAILS), MRI ALSO COMPLETED (RESULTS REMAIN PENDING). BLOOD AND URINE CULTURES SENT. PT EMPIRICALLY STARTED ON ACYCLOVIR, CEFTRIAXONE AND DECADRON. ALSO GIVEN MORPHINE 4 MG FOR C/O HA. PT BEING FOLLOWED BY ID AND SEVERAL VIRAL STUDY LABS SENT OUT PER ID REQUEST. PT SENT TO MICU FOR FURTHER MANAGEMENT.\\n\\nNEURO: PT ALERT, ORIENTED X 3. PUPILS EQUAL/REACTIVE. MAE. FOLLOWS COMMANDS. + PROTECTIVE REFLEXES, PT C/O HA TREATED WITH TYLENOL 650 MG PO. PT REMAINS ON Q 1 HOUR NEURO CHECKS AND BEDREST.\\n\\nCV: TMAX 99.5 BP 110-140/50-70 HR 80-90 NSR NO ECTOPY NOTED. PT DENIES CHEST PAIN, DIZZINESS, SOB. - EDEMA + PULSES.\\n\\nPULM: PT REMAINS ON RA SATS 95-100%. LUNGS CTA WITH NON PRODUCTIVE COUGH. PT DENIES SOB.\\n\\nGI/GU: ABD SOFT, NONTENDER + BOWEL SOUNDS. TOLERATING POs WITHOUT DIFFICULTY. PT DENIES N/V. - BM OVERNIGHT. PT VOIDING IN COMMODE + MENSTRUAL CYCLE.\\n\\nENDOCRINE: CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI AS ORDERED.\\n\\nID: PT WITH X 2. BLOOD AND URINE CULTURES PENDING. ID FOLLOWING PATIENT ALL VIRAL STUDIES PENDING. PT REMAINS ON AMPICILLIN, ACYCLOVIR, CEFTRIAXONE, AND ANTIRETROVIRAL MEDS.\\n\\nSOCIAL: PT CURRENTLY LIVES WITH SON'S FATHER AND SON WHO HAS CP AND IS HIV +, ALSO HAS A DAUGHTER THAT IS IN COLLEGE. PT MOTHER AND FATHER IN TO SEE PATIENT. PT REPORTS A SUPPORTIVE FAMILY.\\n\\nPLAN: FOLLOW CULTURES, CONT IV DECADRON, CONT ANTIBIOTICS, CONT FREQUENT NEURO CHECKS, CONT BEDREST RESTRICTIONS, FOLLOW VIRAL STUDIES, WILL CONT TO MONITOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1545816,\n \"text\": \"see nsg transfer note\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-06 00:00:00.000\",\n \"description\": \"MRA BRAIN W/O CONTRAST\",\n \"row_id\": 885877,\n \"text\": \" 8:04 PM\\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \\n MRA BRAIN W/O CONTRAST\\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\\n Contrast: MAGNEVIST Amt: 14\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 38 year old woman with HIV and HA, nausea, vomiting;\\n REASON FOR THIS EXAMINATION:\\n eval: abn CT with edema, ?herniation; please do mra/v as well to r/o venous\\n sinus thrombosis\\n ______________________________________________________________________________\\n WET READ: MRSg FRI 12:01 AM\\n Diffuse T2/FLAIR hyperintensity in subcortical white matter. No abnormal\\n enhancement identified in these areas, and no abnormal meningeal enhancement\\n or extraaxial fluid collections are identified. Diffuse sulcal narrowing\\n without shift of normally midline structures. No hydrocephalus. MRV: No\\n definite evidence of venous sinus thrombosis.\\n\\n Differential diagnosis includes HIV encephalopathy, viral encephalitis such as\\n CMV, PML, other infectious etiology.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: HIV. Headache, nausea, vomiting, and abnormal CT scan with\\n evidence of intracranial edema. Assess for herniation or venous thrombosis.\\n\\n TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the brain including\\n diffusion-weighted imaging, before and following administration of gadolinium.\\n\\n COMPARISON: MRI of the cervical spine from .\\n\\n MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: There is downward protrusion of\\n the cerebellar tonsils, measuring approximately 8 mm. This is increased since\\n the limited assessment on the cervical spine MR , but the\\n supracerebellar cistern remains visible. Nevertheless, the findings are\\n likely in part due to cerebral/cerebellar edema. Assessment of the T2 and\\n FLAIR sequences shows large areas of abnormal T2 signal hyperintensity within\\n both frontal lobes, both parietal lobes, and both temporal lobes. The\\n greatest abnormality is located within white matter, but there is also\\n blurring and indistinction of matter margins, most pronounced in the\\n right frontal lobe. There are no areas of abnormal enhancement within the\\n brain parenchyma or leptomeninges. No signal abnormality is seen on\\n diffusion-weighted imaging. There is no evidence of intracranial hemorrhage.\\n The majority of the sulci over both cerebral convexities are effaced but both\\n lateral ventricles are likely normal in size.\\n\\n BRAIN MRA:\\n\\n TECHNIQUE: 3D time-of-flight imaging of the circle of and its major\\n branches with multiplanar reconstructions.\\n\\n FINDINGS: The distal right vertebral artery is diminutive, and largely ends\\n at the posterior inferior cerebellar artery on the right. The left posterior\\n (Over)\\n\\n 8:04 PM\\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \\n MRA BRAIN W/O CONTRAST\\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\\n Contrast: MAGNEVIST Amt: 14\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n inferior cerebellar artery is not visualized. Both superior cerebellar and\\n anterior inferior cerebellar arteries are visualized and are normal in\\n caliber. The basilar artery is slightly small, but otherwise, unremarkable.\\n Both posterior cerebral arteries are normal in caliber without aneurysmal\\n dilatation. The right posterior communicating artery is normal. The left is\\n not definitely visualized. Both internal carotid arteries demonstrate normal\\n signal and caliber. Both anterior cerebral and middle cerebral arteries\\n proximally are normal in caliber without aneurysmal dilatation. The anterior\\n communicating artery is not definitely visualized.\\n\\n MRV OF THE BRAIN:\\n\\n TECHNIQUE: Sagittal 2D time-of-flight imaging through the brain and venous\\n sinuses.\\n\\n FINDINGS: The sagittal sinus, straight sinus, transverse sinus, and vein of\\n are all show normal signal without evidence of thrombosis. Both\\n internal jugular veins are patent.\\n\\n IMPRESSION:\\n 1. Diffuse abnormal T2 signal within the white matter and some areas of \\n matter, associated with sulcal effacement. Imaging findings are most\\n consistent with brain edema that may be related to an infectious or\\n inflammatory condition, although, clinical correlation is necessary. A form of\\n reversible leukoencephalopathy is also possible. Findings are not typical for\\n PML, though it is possible. Meningitis also cannot be excluded.\\n 2. Worsening downward displacement of cerebellar tonsils. This is likely\\n secondary to cerebellar edema, and though the amount has progressed since the\\n prior MR of the cervical spine from , the supracerebellar cistern\\n remains patent.\\n 3. Normal MRA and MRV.\\n\\n Results were discussed with Dr. at 11:50 a.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 258761,\n \"text\": \"Sinus rhythm with sinus arrhythmia\\nProminent U waves suggested - are nonspecific and baseline artifact in leads\\nV1-V3 makes assessment difficult\\nOtherwise probably normal ECG\\nNo previous tracing available for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":24977,"cells":{"subject_id":{"kind":"number","value":78301,"string":"78,301"},"hadm_id":{"kind":"number","value":108493,"string":"108,493"},"target_text":{"kind":"string","value":"The patient was admitted to the vascular surgery service on to manage his aortic dissection. Upon admission, the patient was started on nitro and esmolol drips to keep his MAP < 70. He was closely monitored in the ICU. As the patient started to tolerate po intake, he was transitioned to oral anti-hypertensive medications. He was kept on a regimen of atenolol, hydralazine, and lisinopril which was very effective in keeping his blood pressure low. Once on po blood pressure regimen, the patient was transferred to the floor. On HD 3, patient had worsening abdominal pain and nausea in the morning. A CTA was performed that showed stable aortic dissection and no signs of impending rupture. As such, patient continued to be managed medically with strict blood pressure control. His diet was advanced to regular and was well tolerated. Physical therapy worked with the patient and determined that he was safe for home, but recommended physical therapy at home. Patient is a Jehovah's witness and as such is not a good surgical candidate. This fact was discussed with the patient and he understood all the issues. At the time of discharge, patient was feeling well. He was afebrile with stable vital signs, pain was well controlled, and he was tolerating regular diet. He will be sent home with new BP medications for strict blood pressure control and will follow up with Dr. in clinic."},"extractive_notes_summ":{"kind":"string","value":"Perfusion of entire false lumen, unchanged from . Decreased perfusion of right kidney relative to left kidney although R renal artery originates from true lumen and is patent. Mesenteric and renal arteries originate from true lumen. As described above, the right kidney is hypoperfused relative to the left kidney. Decreased perfusion of the right kidney relative to the left kidney, although the right renal artery originates from the true lumen and is patent. A small pericardial effusion is seen. Airways are patent to the level of subsegmental bronchi bilaterally. Perfusion of the entire false lumen is unchanged from . Prominent limb lead QRS voltage suggests left ventricularhypertrophy. RSR' pattern in lead V1. Mesenteric and renal arteries originate from the true lumen. The intramural hematoma at the level of the aortic arch is stable. Small bilateral pleural effusions and associated compressive atelectasis are new from . A 1.3 cm hypodensity (2:81) is a cyst. RSR' pattern in lead V1 may be normal variant. Extends to right superficial femoral and deep femoral arteries and to Left external iliac, possibly to left common femoral (artifact from L THR limits eval). Compression fractures of L1 and L2, stable from . Type B dissection originating just distal to L subclav. The rectum and sigmoid colon are normal. The celiac trunk, SMA, and renal arteries originate from the true lumen. Small pleural effusions and associated compressive atelectasis are new from . Low lateral precordial leadQRS voltage. Diverticula are seen throughout the sigmoid colon without inflammatory changes. The entire false lumen is perfused, unchanged from the prior study. Sinus rhythm. Sinus rhythm. Status post left total hip arthroplasty. Prostatic seeds are in place bilaterally. Prominent limb lead QRS voltagesuggests left ventricular hypertrophy. Stable compression fractures of L1 and L2. originates from false lumen. IMPRESSION: 1. There is decreased perfusion of the right kidney relative to the left kidney, although the right renal artery originates from the true lumen. A left adominal wall lipoma measures 1.5cm. Small bilateral pleural effusions and associated compressive atelectasis (Over) 7:15 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: please assess for progression of dissection, initial scan wi Admitting Diagnosis: TYPE B AORTIC DISSECTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) are new from . Compression fractures of L1 and L2 are stable from . Low laterallimb lead QRS voltage is non-specific. The originates from the false lumen. Stable from with no extention of dissection. Inferolateral lead T wave changes. The dissection course is stable from . The small and large bowels are normal in course and caliber. There is apparent fusion of the L5 and S1 vertebral bodies. Since the previous tracing of the samedate probably no significant change.TRACING #2 Type B aortic dissection as described above. A Foley catheter is in place. A right abdominal wall lipoma measures 3.8 x 5.2cm. (Over) 7:15 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: please assess for progression of dissection, initial scan wi Admitting Diagnosis: TYPE B AORTIC DISSECTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Calcifications and possible stenosis at the celiac artery origin are noted with a widely patent celiac artery just beyond the origin. Dissection is stable since with no evidence of extension. The spleen, pancreas, and bilateral adrenal glands are normal. CT ABDOMEN: The liver is normal. CT PELVIS: Left total hip arthroplasty limits evaluation of details at the pelvis. No contraindications for IV contrast WET READ: 10:41 AM 1. 4. 4. 2. 2. The originates from the false lumen with no perfusion over a 5 mm segment just distal to the origin of the , but the is very well perfused distally. 3. 3. Multilevel degenerative change is noted with loss of disc space height at multiple levels. The dissection does not extend into the mesenteric, renal, or internal iliac arteries. Thyroid is unremarkable without nodules. TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic symphysis were displayed with 2.5-mm slice thickness with 75 mL Optiray intravenous contrast. 5. 5. Findings are non-specific.No previous tracing available for comparison.TRACING #1 COMPARISON: Outside CT . No pathologically enlarged mediastinal, axillary or hilar lymph nodes are present. The largest aortic diameter is 4.5 cm, just above the diaphragm. CT ANGIOGRAM: A type B aortic dissection originates just distal to the left subclavian takeoff and extends to the right superficial and right deep femoral arteries and definitely to the left external iliac artery and possibly into the left common femoral artery, although complete evaluation is limited due to artifact from left hip arthroplasty. Coronal and sagittal reformats were displayed with 5-mm slice thickness. 6. 6. No mesenteric or retroperitoneal lymphadenopathy. Now wit abdominal pain and vomiting REASON FOR THIS EXAMINATION: please assess for progression of dissection, initial scan with mesenteric and renal vessels off true lumen except for . The heart is enlarged."},"n_notes":{"kind":"number","value":3,"string":"3"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2171-04-18 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1184482,"text":" 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with type B descending aortic dissection, from OSH with scan\n from 48 hours ago. Now wit abdominal pain and vomiting\n REASON FOR THIS EXAMINATION:\n please assess for progression of dissection, initial scan with mesenteric and\n renal vessels off true lumen except for . Assess for change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:41 AM\n 1. Type B dissection originating just distal to L subclav. Extends to right\n superficial femoral and deep femoral arteries and to Left external iliac,\n possibly to left common femoral (artifact from L THR limits eval). Stable from\n with no extention of dissection.\n 2. Mesenteric and renal arteries originate from true lumen. originates\n from false lumen.\n 3. Decreased perfusion of right kidney relative to left kidney although R\n renal artery originates from true lumen and is patent.\n 4. Perfusion of entire false lumen, unchanged from .\n 5. Small pleural effusions and associated compressive atelectasis are new from\n .\n 6. Compression fractures of L1 and L2, stable from .\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain and vomiting, type B aortic dissection, evaluate\n for interval change.\n\n COMPARISON: Outside CT .\n\n TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic\n symphysis were displayed with 2.5-mm slice thickness with 75 mL Optiray\n intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm\n slice thickness.\n\n CT ANGIOGRAM: A type B aortic dissection originates just distal to the left\n subclavian takeoff and extends to the right superficial and right deep femoral\n arteries and definitely to the left external iliac artery and possibly into\n the left common femoral artery, although complete evaluation is limited due to\n artifact from left hip arthroplasty. The dissection does not extend into the\n mesenteric, renal, or internal iliac arteries. The dissection course is stable\n from . The largest aortic diameter is 4.5 cm, just above the diaphragm.\n The entire false lumen is perfused, unchanged from the prior study.\n\n The celiac trunk, SMA, and renal arteries originate from the true lumen. The\n originates from the false lumen with no perfusion over a 5 mm segment just\n distal to the origin of the , but the is very well perfused distally.\n (Over)\n\n 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Calcifications and possible stenosis at the celiac artery origin are noted\n with a widely patent celiac artery just beyond the origin. There is decreased\n perfusion of the right kidney relative to the left kidney, although the right\n renal artery originates from the true lumen. The intramural hematoma at the\n level of the aortic arch is stable.\n\n CT CHEST: Contrast bolus timing is not optimized to evaluate for pulmonary\n embolism, but there is no large central PE. No pathologically enlarged\n mediastinal, axillary or hilar lymph nodes are present. The heart is\n enlarged. A small pericardial effusion is seen. Small bilateral pleural\n effusions and associated compressive atelectasis are new from .\n Thyroid is unremarkable without nodules. Airways are patent to the level of\n subsegmental bronchi bilaterally.\n\n CT ABDOMEN: The liver is normal. A 1.3 cm hypodensity (2:81) is a cyst.\n Hyperdensity of the gallbladder is due to vicarious excretion of contrast. The\n spleen, pancreas, and bilateral adrenal glands are normal. As described\n above, the right kidney is hypoperfused relative to the left kidney. The\n small and large bowels are normal in course and caliber. No free air and no\n free fluid. No mesenteric or retroperitoneal lymphadenopathy. A right\n abdominal wall lipoma measures 3.8 x 5.2cm. A left adominal wall lipoma\n measures 1.5cm.\n\n CT PELVIS: Left total hip arthroplasty limits evaluation of details at the\n pelvis. A Foley catheter is in place. The rectum and sigmoid colon are\n normal. Diverticula are seen throughout the sigmoid colon without\n inflammatory changes. Prostatic seeds are in place bilaterally. No free\n fluid and no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No lytic or sclerotic lesion suspicious for malignancy is seen.\n Multilevel degenerative change is noted with loss of disc space height at\n multiple levels. Compression fractures of L1 and L2 are stable from .\n There is apparent fusion of the L5 and S1 vertebral bodies. Status post left\n total hip arthroplasty.\n\n IMPRESSION:\n 1. Type B aortic dissection as described above. Dissection is stable since\n with no evidence of extension.\n 2. Mesenteric and renal arteries originate from the true lumen. The \n originates from the false lumen.\n 3. Decreased perfusion of the right kidney relative to the left kidney,\n although the right renal artery originates from the true lumen and is patent.\n 4. Perfusion of the entire false lumen is unchanged from .\n 5. Small bilateral pleural effusions and associated compressive atelectasis\n (Over)\n\n 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are new from .\n 6. Stable compression fractures of L1 and L2.\n\n Findings discussed with Dr. by phone, 9:20 a.m. .\n\n"},{"category":"ECG","chartdate":"2171-04-16 00:00:00.000","description":"Report","row_id":255124,"text":"Sinus rhythm. Prominent limb lead QRS voltage suggests left ventricular\nhypertrophy. RSR' pattern in lead V1 may be normal variant. Low lateral\nlimb lead QRS voltage is non-specific. Since the previous tracing of the same\ndate probably no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2171-04-16 00:00:00.000","description":"Report","row_id":255125,"text":"Sinus rhythm. RSR' pattern in lead V1. Prominent limb lead QRS voltage\nsuggests left ventricular hypertrophy. Low lateral precordial lead\nQRS voltage. Inferolateral lead T wave changes. Findings are non-specific.\nNo previous tracing available for comparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-04-18 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1184482,\n \"text\": \" 7:15 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: please assess for progression of dissection, initial scan wi\\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old man with type B descending aortic dissection, from OSH with scan\\n from 48 hours ago. Now wit abdominal pain and vomiting\\n REASON FOR THIS EXAMINATION:\\n please assess for progression of dissection, initial scan with mesenteric and\\n renal vessels off true lumen except for . Assess for change.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 10:41 AM\\n 1. Type B dissection originating just distal to L subclav. Extends to right\\n superficial femoral and deep femoral arteries and to Left external iliac,\\n possibly to left common femoral (artifact from L THR limits eval). Stable from\\n with no extention of dissection.\\n 2. Mesenteric and renal arteries originate from true lumen. originates\\n from false lumen.\\n 3. Decreased perfusion of right kidney relative to left kidney although R\\n renal artery originates from true lumen and is patent.\\n 4. Perfusion of entire false lumen, unchanged from .\\n 5. Small pleural effusions and associated compressive atelectasis are new from\\n .\\n 6. Compression fractures of L1 and L2, stable from .\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Abdominal pain and vomiting, type B aortic dissection, evaluate\\n for interval change.\\n\\n COMPARISON: Outside CT .\\n\\n TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic\\n symphysis were displayed with 2.5-mm slice thickness with 75 mL Optiray\\n intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm\\n slice thickness.\\n\\n CT ANGIOGRAM: A type B aortic dissection originates just distal to the left\\n subclavian takeoff and extends to the right superficial and right deep femoral\\n arteries and definitely to the left external iliac artery and possibly into\\n the left common femoral artery, although complete evaluation is limited due to\\n artifact from left hip arthroplasty. The dissection does not extend into the\\n mesenteric, renal, or internal iliac arteries. The dissection course is stable\\n from . The largest aortic diameter is 4.5 cm, just above the diaphragm.\\n The entire false lumen is perfused, unchanged from the prior study.\\n\\n The celiac trunk, SMA, and renal arteries originate from the true lumen. The\\n originates from the false lumen with no perfusion over a 5 mm segment just\\n distal to the origin of the , but the is very well perfused distally.\\n (Over)\\n\\n 7:15 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: please assess for progression of dissection, initial scan wi\\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Calcifications and possible stenosis at the celiac artery origin are noted\\n with a widely patent celiac artery just beyond the origin. There is decreased\\n perfusion of the right kidney relative to the left kidney, although the right\\n renal artery originates from the true lumen. The intramural hematoma at the\\n level of the aortic arch is stable.\\n\\n CT CHEST: Contrast bolus timing is not optimized to evaluate for pulmonary\\n embolism, but there is no large central PE. No pathologically enlarged\\n mediastinal, axillary or hilar lymph nodes are present. The heart is\\n enlarged. A small pericardial effusion is seen. Small bilateral pleural\\n effusions and associated compressive atelectasis are new from .\\n Thyroid is unremarkable without nodules. Airways are patent to the level of\\n subsegmental bronchi bilaterally.\\n\\n CT ABDOMEN: The liver is normal. A 1.3 cm hypodensity (2:81) is a cyst.\\n Hyperdensity of the gallbladder is due to vicarious excretion of contrast. The\\n spleen, pancreas, and bilateral adrenal glands are normal. As described\\n above, the right kidney is hypoperfused relative to the left kidney. The\\n small and large bowels are normal in course and caliber. No free air and no\\n free fluid. No mesenteric or retroperitoneal lymphadenopathy. A right\\n abdominal wall lipoma measures 3.8 x 5.2cm. A left adominal wall lipoma\\n measures 1.5cm.\\n\\n CT PELVIS: Left total hip arthroplasty limits evaluation of details at the\\n pelvis. A Foley catheter is in place. The rectum and sigmoid colon are\\n normal. Diverticula are seen throughout the sigmoid colon without\\n inflammatory changes. Prostatic seeds are in place bilaterally. No free\\n fluid and no pelvic or inguinal lymphadenopathy.\\n\\n BONE WINDOWS: No lytic or sclerotic lesion suspicious for malignancy is seen.\\n Multilevel degenerative change is noted with loss of disc space height at\\n multiple levels. Compression fractures of L1 and L2 are stable from .\\n There is apparent fusion of the L5 and S1 vertebral bodies. Status post left\\n total hip arthroplasty.\\n\\n IMPRESSION:\\n 1. Type B aortic dissection as described above. Dissection is stable since\\n with no evidence of extension.\\n 2. Mesenteric and renal arteries originate from the true lumen. The \\n originates from the false lumen.\\n 3. Decreased perfusion of the right kidney relative to the left kidney,\\n although the right renal artery originates from the true lumen and is patent.\\n 4. Perfusion of the entire false lumen is unchanged from .\\n 5. Small bilateral pleural effusions and associated compressive atelectasis\\n (Over)\\n\\n 7:15 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: please assess for progression of dissection, initial scan wi\\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n are new from .\\n 6. Stable compression fractures of L1 and L2.\\n\\n Findings discussed with Dr. by phone, 9:20 a.m. .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 255124,\n \"text\": \"Sinus rhythm. Prominent limb lead QRS voltage suggests left ventricular\\nhypertrophy. RSR' pattern in lead V1 may be normal variant. Low lateral\\nlimb lead QRS voltage is non-specific. Since the previous tracing of the same\\ndate probably no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-04-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 255125,\n \"text\": \"Sinus rhythm. RSR' pattern in lead V1. Prominent limb lead QRS voltage\\nsuggests left ventricular hypertrophy. Low lateral precordial lead\\nQRS voltage. Inferolateral lead T wave changes. Findings are non-specific.\\nNo previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":24978,"cells":{"subject_id":{"kind":"number","value":4857,"string":"4,857"},"hadm_id":{"kind":"number","value":118301,"string":"118,301"},"target_text":{"kind":"string","value":"75F with hx HTN admitted with ant NSTEMI and found to have 3VD at , transferred for high risk cath: s/p stent to LAD and LCx-OM1 on . Pt was started on Metoprolol 25 mg PO BID (switched to carvedilol 6.25mg PO bid the next morning), ASA 325 mg PO qD, Plavix 75 mg PO qD (loaded with 300 mg in cath lab), captopril 6.25 mg PO TID (gradually increased to 25mg PO tid), and atorvastatin 80mg PO qD. Given EF of % and global HK, considered anti-coagulation with heparin or coumadin, but did not do so due to bleeding during hospital stay. OSH reported vaginal bleeding after starting integrillin. Pelvic U/S was normal, and pt refused pelvic exam. Since admission to CCU, has been guiac positive on all stools. Hct has been stable, and pt was told to f/u with PCP for outpatient colonoscopy. Initial and CXR consistent with pulmonary edema with bilateral pleural effusions. Ms. experienced episodes of a-fib in cath lab, and continued to flip between sinus and afib in the CCU until converting back to sinus during the evening of . Pt was in ARF on admission to CCU, with Cr 1.4, and 2.2 on transfer from OSH. Baseline 1.1. She was treated with mucomyst and bicarbonate IVF, and monitored closely. She gradually recovered, with creatinine dropping to 1.2 by discharge. Urine cultured Alpha strep and lactobacillus at OSH, pt admitted on Ciprofloxacin. Changed to 7 days of levofloxacin 250mg PO qd for better alpha strep coverage. Ms. pre-existing hypertension continued to be managed with the use of beta blockers and ACEIs. An atypical CBC differential at OSH led to a new diagnosis of CLL. Heme Onc consulted, and reported the following: \"Impression: The patient may have very early CLL. Her increased retics, LDH, and bilirubin may indicate the presence of hemolysis. Plan includes ordering flow studies on her lymphocytes along with Coombs testing. If this is stage zero CLL, no treatment is indicated at the present time, although Coombs positive hemolytic anemia, if present, may need treatment.\" Flow cytometry supported this dx, with CD519+, CD23+, FMC7-, and CD20dim."},"extractive_notes_summ":{"kind":"string","value":"Compared to the previous tracingof atrial fibrillation is now present.TRACING #1 Normal ascending aorta diameter. Left ventricular wall thicknesses arenormal. There is a latetransition consistent with possible prior anterior myocardial infarction.Diffuse non-specific ST-T wave changes. Left atrial abnormality. Sinus rhythm with atrial ectopy. The aorta is calcified. The aorta is calcified. Mild (1+) mitralregurgitation is seen. Atrial ectopic beats. Sinus arrhythmia. There is again noted perihilar haziness and bilateral pleural effusions (left greater than right). Non-specificinferior ST-T wave changes. Non-specificinferior ST-T wave changes. Severelydepressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - hypo; basal inferior - hypo; mid inferior - hypo; basalinferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; lateralapex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. IMPRESSION: Findings consistent with CHF with interstitial edema and bilateral pleural effusions (left greater than right). There is slight perihilar haziness of the pulmonary vascularity and septal lines. ST segmentdepression in leads V3-V6 - consider anterolateral ischemia. Right pleuraleffusion.Conclusions:The left atrium is normal in size. Diffuse non-specific ST-T wave changes. Compared to the previous tracing there ismore atrial ectopy.TRACING #2 Sinus rhythm. Sinus rhythm. P-R interval 0.12. Thereis a late transition with inverted T waves in the anterior and anterolateralleads consistent with prior anterior myocardial infarction. The QTc interval isprolonged. Sinus rhythm with atrial ectopy and atrial tachycardia. Compared to the previous tracing of therhythm is now sinus.TRACING #2 Question of CHF. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Late transitionwith anterior and anterolateral ST-T wave changes consistent with possibleprior anterior myocardial infarction. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). There is a late transition with anterior and anterolateralST-T wave changes consistent with possible prior anterior myocardialinfarction. No AR.MITRAL VALVE: Normal mitral valve leaflets. Compared to the previous tracing of the ST segment depressions are less prominent.TRACING #1 These findings most likely represent CHF. The left ventricular cavity size is normal. Normal LV cavity size. FINDINGS: The heart is of normal size. FINDINGS: The heart is of normal size. Prolonged QTc interval. IMPRESSION: Persistent pulmonary edema and bilateral pleural effusions (left greater than right). Resting regional wall motionabnormalities include anteroseptal, apical, inferior and inferolateral severehypokinesis/akinesis. TECHNIQUE: AP portable single view of the chest. Shortness of breath. TECHNIQUE: PA and lateral views of the chest. No AS. No AS. Right ventricularchamber size and free wall motion are normal. The mediastinal and hilar contours are stable when compared to prior study. Atrial fibrillation with a rapid ventricular response. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 64Weight (lb): 121BSA (m2): 1.58 m2BP (mm Hg): 117/69HR (bpm): 88Status: InpatientDate/Time: at 10:40Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The mitral valve leaflets are structurally normal. QTc interval is prolonged. Overall left ventricularsystolic function is severely depressed. Diffuse non-specific ST-T wave changes.Compared to the previous tracing of there is no diagnostic change.TRACING #2 Pre- operative evaluation. P-R interval 120 milliseconds. No AR. No previous tracingavailable for comparison.TRACING #1 The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aorticregurgitation. No aortic regurgitation isseen. Antegrade flow is seen in both vertebral arteries. FINDINGS: Duplex evaluation of bilateral extracranial internal carotid arteries and vertebral arteries was performed, which demonstrates peak velocities on the right to be 149, 50, 58 cm per second, and on the left to be 149, 65, and 112 cm per second, corresponding to ICA to CCA ratio of 2.61 on the right and 2.9 on the left. The apex is not fully visualized. There is no pericardial effusion. There are also bilateral pleural effusions (left greater than right). COMPARISON: Comparison is made to . There is no aortic valve stenosis. There is also septal lines consistent with pulmonary edema. No significant plaque formation is demonstrated. There is no evidence of pneumothorax. IMPRESSION: 40-59% stenosis, bilateral internal carotid arteries, more towards 59%. 11:15 AM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE MEDICAL CONDITION: 75 year old woman with CAD/Low EF REASON FOR THIS EXAMINATION: Pre Op FINAL REPORT INDICATION: 75-year-old woman with CAD and low ejection fraction. 7:16 AM CHEST (PORTABLE AP) Clip # Reason: ?CHF Admitting Diagnosis: CORONARY ARTERY DISEASE MEDICAL CONDITION: 75 year old woman with hx CHF REASON FOR THIS EXAMINATION: ?CHF FINAL REPORT INDICATION: 75-year-old woman with history of CHF."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2174-07-13 00:00:00.000","description":"Report","row_id":69614,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 121\nBSA (m2): 1.58 m2\nBP (mm Hg): 117/69\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 10:40\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; lateral\napex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural\neffusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is severely depressed. Resting regional wall motion\nabnormalities include anteroseptal, apical, inferior and inferolateral severe\nhypokinesis/akinesis. The apex is not fully visualized. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n"},{"category":"Radiology","chartdate":"2174-07-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":871153,"text":" 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hx CHF\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with history of CHF. Shortness of breath.\n Question of CHF.\n\n COMPARISON: Comparison is made to .\n\n TECHNIQUE: AP portable single view of the chest.\n\n FINDINGS: The heart is of normal size. The aorta is calcified. The\n mediastinal and hilar contours are stable when compared to prior study. There\n is again noted perihilar haziness and bilateral pleural effusions (left\n greater than right). There is also septal lines consistent with pulmonary\n edema.\n\n IMPRESSION: Persistent pulmonary edema and bilateral pleural effusions (left\n greater than right).\n\n\n\n\n"},{"category":"Radiology","chartdate":"2174-07-13 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":870929,"text":" 10:03 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o carotid stenosis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe CAD; pre op CABG\n REASON FOR THIS EXAMINATION:\n r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preoperative CABG surgery.\n\n FINDINGS: Duplex evaluation of bilateral extracranial internal carotid\n arteries and vertebral arteries was performed, which demonstrates peak\n velocities on the right to be 149, 50, 58 cm per second, and on the left to be\n 149, 65, and 112 cm per second, corresponding to ICA to CCA ratio of 2.61 on\n the right and 2.9 on the left. No significant plaque formation is\n demonstrated. Antegrade flow is seen in both vertebral arteries.\n\n IMPRESSION: 40-59% stenosis, bilateral internal carotid arteries, more\n towards 59%.\n\n\n"},{"category":"Radiology","chartdate":"2174-07-13 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":870940,"text":" 11:15 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD/Low EF\n REASON FOR THIS EXAMINATION:\n Pre Op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with CAD and low ejection fraction. Pre-\n operative evaluation.\n\n TECHNIQUE: PA and lateral views of the chest.\n\n FINDINGS: The heart is of normal size. The aorta is calcified. There is\n slight perihilar haziness of the pulmonary vascularity and septal lines. There\n are also bilateral pleural effusions (left greater than right). These findings\n most likely represent CHF. There is no evidence of pneumothorax.\n\n IMPRESSION: Findings consistent with CHF with interstitial edema and\n bilateral pleural effusions (left greater than right).\n\n"},{"category":"ECG","chartdate":"2174-07-15 00:00:00.000","description":"Report","row_id":163334,"text":"Sinus rhythm. P-R interval 120 milliseconds. QTc interval is prolonged. There\nis a late transition with inverted T waves in the anterior and anterolateral\nleads consistent with prior anterior myocardial infarction. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of the\nrhythm is now sinus.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2174-07-14 00:00:00.000","description":"Report","row_id":163335,"text":"Atrial fibrillation with a rapid ventricular response. There is a late\ntransition consistent with possible prior anterior myocardial infarction.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof atrial fibrillation is now present.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2174-07-13 00:00:00.000","description":"Report","row_id":163551,"text":"Sinus rhythm with atrial ectopy. P-R interval 0.12. Late transition\nwith anterior and anterolateral ST-T wave changes consistent with possible\nprior anterior myocardial infarction. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing of there is no diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2174-07-13 00:00:00.000","description":"Report","row_id":163552,"text":"Sinus rhythm with atrial ectopy and atrial tachycardia. The QTc interval is\nprolonged. There is a late transition with anterior and anterolateral\nST-T wave changes consistent with possible prior anterior myocardial\ninfarction. Diffuse non-specific ST-T wave changes. No previous tracing\navailable for comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2174-07-16 00:00:00.000","description":"Report","row_id":163332,"text":"Sinus rhythm. Atrial ectopic beats. Compared to the previous tracing there is\nmore atrial ectopy.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2174-07-15 00:00:00.000","description":"Report","row_id":163333,"text":"Sinus arrhythmia. Prolonged QTc interval. Left atrial abnormality. ST segment\ndepression in leads V3-V6 - consider anterolateral ischemia. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of \nthe ST segment depressions are less prominent.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2174-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69614,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 64\\nWeight (lb): 121\\nBSA (m2): 1.58 m2\\nBP (mm Hg): 117/69\\nHR (bpm): 88\\nStatus: Inpatient\\nDate/Time: at 10:40\\nTest: Portable TTE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\\ndepressed LVEF.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\\nanteroseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\\ninferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; lateral\\napex - hypo;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural\\neffusion.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity size is normal. Overall left ventricular\\nsystolic function is severely depressed. Resting regional wall motion\\nabnormalities include anteroseptal, apical, inferior and inferolateral severe\\nhypokinesis/akinesis. The apex is not fully visualized. Right ventricular\\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\\nappear structurally normal with good leaflet excursion and no aortic\\nregurgitation. There is no aortic valve stenosis. No aortic regurgitation is\\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\\nregurgitation is seen. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 871153,\n \"text\": \" 7:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?CHF\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with hx CHF\\n REASON FOR THIS EXAMINATION:\\n ?CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 75-year-old woman with history of CHF. Shortness of breath.\\n Question of CHF.\\n\\n COMPARISON: Comparison is made to .\\n\\n TECHNIQUE: AP portable single view of the chest.\\n\\n FINDINGS: The heart is of normal size. The aorta is calcified. The\\n mediastinal and hilar contours are stable when compared to prior study. There\\n is again noted perihilar haziness and bilateral pleural effusions (left\\n greater than right). There is also septal lines consistent with pulmonary\\n edema.\\n\\n IMPRESSION: Persistent pulmonary edema and bilateral pleural effusions (left\\n greater than right).\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-13 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 870929,\n \"text\": \" 10:03 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: r/o carotid stenosis\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe CAD; pre op CABG\\n REASON FOR THIS EXAMINATION:\\n r/o carotid stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Preoperative CABG surgery.\\n\\n FINDINGS: Duplex evaluation of bilateral extracranial internal carotid\\n arteries and vertebral arteries was performed, which demonstrates peak\\n velocities on the right to be 149, 50, 58 cm per second, and on the left to be\\n 149, 65, and 112 cm per second, corresponding to ICA to CCA ratio of 2.61 on\\n the right and 2.9 on the left. No significant plaque formation is\\n demonstrated. Antegrade flow is seen in both vertebral arteries.\\n\\n IMPRESSION: 40-59% stenosis, bilateral internal carotid arteries, more\\n towards 59%.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-07-13 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 870940,\n \"text\": \" 11:15 AM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: CORONARY ARTERY DISEASE\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with CAD/Low EF\\n REASON FOR THIS EXAMINATION:\\n Pre Op\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 75-year-old woman with CAD and low ejection fraction. Pre-\\n operative evaluation.\\n\\n TECHNIQUE: PA and lateral views of the chest.\\n\\n FINDINGS: The heart is of normal size. The aorta is calcified. There is\\n slight perihilar haziness of the pulmonary vascularity and septal lines. There\\n are also bilateral pleural effusions (left greater than right). These findings\\n most likely represent CHF. There is no evidence of pneumothorax.\\n\\n IMPRESSION: Findings consistent with CHF with interstitial edema and\\n bilateral pleural effusions (left greater than right).\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163334,\n \"text\": \"Sinus rhythm. P-R interval 120 milliseconds. QTc interval is prolonged. There\\nis a late transition with inverted T waves in the anterior and anterolateral\\nleads consistent with prior anterior myocardial infarction. Non-specific\\ninferior ST-T wave changes. Compared to the previous tracing of the\\nrhythm is now sinus.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163335,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. There is a late\\ntransition consistent with possible prior anterior myocardial infarction.\\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\\nof atrial fibrillation is now present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163551,\n \"text\": \"Sinus rhythm with atrial ectopy. P-R interval 0.12. Late transition\\nwith anterior and anterolateral ST-T wave changes consistent with possible\\nprior anterior myocardial infarction. Diffuse non-specific ST-T wave changes.\\nCompared to the previous tracing of there is no diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163552,\n \"text\": \"Sinus rhythm with atrial ectopy and atrial tachycardia. The QTc interval is\\nprolonged. There is a late transition with anterior and anterolateral\\nST-T wave changes consistent with possible prior anterior myocardial\\ninfarction. Diffuse non-specific ST-T wave changes. No previous tracing\\navailable for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163332,\n \"text\": \"Sinus rhythm. Atrial ectopic beats. Compared to the previous tracing there is\\nmore atrial ectopy.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 163333,\n \"text\": \"Sinus arrhythmia. Prolonged QTc interval. Left atrial abnormality. ST segment\\ndepression in leads V3-V6 - consider anterolateral ischemia. Non-specific\\ninferior ST-T wave changes. Compared to the previous tracing of \\nthe ST segment depressions are less prominent.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":24979,"cells":{"subject_id":{"kind":"number","value":99785,"string":"99,785"},"hadm_id":{"kind":"number","value":120655,"string":"120,655"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"There is mild-to-moderate loss of height of the L1 vertebral body with irregularity of the endplates, anterior and posterior osteophytes and Schmorl's nodes and marrow edema in the superior portion of L1. Cardiac silhouette is unchanged and there is again evidence of bilateral pleural effusions with compressive atelectasis at the bases. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and temporal lobes and extending into the suprasellar, prepontine and interpeduncular cisterns with indentation on the pons. There is redemonstration of the bilateral subarachnoid hemorrhage noted in both frontotemporal regions and layering within the Sylvian fissure, suprasellar cisterns, and interpeduncular cisterns, volume and distribution appears relatively stable compared to prior study. Persistent moderate right and small left pleural effusion as well as bibasilar retrocardiac opacities. FINDINGS: Limited examination due to subcutaneous edema. Moderate loss of height T12 vertebral body with Schmorl's nodes, likely chronic. Minimal increase of the intraventricular hemorrhage layering in the occipital horns. Minimal increase in the intraventricular hemorrhage layering in the occipital horns. Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's node with an acute component of marrow edema in the L1 vertebral body. There is edema within the inferior left frontal lobe, compatible with contusion. FINDINGS: Since , there is minimal increase of the intraventricular hemorrhage layering in the occipital horns. There is a possibile small subdural hematoma overlying the right frontal convexity; however, this may simply represent bridging cortical veins. At T7-T8, disc desiccation, small Schmorl's nodes and mild bulge along with a more focal component of disc protrusion/extrusion on the right side is seen to indent the ventral cord with deformity. Increased retrocardiac density concerning for atelectasis or concomitant consolidation and minimal left pleural effusions are unchanged. Otherwise, the left frontal lobe contusion and multifocal intraparenchymal hemorrhage, subdural hemorrhage along the falx and the multifocal subarachnoid hemorrhage including in the prepontine cistern indenting the pons are unchanged. While part of this may be related to pulsation artifacts, presence of hemorrhagic components cannot be completely excluded given the presence of subarachnoid and intraventricular hemorrhage, on the concurrent CT head. Bilateral pleural effusions are noted. Bilateral pleural effusions and distended gall bladder -correlate with dedicated imaging. Grayscale and Doppler son of bilateral common femoral, femoral and popliteal veins were performed. Within that limitation, the cardiomediastinal and hilar contours appear within normal limits. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. def of T12 and L1; small disc extrusion on the right side at T7/8 indenting the thecal sac. Multilevel degenerative changes are noted in the form of disc desiccation, narrowing of the disc space, disc osteophyte complexes and facet degenerative changes indenting the ventral thecal sac resulting in mild canal stenosis. FINDINGS: There is diffuse osteopenia. Partially imaged is a comminuted distal femoral fracture with evidence of lipohemarthrosis. There is a diffuse osteopenia. BILATERAL HIPS, TWO VIEWS EACH INCLUDING A VIEW WITH TRACTION: Comminuted right intertrochanteric fracture is identified with minimal displacement. Underlying this fracture is a tiny focus of pneumocephalus. A small step-off is seen at the roof of the right sphenoid sinus which may represent a neurovascular channel or a small nondisplaced fracture. There are bilateral pleural effusions, with associated bibasilar dependent consolidations most likely reflecting atelectasis. A displaced nasal bone fracture is identified. Likely chronic compression deformity of L1 is noted, as described above. Small foci of pneumocephalus posterior to the right frontal sinus. Small foci of pneumocephalus posterior to the right frontal sinus. Small foci of pneumocephalus posterior to the right frontal sinus. Please see seperately reported thoracic spine CT for comments regarding the low thoracic spine. Left retrocardiac atelectasis has developed in the interim, associated with small amount of pleural effusion. In the lower lumbar spine there is facet arthropathy. Partially imaged comminuted fracture of distal right femur with associated lipohemarthrosis. Evaluation of left ankle is somewhat suboptimal, with degenerative changes of the tibiotalar joint present. Compression deformities involving the T11, T12, and L1 vertebral bodies. Compression deformities involving the T11, T12, and L1 vertebral bodies. Compression deformities involving the T11, T12, and L1 vertebral bodies. There is mild atherosclerosis. There is additional compression deformity at L1, also without specific evidence of acuity, and with marked degenerative osteophyte formation at T12-L1 suggesting chronicity. Bilateral complex supracondylar fractures. bilateral comminuted, angulated and slightly impacted distal femur fractures. There is hematoma at the fracture site. RIGHT: There is a comminuted impacted angulated fracture of the femoral neck and intertrochanteric fracture with varus angulation. FINDINGS: There is subtle loss of height involving the posterior aspect of the T3 vertebral body, with associated irregularity/buckling of the posterior cortex. There is associated soft tissue hematoma and joint effusion. There is diffuse osteopenia which limits the sensitivity for detection of subtle fractures. Another fracture is seen on the medial wall of the right sphenoid sinus with slight displacement of the inferior fragment laterally into the sinus. Nonspecific fat stranding about the rectum; correlate clinically. Marked associated degenerative change at T12-L1 with anterior osteophyte formation and a prominent L1 superior enplate Schmorl's node favor chronicity. There is bilateral lipohemarthrosis of the knees. expected soft tissue changes with bilateral lipohemarthoses of the knees. Multilevel degenerative change is present, with posterior disc-osteophyte complexes noted at T6-7 and T7-8 effacing the thecal sac at these levels. Severe osteopenia. Another fracture is seen through the posterior margin of the left side of sphenoid sinus which extends into the sphenoid septations and nasal septum. See subsequent MRI Mild degenerative change at L3-S1, without apparent critical canal stenosis. There are some irregular lucencies noted within the (Over) 6:19 PM CT T-SPINE W/O CONTRAST Clip # Reason: please perfor CT of thoracic and lumbar spine to evaluate fo Admitting Diagnosis: BILATERAL FEMORAL FRACTURES FINAL REPORT (Cont) vertebral body, though no discrete fracture line is identified, and these lucencies may reflect a combination osteopenia and a superior endplate Schmorl's node."},"n_notes":{"kind":"number","value":31,"string":"31"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1207422,"text":" 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall w/ known SAH/SDH.\n REASON FOR THIS EXAMINATION:\n evaluate for progression of SAH/SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:41 PM\n No significant change compared to study performed approximately 12 hours\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\n Extensive facial fractures with blood in the paranasal sinuses was better\n characterized on prior dedicated facial bones CT. There is again no midline\n shift or evidence of central brain herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall. Evaluate for progression of\n intracranial hemorrhage.\n\n COMPARISON: at 05:46 hours.\n\n NON-CONTRAST HEAD CT:\n\n There is little change from prior study. A large right frontal subgaleal\n hematoma/contusion is identified, with underlying facial fractures and\n hemorrhage in the paranasal sinuses, better characterized on recent dedicated\n facial bone CT.\n\n Intracranially, there is extensive subarachnoid hemorrhage identified,\n throughout the basal cisterns, about the bilateral frontal lobes, and in the\n sylvian fissures. Intraventricular blood is also identified layering in the\n occipital horns of the lateral ventricles. Subdural blood is seen over the\n left frontal lobe, as well as along the falx posteriorly at the vertex. There\n is edema within the inferior left frontal lobe, compatible with contusion.\n There is no shift of midline structures or evidence of central brain\n herniation. The basal cisterns remain patent, and the ventricles are\n unchanged in size. There is no CT evidence of acute territorial infarct.\n\n IMPRESSION: No significant change compared to study performed approximately\n 12 hours prior. Multifocal subarachnoid, subdural, or intraventricular\n hemorrhage is redemonstrated, as is a contusion involving the left inferior\n frontal lobe. Extensive facial fractures with blood in the paranasal sinuses\n was better characterized on prior dedicated facial bones CT. There is again\n no midline shift or evidence of central brain herniation.\n\n (Over)\n\n 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1207423,"text":", J. TSICU 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall w/ known SAH/SDH.\n REASON FOR THIS EXAMINATION:\n evaluate for progression of SAH/SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to study performed approximately 12 hours\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\n Extensive facial fractures with blood in the paranasal sinuses was better\n characterized on prior dedicated facial bones CT. There is again no midline\n shift or evidence of central brain herniation.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-10 00:00:00.000","description":"MR THORACIC SPINE W/O CONTRAST","row_id":1207627,"text":" 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH, T2/T3 fractures, bilateral\n hip fractures s/p hemiarthroplasty on left, TFN on right now with T3 fracture\n and inability to move upper or lower extremities\n REASON FOR THIS EXAMINATION:\n please evaluate for spinal cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SAT 8:08 PM\n Marrow edema in t2 and t3 from injury.\n Comp. def of T12 and L1; small disc extrusion on the right side at T7/8\n indenting the thecal sac.\n\n Diffusely altered signal intensity in the thecal sac, may relate to pulsation\n artifacts; however, blood products cannot be completely excluded given the\n presence of subarachnoid and intraventricular hemorrhage on the prior CT head\n study.\n Vague areas of increased signal intensity in the thoracic cord, nature of\n which is uncertain. Attention on followup can be considered.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, with loss of consciousness, diffuse multifocal\n intracranial hemorrhage, T2 and T3 fractures, inability to move upper and\n lower extremities, to evaluate for spinal cord injury.\n\n COMPARISON: CT of the T-spine done on .\n\n TECHNIQUE: MR T AND L SPINE WITHOUT CONTRAST\n\n FINDINGS:\n\n MR T SPINE WITHOUT CONTRAST:\n\n\n The numbering used for the present study is shown on series 7, image 9.\n There is diffuse hypointense signal of the marrow which needs correlation with\n hematology labs for anaemia, systemic disease or infiltrative disorders.\n\n There is kyphosis in the lower cervical and upper thoracic regions. Areas of\n marrow edema are noted at T2 and T3 vertebral bodies along the endplates and\n extending into the vertebral body and may relate to recent trauma.\n\n There is moderate-to-severe loss of height of the T12 vertebral body and mild\n loss of height of the T11 vertebral body.\n\n Disc desiccation is noted at multiple levels along with degenerative changes\n in the facets.\n\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n At T3, there is mild anterior displacement of the vertebral body with\n irregularity of the posterior cortex, which is seen to efface the ventral CSF\n space and indent the ventral surface of the cord with some degree of deformity\n on the cord.\n\n At T6-T7, mild bulge and small central protrusion are noted, effacing the\n ventral CSF space and indenting the ventral surface of the cord.\n\n At T7-T8, disc desiccation, small Schmorl's nodes and mild bulge along with a\n more focal component of disc protrusion/extrusion on the right side is seen to\n indent the ventral cord with deformity.\n\n At T8-T9, T9-T10 and T10-T11 levels, no disc herniation to the canal is noted.\n\n At T11-T12, Schmorl's nodes are noted, causing indentation on the adjacent\n endplates. No disc herniation into the canal.\n\n There are areas of altered signal intensity diffusely on the posterior thecal\n sac, assessment of which is limited. While part of this may be related to\n pulsation artifacts, presence of hemorrhagic components cannot be completely\n excluded given the presence of subarachnoid and intraventricular hemorrhage,\n on the concurrent CT head. No pre- or para-vertebral soft tissue swelling or\n masses are noted.\n\n Areas of signal intensity in the cord are of uncertain significance and\n attention on followup can be considered for better assessment. Axial images\n are limited due to artifacts.\n\n Bilateral pleural effusions are noted. Distended gallbladder incompletely\n imaged.\n\n MR OF THE LUMBAR SPINE:\n\n Numbering used for the present study is shown on series 13, image 11.\n\n The lumbar vertebral bodies are normal in height, signal intensity, and\n alignment from L2-L5. There is mild-to-moderate loss of height of the L1\n vertebral body with irregularity of the endplates, anterior and posterior\n osteophytes and Schmorl's nodes and marrow edema in the superior portion of\n L1.\n\n Disc desiccation and facet degenerative changes are noted at all levels.\n Minimal indentation on the ventral thecal sac is noted from the disc bulges.\n Mild foraminal narrowing is noted at L4 and L5 levels. No definite\n compression on the nerves is noted.\n\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The spinal cord ends atL1-2 level; the roots of the cauda equina are\n unremarkable.\n No pre- or para-vertebral soft tissue swelling or masses are noted.\n\n There is atrophy of the paraspinal muscles with fat infiltration.\n\n IMPRESSION:\n\n Limited due to motion-related artifacts.\n\n 1. Areas of marrow edema in the T2 and T3 vertebral bodies, with mild contour\n irregularity of the posterior cortex of T3 which is seen to indent the ventral\n thecal sac and the ventral surface of the cord. Osseous details are better\n assessed on the prior CT.\n\n Mild diffuse disc bulge, with small-to-moderate sized disc extrusion, on the\n right side deforming the right side of the cord at T7/8.\n Small central protrusion at T6-T7 level indenting the ventral thecal sac and\n ventral cord.\n\n Moderate loss of height T12 vertebral body with Schmorl's nodes, likely\n chronic.\n\n Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's\n node with an acute component of marrow edema in the L1 vertebral body.\n\n Multilevel disc and facet degenerative changes in the lumbar spine with mild\n foraminal narrowing at L4 and L5 levels.\n\n 2. Diffusely altered signal intensity in the thecal sac, may relate to\n pulsation artifacts; however, blood products cannot be completely excluded\n given the presence of subarachnoid and intraventricular hemorrhage on the\n prior CT head study.\n\n 3. Vague areas of increased signal intensity in the thoracic cord, nature of\n which is uncertain. Assessment of cord lesions is limited due to artifacts.\n Attention on followup can be considered.\n\n\n 4. Diffuse hypointense signal of the marrow- correlate with hematology labs.\n\n 5. Bilateral pleural effusions and distended gall bladder -correlate with\n dedicated imaging.\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2122-10-12 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1207923,"text":" 9:13 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: dvt\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with tachcardia\n REASON FOR THIS EXAMINATION:\n dvt\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE EXAMINATION: 72-year-old woman with tachycardia, to rule out\n DVT.\n\n COMPARISON: No comparisons are available.\n\n FINDINGS:\n Limited examination due to subcutaneous edema.\n Grayscale and Doppler son of bilateral common femoral, femoral and\n popliteal veins were performed. There is normal compressibility, flow and\n augmentation.\n The calf vesssles were not visualized.\n\n IMPRESSION: No evidence of DVT in right or left lower extremity.\n\n"},{"category":"Radiology","chartdate":"2122-10-14 00:00:00.000","description":"O ABDOMEN (SUPINE ONLY) IN O.R.","row_id":1208234,"text":" 12:29 AM\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb FRI 12:34 PM\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\n vertebra.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old woman status post trauma, undergoing IVC filter\n placement.\n\n COMPARISON: None.\n\n FINDINGS: A single intraoperative spot view of the abdomen shows an IVC\n filter in vertical orientation with its tip at the level of the lower\n one-third of the L1 vertebra. An NG tube is also seen.\n\n IMPRESSION: Vertically oriented IVC filter with the tip at the lower\n one-third of the L1 vertebra.\n\n"},{"category":"Radiology","chartdate":"2122-10-14 00:00:00.000","description":"O ABDOMEN (SUPINE ONLY) IN O.R.","row_id":1208235,"text":", J. TSICU 12:29 AM\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n PFI REPORT\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\n vertebra.\n\n"},{"category":"Radiology","chartdate":"2122-10-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1208079,"text":" 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is status post intubation, to look for interval\n changes in the lung.\n\n TECHNIQUE: Supine portable semi-upright radiograph of chest.\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: Left subclavian line ends at mid SVC. Endotracheal tube ends\n approximately 3.1 cm above the carina. Orogastric tube is seen coursing below\n the diaphragm with distal end within the stomach and is adequately placed.\n Bilateral moderate pulmonary edema has minimally improved. Increased left\n retrocardiac density is no different from prior radiograph and may either\n represent a left lower lung atelectasis or a concomitant lung pneumonia.\n Minimal left pleural effusion has been stable.\n\n IMPRESSION: Since , there is minimal improvement in the\n moderate pulmonary edema. Increased retrocardiac density concerning for\n atelectasis or concomitant consolidation and minimal left pleural effusions\n are unchanged.\n\n\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"LO HIP UNILAT MIN 2 VIEWS LEFT IN O.R.","row_id":1207369,"text":" 2:09 PM\n HIP UNILAT MIN 2 VIEWS LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN\n LOWER EXTREMITY WITHOUT RADIOLOGIST IN O.R.\n Reason: LEFT THR, FEMUR HRDWARE\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hip intraoperative studies .\n\n CLINICAL HISTORY: Patient with left total hip arthroplasty.\n\n FINDINGS: Multiple fluoroscopic images from the operating room demonstrate\n interval placement of a left hemiarthroplasty with a cemented femoral\n component. There are no signs for hardware-related complications. There is\n also a fracture involving the distal femoral metaphysis. This is fixated by a\n large fracture plate with mobile associated cortical screws. Please refer to\n the operative note for additional details. The total intraservice\n fluoroscopic time was 8.8 seconds.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"BO FEMUR (AP & LAT) BILAT IN O.R.","row_id":1207310,"text":" 10:23 AM\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILATClip # \n Reason: ORIF BILATERAL DISTAL FEMURS\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ORIF of bilateral distal femurs.\n\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\n radiologist present. Fourteen spot views were obtained. These demonstrate\n ORIF of bilateral distal femoral fractures with placement of bilateral lateral\n plates and screws. A total of 69.2 seconds of fluoroscopic time was used.\n Please refer to the operative note for further details.\n\n"},{"category":"Radiology","chartdate":"2122-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1209311,"text":" 9:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for intrapulmonary process\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with TBI and hx of MRSA pneumonia\n REASON FOR THIS EXAMINATION:\n please evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MRSA pneumonia.\n\n FINDINGS: In comparison with study of , the tracheostomy tube is in\n place. The left double-lumen tube is not appreciated at this time. Cardiac\n silhouette is unchanged and there is again evidence of bilateral pleural\n effusions with compressive atelectasis at the bases. Elevation of pulmonary\n venous pressure is again noted.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-07 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1207193,"text":" 4:21 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old female status post fall.\n\n STUDY: Portable AP chest radiograph.\n\n COMPARISON: CT of the chest on at 12:36 p.m.\n\n FINDINGS: The endotracheal tube sits 2.5 cm above the carina. Right-sided\n central venous catheter tip sits in the lower SVC. The endogastric tube side\n port sits just below the GE junction. The patient is situated on a trauma\n board, limiting assessment for fine detail. Within that limitation, the\n cardiomediastinal and hilar contours appear within normal limits. The lungs\n are clear. There is no large pleural effusion or pneumothorax. Irregularity\n along multiple right posterior ribs and the right proximal humerus are most\n compatible with old injuries.\n\n IMPRESSION:\n 1. Lines and tubes as described above.\n 2. No evidence of acute intrathoracic injury.\n\n"},{"category":"Radiology","chartdate":"2122-10-09 00:00:00.000","description":"MR CERVICAL SPINE W/O CONTRAST","row_id":1207581,"text":" 4:29 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please evaluate for c-spine bone, cord or ligamentous\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for c-spine bone, cord or ligamentous\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SAT 8:12 PM\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\n multifactorial degenerative changes, with assessment of details being\n significantly limited on the axial images, due to motion-related artifacts.\n\n Areas of altered signal intensity in the thecal sac may relate to blood\n products/pulsation artifacts or a combination of both given the presence of\n subarachnoid and intraventricular hemorrhage on prior CT head study.\n Correlate clinically. Please see important findings on the MR and\n L-spine performed as a separate study on the same day.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, with SAH and SDH and intraventricular\n hemorrhage, to evaluate for C-spine bone, cord or ligamentous lesions.\n\n COMPARISON: No prior C-spine studies.\n\n TECHNIQUE: MR of the cervical spine without contrast.\n\n FINDINGS:\n\n The cervical vertebral bodies are normal in height, signal intensity and\n alignment.\n Multilevel degenerative changes are noted in the form of disc desiccation,\n narrowing of the disc space, disc osteophyte complexes and facet degenerative\n changes indenting the ventral thecal sac resulting in mild canal stenosis.\n Most prominent changes are noted at C5-6 level. No pre- or para-vertebral\n soft tissue swelling or masses are noted. However, assessment is limited due\n to intubation.\n Vague areas of cord signal intensity are noted, inadequately assessed on the\n present study.\n Areas of altered signal intensity in the thecal sac may relate to pulsation\n artifacts versus blood products.\n\n Areas of marrow edema in T2 and T3 bodies- pl. see concurrent MR T spine\n study.\n Increased signal is noted in the mastoid air cells from fluid/mucosal\n thickening.\n\n IMPRESSION:\n (Over)\n\n 4:29 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please evaluate for c-spine bone, cord or ligamentous\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\n multifactorial degenerative changes, with adequate assessment is significantly\n limited on the axial images, due to motion-related artifacts. Osseous details\n can be better assessed with CT if necessary.\n Vague areas of cord signal intensity are noted, inadequately assessed on the\n present study.\n Areas of altered signal intensity in the thecal sac may relate to blood\n products/pulsation artifacts or a combination of both given the presence of\n subarachnoid and intraventricular hemorrhage on prior CT head study.\n Correlate clinically.\n\n Please see important findings on the MR and L-spine performed as a\n separate study on the same day.\n\n\n\n"},{"category":"Radiology","chartdate":"2122-10-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1207894,"text":" 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall, w/ fever, increased sputum production, increased\n ventilatory requirements\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fall, fever.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained on .\n\n There is interval progression of pulmonary edema. The left lower lobe\n consolidation has increased and there are also bilateral pleural effusion\n noted. Findings are consistent with progression of pulmonary edema, effusions\n and potentially worsening of the left lower lobe infectious process.\n Supporting devices are in unchanged position.\n\n"},{"category":"Radiology","chartdate":"2122-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1209426,"text":" 2:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 72 year old woman with TBI, VAP with increased WOB, RR 30s w\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\n oxygen requirement.\n REASON FOR THIS EXAMINATION:\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\n oxygen requirement: assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Chest x-ray .\n\n FINDINGS: Tracheostomy tube remains in standard position. Persistent\n moderate right and small left pleural effusion as well as bibasilar\n retrocardiac opacities. No new or worsening lung or pleural abnormalities.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-10 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1207657,"text":" 8:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate stability of bleed\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with MS and head bleed\n REASON FOR THIS EXAMINATION:\n please evaluate stability of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 10:09 AM\n 1. Minimal increase in the intraventricular hemorrhage layering in the\n occipital horns.\n 2. Otherwise no change, including no new hemorrhage, no intracranial\n herniation and no midline shift.\n 3. Stable mild dilatation of the ventricles.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with MS and head bleed. Please evaluate\n change.\n\n TECHNIQUE: Axial images through the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: CT of the head from , and ,\n CT of the facial bones from .\n\n FINDINGS:\n\n Since , there is minimal increase of the intraventricular\n hemorrhage layering in the occipital horns. Otherwise, the left frontal lobe\n contusion and multifocal intraparenchymal hemorrhage, subdural hemorrhage\n along the falx and the multifocal subarachnoid hemorrhage including in the\n prepontine cistern indenting the pons are unchanged. There is stable minimal\n dilatation of the ventricles. There is no shift of midline structures and no\n herniation. The basilar cisterns are patent.\n\n On a facial bone CT from , multiple facial bone and sphenoid\n bone fractures are unchanged but better evaluated on this prior exam.\n\n IMPRESSION:\n 1. Minimal increase of the intraventricular hemorrhage layering in the\n occipital horns. Otherwise, no change of the intraparenchymal, subarachnoid\n and subdural hemorrhage.\n 2. No shift of midline structures and no intracranial herniation.\n 3. Stable minimal dilatation of the ventricles.\n (Over)\n\n 8:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate stability of bleed\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1207256,"text":" 3:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with SAH/SDH s/p fall\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with subarachnoid hemorrhage/subdural hematoma after\n fall, please evaluate for interval change.\n\n COMPARISON: Comparison is made to outside hospital head CT performed\n .\n\n TECHNIQUE: Non-contrast axial images obtained through the brain. Coronal and\n sagittal reformations were provided.\n\n FINDINGS:\n\n There is redemonstration of the left extra-axial hematoma overlying the\n convexity of the left frontal lobe, slightly increased in size, measuring 8 mm\n on current study compared to 7 mm on prior study and without associated mass\n effect. There is a possibile small subdural hematoma overlying the right\n frontal convexity; however, this may simply represent bridging cortical veins.\n\n There is redemonstration of the bilateral subarachnoid hemorrhage noted in\n both frontotemporal regions and layering within the Sylvian fissure,\n suprasellar cisterns, and interpeduncular cisterns, volume and distribution\n appears relatively stable compared to prior study. Bilateral\n intraventricular hemorrhages are noted layering in the occipital horns, new\n compared to prior study.\n High-density material, likely blood is noted within the bilateral maxillary\n sinuses. Ventricles and sulci are prominent. No calvarial fracture\n identified, though there appears to be anterior maxillary sinus fractures as\n well as a displaced nasal bone fracture identified. These fractures may be\n better evaluated on the subsequent maxillofacial CT. The ethmoid air cells as\n well as sphenoid sinus demonstrate increased opacification with high-density\n fluid. A subgaleal hematoma overlys the right frontal bone.\n Small amount of gas is noted in the soft tissues of the left cheek.\n\n\n IMPRESSION:\n\n 1. Slightly increased small extra-axial hematoma overlying the left frontal\n lobe convexity and possible small secondary frontal hematoma noted on the\n right.\n 2. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and\n temporal lobes and extending into the suprasellar, prepontine and\n interpeduncular cisterns with indentation on the pons.\n (Over)\n\n 3:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Likely anterior maxillary and nasal bone fractures better evaluated on\n subsequent maxillofacial CT. Opacification of the paranasal sinuses likely\n related to blood.\n 4. Subgaleal hematoma overlying the right frontal bone.\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1207257,"text":" 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p fall with trauma to the face\n REASON FOR THIS EXAMINATION:\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\n with head CT*\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:48 PM\n PFI:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall with trauma to face, evaluate for facial\n fractures.\n\n COMPARISON: Head CT from at 05:46 a.m.\n\n TECHNIQUE: Routine MDCT study of the facial bones was performed with 1.25-mm\n slice thickness. Coronal and sagittal reconstructions were provided.\n\n FINDINGS: There are multiple fractures seen.\n\n There are two fractures through the frontal bone, one of which extends through\n the cribriform region and into the right ethmoidal air cells. Underlying this\n fracture is a tiny focus of pneumocephalus. A dural tear with a CSF leak\n cannot be excluded as the fracture line does extend through the posterior\n table.\n Another fracture is seen through the posterior margin of the left side of\n sphenoid sinus which extends into the sphenoid septations and nasal septum.\n The posterior fragments are overriding and again an underlying dural tear with\n CSF leak cannot be excluded. Another fracture is seen on the medial wall of\n the right sphenoid sinus with slight displacement of the inferior fragment\n laterally into the sinus. A small step-off is seen at the roof of the right\n sphenoid sinus which may represent a neurovascular channel or a small\n nondisplaced fracture.\n No fracture fragments are seen within the orbital cavity.\n Mastoid air cells are opacified, right greater than left, and there is fluid\n surrounding the right ossicular chain and therefore a fracture or dislocation\n cannot be excluded. Small amount of fluid is noted in the left mastoid air\n cells. Evaluation for T bone fractures is limited.\n There are multiple fractures noted involving the nasal bones, nasal septum and\n (Over)\n\n 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the bilateral maxillae with displacement of a few small fragments.\n\n A displaced nasal bone fracture is identified. There is high-density fluid\n throughout the paranasal sinuses, which most likely represents acute bleeding.\n There are scattered foci of soft tissue gas secondary to recent trauma. No\n osseous fragments are seen intracranially or within the orbital cavities. The\n bones are diffusely demineralized which makes identification of any additional\n fractures difficult to exclude.\n\n Areas of high attenuation are seen intracranially which represent subarachnoid\n and intraparenchymal hemorrhage. This is further characterized on concurrent\n head CT. A large right frontal subgaleal hematoma is seen without any\n radiodense foreign object embedded within. An ET tube and OG tube have been\n placed.\n\n IMPRESSION:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the right maxillary sinus and anterior wall of the left maxillary\n sinus and nasal bones . The bones are diffusely demineralized which makes\n identification of any additional fractures difficult to exclude.\n CTA can be considered for assessment of vascular structures and T bones.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n\n D/w Dr., Ortho by Dr. in the room on \n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1207258,"text":", J. TSICU 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p fall with trauma to the face\n REASON FOR THIS EXAMINATION:\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\n with head CT*\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"RO HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.","row_id":1207331,"text":" 11:51 AM\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RIGHT HIP DHS\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with ORIF of the right hip with dynamic hip\n screw.\n\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\n radiologist present. Twelve fluoroscopic spot views were obtained. Images\n demonstrate placement of markers into the femoral shaft and the femoral neck,\n followed by insertion of an intramedullary rod with dynamic hip screw fixation\n of a right intertrochanteric fracture. A total of 75.1 seconds of\n fluoroscopic time was used. Please refer to the operative note for further\n details.\n\n"},{"category":"Radiology","chartdate":"2122-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1207822,"text":" 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with IPH, desat + fever\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n WET READ: MDAg SUN 9:43 PM\n 1. Increased retrocardiac opacity since could be atelectasis or\n infection. could be evaluated on with PA and lateral views if clinically\n feasible.\n 2. NG tube side port ends at GE junction and could be advanced.\n 3. Remainder of support devices in satisfactory position.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Desaturations in a patient with intraparenchymal\n hemorrhage.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is 3 cm above the carina. The right PICC line tip is at the\n cavoatrial junction. The left subclavian line is at the left brachiocephalic\n vein/SVC junction. The NG tube tip is in the stomach, but the side hole is at\n the gastroesophageal junction and should be advanced.\n\n Heart size and mediastinal contours are stable. There is interval development\n of interstitial pulmonary edema, mild. Left retrocardiac atelectasis has\n developed in the interim, associated with small amount of pleural effusion.\n Right pleural effusion is most likely present as well.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1208604,"text":" 9:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for intrapulmonary process\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with MS s/p TBI\n REASON FOR THIS EXAMINATION:\n please evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for intrapulmonary process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a technically\n limited examination given hardware overlaying the thorax. The patient has\n been extubated, the nasogastric tube has been removed. The left double-lumen\n catheter is in unchanged position. The size of the cardiac silhouette is\n unchanged, extensive retrocardiac atelectasis and presence of bilateral\n pleural effusions. The pre-existing signs of pulmonary edema might have\n minimally decreased in the interval. This increase, however, is not\n substantial. Otherwise, no relevant changes are seen.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1208255,"text":" 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72F wheelchair bound female w MS who tx from OSH after fall from\n wheelchair lift onto face (facial fxs, B femur fx, SAH, SDH) now s/p repair B/L\n femur fx's \n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multiple medical\n problems, bedridden.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip, the left subclavian line and the NG tube are in unchanged\n position. Moderate pulmonary edema is unchanged as well as left lower lobe\n consolidation and bilateral pleural effusions. No definitive pneumothorax is\n seen.\n\n\n"},{"category":"Radiology","chartdate":"2122-10-09 00:00:00.000","description":"CT T-SPINE W/O CONTRAST","row_id":1207593,"text":" 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n s/p repair, intubated, sedated\n REASON FOR THIS EXAMINATION:\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\n injury to obtain clearance of the thoracic and lumbar spines\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 9:22 PM\n 1. Findings concerning for acute fracture of the T3 vertebral body.\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\n not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While these may also be chronic, given the concurrent acute injury in the\n upper thoracic spine, it is difficult to exclude acute compression injury at\n these levels, and further evaluation with MRI of the thoracic spine can be\n considered.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall with bilateral hip fractures.\n The patient is intubated and sedated. Evaluate for thoracic spine fracture.\n\n COMPARISON: MR cervical spine performed the same day. No prior imaging of\n the thoracic spine is available for review.\n\n TECHNIQUE: MDCT imaging of the thoracic spine was performed without contrast.\n Multiplanar reformats are prepared and reviewed in bone and soft tissue\n algorithm.\n\n FINDINGS:\n\n There is subtle loss of height involving the posterior aspect of the T3\n vertebral body, with associated irregularity/buckling of the posterior cortex.\n The inferior aspect of the posterior cortex is displaced posteriorly by\n approximately 3 mm, likely causing associated thecal sac effacement. A subtle\n lucency is seen traversing the T3 vertebral body. These findings are\n suspicious for an acute fracture, as confirmed by marrow edema seen on\n concurrent cervical spine MRI. Of note, T2 fracture suggested by additional\n marrow edema seen at that level is not apparent by CT.\n\n From T4 through T10, vertebral body heights are preserved, and there is no\n evidence of fracture. The alignments are similarly normal. Multilevel\n degenerative change is present, with posterior disc-osteophyte complexes noted\n at T6-7 and T7-8 effacing the thecal sac at these levels.\n\n The T11 vertebral body demonstrates mild, less than 25%, superior end plate\n depression anteriorly. There are some irregular lucencies noted within the\n (Over)\n\n 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vertebral body, though no discrete fracture line is identified, and these\n lucencies may reflect a combination osteopenia and a superior endplate\n Schmorl's node. There is no adjacent soft tissue change to specifically\n suggest an acute injury.\n\n There is approximately 50% loss of height involving the anterior aspect of the\n T12 vertebral body, with some associated irregularity of the posterior cortex\n which can relate to buckling from injury , though again no acute fracture line\n or associated soft tissue change is seen.\n There is additional compression deformity at L1, also without specific\n evidence of acuity, and with marked degenerative osteophyte formation at\n T12-L1 suggesting chronicity.\n There is angulated appearance of the posterosuperior portions of T12 and L1\n vertebral bodies indenting the thecal sac.\n\n The included mediastinal structures are normal within the limits of a\n non-contrast evaluation. Right and left central lines terminate in the SVC.\n Nasogastric tube seen entering the stomach. The patient is intubated with an\n endotracheal tube terminating in the mid trachea. There is no adenopathy. A\n small amount of fluid is seen in the pericardial recess.\n\n There are bilateral pleural effusions, with associated bibasilar dependent\n consolidations most likely reflecting atelectasis. Remainder of the lung\n parenchyma included is well aerated.\n\n IMPRESSION:\n\n 1. Acute compression fracture of the T3 vertebral body, with buckling of the\n posterior cortex, the inferior aspect of which is displaced posteriorly by\n approximately 3 mm. Suspected T2 vertebral body fracture (seen on concurrent\n cervical spine MRI) is not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While as detailed above these may be chronic, given the concurrent acute\n injury in the upper thoracic spine, it is difficult to exclude an acute\n component. Further evaluation with MRI of the thoracic spine can be\n considered as clinically indicated.\n\n Discussed with Dr at 8pm by Dr via phone.\n\n"},{"category":"Radiology","chartdate":"2122-10-07 00:00:00.000","description":"BILAT HIPS (AP,LAT & AP PELVIS)","row_id":1207198,"text":" 5:05 PM\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \n ANKLE (AP, LAT & OBLIQUE) BILAT\n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with bilateral femoral head/neck fractures\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral femoral neck and head fractures.\n\n COMPARISON: CT torso performed at 12:36.\n\n BILATERAL HIPS, TWO VIEWS EACH INCLUDING A VIEW WITH TRACTION: Comminuted\n right intertrochanteric fracture is identified with minimal displacement. No\n dislocation is identified. On the left, there is a mildly displaced\n subcapital femoral neck fracture with mild superior displacement of the distal\n fracture fragment. No dislocation is present. After traction, the degree of\n displacement of both fractures appear improved. There are degenerative\n changes in both hips with joint space narrowing. There is diffuse osteopenia\n which limits the sensitivity for detection of subtle fractures. There is no\n diastasis of the pubic symphysis or sacroiliac joints. Dense material within\n the region of the bladder likely represents excreted contrast.\n\n RIGHT TIBIA AND FIBULA, TWO VIEWS, AND RIGHT ANKLE, THREE VIEWS: No acute\n fracture or dislocation is identified. The ankle mortise is preserved. The\n talar dome appears smooth. There is diffuse demineralization of the osseous\n structures which limits sensitivity for detection of subtle fractures. Soft\n tissue swelling is noted about the ankle and foot. Partially imaged is a\n comminuted distal femoral fracture with evidence of lipohemarthrosis. Soft\n tissue calcification within the anterior aspect of the knee is likely vascular\n in etiology.\n\n LEFT TIBIA AND FIBULA, TWO VIEWS, AND LEFT ANKLE, THREE VIEWS: No acute\n fracture or dislocation is identified. There is diffuse soft tissue swelling.\n Rounded calcifications within the anterior soft tissues of the knee and lower\n leg likely represent vascular calcifications. Evaluation of left ankle is\n somewhat suboptimal, with degenerative changes of the tibiotalar joint\n present. Degenerative changes of the mid foot and hindfoot are also\n visualized, without a significant joint effusion.\n\n IMPRESSION:\n 1. Bilateral femoral neck fractures.\n\n 2. Partially imaged comminuted fracture of distal right femur with associated\n lipohemarthrosis.\n\n 3. No acute fracture or dislocation within either tibia or fibula, or ankle.\n DFDdp\n (Over)\n\n 5:05 PM\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \n ANKLE (AP, LAT & OBLIQUE) BILAT\n Reason: eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2122-10-08 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1207283,"text":" 7:58 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval line placement\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with polytrauma, intubated\n REASON FOR THIS EXAMINATION:\n Eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with polytrauma, status post intubation.\n Evaluate line placement.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: Endotracheal tube is 3.0 cm above the carina.\n Nasogastric tube follows a normal course terminating in the left upper\n quadrant with last side port just below the GE junction. Left subclavian\n central venous catheter terminates just beyond the junction of the\n brachiocephalic and SVC. Right-sided PICC follows a normal course terminating\n in the distal SVC.\n\n There is bibasilar atelectasis, but lungs are elsewhere clear. There is no\n large pleural effusion or pneumothorax. Heart size is normal. Mediastinal\n silhouette, hilar contours and pulmonary vasculature are normal. There is no\n displaced rib fracture.\n\n"},{"category":"Radiology","chartdate":"2122-10-09 00:00:00.000","description":"CT T-SPINE W/O CONTRAST","row_id":1207594,"text":", J. TSICU 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n s/p repair, intubated, sedated\n REASON FOR THIS EXAMINATION:\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\n injury to obtain clearance of the thoracic and lumbar spines\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Findings concerning for acute fracture of the T3 vertebral body.\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\n not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While these may also be chronic, given the concurrent acute injury in the\n upper thoracic spine, it is difficult to exclude acute compression injury at\n these levels, and further evaluation with MRI of the thoracic spine can be\n considered.\n\n"},{"category":"Radiology","chartdate":"2122-10-09 00:00:00.000","description":"CT L-SPINE W/O CONTRAST","row_id":1207595,"text":" 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for thoracic or lumbar processes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 7:56 PM\n No secure evidence of acute lumbar spine fracture. Compression deformities of\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\n fracture lines identified. These are most likely chronic. Bony canal appears\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\n Intrathecal detail is poorly assessed by CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall from wheelchair with\n bilateral hip fractures. Evaluate for fracture involving the lumbar spine.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT imaging of the lumbar spine was performed without contrast.\n Multiplanar reformats were prepared and reviewed in bone and soft tissue\n algorithm.\n\n FINDINGS:\n\n There is diffuse osteopenia.\n There is no obvious evidence of acute fracture involving the lumbar spine.\n The L1 - L5 vertebral bodies are preserved in alignment, and there is no\n prevertebral or paravertebral soft tissue change to suggest acute injury.\n\n There is superior endplate compression deformity involving L1, with 25-50%\n height loss of L1 anteriorly but preservation of the posterior cortex.\n Angulated postero-superior aspect of L1 is seen to indent the ventral thecal\n sac.\n Marked associated degenerative change at T12-L1 with anterior osteophyte\n formation and a prominent L1 superior enplate Schmorl's node favor chronicity.\n (However, small amount of marrow edema is noted adjacent to the Schmorl's node\n on susequent MRI).\n\n Milder degenerative change is seen in the lower lumbar spine, with additional\n disc space narrowing at L3-L4 and small posterior disc protrusions at L4-L5\n and L5-S1. There is however only minimal facet arthropathy, and no\n significant central canal or neural foraminal narrowing, however, intrathecal\n detail is poorly assessed by CT.\n\n There are no suspiciou/concerning lytic or sclerotic osseous lesions.\n There is excreted contrast within the renal collecting systems, reflecting\n prior contrast administration. There is mild atherosclerosis. There is no\n (Over)\n\n 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aneurysm or retroperitoneal adenopathy/mass identified.\n\n IMPRESSION:\n\n No definite acute fractures or malalignment involving the lumbar spine.\n Likely chronic compression deformity of L1 is noted, as described above. See\n subsequent MRI\n\n Mild degenerative change at L3-S1, without apparent critical canal stenosis.\n\n Please see seperately reported thoracic spine CT for comments regarding the\n low thoracic spine.\n\n\n\n"},{"category":"Radiology","chartdate":"2122-10-09 00:00:00.000","description":"CT L-SPINE W/O CONTRAST","row_id":1207596,"text":", J. TSICU 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for thoracic or lumbar processes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No secure evidence of acute lumbar spine fracture. Compression deformities of\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\n fracture lines identified. These are most likely chronic. Bony canal appears\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\n Intrathecal detail is poorly assessed by CT.\n\n"},{"category":"Radiology","chartdate":"2122-10-07 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":1207220,"text":" 7:17 PM\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \n Reason: surgical planning\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with bilateral femoral neck and distal femur fx\n REASON FOR THIS EXAMINATION:\n surgical planning\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:06 AM\n\n comminuted right intertrochanteric proximal femur fracture with angulation of\n the femoral neck. left subcapital femoral neck fx with mild-moderate superior\n translation of the distal femur relative to the femoral head. bilateral\n comminuted, angulated and slightly impacted distal femur fractures. no pelvic\n fractures. expected soft tissue changes with bilateral lipohemarthoses of the\n knees. no large pelvic or retroperitoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral femoral neck and distal femur fracture for surgical\n planning.\n\n TECHNIQUE: CT of pelvis and bilateral femurs without IV contrast with coronal\n and sagittal reformatted images per protocol.\n\n COMPARISON: Bilateral hips radiograph .\n\n FINDINGS: There is a Foley catheter in the urinary bladder with suprapubic\n access. There is air within the urinary bladder presumably from catheter\n placement; however, correlate clinically. There is mild stranding about the\n rectum (3:47); nonspecific.\n\n There is a diffuse osteopenia. In the lower lumbar spine there is facet\n arthropathy. Degenerative changes are seen in the SI and hip joints\n bilaterally.\n\n RIGHT:\n\n There is a comminuted impacted angulated fracture of the femoral neck and\n intertrochanteric fracture with varus angulation. There is associated soft\n tissue hematoma and joint effusion.\n\n There is a supracondylar highly comminuted impacted fracture with marked\n angulation and distraction of fracture fragments. There is moderate\n angulation of major distal fracture fragments anterior and lateral with\n rotation. The right knee joint is incongruent. Fracture extends into the\n posterior aspect of the medial femoral condyle and intercondylar notch;\n involves the majority of the medial femoral condyle. The right proximal tibia\n appears intact.\n\n LEFT:\n (Over)\n\n 7:17 PM\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \n Reason: surgical planning\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a comminuted fracture of the femoral neck with varus angulation and\n impaction. There is associated joint effusion. There is a highly comminuted\n impacted supracondylar fracture with anterior angulation of major distal\n fracture fragment overriding and shortening the limp. There is hematoma at\n the fracture site. There is distraction of fracture fragments. The fracture\n line involves both medial and lateral condyle extending to the lateral condyle\n joint surface and medial trochlea.\n\n There is extensive hematoma in the subcutaneous soft tissue tracking along\n bilateral thighs. There is bilateral lipohemarthrosis of the knees.\n\n IMPRESSION:\n\n 1. Complex fracture of the right femoral neck and intertrochanteric region.\n 2. Complex fracture of the left femoral neck.\n 3. Bilateral complex supracondylar fractures.\n 4. Bilateral hemarthrosis of the knees.\n 5. Subcutaneous soft tissue hematoma tracking along bilateral thigh.\n 6. Severe osteopenia.\n 7. Degenerative changes in the lower lumbar spine, SI and hip joints.\n 8. Suprapubic Foley catheter in the urinary bladder and air in the urinary\n bladder, presumably from catheter placement; correlate clinically.\n 9. Nonspecific fat stranding about the rectum; correlate clinically.\n\n"},{"category":"ECG","chartdate":"2122-10-11 00:00:00.000","description":"Report","row_id":248512,"text":"Sinus tachycardia. Low limb lead voltage. Non-specific ST-T wave changes.\nCompared to the previous tracing of there is no significant change.\n\n"},{"category":"ECG","chartdate":"2122-10-08 00:00:00.000","description":"Report","row_id":248513,"text":"Sinus tachycardia. Non-specific ST-T wave changes are diffuse. No previous\ntracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1207422,\n \"text\": \" 5:14 PM\\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \\n Reason: evaluate for progression of SAH/SDH\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p fall w/ known SAH/SDH.\\n REASON FOR THIS EXAMINATION:\\n evaluate for progression of SAH/SDH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:41 PM\\n No significant change compared to study performed approximately 12 hours\\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\\n Extensive facial fractures with blood in the paranasal sinuses was better\\n characterized on prior dedicated facial bones CT. There is again no midline\\n shift or evidence of central brain herniation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female status post fall. Evaluate for progression of\\n intracranial hemorrhage.\\n\\n COMPARISON: at 05:46 hours.\\n\\n NON-CONTRAST HEAD CT:\\n\\n There is little change from prior study. A large right frontal subgaleal\\n hematoma/contusion is identified, with underlying facial fractures and\\n hemorrhage in the paranasal sinuses, better characterized on recent dedicated\\n facial bone CT.\\n\\n Intracranially, there is extensive subarachnoid hemorrhage identified,\\n throughout the basal cisterns, about the bilateral frontal lobes, and in the\\n sylvian fissures. Intraventricular blood is also identified layering in the\\n occipital horns of the lateral ventricles. Subdural blood is seen over the\\n left frontal lobe, as well as along the falx posteriorly at the vertex. There\\n is edema within the inferior left frontal lobe, compatible with contusion.\\n There is no shift of midline structures or evidence of central brain\\n herniation. The basal cisterns remain patent, and the ventricles are\\n unchanged in size. There is no CT evidence of acute territorial infarct.\\n\\n IMPRESSION: No significant change compared to study performed approximately\\n 12 hours prior. Multifocal subarachnoid, subdural, or intraventricular\\n hemorrhage is redemonstrated, as is a contusion involving the left inferior\\n frontal lobe. Extensive facial fractures with blood in the paranasal sinuses\\n was better characterized on prior dedicated facial bones CT. There is again\\n no midline shift or evidence of central brain herniation.\\n\\n (Over)\\n\\n 5:14 PM\\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \\n Reason: evaluate for progression of SAH/SDH\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1207423,\n \"text\": \", J. TSICU 5:14 PM\\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \\n Reason: evaluate for progression of SAH/SDH\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p fall w/ known SAH/SDH.\\n REASON FOR THIS EXAMINATION:\\n evaluate for progression of SAH/SDH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No significant change compared to study performed approximately 12 hours\\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\\n Extensive facial fractures with blood in the paranasal sinuses was better\\n characterized on prior dedicated facial bones CT. There is again no midline\\n shift or evidence of central brain herniation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-10 00:00:00.000\",\n \"description\": \"MR THORACIC SPINE W/O CONTRAST\",\n \"row_id\": 1207627,\n \"text\": \" 3:12 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for spinal cord injury\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH, T2/T3 fractures, bilateral\\n hip fractures s/p hemiarthroplasty on left, TFN on right now with T3 fracture\\n and inability to move upper or lower extremities\\n REASON FOR THIS EXAMINATION:\\n please evaluate for spinal cord injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: NPw SAT 8:08 PM\\n Marrow edema in t2 and t3 from injury.\\n Comp. def of T12 and L1; small disc extrusion on the right side at T7/8\\n indenting the thecal sac.\\n\\n Diffusely altered signal intensity in the thecal sac, may relate to pulsation\\n artifacts; however, blood products cannot be completely excluded given the\\n presence of subarachnoid and intraventricular hemorrhage on the prior CT head\\n study.\\n Vague areas of increased signal intensity in the thoracic cord, nature of\\n which is uncertain. Attention on followup can be considered.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post fall, with loss of consciousness, diffuse multifocal\\n intracranial hemorrhage, T2 and T3 fractures, inability to move upper and\\n lower extremities, to evaluate for spinal cord injury.\\n\\n COMPARISON: CT of the T-spine done on .\\n\\n TECHNIQUE: MR T AND L SPINE WITHOUT CONTRAST\\n\\n FINDINGS:\\n\\n MR T SPINE WITHOUT CONTRAST:\\n\\n\\n The numbering used for the present study is shown on series 7, image 9.\\n There is diffuse hypointense signal of the marrow which needs correlation with\\n hematology labs for anaemia, systemic disease or infiltrative disorders.\\n\\n There is kyphosis in the lower cervical and upper thoracic regions. Areas of\\n marrow edema are noted at T2 and T3 vertebral bodies along the endplates and\\n extending into the vertebral body and may relate to recent trauma.\\n\\n There is moderate-to-severe loss of height of the T12 vertebral body and mild\\n loss of height of the T11 vertebral body.\\n\\n Disc desiccation is noted at multiple levels along with degenerative changes\\n in the facets.\\n\\n (Over)\\n\\n 3:12 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for spinal cord injury\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n At T3, there is mild anterior displacement of the vertebral body with\\n irregularity of the posterior cortex, which is seen to efface the ventral CSF\\n space and indent the ventral surface of the cord with some degree of deformity\\n on the cord.\\n\\n At T6-T7, mild bulge and small central protrusion are noted, effacing the\\n ventral CSF space and indenting the ventral surface of the cord.\\n\\n At T7-T8, disc desiccation, small Schmorl's nodes and mild bulge along with a\\n more focal component of disc protrusion/extrusion on the right side is seen to\\n indent the ventral cord with deformity.\\n\\n At T8-T9, T9-T10 and T10-T11 levels, no disc herniation to the canal is noted.\\n\\n At T11-T12, Schmorl's nodes are noted, causing indentation on the adjacent\\n endplates. No disc herniation into the canal.\\n\\n There are areas of altered signal intensity diffusely on the posterior thecal\\n sac, assessment of which is limited. While part of this may be related to\\n pulsation artifacts, presence of hemorrhagic components cannot be completely\\n excluded given the presence of subarachnoid and intraventricular hemorrhage,\\n on the concurrent CT head. No pre- or para-vertebral soft tissue swelling or\\n masses are noted.\\n\\n Areas of signal intensity in the cord are of uncertain significance and\\n attention on followup can be considered for better assessment. Axial images\\n are limited due to artifacts.\\n\\n Bilateral pleural effusions are noted. Distended gallbladder incompletely\\n imaged.\\n\\n MR OF THE LUMBAR SPINE:\\n\\n Numbering used for the present study is shown on series 13, image 11.\\n\\n The lumbar vertebral bodies are normal in height, signal intensity, and\\n alignment from L2-L5. There is mild-to-moderate loss of height of the L1\\n vertebral body with irregularity of the endplates, anterior and posterior\\n osteophytes and Schmorl's nodes and marrow edema in the superior portion of\\n L1.\\n\\n Disc desiccation and facet degenerative changes are noted at all levels.\\n Minimal indentation on the ventral thecal sac is noted from the disc bulges.\\n Mild foraminal narrowing is noted at L4 and L5 levels. No definite\\n compression on the nerves is noted.\\n\\n (Over)\\n\\n 3:12 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for spinal cord injury\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n The spinal cord ends atL1-2 level; the roots of the cauda equina are\\n unremarkable.\\n No pre- or para-vertebral soft tissue swelling or masses are noted.\\n\\n There is atrophy of the paraspinal muscles with fat infiltration.\\n\\n IMPRESSION:\\n\\n Limited due to motion-related artifacts.\\n\\n 1. Areas of marrow edema in the T2 and T3 vertebral bodies, with mild contour\\n irregularity of the posterior cortex of T3 which is seen to indent the ventral\\n thecal sac and the ventral surface of the cord. Osseous details are better\\n assessed on the prior CT.\\n\\n Mild diffuse disc bulge, with small-to-moderate sized disc extrusion, on the\\n right side deforming the right side of the cord at T7/8.\\n Small central protrusion at T6-T7 level indenting the ventral thecal sac and\\n ventral cord.\\n\\n Moderate loss of height T12 vertebral body with Schmorl's nodes, likely\\n chronic.\\n\\n Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's\\n node with an acute component of marrow edema in the L1 vertebral body.\\n\\n Multilevel disc and facet degenerative changes in the lumbar spine with mild\\n foraminal narrowing at L4 and L5 levels.\\n\\n 2. Diffusely altered signal intensity in the thecal sac, may relate to\\n pulsation artifacts; however, blood products cannot be completely excluded\\n given the presence of subarachnoid and intraventricular hemorrhage on the\\n prior CT head study.\\n\\n 3. Vague areas of increased signal intensity in the thoracic cord, nature of\\n which is uncertain. Assessment of cord lesions is limited due to artifacts.\\n Attention on followup can be considered.\\n\\n\\n 4. Diffuse hypointense signal of the marrow- correlate with hematology labs.\\n\\n 5. Bilateral pleural effusions and distended gall bladder -correlate with\\n dedicated imaging.\\n (Over)\\n\\n 3:12 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for spinal cord injury\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-12 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1207923,\n \"text\": \" 9:13 AM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: dvt\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with tachcardia\\n REASON FOR THIS EXAMINATION:\\n dvt\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR THE EXAMINATION: 72-year-old woman with tachycardia, to rule out\\n DVT.\\n\\n COMPARISON: No comparisons are available.\\n\\n FINDINGS:\\n Limited examination due to subcutaneous edema.\\n Grayscale and Doppler son of bilateral common femoral, femoral and\\n popliteal veins were performed. There is normal compressibility, flow and\\n augmentation.\\n The calf vesssles were not visualized.\\n\\n IMPRESSION: No evidence of DVT in right or left lower extremity.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-14 00:00:00.000\",\n \"description\": \"O ABDOMEN (SUPINE ONLY) IN O.R.\",\n \"row_id\": 1208234,\n \"text\": \" 12:29 AM\\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \\n Reason: IVC FILTER\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb FRI 12:34 PM\\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\\n vertebra.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 72-year-old woman status post trauma, undergoing IVC filter\\n placement.\\n\\n COMPARISON: None.\\n\\n FINDINGS: A single intraoperative spot view of the abdomen shows an IVC\\n filter in vertical orientation with its tip at the level of the lower\\n one-third of the L1 vertebra. An NG tube is also seen.\\n\\n IMPRESSION: Vertically oriented IVC filter with the tip at the lower\\n one-third of the L1 vertebra.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-14 00:00:00.000\",\n \"description\": \"O ABDOMEN (SUPINE ONLY) IN O.R.\",\n \"row_id\": 1208235,\n \"text\": \", J. TSICU 12:29 AM\\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \\n Reason: IVC FILTER\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n PFI REPORT\\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\\n vertebra.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208079,\n \"text\": \" 5:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: intubated\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with intubation\\n REASON FOR THIS EXAMINATION:\\n intubated\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: The patient is status post intubation, to look for interval\\n changes in the lung.\\n\\n TECHNIQUE: Supine portable semi-upright radiograph of chest.\\n\\n Comparisons were made with prior chest radiographs through \\n with the most recent from .\\n\\n FINDINGS: Left subclavian line ends at mid SVC. Endotracheal tube ends\\n approximately 3.1 cm above the carina. Orogastric tube is seen coursing below\\n the diaphragm with distal end within the stomach and is adequately placed.\\n Bilateral moderate pulmonary edema has minimally improved. Increased left\\n retrocardiac density is no different from prior radiograph and may either\\n represent a left lower lung atelectasis or a concomitant lung pneumonia.\\n Minimal left pleural effusion has been stable.\\n\\n IMPRESSION: Since , there is minimal improvement in the\\n moderate pulmonary edema. Increased retrocardiac density concerning for\\n atelectasis or concomitant consolidation and minimal left pleural effusions\\n are unchanged.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"LO HIP UNILAT MIN 2 VIEWS LEFT IN O.R.\",\n \"row_id\": 1207369,\n \"text\": \" 2:09 PM\\n HIP UNILAT MIN 2 VIEWS LEFT IN O.R.; -76 BY SAME PHYSICIAN # \\n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN\\n LOWER EXTREMITY WITHOUT RADIOLOGIST IN O.R.\\n Reason: LEFT THR, FEMUR HRDWARE\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Left hip intraoperative studies .\\n\\n CLINICAL HISTORY: Patient with left total hip arthroplasty.\\n\\n FINDINGS: Multiple fluoroscopic images from the operating room demonstrate\\n interval placement of a left hemiarthroplasty with a cemented femoral\\n component. There are no signs for hardware-related complications. There is\\n also a fracture involving the distal femoral metaphysis. This is fixated by a\\n large fracture plate with mobile associated cortical screws. Please refer to\\n the operative note for additional details. The total intraservice\\n fluoroscopic time was 8.8 seconds.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"BO FEMUR (AP & LAT) BILAT IN O.R.\",\n \"row_id\": 1207310,\n \"text\": \" 10:23 AM\\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILATClip # \\n Reason: ORIF BILATERAL DISTAL FEMURS\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: ORIF of bilateral distal femurs.\\n\\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\\n radiologist present. Fourteen spot views were obtained. These demonstrate\\n ORIF of bilateral distal femoral fractures with placement of bilateral lateral\\n plates and screws. A total of 69.2 seconds of fluoroscopic time was used.\\n Please refer to the operative note for further details.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209311,\n \"text\": \" 9:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for intrapulmonary process\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with TBI and hx of MRSA pneumonia\\n REASON FOR THIS EXAMINATION:\\n please evaluate for intrapulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: MRSA pneumonia.\\n\\n FINDINGS: In comparison with study of , the tracheostomy tube is in\\n place. The left double-lumen tube is not appreciated at this time. Cardiac\\n silhouette is unchanged and there is again evidence of bilateral pleural\\n effusions with compressive atelectasis at the bases. Elevation of pulmonary\\n venous pressure is again noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-07 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1207193,\n \"text\": \" 4:21 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: S/P FALL\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 72-year-old female status post fall.\\n\\n STUDY: Portable AP chest radiograph.\\n\\n COMPARISON: CT of the chest on at 12:36 p.m.\\n\\n FINDINGS: The endotracheal tube sits 2.5 cm above the carina. Right-sided\\n central venous catheter tip sits in the lower SVC. The endogastric tube side\\n port sits just below the GE junction. The patient is situated on a trauma\\n board, limiting assessment for fine detail. Within that limitation, the\\n cardiomediastinal and hilar contours appear within normal limits. The lungs\\n are clear. There is no large pleural effusion or pneumothorax. Irregularity\\n along multiple right posterior ribs and the right proximal humerus are most\\n compatible with old injuries.\\n\\n IMPRESSION:\\n 1. Lines and tubes as described above.\\n 2. No evidence of acute intrathoracic injury.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-09 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE W/O CONTRAST\",\n \"row_id\": 1207581,\n \"text\": \" 4:29 PM\\n MR CERVICAL SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for c-spine bone, cord or ligamentous\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\\n REASON FOR THIS EXAMINATION:\\n please evaluate for c-spine bone, cord or ligamentous\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: NPw SAT 8:12 PM\\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\\n multifactorial degenerative changes, with assessment of details being\\n significantly limited on the axial images, due to motion-related artifacts.\\n\\n Areas of altered signal intensity in the thecal sac may relate to blood\\n products/pulsation artifacts or a combination of both given the presence of\\n subarachnoid and intraventricular hemorrhage on prior CT head study.\\n Correlate clinically. Please see important findings on the MR and\\n L-spine performed as a separate study on the same day.\\n\\n\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post fall, with SAH and SDH and intraventricular\\n hemorrhage, to evaluate for C-spine bone, cord or ligamentous lesions.\\n\\n COMPARISON: No prior C-spine studies.\\n\\n TECHNIQUE: MR of the cervical spine without contrast.\\n\\n FINDINGS:\\n\\n The cervical vertebral bodies are normal in height, signal intensity and\\n alignment.\\n Multilevel degenerative changes are noted in the form of disc desiccation,\\n narrowing of the disc space, disc osteophyte complexes and facet degenerative\\n changes indenting the ventral thecal sac resulting in mild canal stenosis.\\n Most prominent changes are noted at C5-6 level. No pre- or para-vertebral\\n soft tissue swelling or masses are noted. However, assessment is limited due\\n to intubation.\\n Vague areas of cord signal intensity are noted, inadequately assessed on the\\n present study.\\n Areas of altered signal intensity in the thecal sac may relate to pulsation\\n artifacts versus blood products.\\n\\n Areas of marrow edema in T2 and T3 bodies- pl. see concurrent MR T spine\\n study.\\n Increased signal is noted in the mastoid air cells from fluid/mucosal\\n thickening.\\n\\n IMPRESSION:\\n (Over)\\n\\n 4:29 PM\\n MR CERVICAL SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for c-spine bone, cord or ligamentous\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\\n multifactorial degenerative changes, with adequate assessment is significantly\\n limited on the axial images, due to motion-related artifacts. Osseous details\\n can be better assessed with CT if necessary.\\n Vague areas of cord signal intensity are noted, inadequately assessed on the\\n present study.\\n Areas of altered signal intensity in the thecal sac may relate to blood\\n products/pulsation artifacts or a combination of both given the presence of\\n subarachnoid and intraventricular hemorrhage on prior CT head study.\\n Correlate clinically.\\n\\n Please see important findings on the MR and L-spine performed as a\\n separate study on the same day.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1207894,\n \"text\": \" 5:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: e/f pneumonia\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman s/p fall, w/ fever, increased sputum production, increased\\n ventilatory requirements\\n REASON FOR THIS EXAMINATION:\\n e/f pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Fall, fever.\\n\\n Portable AP chest radiograph was reviewed in comparison to prior study\\n obtained on .\\n\\n There is interval progression of pulmonary edema. The left lower lobe\\n consolidation has increased and there are also bilateral pleural effusion\\n noted. Findings are consistent with progression of pulmonary edema, effusions\\n and potentially worsening of the left lower lobe infectious process.\\n Supporting devices are in unchanged position.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209426,\n \"text\": \" 2:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 72 year old woman with TBI, VAP with increased WOB, RR 30s w\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\\n oxygen requirement.\\n REASON FOR THIS EXAMINATION:\\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\\n oxygen requirement: assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: Chest x-ray .\\n\\n FINDINGS: Tracheostomy tube remains in standard position. Persistent\\n moderate right and small left pleural effusion as well as bibasilar\\n retrocardiac opacities. No new or worsening lung or pleural abnormalities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-10 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1207657,\n \"text\": \" 8:56 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate stability of bleed\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with MS and head bleed\\n REASON FOR THIS EXAMINATION:\\n please evaluate stability of bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe SAT 10:09 AM\\n 1. Minimal increase in the intraventricular hemorrhage layering in the\\n occipital horns.\\n 2. Otherwise no change, including no new hemorrhage, no intracranial\\n herniation and no midline shift.\\n 3. Stable mild dilatation of the ventricles.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old woman with MS and head bleed. Please evaluate\\n change.\\n\\n TECHNIQUE: Axial images through the head were obtained. Coronal and sagittal\\n reformats were acquired.\\n\\n COMPARISON: CT of the head from , and ,\\n CT of the facial bones from .\\n\\n FINDINGS:\\n\\n Since , there is minimal increase of the intraventricular\\n hemorrhage layering in the occipital horns. Otherwise, the left frontal lobe\\n contusion and multifocal intraparenchymal hemorrhage, subdural hemorrhage\\n along the falx and the multifocal subarachnoid hemorrhage including in the\\n prepontine cistern indenting the pons are unchanged. There is stable minimal\\n dilatation of the ventricles. There is no shift of midline structures and no\\n herniation. The basilar cisterns are patent.\\n\\n On a facial bone CT from , multiple facial bone and sphenoid\\n bone fractures are unchanged but better evaluated on this prior exam.\\n\\n IMPRESSION:\\n 1. Minimal increase of the intraventricular hemorrhage layering in the\\n occipital horns. Otherwise, no change of the intraparenchymal, subarachnoid\\n and subdural hemorrhage.\\n 2. No shift of midline structures and no intracranial herniation.\\n 3. Stable minimal dilatation of the ventricles.\\n (Over)\\n\\n 8:56 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate stability of bleed\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1207256,\n \"text\": \" 3:44 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: interval change\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with SAH/SDH s/p fall\\n REASON FOR THIS EXAMINATION:\\n interval change\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient with subarachnoid hemorrhage/subdural hematoma after\\n fall, please evaluate for interval change.\\n\\n COMPARISON: Comparison is made to outside hospital head CT performed\\n .\\n\\n TECHNIQUE: Non-contrast axial images obtained through the brain. Coronal and\\n sagittal reformations were provided.\\n\\n FINDINGS:\\n\\n There is redemonstration of the left extra-axial hematoma overlying the\\n convexity of the left frontal lobe, slightly increased in size, measuring 8 mm\\n on current study compared to 7 mm on prior study and without associated mass\\n effect. There is a possibile small subdural hematoma overlying the right\\n frontal convexity; however, this may simply represent bridging cortical veins.\\n\\n There is redemonstration of the bilateral subarachnoid hemorrhage noted in\\n both frontotemporal regions and layering within the Sylvian fissure,\\n suprasellar cisterns, and interpeduncular cisterns, volume and distribution\\n appears relatively stable compared to prior study. Bilateral\\n intraventricular hemorrhages are noted layering in the occipital horns, new\\n compared to prior study.\\n High-density material, likely blood is noted within the bilateral maxillary\\n sinuses. Ventricles and sulci are prominent. No calvarial fracture\\n identified, though there appears to be anterior maxillary sinus fractures as\\n well as a displaced nasal bone fracture identified. These fractures may be\\n better evaluated on the subsequent maxillofacial CT. The ethmoid air cells as\\n well as sphenoid sinus demonstrate increased opacification with high-density\\n fluid. A subgaleal hematoma overlys the right frontal bone.\\n Small amount of gas is noted in the soft tissues of the left cheek.\\n\\n\\n IMPRESSION:\\n\\n 1. Slightly increased small extra-axial hematoma overlying the left frontal\\n lobe convexity and possible small secondary frontal hematoma noted on the\\n right.\\n 2. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and\\n temporal lobes and extending into the suprasellar, prepontine and\\n interpeduncular cisterns with indentation on the pons.\\n (Over)\\n\\n 3:44 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: interval change\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 3. Likely anterior maxillary and nasal bone fractures better evaluated on\\n subsequent maxillofacial CT. Opacification of the paranasal sinuses likely\\n related to blood.\\n 4. Subgaleal hematoma overlying the right frontal bone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1207257,\n \"text\": \" 3:44 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: ?facial fractures *please obtain thin cuts to the face, if p\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with s/p fall with trauma to the face\\n REASON FOR THIS EXAMINATION:\\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\\n with head CT*\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:48 PM\\n PFI:\\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\\n underlying dural tear and CSF leak cannot be excluded.\\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\\n CT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post fall with trauma to face, evaluate for facial\\n fractures.\\n\\n COMPARISON: Head CT from at 05:46 a.m.\\n\\n TECHNIQUE: Routine MDCT study of the facial bones was performed with 1.25-mm\\n slice thickness. Coronal and sagittal reconstructions were provided.\\n\\n FINDINGS: There are multiple fractures seen.\\n\\n There are two fractures through the frontal bone, one of which extends through\\n the cribriform region and into the right ethmoidal air cells. Underlying this\\n fracture is a tiny focus of pneumocephalus. A dural tear with a CSF leak\\n cannot be excluded as the fracture line does extend through the posterior\\n table.\\n Another fracture is seen through the posterior margin of the left side of\\n sphenoid sinus which extends into the sphenoid septations and nasal septum.\\n The posterior fragments are overriding and again an underlying dural tear with\\n CSF leak cannot be excluded. Another fracture is seen on the medial wall of\\n the right sphenoid sinus with slight displacement of the inferior fragment\\n laterally into the sinus. A small step-off is seen at the roof of the right\\n sphenoid sinus which may represent a neurovascular channel or a small\\n nondisplaced fracture.\\n No fracture fragments are seen within the orbital cavity.\\n Mastoid air cells are opacified, right greater than left, and there is fluid\\n surrounding the right ossicular chain and therefore a fracture or dislocation\\n cannot be excluded. Small amount of fluid is noted in the left mastoid air\\n cells. Evaluation for T bone fractures is limited.\\n There are multiple fractures noted involving the nasal bones, nasal septum and\\n (Over)\\n\\n 3:44 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: ?facial fractures *please obtain thin cuts to the face, if p\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n the bilateral maxillae with displacement of a few small fragments.\\n\\n A displaced nasal bone fracture is identified. There is high-density fluid\\n throughout the paranasal sinuses, which most likely represents acute bleeding.\\n There are scattered foci of soft tissue gas secondary to recent trauma. No\\n osseous fragments are seen intracranially or within the orbital cavities. The\\n bones are diffusely demineralized which makes identification of any additional\\n fractures difficult to exclude.\\n\\n Areas of high attenuation are seen intracranially which represent subarachnoid\\n and intraparenchymal hemorrhage. This is further characterized on concurrent\\n head CT. A large right frontal subgaleal hematoma is seen without any\\n radiodense foreign object embedded within. An ET tube and OG tube have been\\n placed.\\n\\n IMPRESSION:\\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\\n wall of the right maxillary sinus and anterior wall of the left maxillary\\n sinus and nasal bones . The bones are diffusely demineralized which makes\\n identification of any additional fractures difficult to exclude.\\n CTA can be considered for assessment of vascular structures and T bones.\\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\\n\\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\\n underlying dural tear and CSF leak cannot be excluded.\\n\\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\\n CT.\\n\\n D/w Dr., Ortho by Dr. in the room on \\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1207258,\n \"text\": \", J. TSICU 3:44 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: ?facial fractures *please obtain thin cuts to the face, if p\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with s/p fall with trauma to the face\\n REASON FOR THIS EXAMINATION:\\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\\n with head CT*\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI:\\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\\n underlying dural tear and CSF leak cannot be excluded.\\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\\n CT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"RO HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.\",\n \"row_id\": 1207331,\n \"text\": \" 11:51 AM\\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \\n Reason: ORIF RIGHT HIP DHS\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female with ORIF of the right hip with dynamic hip\\n screw.\\n\\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\\n radiologist present. Twelve fluoroscopic spot views were obtained. Images\\n demonstrate placement of markers into the femoral shaft and the femoral neck,\\n followed by insertion of an intramedullary rod with dynamic hip screw fixation\\n of a right intertrochanteric fracture. A total of 75.1 seconds of\\n fluoroscopic time was used. Please refer to the operative note for further\\n details.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1207822,\n \"text\": \" 3:00 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: e/f pneumonia\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with IPH, desat + fever\\n REASON FOR THIS EXAMINATION:\\n e/f pneumonia\\n ______________________________________________________________________________\\n WET READ: MDAg SUN 9:43 PM\\n 1. Increased retrocardiac opacity since could be atelectasis or\\n infection. could be evaluated on with PA and lateral views if clinically\\n feasible.\\n 2. NG tube side port ends at GE junction and could be advanced.\\n 3. Remainder of support devices in satisfactory position.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Desaturations in a patient with intraparenchymal\\n hemorrhage.\\n\\n Portable AP chest radiograph was reviewed in comparison to .\\n\\n The ET tube tip is 3 cm above the carina. The right PICC line tip is at the\\n cavoatrial junction. The left subclavian line is at the left brachiocephalic\\n vein/SVC junction. The NG tube tip is in the stomach, but the side hole is at\\n the gastroesophageal junction and should be advanced.\\n\\n Heart size and mediastinal contours are stable. There is interval development\\n of interstitial pulmonary edema, mild. Left retrocardiac atelectasis has\\n developed in the interim, associated with small amount of pleural effusion.\\n Right pleural effusion is most likely present as well.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208604,\n \"text\": \" 9:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for intrapulmonary process\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with MS s/p TBI\\n REASON FOR THIS EXAMINATION:\\n please evaluate for intrapulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Evaluation for intrapulmonary process.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is a technically\\n limited examination given hardware overlaying the thorax. The patient has\\n been extubated, the nasogastric tube has been removed. The left double-lumen\\n catheter is in unchanged position. The size of the cardiac silhouette is\\n unchanged, extensive retrocardiac atelectasis and presence of bilateral\\n pleural effusions. The pre-existing signs of pulmonary edema might have\\n minimally decreased in the interval. This increase, however, is not\\n substantial. Otherwise, no relevant changes are seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208255,\n \"text\": \" 4:59 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72F wheelchair bound female w MS who tx from OSH after fall from\\n wheelchair lift onto face (facial fxs, B femur fx, SAH, SDH) now s/p repair B/L\\n femur fx's \\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with multiple medical\\n problems, bedridden.\\n\\n Portable AP chest radiograph was compared to .\\n\\n The ET tube tip, the left subclavian line and the NG tube are in unchanged\\n position. Moderate pulmonary edema is unchanged as well as left lower lobe\\n consolidation and bilateral pleural effusions. No definitive pneumothorax is\\n seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-09 00:00:00.000\",\n \"description\": \"CT T-SPINE W/O CONTRAST\",\n \"row_id\": 1207593,\n \"text\": \" 6:19 PM\\n CT T-SPINE W/O CONTRAST Clip # \\n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\\n s/p repair, intubated, sedated\\n REASON FOR THIS EXAMINATION:\\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\\n injury to obtain clearance of the thoracic and lumbar spines\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 9:22 PM\\n 1. Findings concerning for acute fracture of the T3 vertebral body.\\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\\n not apparent by CT.\\n\\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\\n While these may also be chronic, given the concurrent acute injury in the\\n upper thoracic spine, it is difficult to exclude acute compression injury at\\n these levels, and further evaluation with MRI of the thoracic spine can be\\n considered.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female status post fall with bilateral hip fractures.\\n The patient is intubated and sedated. Evaluate for thoracic spine fracture.\\n\\n COMPARISON: MR cervical spine performed the same day. No prior imaging of\\n the thoracic spine is available for review.\\n\\n TECHNIQUE: MDCT imaging of the thoracic spine was performed without contrast.\\n Multiplanar reformats are prepared and reviewed in bone and soft tissue\\n algorithm.\\n\\n FINDINGS:\\n\\n There is subtle loss of height involving the posterior aspect of the T3\\n vertebral body, with associated irregularity/buckling of the posterior cortex.\\n The inferior aspect of the posterior cortex is displaced posteriorly by\\n approximately 3 mm, likely causing associated thecal sac effacement. A subtle\\n lucency is seen traversing the T3 vertebral body. These findings are\\n suspicious for an acute fracture, as confirmed by marrow edema seen on\\n concurrent cervical spine MRI. Of note, T2 fracture suggested by additional\\n marrow edema seen at that level is not apparent by CT.\\n\\n From T4 through T10, vertebral body heights are preserved, and there is no\\n evidence of fracture. The alignments are similarly normal. Multilevel\\n degenerative change is present, with posterior disc-osteophyte complexes noted\\n at T6-7 and T7-8 effacing the thecal sac at these levels.\\n\\n The T11 vertebral body demonstrates mild, less than 25%, superior end plate\\n depression anteriorly. There are some irregular lucencies noted within the\\n (Over)\\n\\n 6:19 PM\\n CT T-SPINE W/O CONTRAST Clip # \\n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n vertebral body, though no discrete fracture line is identified, and these\\n lucencies may reflect a combination osteopenia and a superior endplate\\n Schmorl's node. There is no adjacent soft tissue change to specifically\\n suggest an acute injury.\\n\\n There is approximately 50% loss of height involving the anterior aspect of the\\n T12 vertebral body, with some associated irregularity of the posterior cortex\\n which can relate to buckling from injury , though again no acute fracture line\\n or associated soft tissue change is seen.\\n There is additional compression deformity at L1, also without specific\\n evidence of acuity, and with marked degenerative osteophyte formation at\\n T12-L1 suggesting chronicity.\\n There is angulated appearance of the posterosuperior portions of T12 and L1\\n vertebral bodies indenting the thecal sac.\\n\\n The included mediastinal structures are normal within the limits of a\\n non-contrast evaluation. Right and left central lines terminate in the SVC.\\n Nasogastric tube seen entering the stomach. The patient is intubated with an\\n endotracheal tube terminating in the mid trachea. There is no adenopathy. A\\n small amount of fluid is seen in the pericardial recess.\\n\\n There are bilateral pleural effusions, with associated bibasilar dependent\\n consolidations most likely reflecting atelectasis. Remainder of the lung\\n parenchyma included is well aerated.\\n\\n IMPRESSION:\\n\\n 1. Acute compression fracture of the T3 vertebral body, with buckling of the\\n posterior cortex, the inferior aspect of which is displaced posteriorly by\\n approximately 3 mm. Suspected T2 vertebral body fracture (seen on concurrent\\n cervical spine MRI) is not apparent by CT.\\n\\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\\n While as detailed above these may be chronic, given the concurrent acute\\n injury in the upper thoracic spine, it is difficult to exclude an acute\\n component. Further evaluation with MRI of the thoracic spine can be\\n considered as clinically indicated.\\n\\n Discussed with Dr at 8pm by Dr via phone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-07 00:00:00.000\",\n \"description\": \"BILAT HIPS (AP,LAT & AP PELVIS)\",\n \"row_id\": 1207198,\n \"text\": \" 5:05 PM\\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \\n ANKLE (AP, LAT & OBLIQUE) BILAT\\n Reason: eval for fracture\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with bilateral femoral head/neck fractures\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Bilateral femoral neck and head fractures.\\n\\n COMPARISON: CT torso performed at 12:36.\\n\\n BILATERAL HIPS, TWO VIEWS EACH INCLUDING A VIEW WITH TRACTION: Comminuted\\n right intertrochanteric fracture is identified with minimal displacement. No\\n dislocation is identified. On the left, there is a mildly displaced\\n subcapital femoral neck fracture with mild superior displacement of the distal\\n fracture fragment. No dislocation is present. After traction, the degree of\\n displacement of both fractures appear improved. There are degenerative\\n changes in both hips with joint space narrowing. There is diffuse osteopenia\\n which limits the sensitivity for detection of subtle fractures. There is no\\n diastasis of the pubic symphysis or sacroiliac joints. Dense material within\\n the region of the bladder likely represents excreted contrast.\\n\\n RIGHT TIBIA AND FIBULA, TWO VIEWS, AND RIGHT ANKLE, THREE VIEWS: No acute\\n fracture or dislocation is identified. The ankle mortise is preserved. The\\n talar dome appears smooth. There is diffuse demineralization of the osseous\\n structures which limits sensitivity for detection of subtle fractures. Soft\\n tissue swelling is noted about the ankle and foot. Partially imaged is a\\n comminuted distal femoral fracture with evidence of lipohemarthrosis. Soft\\n tissue calcification within the anterior aspect of the knee is likely vascular\\n in etiology.\\n\\n LEFT TIBIA AND FIBULA, TWO VIEWS, AND LEFT ANKLE, THREE VIEWS: No acute\\n fracture or dislocation is identified. There is diffuse soft tissue swelling.\\n Rounded calcifications within the anterior soft tissues of the knee and lower\\n leg likely represent vascular calcifications. Evaluation of left ankle is\\n somewhat suboptimal, with degenerative changes of the tibiotalar joint\\n present. Degenerative changes of the mid foot and hindfoot are also\\n visualized, without a significant joint effusion.\\n\\n IMPRESSION:\\n 1. Bilateral femoral neck fractures.\\n\\n 2. Partially imaged comminuted fracture of distal right femur with associated\\n lipohemarthrosis.\\n\\n 3. No acute fracture or dislocation within either tibia or fibula, or ankle.\\n DFDdp\\n (Over)\\n\\n 5:05 PM\\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \\n ANKLE (AP, LAT & OBLIQUE) BILAT\\n Reason: eval for fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1207283,\n \"text\": \" 7:58 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Eval line placement\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with polytrauma, intubated\\n REASON FOR THIS EXAMINATION:\\n Eval line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female with polytrauma, status post intubation.\\n Evaluate line placement.\\n\\n COMPARISON: .\\n\\n SUPINE AP VIEW OF THE CHEST: Endotracheal tube is 3.0 cm above the carina.\\n Nasogastric tube follows a normal course terminating in the left upper\\n quadrant with last side port just below the GE junction. Left subclavian\\n central venous catheter terminates just beyond the junction of the\\n brachiocephalic and SVC. Right-sided PICC follows a normal course terminating\\n in the distal SVC.\\n\\n There is bibasilar atelectasis, but lungs are elsewhere clear. There is no\\n large pleural effusion or pneumothorax. Heart size is normal. Mediastinal\\n silhouette, hilar contours and pulmonary vasculature are normal. There is no\\n displaced rib fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-09 00:00:00.000\",\n \"description\": \"CT T-SPINE W/O CONTRAST\",\n \"row_id\": 1207594,\n \"text\": \", J. TSICU 6:19 PM\\n CT T-SPINE W/O CONTRAST Clip # \\n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\\n s/p repair, intubated, sedated\\n REASON FOR THIS EXAMINATION:\\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\\n injury to obtain clearance of the thoracic and lumbar spines\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Findings concerning for acute fracture of the T3 vertebral body.\\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\\n not apparent by CT.\\n\\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\\n While these may also be chronic, given the concurrent acute injury in the\\n upper thoracic spine, it is difficult to exclude acute compression injury at\\n these levels, and further evaluation with MRI of the thoracic spine can be\\n considered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-09 00:00:00.000\",\n \"description\": \"CT L-SPINE W/O CONTRAST\",\n \"row_id\": 1207595,\n \"text\": \" 6:24 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for thoracic or lumbar processes\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\\n REASON FOR THIS EXAMINATION:\\n please evaluate for thoracic or lumbar processes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 7:56 PM\\n No secure evidence of acute lumbar spine fracture. Compression deformities of\\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\\n fracture lines identified. These are most likely chronic. Bony canal appears\\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\\n Intrathecal detail is poorly assessed by CT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female status post fall from wheelchair with\\n bilateral hip fractures. Evaluate for fracture involving the lumbar spine.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT imaging of the lumbar spine was performed without contrast.\\n Multiplanar reformats were prepared and reviewed in bone and soft tissue\\n algorithm.\\n\\n FINDINGS:\\n\\n There is diffuse osteopenia.\\n There is no obvious evidence of acute fracture involving the lumbar spine.\\n The L1 - L5 vertebral bodies are preserved in alignment, and there is no\\n prevertebral or paravertebral soft tissue change to suggest acute injury.\\n\\n There is superior endplate compression deformity involving L1, with 25-50%\\n height loss of L1 anteriorly but preservation of the posterior cortex.\\n Angulated postero-superior aspect of L1 is seen to indent the ventral thecal\\n sac.\\n Marked associated degenerative change at T12-L1 with anterior osteophyte\\n formation and a prominent L1 superior enplate Schmorl's node favor chronicity.\\n (However, small amount of marrow edema is noted adjacent to the Schmorl's node\\n on susequent MRI).\\n\\n Milder degenerative change is seen in the lower lumbar spine, with additional\\n disc space narrowing at L3-L4 and small posterior disc protrusions at L4-L5\\n and L5-S1. There is however only minimal facet arthropathy, and no\\n significant central canal or neural foraminal narrowing, however, intrathecal\\n detail is poorly assessed by CT.\\n\\n There are no suspiciou/concerning lytic or sclerotic osseous lesions.\\n There is excreted contrast within the renal collecting systems, reflecting\\n prior contrast administration. There is mild atherosclerosis. There is no\\n (Over)\\n\\n 6:24 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for thoracic or lumbar processes\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n aneurysm or retroperitoneal adenopathy/mass identified.\\n\\n IMPRESSION:\\n\\n No definite acute fractures or malalignment involving the lumbar spine.\\n Likely chronic compression deformity of L1 is noted, as described above. See\\n subsequent MRI\\n\\n Mild degenerative change at L3-S1, without apparent critical canal stenosis.\\n\\n Please see seperately reported thoracic spine CT for comments regarding the\\n low thoracic spine.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-09 00:00:00.000\",\n \"description\": \"CT L-SPINE W/O CONTRAST\",\n \"row_id\": 1207596,\n \"text\": \", J. TSICU 6:24 PM\\n CT L-SPINE W/O CONTRAST Clip # \\n Reason: please evaluate for thoracic or lumbar processes\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\\n REASON FOR THIS EXAMINATION:\\n please evaluate for thoracic or lumbar processes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No secure evidence of acute lumbar spine fracture. Compression deformities of\\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\\n fracture lines identified. These are most likely chronic. Bony canal appears\\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\\n Intrathecal detail is poorly assessed by CT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-10-07 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 1207220,\n \"text\": \" 7:17 PM\\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \\n Reason: surgical planning\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with bilateral femoral neck and distal femur fx\\n REASON FOR THIS EXAMINATION:\\n surgical planning\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 12:06 AM\\n\\n comminuted right intertrochanteric proximal femur fracture with angulation of\\n the femoral neck. left subcapital femoral neck fx with mild-moderate superior\\n translation of the distal femur relative to the femoral head. bilateral\\n comminuted, angulated and slightly impacted distal femur fractures. no pelvic\\n fractures. expected soft tissue changes with bilateral lipohemarthoses of the\\n knees. no large pelvic or retroperitoneal bleed.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Bilateral femoral neck and distal femur fracture for surgical\\n planning.\\n\\n TECHNIQUE: CT of pelvis and bilateral femurs without IV contrast with coronal\\n and sagittal reformatted images per protocol.\\n\\n COMPARISON: Bilateral hips radiograph .\\n\\n FINDINGS: There is a Foley catheter in the urinary bladder with suprapubic\\n access. There is air within the urinary bladder presumably from catheter\\n placement; however, correlate clinically. There is mild stranding about the\\n rectum (3:47); nonspecific.\\n\\n There is a diffuse osteopenia. In the lower lumbar spine there is facet\\n arthropathy. Degenerative changes are seen in the SI and hip joints\\n bilaterally.\\n\\n RIGHT:\\n\\n There is a comminuted impacted angulated fracture of the femoral neck and\\n intertrochanteric fracture with varus angulation. There is associated soft\\n tissue hematoma and joint effusion.\\n\\n There is a supracondylar highly comminuted impacted fracture with marked\\n angulation and distraction of fracture fragments. There is moderate\\n angulation of major distal fracture fragments anterior and lateral with\\n rotation. The right knee joint is incongruent. Fracture extends into the\\n posterior aspect of the medial femoral condyle and intercondylar notch;\\n involves the majority of the medial femoral condyle. The right proximal tibia\\n appears intact.\\n\\n LEFT:\\n (Over)\\n\\n 7:17 PM\\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \\n Reason: surgical planning\\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is a comminuted fracture of the femoral neck with varus angulation and\\n impaction. There is associated joint effusion. There is a highly comminuted\\n impacted supracondylar fracture with anterior angulation of major distal\\n fracture fragment overriding and shortening the limp. There is hematoma at\\n the fracture site. There is distraction of fracture fragments. The fracture\\n line involves both medial and lateral condyle extending to the lateral condyle\\n joint surface and medial trochlea.\\n\\n There is extensive hematoma in the subcutaneous soft tissue tracking along\\n bilateral thighs. There is bilateral lipohemarthrosis of the knees.\\n\\n IMPRESSION:\\n\\n 1. Complex fracture of the right femoral neck and intertrochanteric region.\\n 2. Complex fracture of the left femoral neck.\\n 3. Bilateral complex supracondylar fractures.\\n 4. Bilateral hemarthrosis of the knees.\\n 5. Subcutaneous soft tissue hematoma tracking along bilateral thigh.\\n 6. Severe osteopenia.\\n 7. Degenerative changes in the lower lumbar spine, SI and hip joints.\\n 8. Suprapubic Foley catheter in the urinary bladder and air in the urinary\\n bladder, presumably from catheter placement; correlate clinically.\\n 9. Nonspecific fat stranding about the rectum; correlate clinically.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 248512,\n \"text\": \"Sinus tachycardia. Low limb lead voltage. Non-specific ST-T wave changes.\\nCompared to the previous tracing of there is no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 248513,\n \"text\": \"Sinus tachycardia. Non-specific ST-T wave changes are diffuse. No previous\\ntracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24980,"cells":{"subject_id":{"kind":"number","value":25580,"string":"25,580"},"hadm_id":{"kind":"number","value":192528,"string":"192,528"},"target_text":{"kind":"string","value":"Patient was transferred for emergent repair of ruptured AAA. For details of this, please see the previously dictated operative note. Post-operatively, the patient was brought to the ICU for monitoring. She remained intubated for 10 days secondary to her open abdomen and volume overload following resuscitation. Throughout this period, she was maintained on vancomycin, Levaquin and Flagyl for antibiotic prophylaxis, fearing a graft infection. On POD #10, she was brought back to the operating room for closure of her abdomen. For details of this, please see the previously dictated operative note. The patient then had a slow wean from mechanical ventilation and was intermittently diuresed with Lasix prn and Lasix gtt. She extubated on POD #20 without event. She did spike fevers and had a mildly elevated WBC (12 - 13) which prompted an infectious work-up which revealed an E. coli pneumonia and urinary tract infection. She was empirically begun on Zosyn while culture data was pending, and continued on Zosyn based on sensitivities. Ultimately, the patient was discharged to rehab on PODs #25 & 15 tolerating a regular diet, in adequate pain control, afebrile and with a normal white count. She has been working with physical therapy to regain her strength and motor function."},"extractive_notes_summ":{"kind":"string","value":"Resp Care,Pt. Afib-rate controlled.GI: Abdomen softly distended. Afib rate controlled. remains intubated on A/C overnoc. Bedside TEE done. Lungs CTAB.CV: Afebrile. See carevue for objective data.Remains sedated on proprofol/fentanyl gtts. Min amt of secretions. CONDITION UPDATEVSS. REMAINS IN AFIB RATE CONTROLLED. Cdif sent.GU: Diuresing. decreasing.GU: Foley to gravity. Assess CO and PAWP and need for continued fluid bolus'. Diuresing well.Labs: Hct stable. Lasix dose given as ordered. Chest PT done. JP'S TO WALL SUCTION - LG AMT OF S/S DRAINAGE OUT. Attempted RSBI, apnea. Enc C&DB. CO/CI CONT TO BE LOW - SICU TEAM AND ATTENDING DR AWARE. Pt & abg showed improvment today with some reduction in sputum noted. Denies pain.Resp: Lungs clear at the upper lobes bilat. AFEBRILE. ,rrtpt. decreased, plan for rsbi in am. BP stable. U/O QS VIA FOLEY. PCXR done this PM.Had an episiode of hypotension to systolic of 60's with turning to the right this AM requiring initiation of levophed. Dobutamine dc'd.See flowsheet for CO/CI/SVR data. Maintain current vent settings. CO , CO . CONT CURRENT ICU CARE AND ASSESSMENT. Plan: Pt. on Fri for closure (per Dr. Fent gtt for comfort Notify H.O. CI and CO running low even after 1U PRBC-may need to give more fluid or start nitro gtt. LYTES REPLETED PRN.ENDO: FS QID COVERAGE PER RISS. Cont wiht generalized 3+ pit edema.LS clear to coarse. DIAMOX WAS ADDED TO OFFSET ALREADY SL ELEVATED TCO2. JP's with seroserosang output.PLAN: Cont vent wean as pt tol. Plan to maintain at this time due to tachypnea with RSBI. PT APPEARS TO BE TOLERATING TF EVEN WITH HYPOACTIVE BOWEL SOUNDS. Tol TF at goal minmal residuals. Arrived on NEO for hypotension. 2200-PT LS /FEW SCATTERED EXP WHEEZES. MONITOR WBC'S/HCT/ABG'S/LYTES PRN. FOCUS: CONDITION UPDATED: SEE CAREVUE FOR SPECIFICSCONTINUES TO IMPROVE, AWAITING VICU BED,OOB TO CHAIR, TOLERATED WELL. Respiratory CarePt.continues on full vent.support t/o shift.Labile b/p at times.Vent.changes made as needed. HR UP TO 130 AND HTN 170'S WHEN ANXIOUS/UNDERSEDATED, SETTLES WITH HR 80-90'S AND SBP 95-120 WHEN COMFORTABLE. 2+ LE edema. Goal is to be 2L neg.Access: RIJ TLC, R rad a-line (positional).ID: T=100.4 oral, all antibx d/c'd yesterdayEndo: FS covered w/ RISSSkin: Abd incision pink w/ necrotic areas as previously noted. CONSOLIDATION IN TH LLL PER SICU TEAM. respiratory CareNo vent. BS hypoactive.GU: Foley to gravity. PLAN-- OR IN AM TO CLOSE ABDOMEN. GIVEN 20 IV LASIX X1 WITH GOOD DIURESIS. Pheripheral Edema +3. BS equal with coares rhonchi & wheezes thoughout. FOLEY TO CD QUANTITY SUFFFICIENT.ENDO- BS STABLE THIS SHIFT.ID- CONTINUES ON VANCO FLAGGYL AND LEVOFLOXICIN T 99.5POC- CONTINUE TO MONITOR-K AND ABG. Diurese, replete lytes. DP/PT pulses dopplerable. DP/PT pulses dopplerable. BS improve some post sxTrach was planed for today. pt had a bronch today lg amt. CXR done. care note - Pt. BS 105-207; RISS q6hr and NPH 10units . tube fdgs via ngt and tol well. pt was reintubated pre bronch today. Pt w/ +3 edema on BUE and BLE. ABG PENDING.GI/GU- NG TO LWS SMALL BILLIOUS DRAINAGE, OPEN ABD. Abdomen softly distended w/ +BS. Abdomen softly distended w/ +BS. HR 90s-120s AF with occ. abd binder intact and abd dsg changed. R TLC line intact and R radial a-line intact.Plan for possible bronch today. Respratory CareNo vent.changes needed overnight.abg's adequate.Plan:continue wean as tolerated CO-4.01 CI- 2.20 LASIX GIVEN TIMES TWO WITH GOOD DIURESIS. Resp. Adequate sedation w/ major care/procedures. Possible bronch today for LLL atelectasis on CXR.GI/GU: Abd. Cont RISS as well. HR 80-101 (A.fib). Lasix 20mg IV x1 ordered and given. amt of sputum today. Monitor BS; NPH . dsgs intact with scant serosang. Open abd wound w/ 2 JP's to sx, decreasing s/s drng. Good ABG'S.Will cont to moniotr resp status. Rhonchi improves post sx. Resp Care Note,Weaned down FIO2 for good ABG. Resp Care Note,Weaned pt 2 ^ peep.Temp 100. Resp CarePt intubated on A/C. open with transparent dsg intact- continues to ooze serosang. Weak but follows commands.CO/CI remain labile requiring fluid boluses prn. FOLLOWING COMMANDS.RESP: LS CLEAR. dsg intact.Plan for closure of abd. Pneumoboots on. Pt stable with present settings. Pt was bronch'd for a lot of secretions f/u CXR showed improvement. TOLERATING REG. support @ this time but continues to have pul. Respiratory Care Pt continues on CPAP/PSV 10/5 in NARD. L glass eye intact.CV: Tmax 101.1 and pan cx'd. JP's still to LWS and draining lge amts. K+ & MG+ repleted.Plan: continue with current plan of care per sicu/ vascular teams. Condition UpdateD: See carevue flowsheet for specificsPatient remains afebrile HR stable in afib with good rate control-pt was started on a small dose of lopressor which was well tolerated. Lungs have been clear and dim in the bases -CXR ordered for tomorrow. drainage in moderate amts. +++ EDEMA. +ATN per team. + PPP BILAT. Lungs are clear and diminished in the bases. Sx'd for scant amts whitish secretions. Simpleatheroma in aortic arch. Again, noted is interstitial edema and moderate bilateral pleural effusions. There are simple atheroma in the aortic arch. There is cardiomegaly, with a calcified, unfolded aorta. Again seen are mild-to-moderate bilateral pleural effusions. There is stable appearance of the heavily calcified thoracic aorta with unchanged appearance of wall thickening at the level of the aortic knob, which may represent chronic dissection or calcification of a thick pseudointima. Lines and tubes are unchanged in position with note again made of overdistention of the endotracheal tube cuff. The aorta is calcified. Left pleural effusion.Conclusions:1. Heart is probably not enlarged, although the aortic knob is markedly dilated and calcified. Heterogeneously echoic fluid collection in the right lower quadrant is incidentally noted. AP BEDSIDE CHEST: There are bilateral moderate-sized pleural effusions with associated basal atelectasis. Various lines and tubes are unchanged in position with note again made of overdistention of endotracheal tube cuff. IMPRESSION: Small-to-moderate bilateral pleural effusions. There is dextroscoliosis of the thoracic spine. There is an endotracheal tube with distal tip at the thoracic inlet. There is slight perihilar haziness and subtle interstitial pattern in the right lung, which may reflect a component of interstitial edema, and there is also a probable small right pleural effusion."},"n_notes":{"kind":"number","value":100,"string":"100"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2111-11-17 00:00:00.000","description":"Report","row_id":1595844,"text":"neuro: Pt remains sedated on propofol and fentanyl. Opens eyes to pain, unable to follow any directions. Appear to have abd/incisional pain with turning and repositioning.\nCV: low grade temp 100.4, HR 100-120's Afib with transient episodes of PVC's, Lytes repleated with noted improvement in ectopy. SBP 80-120's, Unable to wean off dobutamine. CVP 11-15, PAP 40's/20's. PAWP 19-20. CO , CO . Requiring significant amounts of fluid bolus' for continued hypotension. HCT 23.8, treated with 2u PRBC's\nRESP: lungs clear to dim at bases, No vent changes overnight. O2 sats >95%. Occasional suctioning of thin white secretions.\nGI: abd open with absent BS. NGT draining mod amounts of bilious drg.\nGU: foley draining 10-15cc of amber urine.\nENDO: blood sugars labile.\nPLAN: Cont to wean dobutamine. Assess CO and PAWP and need for continued fluid bolus'. Monitor pain and effectiveness of fentanyl gtt.\n"},{"category":"Nursing/other","chartdate":"2111-11-18 00:00:00.000","description":"Report","row_id":1595850,"text":"Abd wound washing/dressing to be done in AM MD.\n"},{"category":"Nursing/other","chartdate":"2111-11-19 00:00:00.000","description":"Report","row_id":1595851,"text":"Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift, ABG acceptable. Attempted RSBI, apnea. Maintain current vent settings.\n"},{"category":"Nursing/other","chartdate":"2111-11-25 00:00:00.000","description":"Report","row_id":1595872,"text":"Respiratory Care:\n\nPatient intubated on mechanical support. Vent settings Vt 450, A/c 14, Fio2 40%, and Peep 5. Bs clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 34. Abg this am reveals metabolic alkalosis. Plan: Pt. to return to OR for closure of Abd. Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2111-11-25 00:00:00.000","description":"Report","row_id":1595873,"text":"Events:\n\nPt To OR for abd closure with mesh return to ICU neo for SBP 90, fluid boluses x2 for SBP and low CVP with good response, Sao2 drop 93, sx for thick yellow, Left upper lung grossly dim bronchial BS, CXR done atelectasis, L plueral effusion\n\nNeuro-sedated on Prop, fent gtt Right PERLA, left glass eye, MAEW\nCV-MP AFib neo gtt weaned to off, will restart lopressor when SBP stable, lasix drip d/c, generalized anasarca, cool extrem x4\nResp-AC rate 16, 60%, TV500, vent wean as tolerated\nFEN-TPN, BS covered with SS insulin, TF held, absent BS, NGT to Liwsx drg bilious green\nU/O >40cc/hr\nID-cont on ABX\nFamily-daughter , request aggressive attempts to wean from ventilator, reassurance given to daughter and all questions answered\n and fentanyl overnight, wean prop in AM, and plan for vent wean, monitor ABG, CBC, and lytes, cont ABX, TPN, prophylaxis protonix\n"},{"category":"Nursing/other","chartdate":"2111-11-25 00:00:00.000","description":"Report","row_id":1595874,"text":"Pt came back from OR on 100% O2. Chest Xray showed Left lung to be largely out with only LUL aerated. Pt sxed for a mod-lg amt. very thick yellow sputum (no plugs noted). Recruetment manuver used to try and open lung.\n"},{"category":"Nursing/other","chartdate":"2111-11-17 00:00:00.000","description":"Report","row_id":1595845,"text":",rrt\npt. tolerating current settings reasonably well, fio2 increased to .60 following am abg due to low pa02, b/l b.s. diminished/slight coarse, sx'ing minimal #'s tan thick/moist sputum, sats remained mid 90's with few drops to high 80's/low 90's, plan to do rsbi this am, will monitor.\n"},{"category":"Nursing/other","chartdate":"2111-11-17 00:00:00.000","description":"Report","row_id":1595846,"text":"See carevue for objective data.\n\nRemains sedated on proprofol/fentanyl gtts. No change in vent settings. Minimal secretions. ETT rotated. PCXR done this PM.\nHad an episiode of hypotension to systolic of 60's with turning to the right this AM requiring initiation of levophed. Dobutamine dc'd.\nSee flowsheet for CO/CI/SVR data. Bedside TEE done. Ventricles under filled-no thrombus/aneurysm MD. PCWP:15-10 CVP: \nMinimal urine output-team aware. PM lytes pending.\nJP's draining large amount of bloody drainage-2L this shift.HCT OK.\nHIT antibody sent for plts<100.\nAbd wound remains open and dressing intact.\n\nFamily in and updated on POC. Support provided.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2111-11-18 00:00:00.000","description":"Report","row_id":1595847,"text":",rrt\nno changes made, sats in the high 90's t/o shift, sx'd min tan secretions,b/l b.s. decreased, plan for rsbi in am.\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595906,"text":"Addendum to NPN:\nPt's tongue w/ thrush; Nystatin oral suspension applied on tongue w/ swabs. Red rash under bilat arms/breasts and groin; miconazole powder applied. Cont to monitor rash.\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595907,"text":" 19/07\n NEURO A/O TALKS AROUND TUBE SEEMS TO UNDERSTAND AND HELPS WITH CARE GIVEN PAIN CONTROL WITH FENT DRIP PERIODS OF AGITATION ABLE TO BE TALKED DOWN OPENLY WANTS ETT OUT AND TO GO HOME\n RESP ETT CPAP 15/5 TOL WELL RSBI 87 IMPROVING TV 450 TO 500 SCANT SPUTUM RHONCHI THRUOUT CLEARS AFTER SUCTIONING\n HEART AF RATES 80 TO M MITRIAL AREA SYS POOR PULSES THRU OUT POS NVD WITH MILD HJR\n ABD DRESSING IN PLACE FOLEY CATH NO B/S\n PLAN WEAN VENT REMOVE TUBE GIVE EMOTIONAL SUPPORT\n"},{"category":"Nursing/other","chartdate":"2111-12-05 00:00:00.000","description":"Report","row_id":1595908,"text":"Respiratory Care\nPt.remains stable on PSV.no changes overnight.RSBI-88,abg's wnl.\n"},{"category":"Nursing/other","chartdate":"2111-12-05 00:00:00.000","description":"Report","row_id":1595909,"text":"Nursing care note\nSee careview for specifics.\nSignificant event: Pt extubated at 1400 hours. Placed in 50% FM. O2 sats have remained 99-100%. No resp. distress. Encouraging C&DB.\n\nNeuro: Awake, oriented to person & place. Moves all extremities. Follows commands. Difficult to move BLE's d/t edema. Right pupil equal and reactive. Denies pain.\n\nResp: Lungs clear at the upper lobes bilat. Diminished bibasilar. Coughing/expectorating thick white sputum. RR 28-35.\n\nCV: Afebrile. Afib rate controlled. BP stable. All 4 extremities warm with palpable pulses.\n\nGI: Abdomen obese with positive BS. Rec's Impact with fiber at goal rate of 80cc/hr. Stooling. Cdif sent.\n\nGU: Diuresing. Lasix given to help mobilize fluid.\n\nSkin: Midline abdominal staples intact. Note small amount of eschar at mid pole. No drainage.\n\nPlan: Pulmonary toilet. Enc C&DB. OOB to recliner tomorrow if tolerates extubation. Provide support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2111-12-05 00:00:00.000","description":"Report","row_id":1595910,"text":"Pt & abg showed improvment today with some reduction in sputum noted. She was extubated @ about 1400pm today. She has a good productive and moist cough plan to continue Deep Breathing & coughing with pt\n"},{"category":"Nursing/other","chartdate":"2111-11-19 00:00:00.000","description":"Report","row_id":1595852,"text":"Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile and HR remains in afib with improved rate control ~80's very little ectopy noted overnight. Swan required re-floating x2 in order to obtain PCWP. Wedge 17-19. CVP 10-13. CI and CO running low even after 1U PRBC-may need to give more fluid or start nitro gtt. Patient making marginal amts of urine.\n Transplant team in at beginning of shift to remove packing from abd and re-explore belly. No ischemic bowel noted (during procedure pt was sedated with ppf and fentanyl gtts BP tolerated well did not require any pressors). JP's not draining as much as over the past couple of days but still dilute sanginous drg. Amino Acids started for nutrition.\n No vent changes made overnight. AM ABG unchanged from previous abg with paO2 80's. Min amt of secretions. Pt remains on fent gtt for comfort. Opens eyes and will open mouth on command but not nodding to questions or moving extremeties on command.\nPLAN:\n ? get cardiology on board\n ?fluid vs nitro gtt\n Return to OR ? on Fri for closure (per Dr. \n Fent gtt for comfort\n Notify H.O. with any changes\n"},{"category":"Nursing/other","chartdate":"2111-11-19 00:00:00.000","description":"Report","row_id":1595853,"text":"CONDITION UPDATE\nVSS. AFEBRILE. REMAINS IN AFIB RATE CONTROLLED. CO/CI CONT TO BE LOW - SICU TEAM AND ATTENDING DR AWARE. UNABLE TO WEDGE SWAN - SICU TEAM AWARE. MAJORITY OF SHIFT PT ALERT. FOLLOWING SIMPLE COMMANDS. REMAINS ON FENT DRIP APPEARS TO HAVE GOOD PAIN MANAGEMENT. LUNGS COARSE THROUGHOUT. MIN SUCTIONING FOR THICK, TAN SPUTUM. ABD REMAINS OPEN. TRANSPARENT DRESSING INTACT. JP'S TO WALL SUCTION - LG AMT OF S/S DRAINAGE OUT. STARTED ON TPN. U/O QS VIA FOLEY. DIURESED W/ 10MG OF LASIX MD'S ORDERS W/ SM EFFECT. SOCIAL WORKEER IN AND SPOKE W/ FAMILY.\nCONT TO MONITOR FOR S/S OF BLEEDING. PAIN MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENT.\n"},{"category":"Nursing/other","chartdate":"2111-11-20 00:00:00.000","description":"Report","row_id":1595854,"text":"Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made overnoc. Currently on A/C ventilation w/ PIP/Pplat = 26/20. BLBS slightly diminished, suctioned for small amounts of thick white secretions. SpO2 remained 90s. ETT secure/patent & in good position. No RSBI d/t apnea. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2111-12-01 00:00:00.000","description":"Report","row_id":1595892,"text":"Respiratory Care\nPt continues to be orally intubated and mechanically ventilated at this time. Currently on PSV 10/5/.50 with tidal volumes 350-500ccs and resp rate 15-30. BS: clear bilaterally. Suctioned for small amts of thick white secretions. Discussion with family about trach/peg today. Plan to attemp rsbi in am and possible extubation.\n"},{"category":"Nursing/other","chartdate":"2111-12-05 00:00:00.000","description":"Report","row_id":1595911,"text":" 19/07\n NEURO A/O RELAXED TALKATIVE MAE IN GOOD SPIRITS\n RESP FM TOL WELL MOBILIZING OWN SPUTUM CLEAR LUNGS\n HEART AF TOL WELL VSS PULSES POS 3 THRU OUT NVD REMAINS CVP WNL LASIX TO MOTIVATE FLUID SHIFT TOL WELL\n GI POS B/S STOOLING TOL T/F WELL ABD DRESSING IN PLACE D/I\n PLAN PROGRESSIVE AMBULATION P/T FAMILY SUPPORT\n"},{"category":"Nursing/other","chartdate":"2111-12-06 00:00:00.000","description":"Report","row_id":1595912,"text":"Nursing care note\nSee careview for specifics\nNeuro: PERL Oriented x3. Follows commands. OOB to recliner. Tolerated well. Denies pain.\nResp: O2 sats 92-98% on 50% FT. Chest PT done. Expectorating thin white sputum. Lungs CTAB.\nCV: Afebrile. VSS. Afib-rate controlled.\nGI: Abdomen softly distended. TOlerating TF's at goal rate of 80cc/hour. Liquid stool ? decreasing.\nGU: Foley to gravity. Lasix dose given as ordered. Diuresing well.\nLabs: Hct stable. Glucoses marginally elevated. Covered with RISS in addition to NPH.\nSocial: Family at the bedside.\nPlan: ?transfer to floor tomorrow. Aggressive pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2111-12-09 00:00:00.000","description":"Report","row_id":1595918,"text":"SICU B NPN:\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain but complaining of \"stiff legs.\" Moving all extremities UE>LE.\nCV: Afeb. HR 80s-90s AF, no ectopy noted. BP stable via NIBP. 3+ edema to extremities. Palpable pedal pulses. CVP 4-6. R IJ TLC line intact with slight redness noted around insertion site, no swelling or drainage noted.\nRESP: On 4L NC with O2 Sat >92% but did desaturate to 87-88 x2 overnight- chest PT given with good results both times. Encouraged to cough and deep breathe and using Yankar to clear secretions. RR 20s-30s. LS coarse and diminished at bases.\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with small amts of loose brown stool draining. Taking pills without difficulty. No NPH insulin given at 2200 due to pt. not eating much and glucose on previous night dipped very low after receiving NPH. Dr. aware. Foley with clear yellow urine >40cc/hr.\nSKIN: Abd. incision site C/D/I with staples, no swelling or drainage. Dsg changed with small amt of serosang. drainage on old dsg. Yeast rash to groin and folds- miconazole powder to affected areas.\nPlan to transfer to VICU when bed avail.\n"},{"category":"Nursing/other","chartdate":"2111-12-09 00:00:00.000","description":"Report","row_id":1595919,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFICS\nCONTINUES TO IMPROVE, AWAITING VICU BED,\nOOB TO CHAIR, TOLERATED WELL. NEEDS AGGRESSIVE PT AS LOWER EXTREMITIES ARE VERY WEAK.\nTOLERATING DIET, YET APPETIT POOR, ENCOURAGED TO TAKE POS AND ENRICHED WITH BOOST.\nCENTRAL LINE OUT, PHERIPHERAL IV PLACED.\nFAMILY SUPPORTIVE.\n REHAB SCREEN.\nWILL CALL WITH ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2111-12-10 00:00:00.000","description":"Report","row_id":1595920,"text":"SICU B NPN:\nNEURO: A&Ox3 with periods of slight disorientation overnight but easily reoriented. MAE x4. Denies pain. R pupil 3mm and brisk. Given 1mg ativan for sleep but did not sleep all night.\nCV: Afeb. HR AF, no ectopy noted. BP stable. Skin warm and dry with weak but palpable pedal pulses bilaterally. 2+ LE edema. Started on warfarin 5mg po. Repleted with KCL po and MGSO4 IV.\nRESP: Weaned to 3L O2 with O2 Sat >92%. LS clear/coarse and diminished at bases. Intermitent non-productive cough. RR 20s-30s.\nGI/GU: Abd. softly distended with positive bowel sounds. Having continous loose stools in small amts, brown. Foley with clear yellow urine- continues on lasix.\nSKIN: Abd. incision with staples C/D/I- old dried blood around staples and area cleaned and dsg changed. Red yeast rash/excoriation to groin and buttocks area- barrier cream applied with miconazole powder.\nOTHER: Daughter to come in this am to visit. Pt. ready to transfer to floor when bed avail. Plan to get OOB to chair this am.\n"},{"category":"Nursing/other","chartdate":"2111-12-01 00:00:00.000","description":"Report","row_id":1595893,"text":"NEURO; MAE, FOLLOWS COMMANDS, NODS APPROPRIATELY AND OCCAS MOUTHES WORDS, A&O TO PERSON, OCCAS WRITES NOTES\n\nCARDIOVASCULAR; HR 80'S-90'S A FIB, A LINE RT RADIAL WAVEFORM COMPLETELY DAMPENED, REMOVED AFTER NEW ALINE PLACED LEFT RADIAL, SYS 110-130'S, OCCAS DOWN TO 90'S, LASIX GTT PRESENTLY AT 5 MGM/HR, (GOAL IS 2 L/NEG IN 24 HRS AND PT IS > 1600 CC NEG THIS SHIFT), K LOW -REPLETED WITH 40 MEQ THIS PM, SHOULD RE-EVALUATE TONOC, MAG LEVEL 1.7-REPLETED, TEMP 99.0, REMAINS WITH EDEMA OF ALL EXTREMITIES, PULSES DOPPLERABLE BOTH FEET\nCVP 5-13\n\nRESPIR; LUNGS CLEAR THIS SHIFT, SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW SECRETIONS, 02 SAT 98-100%, REMAINS ON SAME VENT SETTINGS,\n\nGI; TUBE FEEDS AT GOAL (80C/HR), OFF FOR ONE HR FOR RESIDUALS > 60CC\n\nENDOCRINE; BS 173 THIS AM, SLIDING SCALE TIGHTENED, PM BS 117-123\n\nWOUND; ABD INCISION SEEN BY VASCULAR TODAY, SMALL NECROTIC AREA LOWER INCISION, SCANT SERO-SANGE DGE, DSD APPLIED, JP MINIMAL DGE, ? REMOVING TOMORROW\n\nPLAN;PULMONARY SUPPORT,? ATTEMPTING EXTUBATION, TRACH OPTION DISCUSSED BY SICU ATTENDING WITH PT AND DAUGHTER AND PT NODDED POSITIVELY TO CONSENTING TO PROCEDURE, WILL BE DISCUSSED FURTHER, ? FAMILY MEETING, SOCIAL WORKER IN WITH DAUGHTER AND UPDATED\n\n"},{"category":"Nursing/other","chartdate":"2111-12-02 00:00:00.000","description":"Report","row_id":1595894,"text":"Respiratory Care Note:\n Patient on PSV of overnight. RSBI this am =108. BS= bilat, decreased slightly over L lung. Suctioned for thick whitish sputum. ET resecured at 19-20 cm by lip after reviewing CXR. See Carevue flowsheet for specifics. Plan to maintain at this time due to tachypnea with RSBI.\n"},{"category":"Nursing/other","chartdate":"2111-12-02 00:00:00.000","description":"Report","row_id":1595895,"text":"cv:hr afib 88-109 . pt received lopressor dose at 2400 hr was 109 at the time and rate decreased to 80's after med.sbp decreased to 88 with mean in 50's requiring neo for ~ 3 hours. neo off at 2330. lasix drip off . pt is 2000cc negative for past 24 hours. fentanyl off for a few hours secondary to hypotension but pt became a bit agiated and nodding \"yes \" when questioned about pain so fentnyl restarted at 20 mics/ with good effect.\n\ngu: diuresed with lasix drip. 2000cc negative at 2400(goal) lasix drip off secondary to hypotension.\n\ngi: several large liquid stools, fecal bag placed.tolerating tube feed at goal Impact with fiber at 80 cc/hr.\n\nintegumentary: generalized edema.perinium red rash..nistatin powder ordered and applied. tongue has thrush nilstatin applied.JP # 1 d.c'd\n# 2 draining serous fluid very small amount.incision is approximated. staples. sm areas of reddnesss along incisional line.\n\nneuro: left eye open at all times. It is a prosthetic eye. pt opens r eye spontaneously and to command. nods appropriately.\n\nresp: cpap 50 % peep 5,ps 10 see careview for abg.o2 sats 98-100%. sx for thick yellow q 2-4 hours.breath sounds decreased l base .after retaping et tube tube breath sounds clear bilateral.\n\nnote: gall bladder us done at 0600. levothyroxine restarted. Tsh elevated.\n"},{"category":"Nursing/other","chartdate":"2111-11-23 00:00:00.000","description":"Report","row_id":1595867,"text":"Neuro: pt is alert MAE slightly on bed very edemitious. R pupil reactive L eye glass.\n\nPain: on 100mcg of fentanyl . Pt comfortable at rest.\n\nCV: AF 80-90's SBP 105-150 up to high of 170 when turned. Palp DP/PT. Pheripheral Edema +3. CVP 8-13.\n\nLungs: AC changed to CPAP at 1500 tolerating well at present. lungs coarse to slightly decreased in bases. upper lobes slighty clearer this PM.\n\nGI: ABD open and packed. NG LWS clamped then TF started at 1400 impact with fiber STR @ 10. BS hypoactive.\n\nGU: Foley to gravity. On 8mg lasix drip. goal to be negative by 2liters. currently > 1400.\n\nSkin: pt without pressure sores. ABD open dsg done by surgical team. TWO Jp\"s to suction slightly bloody drainage moderate amt.\n\nA Stable\nP monitor output closely maintain goal of 2 liters negative. monitor labs repleat lytes as indicated. send ABG on CPAP support resp as indicated. possible wound closure on thursday. skin and wound care as indicated. Adance TF as tolerated.\n"},{"category":"Nursing/other","chartdate":"2111-11-24 00:00:00.000","description":"Report","row_id":1595868,"text":"RESP CARE: Pt remains intubated/on vent on 16 PS all shiftSEE CAREVUE. Lungs coarse with wheezes. Sxd thick yellow/white sputum. RSBI-148.\n"},{"category":"Nursing/other","chartdate":"2111-11-24 00:00:00.000","description":"Report","row_id":1595869,"text":"NURSING UPDATE\nCV:\n TMAX 100 PO. REMAINS IN AFIB. HR UP TO 130 AND HTN 170'S WHEN ANXIOUS/UNDERSEDATED, SETTLES WITH HR 80-90'S AND SBP 95-120 WHEN COMFORTABLE. DIURESING ON LASIX GTTS. FLUID BALANCE DOWN 1800CC YESTERDAY BUT WEIGHT DOWN 5KG, PT OOZING LARGE AMOUNT OF FLUID INTO BED. FENTANYL GTTS MAINTAINING ADEQUATE LEVEL OF PAIN RELIEF AND SEDATION.\n\nGI:\n TROPHIC TUBE FEEDS @ 10CC/H UNTIL 4AM, STOPPED PER REQUEST OF DR , PT POSSIBLY RETURN TO O.R. TODAY FOR CLOSURE OF INCISION, BUT PLAN REMAINS UNCLEAR AT THIS TIME. NUTRITION ALSO MAINTAINED WITH TPN. BOWEL SOUNDS HYPOACTIVE, NO BM. ABDOMEN OPEN LEAKING LARGE AMOUNT OF SEROUS FLUID BENEATH DRESSING, AND 150CC VIA JP'S TO LWS.\n\nPLAN:\n CLOSURE OF INCISION, DATE/TIME YET TO BE CONFIRMED BY DR .\n CONT TO DIURESE AS TOLERATED, STILL EDEMATOUS AND 20L POSITIVE LOS.\n"},{"category":"Nursing/other","chartdate":"2111-11-24 00:00:00.000","description":"Report","row_id":1595870,"text":"STATUS UPDATE\nDATA- SEE CAREVIEW FOR DETAILS\nN-ALERT RIGHT PUPIL REACTIVE TO LIGHT. MOVING ALL EXTREMITIES ON BED. ABLE TO FOLLOW COMANDS, IS ABLE TO NOD HEAD YES OR NO TO DIRECT QUESTIONS. ON FENTANYL FOR PAIN WITH GOOD EFFECT. ATIVAN 1 MG GIVEN DURING ET TUBE REPOSITIONING FOR ANXIETY WITH GOOD EFFECT.\n\n\nCV- A-FIB MOST OF SHIFT 90S-130'S WITHOUT ECTOPY SBP 100'S-130'S CVP 8-12. PERIPHERAL EDEMA + GOOD PALPABLE PULSES.\n\nRESP-CHANGED TO AC- FI02 40% 450 X 14WITH 8 OF PEEP\nSUCTIONED FOR SMALL AMOUNTS THICK WHITE SECRETIONS. LUNGS SOUNDS COARSE.NO VENT CHANGES OVERNIGHT.\n\nGI/GU- ABD OPEN- TRANSPARENT DRESSING DRAINAGE REINFORCED TIMES TWO- DRAINING SERO-SANG DRAINAGE.TWO JP DRAING TO LWS SERO-SANG DRAIAGE.\n TROPHIC TUBE FEEDS RESTARTED 5PM AT 10CC/HOUR. TPN AT 74 CC/HOUR.\nPATIENT TO HAVE SURGERY THIS10/29- ? WHEN TO START NPO.\n\nFOLEY TO GRAVITY DRAING LARGE AMOUNTS CLEAR YELLOW DRAINAGE. BUN 30 LASIX GTT DOWN TO 6MG/HOUR. NOW -1400\n\n\nPOC- CONTINUE TO MONITOR DIURESEIS,PAIN CONTROLL. PLAN-- OR IN AM TO CLOSE ABDOMEN.\n"},{"category":"Nursing/other","chartdate":"2111-11-16 00:00:00.000","description":"Report","row_id":1595840,"text":"Pt arrived from OR at 2100, S/P AAA repair.\nNeuro: Sedated on propofol. R pupil 3mm brisk. L artificial. MAE when sedation off for neuro exam. Appears to respond to name but unable to follow any directions.\nCV: Initially on arrival Temp 91.2, bare hugger on and present Temp 95.9. HR 60-80's afib with occasional to frequent PVC's. Arrived on NEO for hypotension. Noted to be having increasing PVC's, labile pressures. CO=1.7. Dr. aware and started pt on dobutamine, noted improvement in SBP, CO 4, SVR 1600 from 2300. Attempting to wean neo. Extremities increasingly warm with bare hugger. Dopplerable pulses DP & PT, femoral pulses palpable.\nRESP: Several vent changes presently on AC, 550X14 peep 5, FIO2 50%. ABG much improved since admission.\nGI: abd open, JP draining large amounts of bloody drg.\nGU: foley draining just adequate amounts of clear yellow urine.\nENDO: blood sugars elevated, Treated with humalog insulin.\nPLAN: Attempt to wean neo, Frequent CO and assess tolerance of dobuamine, Frequent labs check for bleeding.\n"},{"category":"Nursing/other","chartdate":"2111-11-16 00:00:00.000","description":"Report","row_id":1595841,"text":"Respiratory Care\nPt.continues on full vent.support t/o shift.Labile b/p at times.Vent.changes made as needed.\n"},{"category":"Nursing/other","chartdate":"2111-11-16 00:00:00.000","description":"Report","row_id":1595842,"text":"Pt had periods of of hypoxia this shift and PEEP was therefore increased from 5 to 8. Her vent settings were also changed to bring them closer to ARDSnet protocol. Plan is to keep her sedated to prevent abdominal breathing at this time.\n"},{"category":"Nursing/other","chartdate":"2111-11-29 00:00:00.000","description":"Report","row_id":1595887,"text":"FULL CODE Universal Precautions Allergy: Percocet\n\n\nNeuro: Awake, alert, nodding approp and mouthing words; becoming frustrated and angry w/ her son - mouthing \"take me home\", \"take out the tube (ETT)\", moving her hands to the tubes (unrestrained while family was at the bedside). Following commands, MAEx4 spont/command. R pupil 3mm/brisk.\n\nCV: HR=90-110s, afib, no ectopy. BP ranges from 100-150s/50-60s. +periph pulses, +edema, extrems warm. CVP=. Lopressor increased from 50mg to TID.\n\nResp: CAPA/PS 50%. Pt very adamant about getting the tube out. She was diaphoretic as she was working herself up. Repeatedly explained the weaning to her and since the hope is to extubate tomorrow, she was placed on CPAP/PS 5/5, but she continued to be agitated w/ RR=30, HR 110s, BP 180/. Med w/ ativan 2mg and she relaxed, but resp status did not improve - it worsened w/ 02sat down to 87%, RR remained hi 20s; RSBI 80s. ABG obtained just before placing her back on CPAP/PS - 7.48/40/43/31/5/84%. On now and RR remains 26-27, 02sat 95-100%, HR to 90s. Lungs fairly clear bilat, sx minimal tan secretions via ETT. CXR ordered for am. Lasix 20mg ordered - goal is 2L neg.\n\nGI/GU: abd firm/distended, +BS, +flatus. Attempted to use bedpan w/ no success. TF FS Impact w/ fiber at 80cc/hr (goal). Foley cath w/ amber urine - lasix 20mg ivp given this am and is now order. Goal is to be 2L neg.\n\nAccess: RIJ TLC, R rad a-line (positional).\n\nID: T=100.4 oral, all antibx d/c'd yesterday\n\nEndo: FS covered w/ RISS\n\nSkin: Abd incision pink w/ necrotic areas as previously noted. JPx2 w/ serous drainage.\n\nSocial: Family in to visit - updated on pt's status.\n\nPlan: Wean as tol. Lasix . Increase lopressor as ordered. Support family\n"},{"category":"Nursing/other","chartdate":"2111-11-29 00:00:00.000","description":"Report","row_id":1595888,"text":"Pt became very agitated with ETT today. Attempt made to wean pt's PEEP and PSV today but SpO2 and PaO2 dropped, pt sx'd for a moderate amount of thick secretions by RN, plan is to attempt more weaning tomorrow.\n"},{"category":"Nursing/other","chartdate":"2111-11-30 00:00:00.000","description":"Report","row_id":1595889,"text":"respiratory Care\nNo vent. changes overnight with stable resp.status.abg's adequate.Rsbi improving to 94 this am.Plan:continue to evaluate for extubation.\n"},{"category":"Nursing/other","chartdate":"2111-11-30 00:00:00.000","description":"Report","row_id":1595890,"text":"CONDITION UPDATE\n\\D. LOW GRADE TEMP AND SLIGHTLY DIAPHORETIC MUCH OF THE TIME.DR. AWARE.SR 90'S TO LOW 100'S REQUIRING INCREASE IN LOPRESSOR. BP STABLE 109-130/60-70.O2 SAT=99-100\n DESPITE IMPROVED OXYGENATION WITH DECREASE IN IPS=8,DECISION BY DR. TO DIURESE TODAY MORE VIGOROUSLY WITH LASIX DRIP WAS STARTED THIS PM. DIAMOX WAS ADDED TO OFFSET ALREADY SL ELEVATED TCO2. CVP STARTED 12 AND HAS DECREASED TO 7 WITH HUO=200ML.\n BY 1800 C-PAP WAS DECREASED TO 5 WITH IPS-8. AWAIT REPEAT ABG'S.SXED FOR SM TO MOD AMT WHITE THICK SECRETIONS FOR WHICH PT WAS STARED ON ROBITUSSIN TO BREAK-UP MORE OF THE ? CONSOLIDATION IN TH LLL PER SICU TEAM.\n DUE TO PT'S FRUSTRATION THAT LEADS TO ANXIETY AT TIMES,PT WAS STARTED ON ANTIANXIETY MED. FENTANYL WAS ALSO WEANED SLIGHTLY TODAY DUE TO PT'S DENIAL OF INCISIONAL PAIN EVEN WITH TURNING IN BED . PT CURRENTLY IS ON 30MCQ OF FENTANYL AND DENIES PAIN.PT IS ALERT AND AWAKE COMMUNICATING BY FORMING WORDS WITH HER LIPS.\n PT APPEARS TO BE TOLERATING TF EVEN WITH HYPOACTIVE BOWEL SOUNDS. ABD APPEARS DISTENDED FOR WHICH SHE WAS GIVEN A SUPPOSITORY AND HAD SM AMT OF LIQUID AND FORMED STOOL.? NEED FOR ANOTHER SUPP. TOMORROW.\n ABD INCISION INTACT WITH SM AREAS OF ? ECCYMOSIS THAT DRAINED A VERY SMALL AMT OF OLD BLOOD.\n DAUGHTER IN.LESS ANXIETY OVER HER MOM TODAY BECAUSE HER MOM APPEARS TO BE LESS ANXIOUS.UPDATE TO FAMILY WAS GIVEN\nA.MONITOR VS CLOSELY. IF PT IS DIURESED TOO QUICKLY AND DUE TO INCREASE IN LOPRESSOR DOSE,PT COULD HAVE A HYPOTENSIVE EPISODE.\n CHECK ABG ON C-PAP5 AND 8 IPS..? INCREASE IN VENT SETTINGS FOR OVERNITE.GOAL= TO BE NEG 1-2 LITERS IN THIS 24HR PERIOD.\nR.CONDITION IMPROVING\n"},{"category":"Nursing/other","chartdate":"2111-12-01 00:00:00.000","description":"Report","row_id":1595891,"text":"Condition Update B:\nPlease refer to creview and remarks for details.\n\nPt wide awake until 0400 after 50mcg bolus of fentanyl. Pt pleasant, copperative. Communicating via mouthing appropriately. OD 3mm and brisk reactive. OS with false eye intact. Daughter taking care of oer nsg report. Pt denies c/o pain/discomfort on fentanyl gtt.\n\nTmax 100.7, cuurently 99.2 po. Aline flat waveform, unable ot draw back from. Discussed with Dr. at . Following NIBP. While asleep SBP down to 90. HR down from 90's to 80's rate controlled afib. CVP down to 5-6. Cont wiht generalized 3+ pit edema.\n\nLS clear to coarse. Suctioned for thick white secretions. Vent rested over night as RR 35-40, and LS CTA. Discussed with Dr, . Vent changed to CPAP and PS on 50%. Morning ABG 7.46 42 79 31 5.Pox 98-100%.\n\nPt neg 850cc at MN. Titrated lasix gtt up, neg 500cc at 0500. CVP 10->5. Tol TF at goal minmal residuals. Abd soft distended. BS present. Med formed BM x one on evening shift. Treating gluose levels per RISS.\n\nNystatin S&S applied to tongue for thrush. Abd inc D&I with erythema and a few small blister/hematoma. JP's with seroserosang output.\n\nPLAN: Cont vent wean as pt tol. Titrate insulin gtt to assist with Goal 1-2L neg by MN. Culture pt for temp spike. Nystatin for thrush. Monitor skin. Call H.O. for changes.\n"},{"category":"Nursing/other","chartdate":"2111-11-16 00:00:00.000","description":"Report","row_id":1595843,"text":"CONDITION UPDATE\nD.TEMP SLOWLY INCREASED THRU THE COURSE OF THE DAY.AF RATE 90'S TO LOW 100'S WITHOUT ECTOPY ON DOBUTAMINE 6MCQ MOST OF THE DAY. PT HAD ALSO RECEIVED 2 PC FOR HCT OF 24.MAINTANENCE FLUID REMAINED AT 150ML/HR.PCWP20,CO-4.98 AND PA=40/23. REPEAT HCT-27. HUO 18-24.\n DESPITE STABLE HCT THIS PM,SBP DROPPED TO 80'D AND PAS TO 30'S.FLUID BOLUS GIVEN WITH IMMEDIATE RESPONSE.REPEAT HCT AT THIS TIME INCREASED TO 28.WHILE VOLUME INFUSING SBP REMAINS ELEVATED DR. AWARE OF ABOVE.HUO CONTINUES TO DECREASE TO 15MLDESPITE MULTIPLE FLUID BOLUSES.DOBUTAMINE WEANED SLOWLY DOWN PER DR. FOR POSSIBLE CAUSE OF ELEVATED HR AND ECTOPY.\n PT INITIALLY WAS GIVEN MORPHINE PRN FOR PAIN ALONG WITH PROPOFOL(OFF PROPOFOL,PT CONFIRMED ABD PAIN).FENTANYL DRIP WAS STARTED AND TITRATED\nUP. PRN ATIVAN WAS ALSO STARTED IN ATTEMPTS TO WEAN OFF PROPOFOL DUE TO LOWER BP.PT TO BE SEDATED WELL ENOUGH FOR NO RESPIRATORY EFFORT ON PART OF PT.PO2 WAS LOW THIS AM REQUIRING VENT CHANGES.WITH THE CHANGES PT BEGAN TO USE HER ABD MUSCLES WITH RESPIRATIONS.THUS CURRENTLY PT REQUIRES 85 MCQ OF FENTANYL AND PROPOFOL DOWN TO 15MCQ.PT HAS RECEIVED A TOTAL OF 2MG ATIVAN.BY THIS PM PT APPEARS MORE COMFORTABLE ON VENTILATOR,NOT USING ABD.MUSCLES.\n THIS AM, PO2 DOWN TO 60'S .BREATH SOUNDS CLEAR AND SXED FOR MINIMAL SECRETIONS.WITH INCREASE OF PEEP TO 8,RR=22 AND TV DOWN TO 450.ONCE SEDATION FOR RESPIRATORY EFFORT REACHED,PO2 INCREASED TO 110.PH NORMAL WITH LACTIC ACID LEVEL AT 3.0\n JP'S CONTINUE TO DRAIN APPROX 100ML/HR OF RED DRAINAGE.ABD WOUND REMAINS COVERED WITH TRANSPARENT DSG.\n DAUGHTER AND SON IN. DAUGHTER IS AN OR NURSE AND UNDERSTANDS THE ONGOING GRAVITY OF HER MOM'S CONDITION.\nA.MAINTAIN MAP >60.CHECK WITH HO REGARDING FLUID BOLI. WEAN DOBUTAMINE MAINTAINING CI >2.0 REPEAT LABS THIS EVENING(SEE ORDERS.\nR.DESPITE REQUIREMENTS OF VOLUME,PT'S CONDITION REMAINS GUARDED.\n\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595903,"text":"CONDITION UPDATE: SEE CARE VUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: ALERT. FOLLOWS SIMPLE COMMANDS. ABLE TO MOUTH WORDS/NODDING. APPROP TO MAKE NEEDS KNOWN. PERRL. MAE WITH PURPOSEFUL MOVEMENT. NO C/O PAIN. CONTINUES ON FENTANYL GTT WITH GOOD PAIN CONTROL.\n\nCARDIAC: HCT-30. AFIB-NO ECTOPY. HR-80-90'S. BP-100'S-140'S/60-70'S. CONTINUES ON LOPRESSOR WITH GOOD HR CONTROL. +RADIAL/PT/DP X2. CLS ON. HEPARIN SC.\n\nRESP: CONTINUES ON CPAP . ABG WITH ADAQUATE OXYGENATION. 2200-PT LS /FEW SCATTERED EXP WHEEZES. GIVEN 20 IV LASIX X1 WITH GOOD DIURESIS. LS-COARSE-DIMINISHED BIBASILAR. SX FOR SM/MOD AMTS OF THICK YELLOW SPUTUMN.\n\nGI: REMAINS NPO. TOLERATING TF WELL WITH NO RESIDUALS. ABD-SD, +BSX4,\nS, TENDERNESS AT INCISION SITE. ABD- INCISION STAPLES INTACT. DSD INTACT. ABD BINDER ON.\n\nGU: FOLEY WITH QS URINE. LYTES REPLETED PRN.\n\nENDO: FS QID COVERAGE PER RISS. STARTED ON NPH .\n\nSKIN: SKIN WDI. AXILLA/UNDER BREASTS/GROIN WITH RED RASH. NYSTATIN POWDER APPLIED.\n\nSOCIAL: SON CALLED OVERNIGHT UPDATED REGARDING POC.\n\nPLAN: MONITOR HEMODYNAMICS. WEAN VENT SETTINGS AS TOLERATED. PULMONARY HYGIENE. MONITOR WBC'S/HCT/ABG'S/LYTES PRN. TITRATE FENTAYL GTT PRN FOR PAIN. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595904,"text":"Pt remains on PSV 15/5 with a lg. amt of sputum today. BS equal with coares rhonchi & wheezes thoughout. BS improve some post sx\nTrach was planed for today. but as yet has not taken place.\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595905,"text":"Nursing Progress Note:\nPlease refer to CareVue for details.\n Fentanyl gtt @ 20mcg/hr; pt appears to be comfortable. Denies any pain. Pt more alert today. Mouthing words and writing on clipboard. Right pupil 3mm; briskly reactive to light. Left glass eye in place. Pt following commands consistently. MAE. +gag/cough reflex. Tmax 98.9. HR 80-90s (A.fib). ABP 100-140s/50-70s. CVP 2-14. Pt w/ +3 generalized edema. Lasix 20mg IV x1 ordered and given. Goal is for pt to be negative 1Liter. DP/PT pulses dopplerable. Skin is warm and dry; pale. Lungs coarse. Suctioned frequently for moderate amount thick white/ yellow secretions. No vent changes; CPAP 50%, PEEP 5, PS 15. Plan for trach (to be done in the OR vs bedside); ?when. Pt w/ strong cough; nonproductive. O2 sat >/= 99%. RR 20-30s. CXR done. Abdomen softly distended w/ +BS. Impact w/ fiber at 80cc/hr via NGT (goal rate); minimal residual. No c/o nausea. BM x2 (soft/liquid brown stool). BS 105-207; RISS q6hr and NPH 10units . Dr. ordered to change foley catheter today d/t pt +E.coli UTI; 16 Fr. foley catheter placed. Urine clear yellow. Midline abdominal incision w/ staples intact; pink around incision site. No drainage noted; DSD changed x1. Pt T&R freq to maintain skin integrity. No skin breakdown noted. son and daughter visited; updated on pt's plan of care and status.\n Plan: Cont to monitor VS, I's and O's, labs. Cont to wean off vent as tolerated. If unable to wean off, trach in future. Titrate fentanyl gtt for comfort. Monitor BS; NPH . Update pt's family w/ plan of care. Cont ICU care and treatment.\n"},{"category":"Nursing/other","chartdate":"2111-11-28 00:00:00.000","description":"Report","row_id":1595883,"text":"see careview for details\nfocus data update\n\nNEURO: FENTANYL GTT DECREASED, MOUTHING WORDS STATING SHE WANTS TO GO HOME, MAE'S, DIFFICULTY LIFTING EXTRIMITIES R/T EDEMA, PT ANXIOUS @ TIMES, RESPONSES WELL TO VERBAL REASSURANCE\n\nRESP: CPAP 8PEEP, 10 PS, POOR RISBEE THIS AM, WILL DIURESIS TODAY AND ATTEMPT VENT WEANING TOMMOROW, B/L BREATH SOUNDS COARSE, IMPROVED NOTED ON LEFT SIDE, ORALLY SX'D FOR SMALL AMT OF THICK WHITE SPUTUM\n\nCV: TMAX 100.1, IV LOPRSSOR CHANGED TO PO, REMAINS IN A-FIB WITHOUT ECTOPY, PITTING EDEMA CONTINUES ON EXTRIMITIES, 10 MG'S IVP LASIX GIVEN, A-LINE AND MULTI-LUMEN CENTRAL LINE PATENT\n\nGI: ABDOMINAL BINDER INTACT, NO DRAINAGE NOTED FROM INCSION, HOWEVER REDDEN, TF'S CHANGED TO FULL STRENGHT AND GRADUALLY INCREASED, BS ACTIVE, NGT FOR FEEDINGS, MINIMAL RESIDUAL NOTED\n\nGU: LASIX 40MG'S IVP GIVEN, CREATINE WNL, ADEQUATE HOURLY U/O\n\nA/P: CONTINUE EDUCATIONAL AND EMOTIONAL SUPPORT TO BOTH PATIENT AND FAMILY\n"},{"category":"Nursing/other","chartdate":"2111-11-28 00:00:00.000","description":"Report","row_id":1595884,"text":"Respiratory Care:\nPt remains on PSV 10/8peep 50%. She seems uncomfortable this eve and\nher PaO2 has to 68 from 144 at AM gas with no changes. Has been grabbing at OET and was restrained. Few secretions...check CareVue\nfor details.\n"},{"category":"Nursing/other","chartdate":"2111-11-29 00:00:00.000","description":"Report","row_id":1595885,"text":"Respratory Care\nNo vent.changes needed overnight.abg's adequate.Plan:continue wean as tolerated\n"},{"category":"Nursing/other","chartdate":"2111-11-29 00:00:00.000","description":"Report","row_id":1595886,"text":"focus hemodynmc\ndata: opens eyes to verbal stimuli. moves arms and legs on the bed. follows commands. tube fdgs via ngt and tol well. abd binder intact and abd dsg changed. incision line pink with ? necrotic areas near the midline incision. foley patent and ddraining yellow urine. on fentanyl gtt at 5omcg and resting comf. update to daughter.\n\nresponse: monitor closely.\n"},{"category":"Nursing/other","chartdate":"2111-11-26 00:00:00.000","description":"Report","row_id":1595877,"text":"Xray improved some. pt had a bronch today lg amt. of secreations cleared not plugs noted. pt was reintubated pre bronch today. changing size from #7 to #7.5\n"},{"category":"Nursing/other","chartdate":"2111-11-15 00:00:00.000","description":"Report","row_id":1595839,"text":"Respiratory Care\nPt. form O.R.s/p leaking AAA repair.Pt. arrived intubated as documented,BBS+.Placed on vent.will follow.\n"},{"category":"Nursing/other","chartdate":"2111-12-03 00:00:00.000","description":"Report","row_id":1595901,"text":"Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice. Right pupil 3mm; briskly reactive (left fake eye in place). Pt mouths words, gestures, and writes on clipboard. Follows commands consistently. MAE. Appropriate behavior; calm. Fentanyl gtt @ 20mcg/hr. Pt c/o of abdominal/incisional pain w/ turning and repositioning, but appears comfortable once settled. Tmax 101.1; Tylenol 650mg given via NGT w/ +effect (pt pan cultured last night). HR 80-101 (A.fib). ABP 90-130s/50-80s. CVP 8-15. Pt w/ +3 edema on BUE and BLE. DP/PT pulses dopplerable. Hct this AM was 26.9; 1unit PRBC transfused. Hct needs to be rechecked post transfusion. Lungs clear, diminished at bases. Pt not extubated today d/t large amount of thick yellow/white secretions; frequently suctioned. RSBI this AM 100; repeat 94.3. Cont CPAP 50%, PEEP 5, PS 10. O2 sat >/= 99%. Abdomen softly distended w/ +BS. Impact w/ fiber restarted at 1200 @ 80cc/hr (goal rate); infusing via NGT w/ minimal residual. Large amount of liquid, brown stool in fecal incontinence bag this AM. FIB bag changed. Needs stool to be sent for C.diff. No c/o nausea, emesis. BS 84-138; NPH 10units ordered. Cont RISS as well. Midline abdominal incision w/ staples intact; pink around incision. No drainage noted; DSD changed x1. Abdominal binder on. Pt's tongue w/ thrush; Nystatin oral suspension given. Miconazole powder applied under bilat breasts and underarms d/t yeast infection. T&R freq to maintain skin integrity; no skin breakdown noted. son and daughter visited today; updated on pt's plan of care and status.\n Plan: Cont to monitor VS, I's and O's, labs. Monitor respiratory status; ?extubate tomorrow if secretions decrease and RSBI improves. Monitor BS. Titrate fentanyl gtt for comfort. Update pt and family w/ plan of care. Cont ICU care and treatment.\n"},{"category":"Nursing/other","chartdate":"2111-12-04 00:00:00.000","description":"Report","row_id":1595902,"text":"Respiratory Care Note:\n Patient on increased PSV overnight with minute ventilation 11-15L, and RR 25-32. BS=bilat, coarse with occassional scattered wheezing noted. Suctioned for whitish sputum. CXR appears wetter. Patient receiving lasix. ET tube resecured. Noted skin breakdown beneath L nare- duoderm applied. RSBI done this am with result of >130. Patient left on PSV of 15/5, 50%.\n\n"},{"category":"Nursing/other","chartdate":"2111-11-27 00:00:00.000","description":"Report","row_id":1595878,"text":"CONDITION UPDATE\nD: SEE CAREVUE FLOWSHEET FOR SPECIFICS\n PATIENT IMPROVED A LITTLE OVERNIGHT. TMAX 100.0-HOWEVER WBC UP TO 30 ON EVENING LABS-TRIPLE IV ANTIBIOTICS WERE RESTARTED PER REC. OF SURGICAL TEAM. HR A LITTLE TACHY IN AFIB WITH A RATE BTWN 90-110 FOR MOST OF THE NIGHT WITH MIN AMT OF ECTOPY NOTED-LOPRESSOR 7.5 IV GIVEN Q6 BUT AFTER DOSE BP NOTED TO DIP BOTH TIMES DOWN INTO THE 80'S-?DECREASE DOSE TO 5MG. NEO WAS WEANED OFF AND ABOUT AN HOUR AFTER TURNING IT OFF BP DIPPED INTO THE 70'S (AFTER AMBU'ING AND LAVAGING PT D/T DESATURATION) INSTEAD OF RESTARTING NEO 1L BOLLUS OF NS WAS GIVEN WITH GOOD EFFECT AND NEO GTT REMAINED OFF FOR REMAINDER OF THE SHIFT. PT MAKING ADEQUATE AMTS OF URINE AND BLADDER PRESSURES WERE CHECKED Q4 RUNNING 15-18.\n PPF GTT WAS ALSO TURNED OFF AND VENT WAS WEANED FROM AC DOWN TO CPAP -PULSE OXIMETRY ~94-96% BUT AM ABG LOOKS GREAT. SUCTIONED A FEW TIMES FOR A SMALL AMT OF THICK CLEAR/WHITE SECRETIONS. PT CONTINUES TO RECEIVE FENT GTT FOR COMFORT AND IS ALERT/FOLLOWS COMMANDS AND NODS A LITTLE YES/NO TO SOME QUESTIONS.\n TROPHIC TF INFUSING VIA NGT-RESIDUALS CHECKED <100 BUT UP TO 90CC AT ONE POINT. ABD INCISION WITH STAPES AND SOME REDNESS BUT MIN AMT OF DRG AND JP'S PUTTING OUT SEROSANG DRG.\n DTR CALLED FOR UPDATE\nPLAN:\n CONT TO WEAN VENT AS TOLERATED\n PULMONARY TOILET\n BLADDER PRESSURES Q4HRS\n FENT FOR PAIN\n NOTIFY H.O. WITH ANY CHANGES\n"},{"category":"Nursing/other","chartdate":"2111-11-27 00:00:00.000","description":"Report","row_id":1595879,"text":"Respiratory Care\nSwitched to PSV overnight and tolerated well.Abg's adequate on current settings.Plan:continue ps wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2111-11-27 00:00:00.000","description":"Report","row_id":1595880,"text":"Resp. care note - Pt. remaines intubated and vented, PEEP weaned to 5 cmH2O, tol ok at this time.\n"},{"category":"Nursing/other","chartdate":"2111-11-27 00:00:00.000","description":"Report","row_id":1595881,"text":"see careview dor details\nfocus data update\n\n\nNEURO: FENTANLY GTT DECREASED TO 75 MCG'S/HR, PT TRACKING, ABLE TO FOLLOW COMMANDS, MAE'S MINIMALLY\n\nRESP: VENT SETTING'S CHANGED PEEP 5, PS 10, DECREASED PO2 57, FIO2 INCREASED TO 50% ABG PENDING, IMPROVED , PT KEPT OFF LEFT SIDE MOST OF DAY, ORALLY SUCTIONED FOR THICK WHITE SECRETIONS, BITING ON ETT\n\nCV: WBC DECREASED, A-LINE CHANGED OVER WIRE, 500CC LR BOLUS X1, EXT'S CONTINUE TO WEEP SEROUS DRAINAGE, CVP 8-10,\n\nGI: NPO, TF HELD THIS AM FOR HIGH RESIDUAL, REGLAN STARTED TF RESUMED THIS PM, ABDOMINAL BINDER APPLIED, DSG CLEAN AND DRY, JP'S PATENT FOR SEROUS DRAINAGE, MTN TO SELF SUCTION, BS HYPOACTIVE\n\nGU: BLADDER PRESSURES 15-20, ADEQUATE HOURLY U/O\n\nA/P: CONTINUE TO LIGHTEN SEDATION, WEAN FROM VENT, CONTINUE EMOTIONAL AND EDUCATIONAL SUPPORT\n\n"},{"category":"Nursing/other","chartdate":"2111-11-28 00:00:00.000","description":"Report","row_id":1595882,"text":"Respiratory Care\nPt.remains on PSV,peep increased to 8, md request for pa02-60's on .50.No further changes needed follow-up abg's reveal improved oxygenation.Plan:attempt further vent.weaning.\n"},{"category":"Nursing/other","chartdate":"2111-11-26 00:00:00.000","description":"Report","row_id":1595875,"text":"SICU B NPN:\nNEURO: Continues on fentanyl gtt at 100mcg/hr and propofol 20mcg/kg/min. Opens L eye to stimuli, no following of commands, moving UEs slightly in bed. L pupil 3mm and briskly reactive to light. L glass eye intact.\nCV: Tmax 101.7- pan cx'd but unable to get sputum yet due to no secretions. HR 90s-120s AF with occ. PACs. Recieved 1L fluid bolus x2 for decreased BP with some effect. Neo titrated to maintain MAP >60 and attempting to wean off. CVP 8-12. Repleted with 2G MGSO4 IV for level 1.8. A-line positional at times. Extremities cool to touch with palpable pulses. Generalized anasarca.\nRESP: Continues on ACV 500x16 FiO2 40% Peep +10 with adequate ABG. O2 Sat >95%. LS coarse and diminished at bases. Sx'd for scant thick yellow secretions. Possible bronch today for LLL atelectasis on CXR.\nGI/GU: Abd. dsgs intact with scant serosang. drainage noted on upper dsg. Two JP drains to bulb sxn with sersang. drainage. Abd. soft with absent bowel sounds. TPN continues at 74cc/hr. Fingersticks QID with 4u reg insulin given x2. NGT to continuous LWS with bilious drainage. Foley with amber clear urine 30-40cc/hr.\nSKIN: Red area to coccyx but skin intact. Pneumoboots and multipodus boots on. R TLC line intact and R radial a-line intact.\nPlan for possible bronch today. Attempting to wean neo off with fluid boluses for low BP.\n"},{"category":"Nursing/other","chartdate":"2111-11-26 00:00:00.000","description":"Report","row_id":1595876,"text":"focus data update\nsee careview for details\n\nNEURO: SEDATED ON PROPOFOL, FENTANYL GTT FOR COMFORT, NO SPONTANEOUS MOVEMENT, AND PRESENTLY UNABLE TO FOLLOW COMMANDS\n\nRESP: VENT SETTINGS UNCHANGED, LLL BREATH SOUNDS DIMINISHED, REINTUBATED WITH 7.5 ETT FOR BRONCHOSCOPY, VECURONIUM,PROPOFOL AND FENTANYL BOLUS GIVEN, BRONCH CULTURE OBTAINED, TENACIOUS THICK WHITE SECRETIONS\n\nCV: NEO GTT INCREASED TO 2MCG/KG/MIN, LOPRESSOR GIVEN TO CONTROL HR, ICU TEAM AWARE. CVP 8-10, 500CC LR BOLUS GIVEN X1, EDEMANOUS AND WEEPING SEROUS FLUID FROM UPPER EXT'S, REPEAT K 5.2, RIJ MULTI-LUMEN PATENT, A-LINE PATENT NEO TITRATED FOR MAP >70, T MAX 100.7 PO,\n\nGI: NPO, ORAL THRUSH NOTED, RX WITH NYSTATIN S/S, NGT PATENT IMPACT WITH FIBER FEEDS STARTED, HELD DURING BRONCHOSCOPY, ABD DRESSING CHANGED MIDLINE INCISION REDDEN SMALL AMOUNT OF SEROUS/SANG DRG NOTED\n\nGU: CREATINE NORMAL, MARGINAL AND CONCETRATED HOURLY U/O NOTED\n\nA/P: HEMODYNAMIC STATUS LABILE, EMOTONAL AND EDUCATIONAL SUPPORT GIVEN TO FAMILY, SOCIAL SERVICES CONTACT AND WILL FOLLOW, DR. NOTIFIED OF NEED FOR EDUCATION AND SUPPORT TO FAMILY, STATES HE WILL F/U\n"},{"category":"Nursing/other","chartdate":"2111-11-20 00:00:00.000","description":"Report","row_id":1595855,"text":"neuro: Calm/coop on fentanyl gtt @125mcg, prn ativan 1mg before major nsg care. Pt becomes anxious, responds to voice, follows command. NV grossly intact.\nCV: afib, rate controlled, min VEA. CI 1.7 after lasix 10mg w/ 500cc diuresis. Lytes repleted. CVP 10-14. + perocardial rub @ apex, positional; no ST changes.\nresp: CMV, 50%, 8PEEP. Improving ABG's, PaO2>100. Dim bases, intermintently rhonchorous, scant white ET secretions.\nGI: silent gut, NG scant bile. Open abd wound w/ 2 JP's to sx, decreasing s/s drng. TPN at target.\nGU: U O/P 30-50cc/hr clear amber.\nEndo: BS labile\nDerm: mod anasarca. Skin grossly intact.\nID: WBC 5.2; cont on vanco, levofloxacin, metronidazole. Core temp 37.\nlabs: HIT neg; plates improving...95.\nPlan: d/c S/G cath. Diurese, replete lytes. ?delete heparin in TPN. vent...? PEEP/FIO2 wean. Follow pericardial rub if not improved after diuresis. Adequate sedation w/ major care/procedures.\n\n"},{"category":"Nursing/other","chartdate":"2111-11-20 00:00:00.000","description":"Report","row_id":1595856,"text":"Resp Care\nPt remains intubated on A/C. Dropped PEEP from 8 to 6 and then to 5. Decreased FIO2 from 505 to 40%. No other changes made.\n"},{"category":"Nursing/other","chartdate":"2111-11-20 00:00:00.000","description":"Report","row_id":1595857,"text":"Update note\nSHIFT A- PLEASE SEE CARE VIEW FOR SPECIFIC DATA.\n\nN- ALERT MOST OF SHIFT ABLE TO FOLLOW COMMANDS AND MOVES ALL EXTREMITIES. CONTINUES ON FENTANYL GTT AT 125 MCG'S /HOUR PATIENT APPEARS COMFORTABLE. RECIEVED TWO DOSES 1MG ATIVAN PRIOR TO CARE WHICH WAS EFFECTIVE WITH AGITATION.\n\nCV- AFIB WITH RARE TO OCCASIONAL PVC'S. CO-4.01 CI- 2.20 LASIX GIVEN TIMES TWO WITH GOOD DIURESIS. GOAL IS -500 - -1 LITER. CVP 6-8 B/P'S 100-120'S. SWAN IN RIJ -DO NOT WEDGE. K REPLETED TIMES ONE WITH 20 AND SECOND ONE WITH 40 K WAS3.7. K LEVEL TO BE REDRAWN TONIGHT. LUNGS CLEAR ALL FIELDS.\n\nRESP- CMV- FIO2 FROM 50 TO 40 PEEP WEENED FROM 8. NOW AT 5. 1700 BLOOD GAS PAC02 WAS 28 RATE DECREASED TO 20. ABG PENDING.\n\nGI/GU- NG TO LWS SMALL BILLIOUS DRAINAGE, OPEN ABD. WOUND 2 JP'S TO LWS DRAINING SEROSANGUINOUS DRAINAGE. TPN AT 73CC/HR. FOLEY TO CD QUANTITY SUFFFICIENT.\n\nENDO- BS STABLE THIS SHIFT.\n\nID- CONTINUES ON VANCO FLAGGYL AND LEVOFLOXICIN T 99.5\n\nPOC- CONTINUE TO MONITOR-K AND ABG. GOAL 500CC- I LITER NEGATIVE FOR TODAY. ABDOMINAL DRESSING NEED REINFORCEMENT.\n\n"},{"category":"Nursing/other","chartdate":"2111-11-21 00:00:00.000","description":"Report","row_id":1595858,"text":"Resp Care Note,Weaned pt 2 ^ peep.Temp 100. HR-A-Fib with PVC'S.Sedated with fentanyl. Good ABG'S.Will cont to moniotr resp status.\n"},{"category":"Nursing/other","chartdate":"2111-11-21 00:00:00.000","description":"Report","row_id":1595859,"text":"CONDITION UPDATE:\nD/A: T MAX 100.2\n\nNEURO: FENTANYL GTT WITH GOOD PAIN CONTROL. ATIVAN X1 FOR BATHING/REPOSITIONING. PT ANXIOUS AT TIMES. TIGHTLY FLEXING ARMS WHEN STIMULATED. FOLLOWING COMMANDS.\n\nRESP: LS CLEAR. VENT SETTINGS INCREASED SLIGHTLY AS PT'S PAO2 DECREASED TO 60'S. AC 50%, 20X450, PEEP 8 WITH CURRENT ABG: 7.36, 42, 95, 25, -1.\n\nCV: HR 80'S-110 AFIB. CVP ~12. ABP ~130/60. PA 40'S/20'S. BEING DIURESED WITH LASIX. FLUID BALANCE -380CC'S. MN-0500 + 163 CC'S. + PPP BILAT. +++ EDEMA. WT DOWN 2 KG'S FROM YESTERDAY. NO PERICARDIAL RUB AUSCULTATED THIS SHIFT.\n\nGI: NGT-LCWS WITH MINIMAL OUTPUT. ABDOMEN OPEN, COVERED WITH OPSITE, X2 JP'S. TROPHIC TUBE FEEDS ORDERED.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: FAMILY VISITED AND CALLED.\n\nR: REQUIRING SLIGHTLY MORE VENTALATOR SUPPORT, MILD DIURESIS, ABDOMEN REMAINS OPEN.\n\nP: CONTINUE CURRENT CLOSE MONITORING AND MANAGEMENT. PAIN CONTROL. GOAL MAP > 60. PT AND FAMILY SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2111-12-02 00:00:00.000","description":"Report","row_id":1595896,"text":"npn 0700-1500;\nNO VENT CHANGES MADE TODAY. PT WAS GOING TO GO FOR /PELVIC CT BUT WAS CANCELLED AFTER DISCUSSION WITH PRIMARY TEAM.\n\nNEURO; AOOX1.WAEKLY MAE TO COMMAND LT EYE FALSE,RT EYE 3MM,BSK.\n\nRESP; LUNGS COARSE WITH INTERMITTENT EXP WHEEZE, DIMINISHED AT BASES SUCTIONED FOR MOD AMOUNTS THICK WHITE SECRETIONS,,SATS 96-100%,RR 26-35. CONTINUEES ON CPAP WITH 10 PS AND 5 PEEP.\n\nCVS; TMAX 100.5 PO AFIB 103-89 GIVEN 25 MGS OF LOPRESSOR INSTEAD OF 50 MGS AS BP 103-110 BY ALINE TOL DOSE WITH NO DRAMATIC DROP IN BP.CURRENTLY 105-115/60 AT REST UP TO 140-160/80 WHEN COUGHING BUT SETTLES QUICKLY. CVP 13-9.\n\nGU; LASIX DRIP REMAINS OFF,PASSING 100-50 MLS/HR, K REPLETED.\n\nGI; TOLERATING T/F AT GOAL BELLY SOFT DISTENDED HYPOACTIVE BS. PASSING SMALL AMOUNTS OF GOLDENYELLOW LIQUID STOOL VA RECTAL BAG .\n\nENDO;COVERED ON RISS.\n\nINTEGRUM;BELLY WOUND UNCHANGED EDEMATOUS , MOIST RED PATCHES UNDER ARMS AND BREASTS,TREATED WITH NYSTATIN POWDER,THRUSH IN MOUTH. TREATED WITH NYSTASTIN.\n\nSOC; DAUGHTER INTO VISIT TEARFUL AT TIMES TALKED WITH LISW . LEFT WITH FRIEND WILL RETURN LATER THIS AFTERNOON.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2111-12-02 00:00:00.000","description":"Report","row_id":1595897,"text":"Respiratory Care\n\n Pt continues on CPAP/PSV 10/5 in NARD. B/S ess clear dim on L sx'd for mod thick white. No changes made today Will continue to follow closely.\n"},{"category":"Nursing/other","chartdate":"2111-12-03 00:00:00.000","description":"Report","row_id":1595898,"text":"Respiratory Care Note:\n Patient continues on PSV 10/5. She appears comfortable with good BS bilat. Suctioned for minimal white secretions. No change in respiratory status. It appears patient is becoming more responsive. Plan to maintain at this time. RSBI yesterday >105, will recheck this am.\n"},{"category":"Nursing/other","chartdate":"2111-11-18 00:00:00.000","description":"Report","row_id":1595848,"text":"Condition Update\nD: See carevue flowsheet for specifics\n Patient's temp coming down to 99.4 from tmax of 100.9. HR at beginning of shift up to rate of 130's with frequent PVC's, labs were sent with no significant findings. HR settled down into the 90's with no intervention. Later in the shift PPF was turned off d/t pt heavily sedated, bed bath was given and pt was positioned on right side HR went up to 120-130 with freuqent PVC's and didn't settle out within an hour so PPF was restarted-HR still did not come down (at this time BP also higher so titrating down on levo gtt). SICU resident notified fluid bollus was given with little effect. Finally pt was repositioned back onto left side and rate came down ~100, second fluid bollus given. CVP all night running . Currently Levo gtt at .04mcg/kg/min with map maintained >60. PA numbers have remained stable but elevated with adequate CO>4 and CI>2. URine output still marginal. Heparin SC was held after discussing with Dr. results of HIT.\n While PPF was off pt appeared more alert, opened mouth on command and had more spontaneous movement. Fent gtt still at 100mcg/hr for pain.\n No vent change were made overnight and oxygenation much improved with am abg. PaO2 up from 78 to 140's. Pt has not been breathing much over the vent and has not been suctioned for much in way of secretions. Lungs are clear and diminished in the bases.\n Abd open and dressing required reinforcement d/t leaking of sanginous drg. JP's still to LWS and draining lge amts. No bowel sounds noted. NGT to LCWS. Pt receiving LR at 150 and not receiving any nutrition at this time. Pt to return to OR today for wash out. No plans to close belly at this time.\nPLAN:\n OR today\n Fent/PPF for sedation\n Levo to keep map>60\n F/U with HIT spec\n Call social worker to speak with family\n Notify H.O. with any changes\n"},{"category":"Nursing/other","chartdate":"2111-11-18 00:00:00.000","description":"Report","row_id":1595849,"text":"See carevue for objective data.\n\nProprofol dc'd this AM with prn ativan for sedation with good results. MAP much improved after proprofol dc'd. Fentanyl gtt remains at 125 mcg/hr. Nods head slightly when asked questions. Weak but follows commands.\nCO/CI remain labile requiring fluid boluses prn. PCWP 15-17. CVP 7-11.\nPA #'s remain elevated as well. Levophed remains off. Body edema present. Less ectopy today-remains in AFIB.\nAbd wound leaking copious amts of sangious fluid around dressing.\nPlan this PM is to wash wound and re-dress. Awaiting MD's to arrive.\nAbd around dressing remains soft.\nUrine output marginal at best. +ATN per team. Will monitor.\nNo vent changes except FIO2 decreased to 50% from 60%. ? decrease PEEP to 5 in AM if PO2 adequate for venous return.\nTPN to be started soon-no order for today. NGT to LCWS-flushed X2 patent and draining bilious fluid.\n\nFamily in and updated on POC. Support/education provided by many members of the team.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2111-12-06 00:00:00.000","description":"Report","row_id":1595913,"text":"Pt remains off vent. support @ this time but continues to have pul. hygien issues. Her cough is productive of a mod-lg amt of thick yellow sputum. Percusion & vibration was started to Left & right sides\nwith bed in mild trendelinburg. deep breathing & coughing was also aggressively encouraged.\n"},{"category":"Nursing/other","chartdate":"2111-12-03 00:00:00.000","description":"Report","row_id":1595899,"text":"SICU B NPN:\nNEURO: Continues on fentanyl gtt at 20mcg/hr. Opens eyes spontaneously, follows commands and nodding/mouthing words. Does nod head yes to pain and appears to be incisional. Fentanyl bolus 25mcg x2 for pain given. MAE in bed UE >LE. Not restrained and no attempts made to pull out ETT or lines. R pupil 3mm and briskly reactive to light. L glass eye intact.\nCV: Tmax 101.1 and pan cx'd. Tylenol given with last temp. 99.9 at 4am. Skin warm and dry with weak but palpable pedal pulses. HR 80s-100s AF, no ectopy noted. BP stable with MAPs >60.\nRESP: No vent changes made. LS coarse and diminished at bases. Sx'd for thick white secretions in moderate to large amts. Large amts of oral secretions also.\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with large amt of liquid-loose brown stool- heme negative. Impact with fiber continues at 80cc/hr via NGT. Requiring insulin with q6hr fingersticks. Foley with clear yellow urine >40cc/hr.\nSKIN: Thrush in mouth with nystatin swabs given. Abd. dsg intact with no drainage noted. Staples to site clean, dry and intact. Abd. binder in place. Pneumoboots on. Yeast rash to underarms, folds and groin with miconazole powder applied.\nOTHER: Daughter called and updated on pt's condition and plan of care.\n"},{"category":"Nursing/other","chartdate":"2111-12-03 00:00:00.000","description":"Report","row_id":1595900,"text":"Pt stable with present settings. Bs deminished in left base with coares rhonchi thoughout. Rhonchi improves post sx. Pt sxed for a lg amount of thick white and yellow sputum. No vent changes requested.\n"},{"category":"Nursing/other","chartdate":"2111-12-06 00:00:00.000","description":"Report","row_id":1595914,"text":" 19/07\n PT A/O RELAXED NO PAIN OR DISCOMFORT NOTED SLEEPS SHORT NAPS UNDERSTANDS AND TRIES TO HELP WITH CARE\n RESP ON .50 FACE TENT TOL WELL SAT 92 TO 100 CLEAR FIELDS\n HEART AF RATES 78 TO 90 PULSES POS 3 THRU OUT VSS\n GI POS B/S NOTED TOL T/F WELL SOFT ABD\n PLAN PROGRESSIVE PT ROM REALITY BASED CARE FAMILY SUPPORT\n\n"},{"category":"Nursing/other","chartdate":"2111-12-07 00:00:00.000","description":"Report","row_id":1595915,"text":"CONDITION UPDATE\nPT TRANSFER TO VICU. VSS, A&OX3, NO C/O PAIN. PLEASE SEE TRANSFER NOTED FOR DETAILS.\nPLAN:\n TRANSFER TO VICU \n"},{"category":"Nursing/other","chartdate":"2111-12-08 00:00:00.000","description":"Report","row_id":1595916,"text":"Condition Update\nPlease see carevue for specifics.\n\nPt is alert and oriented x 3, but does get confused at times ? sundowning. She is easy to reorient. Otherwise, behavior is appropriate. She had no c/o pain throughout the noc. She is able to move all extremities w/ equal strength. Afebrile. Chronic afib. 02 sats 93-97% Cool mist face tent remains on to help loosen secretions. Robitussin also given q 6 hours. She is able to expectorate small to moderate amts of thick, white secretions using the yankaur independently. LS are coarse b/l. Foley is patent and draining adequate amts of clear urine. She tolerated liquids throughout the noc. Pt is incontenent of liquid, brown stool. FIB placed. Peri area is excoriated. double gaurd cream applied. Pt has a riss and am/pm nph for bs coverage. K+ & MG+ repleted.\n\nPlan: continue with current plan of care per sicu/ vascular teams. Xfer to VICU when bed is available.\n"},{"category":"Nursing/other","chartdate":"2111-12-08 00:00:00.000","description":"Report","row_id":1595917,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.\nPATIENT DOING WELL TODAY, ALERT AND COOPERATIVE. TOLERATING REG. DIET SLOWLY, ENCOURAGED TO DRINK BOOST.\nOOB FOR ABOUT 1 HR, ANXIOUS TO GET BACK INTO BED.\nDIURESING SLOWLY WITH LASIX.\nSATS GOOD ON 4L NASAL PRONGS, ENCOURAGED TO TCDB.\nFOLEY WITH CLEAR YELLOW URINE.\nP: TO VICU WHEN BED AVAILABLE.\nWILL CALL HOW WITH ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2111-11-25 00:00:00.000","description":"Report","row_id":1595871,"text":"SICUB NPN:\nNEURO: Intermittently agitated at times- ativan 1mg x2 with good effect. Right pupil 3mm and brisk. Moving all extremites in bed UE>LE. Follows commands and does not appear in to be in pain. Fentanyl gtt at 100mcg/hr.\nCV: Tmax 99.0. HR 70s-100s AF with occ. PACs. Occasional P waves noted. BP stable with MAPs >60. SBP up to 180s with turning and agitation. CVP 8-10. Receiving MGSO4 and KCL repletion. A-line positional at times and difficult to draw blood from.\nRESP: No vent changes - continues on ACV 450x14 FiO2 40% Peep +5, breathing over vent 4-6 breaths per minute. LS coarse and diminished at bases. Sx'd for scant amts whitish secretions. O2 Sat >95%.\nGI/GU: Abd. open with transparent dsg intact- continues to ooze serosang. drainage in moderate amts. TF shut off at 12am for planned OR today. 2 JP drains continue to LWS. TPN continues at 74cc/hr. Foley with clear yellow urine >100cc/hr- lasix gtt increased to 8mg/hr for goal negative 2L in 24hr (was -1500cc last 24hrs).\nSKIN: Coccyx red but skin intact. Abd. dsg intact.\nPlan for closure of abd. wound in OR today. Consents signed by daughter. TF off since MN.\n"},{"category":"Nursing/other","chartdate":"2111-11-21 00:00:00.000","description":"Report","row_id":1595860,"text":"Condition Update\nD: See carevue flowsheet for specifics\nPatient remains afebrile HR stable in afib with good rate control-pt was started on a small dose of lopressor which was well tolerated. Swan was changed over a wire to a multilumen which was then leaking after placement had been confirmed so a 2nd line was placed (over a wire). CVP still ~12 and pt was started on a lasix gtt to diurese to 1L negative by midnight but due to difficulty with access throughout the day that goal may not be achieved.\n In the second CXR done to confirm line placement left lung noted to be out. O2 sats at the time down to ~94-95%, lung sounds diminished on left. Pt was bronch'd for a lot of secretions f/u CXR showed improvement. PT still on AC PEEP increased to 12 after bronch otherwise settings unchanged 450x22 fio2 50%.\n Abd assessment unchanged. Pt was started on trophic feeds this am. Abd still open and leaking a lot of serosang drg from around dressing. Pt also receiving TPN for nutrition.\n Family has been at bedside throughout the day and has been updated as to todays events.\nPLAN:\n Return to OR on monday\n Wean PEEP tonight if abg adequate\n Lasix gtt to diurese to 1L negative by midnight.\n Notify H.O. with any changes\n"},{"category":"Nursing/other","chartdate":"2111-11-21 00:00:00.000","description":"Report","row_id":1595861,"text":"Resp Care\nPt intubated on A/C. Pt bronched for large amt thick secretions. Increased PEEP from 8 to 12 due to increased fluid in right lung seen on latest X-ray. No other changes made.\n"},{"category":"Nursing/other","chartdate":"2111-11-22 00:00:00.000","description":"Report","row_id":1595862,"text":"Resp Care Note,Weaned down FIO2 for good ABG. Sedated with fentanyl. Getting lasix.Suctioned for sml amts thick white secretions. Temp 100. Will cont to monitor resp status.Will try to wean peep today.\n"},{"category":"Nursing/other","chartdate":"2111-11-22 00:00:00.000","description":"Report","row_id":1595863,"text":"Condition Update\nD: See carevue flowsheet for specifics\n Patient remains afebrile-hemodynamically stable and tolerating diuresis well on lasix gtt. HR in afib with rate controlled in 80's on a small dose of lopressor. Goal is to keep SBP>100 and diurese to negative 2L by midnight. Currently close to 1L negative this afternoon. Lytes requiring frequent repleting.\n No vent changes were made today and still has not required much suctioning. Lungs have been clear and dim in the bases -CXR ordered for tomorrow.\n No change in abd exam, continues to leak lge amts of serosang drg from around transparent dressing. Tube feeds have remained off d/t lge residual overnight. TPN infusing-SSI tightened.\nPLAN:\n Cont to diurese with lasix gtt\n ? return to OR tomorrow for closure\n Notify H.O. of any changes\n"},{"category":"Nursing/other","chartdate":"2111-11-22 00:00:00.000","description":"Report","row_id":1595864,"text":"Resp Care\nPt remains intubated on A/C. Dropped PEEP from 12 to 8 due to improved X-ray. No other changes made.\n"},{"category":"Nursing/other","chartdate":"2111-11-23 00:00:00.000","description":"Report","row_id":1595865,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. HR-A-Fib. Temp 100.8. Sedated with fentanyl. Getting lasix.Will cont to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2111-11-23 00:00:00.000","description":"Report","row_id":1595866,"text":"D: neuro intact, anxiety @ times requires PRN ativan. minimal mov't of extremities due to fluid accumulation. VSS, low grade temps. Fluid overload, pt on lasix gtt with good u/o. No vent changes overnoc. NGT placed to wall suction and 200ml bilious drg returned. NGT left to LCWS. Oozing large am't serosang drg from around open abd wound from beneath opsite. Extra pads used to collect drg.\nA:Stable\nP:Diurese as ordered.\nEventual closure of wound in OR.\nSupport pt and family\n\n\n\n\n"},{"category":"Echo","chartdate":"2111-11-17 00:00:00.000","description":"Report","row_id":79454,"text":"PATIENT/TEST INFORMATION:\nIndication: Ascending aortic aneurysm\nHeight: (in) 65\nWeight (lb): 175\nBSA (m2): 1.87 m2\nBP (mm Hg): 91/49\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 17:28\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function.\nHyperdynamic LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter. Simple\natheroma in aortic arch. Focal calcifications in aortic arch. Focal\ncalcifications in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. Echocardiographic results were reviewed with the\nhouseofficer caring for the patient. Left pleural effusion.\n\nConclusions:\n1. The left atrium is moderately dilated. The right atrium is dilated.\n2. The left ventricular cavity size is normal. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\n3. There are simple atheroma in the aortic arch. There are focal\ncalcifications in the aortic arch.\n4. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6. No aortic aneurysm is seen.\n\n\n"},{"category":"Radiology","chartdate":"2111-11-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885650,"text":" 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pleural effusions\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n assess pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm bronchoscopy; assess\n effusions.\n\n PORTABLE AP CHEST: Comparison is made to study dated .\n Endotracheal tube, nasogastric tube, and right IJ central venous catheter\n remain in stable, satisfactory position. Assessment is limited by patient\n rotation. Allowing for this, cardiac and mediastinal contours are likely\n unchanged. The aortic knob remains indistinct. In the interval, interstitial\n edema has improved and pleural effusions have decreased in size, with\n resolution of the right pleural effusion. There is a persistent small left\n pleural effusion as well as a left lower lobe atelectasis.\n\n IMPRESSION: Resolving congestive heart failure pattern. Persistent small left\n pleural effusion and left lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2111-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885341,"text":" 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for atelectasis\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n assess for atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm and line placement status post\n bronchoscopy.\n\n PORTABLE AP CHEST: Comparison is made to study, dated .\n\n FINDINGS: Endotracheal tube, nasogastric tube, and right IJ central venous\n catheter remaining stable, satisfactory position. No new central venous\n catheters are identified. Cardiac and mediastinal contours are unchanged.\n Again, noted is interstitial edema and moderate bilateral pleural effusions.\n Dense left retrocardiac density is consistent with atelectasis and appears\n unchanged.\n\n IMPRESSION: No significant interval change in pulmonary edema, small-to-\n moderate bilateral pleural effusions and left lower lobe atelectasis.\n\n"},{"category":"Radiology","chartdate":"2111-11-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885691,"text":" 12:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p abd closure, decreased BS on L, eval tube placement and\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n s/p abd closure, decreased BS on L, eval tube placement and for pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured aneurysm and decreased breath sounds on the left.\n\n PORTABLE AP CHEST: Comparison is made to study performed 5 hours prior.\n Endotracheal tube terminates approximately 3.8 cm above the level of the\n carina. There is expansion of the tracheal contour, consistent with\n overinflation of the cuff. Right IJ central venous catheter and nasogastric\n tube remain in stable position. As before, there is atelectasis of the left\n lower lobe with associated volume loss and some shift of the heart and\n mediastinal structures. There appears to be an abrupt cutoff of the left\n lower lobe bronchus, finding consistent with obstructing mucous plug. There\n may be a small left pleural effusion. The right lung is grossly clear.\n\n IMPRESSION:\n 1. Apparent overdistention of the endotracheal tube cuff as above.\n 2. Left lower lobe collapse and abrupt occlusion of the left lower lobe\n bronchus. These findings are most consistent with an obstructing mucous plug.\n\n These findings were conveyed to Dr. at the time of interpretation.\n\n"},{"category":"Radiology","chartdate":"2111-11-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":884614,"text":" 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desat\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n\n REASON FOR THIS EXAMINATION:\n desat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with ruptured AAA and desaturation.\n\n COMPARISONS: Comparison is made to immediate postoperative radiograph from\n .\n\n TECHNIQUE: AP single view of the chest.\n\n There is an ET tube in good position. There is a Swan-Ganz catheter with the\n tip in the pulmonary artery trunk. The NG tube within the stomach. There are\n two drains into the abdomen. There are bibasilar atelectases. Left\n retrocardiac opacity could represent atelectasis Vs. consolidation Vs.\n aspiration. Severe scoliosis of the thoracic spine. The pulmonary\n vascularity is within normal limits without evidence of CHF. There are\n probable bilateral pleural effusions. There is no evidence of pneumothorax.\n The aorta is tortuous and calcified. The splenic artery is calcified. There\n are clips in the left axilla.\n\n IMPRESSION:\n 1. Bibasilar atelectases.\n 2. Left retrocardiac opacity could represent atelectasis, consolidation or\n aspiration. The shift of the mediastinum to the left suggests atelectasis.\n Clinical correlation recommended.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2111-12-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886853,"text":" 9:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, spiking fevers\n REASON FOR THIS EXAMINATION:\n eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman status post repair of ruptured AAA, now spiking\n fevers. Please assess for pneumonia.\n\n TECHNIQUE: Single AP upright portable chest radiograph was obtained.\n\n COMPARISON: Supine AP portable chest radiograph, .\n\n FINDINGS: There is an endotracheal tube with tip approximately 3 cm above the\n carina. There is a nasogastric tube with tip within the stomach. The right\n internal jugular central catheter with tip in the SVC. There is stable\n appearance of the heavily calcified thoracic aorta with unchanged appearance\n of wall thickening at the level of the aortic knob, which may represent\n chronic dissection or calcification of a thick pseudointima. Again noted are\n small bilateral pleural effusions. Overall, there has been no significant\n interval change in appearance of the chest compared to .\n\n IMPRESSION: Tubes and lines in satisfactory position. Persistent small\n bilateral pleural effusions. Overall, no significant change in appearance of\n the chest compared to .\n\n\n"},{"category":"Radiology","chartdate":"2111-11-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885867,"text":" 4:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: exchange of ETT please eval position s/p bronch\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\n maneuver\n REASON FOR THIS EXAMINATION:\n exchange of ETT please eval position s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured AAA status post OR, exchange of endotracheal tube.\n\n COMPARISON: Radiograph dated at 5:21 a.m.\n\n SINGLE AP PORTABLE SUPINE VIEW OF THE CHEST: A right internal jugular\n catheter is unchanged. An NG tube was again demonstrated with distal tip\n terminating below the diaphragm below the lower margin of this film. Anterior\n abdominal midline staples are seen at the lower margin of the film. There is\n an endotracheal tube with distal tip at the thoracic inlet. The exam is\n otherwise not significantly changed compared to the prior study.\n\n IMPRESSION: ET tube in satisfactory position with no other significant\n interval change compared to the exam of 12 hours prior.\n\n\n"},{"category":"Radiology","chartdate":"2111-11-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886214,"text":" 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: am chest xray to eval progression of lung process\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p\n recruitment maneuver\n REASON FOR THIS EXAMINATION:\n am chest xray to eval progression of lung process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:40 A.M., \n\n HISTORY: Ruptured aortic aneurysm.\n\n IMPRESSION: AP chest compared to and 20th.\n\n Left lower lobe collapse persists. Small bilateral pleural effusions are\n unchanged since while borderline pulmonary edema has improved.\n The heart is top normal size. ET tube, right internal jugular line, and\n nasogastric tube are in standard placements respectively. No pneumothorax.\n\n The thoracic aorta is heavily calcified. Thickening of the wall at the level\n of the aortic knob could be due to chronic dissection or calcification of a\n thick pseudointima, but is not changed acutely.\n\n\n"},{"category":"Radiology","chartdate":"2111-12-02 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":886572,"text":" 5:02 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval liver/gallbladder\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman w/ labile BPs and rising LFTS\n REASON FOR THIS EXAMINATION:\n eval liver/gallbladder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rising LFTs, evaluate liver and gallbladder.\n\n COMPARISON: None.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n RIGHT UPPER QUADRANT ULTRASOUND: Limited images of the liver are provided.\n The hepatic echotexture appears within normal limits. No definite masses are\n identified within the hepatic parenchyma.\n\n The gallbladder is distended and contains echogenic sludge. No definite\n shadowing gallstones are identified. There is no definite gallbladder wall\n thickening or edema. A small amount of fluid adjacent to the gallbladder on\n several images may be located within the adjacent bowel. The common hepatic\n duct is nondilated (measuring 2 mm). Visualization of the common bile duct is\n limited on the images provided from this examination, which was performed\n portably.\n\n The right kidney measures 10.9 cm. A simple cyst is seen within the\n interpolar region of the right kidney measuring 3.1 cm in diameter.\n\n Note is made of a heterogeneously echoic fluid collection in the right lower\n quadrant, which measures 12.9 x 4.5 cm.\n\n IMPRESSION:\n 1. Markedly dilated gallbladder containing sludge. No definite evidence of\n acute cholecystitis.\n\n 2. Heterogeneously echoic fluid collection in the right lower quadrant is\n incidentally noted. This measures 12.9 cm in diameter. The etiology is\n uncertain and this may be further evaluated with CT.\n\n 3. 3-cm simple cyst in the interpolar region of the right kidney.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2111-11-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885710,"text":" 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: repeat - old film rotated. upright to eval for CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n FINAL ADDENDUM\n INDICATION: Status post bronchoscopy. Repeat chest x-ray requested due to\n rotation on prior film.\n\n The patient is similarly rotated on the current film as on the previous\n studies. Various lines and tubes are unchanged in position with note again\n made of overdistention of endotracheal tube cuff. There remains collapse of\n the left lower lobe. There is increasing opacity in the left hemithorax,\n difficult to assess due to the degree of rotation, which could be due to\n partially layering pleural fluid or increasing atelectasis within the left\n lung. Within the right lung, previously noted right pleural effusion appears\n slightly smaller, possibly due to positional differences. There is minimal\n perihilar haziness in the right lung, suggesting a component of mild perihilar\n edema.\n\n\n\n\n 2:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: repeat - old film rotated. upright to eval for CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n repeat - old film rotated. upright to eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF AT 14:41.\n\n Comparison is made to previous study of approximately one hour earlier.\n\n INDICATION: Evaluate for congestive heart failure.\n\n Lines and tubes are unchanged in position with note again made of\n overdistention of the endotracheal tube cuff. Again demonstrated is left\n lower lobe collapse with abrupt cut off of the left lower lobe bronchus\n suggesting mucus plugging. There is increasing hazy opacity in the left\n hemithorax extending to the level of the lower portion of the aortic knob,\n possibly due to increasing pleural fluid on this side. There is slight\n perihilar haziness and subtle interstitial pattern in the right lung, which\n may reflect a component of interstitial edema, and there is also a probable\n small right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2111-12-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886921,"text":" 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm process\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, spiking fevers\n\n REASON FOR THIS EXAMINATION:\n eval pulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Repair ruptured AAA. Fever.\n\n AP BEDSIDE CHEST: There are bilateral moderate-sized pleural effusions with\n associated basal atelectasis. I doubt the presence of consolidations although\n this cannot be assessed in the obscured left lower lobe. Heart is probably\n not enlarged, although the aortic knob is markedly dilated and calcified. No\n vascular congestion. Tubes and catheters satisfactorily positioned.\n Appearances unchanged from similar exam one day ago ().\n\n"},{"category":"Radiology","chartdate":"2111-11-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885768,"text":" 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of collapse, need for bronch\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure.\n\n REASON FOR THIS EXAMINATION:\n question of collapse, need for bronch\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:21 A.M. ON :\n\n HISTORY: Ruptured aneurysm. Possible lobar collapse and the need for\n bronchoscopy.\n\n IMPRESSION: AP chest compared to and 19, :\n\n Left lower lobe remains collapsed, although volume loss indicated by leftward\n mediastinal shift is not quite as severe as it was on . Right lung\n volume is lower and new opacification in the right lower lung is concerning\n for either atelectasis or new pneumonia while mild interstitial edema is more\n pronounced and small bilateral pleural effusions have increased. ET tube,\n nasogastric tube, and a right internal jugular line are in standard placements\n respectively. There is no pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2111-12-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887215,"text":" 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrates, CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, tachypnic\n REASON FOR THIS EXAMINATION:\n eval infiltrates, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachypneic, evaluate infiltrate, CHF.\n\n CHEST, SINGLE AP VIEW.\n\n There is cardiomegaly, with a calcified, unfolded aorta. Parenchymal detail\n is difficult to assess due to overpenetration. In particular, it is difficult\n to assess for CHF. There is probable upper zone redistribution, without\n interstitial edema. There is increased retrocardiac opacity consistent with\n left lower lobe collapse and/or consolidation and a small left effusion. There\n is patchy opacity at the right base. Compared with , this appearance\n is probably unchanged. There has been interval removal of the ET tube. A\n right IJ central line is present, tip over distal SVC, unchanged.\n\n"},{"category":"Radiology","chartdate":"2111-11-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":885167,"text":" 1:04 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt\n REASON FOR THIS EXAMINATION:\n eval line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: new line placement.\n\n FINDINGS: Single radiograph of the chest reveals moderate right pleural\n effusion. Left hemithorax opacity with mediastinal shift which could be due\n to positioning of the patient partially as well as volume loss. Subsequent\n radiograph taken on same day, , at 4:25 PM shows aerated left\n lung. The tubes are in satisfactory position.\n\n IMPRESSION: Moderate right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2111-11-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":884344,"text":" 9:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia, vol overload\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n REASON FOR THIS EXAMINATION:\n pneumonia, vol overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST , WITH NO PRIOR FILMS FOR COMPARISON.\n\n INDICATION: Ruptured AAA.\n\n An endotracheal tube terminates approximately 1.5 cm above the carina. A\n nasogastric tube terminates in the stomach, and a Swan-Ganz catheter\n terminates in the distal right pulmonary artery. There is no pneumothorax.\n\n There is widening of the mediastinum in the region of the aortic arch. The\n cardiac silhouette is upper limits of normal in size allowing for rotation and\n portable technique. There is bilateral perihilar haziness, and there are\n several septal lines within the lung periphery. Patchy opacities are noted in\n both lower lung zones and may relate to patchy atelectasis or aspiration.\n Small pleural effusions are present, blunting the left costophrenic sulcus and\n thickening the right minor fissure. Note is made of apparent left mastectomy\n and axillary lymph node dissection.\n\n IMPRESSION:\n 1. Low position of endotracheal tube, which could be withdrawn 1 to 2 cm for\n more optimal placement.\n 2. Widened mediastinum in region of aortic knob, which may be related to\n tortuosity and/or dilation of the structure.\n 3. Interstitial pulmonary edema.\n 4. Patchy bibasilar atelectasis versus aspiration.\n\n"},{"category":"Radiology","chartdate":"2111-11-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":885144,"text":" 9:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CVL placement\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n\n REASON FOR THIS EXAMINATION:\n CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ruptured abdominal aortic aneurysm.\n\n Single portable chest radiograph demonstrates no change in the\n cardiomediastinal silhouette when compared to . Endotracheal tube\n is present with its tip at the clavicular heads. Right internal jugular\n central venous catheter is present with its tip in the SVC. Nasogastric tube\n is seen to course through the stomach and off the inferior aspect of the\n imaged field of view. There are small-to-moderate bilateral pleural\n effusions. The plate-like atelectasis in the right lower lung seen on the\n previous study has markedly improved. Assessment is slightly limited by\n patient positioning. There is dextroscoliosis of the thoracic spine. The\n aorta is calcified. Surgical clips project over the left axilla. The right\n internal jugular Swan-Ganz catheter has been removed.\n\n IMPRESSION:\n\n Small-to-moderate bilateral pleural effusions.\n\n Interval improvement in right mid lung atelectasis.\n\n Support lines as described.\n\n"},{"category":"Radiology","chartdate":"2111-11-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885190,"text":" 3:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 80 yo female sp broncoscopy\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt\n\n REASON FOR THIS EXAMINATION:\n 80 yo female sp broncoscopy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ruptured abdominal aortic aneurysm.\n\n Single portable chest radiogram demonstrates an endotracheal tube with its tip\n at the clavicular head. A nasogastric tube courses through the stomach and\n below the inferior aspect of the imaged field of view. A right internal\n jugular central venous catheter is present with its tip in the superior vena\n cava. There is again evidence of volume loss in the left, although this is\n markedly improved when compared to the chest radiograph obtained three hours\n prior. Again seen are mild-to-moderate bilateral pleural effusions.\n Prominent vascular markings in the right lung likely represents mild fluid\n overload. Degenerative changes are present throughout the thoracic spine.\n\n Surgical clips project over the left axilla.\n\n IMPRESSION:\n\n Small-to-moderate bilateral pleural effusions, unchanged.\n\n Interval improvement of left-sided atelectasis and volume loss.\n\n Support lines as described.\n\n\n"},{"category":"Radiology","chartdate":"2111-11-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":885742,"text":" 8:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess left lower lobe collapse, please perform x-ray at 9pm\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\n maneuver\n REASON FOR THIS EXAMINATION:\n assess left lower lobe collapse, please perform x-ray at 9pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm, now with persistent left\n lower lobe collapse.\n\n PORTABLE AP CHEST: Comparison is made to study performed seven hours prior.\n There has been no interval change in the appearance of the chest. Endotracheal\n tube, nasogastric tube, and right IJ central venous catheter remain in stable\n position. Again, demonstrated is left lower lobe collapse with volume loss\n and shift of the heart and mediastinal structures. Interstitial edema has\n improved in the interval. There are persistent small bilateral pleural\n effusions.\n\n IMPRESSION: Persistent left lower lobe collapse, likely due to mucous\n plugging. Improving interstitial edema.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595844,\n \"text\": \"neuro: Pt remains sedated on propofol and fentanyl. Opens eyes to pain, unable to follow any directions. Appear to have abd/incisional pain with turning and repositioning.\\nCV: low grade temp 100.4, HR 100-120's Afib with transient episodes of PVC's, Lytes repleated with noted improvement in ectopy. SBP 80-120's, Unable to wean off dobutamine. CVP 11-15, PAP 40's/20's. PAWP 19-20. CO , CO . Requiring significant amounts of fluid bolus' for continued hypotension. HCT 23.8, treated with 2u PRBC's\\nRESP: lungs clear to dim at bases, No vent changes overnight. O2 sats >95%. Occasional suctioning of thin white secretions.\\nGI: abd open with absent BS. NGT draining mod amounts of bilious drg.\\nGU: foley draining 10-15cc of amber urine.\\nENDO: blood sugars labile.\\nPLAN: Cont to wean dobutamine. Assess CO and PAWP and need for continued fluid bolus'. Monitor pain and effectiveness of fentanyl gtt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595850,\n \"text\": \"Abd wound washing/dressing to be done in AM MD.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595851,\n \"text\": \"Resp Care,\\nPt. remains intubated on A/C overnoc. No vent changes this shift, ABG acceptable. Attempted RSBI, apnea. Maintain current vent settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595872,\n \"text\": \"Respiratory Care:\\n\\nPatient intubated on mechanical support. Vent settings Vt 450, A/c 14, Fio2 40%, and Peep 5. Bs clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 34. Abg this am reveals metabolic alkalosis. Plan: Pt. to return to OR for closure of Abd. Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595873,\n \"text\": \"Events:\\n\\nPt To OR for abd closure with mesh return to ICU neo for SBP 90, fluid boluses x2 for SBP and low CVP with good response, Sao2 drop 93, sx for thick yellow, Left upper lung grossly dim bronchial BS, CXR done atelectasis, L plueral effusion\\n\\nNeuro-sedated on Prop, fent gtt Right PERLA, left glass eye, MAEW\\nCV-MP AFib neo gtt weaned to off, will restart lopressor when SBP stable, lasix drip d/c, generalized anasarca, cool extrem x4\\nResp-AC rate 16, 60%, TV500, vent wean as tolerated\\nFEN-TPN, BS covered with SS insulin, TF held, absent BS, NGT to Liwsx drg bilious green\\nU/O >40cc/hr\\nID-cont on ABX\\nFamily-daughter , request aggressive attempts to wean from ventilator, reassurance given to daughter and all questions answered\\n and fentanyl overnight, wean prop in AM, and plan for vent wean, monitor ABG, CBC, and lytes, cont ABX, TPN, prophylaxis protonix\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595874,\n \"text\": \"Pt came back from OR on 100% O2. Chest Xray showed Left lung to be largely out with only LUL aerated. Pt sxed for a mod-lg amt. very thick yellow sputum (no plugs noted). Recruetment manuver used to try and open lung.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595845,\n \"text\": \",rrt\\npt. tolerating current settings reasonably well, fio2 increased to .60 following am abg due to low pa02, b/l b.s. diminished/slight coarse, sx'ing minimal #'s tan thick/moist sputum, sats remained mid 90's with few drops to high 80's/low 90's, plan to do rsbi this am, will monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595846,\n \"text\": \"See carevue for objective data.\\n\\nRemains sedated on proprofol/fentanyl gtts. No change in vent settings. Minimal secretions. ETT rotated. PCXR done this PM.\\nHad an episiode of hypotension to systolic of 60's with turning to the right this AM requiring initiation of levophed. Dobutamine dc'd.\\nSee flowsheet for CO/CI/SVR data. Bedside TEE done. Ventricles under filled-no thrombus/aneurysm MD. PCWP:15-10 CVP: \\nMinimal urine output-team aware. PM lytes pending.\\nJP's draining large amount of bloody drainage-2L this shift.HCT OK.\\nHIT antibody sent for plts<100.\\nAbd wound remains open and dressing intact.\\n\\nFamily in and updated on POC. Support provided.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595847,\n \"text\": \",rrt\\nno changes made, sats in the high 90's t/o shift, sx'd min tan secretions,b/l b.s. decreased, plan for rsbi in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595906,\n \"text\": \"Addendum to NPN:\\nPt's tongue w/ thrush; Nystatin oral suspension applied on tongue w/ swabs. Red rash under bilat arms/breasts and groin; miconazole powder applied. Cont to monitor rash.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595907,\n \"text\": \" 19/07\\n NEURO A/O TALKS AROUND TUBE SEEMS TO UNDERSTAND AND HELPS WITH CARE GIVEN PAIN CONTROL WITH FENT DRIP PERIODS OF AGITATION ABLE TO BE TALKED DOWN OPENLY WANTS ETT OUT AND TO GO HOME\\n RESP ETT CPAP 15/5 TOL WELL RSBI 87 IMPROVING TV 450 TO 500 SCANT SPUTUM RHONCHI THRUOUT CLEARS AFTER SUCTIONING\\n HEART AF RATES 80 TO M MITRIAL AREA SYS POOR PULSES THRU OUT POS NVD WITH MILD HJR\\n ABD DRESSING IN PLACE FOLEY CATH NO B/S\\n PLAN WEAN VENT REMOVE TUBE GIVE EMOTIONAL SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595908,\n \"text\": \"Respiratory Care\\nPt.remains stable on PSV.no changes overnight.RSBI-88,abg's wnl.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595909,\n \"text\": \"Nursing care note\\nSee careview for specifics.\\nSignificant event: Pt extubated at 1400 hours. Placed in 50% FM. O2 sats have remained 99-100%. No resp. distress. Encouraging C&DB.\\n\\nNeuro: Awake, oriented to person & place. Moves all extremities. Follows commands. Difficult to move BLE's d/t edema. Right pupil equal and reactive. Denies pain.\\n\\nResp: Lungs clear at the upper lobes bilat. Diminished bibasilar. Coughing/expectorating thick white sputum. RR 28-35.\\n\\nCV: Afebrile. Afib rate controlled. BP stable. All 4 extremities warm with palpable pulses.\\n\\nGI: Abdomen obese with positive BS. Rec's Impact with fiber at goal rate of 80cc/hr. Stooling. Cdif sent.\\n\\nGU: Diuresing. Lasix given to help mobilize fluid.\\n\\nSkin: Midline abdominal staples intact. Note small amount of eschar at mid pole. No drainage.\\n\\nPlan: Pulmonary toilet. Enc C&DB. OOB to recliner tomorrow if tolerates extubation. Provide support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595910,\n \"text\": \"Pt & abg showed improvment today with some reduction in sputum noted. She was extubated @ about 1400pm today. She has a good productive and moist cough plan to continue Deep Breathing & coughing with pt\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595852,\n \"text\": \"Condition Update\\nD: See carevue flowsheet for specifics\\n Patient afebrile and HR remains in afib with improved rate control ~80's very little ectopy noted overnight. Swan required re-floating x2 in order to obtain PCWP. Wedge 17-19. CVP 10-13. CI and CO running low even after 1U PRBC-may need to give more fluid or start nitro gtt. Patient making marginal amts of urine.\\n Transplant team in at beginning of shift to remove packing from abd and re-explore belly. No ischemic bowel noted (during procedure pt was sedated with ppf and fentanyl gtts BP tolerated well did not require any pressors). JP's not draining as much as over the past couple of days but still dilute sanginous drg. Amino Acids started for nutrition.\\n No vent changes made overnight. AM ABG unchanged from previous abg with paO2 80's. Min amt of secretions. Pt remains on fent gtt for comfort. Opens eyes and will open mouth on command but not nodding to questions or moving extremeties on command.\\nPLAN:\\n ? get cardiology on board\\n ?fluid vs nitro gtt\\n Return to OR ? on Fri for closure (per Dr. \\n Fent gtt for comfort\\n Notify H.O. with any changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595853,\n \"text\": \"CONDITION UPDATE\\nVSS. AFEBRILE. REMAINS IN AFIB RATE CONTROLLED. CO/CI CONT TO BE LOW - SICU TEAM AND ATTENDING DR AWARE. UNABLE TO WEDGE SWAN - SICU TEAM AWARE. MAJORITY OF SHIFT PT ALERT. FOLLOWING SIMPLE COMMANDS. REMAINS ON FENT DRIP APPEARS TO HAVE GOOD PAIN MANAGEMENT. LUNGS COARSE THROUGHOUT. MIN SUCTIONING FOR THICK, TAN SPUTUM. ABD REMAINS OPEN. TRANSPARENT DRESSING INTACT. JP'S TO WALL SUCTION - LG AMT OF S/S DRAINAGE OUT. STARTED ON TPN. U/O QS VIA FOLEY. DIURESED W/ 10MG OF LASIX MD'S ORDERS W/ SM EFFECT. SOCIAL WORKEER IN AND SPOKE W/ FAMILY.\\nCONT TO MONITOR FOR S/S OF BLEEDING. PAIN MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595854,\n \"text\": \"Respiratory Therapy\\n\\nPt remains orally intubated on full mechanical support. No vent changes made overnoc. Currently on A/C ventilation w/ PIP/Pplat = 26/20. BLBS slightly diminished, suctioned for small amounts of thick white secretions. SpO2 remained 90s. ETT secure/patent & in good position. No RSBI d/t apnea. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595892,\n \"text\": \"Respiratory Care\\nPt continues to be orally intubated and mechanically ventilated at this time. Currently on PSV 10/5/.50 with tidal volumes 350-500ccs and resp rate 15-30. BS: clear bilaterally. Suctioned for small amts of thick white secretions. Discussion with family about trach/peg today. Plan to attemp rsbi in am and possible extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595911,\n \"text\": \" 19/07\\n NEURO A/O RELAXED TALKATIVE MAE IN GOOD SPIRITS\\n RESP FM TOL WELL MOBILIZING OWN SPUTUM CLEAR LUNGS\\n HEART AF TOL WELL VSS PULSES POS 3 THRU OUT NVD REMAINS CVP WNL LASIX TO MOTIVATE FLUID SHIFT TOL WELL\\n GI POS B/S STOOLING TOL T/F WELL ABD DRESSING IN PLACE D/I\\n PLAN PROGRESSIVE AMBULATION P/T FAMILY SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595912,\n \"text\": \"Nursing care note\\nSee careview for specifics\\nNeuro: PERL Oriented x3. Follows commands. OOB to recliner. Tolerated well. Denies pain.\\nResp: O2 sats 92-98% on 50% FT. Chest PT done. Expectorating thin white sputum. Lungs CTAB.\\nCV: Afebrile. VSS. Afib-rate controlled.\\nGI: Abdomen softly distended. TOlerating TF's at goal rate of 80cc/hour. Liquid stool ? decreasing.\\nGU: Foley to gravity. Lasix dose given as ordered. Diuresing well.\\nLabs: Hct stable. Glucoses marginally elevated. Covered with RISS in addition to NPH.\\nSocial: Family at the bedside.\\nPlan: ?transfer to floor tomorrow. Aggressive pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595918,\n \"text\": \"SICU B NPN:\\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain but complaining of \\\"stiff legs.\\\" Moving all extremities UE>LE.\\nCV: Afeb. HR 80s-90s AF, no ectopy noted. BP stable via NIBP. 3+ edema to extremities. Palpable pedal pulses. CVP 4-6. R IJ TLC line intact with slight redness noted around insertion site, no swelling or drainage noted.\\nRESP: On 4L NC with O2 Sat >92% but did desaturate to 87-88 x2 overnight- chest PT given with good results both times. Encouraged to cough and deep breathe and using Yankar to clear secretions. RR 20s-30s. LS coarse and diminished at bases.\\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with small amts of loose brown stool draining. Taking pills without difficulty. No NPH insulin given at 2200 due to pt. not eating much and glucose on previous night dipped very low after receiving NPH. Dr. aware. Foley with clear yellow urine >40cc/hr.\\nSKIN: Abd. incision site C/D/I with staples, no swelling or drainage. Dsg changed with small amt of serosang. drainage on old dsg. Yeast rash to groin and folds- miconazole powder to affected areas.\\nPlan to transfer to VICU when bed avail.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595919,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFICS\\nCONTINUES TO IMPROVE, AWAITING VICU BED,\\nOOB TO CHAIR, TOLERATED WELL. NEEDS AGGRESSIVE PT AS LOWER EXTREMITIES ARE VERY WEAK.\\nTOLERATING DIET, YET APPETIT POOR, ENCOURAGED TO TAKE POS AND ENRICHED WITH BOOST.\\nCENTRAL LINE OUT, PHERIPHERAL IV PLACED.\\nFAMILY SUPPORTIVE.\\n REHAB SCREEN.\\nWILL CALL WITH ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595920,\n \"text\": \"SICU B NPN:\\nNEURO: A&Ox3 with periods of slight disorientation overnight but easily reoriented. MAE x4. Denies pain. R pupil 3mm and brisk. Given 1mg ativan for sleep but did not sleep all night.\\nCV: Afeb. HR AF, no ectopy noted. BP stable. Skin warm and dry with weak but palpable pedal pulses bilaterally. 2+ LE edema. Started on warfarin 5mg po. Repleted with KCL po and MGSO4 IV.\\nRESP: Weaned to 3L O2 with O2 Sat >92%. LS clear/coarse and diminished at bases. Intermitent non-productive cough. RR 20s-30s.\\nGI/GU: Abd. softly distended with positive bowel sounds. Having continous loose stools in small amts, brown. Foley with clear yellow urine- continues on lasix.\\nSKIN: Abd. incision with staples C/D/I- old dried blood around staples and area cleaned and dsg changed. Red yeast rash/excoriation to groin and buttocks area- barrier cream applied with miconazole powder.\\nOTHER: Daughter to come in this am to visit. Pt. ready to transfer to floor when bed avail. Plan to get OOB to chair this am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595893,\n \"text\": \"NEURO; MAE, FOLLOWS COMMANDS, NODS APPROPRIATELY AND OCCAS MOUTHES WORDS, A&O TO PERSON, OCCAS WRITES NOTES\\n\\nCARDIOVASCULAR; HR 80'S-90'S A FIB, A LINE RT RADIAL WAVEFORM COMPLETELY DAMPENED, REMOVED AFTER NEW ALINE PLACED LEFT RADIAL, SYS 110-130'S, OCCAS DOWN TO 90'S, LASIX GTT PRESENTLY AT 5 MGM/HR, (GOAL IS 2 L/NEG IN 24 HRS AND PT IS > 1600 CC NEG THIS SHIFT), K LOW -REPLETED WITH 40 MEQ THIS PM, SHOULD RE-EVALUATE TONOC, MAG LEVEL 1.7-REPLETED, TEMP 99.0, REMAINS WITH EDEMA OF ALL EXTREMITIES, PULSES DOPPLERABLE BOTH FEET\\nCVP 5-13\\n\\nRESPIR; LUNGS CLEAR THIS SHIFT, SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW SECRETIONS, 02 SAT 98-100%, REMAINS ON SAME VENT SETTINGS,\\n\\nGI; TUBE FEEDS AT GOAL (80C/HR), OFF FOR ONE HR FOR RESIDUALS > 60CC\\n\\nENDOCRINE; BS 173 THIS AM, SLIDING SCALE TIGHTENED, PM BS 117-123\\n\\nWOUND; ABD INCISION SEEN BY VASCULAR TODAY, SMALL NECROTIC AREA LOWER INCISION, SCANT SERO-SANGE DGE, DSD APPLIED, JP MINIMAL DGE, ? REMOVING TOMORROW\\n\\nPLAN;PULMONARY SUPPORT,? ATTEMPTING EXTUBATION, TRACH OPTION DISCUSSED BY SICU ATTENDING WITH PT AND DAUGHTER AND PT NODDED POSITIVELY TO CONSENTING TO PROCEDURE, WILL BE DISCUSSED FURTHER, ? FAMILY MEETING, SOCIAL WORKER IN WITH DAUGHTER AND UPDATED\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595894,\n \"text\": \"Respiratory Care Note:\\n Patient on PSV of overnight. RSBI this am =108. BS= bilat, decreased slightly over L lung. Suctioned for thick whitish sputum. ET resecured at 19-20 cm by lip after reviewing CXR. See Carevue flowsheet for specifics. Plan to maintain at this time due to tachypnea with RSBI.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595895,\n \"text\": \"cv:hr afib 88-109 . pt received lopressor dose at 2400 hr was 109 at the time and rate decreased to 80's after med.sbp decreased to 88 with mean in 50's requiring neo for ~ 3 hours. neo off at 2330. lasix drip off . pt is 2000cc negative for past 24 hours. fentanyl off for a few hours secondary to hypotension but pt became a bit agiated and nodding \\\"yes \\\" when questioned about pain so fentnyl restarted at 20 mics/ with good effect.\\n\\ngu: diuresed with lasix drip. 2000cc negative at 2400(goal) lasix drip off secondary to hypotension.\\n\\ngi: several large liquid stools, fecal bag placed.tolerating tube feed at goal Impact with fiber at 80 cc/hr.\\n\\nintegumentary: generalized edema.perinium red rash..nistatin powder ordered and applied. tongue has thrush nilstatin applied.JP # 1 d.c'd\\n# 2 draining serous fluid very small amount.incision is approximated. staples. sm areas of reddnesss along incisional line.\\n\\nneuro: left eye open at all times. It is a prosthetic eye. pt opens r eye spontaneously and to command. nods appropriately.\\n\\nresp: cpap 50 % peep 5,ps 10 see careview for abg.o2 sats 98-100%. sx for thick yellow q 2-4 hours.breath sounds decreased l base .after retaping et tube tube breath sounds clear bilateral.\\n\\nnote: gall bladder us done at 0600. levothyroxine restarted. Tsh elevated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595867,\n \"text\": \"Neuro: pt is alert MAE slightly on bed very edemitious. R pupil reactive L eye glass.\\n\\nPain: on 100mcg of fentanyl . Pt comfortable at rest.\\n\\nCV: AF 80-90's SBP 105-150 up to high of 170 when turned. Palp DP/PT. Pheripheral Edema +3. CVP 8-13.\\n\\nLungs: AC changed to CPAP at 1500 tolerating well at present. lungs coarse to slightly decreased in bases. upper lobes slighty clearer this PM.\\n\\nGI: ABD open and packed. NG LWS clamped then TF started at 1400 impact with fiber STR @ 10. BS hypoactive.\\n\\nGU: Foley to gravity. On 8mg lasix drip. goal to be negative by 2liters. currently > 1400.\\n\\nSkin: pt without pressure sores. ABD open dsg done by surgical team. TWO Jp\\\"s to suction slightly bloody drainage moderate amt.\\n\\nA Stable\\nP monitor output closely maintain goal of 2 liters negative. monitor labs repleat lytes as indicated. send ABG on CPAP support resp as indicated. possible wound closure on thursday. skin and wound care as indicated. Adance TF as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595868,\n \"text\": \"RESP CARE: Pt remains intubated/on vent on 16 PS all shiftSEE CAREVUE. Lungs coarse with wheezes. Sxd thick yellow/white sputum. RSBI-148.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595869,\n \"text\": \"NURSING UPDATE\\nCV:\\n TMAX 100 PO. REMAINS IN AFIB. HR UP TO 130 AND HTN 170'S WHEN ANXIOUS/UNDERSEDATED, SETTLES WITH HR 80-90'S AND SBP 95-120 WHEN COMFORTABLE. DIURESING ON LASIX GTTS. FLUID BALANCE DOWN 1800CC YESTERDAY BUT WEIGHT DOWN 5KG, PT OOZING LARGE AMOUNT OF FLUID INTO BED. FENTANYL GTTS MAINTAINING ADEQUATE LEVEL OF PAIN RELIEF AND SEDATION.\\n\\nGI:\\n TROPHIC TUBE FEEDS @ 10CC/H UNTIL 4AM, STOPPED PER REQUEST OF DR , PT POSSIBLY RETURN TO O.R. TODAY FOR CLOSURE OF INCISION, BUT PLAN REMAINS UNCLEAR AT THIS TIME. NUTRITION ALSO MAINTAINED WITH TPN. BOWEL SOUNDS HYPOACTIVE, NO BM. ABDOMEN OPEN LEAKING LARGE AMOUNT OF SEROUS FLUID BENEATH DRESSING, AND 150CC VIA JP'S TO LWS.\\n\\nPLAN:\\n CLOSURE OF INCISION, DATE/TIME YET TO BE CONFIRMED BY DR .\\n CONT TO DIURESE AS TOLERATED, STILL EDEMATOUS AND 20L POSITIVE LOS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595870,\n \"text\": \"STATUS UPDATE\\nDATA- SEE CAREVIEW FOR DETAILS\\nN-ALERT RIGHT PUPIL REACTIVE TO LIGHT. MOVING ALL EXTREMITIES ON BED. ABLE TO FOLLOW COMANDS, IS ABLE TO NOD HEAD YES OR NO TO DIRECT QUESTIONS. ON FENTANYL FOR PAIN WITH GOOD EFFECT. ATIVAN 1 MG GIVEN DURING ET TUBE REPOSITIONING FOR ANXIETY WITH GOOD EFFECT.\\n\\n\\nCV- A-FIB MOST OF SHIFT 90S-130'S WITHOUT ECTOPY SBP 100'S-130'S CVP 8-12. PERIPHERAL EDEMA + GOOD PALPABLE PULSES.\\n\\nRESP-CHANGED TO AC- FI02 40% 450 X 14WITH 8 OF PEEP\\nSUCTIONED FOR SMALL AMOUNTS THICK WHITE SECRETIONS. LUNGS SOUNDS COARSE.NO VENT CHANGES OVERNIGHT.\\n\\nGI/GU- ABD OPEN- TRANSPARENT DRESSING DRAINAGE REINFORCED TIMES TWO- DRAINING SERO-SANG DRAINAGE.TWO JP DRAING TO LWS SERO-SANG DRAIAGE.\\n TROPHIC TUBE FEEDS RESTARTED 5PM AT 10CC/HOUR. TPN AT 74 CC/HOUR.\\nPATIENT TO HAVE SURGERY THIS10/29- ? WHEN TO START NPO.\\n\\nFOLEY TO GRAVITY DRAING LARGE AMOUNTS CLEAR YELLOW DRAINAGE. BUN 30 LASIX GTT DOWN TO 6MG/HOUR. NOW -1400\\n\\n\\nPOC- CONTINUE TO MONITOR DIURESEIS,PAIN CONTROLL. PLAN-- OR IN AM TO CLOSE ABDOMEN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595840,\n \"text\": \"Pt arrived from OR at 2100, S/P AAA repair.\\nNeuro: Sedated on propofol. R pupil 3mm brisk. L artificial. MAE when sedation off for neuro exam. Appears to respond to name but unable to follow any directions.\\nCV: Initially on arrival Temp 91.2, bare hugger on and present Temp 95.9. HR 60-80's afib with occasional to frequent PVC's. Arrived on NEO for hypotension. Noted to be having increasing PVC's, labile pressures. CO=1.7. Dr. aware and started pt on dobutamine, noted improvement in SBP, CO 4, SVR 1600 from 2300. Attempting to wean neo. Extremities increasingly warm with bare hugger. Dopplerable pulses DP & PT, femoral pulses palpable.\\nRESP: Several vent changes presently on AC, 550X14 peep 5, FIO2 50%. ABG much improved since admission.\\nGI: abd open, JP draining large amounts of bloody drg.\\nGU: foley draining just adequate amounts of clear yellow urine.\\nENDO: blood sugars elevated, Treated with humalog insulin.\\nPLAN: Attempt to wean neo, Frequent CO and assess tolerance of dobuamine, Frequent labs check for bleeding.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595841,\n \"text\": \"Respiratory Care\\nPt.continues on full vent.support t/o shift.Labile b/p at times.Vent.changes made as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595842,\n \"text\": \"Pt had periods of of hypoxia this shift and PEEP was therefore increased from 5 to 8. Her vent settings were also changed to bring them closer to ARDSnet protocol. Plan is to keep her sedated to prevent abdominal breathing at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595887,\n \"text\": \"FULL CODE Universal Precautions Allergy: Percocet\\n\\n\\nNeuro: Awake, alert, nodding approp and mouthing words; becoming frustrated and angry w/ her son - mouthing \\\"take me home\\\", \\\"take out the tube (ETT)\\\", moving her hands to the tubes (unrestrained while family was at the bedside). Following commands, MAEx4 spont/command. R pupil 3mm/brisk.\\n\\nCV: HR=90-110s, afib, no ectopy. BP ranges from 100-150s/50-60s. +periph pulses, +edema, extrems warm. CVP=. Lopressor increased from 50mg to TID.\\n\\nResp: CAPA/PS 50%. Pt very adamant about getting the tube out. She was diaphoretic as she was working herself up. Repeatedly explained the weaning to her and since the hope is to extubate tomorrow, she was placed on CPAP/PS 5/5, but she continued to be agitated w/ RR=30, HR 110s, BP 180/. Med w/ ativan 2mg and she relaxed, but resp status did not improve - it worsened w/ 02sat down to 87%, RR remained hi 20s; RSBI 80s. ABG obtained just before placing her back on CPAP/PS - 7.48/40/43/31/5/84%. On now and RR remains 26-27, 02sat 95-100%, HR to 90s. Lungs fairly clear bilat, sx minimal tan secretions via ETT. CXR ordered for am. Lasix 20mg ordered - goal is 2L neg.\\n\\nGI/GU: abd firm/distended, +BS, +flatus. Attempted to use bedpan w/ no success. TF FS Impact w/ fiber at 80cc/hr (goal). Foley cath w/ amber urine - lasix 20mg ivp given this am and is now order. Goal is to be 2L neg.\\n\\nAccess: RIJ TLC, R rad a-line (positional).\\n\\nID: T=100.4 oral, all antibx d/c'd yesterday\\n\\nEndo: FS covered w/ RISS\\n\\nSkin: Abd incision pink w/ necrotic areas as previously noted. JPx2 w/ serous drainage.\\n\\nSocial: Family in to visit - updated on pt's status.\\n\\nPlan: Wean as tol. Lasix . Increase lopressor as ordered. Support family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595888,\n \"text\": \"Pt became very agitated with ETT today. Attempt made to wean pt's PEEP and PSV today but SpO2 and PaO2 dropped, pt sx'd for a moderate amount of thick secretions by RN, plan is to attempt more weaning tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595889,\n \"text\": \"respiratory Care\\nNo vent. changes overnight with stable resp.status.abg's adequate.Rsbi improving to 94 this am.Plan:continue to evaluate for extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595890,\n \"text\": \"CONDITION UPDATE\\n\\\\D. LOW GRADE TEMP AND SLIGHTLY DIAPHORETIC MUCH OF THE TIME.DR. AWARE.SR 90'S TO LOW 100'S REQUIRING INCREASE IN LOPRESSOR. BP STABLE 109-130/60-70.O2 SAT=99-100\\n DESPITE IMPROVED OXYGENATION WITH DECREASE IN IPS=8,DECISION BY DR. TO DIURESE TODAY MORE VIGOROUSLY WITH LASIX DRIP WAS STARTED THIS PM. DIAMOX WAS ADDED TO OFFSET ALREADY SL ELEVATED TCO2. CVP STARTED 12 AND HAS DECREASED TO 7 WITH HUO=200ML.\\n BY 1800 C-PAP WAS DECREASED TO 5 WITH IPS-8. AWAIT REPEAT ABG'S.SXED FOR SM TO MOD AMT WHITE THICK SECRETIONS FOR WHICH PT WAS STARED ON ROBITUSSIN TO BREAK-UP MORE OF THE ? CONSOLIDATION IN TH LLL PER SICU TEAM.\\n DUE TO PT'S FRUSTRATION THAT LEADS TO ANXIETY AT TIMES,PT WAS STARTED ON ANTIANXIETY MED. FENTANYL WAS ALSO WEANED SLIGHTLY TODAY DUE TO PT'S DENIAL OF INCISIONAL PAIN EVEN WITH TURNING IN BED . PT CURRENTLY IS ON 30MCQ OF FENTANYL AND DENIES PAIN.PT IS ALERT AND AWAKE COMMUNICATING BY FORMING WORDS WITH HER LIPS.\\n PT APPEARS TO BE TOLERATING TF EVEN WITH HYPOACTIVE BOWEL SOUNDS. ABD APPEARS DISTENDED FOR WHICH SHE WAS GIVEN A SUPPOSITORY AND HAD SM AMT OF LIQUID AND FORMED STOOL.? NEED FOR ANOTHER SUPP. TOMORROW.\\n ABD INCISION INTACT WITH SM AREAS OF ? ECCYMOSIS THAT DRAINED A VERY SMALL AMT OF OLD BLOOD.\\n DAUGHTER IN.LESS ANXIETY OVER HER MOM TODAY BECAUSE HER MOM APPEARS TO BE LESS ANXIOUS.UPDATE TO FAMILY WAS GIVEN\\nA.MONITOR VS CLOSELY. IF PT IS DIURESED TOO QUICKLY AND DUE TO INCREASE IN LOPRESSOR DOSE,PT COULD HAVE A HYPOTENSIVE EPISODE.\\n CHECK ABG ON C-PAP5 AND 8 IPS..? INCREASE IN VENT SETTINGS FOR OVERNITE.GOAL= TO BE NEG 1-2 LITERS IN THIS 24HR PERIOD.\\nR.CONDITION IMPROVING\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595891,\n \"text\": \"Condition Update B:\\nPlease refer to creview and remarks for details.\\n\\nPt wide awake until 0400 after 50mcg bolus of fentanyl. Pt pleasant, copperative. Communicating via mouthing appropriately. OD 3mm and brisk reactive. OS with false eye intact. Daughter taking care of oer nsg report. Pt denies c/o pain/discomfort on fentanyl gtt.\\n\\nTmax 100.7, cuurently 99.2 po. Aline flat waveform, unable ot draw back from. Discussed with Dr. at . Following NIBP. While asleep SBP down to 90. HR down from 90's to 80's rate controlled afib. CVP down to 5-6. Cont wiht generalized 3+ pit edema.\\n\\nLS clear to coarse. Suctioned for thick white secretions. Vent rested over night as RR 35-40, and LS CTA. Discussed with Dr, . Vent changed to CPAP and PS on 50%. Morning ABG 7.46 42 79 31 5.Pox 98-100%.\\n\\nPt neg 850cc at MN. Titrated lasix gtt up, neg 500cc at 0500. CVP 10->5. Tol TF at goal minmal residuals. Abd soft distended. BS present. Med formed BM x one on evening shift. Treating gluose levels per RISS.\\n\\nNystatin S&S applied to tongue for thrush. Abd inc D&I with erythema and a few small blister/hematoma. JP's with seroserosang output.\\n\\nPLAN: Cont vent wean as pt tol. Titrate insulin gtt to assist with Goal 1-2L neg by MN. Culture pt for temp spike. Nystatin for thrush. Monitor skin. Call H.O. for changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595843,\n \"text\": \"CONDITION UPDATE\\nD.TEMP SLOWLY INCREASED THRU THE COURSE OF THE DAY.AF RATE 90'S TO LOW 100'S WITHOUT ECTOPY ON DOBUTAMINE 6MCQ MOST OF THE DAY. PT HAD ALSO RECEIVED 2 PC FOR HCT OF 24.MAINTANENCE FLUID REMAINED AT 150ML/HR.PCWP20,CO-4.98 AND PA=40/23. REPEAT HCT-27. HUO 18-24.\\n DESPITE STABLE HCT THIS PM,SBP DROPPED TO 80'D AND PAS TO 30'S.FLUID BOLUS GIVEN WITH IMMEDIATE RESPONSE.REPEAT HCT AT THIS TIME INCREASED TO 28.WHILE VOLUME INFUSING SBP REMAINS ELEVATED DR. AWARE OF ABOVE.HUO CONTINUES TO DECREASE TO 15MLDESPITE MULTIPLE FLUID BOLUSES.DOBUTAMINE WEANED SLOWLY DOWN PER DR. FOR POSSIBLE CAUSE OF ELEVATED HR AND ECTOPY.\\n PT INITIALLY WAS GIVEN MORPHINE PRN FOR PAIN ALONG WITH PROPOFOL(OFF PROPOFOL,PT CONFIRMED ABD PAIN).FENTANYL DRIP WAS STARTED AND TITRATED\\nUP. PRN ATIVAN WAS ALSO STARTED IN ATTEMPTS TO WEAN OFF PROPOFOL DUE TO LOWER BP.PT TO BE SEDATED WELL ENOUGH FOR NO RESPIRATORY EFFORT ON PART OF PT.PO2 WAS LOW THIS AM REQUIRING VENT CHANGES.WITH THE CHANGES PT BEGAN TO USE HER ABD MUSCLES WITH RESPIRATIONS.THUS CURRENTLY PT REQUIRES 85 MCQ OF FENTANYL AND PROPOFOL DOWN TO 15MCQ.PT HAS RECEIVED A TOTAL OF 2MG ATIVAN.BY THIS PM PT APPEARS MORE COMFORTABLE ON VENTILATOR,NOT USING ABD.MUSCLES.\\n THIS AM, PO2 DOWN TO 60'S .BREATH SOUNDS CLEAR AND SXED FOR MINIMAL SECRETIONS.WITH INCREASE OF PEEP TO 8,RR=22 AND TV DOWN TO 450.ONCE SEDATION FOR RESPIRATORY EFFORT REACHED,PO2 INCREASED TO 110.PH NORMAL WITH LACTIC ACID LEVEL AT 3.0\\n JP'S CONTINUE TO DRAIN APPROX 100ML/HR OF RED DRAINAGE.ABD WOUND REMAINS COVERED WITH TRANSPARENT DSG.\\n DAUGHTER AND SON IN. DAUGHTER IS AN OR NURSE AND UNDERSTANDS THE ONGOING GRAVITY OF HER MOM'S CONDITION.\\nA.MAINTAIN MAP >60.CHECK WITH HO REGARDING FLUID BOLI. WEAN DOBUTAMINE MAINTAINING CI >2.0 REPEAT LABS THIS EVENING(SEE ORDERS.\\nR.DESPITE REQUIREMENTS OF VOLUME,PT'S CONDITION REMAINS GUARDED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595903,\n \"text\": \"CONDITION UPDATE: SEE CARE VUE FOR OBJECTIVE DATA AND TRENDS\\n\\nNEURO: ALERT. FOLLOWS SIMPLE COMMANDS. ABLE TO MOUTH WORDS/NODDING. APPROP TO MAKE NEEDS KNOWN. PERRL. MAE WITH PURPOSEFUL MOVEMENT. NO C/O PAIN. CONTINUES ON FENTANYL GTT WITH GOOD PAIN CONTROL.\\n\\nCARDIAC: HCT-30. AFIB-NO ECTOPY. HR-80-90'S. BP-100'S-140'S/60-70'S. CONTINUES ON LOPRESSOR WITH GOOD HR CONTROL. +RADIAL/PT/DP X2. CLS ON. HEPARIN SC.\\n\\nRESP: CONTINUES ON CPAP . ABG WITH ADAQUATE OXYGENATION. 2200-PT LS /FEW SCATTERED EXP WHEEZES. GIVEN 20 IV LASIX X1 WITH GOOD DIURESIS. LS-COARSE-DIMINISHED BIBASILAR. SX FOR SM/MOD AMTS OF THICK YELLOW SPUTUMN.\\n\\nGI: REMAINS NPO. TOLERATING TF WELL WITH NO RESIDUALS. ABD-SD, +BSX4,\\nS, TENDERNESS AT INCISION SITE. ABD- INCISION STAPLES INTACT. DSD INTACT. ABD BINDER ON.\\n\\nGU: FOLEY WITH QS URINE. LYTES REPLETED PRN.\\n\\nENDO: FS QID COVERAGE PER RISS. STARTED ON NPH .\\n\\nSKIN: SKIN WDI. AXILLA/UNDER BREASTS/GROIN WITH RED RASH. NYSTATIN POWDER APPLIED.\\n\\nSOCIAL: SON CALLED OVERNIGHT UPDATED REGARDING POC.\\n\\nPLAN: MONITOR HEMODYNAMICS. WEAN VENT SETTINGS AS TOLERATED. PULMONARY HYGIENE. MONITOR WBC'S/HCT/ABG'S/LYTES PRN. TITRATE FENTAYL GTT PRN FOR PAIN. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595904,\n \"text\": \"Pt remains on PSV 15/5 with a lg. amt of sputum today. BS equal with coares rhonchi & wheezes thoughout. BS improve some post sx\\nTrach was planed for today. but as yet has not taken place.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595905,\n \"text\": \"Nursing Progress Note:\\nPlease refer to CareVue for details.\\n Fentanyl gtt @ 20mcg/hr; pt appears to be comfortable. Denies any pain. Pt more alert today. Mouthing words and writing on clipboard. Right pupil 3mm; briskly reactive to light. Left glass eye in place. Pt following commands consistently. MAE. +gag/cough reflex. Tmax 98.9. HR 80-90s (A.fib). ABP 100-140s/50-70s. CVP 2-14. Pt w/ +3 generalized edema. Lasix 20mg IV x1 ordered and given. Goal is for pt to be negative 1Liter. DP/PT pulses dopplerable. Skin is warm and dry; pale. Lungs coarse. Suctioned frequently for moderate amount thick white/ yellow secretions. No vent changes; CPAP 50%, PEEP 5, PS 15. Plan for trach (to be done in the OR vs bedside); ?when. Pt w/ strong cough; nonproductive. O2 sat >/= 99%. RR 20-30s. CXR done. Abdomen softly distended w/ +BS. Impact w/ fiber at 80cc/hr via NGT (goal rate); minimal residual. No c/o nausea. BM x2 (soft/liquid brown stool). BS 105-207; RISS q6hr and NPH 10units . Dr. ordered to change foley catheter today d/t pt +E.coli UTI; 16 Fr. foley catheter placed. Urine clear yellow. Midline abdominal incision w/ staples intact; pink around incision site. No drainage noted; DSD changed x1. Pt T&R freq to maintain skin integrity. No skin breakdown noted. son and daughter visited; updated on pt's plan of care and status.\\n Plan: Cont to monitor VS, I's and O's, labs. Cont to wean off vent as tolerated. If unable to wean off, trach in future. Titrate fentanyl gtt for comfort. Monitor BS; NPH . Update pt's family w/ plan of care. Cont ICU care and treatment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595883,\n \"text\": \"see careview for details\\nfocus data update\\n\\nNEURO: FENTANYL GTT DECREASED, MOUTHING WORDS STATING SHE WANTS TO GO HOME, MAE'S, DIFFICULTY LIFTING EXTRIMITIES R/T EDEMA, PT ANXIOUS @ TIMES, RESPONSES WELL TO VERBAL REASSURANCE\\n\\nRESP: CPAP 8PEEP, 10 PS, POOR RISBEE THIS AM, WILL DIURESIS TODAY AND ATTEMPT VENT WEANING TOMMOROW, B/L BREATH SOUNDS COARSE, IMPROVED NOTED ON LEFT SIDE, ORALLY SX'D FOR SMALL AMT OF THICK WHITE SPUTUM\\n\\nCV: TMAX 100.1, IV LOPRSSOR CHANGED TO PO, REMAINS IN A-FIB WITHOUT ECTOPY, PITTING EDEMA CONTINUES ON EXTRIMITIES, 10 MG'S IVP LASIX GIVEN, A-LINE AND MULTI-LUMEN CENTRAL LINE PATENT\\n\\nGI: ABDOMINAL BINDER INTACT, NO DRAINAGE NOTED FROM INCSION, HOWEVER REDDEN, TF'S CHANGED TO FULL STRENGHT AND GRADUALLY INCREASED, BS ACTIVE, NGT FOR FEEDINGS, MINIMAL RESIDUAL NOTED\\n\\nGU: LASIX 40MG'S IVP GIVEN, CREATINE WNL, ADEQUATE HOURLY U/O\\n\\nA/P: CONTINUE EDUCATIONAL AND EMOTIONAL SUPPORT TO BOTH PATIENT AND FAMILY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595884,\n \"text\": \"Respiratory Care:\\nPt remains on PSV 10/8peep 50%. She seems uncomfortable this eve and\\nher PaO2 has to 68 from 144 at AM gas with no changes. Has been grabbing at OET and was restrained. Few secretions...check CareVue\\nfor details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595885,\n \"text\": \"Respratory Care\\nNo vent.changes needed overnight.abg's adequate.Plan:continue wean as tolerated\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595886,\n \"text\": \"focus hemodynmc\\ndata: opens eyes to verbal stimuli. moves arms and legs on the bed. follows commands. tube fdgs via ngt and tol well. abd binder intact and abd dsg changed. incision line pink with ? necrotic areas near the midline incision. foley patent and ddraining yellow urine. on fentanyl gtt at 5omcg and resting comf. update to daughter.\\n\\nresponse: monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595877,\n \"text\": \"Xray improved some. pt had a bronch today lg amt. of secreations cleared not plugs noted. pt was reintubated pre bronch today. changing size from #7 to #7.5\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595839,\n \"text\": \"Respiratory Care\\nPt. form O.R.s/p leaking AAA repair.Pt. arrived intubated as documented,BBS+.Placed on vent.will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595901,\n \"text\": \"Nursing Progress Note:\\nPlease refer to CareVue for details.\\n Pt easily arousable to voice. Right pupil 3mm; briskly reactive (left fake eye in place). Pt mouths words, gestures, and writes on clipboard. Follows commands consistently. MAE. Appropriate behavior; calm. Fentanyl gtt @ 20mcg/hr. Pt c/o of abdominal/incisional pain w/ turning and repositioning, but appears comfortable once settled. Tmax 101.1; Tylenol 650mg given via NGT w/ +effect (pt pan cultured last night). HR 80-101 (A.fib). ABP 90-130s/50-80s. CVP 8-15. Pt w/ +3 edema on BUE and BLE. DP/PT pulses dopplerable. Hct this AM was 26.9; 1unit PRBC transfused. Hct needs to be rechecked post transfusion. Lungs clear, diminished at bases. Pt not extubated today d/t large amount of thick yellow/white secretions; frequently suctioned. RSBI this AM 100; repeat 94.3. Cont CPAP 50%, PEEP 5, PS 10. O2 sat >/= 99%. Abdomen softly distended w/ +BS. Impact w/ fiber restarted at 1200 @ 80cc/hr (goal rate); infusing via NGT w/ minimal residual. Large amount of liquid, brown stool in fecal incontinence bag this AM. FIB bag changed. Needs stool to be sent for C.diff. No c/o nausea, emesis. BS 84-138; NPH 10units ordered. Cont RISS as well. Midline abdominal incision w/ staples intact; pink around incision. No drainage noted; DSD changed x1. Abdominal binder on. Pt's tongue w/ thrush; Nystatin oral suspension given. Miconazole powder applied under bilat breasts and underarms d/t yeast infection. T&R freq to maintain skin integrity; no skin breakdown noted. son and daughter visited today; updated on pt's plan of care and status.\\n Plan: Cont to monitor VS, I's and O's, labs. Monitor respiratory status; ?extubate tomorrow if secretions decrease and RSBI improves. Monitor BS. Titrate fentanyl gtt for comfort. Update pt and family w/ plan of care. Cont ICU care and treatment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595902,\n \"text\": \"Respiratory Care Note:\\n Patient on increased PSV overnight with minute ventilation 11-15L, and RR 25-32. BS=bilat, coarse with occassional scattered wheezing noted. Suctioned for whitish sputum. CXR appears wetter. Patient receiving lasix. ET tube resecured. Noted skin breakdown beneath L nare- duoderm applied. RSBI done this am with result of >130. Patient left on PSV of 15/5, 50%.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595878,\n \"text\": \"CONDITION UPDATE\\nD: SEE CAREVUE FLOWSHEET FOR SPECIFICS\\n PATIENT IMPROVED A LITTLE OVERNIGHT. TMAX 100.0-HOWEVER WBC UP TO 30 ON EVENING LABS-TRIPLE IV ANTIBIOTICS WERE RESTARTED PER REC. OF SURGICAL TEAM. HR A LITTLE TACHY IN AFIB WITH A RATE BTWN 90-110 FOR MOST OF THE NIGHT WITH MIN AMT OF ECTOPY NOTED-LOPRESSOR 7.5 IV GIVEN Q6 BUT AFTER DOSE BP NOTED TO DIP BOTH TIMES DOWN INTO THE 80'S-?DECREASE DOSE TO 5MG. NEO WAS WEANED OFF AND ABOUT AN HOUR AFTER TURNING IT OFF BP DIPPED INTO THE 70'S (AFTER AMBU'ING AND LAVAGING PT D/T DESATURATION) INSTEAD OF RESTARTING NEO 1L BOLLUS OF NS WAS GIVEN WITH GOOD EFFECT AND NEO GTT REMAINED OFF FOR REMAINDER OF THE SHIFT. PT MAKING ADEQUATE AMTS OF URINE AND BLADDER PRESSURES WERE CHECKED Q4 RUNNING 15-18.\\n PPF GTT WAS ALSO TURNED OFF AND VENT WAS WEANED FROM AC DOWN TO CPAP -PULSE OXIMETRY ~94-96% BUT AM ABG LOOKS GREAT. SUCTIONED A FEW TIMES FOR A SMALL AMT OF THICK CLEAR/WHITE SECRETIONS. PT CONTINUES TO RECEIVE FENT GTT FOR COMFORT AND IS ALERT/FOLLOWS COMMANDS AND NODS A LITTLE YES/NO TO SOME QUESTIONS.\\n TROPHIC TF INFUSING VIA NGT-RESIDUALS CHECKED <100 BUT UP TO 90CC AT ONE POINT. ABD INCISION WITH STAPES AND SOME REDNESS BUT MIN AMT OF DRG AND JP'S PUTTING OUT SEROSANG DRG.\\n DTR CALLED FOR UPDATE\\nPLAN:\\n CONT TO WEAN VENT AS TOLERATED\\n PULMONARY TOILET\\n BLADDER PRESSURES Q4HRS\\n FENT FOR PAIN\\n NOTIFY H.O. WITH ANY CHANGES\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595879,\n \"text\": \"Respiratory Care\\nSwitched to PSV overnight and tolerated well.Abg's adequate on current settings.Plan:continue ps wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595880,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, PEEP weaned to 5 cmH2O, tol ok at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595881,\n \"text\": \"see careview dor details\\nfocus data update\\n\\n\\nNEURO: FENTANLY GTT DECREASED TO 75 MCG'S/HR, PT TRACKING, ABLE TO FOLLOW COMMANDS, MAE'S MINIMALLY\\n\\nRESP: VENT SETTING'S CHANGED PEEP 5, PS 10, DECREASED PO2 57, FIO2 INCREASED TO 50% ABG PENDING, IMPROVED , PT KEPT OFF LEFT SIDE MOST OF DAY, ORALLY SUCTIONED FOR THICK WHITE SECRETIONS, BITING ON ETT\\n\\nCV: WBC DECREASED, A-LINE CHANGED OVER WIRE, 500CC LR BOLUS X1, EXT'S CONTINUE TO WEEP SEROUS DRAINAGE, CVP 8-10,\\n\\nGI: NPO, TF HELD THIS AM FOR HIGH RESIDUAL, REGLAN STARTED TF RESUMED THIS PM, ABDOMINAL BINDER APPLIED, DSG CLEAN AND DRY, JP'S PATENT FOR SEROUS DRAINAGE, MTN TO SELF SUCTION, BS HYPOACTIVE\\n\\nGU: BLADDER PRESSURES 15-20, ADEQUATE HOURLY U/O\\n\\nA/P: CONTINUE TO LIGHTEN SEDATION, WEAN FROM VENT, CONTINUE EMOTIONAL AND EDUCATIONAL SUPPORT\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595882,\n \"text\": \"Respiratory Care\\nPt.remains on PSV,peep increased to 8, md request for pa02-60's on .50.No further changes needed follow-up abg's reveal improved oxygenation.Plan:attempt further vent.weaning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595875,\n \"text\": \"SICU B NPN:\\nNEURO: Continues on fentanyl gtt at 100mcg/hr and propofol 20mcg/kg/min. Opens L eye to stimuli, no following of commands, moving UEs slightly in bed. L pupil 3mm and briskly reactive to light. L glass eye intact.\\nCV: Tmax 101.7- pan cx'd but unable to get sputum yet due to no secretions. HR 90s-120s AF with occ. PACs. Recieved 1L fluid bolus x2 for decreased BP with some effect. Neo titrated to maintain MAP >60 and attempting to wean off. CVP 8-12. Repleted with 2G MGSO4 IV for level 1.8. A-line positional at times. Extremities cool to touch with palpable pulses. Generalized anasarca.\\nRESP: Continues on ACV 500x16 FiO2 40% Peep +10 with adequate ABG. O2 Sat >95%. LS coarse and diminished at bases. Sx'd for scant thick yellow secretions. Possible bronch today for LLL atelectasis on CXR.\\nGI/GU: Abd. dsgs intact with scant serosang. drainage noted on upper dsg. Two JP drains to bulb sxn with sersang. drainage. Abd. soft with absent bowel sounds. TPN continues at 74cc/hr. Fingersticks QID with 4u reg insulin given x2. NGT to continuous LWS with bilious drainage. Foley with amber clear urine 30-40cc/hr.\\nSKIN: Red area to coccyx but skin intact. Pneumoboots and multipodus boots on. R TLC line intact and R radial a-line intact.\\nPlan for possible bronch today. Attempting to wean neo off with fluid boluses for low BP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595876,\n \"text\": \"focus data update\\nsee careview for details\\n\\nNEURO: SEDATED ON PROPOFOL, FENTANYL GTT FOR COMFORT, NO SPONTANEOUS MOVEMENT, AND PRESENTLY UNABLE TO FOLLOW COMMANDS\\n\\nRESP: VENT SETTINGS UNCHANGED, LLL BREATH SOUNDS DIMINISHED, REINTUBATED WITH 7.5 ETT FOR BRONCHOSCOPY, VECURONIUM,PROPOFOL AND FENTANYL BOLUS GIVEN, BRONCH CULTURE OBTAINED, TENACIOUS THICK WHITE SECRETIONS\\n\\nCV: NEO GTT INCREASED TO 2MCG/KG/MIN, LOPRESSOR GIVEN TO CONTROL HR, ICU TEAM AWARE. CVP 8-10, 500CC LR BOLUS GIVEN X1, EDEMANOUS AND WEEPING SEROUS FLUID FROM UPPER EXT'S, REPEAT K 5.2, RIJ MULTI-LUMEN PATENT, A-LINE PATENT NEO TITRATED FOR MAP >70, T MAX 100.7 PO,\\n\\nGI: NPO, ORAL THRUSH NOTED, RX WITH NYSTATIN S/S, NGT PATENT IMPACT WITH FIBER FEEDS STARTED, HELD DURING BRONCHOSCOPY, ABD DRESSING CHANGED MIDLINE INCISION REDDEN SMALL AMOUNT OF SEROUS/SANG DRG NOTED\\n\\nGU: CREATINE NORMAL, MARGINAL AND CONCETRATED HOURLY U/O NOTED\\n\\nA/P: HEMODYNAMIC STATUS LABILE, EMOTONAL AND EDUCATIONAL SUPPORT GIVEN TO FAMILY, SOCIAL SERVICES CONTACT AND WILL FOLLOW, DR. NOTIFIED OF NEED FOR EDUCATION AND SUPPORT TO FAMILY, STATES HE WILL F/U\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595855,\n \"text\": \"neuro: Calm/coop on fentanyl gtt @125mcg, prn ativan 1mg before major nsg care. Pt becomes anxious, responds to voice, follows command. NV grossly intact.\\nCV: afib, rate controlled, min VEA. CI 1.7 after lasix 10mg w/ 500cc diuresis. Lytes repleted. CVP 10-14. + perocardial rub @ apex, positional; no ST changes.\\nresp: CMV, 50%, 8PEEP. Improving ABG's, PaO2>100. Dim bases, intermintently rhonchorous, scant white ET secretions.\\nGI: silent gut, NG scant bile. Open abd wound w/ 2 JP's to sx, decreasing s/s drng. TPN at target.\\nGU: U O/P 30-50cc/hr clear amber.\\nEndo: BS labile\\nDerm: mod anasarca. Skin grossly intact.\\nID: WBC 5.2; cont on vanco, levofloxacin, metronidazole. Core temp 37.\\nlabs: HIT neg; plates improving...95.\\nPlan: d/c S/G cath. Diurese, replete lytes. ?delete heparin in TPN. vent...? PEEP/FIO2 wean. Follow pericardial rub if not improved after diuresis. Adequate sedation w/ major care/procedures.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595856,\n \"text\": \"Resp Care\\nPt remains intubated on A/C. Dropped PEEP from 8 to 6 and then to 5. Decreased FIO2 from 505 to 40%. No other changes made.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595857,\n \"text\": \"Update note\\nSHIFT A- PLEASE SEE CARE VIEW FOR SPECIFIC DATA.\\n\\nN- ALERT MOST OF SHIFT ABLE TO FOLLOW COMMANDS AND MOVES ALL EXTREMITIES. CONTINUES ON FENTANYL GTT AT 125 MCG'S /HOUR PATIENT APPEARS COMFORTABLE. RECIEVED TWO DOSES 1MG ATIVAN PRIOR TO CARE WHICH WAS EFFECTIVE WITH AGITATION.\\n\\nCV- AFIB WITH RARE TO OCCASIONAL PVC'S. CO-4.01 CI- 2.20 LASIX GIVEN TIMES TWO WITH GOOD DIURESIS. GOAL IS -500 - -1 LITER. CVP 6-8 B/P'S 100-120'S. SWAN IN RIJ -DO NOT WEDGE. K REPLETED TIMES ONE WITH 20 AND SECOND ONE WITH 40 K WAS3.7. K LEVEL TO BE REDRAWN TONIGHT. LUNGS CLEAR ALL FIELDS.\\n\\nRESP- CMV- FIO2 FROM 50 TO 40 PEEP WEENED FROM 8. NOW AT 5. 1700 BLOOD GAS PAC02 WAS 28 RATE DECREASED TO 20. ABG PENDING.\\n\\nGI/GU- NG TO LWS SMALL BILLIOUS DRAINAGE, OPEN ABD. WOUND 2 JP'S TO LWS DRAINING SEROSANGUINOUS DRAINAGE. TPN AT 73CC/HR. FOLEY TO CD QUANTITY SUFFFICIENT.\\n\\nENDO- BS STABLE THIS SHIFT.\\n\\nID- CONTINUES ON VANCO FLAGGYL AND LEVOFLOXICIN T 99.5\\n\\nPOC- CONTINUE TO MONITOR-K AND ABG. GOAL 500CC- I LITER NEGATIVE FOR TODAY. ABDOMINAL DRESSING NEED REINFORCEMENT.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595858,\n \"text\": \"Resp Care Note,Weaned pt 2 ^ peep.Temp 100. HR-A-Fib with PVC'S.Sedated with fentanyl. Good ABG'S.Will cont to moniotr resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595859,\n \"text\": \"CONDITION UPDATE:\\nD/A: T MAX 100.2\\n\\nNEURO: FENTANYL GTT WITH GOOD PAIN CONTROL. ATIVAN X1 FOR BATHING/REPOSITIONING. PT ANXIOUS AT TIMES. TIGHTLY FLEXING ARMS WHEN STIMULATED. FOLLOWING COMMANDS.\\n\\nRESP: LS CLEAR. VENT SETTINGS INCREASED SLIGHTLY AS PT'S PAO2 DECREASED TO 60'S. AC 50%, 20X450, PEEP 8 WITH CURRENT ABG: 7.36, 42, 95, 25, -1.\\n\\nCV: HR 80'S-110 AFIB. CVP ~12. ABP ~130/60. PA 40'S/20'S. BEING DIURESED WITH LASIX. FLUID BALANCE -380CC'S. MN-0500 + 163 CC'S. + PPP BILAT. +++ EDEMA. WT DOWN 2 KG'S FROM YESTERDAY. NO PERICARDIAL RUB AUSCULTATED THIS SHIFT.\\n\\nGI: NGT-LCWS WITH MINIMAL OUTPUT. ABDOMEN OPEN, COVERED WITH OPSITE, X2 JP'S. TROPHIC TUBE FEEDS ORDERED.\\n\\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\\n\\nSX: FAMILY VISITED AND CALLED.\\n\\nR: REQUIRING SLIGHTLY MORE VENTALATOR SUPPORT, MILD DIURESIS, ABDOMEN REMAINS OPEN.\\n\\nP: CONTINUE CURRENT CLOSE MONITORING AND MANAGEMENT. PAIN CONTROL. GOAL MAP > 60. PT AND FAMILY SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595896,\n \"text\": \"npn 0700-1500;\\nNO VENT CHANGES MADE TODAY. PT WAS GOING TO GO FOR /PELVIC CT BUT WAS CANCELLED AFTER DISCUSSION WITH PRIMARY TEAM.\\n\\nNEURO; AOOX1.WAEKLY MAE TO COMMAND LT EYE FALSE,RT EYE 3MM,BSK.\\n\\nRESP; LUNGS COARSE WITH INTERMITTENT EXP WHEEZE, DIMINISHED AT BASES SUCTIONED FOR MOD AMOUNTS THICK WHITE SECRETIONS,,SATS 96-100%,RR 26-35. CONTINUEES ON CPAP WITH 10 PS AND 5 PEEP.\\n\\nCVS; TMAX 100.5 PO AFIB 103-89 GIVEN 25 MGS OF LOPRESSOR INSTEAD OF 50 MGS AS BP 103-110 BY ALINE TOL DOSE WITH NO DRAMATIC DROP IN BP.CURRENTLY 105-115/60 AT REST UP TO 140-160/80 WHEN COUGHING BUT SETTLES QUICKLY. CVP 13-9.\\n\\nGU; LASIX DRIP REMAINS OFF,PASSING 100-50 MLS/HR, K REPLETED.\\n\\nGI; TOLERATING T/F AT GOAL BELLY SOFT DISTENDED HYPOACTIVE BS. PASSING SMALL AMOUNTS OF GOLDENYELLOW LIQUID STOOL VA RECTAL BAG .\\n\\nENDO;COVERED ON RISS.\\n\\nINTEGRUM;BELLY WOUND UNCHANGED EDEMATOUS , MOIST RED PATCHES UNDER ARMS AND BREASTS,TREATED WITH NYSTATIN POWDER,THRUSH IN MOUTH. TREATED WITH NYSTASTIN.\\n\\nSOC; DAUGHTER INTO VISIT TEARFUL AT TIMES TALKED WITH LISW . LEFT WITH FRIEND WILL RETURN LATER THIS AFTERNOON.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595897,\n \"text\": \"Respiratory Care\\n\\n Pt continues on CPAP/PSV 10/5 in NARD. B/S ess clear dim on L sx'd for mod thick white. No changes made today Will continue to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595898,\n \"text\": \"Respiratory Care Note:\\n Patient continues on PSV 10/5. She appears comfortable with good BS bilat. Suctioned for minimal white secretions. No change in respiratory status. It appears patient is becoming more responsive. Plan to maintain at this time. RSBI yesterday >105, will recheck this am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595848,\n \"text\": \"Condition Update\\nD: See carevue flowsheet for specifics\\n Patient's temp coming down to 99.4 from tmax of 100.9. HR at beginning of shift up to rate of 130's with frequent PVC's, labs were sent with no significant findings. HR settled down into the 90's with no intervention. Later in the shift PPF was turned off d/t pt heavily sedated, bed bath was given and pt was positioned on right side HR went up to 120-130 with freuqent PVC's and didn't settle out within an hour so PPF was restarted-HR still did not come down (at this time BP also higher so titrating down on levo gtt). SICU resident notified fluid bollus was given with little effect. Finally pt was repositioned back onto left side and rate came down ~100, second fluid bollus given. CVP all night running . Currently Levo gtt at .04mcg/kg/min with map maintained >60. PA numbers have remained stable but elevated with adequate CO>4 and CI>2. URine output still marginal. Heparin SC was held after discussing with Dr. results of HIT.\\n While PPF was off pt appeared more alert, opened mouth on command and had more spontaneous movement. Fent gtt still at 100mcg/hr for pain.\\n No vent change were made overnight and oxygenation much improved with am abg. PaO2 up from 78 to 140's. Pt has not been breathing much over the vent and has not been suctioned for much in way of secretions. Lungs are clear and diminished in the bases.\\n Abd open and dressing required reinforcement d/t leaking of sanginous drg. JP's still to LWS and draining lge amts. No bowel sounds noted. NGT to LCWS. Pt receiving LR at 150 and not receiving any nutrition at this time. Pt to return to OR today for wash out. No plans to close belly at this time.\\nPLAN:\\n OR today\\n Fent/PPF for sedation\\n Levo to keep map>60\\n F/U with HIT spec\\n Call social worker to speak with family\\n Notify H.O. with any changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595849,\n \"text\": \"See carevue for objective data.\\n\\nProprofol dc'd this AM with prn ativan for sedation with good results. MAP much improved after proprofol dc'd. Fentanyl gtt remains at 125 mcg/hr. Nods head slightly when asked questions. Weak but follows commands.\\nCO/CI remain labile requiring fluid boluses prn. PCWP 15-17. CVP 7-11.\\nPA #'s remain elevated as well. Levophed remains off. Body edema present. Less ectopy today-remains in AFIB.\\nAbd wound leaking copious amts of sangious fluid around dressing.\\nPlan this PM is to wash wound and re-dress. Awaiting MD's to arrive.\\nAbd around dressing remains soft.\\nUrine output marginal at best. +ATN per team. Will monitor.\\nNo vent changes except FIO2 decreased to 50% from 60%. ? decrease PEEP to 5 in AM if PO2 adequate for venous return.\\nTPN to be started soon-no order for today. NGT to LCWS-flushed X2 patent and draining bilious fluid.\\n\\nFamily in and updated on POC. Support/education provided by many members of the team.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595913,\n \"text\": \"Pt remains off vent. support @ this time but continues to have pul. hygien issues. Her cough is productive of a mod-lg amt of thick yellow sputum. Percusion & vibration was started to Left & right sides\\nwith bed in mild trendelinburg. deep breathing & coughing was also aggressively encouraged.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595899,\n \"text\": \"SICU B NPN:\\nNEURO: Continues on fentanyl gtt at 20mcg/hr. Opens eyes spontaneously, follows commands and nodding/mouthing words. Does nod head yes to pain and appears to be incisional. Fentanyl bolus 25mcg x2 for pain given. MAE in bed UE >LE. Not restrained and no attempts made to pull out ETT or lines. R pupil 3mm and briskly reactive to light. L glass eye intact.\\nCV: Tmax 101.1 and pan cx'd. Tylenol given with last temp. 99.9 at 4am. Skin warm and dry with weak but palpable pedal pulses. HR 80s-100s AF, no ectopy noted. BP stable with MAPs >60.\\nRESP: No vent changes made. LS coarse and diminished at bases. Sx'd for thick white secretions in moderate to large amts. Large amts of oral secretions also.\\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with large amt of liquid-loose brown stool- heme negative. Impact with fiber continues at 80cc/hr via NGT. Requiring insulin with q6hr fingersticks. Foley with clear yellow urine >40cc/hr.\\nSKIN: Thrush in mouth with nystatin swabs given. Abd. dsg intact with no drainage noted. Staples to site clean, dry and intact. Abd. binder in place. Pneumoboots on. Yeast rash to underarms, folds and groin with miconazole powder applied.\\nOTHER: Daughter called and updated on pt's condition and plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595900,\n \"text\": \"Pt stable with present settings. Bs deminished in left base with coares rhonchi thoughout. Rhonchi improves post sx. Pt sxed for a lg amount of thick white and yellow sputum. No vent changes requested.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595914,\n \"text\": \" 19/07\\n PT A/O RELAXED NO PAIN OR DISCOMFORT NOTED SLEEPS SHORT NAPS UNDERSTANDS AND TRIES TO HELP WITH CARE\\n RESP ON .50 FACE TENT TOL WELL SAT 92 TO 100 CLEAR FIELDS\\n HEART AF RATES 78 TO 90 PULSES POS 3 THRU OUT VSS\\n GI POS B/S NOTED TOL T/F WELL SOFT ABD\\n PLAN PROGRESSIVE PT ROM REALITY BASED CARE FAMILY SUPPORT\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595915,\n \"text\": \"CONDITION UPDATE\\nPT TRANSFER TO VICU. VSS, A&OX3, NO C/O PAIN. PLEASE SEE TRANSFER NOTED FOR DETAILS.\\nPLAN:\\n TRANSFER TO VICU \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595916,\n \"text\": \"Condition Update\\nPlease see carevue for specifics.\\n\\nPt is alert and oriented x 3, but does get confused at times ? sundowning. She is easy to reorient. Otherwise, behavior is appropriate. She had no c/o pain throughout the noc. She is able to move all extremities w/ equal strength. Afebrile. Chronic afib. 02 sats 93-97% Cool mist face tent remains on to help loosen secretions. Robitussin also given q 6 hours. She is able to expectorate small to moderate amts of thick, white secretions using the yankaur independently. LS are coarse b/l. Foley is patent and draining adequate amts of clear urine. She tolerated liquids throughout the noc. Pt is incontenent of liquid, brown stool. FIB placed. Peri area is excoriated. double gaurd cream applied. Pt has a riss and am/pm nph for bs coverage. K+ & MG+ repleted.\\n\\nPlan: continue with current plan of care per sicu/ vascular teams. Xfer to VICU when bed is available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-12-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595917,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.\\nPATIENT DOING WELL TODAY, ALERT AND COOPERATIVE. TOLERATING REG. DIET SLOWLY, ENCOURAGED TO DRINK BOOST.\\nOOB FOR ABOUT 1 HR, ANXIOUS TO GET BACK INTO BED.\\nDIURESING SLOWLY WITH LASIX.\\nSATS GOOD ON 4L NASAL PRONGS, ENCOURAGED TO TCDB.\\nFOLEY WITH CLEAR YELLOW URINE.\\nP: TO VICU WHEN BED AVAILABLE.\\nWILL CALL HOW WITH ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595871,\n \"text\": \"SICUB NPN:\\nNEURO: Intermittently agitated at times- ativan 1mg x2 with good effect. Right pupil 3mm and brisk. Moving all extremites in bed UE>LE. Follows commands and does not appear in to be in pain. Fentanyl gtt at 100mcg/hr.\\nCV: Tmax 99.0. HR 70s-100s AF with occ. PACs. Occasional P waves noted. BP stable with MAPs >60. SBP up to 180s with turning and agitation. CVP 8-10. Receiving MGSO4 and KCL repletion. A-line positional at times and difficult to draw blood from.\\nRESP: No vent changes - continues on ACV 450x14 FiO2 40% Peep +5, breathing over vent 4-6 breaths per minute. LS coarse and diminished at bases. Sx'd for scant amts whitish secretions. O2 Sat >95%.\\nGI/GU: Abd. open with transparent dsg intact- continues to ooze serosang. drainage in moderate amts. TF shut off at 12am for planned OR today. 2 JP drains continue to LWS. TPN continues at 74cc/hr. Foley with clear yellow urine >100cc/hr- lasix gtt increased to 8mg/hr for goal negative 2L in 24hr (was -1500cc last 24hrs).\\nSKIN: Coccyx red but skin intact. Abd. dsg intact.\\nPlan for closure of abd. wound in OR today. Consents signed by daughter. TF off since MN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595860,\n \"text\": \"Condition Update\\nD: See carevue flowsheet for specifics\\nPatient remains afebrile HR stable in afib with good rate control-pt was started on a small dose of lopressor which was well tolerated. Swan was changed over a wire to a multilumen which was then leaking after placement had been confirmed so a 2nd line was placed (over a wire). CVP still ~12 and pt was started on a lasix gtt to diurese to 1L negative by midnight but due to difficulty with access throughout the day that goal may not be achieved.\\n In the second CXR done to confirm line placement left lung noted to be out. O2 sats at the time down to ~94-95%, lung sounds diminished on left. Pt was bronch'd for a lot of secretions f/u CXR showed improvement. PT still on AC PEEP increased to 12 after bronch otherwise settings unchanged 450x22 fio2 50%.\\n Abd assessment unchanged. Pt was started on trophic feeds this am. Abd still open and leaking a lot of serosang drg from around dressing. Pt also receiving TPN for nutrition.\\n Family has been at bedside throughout the day and has been updated as to todays events.\\nPLAN:\\n Return to OR on monday\\n Wean PEEP tonight if abg adequate\\n Lasix gtt to diurese to 1L negative by midnight.\\n Notify H.O. with any changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595861,\n \"text\": \"Resp Care\\nPt intubated on A/C. Pt bronched for large amt thick secretions. Increased PEEP from 8 to 12 due to increased fluid in right lung seen on latest X-ray. No other changes made.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595862,\n \"text\": \"Resp Care Note,Weaned down FIO2 for good ABG. Sedated with fentanyl. Getting lasix.Suctioned for sml amts thick white secretions. Temp 100. Will cont to monitor resp status.Will try to wean peep today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595863,\n \"text\": \"Condition Update\\nD: See carevue flowsheet for specifics\\n Patient remains afebrile-hemodynamically stable and tolerating diuresis well on lasix gtt. HR in afib with rate controlled in 80's on a small dose of lopressor. Goal is to keep SBP>100 and diurese to negative 2L by midnight. Currently close to 1L negative this afternoon. Lytes requiring frequent repleting.\\n No vent changes were made today and still has not required much suctioning. Lungs have been clear and dim in the bases -CXR ordered for tomorrow.\\n No change in abd exam, continues to leak lge amts of serosang drg from around transparent dressing. Tube feeds have remained off d/t lge residual overnight. TPN infusing-SSI tightened.\\nPLAN:\\n Cont to diurese with lasix gtt\\n ? return to OR tomorrow for closure\\n Notify H.O. of any changes\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595864,\n \"text\": \"Resp Care\\nPt remains intubated on A/C. Dropped PEEP from 12 to 8 due to improved X-ray. No other changes made.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595865,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. HR-A-Fib. Temp 100.8. Sedated with fentanyl. Getting lasix.Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1595866,\n \"text\": \"D: neuro intact, anxiety @ times requires PRN ativan. minimal mov't of extremities due to fluid accumulation. VSS, low grade temps. Fluid overload, pt on lasix gtt with good u/o. No vent changes overnoc. NGT placed to wall suction and 200ml bilious drg returned. NGT left to LCWS. Oozing large am't serosang drg from around open abd wound from beneath opsite. Extra pads used to collect drg.\\nA:Stable\\nP:Diurese as ordered.\\nEventual closure of wound in OR.\\nSupport pt and family\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2111-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79454,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Ascending aortic aneurysm\\nHeight: (in) 65\\nWeight (lb): 175\\nBSA (m2): 1.87 m2\\nBP (mm Hg): 91/49\\nHR (bpm): 94\\nStatus: Inpatient\\nDate/Time: at 17:28\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\\nin the RA.\\n\\nLEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function.\\nHyperdynamic LVEF.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal aortic arch diameter. Simple\\natheroma in aortic arch. Focal calcifications in aortic arch. Focal\\ncalcifications in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient was sedated for\\nthe TEE. Medications and dosages are listed above (see Test Information\\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\\nrelated complications. Echocardiographic results were reviewed with the\\nhouseofficer caring for the patient. Left pleural effusion.\\n\\nConclusions:\\n1. The left atrium is moderately dilated. The right atrium is dilated.\\n2. The left ventricular cavity size is normal. Regional left ventricular wall\\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\\n3. There are simple atheroma in the aortic arch. There are focal\\ncalcifications in the aortic arch.\\n4. The aortic valve leaflets (3) are mildly thickened. Trace aortic\\nregurgitation is seen.\\n5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\\nregurgitation is seen.\\n6. No aortic aneurysm is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885650,\n \"text\": \" 8:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess pleural effusions\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt, had bronch\\n\\n REASON FOR THIS EXAMINATION:\\n assess pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ruptured abdominal aortic aneurysm bronchoscopy; assess\\n effusions.\\n\\n PORTABLE AP CHEST: Comparison is made to study dated .\\n Endotracheal tube, nasogastric tube, and right IJ central venous catheter\\n remain in stable, satisfactory position. Assessment is limited by patient\\n rotation. Allowing for this, cardiac and mediastinal contours are likely\\n unchanged. The aortic knob remains indistinct. In the interval, interstitial\\n edema has improved and pleural effusions have decreased in size, with\\n resolution of the right pleural effusion. There is a persistent small left\\n pleural effusion as well as a left lower lobe atelectasis.\\n\\n IMPRESSION: Resolving congestive heart failure pattern. Persistent small left\\n pleural effusion and left lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885341,\n \"text\": \" 5:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for atelectasis\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt, had bronch\\n\\n REASON FOR THIS EXAMINATION:\\n assess for atelectasis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ruptured abdominal aortic aneurysm and line placement status post\\n bronchoscopy.\\n\\n PORTABLE AP CHEST: Comparison is made to study, dated .\\n\\n FINDINGS: Endotracheal tube, nasogastric tube, and right IJ central venous\\n catheter remaining stable, satisfactory position. No new central venous\\n catheters are identified. Cardiac and mediastinal contours are unchanged.\\n Again, noted is interstitial edema and moderate bilateral pleural effusions.\\n Dense left retrocardiac density is consistent with atelectasis and appears\\n unchanged.\\n\\n IMPRESSION: No significant interval change in pulmonary edema, small-to-\\n moderate bilateral pleural effusions and left lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885691,\n \"text\": \" 12:59 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: s/p abd closure, decreased BS on L, eval tube placement and\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt, had bronch\\n\\n REASON FOR THIS EXAMINATION:\\n s/p abd closure, decreased BS on L, eval tube placement and for pulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ruptured aneurysm and decreased breath sounds on the left.\\n\\n PORTABLE AP CHEST: Comparison is made to study performed 5 hours prior.\\n Endotracheal tube terminates approximately 3.8 cm above the level of the\\n carina. There is expansion of the tracheal contour, consistent with\\n overinflation of the cuff. Right IJ central venous catheter and nasogastric\\n tube remain in stable position. As before, there is atelectasis of the left\\n lower lobe with associated volume loss and some shift of the heart and\\n mediastinal structures. There appears to be an abrupt cutoff of the left\\n lower lobe bronchus, finding consistent with obstructing mucous plug. There\\n may be a small left pleural effusion. The right lung is grossly clear.\\n\\n IMPRESSION:\\n 1. Apparent overdistention of the endotracheal tube cuff as above.\\n 2. Left lower lobe collapse and abrupt occlusion of the left lower lobe\\n bronchus. These findings are most consistent with an obstructing mucous plug.\\n\\n These findings were conveyed to Dr. at the time of interpretation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 884614,\n \"text\": \" 4:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: desat\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA.\\n\\n REASON FOR THIS EXAMINATION:\\n desat\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old female with ruptured AAA and desaturation.\\n\\n COMPARISONS: Comparison is made to immediate postoperative radiograph from\\n .\\n\\n TECHNIQUE: AP single view of the chest.\\n\\n There is an ET tube in good position. There is a Swan-Ganz catheter with the\\n tip in the pulmonary artery trunk. The NG tube within the stomach. There are\\n two drains into the abdomen. There are bibasilar atelectases. Left\\n retrocardiac opacity could represent atelectasis Vs. consolidation Vs.\\n aspiration. Severe scoliosis of the thoracic spine. The pulmonary\\n vascularity is within normal limits without evidence of CHF. There are\\n probable bilateral pleural effusions. There is no evidence of pneumothorax.\\n The aorta is tortuous and calcified. The splenic artery is calcified. There\\n are clips in the left axilla.\\n\\n IMPRESSION:\\n 1. Bibasilar atelectases.\\n 2. Left retrocardiac opacity could represent atelectasis, consolidation or\\n aspiration. The shift of the mediastinum to the left suggests atelectasis.\\n Clinical correlation recommended.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-12-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886853,\n \"text\": \" 9:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrates\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p repair, spiking fevers\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old woman status post repair of ruptured AAA, now spiking\\n fevers. Please assess for pneumonia.\\n\\n TECHNIQUE: Single AP upright portable chest radiograph was obtained.\\n\\n COMPARISON: Supine AP portable chest radiograph, .\\n\\n FINDINGS: There is an endotracheal tube with tip approximately 3 cm above the\\n carina. There is a nasogastric tube with tip within the stomach. The right\\n internal jugular central catheter with tip in the SVC. There is stable\\n appearance of the heavily calcified thoracic aorta with unchanged appearance\\n of wall thickening at the level of the aortic knob, which may represent\\n chronic dissection or calcification of a thick pseudointima. Again noted are\\n small bilateral pleural effusions. Overall, there has been no significant\\n interval change in appearance of the chest compared to .\\n\\n IMPRESSION: Tubes and lines in satisfactory position. Persistent small\\n bilateral pleural effusions. Overall, no significant change in appearance of\\n the chest compared to .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885867,\n \"text\": \" 4:34 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: exchange of ETT please eval position s/p bronch\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\\n maneuver\\n REASON FOR THIS EXAMINATION:\\n exchange of ETT please eval position s/p bronch\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ruptured AAA status post OR, exchange of endotracheal tube.\\n\\n COMPARISON: Radiograph dated at 5:21 a.m.\\n\\n SINGLE AP PORTABLE SUPINE VIEW OF THE CHEST: A right internal jugular\\n catheter is unchanged. An NG tube was again demonstrated with distal tip\\n terminating below the diaphragm below the lower margin of this film. Anterior\\n abdominal midline staples are seen at the lower margin of the film. There is\\n an endotracheal tube with distal tip at the thoracic inlet. The exam is\\n otherwise not significantly changed compared to the prior study.\\n\\n IMPRESSION: ET tube in satisfactory position with no other significant\\n interval change compared to the exam of 12 hours prior.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886214,\n \"text\": \" 5:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: am chest xray to eval progression of lung process\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p\\n recruitment maneuver\\n REASON FOR THIS EXAMINATION:\\n am chest xray to eval progression of lung process\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:40 A.M., \\n\\n HISTORY: Ruptured aortic aneurysm.\\n\\n IMPRESSION: AP chest compared to and 20th.\\n\\n Left lower lobe collapse persists. Small bilateral pleural effusions are\\n unchanged since while borderline pulmonary edema has improved.\\n The heart is top normal size. ET tube, right internal jugular line, and\\n nasogastric tube are in standard placements respectively. No pneumothorax.\\n\\n The thoracic aorta is heavily calcified. Thickening of the wall at the level\\n of the aortic knob could be due to chronic dissection or calcification of a\\n thick pseudointima, but is not changed acutely.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-12-02 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 886572,\n \"text\": \" 5:02 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: eval liver/gallbladder\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman w/ labile BPs and rising LFTS\\n REASON FOR THIS EXAMINATION:\\n eval liver/gallbladder\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Rising LFTs, evaluate liver and gallbladder.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Right upper quadrant ultrasound.\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: Limited images of the liver are provided.\\n The hepatic echotexture appears within normal limits. No definite masses are\\n identified within the hepatic parenchyma.\\n\\n The gallbladder is distended and contains echogenic sludge. No definite\\n shadowing gallstones are identified. There is no definite gallbladder wall\\n thickening or edema. A small amount of fluid adjacent to the gallbladder on\\n several images may be located within the adjacent bowel. The common hepatic\\n duct is nondilated (measuring 2 mm). Visualization of the common bile duct is\\n limited on the images provided from this examination, which was performed\\n portably.\\n\\n The right kidney measures 10.9 cm. A simple cyst is seen within the\\n interpolar region of the right kidney measuring 3.1 cm in diameter.\\n\\n Note is made of a heterogeneously echoic fluid collection in the right lower\\n quadrant, which measures 12.9 x 4.5 cm.\\n\\n IMPRESSION:\\n 1. Markedly dilated gallbladder containing sludge. No definite evidence of\\n acute cholecystitis.\\n\\n 2. Heterogeneously echoic fluid collection in the right lower quadrant is\\n incidentally noted. This measures 12.9 cm in diameter. The etiology is\\n uncertain and this may be further evaluated with CT.\\n\\n 3. 3-cm simple cyst in the interpolar region of the right kidney.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885710,\n \"text\": \" 2:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: repeat - old film rotated. upright to eval for CHF\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n INDICATION: Status post bronchoscopy. Repeat chest x-ray requested due to\\n rotation on prior film.\\n\\n The patient is similarly rotated on the current film as on the previous\\n studies. Various lines and tubes are unchanged in position with note again\\n made of overdistention of endotracheal tube cuff. There remains collapse of\\n the left lower lobe. There is increasing opacity in the left hemithorax,\\n difficult to assess due to the degree of rotation, which could be due to\\n partially layering pleural fluid or increasing atelectasis within the left\\n lung. Within the right lung, previously noted right pleural effusion appears\\n slightly smaller, possibly due to positional differences. There is minimal\\n perihilar haziness in the right lung, suggesting a component of mild perihilar\\n edema.\\n\\n\\n\\n\\n 2:20 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: repeat - old film rotated. upright to eval for CHF\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt, had bronch\\n\\n REASON FOR THIS EXAMINATION:\\n repeat - old film rotated. upright to eval for CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE SUPINE CHEST OF AT 14:41.\\n\\n Comparison is made to previous study of approximately one hour earlier.\\n\\n INDICATION: Evaluate for congestive heart failure.\\n\\n Lines and tubes are unchanged in position with note again made of\\n overdistention of the endotracheal tube cuff. Again demonstrated is left\\n lower lobe collapse with abrupt cut off of the left lower lobe bronchus\\n suggesting mucus plugging. There is increasing hazy opacity in the left\\n hemithorax extending to the level of the lower portion of the aortic knob,\\n possibly due to increasing pleural fluid on this side. There is slight\\n perihilar haziness and subtle interstitial pattern in the right lung, which\\n may reflect a component of interstitial edema, and there is also a probable\\n small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-12-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886921,\n \"text\": \" 10:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pulm process\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p repair, spiking fevers\\n\\n REASON FOR THIS EXAMINATION:\\n eval pulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Repair ruptured AAA. Fever.\\n\\n AP BEDSIDE CHEST: There are bilateral moderate-sized pleural effusions with\\n associated basal atelectasis. I doubt the presence of consolidations although\\n this cannot be assessed in the obscured left lower lobe. Heart is probably\\n not enlarged, although the aortic knob is markedly dilated and calcified. No\\n vascular congestion. Tubes and catheters satisfactorily positioned.\\n Appearances unchanged from similar exam one day ago ().\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885768,\n \"text\": \" 4:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: question of collapse, need for bronch\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p OR for abd closure.\\n\\n REASON FOR THIS EXAMINATION:\\n question of collapse, need for bronch\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 5:21 A.M. ON :\\n\\n HISTORY: Ruptured aneurysm. Possible lobar collapse and the need for\\n bronchoscopy.\\n\\n IMPRESSION: AP chest compared to and 19, :\\n\\n Left lower lobe remains collapsed, although volume loss indicated by leftward\\n mediastinal shift is not quite as severe as it was on . Right lung\\n volume is lower and new opacification in the right lower lung is concerning\\n for either atelectasis or new pneumonia while mild interstitial edema is more\\n pronounced and small bilateral pleural effusions have increased. ET tube,\\n nasogastric tube, and a right internal jugular line are in standard placements\\n respectively. There is no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-12-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887215,\n \"text\": \" 6:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval infiltrates, CHF\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p repair, tachypnic\\n REASON FOR THIS EXAMINATION:\\n eval infiltrates, CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Tachypneic, evaluate infiltrate, CHF.\\n\\n CHEST, SINGLE AP VIEW.\\n\\n There is cardiomegaly, with a calcified, unfolded aorta. Parenchymal detail\\n is difficult to assess due to overpenetration. In particular, it is difficult\\n to assess for CHF. There is probable upper zone redistribution, without\\n interstitial edema. There is increased retrocardiac opacity consistent with\\n left lower lobe collapse and/or consolidation and a small left effusion. There\\n is patchy opacity at the right base. Compared with , this appearance\\n is probably unchanged. There has been interval removal of the ET tube. A\\n right IJ central line is present, tip over distal SVC, unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 885167,\n \"text\": \" 1:04 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: eval line\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt\\n REASON FOR THIS EXAMINATION:\\n eval line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: new line placement.\\n\\n FINDINGS: Single radiograph of the chest reveals moderate right pleural\\n effusion. Left hemithorax opacity with mediastinal shift which could be due\\n to positioning of the patient partially as well as volume loss. Subsequent\\n radiograph taken on same day, , at 4:25 PM shows aerated left\\n lung. The tubes are in satisfactory position.\\n\\n IMPRESSION: Moderate right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 884344,\n \"text\": \" 9:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pneumonia, vol overload\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA.\\n REASON FOR THIS EXAMINATION:\\n pneumonia, vol overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST , WITH NO PRIOR FILMS FOR COMPARISON.\\n\\n INDICATION: Ruptured AAA.\\n\\n An endotracheal tube terminates approximately 1.5 cm above the carina. A\\n nasogastric tube terminates in the stomach, and a Swan-Ganz catheter\\n terminates in the distal right pulmonary artery. There is no pneumothorax.\\n\\n There is widening of the mediastinum in the region of the aortic arch. The\\n cardiac silhouette is upper limits of normal in size allowing for rotation and\\n portable technique. There is bilateral perihilar haziness, and there are\\n several septal lines within the lung periphery. Patchy opacities are noted in\\n both lower lung zones and may relate to patchy atelectasis or aspiration.\\n Small pleural effusions are present, blunting the left costophrenic sulcus and\\n thickening the right minor fissure. Note is made of apparent left mastectomy\\n and axillary lymph node dissection.\\n\\n IMPRESSION:\\n 1. Low position of endotracheal tube, which could be withdrawn 1 to 2 cm for\\n more optimal placement.\\n 2. Widened mediastinum in region of aortic knob, which may be related to\\n tortuosity and/or dilation of the structure.\\n 3. Interstitial pulmonary edema.\\n 4. Patchy bibasilar atelectasis versus aspiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 885144,\n \"text\": \" 9:29 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: CVL placement\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA.\\n\\n REASON FOR THIS EXAMINATION:\\n CVL placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Ruptured abdominal aortic aneurysm.\\n\\n Single portable chest radiograph demonstrates no change in the\\n cardiomediastinal silhouette when compared to . Endotracheal tube\\n is present with its tip at the clavicular heads. Right internal jugular\\n central venous catheter is present with its tip in the SVC. Nasogastric tube\\n is seen to course through the stomach and off the inferior aspect of the\\n imaged field of view. There are small-to-moderate bilateral pleural\\n effusions. The plate-like atelectasis in the right lower lung seen on the\\n previous study has markedly improved. Assessment is slightly limited by\\n patient positioning. There is dextroscoliosis of the thoracic spine. The\\n aorta is calcified. Surgical clips project over the left axilla. The right\\n internal jugular Swan-Ganz catheter has been removed.\\n\\n IMPRESSION:\\n\\n Small-to-moderate bilateral pleural effusions.\\n\\n Interval improvement in right mid lung atelectasis.\\n\\n Support lines as described.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885190,\n \"text\": \" 3:53 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: 80 yo female sp broncoscopy\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA and new line plcmt\\n\\n REASON FOR THIS EXAMINATION:\\n 80 yo female sp broncoscopy\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Ruptured abdominal aortic aneurysm.\\n\\n Single portable chest radiogram demonstrates an endotracheal tube with its tip\\n at the clavicular head. A nasogastric tube courses through the stomach and\\n below the inferior aspect of the imaged field of view. A right internal\\n jugular central venous catheter is present with its tip in the superior vena\\n cava. There is again evidence of volume loss in the left, although this is\\n markedly improved when compared to the chest radiograph obtained three hours\\n prior. Again seen are mild-to-moderate bilateral pleural effusions.\\n Prominent vascular markings in the right lung likely represents mild fluid\\n overload. Degenerative changes are present throughout the thoracic spine.\\n\\n Surgical clips project over the left axilla.\\n\\n IMPRESSION:\\n\\n Small-to-moderate bilateral pleural effusions, unchanged.\\n\\n Interval improvement of left-sided atelectasis and volume loss.\\n\\n Support lines as described.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-11-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 885742,\n \"text\": \" 8:41 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: assess left lower lobe collapse, please perform x-ray at 9pm\\n Admitting Diagnosis: S/P AAA REPAIR\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\\n maneuver\\n REASON FOR THIS EXAMINATION:\\n assess left lower lobe collapse, please perform x-ray at 9pm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ruptured abdominal aortic aneurysm, now with persistent left\\n lower lobe collapse.\\n\\n PORTABLE AP CHEST: Comparison is made to study performed seven hours prior.\\n There has been no interval change in the appearance of the chest. Endotracheal\\n tube, nasogastric tube, and right IJ central venous catheter remain in stable\\n position. Again, demonstrated is left lower lobe collapse with volume loss\\n and shift of the heart and mediastinal structures. Interstitial edema has\\n improved in the interval. There are persistent small bilateral pleural\\n effusions.\\n\\n IMPRESSION: Persistent left lower lobe collapse, likely due to mucous\\n plugging. Improving interstitial edema.\\n\\n\"\n }\n]"}}},{"rowIdx":24981,"cells":{"subject_id":{"kind":"number","value":141,"string":"141"},"hadm_id":{"kind":"number","value":168006,"string":"168,006"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"There is a small amount of hyperattenuating fluid over the right parietal lobe which was seen previously and relates to subarachnoid hemorrhage. Again noted is a small right pleural effusion with pleural thickening/fluid noted in the right lower lateral hemithorax. TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT CONTRAST: There has been progression of a large infarct including the left-sided parietal, temporal and occipital lobes. There is hyperattenuating fluid overlying the tentorium which was seen previously and corresponds to a subdural hematoma which has not changed in appearance. Again noted is a right pleural effusion and effusion/pleural thickening along the lateral right pleura, which is unchanged. 3) Persistent small right pleural effusion and pleural thickening/fluid within the right lower lateral hemithorax. The ascending aorta is mildlydilated. Grayscale and Doppler images of the right and left common femoral, superficial femoral, greater saphenous, popliteal veins were obtained. There is edema associated with this area with mass effect and right-sided midline shift. There is moderate pulmonary artery systolichypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is elongated. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve appears structurally normal with trivial mitralregurgitation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. CT ABDOMEN WITHOUT CONTRAST: There are moderate size bilateral pleural effusions. There are calcifications within the carotid bifurcations bilaterally. There is a stable amount of subarachnoid hemorrhage overlying the sulci of the left frontal lobe, left temporoparietal and right temporoparietal regions. There is moderatepulmonary artery systolic hypertension. TECHNIQUE: Noncontrast head CT. There is noaortic valve stenosis. This could be related to intrabladder hematoma, although other space occupying mass cannot be excluded. Retroperitoneal hematoma. CT PELVIS WITH CONTRAST: There is soft tissue stranding extending along the lateral conal fascia, psoas muscle and retroperitoneum. Left frontal lobe subarachnoid hemorrhage. FINDINGS: Again there is intraparenchymal hemorrhage in the anterior portion of the left temporal lobe. There is slight left ventricular enlargement with minimal upper zone redistribution which may be related to patient's positioning. There is fluid withn the sphenoid sinus and the right mastoid air cells. This may be due to asymmetric prostatic enlargement. There is opacification within the the right lung apex. Additionally there is fluid within the sphenoid sinus and ethmoid air cells without associated fractures of these sites appreciated. There is ill-defined opacity at the right lung base, of unknown chronicity. FINDINGS: There is hemorrhage seen in the left temporal pole. There is left neural foraminal narrowing at the left C2/3 and C3/4 levels. There also appears to be a small amount of left- sided uncal herniation which was present previously and has not changed in appearance. There is a small amount of blood within the occipital horns of the lateral ventricles. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets are mildly thickened. The prevertebral soft tissues cannot be assessed more inferiorly. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Comparison is made to previous lower extremity bilateral venous ultrasound dated . ABD FIRM AND DISTENDED WITH BOWEL SOUNDS.GU: FOLEY CATH CONT TO LEAK, U/O LOW. OGT to low intermittent sx draining brow, bilious liquid.ID: Remains afebrile.Access: Has triple lumen in L groin. Aspen collar intact.resp: remains intubated and vented with a/c 14/600/40%/5peep, min vol 8.7 L, sxn for small amts thick blood tinged secretions, breath sounds coarse.cv: HR 80-90 SR, no VEA, BP 160-170 IV NTG gtt initiated, titrate to goal BP 120-140,heme: transfused with second unit PRBC's, 1 bag plt, hct 24, post plt ct 124gu: foley leaking around catheter, foley replaced with #18, urine 40-60cc/hrid: cont clinda/levoflox, afebrile, wbc 1.8 this amsocial: NH called for update on status, no contact from family member or guardian, social work involvedPLAN: follow neuro exam, titrate NTG gtt to goal BP 120-140, follow coags, correct coagulopathy NTG D/C'D AND STARTED ON NIPRIDE, TITRATED UP TO 2.0 MCQ/KG, WEANING DOWN THIS AM TO 1.2MCQ'S. PT SX FOR MOD AMT'S OF THIN BLOOD TINGED SECRETIONS. CXR done after first attempt.F&E: K and Mg to be repleted once access is obtained.Heme: Hct. keep sbp 120/-140/ neuro check q 1 hr vit k 10 mg sc x3 daysinsulin gt titratefollow lactate, ivf TEMP MAX 99.2 PO.RESP: PT VERY TACHYPNEIC WITH RATES IN THE 30'S, PT VERY WHEEZY INSP/EXP. Patient remains on mechanical ventilation, transfused this morning for low Hct.BS diminished, not much secretion bloody catheter instead. SX FOR BLOODY SECRETIONS.GI: PT HAS OGT WHICH WAS PLACED DURING INTUBATION WHICH WAS PASSED THROUGH AN ETT. Pt sedated. micu npn 0700-1900review of systems:neuro: sedated with propofol gtt, am wake up, RR 30's grimacing, out of synch with ventilator, no spontaneous movement, resedated. HCT 20, IS PRESENTLY RECEIVING A UNIT OF PACKED CELLS.. PT HAS SMALL RETROPERITONEAL BLEED FROM LINE PLACEMENT EARLIER IN THE DAY.LACTIC ACID DOWN TO 6.5 FROM 15.PT REMAINS FULL CODE. remains sedated on Propofol 43mcg/kg gtt. HO notified and pronounced pt dead. patient does not follow commands.aspen collar in place.hems: transfused 2 units prbc's afer multilumen inserted. Add 1830p given 2 uffp inr 1.6, bc x2 sent, nasal swab for msra sent, given lopressor 5mg iv x1 sbp >150 KEEP BP 120-140 RANGE, TREAT WITH LOPRESSOR. Compared to the previous tracing of nosignificant change. R pupil is pinpoint and reactive, L has cataract-3mm. HR IN 70'S -80'S WITH NO ECTOPY.AFEBRILE, TAKING FEW SPONTANEOUS BREATHS OVER THE VENT.GI: PT HAS ORAL GT. Some inspiratory wheezes on exam. cerebral hemmorhagedkametabolic acidosisarfuti pna lt retrocardiac opacityincrease inrrhabdomyolysisp. post transfusion hct= 26.8.endo: following q 6 hr glucose and tx with sliding scale. On Nitroprusside at 1.2mcg/kg. O2 SAT'S HIGH 90'S TO 100%.NEURO: PT WELL SEDATED, PT AROUSES WITH PAINFUL STIMULI. grimacing and furrowing forehead when suctioned or attempts at mouth care. AT 2330 IT WAS DECIDED TO ELECTIVELY AND SEDATE PT IN ORDER TO OBTAIN ACCURATE CT SCAN AND CORRECT LOW PO2. sedation stopped this last pm for eval by neuro. Pt died comfortable on the morphine drip."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2140-11-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":804020,"text":" 7:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p fall. change in MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall. change in MS\n contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe SUN 10:01 AM\n L temp lobe hemorrhage. L frontal small SAH\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: 80 year old man status post fall with change in mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is hemorrhage seen in the left temporal pole. In addition,\n there is high attenuation material at the periphery of the left frontal lobe.\n There is no mass effect or shift of the normally midline structures. The\n ventricles and sulci are unremarkable. Again seen is deep white matter low\n attenuation, also seen in the subinsular regions. These are unchanged from\n the prior study.\n\n Bone windows demonstrate no fractures. The overall study is somewhat limited\n by motion artifact.\n\n IMPRESSION: Left temporal lobe contusion. Left frontal lobe subarachnoid\n hemorrhage.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":804021,"text":" 7:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p fall, hypoxic\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall, hypoxic\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and fall.\n\n FINDINGS: This study is limited by patient motion. There is prominence of\n the upper mediastinum which is likely secondary to the supine\n technique. There is ill-defined opacity at the right lung base, of unknown\n chronicity. There is miniaml patchy increased density in the left\n retrocardiac region. There is no evidence of pneumothorax or definite pleural\n effusion. There is no evidence of overt heart failure. There are fractures of\n the left 4th, 5th, and 6th ribs posterolaterally. One of these rib fractures\n demonstrates evidence of callus formation. Other of these fractures\n demonstrate distraction without callus formation.\n\n IMPRESSION: 1. Ill-defined density right lung base and left retrocardiac\n area, of unknown chronicity/etiology. An acute process in these areas cannot\n be excluded. PA and lateral chest radiograph would be helpful when possible.\n\n 2. Left 4th, 5th, and 6th posterior rib fractures. One of these fractures\n demonstrates callus formation; the other two demonstrate distraction without\n callus formation. These may all be chronic or subacute; given the history of\n fall, clinical correlation is recommended.\n\n"},{"category":"Radiology","chartdate":"2140-11-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":804311,"text":" 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm L SC line placement, r/o PTX\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p L SC central line placement\n REASON FOR THIS EXAMINATION:\n confirm L SC line placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n For CV line placement.\n\n Tip of left subclavian CV line overlies proximal SVC. ETT is 3 cm above\n carina. Tip of NG tube is in distal antrum of stomach. No change in appearance\n of heart or lungs since prior film of same date.\n\n IMPRESSION: Lines and tubes as described and satisfactorily located. No\n pneumothorax or other change since prior film of same date.\n\n"},{"category":"Radiology","chartdate":"2140-11-07 00:00:00.000","description":"P BILAT LOWER EXT VEINS PORT","row_id":804115,"text":" 9:03 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: HYPOXIA AND INCREASED RESP STATUS, EVAL FOR DVT\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with hypoxia and increased respiratory status, h/o of\n immobility in nursing home\n REASON FOR THIS EXAMINATION:\n Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, increased respiratory distress, history of immobility.\n Please evaluate for DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Comparison is made to previous\n lower extremity bilateral venous ultrasound dated . Grayscale and\n Doppler images of the right and left common femoral, superficial femoral,\n greater saphenous, popliteal veins were obtained. Normal flow,\n compressibility, and augmentation were present throughout. No intraluminal\n thrombus was identified.\n\n IMPRESSION: No evidence of lower extremity deep venous thrombosis.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-06 00:00:00.000","description":"C-SPINE, TRAUMA","row_id":804041,"text":" 11:11 AM\n C-SPINE, TRAUMA Clip # \n Reason: s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Change in mental status s[ fall.\n\n AP, LATERAL AND ODONTOID VIEWS OF THE CERVICAL SPINE: Imaging of the mid and\n lower cervical spine is suboptimal due to overlying soft tissue and humerus.\n There is no prevertebral soft tissue swelling at the C1 through C3 levels,\n although there appeared to be some increase in soft tissue in the posterior\n pharynx. The prevertebral soft tissues cannot be assessed more inferiorly.\n\n On the swimmer's view, there is a quesiton of cortical step-off at the\n posterior margin of the dens; this could be an artifact of limited bone detail\n on this view (the odontoid view shows no abnormality), although further\n evaluation is recommended.\n\n Evaluation of vertebral body alignment is limited. Degenerative change is\n noted.\n\n IMPRESSION: Nondiagnostic study, as detailed above. See above comments\n regarding the appearance of the dens on the swimmer's view. A CT of the\n cervical spine should be strongly considered based on these findings.\n\n These findings were discussed with the requesting physician, . , at\n approximately 12:05 p.m. on the date of study.\n\n"},{"category":"Radiology","chartdate":"2140-11-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":804082,"text":" 12:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for ETT placement\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with delta MA, metabolic acidosis, s/p head bleed s/p ETT\n placement.\n REASON FOR THIS EXAMINATION:\n Please assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change, metabolic acidosis, s/p head bleed and ETT\n placement.\n\n VIEWS: Semierect AP view compared with supine AP view from .\n\n FINDINGS: There has been interval placement of ETT with tip approximately 4\n cm above the carina. A NGT has also been placed with the tip below the\n diaphragm and extending off the inferior borders of the film. No pneumothorax\n is identified. The left lateral hemithorax is excluded from this film. There\n is slight left ventricular enlargement with minimal upper zone redistribution\n which may be related to patient's positioning. Again noted is a small right\n pleural effusion with pleural thickening/fluid noted in the right lower\n lateral hemithorax. Numerous rib fractures are again noted within the right\n posterior ribs. No pneumothorax is present.\n\n IMPRESSION:\n 1) Satisfactory placement of ETT and NGT.\n 2) Slight left ventricular enlargement and minimal upper zone redistribution,\n likely related to patient positioning, however minimal left ventricular\n failure cannot be excluded.\n 3) Persistent small right pleural effusion and pleural thickening/fluid\n within the right lower lateral hemithorax.\n\n"},{"category":"Radiology","chartdate":"2140-11-07 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":804084,"text":" 12:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for evolution of head bleed.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man found down with acute head bleed seen on head CT now\n with continued delta MS neuro exam\n REASON FOR THIS EXAMINATION:\n Please eval for evolution of head bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old man found down with an acute head bleed seen on prior\n CT now with continued mental status changes and nonfocal neural examination.\n Evaluate for progression of intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Again there is intraparenchymal hemorrhage in the anterior portion\n of the left temporal lobe. Better visualized is contusion of the inferior\n frontal lobes, greater on the left. There is a stable amount of subarachnoid\n hemorrhage overlying the sulci of the left frontal lobe, left temporoparietal\n and right temporoparietal regions. Additionally there is subarachnoid blood in\n the intrapeduncular cistern. There is a small amount of blood within the\n occipital horns of the lateral ventricles. While this is not commented upon in\n the prior study, there is motion limiting the evaluation on the previous\n study. Thin subdural CSF density collections have developed.\n\n Again seen is the white matter low attenuation in the subinsular and\n periventricular white matter, unchanged. There is no shift of normally midline\n structures. Ventricles are not dilated.\n\n BONE WINDOWS: There is a nondisplaced fracture through the right temporal\n bone, mastoid air cells and middle ear cavity. There is fluid within the right\n mastoid air cells. There is soft tissue density deep to the eardrum in the\n middle ear cavity which is most likely blood given the associated fracture.\n Additionally there is fluid within the sphenoid sinus and ethmoid air cells\n without associated fractures of these sites appreciated. These frontal\n sinuses, and upper portions of the maxillary sinuses and left mastoid air\n cells are free of fluid.\n\n IMPRESSION:\n\n 1) Given the differences in technique, there is no significant difference in\n the appearance of the brain parenchyma and its various hemorrhages since the\n prior study.\n 2) Fracture through the right mastoid air cells with fluid in the mastoid air\n cells in the middle ear cavity, presumably blood related to the patient's\n fracture. No other fractures are appreciated.\n\n (Over)\n\n 12:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for evolution of head bleed.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n These findings were telephoned to Dr. , physican caring for the\n patient at the time of the study.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-07 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":804085,"text":" 1:00 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please eval for C-spine fracture.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status s/p fall and ?dens fracture on plain\n films\n REASON FOR THIS EXAMINATION:\n Please eval for C-spine fracture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Elderly man s/p fall, evaluate for cervical spine fracture.\n Questionable dens abnormality on plain films.\n\n TECHNIQUE: Axial images were performed through cervical spine with sagittal\n and coronal reformatted images.\n\n FINDINGS: On the sagittal reformatted series, images 20 and 22 there is a\n lucent line through the base of the dens. This does appear to violate the\n posterior cortex on image 20. There is no displacement. This is not well\n appreciated on the axial or coronal reformatted series, while this may be\n artifactual or a vascular groove, a nondisplaced dens fracture cannot be\n entirely excluded. There is some thickening of the prevertebral soft tissues\n anterior to this. No other area suspicious for cervical spine fracture is\n identified. There is cervical spondylosis in the mid cervical spine with\n endplate sclerosis and loss of disc height at the C3-4, C4-5 and C5-6 levels.\n There is normal alignment of the cervical vertebral bodies. No evidence of\n spinal canal compromise is apparent.\n\n There is fluid withn the sphenoid sinus and the right mastoid air cells. There\n is evidence of a skull fracture extending through the mastoid air cells\n accounting for the fluid within them. Additionally there is soft tissue\n density within the right middle ear canal, deep to the tympanic membrane. This\n may represent blood. No other fractures are appreciated.\n\n There is opacification within the the right lung apex. There are\n calcifications within the carotid bifurcations bilaterally.\n\n IMPRESSION:\n\n 1) Possible nondisplaced fracture through the dens of C2. v. artifact or\n vascular groove.\n 2) Right basilar skull fracture through the right mastoid air cells.\n Additionally there is soft tissues density within the middle ear cavity which\n could represent acute blood products.\n 3) Fluid within the sphenoid sinus without a fracture seen. However, the\n entire sphenoid sinus is not imaged.\n\n These findings were telephoned to Dr. , the physician caring for\n the patient at the time of the study.\n\n (Over)\n\n 1:00 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please eval for C-spine fracture.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n NOTE: An MRI study of the cervical spine may be helpful in excluding edema in\n C2, which if present, would support the presence of a fracture. However, a\n negative result does not exclude a fracture.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-07 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":804086,"text":" 1:01 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please assess for mesenteric ischemia\n Admitting Diagnosis: DRA, SAH\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\n with guaiac positive stools.\n REASON FOR THIS EXAMINATION:\n Please assess for mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 80 year old man with altered mental status, 10. hematocrit drop,\n distended abdomen and quiac positive stools. The patient has a mildly elevated\n creatine. Evaluate for mesenteric ischemia or retroperitoneal hematoma.\n\n TECHNIQUE: Noncontrast images were obtained from the lung bases to the pubic\n symphysis. There are no prior studies for comparison.\n\n CT ABDOMEN WITHOUT CONTRAST: There are moderate size bilateral pleural\n effusions. There is dense consolidation at the right lung base with air\n bronchograms. This could represent aspiration vs pneumonia.\n\n Noncontrast images of the liver, gallbladder, pancreas, spleen, adrenals and\n kidneys are within normal limits. The upper bowel loops are unremarkable.\n\n CT PELVIS WITH CONTRAST: There is soft tissue stranding extending along the\n lateral conal fascia, psoas muscle and retroperitoneum. This extends to the\n left groin and can be seen with recent femoral puncture and bleeding. There is\n no large focal hematoma. The unopacified bowel loops are within normal\n limits. The bowel loops are not dilated and there is no evidence of wall\n thickening to suggest ischemia. There is a moderate amount of calcification at\n the origin of the celiac and SMA vessels. There is no calcification at the\n origin of the . There is a lobulated appearance to the prostate gland with\n the Foley catheter being deviated to the right as it enters the urinary\n bladder. This may be due to asymmetric prostatic enlargement.\n\n BONE WINDOWS: There are multiple bilateral fractures of the lower ribs. Each\n rib is broken in more than one place. This can result in a flail chest.\n Additionally there are fractures of the L1 and L2 right transverse processes.\n\n IMPRESSION:\n\n 1) Mild amount of stranding extending from the left groin up along the left\n psoas muscle consistent with a mild amount of retroperitoneal bleeding given\n the recent history of a line placement at this site.\n\n 2) No secondary signs of mesenteric ischemia.\n\n 3) Asymmetric appearance to the base of the bladder. This may be due to\n (Over)\n\n 1:01 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please assess for mesenteric ischemia\n Admitting Diagnosis: DRA, SAH\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n asymmetric hypertrophy of the prostate.\n\n 4) Multiple bilateral rib fractures and transverse process fractures. Has the\n patient had a recent cardiopulmonary resuscitation or trauma?\n\n\n\n\n"},{"category":"Radiology","chartdate":"2140-11-06 00:00:00.000","description":"P PELVIS (AP ONLY) PORT","row_id":804022,"text":" 7:54 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n FINDINGS: This study is limited by patient motion. This single AP view of\n the pelvis demonstrates no evidence of obvious fracture or dislocation. There\n is a left-sided femoral line in position with its distal tip within the left\n hemipelvis. There is no evidence of overt bone destruction or bone erosion.\n\n IMPRESSION: No obvious fracture on this limited study.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":804252,"text":" 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u L temporal contusion\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man w/ L temp contusion\n REASON FOR THIS EXAMINATION:\n f/u L temporal contusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old man status post fall with decreased mental status.\n Left temporal contusion.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT CONTRAST: There has been progression of a large infarct\n including the left-sided parietal, temporal and occipital lobes. This infarct\n is within the MCA distribution, and may be secondary to an internal carotid\n dissection at the time of the trauma. There is edema associated with this\n area with mass effect and right-sided midline shift. There has been complete\n effacement of the left lateral ventricles. There is also an area of infarct\n within the left temporal and frontal lobes which corresponds to the previous\n areas of contusion.\n\n No new evidence of intracranial hemorrhage when compared to the previous exam.\n There is increased intraparenchymal blood as well as well as a subdural\n hematoma within the left middle cranial fossa and the left temporal lobe.\n There is hyperattenuating fluid overlying the tentorium which was seen\n previously and corresponds to a subdural hematoma which has not changed in\n appearance. This blood is also seen tracking up the falx. There is a small\n amount of hyperattenuating fluid over the right parietal lobe which was seen\n previously and relates to subarachnoid hemorrhage. There also appears to be a\n small amount of left- sided uncal herniation which was present previously and\n has not changed in appearance.\n\n There is opacification of the bilateral mastoid air cells, and there is\n opacification within the right middle ear and fluid within the sphenoid sinus.\n\n IMPRESSION: Continued evolution of a large left middle cerebral artery\n infarction. Increased mass effect secondary to edema of this infarction with\n right-sided shift and effacement of the left lateral ventricles. No new\n hemorrhage when compared to the previous exam. These findings were called to\n the caring team at the time of the exam.\n\n"},{"category":"Radiology","chartdate":"2140-11-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":804301,"text":" 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pnuemothorax\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p R SC central line attempt with arterial puncture\n REASON FOR THIS EXAMINATION:\n r/o pnuemothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right subclavian central line placement with arterial\n puncture. ? placement/pneumothorax.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The cardiomediastinal and hilar contours are stable.\n There is interval increase in diffuse interstitial opacification and the\n pulmonary vasculature appears more prominent than in the prior study. Again\n noted is a right pleural effusion and effusion/pleural thickening along the\n lateral right pleura, which is unchanged. The left CP angle is not included\n in the study, and a left effusion cannot be excluded. The ET and NG tubes\n remain unchanged in position. There is no pneumothorax. Numerous rib\n fractures are again noted.\n\n IMPRESSION:\n\n 1. No evidence of pneumothorax.\n 2. Interval increase in interstitial edema and prominence of the pulmonary\n vasculature in the setting of right effusion, consistent with slightly\n worsened heart failure.\n 3. Stable ET & NG tubes.\n\n\n"},{"category":"Radiology","chartdate":"2140-11-08 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":804260,"text":" 11:41 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\n Admitting Diagnosis: DRA, SAH\n Field of view: 43\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\n with guaiac positive stools.\n REASON FOR THIS EXAMINATION:\n bleed? Will be there soon for head CT.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS\n\n INDICATION: Guaiac positive stools. Continued drop in hematocrit.\n Retroperitoneal hematoma.\n\n Comparison is made to the prior exam of one day earlier on .\n\n TECHNIQUE: Noncontrast images of the abdomen and pelvis were performed.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Multiple bilateral rib fractures and\n fractures of the L1 and L2 transverse processes are again noted. No\n pneumothoraces at the lung bases are seen. There is interval increase in size\n of small-moderate bilateral pleural effusions, left greater than right with\n adjacent basilar consolidation. An NG tube is seen with it's tip at the\n gastroduodenal junction. No free air seen. The liver, gallbladder, pancreas,\n spleen, adrenal glands, and kidneys are stable in appearance. Newly\n appreciated within the right lower quadrant, is a 5.9 x 4.3 cm fluid\n collection of increased density overlying and most probably related to the\n cecum.\n\n The previously appreciated increased thickening and stranding extending from\n the left groin to the retroperitoneum and lateral coronal fascia is slightly\n increased in the interval. The stomach and small bowel loops are\n unremarkable. Note is made of high density material within the large bowel\n lumen distal to the site of likely cecal hematoma. This high density extends\n throughout the colon and is most notable in the rectum and sigmoid. No oral\n contrast was administered.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The bladder contains high density fluid,\n and a balloon Foley catheter tip is seen displaced to the right and\n anteriorly.\n\n IMPRESSION: 1. Newly identified high density localized fluid collection\n related to the cecum measuring 5.9 x 4.3 cm. Increased density intraluminal\n material throughout the large bowel distal to this presumed cecal hematoma\n presumably relates to intraluminal blood products, as oral contrast was not\n administered.\n 2. Mild interval increase in amount of soft tissue stranding\n extending from the left groin and tracking through the retroperitoneum,\n (Over)\n\n 11:41 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\n Admitting Diagnosis: DRA, SAH\n Field of view: 43\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n probably related to mild hemorrhage from left femoral line placement.\n 3. High density material within the bladder seen to displace the\n balloon Foley tip. This could be related to intrabladder hematoma, although\n other space occupying mass cannot be excluded. The appearance of this is\n unchanged from yesterday.\n 4. Interval mild increase in size of bilateral pleural\n effusions, left greater than right, with adjacent basilar consolidation.\n\n"},{"category":"Radiology","chartdate":"2140-11-08 00:00:00.000","description":"MR CERVICAL SPINE","row_id":804270,"text":" 1:09 PM\n MR CERVICAL SPINE Clip # \n Reason: w/ inversion recovery images. ? dens fx, r/o ligamentous i\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with L temporal contusion s/p fall\n REASON FOR THIS EXAMINATION:\n w/ inversion recovery images. ? dens fx, r/o ligamentous injury s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left temporal contusions, S/P fall. Evaluate for dens fracture\n or ligamentous injury.\n\n TECHNIQUE: Sagittal T2, T1, inversion recovery, and axial gradient echo\n sequences.\n\n FINDINGS: Comparison is made to the C-spine CT from . No\n abnormal signal on inversion recovery sequences or T2 sequences are seen\n within the odontoid process. Nevertheless, a fracture cannot be excluded.\n There is increased T2 and inversion recovery signal intensity anterior to the\n vertebral bodies, which may reflect ligamentous injury. Prevertebral soft\n tissue swelling is present. Multilevel degenerative changes are present, with\n desiccation of intervertebral disks and loss of disk space height, most\n pronounced at C3/4, C4/5, and C5/6. There is also moderately severe anterior\n osteophyte formation at these levels. There is left neural foraminal\n narrowing at the left C2/3 and C3/4 levels.\n\n Also noted on the STIR sequences increased signal within the T4 vertebral\n body, which may represent a fracture.\n\n IMPRESSION: 1) No signal abnormality within the odontoid process.\n Nevertheless, a fracture at this level cannot be excluded.\n\n 2) Increased T2 and STIR signal intensity within the prevertebral soft tissue\n and the anterior longitudinal ligament. This may reflect a ligamentous\n injury.\n\n 3) Increased T2 signal intensity within the T4 vertebral body, with irregular\n marrow signal. Findings may represent a fracture.\n\n"},{"category":"Echo","chartdate":"2140-11-07 00:00:00.000","description":"Report","row_id":69871,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Valvular heart disease.\nBP (mm Hg): 181/75\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 13:24\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is moderate pulmonary artery systolic\nhypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thickness, cavity size,\nand systolic function are normal (LVEF>55%). The ascending aorta is mildly\ndilated. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. Trace aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared to previous report (study not available for review) from ,\nthe right ventricular systolic pressure has increased.\n\n\n"},{"category":"ECG","chartdate":"2140-11-07 00:00:00.000","description":"Report","row_id":151559,"text":"Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2140-11-06 00:00:00.000","description":"Report","row_id":151560,"text":"Sinus rhythm. Supraventriciular extrasystoles. Inferior/lateral ST-T wave\nchanges are non-specific. Compared to the previous tracing of no\nsignificant change.\n\n"},{"category":"Nursing/other","chartdate":"2140-11-06 00:00:00.000","description":"Report","row_id":1261991,"text":"Admit note 80 yo black male NH resident found down at NH approx 1.5 hrs noted to have laceration on back of head lt side he was alert and oriented at that time. His o2 sat was 87% came into the ed disoriented and c collar not in place had lt lac head, labs glucose 393 anion gap 30, cpk 2135, phos 5.8. ekg elevated t waves v2-3 CT showed lt temporal hemorrhage with lt SAH small inr was elevated. Has rib fx, found to have UTI given 500mg levo iv WBC 15.6 cxr lt retrocardiac opacity\nPMH cardiopulm emboli, dementia, psychosis, syndrome of inappropirate antidiuretic hormone, urine incont. prostatic hypertrophy, htn, dm II, cva, lung abscess ribs removed, ? hepatitis B, +MRSA\nsocial etoh abuse, ivda, was homeless now in NH demented has (notified has not seen in awhile), , allergies nka\nNeuro arrived to floor garbled speech pearla 2mm brisk was not fc after few hrs would fc inconsistently tylenol and etoh levels neg\ncorneal reflex intact face symetrical, collar on logrolled\ncardiac K+ in er 3.4 tx ivf 40 kcl k+ 4.7, ST 100-110 without ectopy sbp 110/-160/, cpk 3827 mb 93\nresp 4lnp 7.26/27/77/-13/13 repeat 7.30/33/91/- lungs exp wheezes throughout RR 36-44\nGI abd snt bs + npo\ngu 0-30 q hr receiving iv boluses cr 1.6 bun 27\nendo bs 211-125 insulin drip titrated lactate 15.3 to 14\nid wbc 15.6 temp max 99.8 on levo and clinda a nasal swab sent msra bc x2 sent\naccess lt fem triple lumen line, lt aline radial\na. cerebral hemmorhage\ndka\nmetabolic acidosis\narf\nuti pna lt retrocardiac opacity\nincrease inr\nrhabdomyolysis\np. keep sbp 120/-140/ neuro check q 1 hr vit k 10 mg sc x3 days\ninsulin gt titrate\nfollow lactate, ivf\n\n\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1262002,"text":"MICU NPN Update Code status:\nFamily met with Dr. and pt's primary care MD also discussed case with pt's guardian at length. Decision was made to withdraw aggressive care this afternoon. Plan is to extubate him after he has a morphine drip started and looks comfortable on this. If he looks stable he will be called out to the floor CMO. All meds are d/c'd as well as blood draws.\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1262003,"text":"MICU NPN Update:\nPt was extubated just a little before 8PM. Pt immediately dropped his sats and BP and by 8:30PM he was asystolic. Pt died comfortable on the morphine drip. HO notified and pronounced pt dead. He will notify family of the death.\n"},{"category":"Nursing/other","chartdate":"2140-11-08 00:00:00.000","description":"Report","row_id":1261997,"text":"NPN 7a-7p\nNeuro: Pt. remains sedated on Propofol 43mcg/kg gtt. R pupil is pinpoint and reactive, L has cataract-3mm. Has mild reaction to painful stimuli, grimaces and flexes. Went for head ct today to evaluate bleed and look for cerebral edema. Pt. has C-2 fx. Also went to MRI to evaluate status of cervical spine, results pnd. Aspen collar in place.\nCV: HR 80's. On Nitroprusside at 1.2mcg/kg. SBP maintained at 130-140 most of the day. Was off Nipride briefly and SBP was 150.\nResp: Remains vented on 50% 600x18 5. Sx for small amount of prulent looking sputum, cx sent. Some inspiratory wheezes on exam. On levo for presumed pneumonia.\nGI: Had ct of abdomen which shows bleed in his cecum. Also has multiple old rib fx. Tube feedings on hold. No stool today. Started on sucralfate today. OGT to low intermittent sx draining brow, bilious liquid.\nID: Remains afebrile.\nAccess: Has triple lumen in L groin. R subclavin attempt was unsuccessful, team will try again. CXR done after first attempt.\nF&E: K and Mg to be repleted once access is obtained.\nHeme: Hct. 21. No overt signs of bleeding. FDP panel snet. Due for 2 u PRBC once line placed.\nSocial: Patients grand niece has been contact and she gave consent for line access. Pt. is DNR. Social work consulted. Spoke with director of nursing at nursing home regarding pt. status.\nSkin: Pt. has large bruise under R axilla which has not increased in size. Area outlined.\nAssessment: Pt. with multiple old rib fx, new SAH and stroke, blood in cecum. ? etiology of multiple injuries.\nPlan:\n-obtain access\n-transfuse 2u PRBC\n-Hct 4 hours post transfusion\n-Replete K and P04.\n-Follow neuro exam.\n-Sx prn\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1261998,"text":"Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 600, A/c 18, Fio2 50%, and Peep 5. Pt sedated. Adequate O2 sats. Bs clear bilaterally. Sx'd for sm amounts of thick yellow sputum. No further vent changes made this shift. Unable to do RSBI this am. No spont effort. Plan: Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1261999,"text":"PaO2 decreasing to 66. Fio2 increased to 60%.\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1262000,"text":"CV goal sbp to be between 120 - 140. niprid increased to 3 mics over night in attemps to get sbp with in goal range.\n"},{"category":"Nursing/other","chartdate":"2140-11-09 00:00:00.000","description":"Report","row_id":1262001,"text":"CV: hr 80-90 nsr No ectopy. goal sbp= 140-160..nipride increased overnight to 2.8 mics/kg/min to maintain this goal.\nGu: foley draining clear yellow urine.some leaking around foley contained by wrapping around catheter and penis. urine ouput is adequate..increase urine ouput after mannitol 100 mg given.\ngi: og tube draining bilious. bowel sounds present but hypoactive.no stool.\nneuro: patient is sedate. on propofol at 43 mics/kg/min. sedation stopped this last pm for eval by neuro. patient moved bioth legs on bed to painful stimuli.moved both hands on bed to paiful stimuli. grimacing and furrowing forehead when suctioned or attempts at mouth care. patient does not follow commands.aspen collar in place.\n\nhems: transfused 2 units prbc's afer multilumen inserted. post transfusion hct= 26.8.\nendo: following q 6 hr glucose and tx with sliding scale. 2 units reg for bs of 167 st 2400. this a.m. glucose =176 tx with 2 units reg at 0530.\nresp: abg ph=7.47/30/po2 =66 fio2 increased to 70 %. suctione dq 2-3 hours for small amounts thick yellow.\n"},{"category":"Nursing/other","chartdate":"2140-11-06 00:00:00.000","description":"Report","row_id":1261992,"text":"Add 1830p given 2 uffp inr 1.6, bc x2 sent, nasal swab for msra sent, given lopressor 5mg iv x1 sbp >150\n"},{"category":"Nursing/other","chartdate":"2140-11-07 00:00:00.000","description":"Report","row_id":1261993,"text":"NURSING PROGRESS NOTE:\nNEURO: PT RECEIVED WITH CERVICAL COLLAR ON, PT MUMBLING AND CALLING OUT. UNABLE TO UNDERSTAND WHAT HE WANTED. MAE, FOLLOWS COMMANDS, PERLA, 2CM REACTING BRISKLY. HO ATTEMPTED NGT PLACEMENT HR DROPPED TO THE 50'S AND BECAME HYPOTENSIVE TO THE 70'S. AFTER THIS IT WAS THEN NOTICED THAT RIGHT PUPIL MUCH LARGER THAN THE LEFT, APPROX 5REACTING SLUGGISHLY AND LEFT 2 REACTIVE BRISKLY. PT HAD REPEAT CT SCAN WHICH SHOWED NO CHG IN BLEED, SKULL FX, QUESTIONABLE C2 FX. PT NOW HAS ASPEN COLLAR IN PLACE. PT CONT TO MAE, RESPONDS TO STIMULI, FOLLOWS SIMPLE COMMANDS. UNABLE TO VISUALIZE POST HEAD LACERATION DUE TO COLLAR AND HAIR.\nCV: PT'S HR NSR 70-80'S WITHOUT ECTOPY. SBP STABLE SEE FLOWSHEET FOR DATA. KEEP BP 120-140 RANGE, TREAT WITH LOPRESSOR. PRESENTLY ON 40MCQ OF PROPOFOL FOR SEDATION WHILE INTUBATED. TEMP MAX 99.2 PO.\nRESP: PT VERY TACHYPNEIC WITH RATES IN THE 30'S, PT VERY WHEEZY INSP/EXP. COARSE AT THE BASES. UNABLE TO COUGH AND RAISE SECRETIONS. SEVERAL ABG'S DRAWN DURING THE NIGHT. SEE FLOWSHEET. AT 2330 IT WAS DECIDED TO ELECTIVELY AND SEDATE PT IN ORDER TO OBTAIN ACCURATE CT SCAN AND CORRECT LOW PO2. 2345 PT AND CONFIRMED PLACEMENT BY CXR. SX FOR BLOODY SECRETIONS.\nGI: PT HAS OGT WHICH WAS PLACED DURING INTUBATION WHICH WAS PASSED THROUGH AN ETT. LWS DRAINING BROWN GUIAIC POS DRAINAGE.\nGU: FOLEY CATH DRAINING VERY SMALL AMT'S OF YELLOW FOUL SMELLING URINE WITH SEDIMENT. 8-60CC/HR. FOLEY LEAKING URINE AROUND CATH, INC FLUID IN BALLOON WHICH SEEMED TO HELP AT THIS TIME.\nENDO: PT IS ON INSULIN DRIP PRESENTLY AT 3UNITS, TITRATED ACCORDING TO FINGERSTICKS.\nPT 2UNITS FFP FOR ELEVATED INR. HCT 20, IS PRESENTLY RECEIVING A UNIT OF PACKED CELLS.. PT HAS SMALL RETROPERITONEAL BLEED FROM LINE PLACEMENT EARLIER IN THE DAY.\nLACTIC ACID DOWN TO 6.5 FROM 15.\nPT REMAINS FULL CODE. PT HAS LEFT FEMORAL TLC WHICH IS IN GREAT DANGER OF BECOMING INFECTED DUE TO LEAKAGE AROUND FOLEY. HO NOTIFIED OF THIS TO CHG THE SITE.\n"},{"category":"Nursing/other","chartdate":"2140-11-07 00:00:00.000","description":"Report","row_id":1261994,"text":"micu npn 0700-1900\n\nreview of systems:\nneuro: sedated with propofol gtt, am wake up, RR 30's grimacing, out of synch with ventilator, no spontaneous movement, resedated. Pupils right 3mm reactive, left pin point nonreact, -corneals, +cough/gag. Aspen collar intact.\n\nresp: remains intubated and vented with a/c 14/600/40%/5peep, min vol 8.7 L, sxn for small amts thick blood tinged secretions, breath sounds coarse.\n\ncv: HR 80-90 SR, no VEA, BP 160-170 IV NTG gtt initiated, titrate to goal BP 120-140,\n\nheme: transfused with second unit PRBC's, 1 bag plt, hct 24, post plt ct 124\n\ngu: foley leaking around catheter, foley replaced with #18, urine 40-60cc/hr\n\nid: cont clinda/levoflox, afebrile, wbc 1.8 this am\n\nsocial: NH called for update on status, no contact from family member or guardian, social work involved\n\nPLAN: follow neuro exam, titrate NTG gtt to goal BP 120-140, follow coags, correct coagulopathy\n\n\n"},{"category":"Nursing/other","chartdate":"2140-11-07 00:00:00.000","description":"Report","row_id":1261995,"text":"Patient remains on mechanical ventilation, transfused this morning for low Hct.BS diminished, not much secretion bloody catheter instead. CT Scan intra-parenchymal bleed @ (L) temporal lobe, no recent ABG maintaining good saturation will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2140-11-08 00:00:00.000","description":"Report","row_id":1261996,"text":"NURSING PROGRESS NOTE;\nPT REMAINS WELL SEDATED ON PROPOFOL. PT REMAINS /VENT ON A/C 600 X 18 +5 40%. ABG PO2 IN THE 70'S, FIO2 INC TO 70% THEN DROPPED TO 60% WHERE HE IS NOW. SEE FLOWSHEET FOR ABG'S. PT SX FOR MOD AMT'S OF THIN BLOOD TINGED SECRETIONS. LUNG SOUNDS COARSE WITH OCC WHEEZES BUT CLEAR WITH SX'ING. O2 SAT'S HIGH 90'S TO 100%.\nNEURO: PT WELL SEDATED, PT AROUSES WITH PAINFUL STIMULI. MOVES EXTREMETIES ON THE BED ONLY. PUPILS RIGHT LARGER THAN THE LEFT, LEFT NONREACTIVE. DOES NOT OPEN EYES UNLESS STRONGLY STIMULATING.\nCV: PT RECEIVED ON NTG TO KEEP BP 120-140, BP CONSISTENTLY IN THE 180'S. NTG D/C'D AND STARTED ON NIPRIDE, TITRATED UP TO 2.0 MCQ/KG, WEANING DOWN THIS AM TO 1.2MCQ'S. HR IN 70'S -80'S WITH NO ECTOPY.\nAFEBRILE, TAKING FEW SPONTANEOUS BREATHS OVER THE VENT.\nGI: PT HAS ORAL GT. LWS DRAINING BROWN/GREEN MATERIAL, GUIAIC POS. NO STOOL AT THIS TIME. ABD FIRM AND DISTENDED WITH BOWEL SOUNDS.\nGU: FOLEY CATH CONT TO LEAK, U/O LOW. URINE YELLOW WITH SEDIMENT.\nENDO: PT ON INSULIN DRIP TITRATED ACCORDING TO FINGERSTICKS. CHECKED Q 1/HR.\nSKIN: PT HAS SOME OPEN SCRAPS FROM WHEN HE FELL, BACITRACIN OINT APPLIED. PT'S TOES REQUIRED MUCH CLEANSING, GUAZE PLACED BETWEEN TO KEEP DRY AND PROMOTE HEALING. PT HAS ECHYMOTIC AREA UNDER RIGHT AXILLA EXTENDING DOWN RIGHT CHEST WALL. HO NOTIFIED.\nNO CALL RECEIVED BY NH/FAMILY.\nPT IS FULL CODE. ASPEN COLLAR ON.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 804020,\n \"text\": \" 7:45 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: s/p fall. change in MS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p fall. change in MS\\n contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SMLe SUN 10:01 AM\\n L temp lobe hemorrhage. L frontal small SAH\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED) *ABNORMAL!\\n INDICATION: 80 year old man status post fall with change in mental status.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Multiple axial images of the head were obtained without IV\\n contrast.\\n\\n FINDINGS: There is hemorrhage seen in the left temporal pole. In addition,\\n there is high attenuation material at the periphery of the left frontal lobe.\\n There is no mass effect or shift of the normally midline structures. The\\n ventricles and sulci are unremarkable. Again seen is deep white matter low\\n attenuation, also seen in the subinsular regions. These are unchanged from\\n the prior study.\\n\\n Bone windows demonstrate no fractures. The overall study is somewhat limited\\n by motion artifact.\\n\\n IMPRESSION: Left temporal lobe contusion. Left frontal lobe subarachnoid\\n hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 804021,\n \"text\": \" 7:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p fall, hypoxic\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p fall, hypoxic\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hypoxia and fall.\\n\\n FINDINGS: This study is limited by patient motion. There is prominence of\\n the upper mediastinum which is likely secondary to the supine\\n technique. There is ill-defined opacity at the right lung base, of unknown\\n chronicity. There is miniaml patchy increased density in the left\\n retrocardiac region. There is no evidence of pneumothorax or definite pleural\\n effusion. There is no evidence of overt heart failure. There are fractures of\\n the left 4th, 5th, and 6th ribs posterolaterally. One of these rib fractures\\n demonstrates evidence of callus formation. Other of these fractures\\n demonstrate distraction without callus formation.\\n\\n IMPRESSION: 1. Ill-defined density right lung base and left retrocardiac\\n area, of unknown chronicity/etiology. An acute process in these areas cannot\\n be excluded. PA and lateral chest radiograph would be helpful when possible.\\n\\n 2. Left 4th, 5th, and 6th posterior rib fractures. One of these fractures\\n demonstrates callus formation; the other two demonstrate distraction without\\n callus formation. These may all be chronic or subacute; given the history of\\n fall, clinical correlation is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 804311,\n \"text\": \" 8:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: confirm L SC line placement, r/o PTX\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man s/p L SC central line placement\\n REASON FOR THIS EXAMINATION:\\n confirm L SC line placement, r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE AP FILM:\\n\\n For CV line placement.\\n\\n Tip of left subclavian CV line overlies proximal SVC. ETT is 3 cm above\\n carina. Tip of NG tube is in distal antrum of stomach. No change in appearance\\n of heart or lungs since prior film of same date.\\n\\n IMPRESSION: Lines and tubes as described and satisfactorily located. No\\n pneumothorax or other change since prior film of same date.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"P BILAT LOWER EXT VEINS PORT\",\n \"row_id\": 804115,\n \"text\": \" 9:03 AM\\n BILAT LOWER EXT VEINS PORT Clip # \\n Reason: HYPOXIA AND INCREASED RESP STATUS, EVAL FOR DVT\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with hypoxia and increased respiratory status, h/o of\\n immobility in nursing home\\n REASON FOR THIS EXAMINATION:\\n Please eval for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hypoxia, increased respiratory distress, history of immobility.\\n Please evaluate for DVT.\\n\\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Comparison is made to previous\\n lower extremity bilateral venous ultrasound dated . Grayscale and\\n Doppler images of the right and left common femoral, superficial femoral,\\n greater saphenous, popliteal veins were obtained. Normal flow,\\n compressibility, and augmentation were present throughout. No intraluminal\\n thrombus was identified.\\n\\n IMPRESSION: No evidence of lower extremity deep venous thrombosis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"C-SPINE, TRAUMA\",\n \"row_id\": 804041,\n \"text\": \" 11:11 AM\\n C-SPINE, TRAUMA Clip # \\n Reason: s/p fall\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p fall\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Change in mental status s[ fall.\\n\\n AP, LATERAL AND ODONTOID VIEWS OF THE CERVICAL SPINE: Imaging of the mid and\\n lower cervical spine is suboptimal due to overlying soft tissue and humerus.\\n There is no prevertebral soft tissue swelling at the C1 through C3 levels,\\n although there appeared to be some increase in soft tissue in the posterior\\n pharynx. The prevertebral soft tissues cannot be assessed more inferiorly.\\n\\n On the swimmer's view, there is a quesiton of cortical step-off at the\\n posterior margin of the dens; this could be an artifact of limited bone detail\\n on this view (the odontoid view shows no abnormality), although further\\n evaluation is recommended.\\n\\n Evaluation of vertebral body alignment is limited. Degenerative change is\\n noted.\\n\\n IMPRESSION: Nondiagnostic study, as detailed above. See above comments\\n regarding the appearance of the dens on the swimmer's view. A CT of the\\n cervical spine should be strongly considered based on these findings.\\n\\n These findings were discussed with the requesting physician, . , at\\n approximately 12:05 p.m. on the date of study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 804082,\n \"text\": \" 12:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess for ETT placement\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with delta MA, metabolic acidosis, s/p head bleed s/p ETT\\n placement.\\n REASON FOR THIS EXAMINATION:\\n Please assess for ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Mental status change, metabolic acidosis, s/p head bleed and ETT\\n placement.\\n\\n VIEWS: Semierect AP view compared with supine AP view from .\\n\\n FINDINGS: There has been interval placement of ETT with tip approximately 4\\n cm above the carina. A NGT has also been placed with the tip below the\\n diaphragm and extending off the inferior borders of the film. No pneumothorax\\n is identified. The left lateral hemithorax is excluded from this film. There\\n is slight left ventricular enlargement with minimal upper zone redistribution\\n which may be related to patient's positioning. Again noted is a small right\\n pleural effusion with pleural thickening/fluid noted in the right lower\\n lateral hemithorax. Numerous rib fractures are again noted within the right\\n posterior ribs. No pneumothorax is present.\\n\\n IMPRESSION:\\n 1) Satisfactory placement of ETT and NGT.\\n 2) Slight left ventricular enlargement and minimal upper zone redistribution,\\n likely related to patient positioning, however minimal left ventricular\\n failure cannot be excluded.\\n 3) Persistent small right pleural effusion and pleural thickening/fluid\\n within the right lower lateral hemithorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 804084,\n \"text\": \" 12:59 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Please eval for evolution of head bleed.\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man found down with acute head bleed seen on head CT now\\n with continued delta MS neuro exam\\n REASON FOR THIS EXAMINATION:\\n Please eval for evolution of head bleed.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80 year old man found down with an acute head bleed seen on prior\\n CT now with continued mental status changes and nonfocal neural examination.\\n Evaluate for progression of intracranial hemorrhage.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: Again there is intraparenchymal hemorrhage in the anterior portion\\n of the left temporal lobe. Better visualized is contusion of the inferior\\n frontal lobes, greater on the left. There is a stable amount of subarachnoid\\n hemorrhage overlying the sulci of the left frontal lobe, left temporoparietal\\n and right temporoparietal regions. Additionally there is subarachnoid blood in\\n the intrapeduncular cistern. There is a small amount of blood within the\\n occipital horns of the lateral ventricles. While this is not commented upon in\\n the prior study, there is motion limiting the evaluation on the previous\\n study. Thin subdural CSF density collections have developed.\\n\\n Again seen is the white matter low attenuation in the subinsular and\\n periventricular white matter, unchanged. There is no shift of normally midline\\n structures. Ventricles are not dilated.\\n\\n BONE WINDOWS: There is a nondisplaced fracture through the right temporal\\n bone, mastoid air cells and middle ear cavity. There is fluid within the right\\n mastoid air cells. There is soft tissue density deep to the eardrum in the\\n middle ear cavity which is most likely blood given the associated fracture.\\n Additionally there is fluid within the sphenoid sinus and ethmoid air cells\\n without associated fractures of these sites appreciated. These frontal\\n sinuses, and upper portions of the maxillary sinuses and left mastoid air\\n cells are free of fluid.\\n\\n IMPRESSION:\\n\\n 1) Given the differences in technique, there is no significant difference in\\n the appearance of the brain parenchyma and its various hemorrhages since the\\n prior study.\\n 2) Fracture through the right mastoid air cells with fluid in the mastoid air\\n cells in the middle ear cavity, presumably blood related to the patient's\\n fracture. No other fractures are appreciated.\\n\\n (Over)\\n\\n 12:59 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Please eval for evolution of head bleed.\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n These findings were telephoned to Dr. , physican caring for the\\n patient at the time of the study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 804085,\n \"text\": \" 1:00 AM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: Please eval for C-spine fracture.\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with altered mental status s/p fall and ?dens fracture on plain\\n films\\n REASON FOR THIS EXAMINATION:\\n Please eval for C-spine fracture.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: Elderly man s/p fall, evaluate for cervical spine fracture.\\n Questionable dens abnormality on plain films.\\n\\n TECHNIQUE: Axial images were performed through cervical spine with sagittal\\n and coronal reformatted images.\\n\\n FINDINGS: On the sagittal reformatted series, images 20 and 22 there is a\\n lucent line through the base of the dens. This does appear to violate the\\n posterior cortex on image 20. There is no displacement. This is not well\\n appreciated on the axial or coronal reformatted series, while this may be\\n artifactual or a vascular groove, a nondisplaced dens fracture cannot be\\n entirely excluded. There is some thickening of the prevertebral soft tissues\\n anterior to this. No other area suspicious for cervical spine fracture is\\n identified. There is cervical spondylosis in the mid cervical spine with\\n endplate sclerosis and loss of disc height at the C3-4, C4-5 and C5-6 levels.\\n There is normal alignment of the cervical vertebral bodies. No evidence of\\n spinal canal compromise is apparent.\\n\\n There is fluid withn the sphenoid sinus and the right mastoid air cells. There\\n is evidence of a skull fracture extending through the mastoid air cells\\n accounting for the fluid within them. Additionally there is soft tissue\\n density within the right middle ear canal, deep to the tympanic membrane. This\\n may represent blood. No other fractures are appreciated.\\n\\n There is opacification within the the right lung apex. There are\\n calcifications within the carotid bifurcations bilaterally.\\n\\n IMPRESSION:\\n\\n 1) Possible nondisplaced fracture through the dens of C2. v. artifact or\\n vascular groove.\\n 2) Right basilar skull fracture through the right mastoid air cells.\\n Additionally there is soft tissues density within the middle ear cavity which\\n could represent acute blood products.\\n 3) Fluid within the sphenoid sinus without a fracture seen. However, the\\n entire sphenoid sinus is not imaged.\\n\\n These findings were telephoned to Dr. , the physician caring for\\n the patient at the time of the study.\\n\\n (Over)\\n\\n 1:00 AM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: Please eval for C-spine fracture.\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n NOTE: An MRI study of the cervical spine may be helpful in excluding edema in\\n C2, which if present, would support the presence of a fracture. However, a\\n negative result does not exclude a fracture.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 804086,\n \"text\": \" 1:01 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please assess for mesenteric ischemia\\n Admitting Diagnosis: DRA, SAH\\n Field of view: 40\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\\n with guaiac positive stools.\\n REASON FOR THIS EXAMINATION:\\n Please assess for mesenteric ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: 80 year old man with altered mental status, 10. hematocrit drop,\\n distended abdomen and quiac positive stools. The patient has a mildly elevated\\n creatine. Evaluate for mesenteric ischemia or retroperitoneal hematoma.\\n\\n TECHNIQUE: Noncontrast images were obtained from the lung bases to the pubic\\n symphysis. There are no prior studies for comparison.\\n\\n CT ABDOMEN WITHOUT CONTRAST: There are moderate size bilateral pleural\\n effusions. There is dense consolidation at the right lung base with air\\n bronchograms. This could represent aspiration vs pneumonia.\\n\\n Noncontrast images of the liver, gallbladder, pancreas, spleen, adrenals and\\n kidneys are within normal limits. The upper bowel loops are unremarkable.\\n\\n CT PELVIS WITH CONTRAST: There is soft tissue stranding extending along the\\n lateral conal fascia, psoas muscle and retroperitoneum. This extends to the\\n left groin and can be seen with recent femoral puncture and bleeding. There is\\n no large focal hematoma. The unopacified bowel loops are within normal\\n limits. The bowel loops are not dilated and there is no evidence of wall\\n thickening to suggest ischemia. There is a moderate amount of calcification at\\n the origin of the celiac and SMA vessels. There is no calcification at the\\n origin of the . There is a lobulated appearance to the prostate gland with\\n the Foley catheter being deviated to the right as it enters the urinary\\n bladder. This may be due to asymmetric prostatic enlargement.\\n\\n BONE WINDOWS: There are multiple bilateral fractures of the lower ribs. Each\\n rib is broken in more than one place. This can result in a flail chest.\\n Additionally there are fractures of the L1 and L2 right transverse processes.\\n\\n IMPRESSION:\\n\\n 1) Mild amount of stranding extending from the left groin up along the left\\n psoas muscle consistent with a mild amount of retroperitoneal bleeding given\\n the recent history of a line placement at this site.\\n\\n 2) No secondary signs of mesenteric ischemia.\\n\\n 3) Asymmetric appearance to the base of the bladder. This may be due to\\n (Over)\\n\\n 1:01 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please assess for mesenteric ischemia\\n Admitting Diagnosis: DRA, SAH\\n Field of view: 40\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n asymmetric hypertrophy of the prostate.\\n\\n 4) Multiple bilateral rib fractures and transverse process fractures. Has the\\n patient had a recent cardiopulmonary resuscitation or trauma?\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"P PELVIS (AP ONLY) PORT\",\n \"row_id\": 804022,\n \"text\": \" 7:54 AM\\n PELVIS (AP ONLY) PORT Clip # \\n Reason: s/p fall\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p fall\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma.\\n\\n FINDINGS: This study is limited by patient motion. This single AP view of\\n the pelvis demonstrates no evidence of obvious fracture or dislocation. There\\n is a left-sided femoral line in position with its distal tip within the left\\n hemipelvis. There is no evidence of overt bone destruction or bone erosion.\\n\\n IMPRESSION: No obvious fracture on this limited study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 804252,\n \"text\": \" 10:55 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: f/u L temporal contusion\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man w/ L temp contusion\\n REASON FOR THIS EXAMINATION:\\n f/u L temporal contusion\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80 year old man status post fall with decreased mental status.\\n Left temporal contusion.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n HEAD CT WITHOUT CONTRAST: There has been progression of a large infarct\\n including the left-sided parietal, temporal and occipital lobes. This infarct\\n is within the MCA distribution, and may be secondary to an internal carotid\\n dissection at the time of the trauma. There is edema associated with this\\n area with mass effect and right-sided midline shift. There has been complete\\n effacement of the left lateral ventricles. There is also an area of infarct\\n within the left temporal and frontal lobes which corresponds to the previous\\n areas of contusion.\\n\\n No new evidence of intracranial hemorrhage when compared to the previous exam.\\n There is increased intraparenchymal blood as well as well as a subdural\\n hematoma within the left middle cranial fossa and the left temporal lobe.\\n There is hyperattenuating fluid overlying the tentorium which was seen\\n previously and corresponds to a subdural hematoma which has not changed in\\n appearance. This blood is also seen tracking up the falx. There is a small\\n amount of hyperattenuating fluid over the right parietal lobe which was seen\\n previously and relates to subarachnoid hemorrhage. There also appears to be a\\n small amount of left- sided uncal herniation which was present previously and\\n has not changed in appearance.\\n\\n There is opacification of the bilateral mastoid air cells, and there is\\n opacification within the right middle ear and fluid within the sphenoid sinus.\\n\\n IMPRESSION: Continued evolution of a large left middle cerebral artery\\n infarction. Increased mass effect secondary to edema of this infarction with\\n right-sided shift and effacement of the left lateral ventricles. No new\\n hemorrhage when compared to the previous exam. These findings were called to\\n the caring team at the time of the exam.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 804301,\n \"text\": \" 4:54 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pnuemothorax\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man s/p R SC central line attempt with arterial puncture\\n REASON FOR THIS EXAMINATION:\\n r/o pnuemothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post right subclavian central line placement with arterial\\n puncture. ? placement/pneumothorax.\\n\\n COMPARISON: .\\n\\n PORTABLE AP CHEST: The cardiomediastinal and hilar contours are stable.\\n There is interval increase in diffuse interstitial opacification and the\\n pulmonary vasculature appears more prominent than in the prior study. Again\\n noted is a right pleural effusion and effusion/pleural thickening along the\\n lateral right pleura, which is unchanged. The left CP angle is not included\\n in the study, and a left effusion cannot be excluded. The ET and NG tubes\\n remain unchanged in position. There is no pneumothorax. Numerous rib\\n fractures are again noted.\\n\\n IMPRESSION:\\n\\n 1. No evidence of pneumothorax.\\n 2. Interval increase in interstitial edema and prominence of the pulmonary\\n vasculature in the setting of right effusion, consistent with slightly\\n worsened heart failure.\\n 3. Stable ET & NG tubes.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 804260,\n \"text\": \" 11:41 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\\n Admitting Diagnosis: DRA, SAH\\n Field of view: 43\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\\n with guaiac positive stools.\\n REASON FOR THIS EXAMINATION:\\n bleed? Will be there soon for head CT.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE ABDOMEN AND PELVIS\\n\\n INDICATION: Guaiac positive stools. Continued drop in hematocrit.\\n Retroperitoneal hematoma.\\n\\n Comparison is made to the prior exam of one day earlier on .\\n\\n TECHNIQUE: Noncontrast images of the abdomen and pelvis were performed.\\n\\n CT OF THE ABDOMEN WITHOUT CONTRAST: Multiple bilateral rib fractures and\\n fractures of the L1 and L2 transverse processes are again noted. No\\n pneumothoraces at the lung bases are seen. There is interval increase in size\\n of small-moderate bilateral pleural effusions, left greater than right with\\n adjacent basilar consolidation. An NG tube is seen with it's tip at the\\n gastroduodenal junction. No free air seen. The liver, gallbladder, pancreas,\\n spleen, adrenal glands, and kidneys are stable in appearance. Newly\\n appreciated within the right lower quadrant, is a 5.9 x 4.3 cm fluid\\n collection of increased density overlying and most probably related to the\\n cecum.\\n\\n The previously appreciated increased thickening and stranding extending from\\n the left groin to the retroperitoneum and lateral coronal fascia is slightly\\n increased in the interval. The stomach and small bowel loops are\\n unremarkable. Note is made of high density material within the large bowel\\n lumen distal to the site of likely cecal hematoma. This high density extends\\n throughout the colon and is most notable in the rectum and sigmoid. No oral\\n contrast was administered.\\n\\n CT OF THE PELVIS WITHOUT CONTRAST: The bladder contains high density fluid,\\n and a balloon Foley catheter tip is seen displaced to the right and\\n anteriorly.\\n\\n IMPRESSION: 1. Newly identified high density localized fluid collection\\n related to the cecum measuring 5.9 x 4.3 cm. Increased density intraluminal\\n material throughout the large bowel distal to this presumed cecal hematoma\\n presumably relates to intraluminal blood products, as oral contrast was not\\n administered.\\n 2. Mild interval increase in amount of soft tissue stranding\\n extending from the left groin and tracking through the retroperitoneum,\\n (Over)\\n\\n 11:41 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\\n Admitting Diagnosis: DRA, SAH\\n Field of view: 43\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n probably related to mild hemorrhage from left femoral line placement.\\n 3. High density material within the bladder seen to displace the\\n balloon Foley tip. This could be related to intrabladder hematoma, although\\n other space occupying mass cannot be excluded. The appearance of this is\\n unchanged from yesterday.\\n 4. Interval mild increase in size of bilateral pleural\\n effusions, left greater than right, with adjacent basilar consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 804270,\n \"text\": \" 1:09 PM\\n MR CERVICAL SPINE Clip # \\n Reason: w/ inversion recovery images. ? dens fx, r/o ligamentous i\\n Admitting Diagnosis: DRA, SAH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old man with L temporal contusion s/p fall\\n REASON FOR THIS EXAMINATION:\\n w/ inversion recovery images. ? dens fx, r/o ligamentous injury s/p fall\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Left temporal contusions, S/P fall. Evaluate for dens fracture\\n or ligamentous injury.\\n\\n TECHNIQUE: Sagittal T2, T1, inversion recovery, and axial gradient echo\\n sequences.\\n\\n FINDINGS: Comparison is made to the C-spine CT from . No\\n abnormal signal on inversion recovery sequences or T2 sequences are seen\\n within the odontoid process. Nevertheless, a fracture cannot be excluded.\\n There is increased T2 and inversion recovery signal intensity anterior to the\\n vertebral bodies, which may reflect ligamentous injury. Prevertebral soft\\n tissue swelling is present. Multilevel degenerative changes are present, with\\n desiccation of intervertebral disks and loss of disk space height, most\\n pronounced at C3/4, C4/5, and C5/6. There is also moderately severe anterior\\n osteophyte formation at these levels. There is left neural foraminal\\n narrowing at the left C2/3 and C3/4 levels.\\n\\n Also noted on the STIR sequences increased signal within the T4 vertebral\\n body, which may represent a fracture.\\n\\n IMPRESSION: 1) No signal abnormality within the odontoid process.\\n Nevertheless, a fracture at this level cannot be excluded.\\n\\n 2) Increased T2 and STIR signal intensity within the prevertebral soft tissue\\n and the anterior longitudinal ligament. This may reflect a ligamentous\\n injury.\\n\\n 3) Increased T2 signal intensity within the T4 vertebral body, with irregular\\n marrow signal. Findings may represent a fracture.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69871,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Valvular heart disease.\\nBP (mm Hg): 181/75\\nHR (bpm): 81\\nStatus: Inpatient\\nDate/Time: at 13:24\\nTest: Portable TTE (Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is elongated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\\nfunction are normal (LVEF>55%).\\n\\nRIGHT VENTRICLE: The right ventricle is not well seen.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\\ndilated.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\\naortic valve stenosis. Trace aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\\nregurgitation.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation. There is moderate pulmonary artery systolic\\nhypertension.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is elongated. Left ventricular wall thickness, cavity size,\\nand systolic function are normal (LVEF>55%). The ascending aorta is mildly\\ndilated. The aortic valve leaflets are mildly thickened. There is no aortic\\nvalve stenosis. Trace aortic regurgitation is seen. The mitral valve appears\\nstructurally normal with trivial mitral regurgitation. There is moderate\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\nCompared to previous report (study not available for review) from ,\\nthe right ventricular systolic pressure has increased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 151559,\n \"text\": \"Sinus rhythm\\nNormal ECG\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 151560,\n \"text\": \"Sinus rhythm. Supraventriciular extrasystoles. Inferior/lateral ST-T wave\\nchanges are non-specific. Compared to the previous tracing of no\\nsignificant change.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261991,\n \"text\": \"Admit note 80 yo black male NH resident found down at NH approx 1.5 hrs noted to have laceration on back of head lt side he was alert and oriented at that time. His o2 sat was 87% came into the ed disoriented and c collar not in place had lt lac head, labs glucose 393 anion gap 30, cpk 2135, phos 5.8. ekg elevated t waves v2-3 CT showed lt temporal hemorrhage with lt SAH small inr was elevated. Has rib fx, found to have UTI given 500mg levo iv WBC 15.6 cxr lt retrocardiac opacity\\nPMH cardiopulm emboli, dementia, psychosis, syndrome of inappropirate antidiuretic hormone, urine incont. prostatic hypertrophy, htn, dm II, cva, lung abscess ribs removed, ? hepatitis B, +MRSA\\nsocial etoh abuse, ivda, was homeless now in NH demented has (notified has not seen in awhile), , allergies nka\\nNeuro arrived to floor garbled speech pearla 2mm brisk was not fc after few hrs would fc inconsistently tylenol and etoh levels neg\\ncorneal reflex intact face symetrical, collar on logrolled\\ncardiac K+ in er 3.4 tx ivf 40 kcl k+ 4.7, ST 100-110 without ectopy sbp 110/-160/, cpk 3827 mb 93\\nresp 4lnp 7.26/27/77/-13/13 repeat 7.30/33/91/- lungs exp wheezes throughout RR 36-44\\nGI abd snt bs + npo\\ngu 0-30 q hr receiving iv boluses cr 1.6 bun 27\\nendo bs 211-125 insulin drip titrated lactate 15.3 to 14\\nid wbc 15.6 temp max 99.8 on levo and clinda a nasal swab sent msra bc x2 sent\\naccess lt fem triple lumen line, lt aline radial\\na. cerebral hemmorhage\\ndka\\nmetabolic acidosis\\narf\\nuti pna lt retrocardiac opacity\\nincrease inr\\nrhabdomyolysis\\np. keep sbp 120/-140/ neuro check q 1 hr vit k 10 mg sc x3 days\\ninsulin gt titrate\\nfollow lactate, ivf\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1262002,\n \"text\": \"MICU NPN Update Code status:\\nFamily met with Dr. and pt's primary care MD also discussed case with pt's guardian at length. Decision was made to withdraw aggressive care this afternoon. Plan is to extubate him after he has a morphine drip started and looks comfortable on this. If he looks stable he will be called out to the floor CMO. All meds are d/c'd as well as blood draws.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1262003,\n \"text\": \"MICU NPN Update:\\nPt was extubated just a little before 8PM. Pt immediately dropped his sats and BP and by 8:30PM he was asystolic. Pt died comfortable on the morphine drip. HO notified and pronounced pt dead. He will notify family of the death.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261997,\n \"text\": \"NPN 7a-7p\\nNeuro: Pt. remains sedated on Propofol 43mcg/kg gtt. R pupil is pinpoint and reactive, L has cataract-3mm. Has mild reaction to painful stimuli, grimaces and flexes. Went for head ct today to evaluate bleed and look for cerebral edema. Pt. has C-2 fx. Also went to MRI to evaluate status of cervical spine, results pnd. Aspen collar in place.\\nCV: HR 80's. On Nitroprusside at 1.2mcg/kg. SBP maintained at 130-140 most of the day. Was off Nipride briefly and SBP was 150.\\nResp: Remains vented on 50% 600x18 5. Sx for small amount of prulent looking sputum, cx sent. Some inspiratory wheezes on exam. On levo for presumed pneumonia.\\nGI: Had ct of abdomen which shows bleed in his cecum. Also has multiple old rib fx. Tube feedings on hold. No stool today. Started on sucralfate today. OGT to low intermittent sx draining brow, bilious liquid.\\nID: Remains afebrile.\\nAccess: Has triple lumen in L groin. R subclavin attempt was unsuccessful, team will try again. CXR done after first attempt.\\nF&E: K and Mg to be repleted once access is obtained.\\nHeme: Hct. 21. No overt signs of bleeding. FDP panel snet. Due for 2 u PRBC once line placed.\\nSocial: Patients grand niece has been contact and she gave consent for line access. Pt. is DNR. Social work consulted. Spoke with director of nursing at nursing home regarding pt. status.\\nSkin: Pt. has large bruise under R axilla which has not increased in size. Area outlined.\\nAssessment: Pt. with multiple old rib fx, new SAH and stroke, blood in cecum. ? etiology of multiple injuries.\\nPlan:\\n-obtain access\\n-transfuse 2u PRBC\\n-Hct 4 hours post transfusion\\n-Replete K and P04.\\n-Follow neuro exam.\\n-Sx prn\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261998,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on mechanical support. Vent settings Vt 600, A/c 18, Fio2 50%, and Peep 5. Pt sedated. Adequate O2 sats. Bs clear bilaterally. Sx'd for sm amounts of thick yellow sputum. No further vent changes made this shift. Unable to do RSBI this am. No spont effort. Plan: Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261999,\n \"text\": \"PaO2 decreasing to 66. Fio2 increased to 60%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1262000,\n \"text\": \"CV goal sbp to be between 120 - 140. niprid increased to 3 mics over night in attemps to get sbp with in goal range.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1262001,\n \"text\": \"CV: hr 80-90 nsr No ectopy. goal sbp= 140-160..nipride increased overnight to 2.8 mics/kg/min to maintain this goal.\\nGu: foley draining clear yellow urine.some leaking around foley contained by wrapping around catheter and penis. urine ouput is adequate..increase urine ouput after mannitol 100 mg given.\\ngi: og tube draining bilious. bowel sounds present but hypoactive.no stool.\\nneuro: patient is sedate. on propofol at 43 mics/kg/min. sedation stopped this last pm for eval by neuro. patient moved bioth legs on bed to painful stimuli.moved both hands on bed to paiful stimuli. grimacing and furrowing forehead when suctioned or attempts at mouth care. patient does not follow commands.aspen collar in place.\\n\\nhems: transfused 2 units prbc's afer multilumen inserted. post transfusion hct= 26.8.\\nendo: following q 6 hr glucose and tx with sliding scale. 2 units reg for bs of 167 st 2400. this a.m. glucose =176 tx with 2 units reg at 0530.\\nresp: abg ph=7.47/30/po2 =66 fio2 increased to 70 %. suctione dq 2-3 hours for small amounts thick yellow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261992,\n \"text\": \"Add 1830p given 2 uffp inr 1.6, bc x2 sent, nasal swab for msra sent, given lopressor 5mg iv x1 sbp >150\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261993,\n \"text\": \"NURSING PROGRESS NOTE:\\nNEURO: PT RECEIVED WITH CERVICAL COLLAR ON, PT MUMBLING AND CALLING OUT. UNABLE TO UNDERSTAND WHAT HE WANTED. MAE, FOLLOWS COMMANDS, PERLA, 2CM REACTING BRISKLY. HO ATTEMPTED NGT PLACEMENT HR DROPPED TO THE 50'S AND BECAME HYPOTENSIVE TO THE 70'S. AFTER THIS IT WAS THEN NOTICED THAT RIGHT PUPIL MUCH LARGER THAN THE LEFT, APPROX 5REACTING SLUGGISHLY AND LEFT 2 REACTIVE BRISKLY. PT HAD REPEAT CT SCAN WHICH SHOWED NO CHG IN BLEED, SKULL FX, QUESTIONABLE C2 FX. PT NOW HAS ASPEN COLLAR IN PLACE. PT CONT TO MAE, RESPONDS TO STIMULI, FOLLOWS SIMPLE COMMANDS. UNABLE TO VISUALIZE POST HEAD LACERATION DUE TO COLLAR AND HAIR.\\nCV: PT'S HR NSR 70-80'S WITHOUT ECTOPY. SBP STABLE SEE FLOWSHEET FOR DATA. KEEP BP 120-140 RANGE, TREAT WITH LOPRESSOR. PRESENTLY ON 40MCQ OF PROPOFOL FOR SEDATION WHILE INTUBATED. TEMP MAX 99.2 PO.\\nRESP: PT VERY TACHYPNEIC WITH RATES IN THE 30'S, PT VERY WHEEZY INSP/EXP. COARSE AT THE BASES. UNABLE TO COUGH AND RAISE SECRETIONS. SEVERAL ABG'S DRAWN DURING THE NIGHT. SEE FLOWSHEET. AT 2330 IT WAS DECIDED TO ELECTIVELY AND SEDATE PT IN ORDER TO OBTAIN ACCURATE CT SCAN AND CORRECT LOW PO2. 2345 PT AND CONFIRMED PLACEMENT BY CXR. SX FOR BLOODY SECRETIONS.\\nGI: PT HAS OGT WHICH WAS PLACED DURING INTUBATION WHICH WAS PASSED THROUGH AN ETT. LWS DRAINING BROWN GUIAIC POS DRAINAGE.\\nGU: FOLEY CATH DRAINING VERY SMALL AMT'S OF YELLOW FOUL SMELLING URINE WITH SEDIMENT. 8-60CC/HR. FOLEY LEAKING URINE AROUND CATH, INC FLUID IN BALLOON WHICH SEEMED TO HELP AT THIS TIME.\\nENDO: PT IS ON INSULIN DRIP PRESENTLY AT 3UNITS, TITRATED ACCORDING TO FINGERSTICKS.\\nPT 2UNITS FFP FOR ELEVATED INR. HCT 20, IS PRESENTLY RECEIVING A UNIT OF PACKED CELLS.. PT HAS SMALL RETROPERITONEAL BLEED FROM LINE PLACEMENT EARLIER IN THE DAY.\\nLACTIC ACID DOWN TO 6.5 FROM 15.\\nPT REMAINS FULL CODE. PT HAS LEFT FEMORAL TLC WHICH IS IN GREAT DANGER OF BECOMING INFECTED DUE TO LEAKAGE AROUND FOLEY. HO NOTIFIED OF THIS TO CHG THE SITE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261994,\n \"text\": \"micu npn 0700-1900\\n\\nreview of systems:\\nneuro: sedated with propofol gtt, am wake up, RR 30's grimacing, out of synch with ventilator, no spontaneous movement, resedated. Pupils right 3mm reactive, left pin point nonreact, -corneals, +cough/gag. Aspen collar intact.\\n\\nresp: remains intubated and vented with a/c 14/600/40%/5peep, min vol 8.7 L, sxn for small amts thick blood tinged secretions, breath sounds coarse.\\n\\ncv: HR 80-90 SR, no VEA, BP 160-170 IV NTG gtt initiated, titrate to goal BP 120-140,\\n\\nheme: transfused with second unit PRBC's, 1 bag plt, hct 24, post plt ct 124\\n\\ngu: foley leaking around catheter, foley replaced with #18, urine 40-60cc/hr\\n\\nid: cont clinda/levoflox, afebrile, wbc 1.8 this am\\n\\nsocial: NH called for update on status, no contact from family member or guardian, social work involved\\n\\nPLAN: follow neuro exam, titrate NTG gtt to goal BP 120-140, follow coags, correct coagulopathy\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261995,\n \"text\": \"Patient remains on mechanical ventilation, transfused this morning for low Hct.BS diminished, not much secretion bloody catheter instead. CT Scan intra-parenchymal bleed @ (L) temporal lobe, no recent ABG maintaining good saturation will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-11-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261996,\n \"text\": \"NURSING PROGRESS NOTE;\\nPT REMAINS WELL SEDATED ON PROPOFOL. PT REMAINS /VENT ON A/C 600 X 18 +5 40%. ABG PO2 IN THE 70'S, FIO2 INC TO 70% THEN DROPPED TO 60% WHERE HE IS NOW. SEE FLOWSHEET FOR ABG'S. PT SX FOR MOD AMT'S OF THIN BLOOD TINGED SECRETIONS. LUNG SOUNDS COARSE WITH OCC WHEEZES BUT CLEAR WITH SX'ING. O2 SAT'S HIGH 90'S TO 100%.\\nNEURO: PT WELL SEDATED, PT AROUSES WITH PAINFUL STIMULI. MOVES EXTREMETIES ON THE BED ONLY. PUPILS RIGHT LARGER THAN THE LEFT, LEFT NONREACTIVE. DOES NOT OPEN EYES UNLESS STRONGLY STIMULATING.\\nCV: PT RECEIVED ON NTG TO KEEP BP 120-140, BP CONSISTENTLY IN THE 180'S. NTG D/C'D AND STARTED ON NIPRIDE, TITRATED UP TO 2.0 MCQ/KG, WEANING DOWN THIS AM TO 1.2MCQ'S. HR IN 70'S -80'S WITH NO ECTOPY.\\nAFEBRILE, TAKING FEW SPONTANEOUS BREATHS OVER THE VENT.\\nGI: PT HAS ORAL GT. LWS DRAINING BROWN/GREEN MATERIAL, GUIAIC POS. NO STOOL AT THIS TIME. ABD FIRM AND DISTENDED WITH BOWEL SOUNDS.\\nGU: FOLEY CATH CONT TO LEAK, U/O LOW. URINE YELLOW WITH SEDIMENT.\\nENDO: PT ON INSULIN DRIP TITRATED ACCORDING TO FINGERSTICKS. CHECKED Q 1/HR.\\nSKIN: PT HAS SOME OPEN SCRAPS FROM WHEN HE FELL, BACITRACIN OINT APPLIED. PT'S TOES REQUIRED MUCH CLEANSING, GUAZE PLACED BETWEEN TO KEEP DRY AND PROMOTE HEALING. PT HAS ECHYMOTIC AREA UNDER RIGHT AXILLA EXTENDING DOWN RIGHT CHEST WALL. HO NOTIFIED.\\nNO CALL RECEIVED BY NH/FAMILY.\\nPT IS FULL CODE. ASPEN COLLAR ON.\\n\\n\"\n }\n]"}}},{"rowIdx":24982,"cells":{"subject_id":{"kind":"number","value":90776,"string":"90,776"},"hadm_id":{"kind":"number","value":181396,"string":"181,396"},"target_text":{"kind":"string","value":"80F history of HTN, arrythmia, PAD presented to OSH with ~16 hours of chest pain, found to have elevated troponin and EKG suggestive of inferior MI, then transferred to for further management. At , she went to the cath lab, where she had BMS to RCA x2 with restoration of flow. . # INFERIOR STEMI: Cath showed total occlusion of proximal RCA. Two BMS were placed in the proximal and mid RCA with restoration of flow. (The LMCA was normal. The LAD was normal and patent. Lcx was patent.) Pt was started on medical management with Plavix 75 mg daily, aspirin 325 mg daily, atorvastatin 80 mg daily. Echo was done in the morning that showed depressed RV function. Beta blocker, verapamil, spironolactone and ACEI were held given low blood pressure and RV infarction. Enzymes were trended and MB peaked at 215 in the morning (troponin peaked at 7.68). AM CXR was benign with no s/s of overload. On AM pt continued to have substernal chest pain, without radiation. MAPs also dropped to 50s, and she was bradycardic, so we increased her dopamine drip to 10; norepinephrine was added, as was aminophylline 150mg/day (only one dose was given). Pt also received 500 mL bolus NS which increased CVP from 10 to 16. The patient's sinus node seemed to recover on , as she went back into sinus rhythm without bradycardia, and this improved her hemodynamics considerably. Pressors were weaned. She was started on lisinopril. Metoprolol can be considered as an outpatient. . # PUMP: Post-cath ECHO showed significant depression of RV function and PCWP of 22. CVP on morning of was 10. Patient required 500mL bolus as her MAP was in the 50s AM, CVP found to be 16 after bolus, with MAP in 60s. Patient was started on Lasix 20mg PO daily prior to discharge. She was euvolumic on discharge. . # RHYTHM: On presentation, pt had bradycardia and an irregular rhythm suggestive of atrial fibrillation with bradycardia. After revascularization and removal of the temporary pacemaker, rhythm was sinus initially, but she did go back into atrial fibrillation over the next 24 hours. Pt was monitored on telemetry, and her HR and BP remained low post procedure (50s, MAP 50s-60s). She required BP support with dopamine and norepinephrine. Aminophylline 150mg x 1 dose was given. The patient's sinus node seemed to recover on , as she went back into sinus rhythm without bradycardia, and this improved her hemodynamics considerably. Pressors were weaned. We did not anticoagulate the patient given that she was in atrial fibrillation for less than 48 hours and in the setting of an acute STEMI. . # COPD: We continued home tiotropium and put the patient on albuterol PRN instead of home metoproterenol. . # PSEUDOGOUT: Patient developed pain in the right knee with swelling, warmth, and an effusion. Rheumatology consult was called. Joint aspirate was done, and result were consistent with CPPD arthropathy. Injection of 40 mg of depo-medrol was performed. Pain improved considerably, and mobility was no longer limited. She will follow up with rheumatology as an outpatient. . # HYPERTENSION: We held her home verapamil, spironolactone, and lisinopril and started lisinopril prior to discharge. . # HYPOTHYROIDISM: We continued her home levothyroxine. . ### TRANSITIONAL ISSUES: - Patient will call Dr. office the day following discharge to request a follow up appointment. - Patient's cardiologist may wish to consider adding metoprolol and/or increasing lisinopril. - Patient will call her PCP tomorrow to request a follow up appointment. - Patient should call rheumatology to make appt with Dr. (fellow) within 1-2 weeks after discharge (); patient was called on and asked to make this follow-up appointment because this had not been written in her discharge paperwork."},"extractive_notes_summ":{"kind":"string","value":"Prior anteroseptal myocardial infarction of indeterminate age.Borderline low voltage. Moderate regional LV systolic dysfunction. Poor anterior R wave progression is consistent with prioranteroseptal myocardial infarction. Q wavesin leads III and aVF are consistent with prior inferior wall myocardialinfarction. Baseline artifact marring interpretation of rhythm but probable low amplitudeP waves consistent with sinus tachycardia and ventricular premature complexes.Acute inferior wall myocardial infarction with evidence of persistentST segment elevations inferiorly and ST segment depressions in the high lateralleads. Previously described inferior ST segment elevations are mucghless apparent. Inferior myocardial infarction with ST segment elevtions,likely acute. Moderatetricuspid regurgitation. Myocardial infarction of indeterminate age. Acute inferior myocardial infarction with persistent ST segmentelevations inferiorly and ST segment depressions in the high lateral leads.Anteroseptal myocardial infarction of indeterminate age. Left axis deviation.Intraventricular conduction delay. Probable prior anteroseptal myocardialinfarction of indeterminate age. Mild tomoderate (+) mitral regurgitation is seen. There are Q waves in the inferior leads consistent with myocardialinfarction. Restingbradycardia (HR<60bpm).Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Anterior wall myocardial infarction, age indeterminate.Prolonged Q-T interval. There is a late transition with small R waves in the anteriorleads consistent with possible myocardial infarction. Non-specific inferolateral repolarization abnormalities areimproved in the lateral limb leads and flatter in the inferior and leftprecordial leads. Probable prior anteroseptal myocardial infarction ofindeterminate age. Consider anteroseptal myocardial infarction of indeterminate age.TRACING #3 Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No restingLVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; midinferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;septal apex - hypo; inferior apex - akinetic;RIGHT VENTRICLE: Dilated RV cavity. Moderate [2+] tricuspidregurgitation is seen. Unchanged moderate cardiomegaly with signs of minimal fluid overload and bilateral areas of atelectasis. Normal ascending aortadiameter. Acute inferior wallmyocardial infarction with ST segment elevation. Non-specific intraventricular conduction delay. Non-specific intraventricular conduction delay. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Right ventricular dilation and severe dysfunction. There are diffuse minimal degenerative changes noted. Mild-to-moderate mitralregurgitation. There is mild pulmonary artery systolic hypertension.There is no pericardial effusion.IMPRESSION: Regional wall motion abnormalities c/w inferior/RV myocardialinfarction. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There is mild osteopenia. Mild pulmonary hypertension. STEMIHeight: (in) 64Weight (lb): 165BSA (m2): 1.80 m2BP (mm Hg): 117/54HR (bpm): 56Status: InpatientDate/Time: at 10:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Myocardial infarction. Inferiormyocardial infarction with ST segment elevation may represent acute myocardialinfarction. Left axis deviation with leftanterior fascicular block, Baseline artifact. Lung volumes are again low. Inferior myocardial infarction withpersistent ST segment elevations concerning for ongoing ischemia. Inferiormyocardial infarction with ST segment elevation may represent acutemyocardial infarction. Acute inferior wall myocardial infarction with ST segmentdepressions in high lateral leads. Moderate [2+] TR. There is most likely small suprapatellar effusion present. Compared to tracing #2 delayedR wave progression in leads V2-V3 persists. IMPRESSION: Mild cardiomegaly. Borderline lowvoltage. The right atrium is moderately dilated. Unchanged venous introduction sheath in the right internal jugular vein. Borderline low voltage. Low amplitude P waves. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Extensive baseline artifact precludes rhythm determination. Sinus tachycardia. Sinus rhythm with P-R interval prolongation. Extensive anterior wall myocardial infarction, age indeterminateHowever, there could be right-sided chest leads submitted.TRACING #2 Non-specific ST-T wavechanges. Left axisdeviation. Mild to moderate(+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Lung volumes are low. Suboptimal image quality - patient unable to cooperate. Compared totracing #3 R waves in leads V4-V6 are less pronounced.TRACING #4 Sinus rhythm. Sinus rhythm. Compared to the previous tracing of earlier the sameday clearly identified P waves are less easily identified.TRACING #3 Compared to the previous tracing of the rate is slower. Compared to the previous tracing of ST segment elevation inthe inferior leads is less but still persists. The right ventricular cavity is dilated with severe global free wallhypokinesis. Severe global RV free wall hypokinesis.Prominent moderator band/trabeculations are noted in the RV apex.AORTA: Normal aortic diameter at the sinus level. Mediastinal contour appears normal. A new right IJ line terminates in the high SVC. Left ventricular wallthickness, cavity size, and global systolic function are normal (LVEF>55%).There is moderate regional left ventricular systolic dysfunction with severehypokinesis to akinesis of the inferior, inferolateral, and inferoseptalwalls. FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusions. Bony structures intact, though high-riding right humeral head suggests chronic rotator cuff injury. Heart is mildly enlarged. FINDINGS: As compared to the previous radiograph, there is no relevant change. No AS. No visible pleural effusions. 7:13 AM CHEST (PORTABLE AP) Clip # Reason: New pleural effusion? CHF, AMI REASON FOR THIS EXAMINATION: r/o CHF No contraindications for IV contrast FINAL REPORT CHEST RADIOGRAPH PERFORMED ON COMPARISON: None. The heart is mildly enlarged. Compared to the previous tracing of earlier the same daythe inferior ST segment elevations may be slightly less prominent but remainconcerning for ongoing ischemia and the ventricular rate is faster.TRACING #1 SINGLE PORTABLE AP VIEW OF THE CHEST: In comparison to the prior exam, there is no significant change. No MVP. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Clinicalcorrelation is suggested. 9:47 PM KNEE (AP, LAT & OBLIQUE) RIGHT PORT Clip # Reason: chondrocalcinosis?"},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2114-08-08 00:00:00.000","description":"Report","row_id":72622,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. STEMI\nHeight: (in) 64\nWeight (lb): 165\nBSA (m2): 1.80 m2\nBP (mm Hg): 117/54\nHR (bpm): 56\nStatus: Inpatient\nDate/Time: at 10:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. IVC dilated (>2.1cm)\nwith <50% decrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Moderate regional LV systolic dysfunction. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\ninferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;\nseptal apex - hypo; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\nProminent moderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Resting\nbradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. The\nestimated right atrial pressure is at least 15 mmHg. Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nThere is moderate regional left ventricular systolic dysfunction with severe\nhypokinesis to akinesis of the inferior, inferolateral, and inferoseptal\nwalls. The right ventricular cavity is dilated with severe global free wall\nhypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Regional wall motion abnormalities c/w inferior/RV myocardial\ninfarction. Right ventricular dilation and severe dysfunction. Moderate\ntricuspid regurgitation. Mild pulmonary hypertension. Mild-to-moderate mitral\nregurgitation.\n\n\n"},{"category":"ECG","chartdate":"2114-08-10 00:00:00.000","description":"Report","row_id":171915,"text":"Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left axis\ndeviation. There are Q waves in the inferior leads consistent with myocardial\ninfarction. There is a late transition with small R waves in the anterior\nleads consistent with possible myocardial infarction. Non-specific ST-T wave\nchanges. Compared to the previous tracing of ST segment elevation in\nthe inferior leads is less but still persists.\n\n"},{"category":"ECG","chartdate":"2114-08-09 00:00:00.000","description":"Report","row_id":171916,"text":"Sinus rhythm. Acute inferior myocardial infarction with persistent ST segment\nelevations inferiorly and ST segment depressions in the high lateral leads.\nAnteroseptal myocardial infarction of indeterminate age. Borderline low\nvoltage. Compared to the previous tracing of earlier the same day the\nventricular rate is slower and P waves are more easily identified.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2114-08-09 00:00:00.000","description":"Report","row_id":171917,"text":"Baseline artifact marring interpretation of rhythm but probable low amplitude\nP waves consistent with sinus tachycardia and ventricular premature complexes.\nAcute inferior wall myocardial infarction with evidence of persistent\nST segment elevations inferiorly and ST segment depressions in the high lateral\nleads. Prior anteroseptal myocardial infarction of indeterminate age.\nBorderline low voltage. Compared to the previous tracing of earlier the same\nday clearly identified P waves are less easily identified.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2114-08-08 00:00:00.000","description":"Report","row_id":171918,"text":"Sinus tachycardia. Acute inferior wall myocardial infarction with ST segment\ndepressions in high lateral leads. Probable prior anteroseptal myocardial\ninfarction of indeterminate age. Borderline low voltage. Compared to the\nprevious tracing of earlier the same day the ventricular response rate is\nmarkedly faster and the inferior ST segment elevations are more pronounced.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2114-08-08 00:00:00.000","description":"Report","row_id":171919,"text":"Accelerated junctional rhythm at 62 beats per minute. Left axis deviation.\nIntraventricular conduction delay. Inferior myocardial infarction with\npersistent ST segment elevations concerning for ongoing ischemia. Clinical\ncorrelation is suggested. Probable prior anteroseptal myocardial infarction of\nindeterminate age. Compared to the previous tracing of earlier the same day\nthe inferior ST segment elevations may be slightly less prominent but remain\nconcerning for ongoing ischemia and the ventricular rate is faster.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2114-08-08 00:00:00.000","description":"Report","row_id":171920,"text":"Junctional rhythm. Inferior myocardial infarction with ST segment elevtions,\nlikely acute. Myocardial infarction of indeterminate age. Compared to\ntracing #3 R waves in leads V4-V6 are less pronounced.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2114-08-12 00:00:00.000","description":"Report","row_id":171914,"text":"Sinus rhythm with P-R interval prolongation. Left axis deviation with left\nanterior fascicular block, Baseline artifact. Low amplitude P waves. Q waves\nin leads III and aVF are consistent with prior inferior wall myocardial\ninfarction. Poor anterior R wave progression is consistent with prior\nanteroseptal myocardial infarction. Compared to the previous tracing of \nthe rate is slower. Non-specific inferolateral repolarization abnormalities are\nimproved in the lateral limb leads and flatter in the inferior and left\nprecordial leads. Previously described inferior ST segment elevations are mucgh\nless apparent.\n\n"},{"category":"ECG","chartdate":"2114-08-08 00:00:00.000","description":"Report","row_id":172136,"text":"Extensive baseline artifact precludes rhythm determination. Acute inferior wall\nmyocardial infarction with ST segment elevation. Compared to tracing #2 delayed\nR wave progression in leads V2-V3 persists. R waves awre now present in\nleads V4-V6. Consider anteroseptal myocardial infarction of indeterminate age.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2114-08-07 00:00:00.000","description":"Report","row_id":172137,"text":"Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\nmyocardial infarction with ST segment elevation may represent acute myocardial\ninfarction. Extensive anterior wall myocardial infarction, age indeterminate\nHowever, there could be right-sided chest leads submitted.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2114-08-07 00:00:00.000","description":"Report","row_id":172138,"text":"Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\nmyocardial infarction with ST segment elevation may represent acute\nmyocardial infarction. Anterior wall myocardial infarction, age indeterminate.\nProlonged Q-T interval. No previous tracing available for comparison.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2114-08-10 00:00:00.000","description":"RP KNEE (AP, LAT & OBLIQUE) RIGHT PORT","row_id":1255089,"text":" 9:47 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: chondrocalcinosis?\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CPPD crystals in right knee\n REASON FOR THIS EXAMINATION:\n chondrocalcinosis?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with known CPPD crystal\n deposition in the right knee.\n\n COMPARISON: No prior studies available for comparison.\n\n Three views of the right knee were reviewed.\n\n There is no evidence of fracture, lytic or sclerotic lesions or dislocation.\n Linear calcifications in both lateral and medial menisci of the knee are\n noted, consistent with CPPD. There is mild osteopenia. There are diffuse\n minimal degenerative changes noted. There is most likely small suprapatellar\n effusion present.\n\n\n"},{"category":"Radiology","chartdate":"2114-08-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254799,"text":" 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with inferior STEMI\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with inferior STEMI. Evaluate for interval\n change.\n\n COMPARISON: at 20:20.\n\n SINGLE PORTABLE AP VIEW OF THE CHEST: In comparison to the prior exam, there\n is no significant change. Heart is mildly enlarged. Lung volumes are again\n low. There is no overt sign of pneumonia or pulmonary edema. No large\n effusion or pneumothorax is seen. An opacity in the right middle lobe which\n silhouettes the heart border and may represent pneumonia in the correct\n clinical setting, however it is likely atelectasis given the low lung volumes.\n A new right IJ line terminates in the high SVC.\n\n"},{"category":"Radiology","chartdate":"2114-08-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254893,"text":" 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New pleural effusion?\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with Inferior MI s/p PCI with BMS\n REASON FOR THIS EXAMINATION:\n New pleural effusion?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pleural effusions.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No visible pleural effusions. Unchanged moderate cardiomegaly with\n signs of minimal fluid overload and bilateral areas of atelectasis. Unchanged\n venous introduction sheath in the right internal jugular vein.\n\n\n"},{"category":"Radiology","chartdate":"2114-08-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254775,"text":" 10:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80F with ? CHF, AMI\n REASON FOR THIS EXAMINATION:\n r/o CHF\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: None.\n\n CLINICAL HISTORY: 80-year-old female with CHF, question acute intrathoracic\n process.\n\n FINDINGS: AP portable upright chest radiograph obtained. The heart is mildly\n enlarged. Lung volumes are low. There is no overt sign of pneumonia or\n pulmonary edema. No large effusion or pneumothorax seen. Mediastinal contour\n appears normal. Bony structures intact, though high-riding right humeral head\n suggests chronic rotator cuff injury.\n\n IMPRESSION: Mild cardiomegaly. Otherwise, normal.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 72622,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Myocardial infarction. STEMI\\nHeight: (in) 64\\nWeight (lb): 165\\nBSA (m2): 1.80 m2\\nBP (mm Hg): 117/54\\nHR (bpm): 56\\nStatus: Inpatient\\nDate/Time: at 10:59\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. IVC dilated (>2.1cm)\\nwith <50% decrease with sniff (estimated RA pressure (>=15 mmHg).\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\\nfunction (LVEF>55%). Moderate regional LV systolic dysfunction. No resting\\nLVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\\ninferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;\\nseptal apex - hypo; inferior apex - akinetic;\\n\\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\\nProminent moderator band/trabeculations are noted in the RV apex.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. Normal aortic arch diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\\n(+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\\nposition. Suboptimal image quality - patient unable to cooperate. Resting\\nbradycardia (HR<60bpm).\\n\\nConclusions:\\nThe left atrium is mildly dilated. The right atrium is moderately dilated. The\\nestimated right atrial pressure is at least 15 mmHg. Left ventricular wall\\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\\nThere is moderate regional left ventricular systolic dysfunction with severe\\nhypokinesis to akinesis of the inferior, inferolateral, and inferoseptal\\nwalls. The right ventricular cavity is dilated with severe global free wall\\nhypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic\\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\\nmoderate (+) mitral regurgitation is seen. Moderate [2+] tricuspid\\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\\nThere is no pericardial effusion.\\n\\nIMPRESSION: Regional wall motion abnormalities c/w inferior/RV myocardial\\ninfarction. Right ventricular dilation and severe dysfunction. Moderate\\ntricuspid regurgitation. Mild pulmonary hypertension. Mild-to-moderate mitral\\nregurgitation.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171915,\n \"text\": \"Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left axis\\ndeviation. There are Q waves in the inferior leads consistent with myocardial\\ninfarction. There is a late transition with small R waves in the anterior\\nleads consistent with possible myocardial infarction. Non-specific ST-T wave\\nchanges. Compared to the previous tracing of ST segment elevation in\\nthe inferior leads is less but still persists.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171916,\n \"text\": \"Sinus rhythm. Acute inferior myocardial infarction with persistent ST segment\\nelevations inferiorly and ST segment depressions in the high lateral leads.\\nAnteroseptal myocardial infarction of indeterminate age. Borderline low\\nvoltage. Compared to the previous tracing of earlier the same day the\\nventricular rate is slower and P waves are more easily identified.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171917,\n \"text\": \"Baseline artifact marring interpretation of rhythm but probable low amplitude\\nP waves consistent with sinus tachycardia and ventricular premature complexes.\\nAcute inferior wall myocardial infarction with evidence of persistent\\nST segment elevations inferiorly and ST segment depressions in the high lateral\\nleads. Prior anteroseptal myocardial infarction of indeterminate age.\\nBorderline low voltage. Compared to the previous tracing of earlier the same\\nday clearly identified P waves are less easily identified.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171918,\n \"text\": \"Sinus tachycardia. Acute inferior wall myocardial infarction with ST segment\\ndepressions in high lateral leads. Probable prior anteroseptal myocardial\\ninfarction of indeterminate age. Borderline low voltage. Compared to the\\nprevious tracing of earlier the same day the ventricular response rate is\\nmarkedly faster and the inferior ST segment elevations are more pronounced.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171919,\n \"text\": \"Accelerated junctional rhythm at 62 beats per minute. Left axis deviation.\\nIntraventricular conduction delay. Inferior myocardial infarction with\\npersistent ST segment elevations concerning for ongoing ischemia. Clinical\\ncorrelation is suggested. Probable prior anteroseptal myocardial infarction of\\nindeterminate age. Compared to the previous tracing of earlier the same day\\nthe inferior ST segment elevations may be slightly less prominent but remain\\nconcerning for ongoing ischemia and the ventricular rate is faster.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171920,\n \"text\": \"Junctional rhythm. Inferior myocardial infarction with ST segment elevtions,\\nlikely acute. Myocardial infarction of indeterminate age. Compared to\\ntracing #3 R waves in leads V4-V6 are less pronounced.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 171914,\n \"text\": \"Sinus rhythm with P-R interval prolongation. Left axis deviation with left\\nanterior fascicular block, Baseline artifact. Low amplitude P waves. Q waves\\nin leads III and aVF are consistent with prior inferior wall myocardial\\ninfarction. Poor anterior R wave progression is consistent with prior\\nanteroseptal myocardial infarction. Compared to the previous tracing of \\nthe rate is slower. Non-specific inferolateral repolarization abnormalities are\\nimproved in the lateral limb leads and flatter in the inferior and left\\nprecordial leads. Previously described inferior ST segment elevations are mucgh\\nless apparent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172136,\n \"text\": \"Extensive baseline artifact precludes rhythm determination. Acute inferior wall\\nmyocardial infarction with ST segment elevation. Compared to tracing #2 delayed\\nR wave progression in leads V2-V3 persists. R waves awre now present in\\nleads V4-V6. Consider anteroseptal myocardial infarction of indeterminate age.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172137,\n \"text\": \"Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\\nmyocardial infarction with ST segment elevation may represent acute myocardial\\ninfarction. Extensive anterior wall myocardial infarction, age indeterminate\\nHowever, there could be right-sided chest leads submitted.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172138,\n \"text\": \"Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\\nmyocardial infarction with ST segment elevation may represent acute\\nmyocardial infarction. Anterior wall myocardial infarction, age indeterminate.\\nProlonged Q-T interval. No previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-10 00:00:00.000\",\n \"description\": \"RP KNEE (AP, LAT & OBLIQUE) RIGHT PORT\",\n \"row_id\": 1255089,\n \"text\": \" 9:47 PM\\n KNEE (AP, LAT & OBLIQUE) RIGHT PORT Clip # \\n Reason: chondrocalcinosis?\\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with CPPD crystals in right knee\\n REASON FOR THIS EXAMINATION:\\n chondrocalcinosis?\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient with known CPPD crystal\\n deposition in the right knee.\\n\\n COMPARISON: No prior studies available for comparison.\\n\\n Three views of the right knee were reviewed.\\n\\n There is no evidence of fracture, lytic or sclerotic lesions or dislocation.\\n Linear calcifications in both lateral and medial menisci of the knee are\\n noted, consistent with CPPD. There is mild osteopenia. There are diffuse\\n minimal degenerative changes noted. There is most likely small suprapatellar\\n effusion present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254799,\n \"text\": \" 7:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with inferior STEMI\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 80-year-old woman with inferior STEMI. Evaluate for interval\\n change.\\n\\n COMPARISON: at 20:20.\\n\\n SINGLE PORTABLE AP VIEW OF THE CHEST: In comparison to the prior exam, there\\n is no significant change. Heart is mildly enlarged. Lung volumes are again\\n low. There is no overt sign of pneumonia or pulmonary edema. No large\\n effusion or pneumothorax is seen. An opacity in the right middle lobe which\\n silhouettes the heart border and may represent pneumonia in the correct\\n clinical setting, however it is likely atelectasis given the low lung volumes.\\n A new right IJ line terminates in the high SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254893,\n \"text\": \" 7:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: New pleural effusion?\\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with Inferior MI s/p PCI with BMS\\n REASON FOR THIS EXAMINATION:\\n New pleural effusion?\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Evaluation for pleural effusions.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. No visible pleural effusions. Unchanged moderate cardiomegaly with\\n signs of minimal fluid overload and bilateral areas of atelectasis. Unchanged\\n venous introduction sheath in the right internal jugular vein.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-08-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254775,\n \"text\": \" 10:21 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 80F with ? CHF, AMI\\n REASON FOR THIS EXAMINATION:\\n r/o CHF\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH PERFORMED ON \\n\\n COMPARISON: None.\\n\\n CLINICAL HISTORY: 80-year-old female with CHF, question acute intrathoracic\\n process.\\n\\n FINDINGS: AP portable upright chest radiograph obtained. The heart is mildly\\n enlarged. Lung volumes are low. There is no overt sign of pneumonia or\\n pulmonary edema. No large effusion or pneumothorax seen. Mediastinal contour\\n appears normal. Bony structures intact, though high-riding right humeral head\\n suggests chronic rotator cuff injury.\\n\\n IMPRESSION: Mild cardiomegaly. Otherwise, normal.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24983,"cells":{"subject_id":{"kind":"number","value":8184,"string":"8,184"},"hadm_id":{"kind":"number","value":157949,"string":"157,949"},"target_text":{"kind":"string","value":"Pursuant with management and plan the patient was admitted to the Trauma CICU where the oral maxillofacial surgery service was consulted for repair of this patient's fracture. The OMFS Service saw the patient shortly after his admission to the and their impression was that this 26 year-old patient should be started on intravenous Clindamycin at 600 mg q 8 hours. Also he should be given Peridex 15 cc swish and spit b.i.d. Pertaining to the operative management they suggested that the patient would require an open reduction and internal fixation of his LeFort 1 fracture. Consultation with ophthalmology was also recommended due to the patient's periorbital swelling. Pursuant to this recommendation, ophthalmology was consulted and on hospital day one they commented that there were no clinical signs of entrapment, although it was difficult to assess vision or voluntary mobility of the eyes due to the patient's mental status. There was no evidence of intraorbital injury per the examination by the ophthalmologist and no signs of compartment syndrome. Their recommendation was for lubrication to the eyes to prevent exposure injury. On hospital day two the OMFS Service commented that per their operative plan the patient would be taken to the Operating Room on hospital day three for open reduction and internal fixation of his facial fracture. Preoperative laboratories and workup were completed and the patient was cleared for this procedure. While in the CICU the patient remained intubated in light of his impending procedure and for protection of his airway in light of his facial fracture. The patient continued to be dosed with intravenous Clindamycin per the recommendation of the OMFS team and the patient continued to be afebrile with stable vital signs. On hospital day three the patient was taken to the Operating Room by the Oral Maxillofacial Surgery Service where an open reduction and internal fixation was performed on the patient's LeFort 1 fracture. This procedure was performed without complications with an estimated blood loss of 200 cc and an intraoperative urine output of 900 cc. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit in stable condition. On postoperative day one as the patient continued to do well and his mental status had continued to be awake, alert and the patient was extubated, the patient was transferred out of the Surgical Intensive Care Unit where his continuing complaints were mild swelling of his face bilaterally, which was being treated postoperatively with intravenous steroids. Cranial nerve examination postoperatively was intact as far as cranial nerve V in the V - II distribution and the patient was started on a po diet consisting of a blenderized diet. On postoperative day two the patient continued to have mild swelling of his face bilaterally, but his nerve examination remained intact and the patient was tolerating a reasonable po diet. On postoperative day three as the patient continued to do well and was cleared for discharge by the Oral Maxillofacial Surgery Service the patient was discharged with prescriptions for Clindamycin to continue until follow up with OMFS as well as appropriate pain medication consisting of Roxicet elixir. The patient's steroids were discontinued after discussion with the Oral Maxillofacial Surgery Service as the patient's swelling had decreased significantly and the intravenous steroids were no longer necessary to control postoperative swelling."},"extractive_notes_summ":{"kind":"string","value":"Pt requests to be suctioned.GI: Pt c/o nausea X1, resolved spontaneously. RUA IV infiltrated, pt with 2 patent #18 IVs in L arm.Resp: Pt changed to PSV this AM, tolerating well with adequate ABGs. Mouth/nose oozes serous type drainage.Endo-no issues,ID-temp. K 4.1/MG 1.7->REPLETEDR: STABLE ABG ON PSV. RETURNED INTUBATED/SEDATED/VENTED. Pt remains NPO, abd soft with good BS throughout.GU/renal: Good u/o via foley catheter. Pt to remain NPO, pepcid started for prophylaxis.GU/renal: Large u/o via foley catheter, brisk diuresis. Keep pt updated on plan of care, offer support, reassurance.R: As above, 2mg ativan IVP with fair-good effect. CONT FROM PREVIOUS NSG ENTRY..CV: MG 1.8-REPLETED. Back intact, collar care provided.Endo: RISS, no coverage required.ID: Low grade temps today, IV Clinda for facial fx.Social; father by anesthesia this AM for consent, aware pt is doing well and plans for OR this PM. PT C/O NAUSEA X1 AND RESOLVED WITHOUT MED. Pt was sedated and returned to . C/O FACIAL/JAW PAIN-->MEDICATED WITH MSO4 PRN WITH EFFECT. CV: SR no ectopy, BP stable via right radial aline.GU: >150/hr. CLEARS BILAT WITH SXN'NG. 7:52 AM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: s/p mvc. Pt appears calm and comofortable on MSO4 PRN and propofol gtt. Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BP stable via A-line. Pt arrived to without C-collar, placed disposible collar in ER and changed to J on arrival to SICU. WILL ATTEMPT TO CLEAR NECK TODAY PRIOR TO OR.CV: HD STABLE. Abd softly distended, hypoactive BS throughout. REC'D 1.5L IVF, 900U/O, 200EBL, AND CA/MG REPLETED. Pt given 2gm mag sulfate for mag 1.2; set of obscure labs this AM repeatd and WNL.Endo: SSI, no coverage requiredSkin: Multiple lacerations to face- deep chin lac on L side of face irrigated and sutured at bedside with other smaller check laceration, Lip lacs sutured in ER. CONT ON IV DECADRON FOR AIRWAY EDEMA.GI: ABD SOFT/DISTENDED WITH HYPO BS. Pt started on SC heparin.Resp: Pt remains intubatd for airway protection with #7 tube at 22 lip line. r/o acute process No contraindications for IV contrast WET READ: PSLa MON 8:48 AM aspiration vs. atelectasis, no acute abdominal process FINAL REPORT INDICATION: Status post MVC high speed. Pt with question of siezure activity when he became light, taken for stat head CT which was negative for bleed/contusion. Nursing Progress NoteS/ pt has been stable throughout the shift, has required suctioning q1 hour by his request for small to mod amts of thin tan sputum. NPNN: PT ALERT/APPROPRIATE/NEURO INTACT. Endo: BS 130's Skin: Grossly intact, sutures at chin/lip intact. CLINDA ATC.ENDO: GLUC 130'S NOT REQUIRING SS COVERAGE.SOC: BROTHER IN VISITING/UPDATED.A/ HD STABLE S/P ORIF FACIAL FX'S.P/ PLAN TO EXTUBATE IF NO AIRWAY EDEMA PRESENT. TLS films completed today, negative per Dr. and logroll precautions d/c'd. decreased, rel clear bilat. WBC 15.5/CLINDA ATC.ENDO: GLUC 132SOC: NO CONTACT WITH FAMILY OVERNIGHT.A/P: STABLE/AWAITING REDUCTION IN NECK SWELLING WITH ASSIST OF DECADRON, CLEAR NECK PRIOR TO OR TODAY. Pt is intubated at this time. TECHNIQUE: Helically acquired contiguous axial images were obtained from the thoracic inlet to the pubic symphysis after the administration of intravenous contrast. LUNGS CLEAR THROUGHOUT SL DIM AT BASES. Pulm:PS settings being tolerated well, lungs clear bilaterally, rr even/unlabored. Pt noted to have +u/a, repeat u/a and cultures sent this PM with MRSA screen. Pt tolerating MSO4 5mg Q2-4 hours PRN for jaw/facial pain.CV: Stable, HR 60-90, no VEA. intubated.o. Hct noted to have sl drop, likely dilutional rresult. Corneals and cough present, gag not checked due to facial fractures.CV: Stable, HR 80-100's, no ectopy noted. Pt remained stable and was vented on IMV. Propofol turned off for neuro exam this AM, has been off ever since with PRN morphine for pain.ROS:Neuro: Pt very calm and appropriate off of propofol today. Pt has been given MSO4 5mg x3 to keep pt comfortable.A/ pt to OR, will return here for post-op care. REMAINS SEDATED ON PROPOFUL OVERNIGHT.CV: NSR 70-120'S WITH COUGHING. K+4.0R: LUNGS OCC COURSE THROUGHOUT. SXN'D PER PT REQUEST FOR SCANT AMTS THICK YELLOW.GI: NPO. c/o pain occasionally, medicated with MS04 with good effect.Resp-no vent changes during night, pt. Pt remains on IMV, 12X700, 40% with 5PEEP, ABGs adequate.GI: OGT placed on arrival to ICU, to LWS with dk red/black drainage. REASON FOR THIS EXAMINATION: s/p mvc. OGT D/C'D IN OR/NOT REPLACED. Pt requesting frequent oral/ett suction with scant return, sats >97%. NPNEVENT: RETURNED FROM OR S/P ORIF OF FACIAL FX'S 8:45PM NASALLY INTUBATED WITH 6.5 ETT (SUTURED TO LEFT NARE). small laceration on left chin is dry, oovered with DSD. NO COMPLICATIONS REPORTED.N: LIGHTENED FROM PROPOFUL GTT AND FC'S CONSISTENTLY. Good ABG's.GI/GU=NPO, BS present, no stool or flatus. AddendumPt returned from OR withoutstabilization of his facial fractures, they were unable to nasally intubate him, decadron given and ordered q8. Please see carevue for further vent inqueries. Stable BP 130-150/sys. MEDICATED WITH MSO4 PRN FOR PAIN WITH EFFECT. Plan to wean and extubate once pt goes to OR. ETT retaped on arrival to SICU. Neuro: A&O, no deficits noted. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal glands and unopacified loops of bowel are normal. They appeared appropriately worried about pt. Continue sedation and pain control. LR WITH THIAMINE/FOLATE/MVI AT 50CC/HR.GU: BRISKLY AUTODIURESING CLEAR YELLOWHEME: HCT 34. LR decreased to 50cc/hr, pt still with good u/o. Will f/u with family, pt tomorrow.A: Stable s/p MVC with significant facial injuriesP: Keep pt intubated and sedated until taken to OR for repair of facial fractures."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2107-01-17 00:00:00.000","description":"CT 150CC NONIONIC CONTRAST","row_id":780407,"text":" 7:52 AM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: s/p mvc. r/o acute process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p high speed unrestrained mvc.\n REASON FOR THIS EXAMINATION:\n s/p mvc. r/o acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa MON 8:48 AM\n aspiration vs. atelectasis, no acute abdominal process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC high speed.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet to the pubic symphysis after the administration of intravenous\n contrast.\n\n CONTRAST: 150 cc of Optiray was administered per trauma protocol.\n\n CHEST CT WITH INTRAVENOUS CONTRAST: There is no significant axillary,\n mediastinal, or hilar lymphadenopathy. The heart and great vessels are normal\n in appearance. The airways are patent as well as the segmental bronchi\n bilaterally. An ET tube is present within the trachea. There are bilateral\n lower lobe consolidations. The remainder of the lungs are clear. There are\n no pleural effusions. There is no pericardial effusion.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n pancreas, adrenal glands and unopacified loops of bowel are normal. The\n kidneys enhance symmetrically and excrete normally. There is no significant\n abdominal adenopathy. There is no free fluid or free air within the abdomen.\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters and urinary\n bladder are unremarkable. The intrapelvic bowel loops are unremarkable.\n\n The osseous structures are normal. No fractures are identified.\n\n IMPRESSION:\n 1) There are increased opacities at the lung bases bilaterally consistent\n with probable aspiration or atelectasis.\n 2) No acute intraabdominal process is identified.\n\n\n"},{"category":"Nursing/other","chartdate":"2107-01-17 00:00:00.000","description":"Report","row_id":1370969,"text":"SOCIAL WORK NOTE:\n\nNew trauma pt on T-SICU. Pt is s/p MVC as unrestrained driver of car vs. cement barrier. Pt is a 26 year old single Caucasian man who lives in with his father, . Pt has a brother and sister. Pt does landscaping work. He is not involved in a dating relationship. Pt transferred here from Hospital for management of facial fractures. Pt is intubated at this time. Pt's etoh level at time of testing at this hospital was 20 and was reportedly higher at OSH. Pt's tox screen at OSH was also + for marijuana.\n\nEarlier, Police were present but have since left hospital. This SW called Police () to clarify pt's legal status. Police officer I spoke with stated that pt was initially arrested but now released to his father's custody and will receive information by mail about citation related to accident (suspected of drunk driving by police). This does not affect his ability to have visitors or his discharge.\n\nThis SW met pt's father and brother, both named , to introduce self, offer support, and gather information. They were not unpleasant but not easily engaged. They appeared appropriately worried about pt. They said that pt drinks \"heavily but not alone\" and they did seem concerned about his substance use. This issue can be explored further later in pt's hospitalization. Family given contact information for this SW and I remain available as needed. Pager .\n"},{"category":"Nursing/other","chartdate":"2107-01-17 00:00:00.000","description":"Report","row_id":1370970,"text":"SICU Admit note\nPt is a 26 yr old gentleman admitted to from an OSH s/p MVC. Pt was the driver of a single car accident, car vs. cement wall. Pt was initally awake and alert, taken to OSH where he was noted to have significant facial fractures, was intubated for airway protection and sent to . Pt's tox screen was + for ETOH and marijuana. On arrival, pt was placed into a C-collar for cervical protection, scans reviewed and pt brought to SICU for care.\nShortly after arrival to SICU, pt noted to have ?siezure activity, taken to stat head CT scan (was negative for bleed/contusion) and also had TLS films completed. Optho and OMFS in to eval pt, ?plan for OR to repair 1 fracture with R mildly medially displaced zygomatic-maxillary complex fractures when OMFS available.\n\nPMH: none\nMeds PTA: denies\n**Drinks <6 beers a day, social marijuana***\n\nROS\nNeuro: Pt brought to SICU chemically paralyzed and sedated. Pt with question of siezure activity when he became light, taken for stat head CT which was negative for bleed/contusion. Pt arrived to without C-collar, placed disposible collar in ER and changed to J on arrival to SICU. TLS films completed today, negative per Dr. and logroll precautions d/c'd. Pt with pupils 2mm and brisk most of day, pupils were dilated at 1430 this afternoon for Optho exam. No further siezure activity noted this PM, no dilantin required. Pt appears calm and comofortable on MSO4 PRN and propofol gtt. Corneals and cough present, gag not checked due to facial fractures.\n\nCV: Stable, HR 80-100's, no ectopy noted. BP stable, SBP 100-150's. Extremities warm and well perfused, easily palpable pulses. Pt arrived to SICU with 2 periph IVs in place, 3rd placed in SICU. A-line placed on arrival, also. Hct noted to have sl drop, likely dilutional rresult. Pt started on SC heparin.\n\nResp: Pt remains intubatd for airway protection with #7 tube at 22 lip line. ETT retaped on arrival to SICU. Lungs coarse throughout, dimished at bilateral bases. Pt with obvious aspiration of blood, suctioned Q1-2 hours for thick, thick dk red blood. Pt remains on IMV, 12X700, 40% with 5PEEP, ABGs adequate.\n\nGI: OGT placed on arrival to ICU, to LWS with dk red/black drainage. Abd softly distended, hypoactive BS throughout. Pt to remain NPO, pepcid started for prophylaxis.\n\nGU/renal: Large u/o via foley catheter, brisk diuresis. LR decreased to 50cc/hr, pt still with good u/o. Pt given 2gm mag sulfate for mag 1.2; set of obscure labs this AM repeatd and WNL.\n\nEndo: SSI, no coverage required\n\nSkin: Multiple lacerations to face- deep chin lac on L side of face irrigated and sutured at bedside with other smaller check laceration, Lip lacs sutured in ER. Small abrasions/laceration noted on medial apsect of R knee\n\nID: Pt on Clinda for facial fracture coverage. Pt noted to have +u/a, repeat u/a and cultures sent this PM with MRSA screen. Tmax 100.4.\n\nSocial: father and brother, both named , in to visit this PM.\n"},{"category":"Nursing/other","chartdate":"2107-01-17 00:00:00.000","description":"Report","row_id":1370971,"text":"SICU Admit note\n(Continued)\n When pt arrived from ER, was under police custody. Pt is no longer under their custody now, does not require sitters or police guard. Social work consulted, also for pt's history of ETOH and Marijuana use. Will f/u with family, pt tomorrow.\n\nA: Stable s/p MVC with significant facial injuries\n\nP: Keep pt intubated and sedated until taken to OR for repair of facial fractures. Closely monitor resp status, WBCs, temp curve due to likely aspiration of blood. Closley observe pt for signs/symptoms of withdrawal due to ETOH and Marijuana use. Plan to wean and extubate once pt goes to OR.\n"},{"category":"Nursing/other","chartdate":"2107-01-20 00:00:00.000","description":"Report","row_id":1370981,"text":"CONT FROM PREVIOUS NSG ENTRY..\nCV: MG 1.8-REPLETED. K+4.0\nR: LUNGS OCC COURSE THROUGHOUT. CLEARS BILAT WITH SXN'NG. REQUIRED SXN FOR SM AMTS THICK YELLOW SEC. WHEN AWAKE, PERSISTENTLY COUGHING WITH VERY SENSITIVE GAG REFLEX. SIMV 14X600, PEEP 5, 50%. CONT ON IV DECADRON FOR AIRWAY EDEMA.\nGI: ABD SOFT/DISTENDED WITH HYPO BS. OGT D/C'D IN OR (D/T MIN OUTPUT) RECEIVING LR @ 50CCHR WITH MVI/THIAMINE/FOLATE/KCL 40MEQ/L.\nGU: URINE OUTPUT CLEAR YELLOW 50-70CC/HR.\nHEME: HCT 30\nID: LOW GRADE TEMPS. WBC 16. CLINDA ATC.\nENDO: GLUC 130'S NOT REQUIRING SS COVERAGE.\nSOC: BROTHER IN VISITING/UPDATED.\nA/ HD STABLE S/P ORIF FACIAL FX'S.\nP/ PLAN TO EXTUBATE IF NO AIRWAY EDEMA PRESENT.\n"},{"category":"Nursing/other","chartdate":"2107-01-20 00:00:00.000","description":"Report","row_id":1370982,"text":"SOCIAL WORK NOTE:\nPt likely to be able to transfer out to floor soon. This SW met with pt briefly this morning to offer support. Pt was drowsy. He engaged pleasantly but was not able to do so at length. Pt still needs f/u about etoh and marijuana use (+ at time of accident). This SW will continue to check-in or will refer to floor SW as necessary. Pager .\n"},{"category":"Nursing/other","chartdate":"2107-01-18 00:00:00.000","description":"Report","row_id":1370975,"text":"Nursing Progress Note\nS/ pt has been stable throughout the shift, has required suctioning q1 hour by his request for small to mod amts of thin tan sputum. pt family in to visit, he is awake and alert and communicating by notes. pt moving all extrems equally. Consent was signed by his father with his knowledge. Pt has been given MSO4 5mg x3 to keep pt comfortable.\nA/ pt to OR, will return here for post-op care.\n"},{"category":"Nursing/other","chartdate":"2107-01-18 00:00:00.000","description":"Report","row_id":1370976,"text":"Addendum\nPt returned from OR withoutstabilization of his facial fractures, they were unable to nasally intubate him, decadron given and ordered q8. Pt was sedated and returned to . Pt remained stable and was vented on IMV. Pt family was notified by surgeon.\nA/P pt is to go to MRI for cervical neck clearance and to OR at 3PM\n"},{"category":"Nursing/other","chartdate":"2107-01-19 00:00:00.000","description":"Report","row_id":1370977,"text":"NPN\nN: PT ALERT/APPROPRIATE/NEURO INTACT. MEDICATED WITH MSO4 PRN FOR PAIN WITH EFFECT. C/O \"WANTING TO SLEEP\"--RESTLESS/AGITATED--> STARTED LOW DOSE PROPOFUL GTT OVERNIGHT. WILL ATTEMPT TO CLEAR NECK TODAY PRIOR TO OR.\nCV: HD STABLE. K 4.1/MG 1.7->REPLETED\nR: STABLE ABG ON PSV. LUNGS CLEAR THROUGHOUT SL DIM AT BASES. SXN'D PER PT REQUEST FOR SCANT AMTS THICK YELLOW.\nGI: NPO. OGT D/C'D IN OR/NOT REPLACED. PT C/O NAUSEA X1 AND RESOLVED WITHOUT MED. LR WITH THIAMINE/FOLATE/MVI AT 50CC/HR.\nGU: BRISKLY AUTODIURESING CLEAR YELLOW\nHEME: HCT 34. COAGS NL.\nID: AFEBRILE. WBC 15.5/CLINDA ATC.\nENDO: GLUC 132\nSOC: NO CONTACT WITH FAMILY OVERNIGHT.\nA/P: STABLE/AWAITING REDUCTION IN NECK SWELLING WITH ASSIST OF DECADRON, CLEAR NECK PRIOR TO OR TODAY. EMOTIONAL SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2107-01-19 00:00:00.000","description":"Report","row_id":1370978,"text":"D: Pls see careview assessment/data. Neuro: A&O, no deficits noted. Pt expressing anxiety, wanting to be \"knocked out\" until surgery. Pulm:PS settings being tolerated well, lungs clear bilaterally, rr even/unlabored. Pt requesting frequent oral/ett suction with scant return, sats >97%. CV: SR no ectopy, BP stable via right radial aline.\nGU: >150/hr. GI: No n/v, abd soft, +bs. Endo: BS 130's Skin: Grossly intact, sutures at chin/lip intact. scattered scrapes/lacs open to air. Peripheral pulses 4+. Surgical team in on rounds, please see orders.\n\nP: Continue full support. keep npo for surgery this afternoon, Ativan prn for anxiety. Keep pt updated on plan of care, offer support, reassurance.\n\nR: As above, 2mg ativan IVP with fair-good effect. Pt with call light in hand.\n"},{"category":"Nursing/other","chartdate":"2107-01-19 00:00:00.000","description":"Report","row_id":1370979,"text":"D: Pt remains a&o, cooperative and calm. OR scheduled for approx 1530. Pt aware of and agreeable to same.\n"},{"category":"Nursing/other","chartdate":"2107-01-20 00:00:00.000","description":"Report","row_id":1370980,"text":"NPN\nEVENT: RETURNED FROM OR S/P ORIF OF FACIAL FX'S 8:45PM NASALLY INTUBATED WITH 6.5 ETT (SUTURED TO LEFT NARE). REC'D 1.5L IVF, 900U/O, 200EBL, AND CA/MG REPLETED. RETURNED INTUBATED/SEDATED/VENTED. NO COMPLICATIONS REPORTED.\n\nN: LIGHTENED FROM PROPOFUL GTT AND FC'S CONSISTENTLY. C/O FACIAL/JAW PAIN-->MEDICATED WITH MSO4 PRN WITH EFFECT. ANXIOUS/AGITATED WITH NASAL ETT, PERSISTENTLY COUGHING/GAGGING->GIVEN ATIVAN 2MG X1 WITH EFFECT. REMAINS SEDATED ON PROPOFUL OVERNIGHT.\nCV: NSR 70-120'S WITH COUGHING. SBP 100-190/ HYPERTENSIVE TRANSIENTLY WITH COUGHING.\n"},{"category":"Nursing/other","chartdate":"2107-01-18 00:00:00.000","description":"Report","row_id":1370972,"text":" 7p-7a Nursing Progress Note\n\ns. Pt. intubated.\n\no. C-V=NSR 70-90's,no VEA. Stable BP 130-150/sys. Strong palpable pedal pulses. peripheral IV's only. Right radial A-line. LR at 50cc/hr.\n\nNeuro=Able to follow commands through Propofol at 20-30mcg/. Squeezes hands, shows fingers, wiggles toes, nods head yes/no. Opens eyes spontaneously and to commands. Gags on ETT, great strong cough. Pupils are PERLA, 3mm. c/o pain occasionally, medicated with MS04 with good effect.\n\nResp-no vent changes during night, pt. pre-op today. Continues on SIMV at 12/700/40%/5PEEP, 02 sats 98-100%. occasionally breathes over vent. Suctioned for thick brown secretions, BS clear but diminished, R>L. Good ABG's.\n\nGI/GU=NPO, BS present, no stool or flatus. NG tube draining coffee-brown secretions. Foley draining ~60cc/hr.\n\nSkin-laceration on right knee, dry crusty blood covers it. small laceration on left chin is dry, oovered with DSD. Mouth/nose oozes serous type drainage.\n\nEndo-no issues,\n\nID-temp. 100.8, on Clindamycin\n\nSocial-Dad called during evening, Dr. was to call him re:surgery.\n\nA.- stable night, sedated on Propofol and MS04.\n\nP.-Pre-op for later this evening. Continue sedation and pain control.\n"},{"category":"Nursing/other","chartdate":"2107-01-18 00:00:00.000","description":"Report","row_id":1370973,"text":"Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BS sl. decreased, rel clear bilat. Not req freq sx'ing by RT. Changed to PSV. ABG WNL. Plan to go back to OR for facial . Please see carevue for further vent inqueries.\n"},{"category":"Nursing/other","chartdate":"2107-01-18 00:00:00.000","description":"Report","row_id":1370974,"text":"SICU NPN\nPt remains intubated and vented in the SICU awaiting surgery for his facial fractures. Propofol turned off for neuro exam this AM, has been off ever since with PRN morphine for pain.\n\nROS:\nNeuro: Pt very calm and appropriate off of propofol today. Pt alert and oriented X3 by writing, asking appropriate questions. Pt follows commands, MAE with good strength. C-collar remains on, pt denies any neck pain/tenderness. Pt tolerating MSO4 5mg Q2-4 hours PRN for jaw/facial pain.\n\nCV: Stable, HR 60-90, no VEA. BP stable via A-line. Pulses easily palpable. RUA IV infiltrated, pt with 2 patent #18 IVs in L arm.\n\nResp: Pt changed to PSV this AM, tolerating well with adequate ABGs. RR 12-18, sats 100% all day. Pt requires suctioning Q2-3 hours for thick, yellowish rusty sputum. Pt requests to be suctioned.\n\nGI: Pt c/o nausea X1, resolved spontaneously. OGT draining small ammts green/dk red output. Pt remains NPO, abd soft with good BS throughout.\n\nGU/renal: Good u/o via foley catheter. Pt rec'd 10 MEq KCL this AM. LR at 50cc/hr.\n\nSkin: facial lacs approximated well with sutures, bacitracin ointment applied. R leg abrasion scabbed over. Back intact, collar care provided.\n\nEndo: RISS, no coverage required.\n\nID: Low grade temps today, IV Clinda for facial fx.\n\nSocial; father by anesthesia this AM for consent, aware pt is doing well and plans for OR this PM. No other family contact.\n\nA: Stable s/p MVC with facial fractures\n\nP: Send pt to OR this PM for repair of facial fractures, plan to return to SICU post-op for extubation and airway monitoring.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-01-17 00:00:00.000\",\n \"description\": \"CT 150CC NONIONIC CONTRAST\",\n \"row_id\": 780407,\n \"text\": \" 7:52 AM\\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: s/p mvc. r/o acute process\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 26 year old man with s/p high speed unrestrained mvc.\\n REASON FOR THIS EXAMINATION:\\n s/p mvc. r/o acute process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: PSLa MON 8:48 AM\\n aspiration vs. atelectasis, no acute abdominal process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post MVC high speed.\\n\\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\\n thoracic inlet to the pubic symphysis after the administration of intravenous\\n contrast.\\n\\n CONTRAST: 150 cc of Optiray was administered per trauma protocol.\\n\\n CHEST CT WITH INTRAVENOUS CONTRAST: There is no significant axillary,\\n mediastinal, or hilar lymphadenopathy. The heart and great vessels are normal\\n in appearance. The airways are patent as well as the segmental bronchi\\n bilaterally. An ET tube is present within the trachea. There are bilateral\\n lower lobe consolidations. The remainder of the lungs are clear. There are\\n no pleural effusions. There is no pericardial effusion.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\\n pancreas, adrenal glands and unopacified loops of bowel are normal. The\\n kidneys enhance symmetrically and excrete normally. There is no significant\\n abdominal adenopathy. There is no free fluid or free air within the abdomen.\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters and urinary\\n bladder are unremarkable. The intrapelvic bowel loops are unremarkable.\\n\\n The osseous structures are normal. No fractures are identified.\\n\\n IMPRESSION:\\n 1) There are increased opacities at the lung bases bilaterally consistent\\n with probable aspiration or atelectasis.\\n 2) No acute intraabdominal process is identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370969,\n \"text\": \"SOCIAL WORK NOTE:\\n\\nNew trauma pt on T-SICU. Pt is s/p MVC as unrestrained driver of car vs. cement barrier. Pt is a 26 year old single Caucasian man who lives in with his father, . Pt has a brother and sister. Pt does landscaping work. He is not involved in a dating relationship. Pt transferred here from Hospital for management of facial fractures. Pt is intubated at this time. Pt's etoh level at time of testing at this hospital was 20 and was reportedly higher at OSH. Pt's tox screen at OSH was also + for marijuana.\\n\\nEarlier, Police were present but have since left hospital. This SW called Police () to clarify pt's legal status. Police officer I spoke with stated that pt was initially arrested but now released to his father's custody and will receive information by mail about citation related to accident (suspected of drunk driving by police). This does not affect his ability to have visitors or his discharge.\\n\\nThis SW met pt's father and brother, both named , to introduce self, offer support, and gather information. They were not unpleasant but not easily engaged. They appeared appropriately worried about pt. They said that pt drinks \\\"heavily but not alone\\\" and they did seem concerned about his substance use. This issue can be explored further later in pt's hospitalization. Family given contact information for this SW and I remain available as needed. Pager .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370970,\n \"text\": \"SICU Admit note\\nPt is a 26 yr old gentleman admitted to from an OSH s/p MVC. Pt was the driver of a single car accident, car vs. cement wall. Pt was initally awake and alert, taken to OSH where he was noted to have significant facial fractures, was intubated for airway protection and sent to . Pt's tox screen was + for ETOH and marijuana. On arrival, pt was placed into a C-collar for cervical protection, scans reviewed and pt brought to SICU for care.\\nShortly after arrival to SICU, pt noted to have ?siezure activity, taken to stat head CT scan (was negative for bleed/contusion) and also had TLS films completed. Optho and OMFS in to eval pt, ?plan for OR to repair 1 fracture with R mildly medially displaced zygomatic-maxillary complex fractures when OMFS available.\\n\\nPMH: none\\nMeds PTA: denies\\n**Drinks <6 beers a day, social marijuana***\\n\\nROS\\nNeuro: Pt brought to SICU chemically paralyzed and sedated. Pt with question of siezure activity when he became light, taken for stat head CT which was negative for bleed/contusion. Pt arrived to without C-collar, placed disposible collar in ER and changed to J on arrival to SICU. TLS films completed today, negative per Dr. and logroll precautions d/c'd. Pt with pupils 2mm and brisk most of day, pupils were dilated at 1430 this afternoon for Optho exam. No further siezure activity noted this PM, no dilantin required. Pt appears calm and comofortable on MSO4 PRN and propofol gtt. Corneals and cough present, gag not checked due to facial fractures.\\n\\nCV: Stable, HR 80-100's, no ectopy noted. BP stable, SBP 100-150's. Extremities warm and well perfused, easily palpable pulses. Pt arrived to SICU with 2 periph IVs in place, 3rd placed in SICU. A-line placed on arrival, also. Hct noted to have sl drop, likely dilutional rresult. Pt started on SC heparin.\\n\\nResp: Pt remains intubatd for airway protection with #7 tube at 22 lip line. ETT retaped on arrival to SICU. Lungs coarse throughout, dimished at bilateral bases. Pt with obvious aspiration of blood, suctioned Q1-2 hours for thick, thick dk red blood. Pt remains on IMV, 12X700, 40% with 5PEEP, ABGs adequate.\\n\\nGI: OGT placed on arrival to ICU, to LWS with dk red/black drainage. Abd softly distended, hypoactive BS throughout. Pt to remain NPO, pepcid started for prophylaxis.\\n\\nGU/renal: Large u/o via foley catheter, brisk diuresis. LR decreased to 50cc/hr, pt still with good u/o. Pt given 2gm mag sulfate for mag 1.2; set of obscure labs this AM repeatd and WNL.\\n\\nEndo: SSI, no coverage required\\n\\nSkin: Multiple lacerations to face- deep chin lac on L side of face irrigated and sutured at bedside with other smaller check laceration, Lip lacs sutured in ER. Small abrasions/laceration noted on medial apsect of R knee\\n\\nID: Pt on Clinda for facial fracture coverage. Pt noted to have +u/a, repeat u/a and cultures sent this PM with MRSA screen. Tmax 100.4.\\n\\nSocial: father and brother, both named , in to visit this PM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370971,\n \"text\": \"SICU Admit note\\n(Continued)\\n When pt arrived from ER, was under police custody. Pt is no longer under their custody now, does not require sitters or police guard. Social work consulted, also for pt's history of ETOH and Marijuana use. Will f/u with family, pt tomorrow.\\n\\nA: Stable s/p MVC with significant facial injuries\\n\\nP: Keep pt intubated and sedated until taken to OR for repair of facial fractures. Closely monitor resp status, WBCs, temp curve due to likely aspiration of blood. Closley observe pt for signs/symptoms of withdrawal due to ETOH and Marijuana use. Plan to wean and extubate once pt goes to OR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370981,\n \"text\": \"CONT FROM PREVIOUS NSG ENTRY..\\nCV: MG 1.8-REPLETED. K+4.0\\nR: LUNGS OCC COURSE THROUGHOUT. CLEARS BILAT WITH SXN'NG. REQUIRED SXN FOR SM AMTS THICK YELLOW SEC. WHEN AWAKE, PERSISTENTLY COUGHING WITH VERY SENSITIVE GAG REFLEX. SIMV 14X600, PEEP 5, 50%. CONT ON IV DECADRON FOR AIRWAY EDEMA.\\nGI: ABD SOFT/DISTENDED WITH HYPO BS. OGT D/C'D IN OR (D/T MIN OUTPUT) RECEIVING LR @ 50CCHR WITH MVI/THIAMINE/FOLATE/KCL 40MEQ/L.\\nGU: URINE OUTPUT CLEAR YELLOW 50-70CC/HR.\\nHEME: HCT 30\\nID: LOW GRADE TEMPS. WBC 16. CLINDA ATC.\\nENDO: GLUC 130'S NOT REQUIRING SS COVERAGE.\\nSOC: BROTHER IN VISITING/UPDATED.\\nA/ HD STABLE S/P ORIF FACIAL FX'S.\\nP/ PLAN TO EXTUBATE IF NO AIRWAY EDEMA PRESENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370982,\n \"text\": \"SOCIAL WORK NOTE:\\nPt likely to be able to transfer out to floor soon. This SW met with pt briefly this morning to offer support. Pt was drowsy. He engaged pleasantly but was not able to do so at length. Pt still needs f/u about etoh and marijuana use (+ at time of accident). This SW will continue to check-in or will refer to floor SW as necessary. Pager .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370975,\n \"text\": \"Nursing Progress Note\\nS/ pt has been stable throughout the shift, has required suctioning q1 hour by his request for small to mod amts of thin tan sputum. pt family in to visit, he is awake and alert and communicating by notes. pt moving all extrems equally. Consent was signed by his father with his knowledge. Pt has been given MSO4 5mg x3 to keep pt comfortable.\\nA/ pt to OR, will return here for post-op care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370976,\n \"text\": \"Addendum\\nPt returned from OR withoutstabilization of his facial fractures, they were unable to nasally intubate him, decadron given and ordered q8. Pt was sedated and returned to . Pt remained stable and was vented on IMV. Pt family was notified by surgeon.\\nA/P pt is to go to MRI for cervical neck clearance and to OR at 3PM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370977,\n \"text\": \"NPN\\nN: PT ALERT/APPROPRIATE/NEURO INTACT. MEDICATED WITH MSO4 PRN FOR PAIN WITH EFFECT. C/O \\\"WANTING TO SLEEP\\\"--RESTLESS/AGITATED--> STARTED LOW DOSE PROPOFUL GTT OVERNIGHT. WILL ATTEMPT TO CLEAR NECK TODAY PRIOR TO OR.\\nCV: HD STABLE. K 4.1/MG 1.7->REPLETED\\nR: STABLE ABG ON PSV. LUNGS CLEAR THROUGHOUT SL DIM AT BASES. SXN'D PER PT REQUEST FOR SCANT AMTS THICK YELLOW.\\nGI: NPO. OGT D/C'D IN OR/NOT REPLACED. PT C/O NAUSEA X1 AND RESOLVED WITHOUT MED. LR WITH THIAMINE/FOLATE/MVI AT 50CC/HR.\\nGU: BRISKLY AUTODIURESING CLEAR YELLOW\\nHEME: HCT 34. COAGS NL.\\nID: AFEBRILE. WBC 15.5/CLINDA ATC.\\nENDO: GLUC 132\\nSOC: NO CONTACT WITH FAMILY OVERNIGHT.\\nA/P: STABLE/AWAITING REDUCTION IN NECK SWELLING WITH ASSIST OF DECADRON, CLEAR NECK PRIOR TO OR TODAY. EMOTIONAL SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370978,\n \"text\": \"D: Pls see careview assessment/data. Neuro: A&O, no deficits noted. Pt expressing anxiety, wanting to be \\\"knocked out\\\" until surgery. Pulm:PS settings being tolerated well, lungs clear bilaterally, rr even/unlabored. Pt requesting frequent oral/ett suction with scant return, sats >97%. CV: SR no ectopy, BP stable via right radial aline.\\nGU: >150/hr. GI: No n/v, abd soft, +bs. Endo: BS 130's Skin: Grossly intact, sutures at chin/lip intact. scattered scrapes/lacs open to air. Peripheral pulses 4+. Surgical team in on rounds, please see orders.\\n\\nP: Continue full support. keep npo for surgery this afternoon, Ativan prn for anxiety. Keep pt updated on plan of care, offer support, reassurance.\\n\\nR: As above, 2mg ativan IVP with fair-good effect. Pt with call light in hand.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370979,\n \"text\": \"D: Pt remains a&o, cooperative and calm. OR scheduled for approx 1530. Pt aware of and agreeable to same.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370980,\n \"text\": \"NPN\\nEVENT: RETURNED FROM OR S/P ORIF OF FACIAL FX'S 8:45PM NASALLY INTUBATED WITH 6.5 ETT (SUTURED TO LEFT NARE). REC'D 1.5L IVF, 900U/O, 200EBL, AND CA/MG REPLETED. RETURNED INTUBATED/SEDATED/VENTED. NO COMPLICATIONS REPORTED.\\n\\nN: LIGHTENED FROM PROPOFUL GTT AND FC'S CONSISTENTLY. C/O FACIAL/JAW PAIN-->MEDICATED WITH MSO4 PRN WITH EFFECT. ANXIOUS/AGITATED WITH NASAL ETT, PERSISTENTLY COUGHING/GAGGING->GIVEN ATIVAN 2MG X1 WITH EFFECT. REMAINS SEDATED ON PROPOFUL OVERNIGHT.\\nCV: NSR 70-120'S WITH COUGHING. SBP 100-190/ HYPERTENSIVE TRANSIENTLY WITH COUGHING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370972,\n \"text\": \" 7p-7a Nursing Progress Note\\n\\ns. Pt. intubated.\\n\\no. C-V=NSR 70-90's,no VEA. Stable BP 130-150/sys. Strong palpable pedal pulses. peripheral IV's only. Right radial A-line. LR at 50cc/hr.\\n\\nNeuro=Able to follow commands through Propofol at 20-30mcg/. Squeezes hands, shows fingers, wiggles toes, nods head yes/no. Opens eyes spontaneously and to commands. Gags on ETT, great strong cough. Pupils are PERLA, 3mm. c/o pain occasionally, medicated with MS04 with good effect.\\n\\nResp-no vent changes during night, pt. pre-op today. Continues on SIMV at 12/700/40%/5PEEP, 02 sats 98-100%. occasionally breathes over vent. Suctioned for thick brown secretions, BS clear but diminished, R>L. Good ABG's.\\n\\nGI/GU=NPO, BS present, no stool or flatus. NG tube draining coffee-brown secretions. Foley draining ~60cc/hr.\\n\\nSkin-laceration on right knee, dry crusty blood covers it. small laceration on left chin is dry, oovered with DSD. Mouth/nose oozes serous type drainage.\\n\\nEndo-no issues,\\n\\nID-temp. 100.8, on Clindamycin\\n\\nSocial-Dad called during evening, Dr. was to call him re:surgery.\\n\\nA.- stable night, sedated on Propofol and MS04.\\n\\nP.-Pre-op for later this evening. Continue sedation and pain control.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370973,\n \"text\": \"Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BS sl. decreased, rel clear bilat. Not req freq sx'ing by RT. Changed to PSV. ABG WNL. Plan to go back to OR for facial . Please see carevue for further vent inqueries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1370974,\n \"text\": \"SICU NPN\\nPt remains intubated and vented in the SICU awaiting surgery for his facial fractures. Propofol turned off for neuro exam this AM, has been off ever since with PRN morphine for pain.\\n\\nROS:\\nNeuro: Pt very calm and appropriate off of propofol today. Pt alert and oriented X3 by writing, asking appropriate questions. Pt follows commands, MAE with good strength. C-collar remains on, pt denies any neck pain/tenderness. Pt tolerating MSO4 5mg Q2-4 hours PRN for jaw/facial pain.\\n\\nCV: Stable, HR 60-90, no VEA. BP stable via A-line. Pulses easily palpable. RUA IV infiltrated, pt with 2 patent #18 IVs in L arm.\\n\\nResp: Pt changed to PSV this AM, tolerating well with adequate ABGs. RR 12-18, sats 100% all day. Pt requires suctioning Q2-3 hours for thick, yellowish rusty sputum. Pt requests to be suctioned.\\n\\nGI: Pt c/o nausea X1, resolved spontaneously. OGT draining small ammts green/dk red output. Pt remains NPO, abd soft with good BS throughout.\\n\\nGU/renal: Good u/o via foley catheter. Pt rec'd 10 MEq KCL this AM. LR at 50cc/hr.\\n\\nSkin: facial lacs approximated well with sutures, bacitracin ointment applied. R leg abrasion scabbed over. Back intact, collar care provided.\\n\\nEndo: RISS, no coverage required.\\n\\nID: Low grade temps today, IV Clinda for facial fx.\\n\\nSocial; father by anesthesia this AM for consent, aware pt is doing well and plans for OR this PM. No other family contact.\\n\\nA: Stable s/p MVC with facial fractures\\n\\nP: Send pt to OR this PM for repair of facial fractures, plan to return to SICU post-op for extubation and airway monitoring.\\n\"\n }\n]"}}},{"rowIdx":24984,"cells":{"subject_id":{"kind":"number","value":41024,"string":"41,024"},"hadm_id":{"kind":"number","value":164431,"string":"164,431"},"target_text":{"kind":"string","value":"This is a 71 yo female with complicated medical including a stroke ~ 30 years ago with residual aphasia and right hemiparesis, chronic SDH bilaterally, afib off AC due to SDH, seizure disorder, and recurrent cycles of UTI/urosepsis (moraxella bacterimia) and C.Diff infections, who had her dilantin discontinued on , and was noted to develop decreased level of alertness and confusion at her NH 2 days PTA. She was diagnosed with a UTI however did not improve after one day of treatment and was thus transferred to OSH, then . She was initially admitted to the medicine service, where CFTX was stopped. A neurology service was consulted to determine whether patient was in NCSE. Her initial exam showed that she does not follow commands, eyes closed, eyes midline, mumbles with pain, and retracts both legs and arms L>R to noxious stimuli. Because the initial EEG showed signs concerning for NCSE, she was transferred to Neurology service for further monitoring and treatment on . Her baseline state includes (confirmed with NH staff): Awake, alert, interacting with staff (maintains eye contact) and answers in one word, often with intelligible sounds without reproducibly following directions with dense right sided hemiparesis requiring full assisstance with transfers and ADLs."},"extractive_notes_summ":{"kind":"string","value":"Fosphenytoin level still subtherapeutic at beginning of shift Remains on continuous EEG NGT in place with placement confirmed by xray per sicu resident +lg semiformed stool (on PO flagyl for cdiff until ) Action: Fosphenytoin re-bolused Response: unsure if seizure activity per EEG Plan: Fosphenytoin level still subtherapeutic at beginning of shift Remains on continuous EEG NGT in place with placement confirmed by xray per sicu resident +lg semiformed stool (on PO flagyl for cdiff until ) Pt receiving IV Hydralazine d/t usual antihypertensives SR and unable to crush Action: Fosphenytoin re-bolused Response: unsure if seizure activity per EEG Plan: Q2hr neuro Cont EEG Withdrawing to pain on right Hx a-fib in NSR 70-80s. Withdrawing to pain on right Hx a-fib in NSR 70-80s. Follow LFT medication, unclear etiology.h/o Cdiff - on flagyl, PO vanco. Withdrawing to pain on right Hx a-fib in NSR/ST 90-100s. D/W resident and versed drip titrated up for sedation this time not for seizure activity Plan: Q2hr neuro Cont EEG Versed drip for seizure control (as well as ETT comfort) Will restart - amlodipine, verapamil, lisinopril, hydral prn. Lansoprazole Oral Disintegrating Tab 18. Lansoprazole Oral Disintegrating Tab 18. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Pneumococcal Vac Polyvalent 23. Pneumococcal Vac Polyvalent 23. Administer Keppra/Dilantin MD order. Administer Keppra/Dilantin MD order. Administer Keppra/Dilantin MD order. Follow 24hr EEG Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril, hydral prn. Follow 24hr EEG Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril, hydral prn. Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Endocrine: DM. Endocrine: DM. Endocrine: DM. Endocrine: DM. + UTI s/p rx w/ ceftriaxone. + UTI s/p rx w/ ceftriaxone. + UTI s/p rx w/ ceftriaxone. LENI today Lines / Tubes / Drains: NGT, PIV, Picc Fluids: KVO Consults: Neuro Billing Diagnosis: Status epilepticus, seizures DVT: SQH Stress ulcer: PPI VAP bundle: + Communication: Code status:FULL Disposition:SICU to floor Lines: PICC Line - 02:55 PM Total time spent: 31 min Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. prior admit for B chronic SDH and acute parafalcine SDH. prior admit for B chronic SDH and acute parafalcine SDH. prior admit for B chronic SDH and acute parafalcine SDH. LENI today Lines / Tubes / Drains: NGT, PIV, Picc Fluids: KVO Consults: Neuro Billing Diagnosis: Status epilepticus, seizures DVT: SQH Stress ulcer: PPI VAP bundle: + Communication: Code status:FULL Disposition:SICU to floor Lines: PICC Line - 02:55 PM Total time spent: Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Since the previous tracingof sinus tachycardia is absent and further ST-T wave changes are seen. Keppra/Dilantin administered MD order. Persistent bibasilar nodular opacities and atelectasis which is again (Over) 8:09 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please eval for intra-abd process FINAL REPORT (Cont) nonspecific. Administer Keppra/Dilantin MD order. Endocrine: DM. Endocrine: DM. Endocrine: DM. IMPRESSION: Initial nasogastric tube below the diaphragm, though subsequent radiograph shows absence of nasogastric tube. Identified now is a right-sided PICC line seen to terminate overlying the SVC at the level 2 cm below the carina. UTI with ceftriaxone. UTI with ceftriaxone. UTI with ceftriaxone. Renal: Recurrent UTI. Renal: Recurrent UTI. Renal: Recurrent UTI. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Atelectasis and nodular opacities in the lung bases persist unchanged from . The first 10:12 p.m. shows a nasogastric tube ending below the diaphragm with its tip not completely evaluated. In the left adnexa, there is either a 3.9cm exophytic fibroid with calcification or enlarged ovary (2:78). The patient has been extubated. FINDINGS: Grayscale, color and Doppler son of bilateral common femoral, superficial femoral, popliteal and tibial veins were performed."},"n_notes":{"kind":"number","value":58,"string":"58"},"notes":{"kind":"list like","value":[{"category":"Nutrition","chartdate":"2172-12-24 00:00:00.000","description":"Clinical Nutrition Note","row_id":712504,"text":"Subjective: patient intubated and sedated. Patient resides in a\n nursing home and takes a regular diet with nectar thick liquids.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 91.5 kg\n 91.3 kg ( 12:00 AM)\n 35.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 52.2 kg\n 175%\n 62 kg\n Diagnosis: Changes in Mental Status\n PMHx: 1. stroke 30 years ago (? location-images not available) with\n residual right hemiparesis, dysarthria, and difficulty to express\n herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n 17. B/L cataract surgery\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Versed, Lantus, RISS, heparin, ABx, KCl, Phos\n and Mag repletions, dextrose 5% with 1/2 normal saline @ 75mL/hr,\n others noted\n Labs:\n Value\n Date\n Glucose\n 171 mg/dL\n 02:14 AM\n Glucose Finger Stick\n 111\n 10:00 AM\n BUN\n 20 mg/dL\n 02:14 AM\n Creatinine\n 0.8 mg/dL\n 02:14 AM\n Sodium\n 142 mEq/L\n 02:14 AM\n Potassium\n 2.8 mEq/L\n 02:14 AM\n Chloride\n 108 mEq/L\n 02:14 AM\n TCO2\n 23 mEq/L\n 02:14 AM\n PO2 (arterial)\n 207 mm Hg\n 05:17 AM\n PCO2 (arterial)\n 36 mm Hg\n 05:17 AM\n pH (arterial)\n 7.44 units\n 05:17 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 05:17 AM\n Calcium non-ionized\n 8.7 mg/dL\n 02:14 AM\n Phosphorus\n 2.8 mg/dL\n 02:14 AM\n Magnesium\n 1.7 mg/dL\n 02:14 AM\n ALT\n 181 IU/L\n 02:14 AM\n Alkaline Phosphate\n 118 IU/L\n 02:14 AM\n AST\n 97 IU/L\n 02:14 AM\n Total Bilirubin\n 0.5 mg/dL\n 02:14 AM\n Phenytoin (Dilantin)\n 16.8 ug/mL\n 07:33 AM\n WBC\n 9.3 K/uL\n 02:14 AM\n Hgb\n 11.4 g/dL\n 02:14 AM\n Hematocrit\n 36.3 %\n 02:14 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Replete with Fiber @ 50mL/hr (1200kcals, 74g protein)\n GI: abd soft/obese, hyperactive bowel sounds, brown liquid stool\n Assessment of Nutritional Status\n Obese\n Estimated Nutritional Needs\n Calories: 1240-1430 (20-23 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Excessive\n Estimation of current intake: Adequate\n Specifics:\n 71 y.o. Female with h/o stroke and seizure disorder transferred from\n outside hospital from nursing home with low grade fever, agitation and\n increased seizure activity. Patient is currently intubated, sedated,\n with NGT in place. Tube feeds were just started and current goal meets\n protein needs but is slightly low on calories. Recommend slightly\n increasing tube feeding goal to better meet needs. Noted K, Phos and\n mag all being repleted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend change tube feeding goal to Replete with Fiber @\n 55mL/hr (1320kcals, 82g protein).\n Continue with lyte repletions.\n Adjust H20 flushes as needed to maintain hydration.\n Followig - #\n"},{"category":"Nursing","chartdate":"2172-12-25 00:00:00.000","description":"Nursing Progress Note","row_id":712745,"text":"Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG . Pt intubated for airway\n protection d/t start of Midazolam gtt for seizure control.\n Midazolam gtt weaned overnoc and at 2mg/hr this mornine\n Intubated on CMV w/ FIO2@ of 40% Peep 10 RR 15 x500.\n Copious oral secretions\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR/ST 90-100s. SBP improved. Given\n Antihypertensive meds this am\n Continuous EEG per Neuro med w/o seizures\n NPO w/ NS w/ 40kcl @100cchr. u/o borderline adequate. 5L\n positive\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level overnoc corrected for Albumin and\n supra-therapeutic in 20s. Goal 18-20\n Action:\n Midazolam gtt stopped in preparation of waking pt up for\n extubation\n TF put on hold\n LFTs remain elevated. Hepatitis panel sent\n Suctioned for some tan sputum via ETT. Sputum cx pending\n Dilantin level prior morning dose supra-therapuetic and\n Phosphenytoin decreased to 150mg IV Q8hrs\n Head CT d/c\nd per \n IVF d/c\n Neuro checks Q2hrs\n Bilateral Lenis performed to r/o DVT d/t Bilateral LE pedal\n edema R>L\n Son at BS to visit mother and able to update\n Response:\n Pt more alert t/o day but falls asleep. Agitated w/\n stimulation. Good gag/cough\n Extubated at 1500. O2 sats stable on Face tent w/ FIO@ at\n 70%\n Pt needs to be encouraged to cough up secretions. Oral\n suction PRN.\n Not following commands. Some words comprehensible but most\n not. Hx of being combative in past w/ LUE\n Tolerating testart of TF and u/o\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Pt may go to neuro step down vs floor if continues to\n progress\n"},{"category":"Nursing","chartdate":"2172-12-23 00:00:00.000","description":"Nursing Progress Note","row_id":712405,"text":"Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Action:\n Fosphenytoin re-bolused\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712409,"text":"Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour\n Action:\n Fosphenytoin re-bolused\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712419,"text":"Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour\n Action:\n Fosphenytoin re-bolused\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712422,"text":"Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on versed drip pt gagging on ETT at first and now\n sedated so slightly withdraws and tries to reach for ETT with LUE\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\n until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n While agitated and tachycardic noted to have ~12 beat run of\n VT\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Response:\n unsure if seizure activity per EEG\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up and\n raising head off bed while LUE reached for ETT. D/W resident and versed\n drip titrated up for sedation this time not for seizure activity\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712423,"text":"Seizure, with status epilepticus\n Assessment:\n No visibile seizure activity noted\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on versed drip pt gagging on ETT at first and now\n sedated so slightly withdraws and tries to reach for ETT with LUE\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\n until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n While agitated and tachycardic noted to have ~12 beat run of\n VT\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Response:\n unsure if seizure activity per EEG\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up and\n raising head off bed while LUE reached for ETT. D/W resident and versed\n drip titrated up for sedation this time not for seizure activity\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712566,"text":"Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\n borderline overnoc w/ increase in Midazolam gtt to control seizures\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\n Intubated on CMV w/ FIO@ of 40% Peep 10 RR 15 x500. Copious\n oral secretions\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\n Continuous EEG per Neuro med w/ seizures per hour this\n am\n NPO w/ D5\n @75cchr. u/o borderline in the 20\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n K- level 2.8\n Action:\n Midazolam gtt increased to 8mg/hr per Neuromed. KCL repleted\n Dilantin level therapeutic w/ Albumin calculation this\n morning >20\n Fosphenytoin 150mg IV Q8hrs\n Attending at BS this morning to eval EEG and placed CT on\n hold\n Neuro checks Q2hrs\n NS bolus of 250cc for low u/o. IVG changed to NS w/ 40KCL w/\n increased rate of 100cc/hr\n Replete w/ fiber started via left NGT. Titrating to goal of\n 55cc/hr\n Response:\n Repeat Dilantin level sub-therapeutic and Fospheytion\n increased to 250mg IV Q8\n Midaz gtt continues at 8mg/hr. Pt now opening eyes\n intermittently to stimulation and continues to purposely go for ETT\n U/o remains still in 20\n Son updated by SICU\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"},{"category":"Physician ","chartdate":"2172-12-24 00:00:00.000","description":"Intensivist Note","row_id":712490,"text":"SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\n epilepsy. She was admitted here in due to prolonged seizures in\n the setting of low Dilantin level and infection (C.diff) and discharged\n on Dilantin and Keppra (750 mg ).\n Two days before her current admission, she had neurosurgical follow up\n for a chronic subdural hematoma, which had resolved. Therefore, she was\n advised to stop her Dilantin. The patient was then admitted to the\n medicine department two days ago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for the UTI, an EEG was performed yesterday\n (), which showed frequent electrographic seizures, originating in\n the right centro-parietal area. She was reloaded with Dilantin and\n Lorazepam was given intermittently, but she continued to have seizures\n overnight, up to 12 an hour. Clinically, she remained marginally\n responsive and rarely had events of gaze deviation to the left which\n were suggestive of seizure activity. She was transferred today to the\n ICU for frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ treatment, in\n case she fails to respond to other anticonvulsants\n Chief complaint:\n Statis epilepticus, UTI, Cdiff\n PMHx:\n PMH:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n .\n PSH:\n bilateral cataract surgery\n Current medications:\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\n Scale Order date: @ 1656\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\n DRIP INFUSION Patient must have adequate airway support prior to\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\n for K > 4 Order date: @ 1652\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\n 24 Hour Events:\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n INTUBATION - At 01:19 AM\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\n Still w//seizures/hr. Intubated in order to start versed to help\n break seizures.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:23 PM\n Vancomycin - 10:23 PM\n Metronidazole - 11:46 PM\n Infusions:\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Hydralazine - 11:46 PM\n Lorazepam (Ativan) - 04:05 AM\n Fosphenytoin - 04:05 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 35.8\nC (96.5\n HR: 91 (76 - 130) bpm\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\n RR: 16 (10 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Total In:\n 458 mL\n 440 mL\n PO:\n Tube feeding:\n IV Fluid:\n 458 mL\n 440 mL\n Blood products:\n Total out:\n 735 mL\n 175 mL\n Urine:\n 735 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n -278 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SPO2: 100%\n ABG: ///23/\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\n sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 171 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 142 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 12:42 AM\n 02:14 AM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Creatinine\n 0.8\n Glucose\n 526\n 171\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\n subtherapeutic dilantin in setting infection. Will load with dilantin\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\n subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans.\n Will discuss with primary team about either increasing or if pt is at\n baseline.\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\n lisinopril, hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\n unclear etiology.h/o Cdiff - on flagyl, PO vanco.\n Last results negative for c diff. Start TF\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI on ceftriaxone D/C. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n"},{"category":"Nursing","chartdate":"2172-12-23 00:00:00.000","description":"Nursing Progress Note","row_id":712384,"text":"Seizure, with status epilepticus\n Assessment:\n Pt admitted to sicu B @ 1330 from 11 with status epilepticus\n per cont EEG , no signs of sz activity noted other than EEG\n , pt lethargic & snoring, no response to verbal command, crying\n out with any nursing care, localizes to pain, mild R side weakness\n noted, pt with h/o stroke, R pupil sluggish, 2 mm, L pupil with\n cataract\n Action:\n Keppra/fosphenytoin loading doses given, pt with clotted R arm PIC\n inserted , PIC changed over wire, CXR done to confirm placement, pt\n NPO, NG tube inserted for po meds, ivf @ 75/hr, ATC iv ativan q 4 hrs,\n fosphenytoin level sent @ 1830\n Response:\n No sz activity noted, VSS, sat stable on 2 L np\n Plan:\n Neuro vs q 2 hrs, cont EEG, iv keppra/fosphenytoin as ordered, ATC iv\n ativan, ? head ct in am\n"},{"category":"Nursing","chartdate":"2172-12-23 00:00:00.000","description":"Nursing Progress Note","row_id":712396,"text":"Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Action:\n Fosphenytoin re-bolused\n Response:\n unsure if seizure activity per EEG\n Plan:\n"},{"category":"Nursing","chartdate":"2172-12-25 00:00:00.000","description":"Nursing Progress Note","row_id":712634,"text":"Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt at 8cc/hr\n Continuous bedside EEG\n No visible seizure activity noted\n Dilantin level 18.3, albumin 3.3\n Action:\n Midazolam gtt weaned to 2 cc/hr\n Dr. aware of Dilantin level. Fosphenytoin dose 250\n mg given.\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n Wean midaz gtt off\n"},{"category":"Physician ","chartdate":"2172-12-25 00:00:00.000","description":"Physician Surgical Progress Note","row_id":712583,"text":"TITLE:\n 24 Hour Events: HPI:71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n : Maximized on keppra and dilantin. Versed weaned off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Metronidazole - 08:01 AM\n Ceftriaxone - 09:58 PM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 03:18 PM\n Fosphenytoin - 05:30 PM\n Other medications:\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\n Disintegrating Tab 30 mg PO/NG DAILY\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\n LeVETiracetam 1500 mg IV Q12H\n Clopidogrel 75 mg PO/NG DAILY\n Lisinopril 40 mg PO/NG DAILY\n Fosphenytoin titated to goal 20\n Midazolam 5-15 mg/hr IV DRIP INFUSION\n Gabapentin 300 mg PO/NG HS\n Potassium Chloride PO Sliding Scale\n Heparin 5000 UNIT SC TID\n Verapamil 120 mg PO Q8H\n HydrALAzine 20 mg IV Q6H\n Flowsheet Data as of 12:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.9\nC (96.7\n HR: 82 (71 - 130) bpm\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\n RR: 20 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 3,869 mL\n PO:\n TF:\n 500 mL\n IVF:\n 2,889 mL\n Blood products:\n Total out:\n 599 mL\n 0 mL\n Urine:\n 599 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,270 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 17 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/36/207/20/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 119 mEq/L\n 146 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Cr\n 0.8\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CT head : resolution of R post parietal subdural fluid\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\n posterior fossa\n EEG showed intermittent seizures consistent with diagnosis\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\n Microbiology: Bld Cx: Moraxella\n Urine Cx: E.coli (s: ceftriaxone)\n Cdiff +\n Bld Cx:P\n Ucx: Ecoli\n Bld Cx:P\n Ucx :P\n C diff Neg\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\n epiliepticus from subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\n - subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication: Son to be in pm woudl likely meeting.\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712451,"text":"Seizure, with status epilepticus\n Assessment:\n No visibile seizure activity noted\n At beginning of shift when not disturbed pt sleeps and does\n not move much spontaneously. Prior to intubation when stimulated pt\n yells out (speech garbled and difficult to understand) kicks with LLE,\n hits and pinches with LUE and tries to pull out NGT also tries to spit.\n Not following any commands. Right sided weakness-moves on bed. Left\n pupil surgical/cataract right pupil reactive. Does not open eyes to\n command\n Fosphenytoin level still subtherapeutic despite bolus\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool then lg liquid stool (on PO vanco and\n IV flagyl for cdiff until )\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n Throughout shift noted to have frequent PVC\ns-incred in freq\n when Tachycardic (during agitation)\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status). SICU resident contact pt\ns son prior\n to intubation.\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Post-intubation ABG drawn\n Response:\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up, becoming\n more agitated and raising head off bed while LUE reached for ETT had\n ~12 beat run of VT. D/W resident and versed drip titrated up for\n sedation this time not for seizure activity\n Current neuro exam is pt does lift head off bed while\n coughing/gaging on ett but not as much as when on lower dose versed.\n Localizes with LUE able to raise towards ETT moves LLE more then RLE on\n bed. Pupils unchanged. Still does not follow commands or open eyes. No\n visible seizure activity noted\n Lytes low (especially potassium) repleted and amt of ectopy\n decreased\n As versed drip increased SBP dropping.\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n Discuss sedation with SICU team on rounds. ?decrease versed\n (if no seizures) and add fent for ETT comfort d/t hypotension with\n versed increase\n"},{"category":"Respiratory ","chartdate":"2172-12-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":712455,"text":"Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Airway protection during Versed drip\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments/Plan\n 71 yo F orally intubated in SICUb for airway protection during Versed\n drip initiation. Versed started for status epilepticus. Ventilating\n easily, airway pressures low. Copious oral secretions noted. No RSBI\n this am secondary to no spont. RR. See flowsheet for further data.\n Will follow.\n 05:55\n"},{"category":"Respiratory ","chartdate":"2172-12-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":712561,"text":"Day of mechanical ventilation: 1\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Pt with continued seizure activity. No vent changes or ABG\ns. CT v MRI\n tomorrow.\n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712551,"text":"Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control\n Action:\n Response:\n Plan:\n Neuro q2hr\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"},{"category":"Nursing","chartdate":"2172-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":712564,"text":"Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\n borderline overnoc w/ increase in Midazolam gtt to control seizures\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\n Continuous EEG per Neuro med w/ seizures per hour this\n am\n Action:\n Response:\n Plan:\n Neuro q2hr\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"},{"category":"Respiratory ","chartdate":"2172-12-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":712624,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 500x14/+5/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 66\n Comments: Maintain support until neuro picture clears.\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":712795,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n NGT replaced right nare\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"},{"category":"Physician ","chartdate":"2172-12-24 00:00:00.000","description":"Intensivist Note","row_id":712440,"text":"SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\n epilepsy. She was admitted here in due to prolonged seizures in\n the setting of low Dilantin level and infection (C.diff) and discharged\n on Dilantin and Keppra (750 mg ).\n Two days before her current admission, she had neurosurgical follow up\n for a chronic subdural hematoma, which had resolved. Therefore, she was\n advised to stop her Dilantin. The patient was then admitted to the\n medicine department two days ago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for the UTI, an EEG was performed yesterday\n (), which showed frequent electrographic seizures, originating in\n the right centro-parietal area. She was reloaded with Dilantin and\n Lorazepam was given intermittently, but she continued to have seizures\n overnight, up to 12 an hour. Clinically, she remained marginally\n responsive and rarely had events of gaze deviation to the left which\n were suggestive of seizure activity. She was transferred today to the\n ICU for frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ treatment, in\n case she fails to respond to other anticonvulsants\n Chief complaint:\n Statis epilepticus, UTI, Cdiff\n PMHx:\n PMH:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n .\n PSH:\n bilateral cataract surgery\n Current medications:\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\n Scale Order date: @ 1656\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\n DRIP INFUSION Patient must have adequate airway support prior to\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\n for K > 4 Order date: @ 1652\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\n 24 Hour Events:\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n INTUBATION - At 01:19 AM\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\n Still w//seizures/hr. Intubated in order to start versed to help\n break seizures.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:23 PM\n Vancomycin - 10:23 PM\n Metronidazole - 11:46 PM\n Infusions:\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Hydralazine - 11:46 PM\n Lorazepam (Ativan) - 04:05 AM\n Fosphenytoin - 04:05 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 35.8\nC (96.5\n HR: 91 (76 - 130) bpm\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\n RR: 16 (10 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Total In:\n 458 mL\n 440 mL\n PO:\n Tube feeding:\n IV Fluid:\n 458 mL\n 440 mL\n Blood products:\n Total out:\n 735 mL\n 175 mL\n Urine:\n 735 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n -278 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SPO2: 100%\n ABG: ///23/\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\n sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 171 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 142 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 12:42 AM\n 02:14 AM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Creatinine\n 0.8\n Glucose\n 526\n 171\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\n subtherapeutic dilantin in setting infection. Will load with dilantin\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\n subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\n lisinopril, hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\n unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI on ceftriaxone (? duration). FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Wounds:\n Imaging:\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n"},{"category":"Respiratory ","chartdate":"2172-12-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":712723,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Tenacious\n Sputum source/amount: Suctioned / Small\n Comments:\n Comments: Pt extubated s/p successful weaning trial with good cuff leak\n noted. PT currently wearing 50% cool aerosol with spo2 100% RR mid to\n low 20s. Will cont to monitor for s/s fatigue.\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":712789,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":712786,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside.\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712966,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n"},{"category":"Nursing","chartdate":"2172-12-25 00:00:00.000","description":"Nursing Progress Note","row_id":712599,"text":"Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt\n Continuous bedside EEG\n No visible seizure activity noted\n Action:\n Midazolam gtt weaned\n Dilantin level\n Fosphenytoin 150mg IV Q8hrs\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Midaz gtt\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n"},{"category":"Nursing","chartdate":"2172-12-25 00:00:00.000","description":"Nursing Progress Note","row_id":712609,"text":"Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt\n Continuous bedside EEG\n No visible seizure activity noted\n Dilantin level 18.3, albumin 3.3\n Action:\n Midazolam gtt weaned\n Dilantin level\n Dr. aware of Dilantin level. Fosphenytoin dose 250\n mg given.\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Midaz gtt\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n"},{"category":"Physician ","chartdate":"2172-12-26 00:00:00.000","description":"Intensivist Note","row_id":712774,"text":"SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Chief complaint:\n status epilepticus\n PMHx:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n Current medications:\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. HydrALAzine 15. 16. Insulin\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\n Vancomycin Oral Liquid 25. Verapamil\n 24 Hour Events:\n : extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Ceftriaxone - 09:58 PM\n Metronidazole - 07:59 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 07:07 PM\n Heparin Sodium (Prophylaxis) - 08:28 PM\n Other medications:\n Flowsheet Data as of 01:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.1\n HR: 104 (91 - 105) bpm\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\n RR: 20 (14 - 21) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,837 mL\n 15 mL\n PO:\n Tube feeding:\n 771 mL\n IV Fluid:\n 1,886 mL\n 15 mL\n Blood products:\n Total out:\n 1,235 mL\n 0 mL\n Urine:\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,602 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 413 (341 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 115 K/uL\n 8.8 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 17 mg/dL\n 116 mEq/L\n 144 mEq/L\n 29.2 %\n 5.5 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n WBC\n 9.3\n 5.5\n Hct\n 36.3\n 27.0\n 29.2\n Plt\n 174\n 115\n Creatinine\n 0.8\n 0.7\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\n with UTI and Cdiff admitted with status epiliepticus from\n subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\n keppra. Goal levels 15-20. Follow 24hr EEG\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated \n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n LENI today\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU to floor\n Lines:\n PICC Line - 02:55 PM\n Total time spent:\n"},{"category":"Physician ","chartdate":"2172-12-26 00:00:00.000","description":"Intensivist Note","row_id":712837,"text":"SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Chief complaint:\n status epilepticus\n PMHx:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n Current medications:\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. HydrALAzine 15. 16. Insulin\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\n Vancomycin Oral Liquid 25. Verapamil\n 24 Hour Events:\n : extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Ceftriaxone - 09:58 PM\n Metronidazole - 07:59 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 07:07 PM\n Heparin Sodium (Prophylaxis) - 08:28 PM\n Other medications:\n Flowsheet Data as of 01:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.1\n HR: 104 (91 - 105) bpm\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\n RR: 20 (14 - 21) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,837 mL\n 15 mL\n PO:\n Tube feeding:\n 771 mL\n IV Fluid:\n 1,886 mL\n 15 mL\n Blood products:\n Total out:\n 1,235 mL\n 0 mL\n Urine:\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,602 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 413 (341 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 115 K/uL\n 8.8 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 17 mg/dL\n 116 mEq/L\n 144 mEq/L\n 29.2 %\n 5.5 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n WBC\n 9.3\n 5.5\n Hct\n 36.3\n 27.0\n 29.2\n Plt\n 174\n 115\n Creatinine\n 0.8\n 0.7\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\n with UTI and Cdiff admitted with status epiliepticus from\n subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\n keppra. Goal levels 15-20. Follow 24hr EEG\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated \n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n LENI today\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU to floor\n Lines:\n PICC Line - 02:55 PM\n Total time spent: 31 min\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Transfer Note","row_id":712856,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\n irregularly shaped and non-reactive (surgical). Can be combative at\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels drawn prior to each dose.\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Transfer Note","row_id":712857,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\n irregularly shaped and non-reactive (surgical). Can be combative at\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels drawn prior to each dose.\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"},{"category":"Physician ","chartdate":"2172-12-25 00:00:00.000","description":"Physician Surgical Progress Note","row_id":712666,"text":"TITLE: Intensivist\n HPI:71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n : Maximized on keppra and dilantin. Versed weaned off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Metronidazole - 08:01 AM\n Ceftriaxone - 09:58 PM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 03:18 PM\n Fosphenytoin - 05:30 PM\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\n Disintegrating Tab 30 mg PO/NG DAILY\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\n LeVETiracetam 1500 mg IV Q12H\n Clopidogrel 75 mg PO/NG DAILY\n Lisinopril 40 mg PO/NG DAILY\n Fosphenytoin titated to goal 20\n Midazolam 5-15 mg/hr IV DRIP INFUSION\n Gabapentin 300 mg PO/NG HS\n Potassium Chloride PO Sliding Scale\n Heparin 5000 UNIT SC TID\n Verapamil 120 mg PO Q8H\n HydrALAzine 20 mg IV Q6H\n Flowsheet Data as of 12:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.9\nC (96.7\n HR: 82 (71 - 130) bpm\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\n RR: 20 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 3,869 mL\n PO:\n TF:\n 500 mL\n IVF:\n 2,889 mL\n Blood products:\n Total out:\n 599 mL\n 0 mL\n Urine:\n 599 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,270 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 17 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/36/207/20/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 119 mEq/L\n 146 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Cr\n 0.8\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CT head : resolution of R post parietal subdural fluid\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\n posterior fossa\n EEG showed intermittent seizures consistent with diagnosis\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\n Microbiology: Bld Cx: Moraxella\n Urine Cx: E.coli (s: ceftriaxone)\n Cdiff +\n Bld Cx:P\n Ucx: Ecoli\n Bld Cx:P\n Ucx :P\n C diff Neg\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\n epiliepticus from subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\n - subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication: Son to be in pm woudl likely meeting.\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments: LENIs today\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 31 minutes\n Patient is critically ill Sezures, Resp Failure\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712944,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\n stimuli. Reported to be patient\ns baseline. LUE/LLE with purposeful\n movement and normal strength. Positive weak cough/gag. No seizure\n activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring and for seizure activity.\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712945,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring and for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712935,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Transfer Note","row_id":713090,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times. No seizure activity noted.\n Action:\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\n monitor levels\n next dilantin level to be drawn am, transfer to\n sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Transfer Note","row_id":713092,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Continue to monitor for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of Ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete Ceftriaxone course: Last dose tonight . Follow-up\n urine cultures.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CHANGE IN MENTAL STATUS\n Code status:\n Height:\n 63 Inch\n Admission weight:\n 91.5 kg\n Daily weight:\n 91.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, Seizures\n CV-PMH: Angina, CVA\n Additional history: a-fib not on coumadin, obesity, dementia,\n cataracts, chronic SDH, recurrent UTI's, PVD, depression,anemia,\n osteoporosis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:65\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,058 mL\n 24h total out:\n 2,790 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 01:55 AM\n Potassium:\n 3.4 mEq/L\n 01:55 AM\n Chloride:\n 109 mEq/L\n 01:55 AM\n CO2:\n 24 mEq/L\n 01:55 AM\n BUN:\n 7 mg/dL\n 01:55 AM\n Creatinine:\n 0.5 mg/dL\n 01:55 AM\n Glucose:\n 145 mg/dL\n 01:55 AM\n Hematocrit:\n 27.2 %\n 01:55 AM\n Finger Stick Glucose:\n 190\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: L-finger yellow colored ring.\n Transferred from: SICU B 675\n Transferred to: 11 Room: 1121.\n Date & time of Transfer: 22:00\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":712824,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n NGT replaced right nare confirmed by XRay by SICU resident\n TF\ns restarted\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712937,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\n stimuli. Reported to be patient\ns baseline. LUE/LLE with purposeful\n movement and normal strength. Positive weak cough/gag. No seizure\n activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":713089,"text":"Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times. No seizure activity noted.\n Action:\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\n monitor levels\n next dilantin level to be drawn am, transfer to\n sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Transfer Note","row_id":712904,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels draw x\ns 2 today. .\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"},{"category":"Nursing","chartdate":"2172-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":712905,"text":"Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels draw x\ns 2 today. .\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"},{"category":"Physician ","chartdate":"2172-12-27 00:00:00.000","description":"Physician Surgical Progress Note","row_id":713004,"text":"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:\n Total time spent: 32 min\n"},{"category":"Physician ","chartdate":"2172-12-27 00:00:00.000","description":"Physician Surgical Progress Note","row_id":713005,"text":"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:sicu\n Total time spent: 32 min\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":712979,"text":"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n"},{"category":"Physician ","chartdate":"2172-12-27 00:00:00.000","description":"Physician Surgical Progress Note","row_id":712994,"text":"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:\n Total time spent: 32 min\n"},{"category":"Nursing","chartdate":"2172-12-27 00:00:00.000","description":"Nursing Transfer Note","row_id":713029,"text":"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels\n next dilantin level to be\n drawn am, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"},{"category":"ECG","chartdate":"2172-12-22 00:00:00.000","description":"Report","row_id":234723,"text":"Sinus rhythm with ventricular premature beat. Left atrial abnormality.\nST-T wave abnormalities are non-specific. Since the previous tracing\nof sinus tachycardia is absent and further ST-T wave changes are seen.\n\n"},{"category":"Radiology","chartdate":"2172-12-22 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1111243,"text":" 8:09 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for intra-abd process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with change in mental status abd pain\n REASON FOR THIS EXAMINATION:\n please eval for intra-abd process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc TUE 9:03 AM\n No acute abnormalities. Diverticulosis without diverticulitis. Rectum\n distended with stool.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with change in mental status and abdominal\n pain. Evaluate for intra-abdominal process.\n\n COMPARISON: .\n\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the abdomen and\n pelvis from the lung bases to the pubic symphysis. Multiplanar reformatted\n images were obtained.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Atelectasis and nodular\n opacities in the lung bases persist unchanged from . The\n liver shows no focal lesion. The gallbladder has been removed. The spleen,\n adrenal glands, and pancreas are unremarkable. The kidneys enhance and\n excrete contrast symmetrically. There is no hydronephrosis. Subcentimeter\n hypodensities in the left kidney are too small to accurately characterize.\n\n The intra-abdominal loops of large and small bowel are normal in caliber.\n There are scattered colonic diverticula without evidence of diverticulitis.\n Note is made of a large amount of stool in the colon, especially within the\n rectum.\n\n There is no free fluid, free air, or lymphadenopathy. The aorta and iliac\n arteries are notable for severe atherosclerotic calcification. Large\n right-sided ventral hernia with post-surgical changes of the overlying\n abdominal wall is unchanged in appearance.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder is collapsed with\n Foley in place. In the left adnexa, there is either a 3.9cm exophytic fibroid\n with calcification or enlarged ovary (2:78). No free fluid or pelvic\n lymphadenopathy. The rectum is markedly distended with stool.\n\n BONE WINDOWS: No lesion worrisome for osseous metastases is identified.\n Multilevel degenerative changes are present throughout the thoracolumbar\n spine.\n\n IMPRESSION:\n 1. Massively fecal impacted rectum.\n 2. Persistent bibasilar nodular opacities and atelectasis which is again\n (Over)\n\n 8:09 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for intra-abd process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n nonspecific. Continued followup is recommended.\n 3. 3.9cm rounded structure in the left adnexa may represent an exophytic\n fibroid or enlarged ovary. Recommend pelvic ultrasound after fecal\n disimpaction.\n\n Discussed with Dr. .\n\n"},{"category":"Radiology","chartdate":"2172-12-22 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1111332,"text":" 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r 46cm dlpicc\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with poor iv access requiring a dlpicc\n REASON FOR THIS EXAMINATION:\n s/p r 46cm dlpicc\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 4:54 PM\n PFI:\n\n Right-sided PICC line terminating in SVC, no pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 71-year-old female patient with poor IV access. Right-sided PICC\n line placed, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. Analysis is performed in direct comparison with the\n next preceding similar study obtained eight hours earlier during the same\n date. Identified now is a right-sided PICC line seen to terminate overlying\n the SVC at the level 2 cm below the carina. No pneumothorax has developed.\n As before, low inspirational volume results in vascular crowding, but there is\n no evidence of any acute infiltrate or significant pleural effusion reaching\n lateral pleural sinuses.\n\n IMPRESSION: Proper placement of PICC line. No complication.\n\n"},{"category":"Radiology","chartdate":"2172-12-22 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1111333,"text":", P. MED 11R 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r 46cm dlpicc\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with poor iv access requiring a dlpicc\n REASON FOR THIS EXAMINATION:\n s/p r 46cm dlpicc\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n Right-sided PICC line terminating in SVC, no pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2172-12-29 00:00:00.000","description":"P ABDOMEN (SUPINE ONLY) PORT","row_id":1112388,"text":" 9:57 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: NG placement\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p NGT\n REASON FOR THIS EXAMINATION:\n NG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post nasogastric tube.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n FINDINGS:\n\n Two supine radiographs of the abdomen are presented for review. The first\n 10:12 p.m. shows a nasogastric tube ending below the diaphragm with its tip\n not completely evaluated. The second radiograph taken at 10:35 p.m. does not\n show an NG tube present. The visualized bones are unremarkable. No dilated\n loops of bowel present.\n\n IMPRESSION:\n\n Initial nasogastric tube below the diaphragm, though subsequent radiograph\n shows absence of nasogastric tube.\n\n These findings were communicated to the SICU resident , M.D. at\n 11:00 a.m. on .\n\n"},{"category":"Radiology","chartdate":"2172-12-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111482,"text":" 2:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new ngt\n REASON FOR THIS EXAMINATION:\n assess position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that extends well into the body of the stomach. Continued\n low lung volumes with probable atelectatic changes at the left base.\n\n\n"},{"category":"Radiology","chartdate":"2172-12-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111551,"text":" 1:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ett location\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman intubated\n REASON FOR THIS EXAMINATION:\n assess ett location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for ETT location.\n\n COMPARISON: .\n\n FINDINGS: Newly inserted endotracheal tube, the tip of the tube projects 1 cm\n above the carina. The tube could be pulled back by 1 to 2 cm. No evidence of\n complication, notably no pneumothorax.\n\n Unchanged course of the nasogastric tube.\n\n Unchanged right PICC line. Low lung volumes with borderline size of the\n cardiac silhouette and minimal increase in diameter of the pulmonary\n vasculature, potentially indicative of mild overhydration. No focal\n parenchymal opacity suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2172-12-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1111239,"text":" 7:19 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulmonary disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with altered mental status.\n\n COMPARISON: .\n\n AP AND LATERAL VIEWS OF THE CHEST: Lung volumes are low, resulting in\n vascular crowding. However, there is no consolidation or pleural effusion.\n There is no pneumothorax. The cardiomediastinal silhouette is stable,\n demonstrating an unfolded aorta. There is no hilar or mediastinal\n enlargement, although the right hilus remains prominent. Pulmonary\n vascularity is normal.\n\n Right upper quadrant clips are consistent with cholecystectomy.\n\n IMPRESSIONS: No acute cardiopulmonary abnormality. Low lung volumes.\n\n"},{"category":"Radiology","chartdate":"2172-12-25 00:00:00.000","description":"P BILAT LOWER EXT VEINS PORT","row_id":1111764,"text":" 9:23 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SWOLLEN LEGS WHILE INTUBATED. EVAL FOR CLOT AND PE\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with swollen legs, while intubated\n REASON FOR THIS EXAMINATION:\n rule out PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old female with swollen legs. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\n superficial femoral, popliteal and tibial veins were performed. Note is made\n that the right peroneal vein could not be identified. There is normal flow,\n compression and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"},{"category":"Radiology","chartdate":"2172-12-23 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1111498,"text":" 3:12 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had a right sided picc line placed 46cm and needs tip con\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new picc who needs cxry to confirm tip location.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed 46cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with new PICC.\n\n COMPARISON: Chest radiograph available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The patient is status post placement of a\n PICC terminating within the low SVC. The cardiac and mediastinal contours are\n unchanged. There is a nasogastric tube with side port located within the\n stomach and the termination point beyond the scope of this examination. There\n is no pneumothorax or pleural effusion.\n\n IMPRESSION: Status post placement of a right-sided PICC terminating within\n the low SVC.\n\n"},{"category":"Radiology","chartdate":"2172-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111893,"text":" 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube position\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with status\n REASON FOR THIS EXAMINATION:\n NG tube position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: NG tube placement.\n\n One portable view. Comparison with the previous study done .\n\n There is continued evidence for mild pulmonary vascular congestion. The heart\n and mediastinal structures are unchanged. The patient has been extubated. A\n nasogastric tube remains in place, terminating well below the diaphragm.\n\n IMPRESSION: No significant change post-extubation.\n\n\n"}],"string":"[\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 712504,\n \"text\": \"Subjective: patient intubated and sedated. Patient resides in a\\n nursing home and takes a regular diet with nectar thick liquids.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 160 cm\\n 91.5 kg\\n 91.3 kg ( 12:00 AM)\\n 35.7\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 52.2 kg\\n 175%\\n 62 kg\\n Diagnosis: Changes in Mental Status\\n PMHx: 1. stroke 30 years ago (? location-images not available) with\\n residual right hemiparesis, dysarthria, and difficulty to express\\n herself\\n 2. Type 2 DM, insulin dependent\\n 3. HLP\\n 4. atrial fibrillation, not on coumadin\\n 5. h/o recurrent UTI\\n 6. seizure disorder, unspecified\\n 7. h/o angina\\n 8. PVD\\n 9. chronic thrombocytopenia\\n 10. anemia\\n 11. depression\\n 12. osteoporosis\\n 13. dementia with delusional features\\n 14. obesity\\n 15. bilateral cataract surgery\\n . prior admit for B chronic SDH and acute parafalcine SDH.\\n 17. B/L cataract surgery\\n Food allergies and intolerances: no known food allergies\\n Pertinent medications: Versed, Lantus, RISS, heparin, ABx, KCl, Phos\\n and Mag repletions, dextrose 5% with 1/2 normal saline @ 75mL/hr,\\n others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 171 mg/dL\\n 02:14 AM\\n Glucose Finger Stick\\n 111\\n 10:00 AM\\n BUN\\n 20 mg/dL\\n 02:14 AM\\n Creatinine\\n 0.8 mg/dL\\n 02:14 AM\\n Sodium\\n 142 mEq/L\\n 02:14 AM\\n Potassium\\n 2.8 mEq/L\\n 02:14 AM\\n Chloride\\n 108 mEq/L\\n 02:14 AM\\n TCO2\\n 23 mEq/L\\n 02:14 AM\\n PO2 (arterial)\\n 207 mm Hg\\n 05:17 AM\\n PCO2 (arterial)\\n 36 mm Hg\\n 05:17 AM\\n pH (arterial)\\n 7.44 units\\n 05:17 AM\\n CO2 (Calc) arterial\\n 25 mEq/L\\n 05:17 AM\\n Calcium non-ionized\\n 8.7 mg/dL\\n 02:14 AM\\n Phosphorus\\n 2.8 mg/dL\\n 02:14 AM\\n Magnesium\\n 1.7 mg/dL\\n 02:14 AM\\n ALT\\n 181 IU/L\\n 02:14 AM\\n Alkaline Phosphate\\n 118 IU/L\\n 02:14 AM\\n AST\\n 97 IU/L\\n 02:14 AM\\n Total Bilirubin\\n 0.5 mg/dL\\n 02:14 AM\\n Phenytoin (Dilantin)\\n 16.8 ug/mL\\n 07:33 AM\\n WBC\\n 9.3 K/uL\\n 02:14 AM\\n Hgb\\n 11.4 g/dL\\n 02:14 AM\\n Hematocrit\\n 36.3 %\\n 02:14 AM\\n Current diet order / nutrition support: Diet: NPO\\n Tube Feeds: Replete with Fiber @ 50mL/hr (1200kcals, 74g protein)\\n GI: abd soft/obese, hyperactive bowel sounds, brown liquid stool\\n Assessment of Nutritional Status\\n Obese\\n Estimated Nutritional Needs\\n Calories: 1240-1430 (20-23 cal/kg)\\n Protein: 62-81 (1-1.3 g/kg)\\n Fluid: per team\\n Calculations based on: Adjusted weight\\n Estimation of previous intake: Excessive\\n Estimation of current intake: Adequate\\n Specifics:\\n 71 y.o. Female with h/o stroke and seizure disorder transferred from\\n outside hospital from nursing home with low grade fever, agitation and\\n increased seizure activity. Patient is currently intubated, sedated,\\n with NGT in place. Tube feeds were just started and current goal meets\\n protein needs but is slightly low on calories. Recommend slightly\\n increasing tube feeding goal to better meet needs. Noted K, Phos and\\n mag all being repleted.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Recommend change tube feeding goal to Replete with Fiber @\\n 55mL/hr (1320kcals, 82g protein).\\n Continue with lyte repletions.\\n Adjust H20 flushes as needed to maintain hydration.\\n Followig - #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712745,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Found to be in status by EEG . Pt intubated for airway\\n protection d/t start of Midazolam gtt for seizure control.\\n Midazolam gtt weaned overnoc and at 2mg/hr this mornine\\n Intubated on CMV w/ FIO2@ of 40% Peep 10 RR 15 x500.\\n Copious oral secretions\\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\\n Left pupil asymmetrical and non-reactive.\\n Left upper extremity w/ normal strength. Moves all other\\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\\n hemiparesis from previous stroke. Withdrawing to pain on right\\n Hx a-fib in NSR/ST 90-100s. SBP improved. Given\\n Antihypertensive meds this am\\n Continuous EEG per Neuro med w/o seizures\\n NPO w/ NS w/ 40kcl @100cchr. u/o borderline adequate. 5L\\n positive\\n Contact precautions for hx of c.diff. Positive E.coli in\\n urine\\n Dilantin level overnoc corrected for Albumin and\\n supra-therapeutic in 20s. Goal 18-20\\n Action:\\n Midazolam gtt stopped in preparation of waking pt up for\\n extubation\\n TF put on hold\\n LFTs remain elevated. Hepatitis panel sent\\n Suctioned for some tan sputum via ETT. Sputum cx pending\\n Dilantin level prior morning dose supra-therapuetic and\\n Phosphenytoin decreased to 150mg IV Q8hrs\\n Head CT d/c\\nd per \\n IVF d/c\\n Neuro checks Q2hrs\\n Bilateral Lenis performed to r/o DVT d/t Bilateral LE pedal\\n edema R>L\\n Son at BS to visit mother and able to update\\n Response:\\n Pt more alert t/o day but falls asleep. Agitated w/\\n stimulation. Good gag/cough\\n Extubated at 1500. O2 sats stable on Face tent w/ FIO@ at\\n 70%\\n Pt needs to be encouraged to cough up secretions. Oral\\n suction PRN.\\n Not following commands. Some words comprehensible but most\\n not. Hx of being combative in past w/ LUE\\n Tolerating testart of TF and u/o\\n Plan:\\n Neuro q2hr\\n Dilantin level one hour before next dose\\n Cont EEG monitoring\\n Pt may go to neuro step down vs floor if continues to\\n progress\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712405,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n When not disturbed pt sleeps and does not move much\\n spontaneously. When stimulated pt yells out (speech garbled and\\n difficult to understand) kicks with LLE, hits and pinches with LUE and\\n tries to pull out NGT also tries to spit. Not following any commands.\\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\\n pupil reactive. Does not open eyes to command.\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO flagyl for cdiff until )\\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\\n and unable to crush\\n Action:\\n Fosphenytoin re-bolused\\n Response:\\n unsure if seizure activity per EEG\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712409,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n When not disturbed pt sleeps and does not move much\\n spontaneously. When stimulated pt yells out (speech garbled and\\n difficult to understand) kicks with LLE, hits and pinches with LUE and\\n tries to pull out NGT also tries to spit. Not following any commands.\\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\\n pupil reactive. Does not open eyes to command.\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO flagyl for cdiff until )\\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\\n and unable to crush\\n Neuromed reported pt continues to have seizures an\\n hour\\n Action:\\n Fosphenytoin re-bolused\\n Intubated for airway protection and midaz drip started\\n (neuromed reports during prior admissions midaz drip has been the only\\n drug to keep pt out of status)\\n Response:\\n unsure if seizure activity per EEG\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712419,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n When not disturbed pt sleeps and does not move much\\n spontaneously. Prior to intubation when stimulated pt yells out (speech\\n garbled and difficult to understand) kicks with LLE, hits and pinches\\n with LUE and tries to pull out NGT also tries to spit. Not following\\n any commands. Right sided weakness-moves on bed. Left pupil\\n surgical/cataract right pupil reactive. Does not open eyes to command.\\n Once intubated on\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO flagyl for cdiff until )\\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\\n and unable to crush\\n Neuromed reported pt continues to have seizures an\\n hour\\n Action:\\n Fosphenytoin re-bolused\\n Intubated for airway protection and midaz drip started\\n (neuromed reports during prior admissions midaz drip has been the only\\n drug to keep pt out of status)\\n Response:\\n unsure if seizure activity per EEG\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712422,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n When not disturbed pt sleeps and does not move much\\n spontaneously. Prior to intubation when stimulated pt yells out (speech\\n garbled and difficult to understand) kicks with LLE, hits and pinches\\n with LUE and tries to pull out NGT also tries to spit. Not following\\n any commands. Right sided weakness-moves on bed. Left pupil\\n surgical/cataract right pupil reactive. Does not open eyes to command.\\n Once intubated on versed drip pt gagging on ETT at first and now\\n sedated so slightly withdraws and tries to reach for ETT with LUE\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\\n until )\\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\\n and unable to crush\\n Neuromed reported pt continues to have seizures an\\n hour requesting versed drip\\n While agitated and tachycardic noted to have ~12 beat run of\\n VT\\n Action:\\n Fosphenytoin re-bolused x2\\n Intubated for airway protection and midaz drip started\\n (neuromed reports during prior admissions midaz drip has been the only\\n drug to keep pt out of status)\\n Midaz titrated up d/t nmed reporting seizure activity and\\n then again for agitation\\n Lytes drawn after run of VT and versed increased\\n Response:\\n unsure if seizure activity per EEG\\n During intubation HR up to 130-140 and pt then became\\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\\n effect HR down to 100 and SBP 140\\ns. After about 10min s/p intubation\\n HR back up to 110-120 and SBP150\\ns. Verapamil SR changed to immediate\\n release and dose given via NGT. Pt also noted to be waking up and\\n raising head off bed while LUE reached for ETT. D/W resident and versed\\n drip titrated up for sedation this time not for seizure activity\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n Versed drip for seizure control (as well as ETT comfort)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712423,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n No visibile seizure activity noted\\n When not disturbed pt sleeps and does not move much\\n spontaneously. Prior to intubation when stimulated pt yells out (speech\\n garbled and difficult to understand) kicks with LLE, hits and pinches\\n with LUE and tries to pull out NGT also tries to spit. Not following\\n any commands. Right sided weakness-moves on bed. Left pupil\\n surgical/cataract right pupil reactive. Does not open eyes to command.\\n Once intubated on versed drip pt gagging on ETT at first and now\\n sedated so slightly withdraws and tries to reach for ETT with LUE\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\\n until )\\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\\n and unable to crush\\n Neuromed reported pt continues to have seizures an\\n hour requesting versed drip\\n While agitated and tachycardic noted to have ~12 beat run of\\n VT\\n Action:\\n Fosphenytoin re-bolused x2\\n Intubated for airway protection and midaz drip started\\n (neuromed reports during prior admissions midaz drip has been the only\\n drug to keep pt out of status)\\n Midaz titrated up d/t nmed reporting seizure activity and\\n then again for agitation\\n Lytes drawn after run of VT and versed increased\\n Response:\\n unsure if seizure activity per EEG\\n During intubation HR up to 130-140 and pt then became\\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\\n effect HR down to 100 and SBP 140\\ns. After about 10min s/p intubation\\n HR back up to 110-120 and SBP150\\ns. Verapamil SR changed to immediate\\n release and dose given via NGT. Pt also noted to be waking up and\\n raising head off bed while LUE reached for ETT. D/W resident and versed\\n drip titrated up for sedation this time not for seizure activity\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n Versed drip for seizure control (as well as ETT comfort)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712566,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Found to be in status by EEG yesterday. Having \\n seizures an hour on night shift. Pt intubated for airway protection\\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\\n borderline overnoc w/ increase in Midazolam gtt to control seizures\\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\\n Intubated on CMV w/ FIO@ of 40% Peep 10 RR 15 x500. Copious\\n oral secretions\\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\\n Left pupil asymmetrical and non-reactive.\\n Left upper extremity w/ normal strength. Moves all other\\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\\n hemiparesis from previous stroke. Withdrawing to pain on right\\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\\n Continuous EEG per Neuro med w/ seizures per hour this\\n am\\n NPO w/ D5\\n @75cchr. u/o borderline in the 20\\n Contact precautions for hx of c.diff. Positive E.coli in\\n urine\\n K- level 2.8\\n Action:\\n Midazolam gtt increased to 8mg/hr per Neuromed. KCL repleted\\n Dilantin level therapeutic w/ Albumin calculation this\\n morning >20\\n Fosphenytoin 150mg IV Q8hrs\\n Attending at BS this morning to eval EEG and placed CT on\\n hold\\n Neuro checks Q2hrs\\n NS bolus of 250cc for low u/o. IVG changed to NS w/ 40KCL w/\\n increased rate of 100cc/hr\\n Replete w/ fiber started via left NGT. Titrating to goal of\\n 55cc/hr\\n Response:\\n Repeat Dilantin level sub-therapeutic and Fospheytion\\n increased to 250mg IV Q8\\n Midaz gtt continues at 8mg/hr. Pt now opening eyes\\n intermittently to stimulation and continues to purposely go for ETT\\n U/o remains still in 20\\n Son updated by SICU\\n Plan:\\n Neuro q2hr\\n Dilantin level one hour before next dose\\n Cont EEG monitoring\\n WEAN off Versed starting at 2am and to off by 8am\\n ? CT vs MRI on \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 712490,\n \"text\": \"SICU\\n HPI:\\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\\n epilepsy. She was admitted here in due to prolonged seizures in\\n the setting of low Dilantin level and infection (C.diff) and discharged\\n on Dilantin and Keppra (750 mg ).\\n Two days before her current admission, she had neurosurgical follow up\\n for a chronic subdural hematoma, which had resolved. Therefore, she was\\n advised to stop her Dilantin. The patient was then admitted to the\\n medicine department two days ago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and being treated with AB for the UTI, an EEG was performed yesterday\\n (), which showed frequent electrographic seizures, originating in\\n the right centro-parietal area. She was reloaded with Dilantin and\\n Lorazepam was given intermittently, but she continued to have seizures\\n overnight, up to 12 an hour. Clinically, she remained marginally\\n responsive and rarely had events of gaze deviation to the left which\\n were suggestive of seizure activity. She was transferred today to the\\n ICU for frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ treatment, in\\n case she fails to respond to other anticonvulsants\\n Chief complaint:\\n Statis epilepticus, UTI, Cdiff\\n PMHx:\\n PMH:\\n 1. stroke 30 years ago (? location-images not available) with residual\\n right hemiparesis, dysarthria, and difficulty to express herself\\n 2. Type 2 DM, insulin dependent\\n 3. HLP\\n 4. atrial fibrillation, not on coumadin\\n 5. h/o recurrent UTI\\n 6. seizure disorder, unspecified\\n 7. h/o angina\\n 8. PVD\\n 9. chronic thrombocytopenia\\n 10. anemia\\n 11. depression\\n 12. osteoporosis\\n 13. dementia with delusional features\\n 14. obesity\\n 15. bilateral cataract surgery\\n . prior admit for B chronic SDH and acute parafalcine SDH.\\n .\\n PSH:\\n bilateral cataract surgery\\n Current medications:\\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\\n Scale Order date: @ 1656\\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \\n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\\n DRIP INFUSION Patient must have adequate airway support prior to\\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \\n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\\n for K > 4 Order date: @ 1652\\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\\n 24 Hour Events:\\n PICC LINE - START 02:55 PM\\n INVASIVE VENTILATION - START 01:15 AM\\n INTUBATION - At 01:19 AM\\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\\n Still w//seizures/hr. Intubated in order to start versed to help\\n break seizures.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:23 PM\\n Vancomycin - 10:23 PM\\n Metronidazole - 11:46 PM\\n Infusions:\\n Midazolam (Versed) - 7 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:29 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Hydralazine - 11:46 PM\\n Lorazepam (Ativan) - 04:05 AM\\n Fosphenytoin - 04:05 AM\\n Other medications:\\n Flowsheet Data as of 04:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (98.9\\n T current: 35.8\\nC (96.5\\n HR: 91 (76 - 130) bpm\\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\\n RR: 16 (10 - 24) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Total In:\\n 458 mL\\n 440 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 458 mL\\n 440 mL\\n Blood products:\\n Total out:\\n 735 mL\\n 175 mL\\n Urine:\\n 735 mL\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -278 mL\\n 265 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 100 cmH2O/mL\\n SPO2: 100%\\n ABG: ///23/\\n Ve: 7.6 L/min\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\\n sounds: Present)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Obese\\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\\n stimuli), Moves all extremities, Sedated\\n Labs / Radiology\\n 174 K/uL\\n 11.4 g/dL\\n 171 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 2.8 mEq/L\\n 20 mg/dL\\n 108 mEq/L\\n 142 mEq/L\\n 36.3 %\\n 9.3 K/uL\\n [image002.jpg]\\n 12:42 AM\\n 02:14 AM\\n WBC\\n 9.3\\n Hct\\n 36.3\\n Plt\\n 174\\n Creatinine\\n 0.8\\n Glucose\\n 526\\n 171\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\\n infection\\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\\n subtherapeutic dilantin in setting infection. Will load with dilantin\\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\\n subclinical seizures based on EEG. Neuro exam - not interactive,\\n lethargic, moans.\\n Will discuss with primary team about either increasing or if pt is at\\n baseline.\\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\\n lisinopril, hydral prn. Cont , .\\n Pulmonary: Intubated for airway protection.\\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\\n unclear etiology.h/o Cdiff - on flagyl, PO vanco.\\n Last results negative for c diff. Start TF\\n Nutrition: NPO. Replete electrolyttes.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI on ceftriaxone D/C. FU repeat cx.\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Fluids: D51/2 NS\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n Prophylaxis:\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Communication:\\n Code status:FULL\\n Disposition:SICU\\n Time: 35 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712384,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Pt admitted to sicu B @ 1330 from 11 with status epilepticus\\n per cont EEG , no signs of sz activity noted other than EEG\\n , pt lethargic & snoring, no response to verbal command, crying\\n out with any nursing care, localizes to pain, mild R side weakness\\n noted, pt with h/o stroke, R pupil sluggish, 2 mm, L pupil with\\n cataract\\n Action:\\n Keppra/fosphenytoin loading doses given, pt with clotted R arm PIC\\n inserted , PIC changed over wire, CXR done to confirm placement, pt\\n NPO, NG tube inserted for po meds, ivf @ 75/hr, ATC iv ativan q 4 hrs,\\n fosphenytoin level sent @ 1830\\n Response:\\n No sz activity noted, VSS, sat stable on 2 L np\\n Plan:\\n Neuro vs q 2 hrs, cont EEG, iv keppra/fosphenytoin as ordered, ATC iv\\n ativan, ? head ct in am\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712396,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n When not disturbed pt sleeps and does not move much\\n spontaneously. When stimulated pt yells out (speech garbled and\\n difficult to understand) kicks with LLE, hits and pinches with LUE and\\n tries to pull out NGT also tries to spit. Not following any commands.\\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\\n pupil reactive. Does not open eyes to command.\\n Fosphenytoin level still subtherapeutic at beginning of\\n shift\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool (on PO flagyl for cdiff until )\\n Action:\\n Fosphenytoin re-bolused\\n Response:\\n unsure if seizure activity per EEG\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712634,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Opens eyes intermittently to voice/stimulation. Does not\\n follow commands.\\n Moving LUE purposefully. LLE moves on bed. Right side\\n withdraws to pain.\\n Remains intubated for airway protection\\n Midaz gtt at 8cc/hr\\n Continuous bedside EEG\\n No visible seizure activity noted\\n Dilantin level 18.3, albumin 3.3\\n Action:\\n Midazolam gtt weaned to 2 cc/hr\\n Dr. aware of Dilantin level. Fosphenytoin dose 250\\n mg given.\\n Neuro checks Q2hrs\\n Response:\\n No change in neuro status\\n Repeat Dilantin level\\n Plan:\\n Continue frequent neuro checks\\n Continue follow labs- Dilantin level\\n Cont EEG monitoring\\n Wean midaz gtt off\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 712583,\n \"text\": \"TITLE:\\n 24 Hour Events: HPI:71 yo woman with HTN, AF, left hemispheric stroke\\n many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Clinically, she remained marginally responsive and rarely had\\n events of gaze deviation to the left which were suggestive of\\n seizure activity. She was transferred today to the ICU for\\n frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ\\n treatment, in case she fails to respond to other anticonvulsants\\n PICC LINE - START 02:55 PM\\n INVASIVE VENTILATION - START 01:15 AM\\n : Maximized on keppra and dilantin. Versed weaned off.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 10:23 PM\\n Metronidazole - 08:01 AM\\n Ceftriaxone - 09:58 PM\\n Infusions:\\n Midazolam (Versed) - 8 mg/hour\\n Other ICU medications:\\n Lorazepam (Ativan) - 04:05 AM\\n Heparin Sodium (Prophylaxis) - 03:18 PM\\n Fosphenytoin - 05:30 PM\\n Other medications:\\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\\n Disintegrating Tab 30 mg PO/NG DAILY\\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\\n LeVETiracetam 1500 mg IV Q12H\\n Clopidogrel 75 mg PO/NG DAILY\\n Lisinopril 40 mg PO/NG DAILY\\n Fosphenytoin titated to goal 20\\n Midazolam 5-15 mg/hr IV DRIP INFUSION\\n Gabapentin 300 mg PO/NG HS\\n Potassium Chloride PO Sliding Scale\\n Heparin 5000 UNIT SC TID\\n Verapamil 120 mg PO Q8H\\n HydrALAzine 20 mg IV Q6H\\n Flowsheet Data as of 12:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36\\nC (96.8\\n Tcurrent: 35.9\\nC (96.7\\n HR: 82 (71 - 130) bpm\\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\\n RR: 20 (10 - 24) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 3,869 mL\\n PO:\\n TF:\\n 500 mL\\n IVF:\\n 2,889 mL\\n Blood products:\\n Total out:\\n 599 mL\\n 0 mL\\n Urine:\\n 599 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,270 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 71.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.44/36/207/20/1\\n Ve: 7.1 L/min\\n PaO2 / FiO2: 518\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\\n )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 174 K/uL\\n 11.4 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 20 mEq/L\\n 4.0 mEq/L\\n 19 mg/dL\\n 119 mEq/L\\n 146 mEq/L\\n 36.3 %\\n 9.3 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n WBC\\n 9.3\\n Hct\\n 36.3\\n Plt\\n 174\\n Cr\\n 0.8\\n 0.7\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\\n Imaging: CT head : resolution of R post parietal subdural fluid\\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\\n posterior fossa\\n EEG showed intermittent seizures consistent with diagnosis\\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\\n Microbiology: Bld Cx: Moraxella\\n Urine Cx: E.coli (s: ceftriaxone)\\n Cdiff +\\n Bld Cx:P\\n Ucx: Ecoli\\n Bld Cx:P\\n Ucx :P\\n C diff Neg\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\\n epiliepticus from subtherapeutic levels vs. infection\\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\\n - subclinical seizures based on EEG. Neuro exam - not interactive,\\n lethargic, moans\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Intubated for airway protection.\\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \\n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\\n Nutrition: NPO. Replete electrolyttes.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Fluids: D51/2 NS\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Communication: Son to be in pm woudl likely meeting.\\n ICU Care\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 02:55 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition:ICU\\n Total time spent: 31 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712451,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n No visibile seizure activity noted\\n At beginning of shift when not disturbed pt sleeps and does\\n not move much spontaneously. Prior to intubation when stimulated pt\\n yells out (speech garbled and difficult to understand) kicks with LLE,\\n hits and pinches with LUE and tries to pull out NGT also tries to spit.\\n Not following any commands. Right sided weakness-moves on bed. Left\\n pupil surgical/cataract right pupil reactive. Does not open eyes to\\n command\\n Fosphenytoin level still subtherapeutic despite bolus\\n Remains on continuous EEG\\n NGT in place with placement confirmed by xray per sicu\\n resident\\n +lg semiformed stool then lg liquid stool (on PO vanco and\\n IV flagyl for cdiff until )\\n Neuromed reported pt continues to have seizures an\\n hour requesting versed drip\\n Throughout shift noted to have frequent PVC\\ns-incred in freq\\n when Tachycardic (during agitation)\\n Action:\\n Fosphenytoin re-bolused x2\\n Intubated for airway protection and midaz drip started\\n (neuromed reports during prior admissions midaz drip has been the only\\n drug to keep pt out of status). SICU resident contact pt\\ns son prior\\n to intubation.\\n Midaz titrated up d/t nmed reporting seizure activity and\\n then again for agitation\\n Lytes drawn after run of VT and versed increased\\n Post-intubation ABG drawn\\n Response:\\n During intubation HR up to 130-140 and pt then became\\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\\n effect HR down to 100 and SBP 140\\ns. After about 10min s/p intubation\\n HR back up to 110-120 and SBP150\\ns. Verapamil SR changed to immediate\\n release and dose given via NGT. Pt also noted to be waking up, becoming\\n more agitated and raising head off bed while LUE reached for ETT had\\n ~12 beat run of VT. D/W resident and versed drip titrated up for\\n sedation this time not for seizure activity\\n Current neuro exam is pt does lift head off bed while\\n coughing/gaging on ett but not as much as when on lower dose versed.\\n Localizes with LUE able to raise towards ETT moves LLE more then RLE on\\n bed. Pupils unchanged. Still does not follow commands or open eyes. No\\n visible seizure activity noted\\n Lytes low (especially potassium) repleted and amt of ectopy\\n decreased\\n As versed drip increased SBP dropping.\\n Plan:\\n Q2hr neuro\\n Cont EEG\\n Versed drip for seizure control (as well as ETT comfort)\\n Discuss sedation with SICU team on rounds. ?decrease versed\\n (if no seizures) and add fent for ETT comfort d/t hypotension with\\n versed increase\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 712455,\n \"text\": \"Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 1\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Airway protection during Versed drip\\n Tube Type\\n ETT:\\n Position: 22 cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments/Plan\\n 71 yo F orally intubated in SICUb for airway protection during Versed\\n drip initiation. Versed started for status epilepticus. Ventilating\\n easily, airway pressures low. Copious oral secretions noted. No RSBI\\n this am secondary to no spont. RR. See flowsheet for further data.\\n Will follow.\\n 05:55\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 712561,\n \"text\": \"Day of mechanical ventilation: 1\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 26 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Clear / Thin\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Pt with continued seizure activity. No vent changes or ABG\\ns. CT v MRI\\n tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712551,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Found to be in status by EEG yesterday. Having \\n seizures an hour on night shift. Pt intubated for airway protection\\n last noc at 0100 d/t start of Midazolam gtt for seizure control\\n Action:\\n Response:\\n Plan:\\n Neuro q2hr\\n Cont EEG monitoring\\n WEAN off Versed starting at 2am and to off by 8am\\n ? CT vs MRI on \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712564,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Found to be in status by EEG yesterday. Having \\n seizures an hour on night shift. Pt intubated for airway protection\\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\\n borderline overnoc w/ increase in Midazolam gtt to control seizures\\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\\n Left pupil asymmetrical and non-reactive.\\n Left upper extremity w/ normal strength. Moves all other\\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\\n hemiparesis from previous stroke. Withdrawing to pain on right\\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\\n Continuous EEG per Neuro med w/ seizures per hour this\\n am\\n Action:\\n Response:\\n Plan:\\n Neuro q2hr\\n Cont EEG monitoring\\n WEAN off Versed starting at 2am and to off by 8am\\n ? CT vs MRI on \\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 712624,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 2\\n Ideal body weight: 52.2\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 22 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff pressure: 26 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: A/C 500x14/+5/.4\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Underlying illness not resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures: RSBI 66\\n Comments: Maintain support until neuro picture clears.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712795,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Alert, unable to assess orientation fue to garbled speech.\\n Follows commands inconsistently. Left side moves purposefully, right\\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\\n Agitated and combative at times, pulled out NGT.\\n No seizure activity observed\\n Beside continuous EEG.\\n PMH Afib. Now in NSR. HR 90\\n Contact precautions for hx of c.diff. Positive E.coli in\\n urine\\n Dilantin level 18.1. Albumin 3.1.\\n Action:\\n Neuro checks q 2-3\\n Dilantin level drawn prior to dosing\\n NGT replaced right nare\\n Encouraged to cough to remove secretions\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Neuro q2hr\\n Dilantin level one hour before next dose\\n Cont EEG monitoring\\n Transfer to neuro SDU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 712440,\n \"text\": \"SICU\\n HPI:\\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\\n epilepsy. She was admitted here in due to prolonged seizures in\\n the setting of low Dilantin level and infection (C.diff) and discharged\\n on Dilantin and Keppra (750 mg ).\\n Two days before her current admission, she had neurosurgical follow up\\n for a chronic subdural hematoma, which had resolved. Therefore, she was\\n advised to stop her Dilantin. The patient was then admitted to the\\n medicine department two days ago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and being treated with AB for the UTI, an EEG was performed yesterday\\n (), which showed frequent electrographic seizures, originating in\\n the right centro-parietal area. She was reloaded with Dilantin and\\n Lorazepam was given intermittently, but she continued to have seizures\\n overnight, up to 12 an hour. Clinically, she remained marginally\\n responsive and rarely had events of gaze deviation to the left which\\n were suggestive of seizure activity. She was transferred today to the\\n ICU for frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ treatment, in\\n case she fails to respond to other anticonvulsants\\n Chief complaint:\\n Statis epilepticus, UTI, Cdiff\\n PMHx:\\n PMH:\\n 1. stroke 30 years ago (? location-images not available) with residual\\n right hemiparesis, dysarthria, and difficulty to express herself\\n 2. Type 2 DM, insulin dependent\\n 3. HLP\\n 4. atrial fibrillation, not on coumadin\\n 5. h/o recurrent UTI\\n 6. seizure disorder, unspecified\\n 7. h/o angina\\n 8. PVD\\n 9. chronic thrombocytopenia\\n 10. anemia\\n 11. depression\\n 12. osteoporosis\\n 13. dementia with delusional features\\n 14. obesity\\n 15. bilateral cataract surgery\\n . prior admit for B chronic SDH and acute parafalcine SDH.\\n .\\n PSH:\\n bilateral cataract surgery\\n Current medications:\\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\\n Scale Order date: @ 1656\\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \\n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\\n DRIP INFUSION Patient must have adequate airway support prior to\\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \\n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\\n for K > 4 Order date: @ 1652\\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\\n 24 Hour Events:\\n PICC LINE - START 02:55 PM\\n INVASIVE VENTILATION - START 01:15 AM\\n INTUBATION - At 01:19 AM\\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\\n Still w//seizures/hr. Intubated in order to start versed to help\\n break seizures.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:23 PM\\n Vancomycin - 10:23 PM\\n Metronidazole - 11:46 PM\\n Infusions:\\n Midazolam (Versed) - 7 mg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:29 PM\\n Heparin Sodium (Prophylaxis) - 08:29 PM\\n Hydralazine - 11:46 PM\\n Lorazepam (Ativan) - 04:05 AM\\n Fosphenytoin - 04:05 AM\\n Other medications:\\n Flowsheet Data as of 04:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (98.9\\n T current: 35.8\\nC (96.5\\n HR: 91 (76 - 130) bpm\\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\\n RR: 16 (10 - 24) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Total In:\\n 458 mL\\n 440 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 458 mL\\n 440 mL\\n Blood products:\\n Total out:\\n 735 mL\\n 175 mL\\n Urine:\\n 735 mL\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -278 mL\\n 265 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 16\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 22 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 100 cmH2O/mL\\n SPO2: 100%\\n ABG: ///23/\\n Ve: 7.6 L/min\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\\n sounds: Present)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Obese\\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\\n stimuli), Moves all extremities, Sedated\\n Labs / Radiology\\n 174 K/uL\\n 11.4 g/dL\\n 171 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 2.8 mEq/L\\n 20 mg/dL\\n 108 mEq/L\\n 142 mEq/L\\n 36.3 %\\n 9.3 K/uL\\n [image002.jpg]\\n 12:42 AM\\n 02:14 AM\\n WBC\\n 9.3\\n Hct\\n 36.3\\n Plt\\n 174\\n Creatinine\\n 0.8\\n Glucose\\n 526\\n 171\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\\n infection\\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\\n subtherapeutic dilantin in setting infection. Will load with dilantin\\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\\n subclinical seizures based on EEG. Neuro exam - not interactive,\\n lethargic, moans\\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\\n lisinopril, hydral prn. Cont , .\\n Pulmonary: Intubated for airway protection.\\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\\n unclear etiology. + Cdiff - on flagyl, PO vanco.\\n Nutrition: NPO. Replete electrolyttes.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI on ceftriaxone (? duration). FU repeat cx.\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Wounds:\\n Imaging:\\n Fluids: D51/2 NS\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n Prophylaxis:\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Comments:\\n Communication:Comments:\\n Code status:FULL\\n Disposition:SICU\\n Time: 35 min\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 712723,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 52.2 None\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Tenacious\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Comments: Pt extubated s/p successful weaning trial with good cuff leak\\n noted. PT currently wearing 50% cool aerosol with spo2 100% RR mid to\\n low 20s. Will cont to monitor for s/s fatigue.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712789,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Alert, unable to assess orientation fue to garbled speech.\\n Follows commands inconsistently. Left side moves purposefully, right\\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\\n Agitated and combative at times, pulled out NGT.\\n No seizure activity observed\\n Beside continuous EEG.\\n PMH Afib. Now in NSR. HR 90\\n Contact precautions for hx of c.diff. Positive E.coli in\\n urine\\n Dilantin level 18.1. Albumin 3.1.\\n Action:\\n Neuro checks q 2-3\\n Dilantin level drawn prior to dosing\\n Encouraged to cough to remove secretions\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Neuro q2hr\\n Dilantin level one hour before next dose\\n Cont EEG monitoring\\n Transfer to neuro SDU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712786,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712966,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\\n noxious stimuli. Reported to be patient\\ns baseline. LUE/LLE with\\n purposeful movement and normal strength. Positive weak cough/gag. No\\n seizure activity noted.\\n Action:\\n Neurological exams every two hours.\\n Continuous EEG monitoring.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n Follow continuous EEG monitoring for seizure activity.\\n Administer Keppra/Dilantin MD order. Follow Dilantin\\n levels.\\n Plan to transfer to SDU.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712599,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Opens eyes intermittently to voice/stimulation. Does not\\n follow commands.\\n Moving LUE purposefully. LLE moves on bed. Right side\\n withdraws to pain.\\n Remains intubated for airway protection\\n Midaz gtt\\n Continuous bedside EEG\\n No visible seizure activity noted\\n Action:\\n Midazolam gtt weaned\\n Dilantin level\\n Fosphenytoin 150mg IV Q8hrs\\n Neuro checks Q2hrs\\n Response:\\n No change in neuro status\\n Repeat Dilantin level\\n Midaz gtt\\n Plan:\\n Continue frequent neuro checks\\n Continue follow labs- Dilantin level\\n Cont EEG monitoring\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712609,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Opens eyes intermittently to voice/stimulation. Does not\\n follow commands.\\n Moving LUE purposefully. LLE moves on bed. Right side\\n withdraws to pain.\\n Remains intubated for airway protection\\n Midaz gtt\\n Continuous bedside EEG\\n No visible seizure activity noted\\n Dilantin level 18.3, albumin 3.3\\n Action:\\n Midazolam gtt weaned\\n Dilantin level\\n Dr. aware of Dilantin level. Fosphenytoin dose 250\\n mg given.\\n Neuro checks Q2hrs\\n Response:\\n No change in neuro status\\n Repeat Dilantin level\\n Midaz gtt\\n Plan:\\n Continue frequent neuro checks\\n Continue follow labs- Dilantin level\\n Cont EEG monitoring\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 712774,\n \"text\": \"SICU\\n HPI:\\n 71 yo woman with HTN, AF, left hemispheric stroke many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Chief complaint:\\n status epilepticus\\n PMHx:\\n 1. stroke 30 years ago (? location-images not available) with residual\\n right hemiparesis, dysarthria, and difficulty to express herself\\n 2. Type 2 DM, insulin dependent\\n 3. HLP\\n 4. atrial fibrillation, not on coumadin\\n 5. h/o recurrent UTI\\n 6. seizure disorder, unspecified\\n 7. h/o angina\\n 8. PVD\\n 9. chronic thrombocytopenia\\n 10. anemia\\n 11. depression\\n 12. osteoporosis\\n 13. dementia with delusional features\\n 14. obesity\\n 15. bilateral cataract surgery\\n . prior admit for B chronic SDH and acute parafalcine SDH.\\n Current medications:\\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\\n 14. HydrALAzine 15. 16. Insulin\\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\\n Vancomycin Oral Liquid 25. Verapamil\\n 24 Hour Events:\\n : extubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 10:23 PM\\n Ceftriaxone - 09:58 PM\\n Metronidazole - 07:59 AM\\n Infusions:\\n Other ICU medications:\\n Fosphenytoin - 07:07 PM\\n Heparin Sodium (Prophylaxis) - 08:28 PM\\n Other medications:\\n Flowsheet Data as of 01:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.7\\n T current: 36.2\\nC (97.1\\n HR: 104 (91 - 105) bpm\\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\\n RR: 20 (14 - 21) insp/min\\n SPO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 2,837 mL\\n 15 mL\\n PO:\\n Tube feeding:\\n 771 mL\\n IV Fluid:\\n 1,886 mL\\n 15 mL\\n Blood products:\\n Total out:\\n 1,235 mL\\n 0 mL\\n Urine:\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,602 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 413 (341 - 413) mL\\n PS : 5 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 66\\n PIP: 11 cmH2O\\n Plateau: 18 cmH2O\\n SPO2: 100%\\n ABG: ////\\n Ve: 7.3 L/min\\n Physical Examination\\n General Appearance: No acute distress\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 115 K/uL\\n 8.8 g/dL\\n 173 mg/dL\\n 0.7 mg/dL\\n 20 mEq/L\\n 4.5 mEq/L\\n 17 mg/dL\\n 116 mEq/L\\n 144 mEq/L\\n 29.2 %\\n 5.5 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n 12:37 AM\\n 09:33 AM\\n WBC\\n 9.3\\n 5.5\\n Hct\\n 36.3\\n 27.0\\n 29.2\\n Plt\\n 174\\n 115\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n 173\\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\\n mg/dL\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\\n with UTI and Cdiff admitted with status epiliepticus from\\n subtherapeutic levels vs. infection\\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\\n keppra. Goal levels 15-20. Follow 24hr EEG\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Extubated \\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \\n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\\n Nutrition: Replete with fiber Full strength.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\\n LENI today\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Fluids: KVO\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Communication:\\n Code status:FULL\\n Disposition:SICU to floor\\n Lines:\\n PICC Line - 02:55 PM\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 712837,\n \"text\": \"SICU\\n HPI:\\n 71 yo woman with HTN, AF, left hemispheric stroke many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Chief complaint:\\n status epilepticus\\n PMHx:\\n 1. stroke 30 years ago (? location-images not available) with residual\\n right hemiparesis, dysarthria, and difficulty to express herself\\n 2. Type 2 DM, insulin dependent\\n 3. HLP\\n 4. atrial fibrillation, not on coumadin\\n 5. h/o recurrent UTI\\n 6. seizure disorder, unspecified\\n 7. h/o angina\\n 8. PVD\\n 9. chronic thrombocytopenia\\n 10. anemia\\n 11. depression\\n 12. osteoporosis\\n 13. dementia with delusional features\\n 14. obesity\\n 15. bilateral cataract surgery\\n . prior admit for B chronic SDH and acute parafalcine SDH.\\n Current medications:\\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\\n 14. HydrALAzine 15. 16. Insulin\\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\\n Vancomycin Oral Liquid 25. Verapamil\\n 24 Hour Events:\\n : extubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 10:23 PM\\n Ceftriaxone - 09:58 PM\\n Metronidazole - 07:59 AM\\n Infusions:\\n Other ICU medications:\\n Fosphenytoin - 07:07 PM\\n Heparin Sodium (Prophylaxis) - 08:28 PM\\n Other medications:\\n Flowsheet Data as of 01:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.7\\n T current: 36.2\\nC (97.1\\n HR: 104 (91 - 105) bpm\\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\\n RR: 20 (14 - 21) insp/min\\n SPO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 2,837 mL\\n 15 mL\\n PO:\\n Tube feeding:\\n 771 mL\\n IV Fluid:\\n 1,886 mL\\n 15 mL\\n Blood products:\\n Total out:\\n 1,235 mL\\n 0 mL\\n Urine:\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,602 mL\\n 15 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 413 (341 - 413) mL\\n PS : 5 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 66\\n PIP: 11 cmH2O\\n Plateau: 18 cmH2O\\n SPO2: 100%\\n ABG: ////\\n Ve: 7.3 L/min\\n Physical Examination\\n General Appearance: No acute distress\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli), Moves all extremities\\n Labs / Radiology\\n 115 K/uL\\n 8.8 g/dL\\n 173 mg/dL\\n 0.7 mg/dL\\n 20 mEq/L\\n 4.5 mEq/L\\n 17 mg/dL\\n 116 mEq/L\\n 144 mEq/L\\n 29.2 %\\n 5.5 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n 12:37 AM\\n 09:33 AM\\n WBC\\n 9.3\\n 5.5\\n Hct\\n 36.3\\n 27.0\\n 29.2\\n Plt\\n 174\\n 115\\n Creatinine\\n 0.8\\n 0.7\\n 0.7\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n 173\\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\\n mg/dL\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\\n with UTI and Cdiff admitted with status epiliepticus from\\n subtherapeutic levels vs. infection\\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\\n keppra. Goal levels 15-20. Follow 24hr EEG\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Extubated \\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \\n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\\n Nutrition: Replete with fiber Full strength.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\\n LENI today\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Fluids: KVO\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Communication:\\n Code status:FULL\\n Disposition:SICU to floor\\n Lines:\\n PICC Line - 02:55 PM\\n Total time spent: 31 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 712856,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\\n irregularly shaped and non-reactive (surgical). Can be combative at\\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\\n Action:\\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid, levels drawn prior to each dose.\\n Response:\\n No seizure activity noted, neuro exam unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\\n keppra and phosphenytoin, monitor levels, transfer to sdu.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 712857,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\\n irregularly shaped and non-reactive (surgical). Can be combative at\\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\\n Action:\\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid, levels drawn prior to each dose.\\n Response:\\n No seizure activity noted, neuro exam unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\\n keppra and phosphenytoin, monitor levels, transfer to sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course and follow up urine cultures.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 712666,\n \"text\": \"TITLE: Intensivist\\n HPI:71 yo woman with HTN, AF, left hemispheric stroke many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Clinically, she remained marginally responsive and rarely had\\n events of gaze deviation to the left which were suggestive of\\n seizure activity. She was transferred today to the ICU for\\n frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ\\n treatment, in case she fails to respond to other anticonvulsants\\n PICC LINE - START 02:55 PM\\n INVASIVE VENTILATION - START 01:15 AM\\n : Maximized on keppra and dilantin. Versed weaned off.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 10:23 PM\\n Metronidazole - 08:01 AM\\n Ceftriaxone - 09:58 PM\\n Infusions:\\n Midazolam (Versed) - 8 mg/hour\\n Other ICU medications:\\n Lorazepam (Ativan) - 04:05 AM\\n Heparin Sodium (Prophylaxis) - 03:18 PM\\n Fosphenytoin - 05:30 PM\\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\\n Disintegrating Tab 30 mg PO/NG DAILY\\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\\n LeVETiracetam 1500 mg IV Q12H\\n Clopidogrel 75 mg PO/NG DAILY\\n Lisinopril 40 mg PO/NG DAILY\\n Fosphenytoin titated to goal 20\\n Midazolam 5-15 mg/hr IV DRIP INFUSION\\n Gabapentin 300 mg PO/NG HS\\n Potassium Chloride PO Sliding Scale\\n Heparin 5000 UNIT SC TID\\n Verapamil 120 mg PO Q8H\\n HydrALAzine 20 mg IV Q6H\\n Flowsheet Data as of 12:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36\\nC (96.8\\n Tcurrent: 35.9\\nC (96.7\\n HR: 82 (71 - 130) bpm\\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\\n RR: 20 (10 - 24) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 3,869 mL\\n PO:\\n TF:\\n 500 mL\\n IVF:\\n 2,889 mL\\n Blood products:\\n Total out:\\n 599 mL\\n 0 mL\\n Urine:\\n 599 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,270 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 28 cmH2O\\n Plateau: 17 cmH2O\\n Compliance: 71.4 cmH2O/mL\\n SpO2: 100%\\n ABG: 7.44/36/207/20/1\\n Ve: 7.1 L/min\\n PaO2 / FiO2: 518\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\\n )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 174 K/uL\\n 11.4 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 20 mEq/L\\n 4.0 mEq/L\\n 19 mg/dL\\n 119 mEq/L\\n 146 mEq/L\\n 36.3 %\\n 9.3 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n WBC\\n 9.3\\n Hct\\n 36.3\\n Plt\\n 174\\n Cr\\n 0.8\\n 0.7\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\\n Imaging: CT head : resolution of R post parietal subdural fluid\\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\\n posterior fossa\\n EEG showed intermittent seizures consistent with diagnosis\\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\\n Microbiology: Bld Cx: Moraxella\\n Urine Cx: E.coli (s: ceftriaxone)\\n Cdiff +\\n Bld Cx:P\\n Ucx: Ecoli\\n Bld Cx:P\\n Ucx :P\\n C diff Neg\\n Assessment and Plan\\n SEIZURE, WITH STATUS EPILEPTICUS\\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\\n epiliepticus from subtherapeutic levels vs. infection\\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\\n - subclinical seizures based on EEG. Neuro exam - not interactive,\\n lethargic, moans\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Intubated for airway protection.\\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \\n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\\n Nutrition: NPO. Replete electrolyttes.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\\n Lines / Tubes / Drains: NGT, PIV, Picc\\n Fluids: D51/2 NS\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP bundle: +\\n Communication: Son to be in pm woudl likely meeting.\\n ICU Care\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n PICC Line - 02:55 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Need for restraints reviewed\\n Comments: LENIs today\\n Communication: Patient discussed on interdisciplinary rounds , Family\\n meeting held , ICU consent signed Comments:\\n Code status: Full code\\n Disposition:ICU\\n Total time spent: 31 minutes\\n Patient is critically ill Sezures, Resp Failure\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712944,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\\n stimuli. Reported to be patient\\ns baseline. LUE/LLE with purposeful\\n movement and normal strength. Positive weak cough/gag. No seizure\\n activity noted.\\n Action:\\n Neurological exams every two hours.\\n Continuous EEG monitoring.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n Follow continuous EEG monitoring and for seizure activity.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712945,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\\n noxious stimuli. Reported to be patient\\ns baseline. LUE/LLE with\\n purposeful movement and normal strength. Positive weak cough/gag. No\\n seizure activity noted.\\n Action:\\n Neurological exams every two hours.\\n Continuous EEG monitoring.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n Follow continuous EEG monitoring and for seizure activity.\\n Administer Keppra/Dilantin MD order. Follow Dilantin\\n levels.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712935,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 713090,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\\n combative at times. No seizure activity noted.\\n Action:\\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid\\n Response:\\n No seizure activity noted, neuro exam remains unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\\n monitor levels\\n next dilantin level to be drawn am, transfer to\\n sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course\\n last dose will be tonight, and follow\\n up urine cultures.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 713092,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and being treated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\\n noxious stimuli. Reported to be patient\\ns baseline. LUE/LLE with\\n purposeful movement and normal strength. Positive weak cough/gag. No\\n seizure activity noted.\\n Action:\\n Neurological exams every two hours.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n Continue to monitor for seizure activity.\\n Administer Keppra/Dilantin MD order. Follow Dilantin\\n levels.\\n Plan to transfer to SDU.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of Ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete Ceftriaxone course: Last dose tonight . Follow-up\\n urine cultures.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n CHANGE IN MENTAL STATUS\\n Code status:\\n Height:\\n 63 Inch\\n Admission weight:\\n 91.5 kg\\n Daily weight:\\n 91.3 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia, Diabetes - Insulin, Seizures\\n CV-PMH: Angina, CVA\\n Additional history: a-fib not on coumadin, obesity, dementia,\\n cataracts, chronic SDH, recurrent UTI's, PVD, depression,anemia,\\n osteoporosis\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:65\\n Temperature:\\n 97.9\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 17 insp/min\\n Heart Rate:\\n 87 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Face tent\\n O2 saturation:\\n 100% %\\n O2 flow:\\n 10 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 2,058 mL\\n 24h total out:\\n 2,790 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 01:55 AM\\n Potassium:\\n 3.4 mEq/L\\n 01:55 AM\\n Chloride:\\n 109 mEq/L\\n 01:55 AM\\n CO2:\\n 24 mEq/L\\n 01:55 AM\\n BUN:\\n 7 mg/dL\\n 01:55 AM\\n Creatinine:\\n 0.5 mg/dL\\n 01:55 AM\\n Glucose:\\n 145 mg/dL\\n 01:55 AM\\n Hematocrit:\\n 27.2 %\\n 01:55 AM\\n Finger Stick Glucose:\\n 190\\n 04:00 PM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: L-finger yellow colored ring.\\n Transferred from: SICU B 675\\n Transferred to: 11 Room: 1121.\\n Date & time of Transfer: 22:00\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712824,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Alert, unable to assess orientation fue to garbled speech.\\n Follows commands inconsistently. Left side moves purposefully, right\\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\\n Agitated and combative at times, pulled out NGT.\\n No seizure activity observed\\n Beside continuous EEG.\\n PMH Afib. Now in NSR. HR 90\\n Contact precautions for hx of c.diff. Positive E.coli in\\n urine\\n Dilantin level 18.1. Albumin 3.1.\\n Action:\\n Neuro checks q 2-3\\n Dilantin level drawn prior to dosing\\n NGT replaced right nare confirmed by XRay by SICU resident\\n TF\\ns restarted\\n Encouraged to cough to remove secretions\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Neuro q2hr\\n Dilantin level one hour before next dose\\n Cont EEG monitoring\\n Transfer to neuro SDU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712937,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\\n stimuli. Reported to be patient\\ns baseline. LUE/LLE with purposeful\\n movement and normal strength. Positive weak cough/gag. No seizure\\n activity noted.\\n Action:\\n Neurological exams every two hours.\\n Continuous EEG monitoring.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 713089,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\\n combative at times. No seizure activity noted.\\n Action:\\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid\\n Response:\\n No seizure activity noted, neuro exam remains unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\\n monitor levels\\n next dilantin level to be drawn am, transfer to\\n sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course\\n last dose will be tonight, and follow\\n up urine cultures.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 712904,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\\n combative at times, occasionally will spit, etc. No seizure activity\\n noted.\\n Action:\\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid, levels draw x\\ns 2 today. .\\n Response:\\n No seizure activity noted, neuro exam unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\\n keppra and phosphenytoin, monitor levels, transfer to sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course and follow up urine cultures.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712905,\n \"text\": \"Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\\n combative at times, occasionally will spit, etc. No seizure activity\\n noted.\\n Action:\\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid, levels draw x\\ns 2 today. .\\n Response:\\n No seizure activity noted, neuro exam unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\\n keppra and phosphenytoin, monitor levels, transfer to sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course and follow up urine cultures.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 713004,\n \"text\": \"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\\n many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Clinically, she remained marginally responsive and rarely had\\n events of gaze deviation to the left which were suggestive of\\n seizure activity. She was transferred today to the ICU for\\n frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ\\n treatment, in case she fails to respond to other anticonvulsants\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Metronidazole - 01:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:43 PM\\n Fosphenytoin - 04:44 AM\\n Other medications:\\n Flowsheet Data as of 08:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.6\\nC (97.9\\n HR: 96 (81 - 98) bpm\\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\\n RR: 16 (13 - 19) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 2,101 mL\\n 816 mL\\n PO:\\n TF:\\n 891 mL\\n 428 mL\\n IVF:\\n 790 mL\\n 178 mL\\n Blood products:\\n Total out:\\n 2,510 mL\\n 910 mL\\n Urine:\\n 2,510 mL\\n 910 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -409 mL\\n -94 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Thin, decreased mental status\\n Eyes / Conjunctiva: PERRL, Sclera edema\\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\\n Distant, No(t) Widely split ), S4, Rub\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\\n Abdominal: No(t) Soft, Non-tender\\n Skin: Not assessed\\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\\n commands\\n Labs / Radiology\\n 112 K/uL\\n 8.7 g/dL\\n 145 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 109 mEq/L\\n 140 mEq/L\\n 27.2 %\\n 6.2 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n 12:37 AM\\n 09:33 AM\\n 03:00 AM\\n 01:55 AM\\n WBC\\n 9.3\\n 5.5\\n 7.0\\n 6.2\\n Hct\\n 36.3\\n 27.0\\n 29.2\\n 27.0\\n 27.2\\n Plt\\n 174\\n 115\\n 120\\n 112\\n Cr\\n 0.8\\n 0.7\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n 173\\n 121\\n 145\\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\\n mg/dL\\n Assessment and Plan\\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\\n admitted with status epiliepticus from subtherapeutic levels vs.\\n infection\\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\\n goal of 15-20. Continue keppra.\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Extubated . Satting adequately on face mask.\\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\\n PO vanco.\\n Nutrition: Replete with fiber Full strength.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\\n Fluids: KVO\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: Heparin 5000 UNIT SC TID\\n Stress ulcer: PPI\\n VAP bundle: N/A\\n Code status:FULL\\n Disposition:SICU to floor\\n Disposition:\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 713005,\n \"text\": \"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\\n many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Clinically, she remained marginally responsive and rarely had\\n events of gaze deviation to the left which were suggestive of\\n seizure activity. She was transferred today to the ICU for\\n frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ\\n treatment, in case she fails to respond to other anticonvulsants\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Metronidazole - 01:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:43 PM\\n Fosphenytoin - 04:44 AM\\n Other medications:\\n Flowsheet Data as of 08:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.6\\nC (97.9\\n HR: 96 (81 - 98) bpm\\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\\n RR: 16 (13 - 19) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 2,101 mL\\n 816 mL\\n PO:\\n TF:\\n 891 mL\\n 428 mL\\n IVF:\\n 790 mL\\n 178 mL\\n Blood products:\\n Total out:\\n 2,510 mL\\n 910 mL\\n Urine:\\n 2,510 mL\\n 910 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -409 mL\\n -94 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Thin, decreased mental status\\n Eyes / Conjunctiva: PERRL, Sclera edema\\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\\n Distant, No(t) Widely split ), S4, Rub\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\\n Abdominal: No(t) Soft, Non-tender\\n Skin: Not assessed\\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\\n commands\\n Labs / Radiology\\n 112 K/uL\\n 8.7 g/dL\\n 145 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 109 mEq/L\\n 140 mEq/L\\n 27.2 %\\n 6.2 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n 12:37 AM\\n 09:33 AM\\n 03:00 AM\\n 01:55 AM\\n WBC\\n 9.3\\n 5.5\\n 7.0\\n 6.2\\n Hct\\n 36.3\\n 27.0\\n 29.2\\n 27.0\\n 27.2\\n Plt\\n 174\\n 115\\n 120\\n 112\\n Cr\\n 0.8\\n 0.7\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n 173\\n 121\\n 145\\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\\n mg/dL\\n Assessment and Plan\\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\\n admitted with status epiliepticus from subtherapeutic levels vs.\\n infection\\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\\n goal of 15-20. Continue keppra.\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Extubated . Satting adequately on face mask.\\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\\n PO vanco.\\n Nutrition: Replete with fiber Full strength.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\\n Fluids: KVO\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: Heparin 5000 UNIT SC TID\\n Stress ulcer: PPI\\n VAP bundle: N/A\\n Code status:FULL\\n Disposition:SICU to floor\\n Disposition:sicu\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 712979,\n \"text\": \"71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\\n and epilepsy. She was admitted on due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\\n current admission, she had neurosurg follow up for a chronic subdural\\n hematoma, which had resolved. She was advised by PCP to stop her\\n Dilantin. The patient was then admitted to the medicine department two\\n days ago for altered mental status in the setting of UTI. When she\\n remained unresponsive despite being afebrile and being treated with\\n antibiotics for MS changes, question of UTI. An EEG was performed ,\\n which showed frequent electrographic seizures, originating in the right\\n centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and placed on continuous bedside EEG monitoring.\\n Seizure, with status epilepticus\\n Assessment:\\n Opening eyes spontaneously or arouses to stimulation. Garble\\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\\n noxious stimuli. Reported to be patient\\ns baseline. LUE/LLE with\\n purposeful movement and normal strength. Positive weak cough/gag. No\\n seizure activity noted.\\n Action:\\n Neurological exams every two hours.\\n Continuous EEG monitoring.\\n Keppra/Dilantin administered MD order. Last Dilantin\\n level 12/12/09-19.6.\\n Response:\\n Neurological exam remains unchanged.\\n No seizure activity noted.\\n Plan:\\n Continue neurological exam every 2 hours.\\n Follow continuous EEG monitoring for seizure activity.\\n Administer Keppra/Dilantin MD order. Follow Dilantin\\n levels.\\n Plan to transfer to SDU.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 712994,\n \"text\": \"24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\\n many\\n years ago and epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and\\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurgical\\n follow up for a chronic subdural hematoma, which had resolved.\\n Therefore, she was advised to stop her Dilantin. The patient was\\n then admitted to the medicine department two days ago for altered\\n mental status in the setting of UTI. When she remained unresponsive\\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\\n performed , which showed frequent electrographic seizures,\\n originating in the right centro-parietal area. She was reloaded\\n with Dilantin and Lorazepam was given intermittently, but she\\n continued to have seizures overnight, up to 12 an hour.\\n Clinically, she remained marginally responsive and rarely had\\n events of gaze deviation to the left which were suggestive of\\n seizure activity. She was transferred today to the ICU for\\n frequent administration of anti-epileptic agents and monitoring\\n of their levels, as well as for eventual continuous BDZ\\n treatment, in case she fails to respond to other anticonvulsants\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 10:00 PM\\n Metronidazole - 01:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:43 PM\\n Fosphenytoin - 04:44 AM\\n Other medications:\\n Flowsheet Data as of 08:08 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.6\\nC (97.9\\n HR: 96 (81 - 98) bpm\\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\\n RR: 16 (13 - 19) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.3 kg (admission): 91.5 kg\\n Height: 63 Inch\\n Total In:\\n 2,101 mL\\n 816 mL\\n PO:\\n TF:\\n 891 mL\\n 428 mL\\n IVF:\\n 790 mL\\n 178 mL\\n Blood products:\\n Total out:\\n 2,510 mL\\n 910 mL\\n Urine:\\n 2,510 mL\\n 910 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -409 mL\\n -94 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Thin, decreased mental status\\n Eyes / Conjunctiva: PERRL, Sclera edema\\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\\n Distant, No(t) Widely split ), S4, Rub\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\\n Abdominal: No(t) Soft, Non-tender\\n Skin: Not assessed\\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\\n commands\\n Labs / Radiology\\n 112 K/uL\\n 8.7 g/dL\\n 145 mg/dL\\n 0.5 mg/dL\\n 24 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 109 mEq/L\\n 140 mEq/L\\n 27.2 %\\n 6.2 K/uL\\n [image002.jpg]\\n 02:14 AM\\n 05:17 AM\\n 01:43 PM\\n 12:37 AM\\n 09:33 AM\\n 03:00 AM\\n 01:55 AM\\n WBC\\n 9.3\\n 5.5\\n 7.0\\n 6.2\\n Hct\\n 36.3\\n 27.0\\n 29.2\\n 27.0\\n 27.2\\n Plt\\n 174\\n 115\\n 120\\n 112\\n Cr\\n 0.8\\n 0.7\\n 0.7\\n 0.6\\n 0.5\\n TCO2\\n 25\\n Glucose\\n 171\\n 97\\n 173\\n 121\\n 145\\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\\n mg/dL\\n Assessment and Plan\\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\\n admitted with status epiliepticus from subtherapeutic levels vs.\\n infection\\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\\n goal of 15-20. Continue keppra.\\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\\n hydral prn. Cont , .\\n Pulmonary: Extubated . Satting adequately on face mask.\\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\\n PO vanco.\\n Nutrition: Replete with fiber Full strength.\\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \\n Endocrine: DM. RISS\\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\\n Fluids: KVO\\n Consults: Neuro\\n Billing Diagnosis: Status epilepticus, seizures\\n DVT: Heparin 5000 UNIT SC TID\\n Stress ulcer: PPI\\n VAP bundle: N/A\\n Code status:FULL\\n Disposition:SICU to floor\\n Disposition:\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2172-12-27 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 713029,\n \"text\": \"71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\\n epilepsy. She was admitted here in due to\\n prolonged seizures in the setting of low Dilantin level and infection\\n (C.diff) and discharged on Dilantin and Keppra (750 mg\\n ). Two days before her current admission, she had neurosurg lfollow\\n up for a chronic subdural hematoma, which had resolved. She was advised\\n by PCP to stop her Dilantin. The patient was then admitted to the\\n medicine department two daysago for altered mental status in the\\n setting of UTI. When she remained unresponsive despite being afebrile\\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\\n , which showed frequent electrographic seizures,originating in the\\n right centro-parietal area (status epilepticus). She was reloaded with\\n Dilantin and put on continuous EEG at bedside. \\\\\\n Seizure, with status epilepticus\\n Assessment:\\n Either alert or arouses to stimulation. Speech is garbled, often makes\\n incomprehensible sounds/groans. Does not follow commands. Moves left\\n upper and lower extremities purposefully and with normal strength.\\n Right upper and lower extremities withdraw to noxsious stimuli\\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\\n combative at times, occasionally will spit, etc. No seizure activity\\n noted.\\n Action:\\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\\n , and phosphenytoin tid\\n Response:\\n No seizure activity noted, neuro exam remains unchanged.\\n Plan:\\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\\n keppra and phosphenytoin, monitor levels\\n next dilantin level to be\\n drawn am, transfer to sdu.\\n Urinary tract infection (UTI)\\n Assessment:\\n Recurrent UTI\\n Action:\\n 7 day course of ceftriaxone (day 1 was )\\n Response:\\n Pending\\n Plan:\\n Complete ceftriaxone course\\n last dose will be tonight, and follow\\n up urine cultures.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 234723,\n \"text\": \"Sinus rhythm with ventricular premature beat. Left atrial abnormality.\\nST-T wave abnormalities are non-specific. Since the previous tracing\\nof sinus tachycardia is absent and further ST-T wave changes are seen.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-22 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1111243,\n \"text\": \" 8:09 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: please eval for intra-abd process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with change in mental status abd pain\\n REASON FOR THIS EXAMINATION:\\n please eval for intra-abd process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc TUE 9:03 AM\\n No acute abnormalities. Diverticulosis without diverticulitis. Rectum\\n distended with stool.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old female with change in mental status and abdominal\\n pain. Evaluate for intra-abdominal process.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the abdomen and\\n pelvis from the lung bases to the pubic symphysis. Multiplanar reformatted\\n images were obtained.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Atelectasis and nodular\\n opacities in the lung bases persist unchanged from . The\\n liver shows no focal lesion. The gallbladder has been removed. The spleen,\\n adrenal glands, and pancreas are unremarkable. The kidneys enhance and\\n excrete contrast symmetrically. There is no hydronephrosis. Subcentimeter\\n hypodensities in the left kidney are too small to accurately characterize.\\n\\n The intra-abdominal loops of large and small bowel are normal in caliber.\\n There are scattered colonic diverticula without evidence of diverticulitis.\\n Note is made of a large amount of stool in the colon, especially within the\\n rectum.\\n\\n There is no free fluid, free air, or lymphadenopathy. The aorta and iliac\\n arteries are notable for severe atherosclerotic calcification. Large\\n right-sided ventral hernia with post-surgical changes of the overlying\\n abdominal wall is unchanged in appearance.\\n\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder is collapsed with\\n Foley in place. In the left adnexa, there is either a 3.9cm exophytic fibroid\\n with calcification or enlarged ovary (2:78). No free fluid or pelvic\\n lymphadenopathy. The rectum is markedly distended with stool.\\n\\n BONE WINDOWS: No lesion worrisome for osseous metastases is identified.\\n Multilevel degenerative changes are present throughout the thoracolumbar\\n spine.\\n\\n IMPRESSION:\\n 1. Massively fecal impacted rectum.\\n 2. Persistent bibasilar nodular opacities and atelectasis which is again\\n (Over)\\n\\n 8:09 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: please eval for intra-abd process\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n nonspecific. Continued followup is recommended.\\n 3. 3.9cm rounded structure in the left adnexa may represent an exophytic\\n fibroid or enlarged ovary. Recommend pelvic ultrasound after fecal\\n disimpaction.\\n\\n Discussed with Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-22 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1111332,\n \"text\": \" 3:08 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: s/p r 46cm dlpicc\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with poor iv access requiring a dlpicc\\n REASON FOR THIS EXAMINATION:\\n s/p r 46cm dlpicc\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 4:54 PM\\n PFI:\\n\\n Right-sided PICC line terminating in SVC, no pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: 71-year-old female patient with poor IV access. Right-sided PICC\\n line placed, check position.\\n\\n FINDINGS: AP single view of the chest has been obtained with patient in\\n semi-upright position. Analysis is performed in direct comparison with the\\n next preceding similar study obtained eight hours earlier during the same\\n date. Identified now is a right-sided PICC line seen to terminate overlying\\n the SVC at the level 2 cm below the carina. No pneumothorax has developed.\\n As before, low inspirational volume results in vascular crowding, but there is\\n no evidence of any acute infiltrate or significant pleural effusion reaching\\n lateral pleural sinuses.\\n\\n IMPRESSION: Proper placement of PICC line. No complication.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-22 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1111333,\n \"text\": \", P. MED 11R 3:08 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: s/p r 46cm dlpicc\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with poor iv access requiring a dlpicc\\n REASON FOR THIS EXAMINATION:\\n s/p r 46cm dlpicc\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI:\\n\\n Right-sided PICC line terminating in SVC, no pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-29 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE ONLY) PORT\",\n \"row_id\": 1112388,\n \"text\": \" 9:57 PM\\n ABDOMEN (SUPINE ONLY) PORT Clip # \\n Reason: NG placement\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p NGT\\n REASON FOR THIS EXAMINATION:\\n NG placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman status post nasogastric tube.\\n\\n COMPARISON: CT of the abdomen and pelvis from .\\n\\n FINDINGS:\\n\\n Two supine radiographs of the abdomen are presented for review. The first\\n 10:12 p.m. shows a nasogastric tube ending below the diaphragm with its tip\\n not completely evaluated. The second radiograph taken at 10:35 p.m. does not\\n show an NG tube present. The visualized bones are unremarkable. No dilated\\n loops of bowel present.\\n\\n IMPRESSION:\\n\\n Initial nasogastric tube below the diaphragm, though subsequent radiograph\\n shows absence of nasogastric tube.\\n\\n These findings were communicated to the SICU resident , M.D. at\\n 11:00 a.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111482,\n \"text\": \" 2:01 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess position\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with new ngt\\n REASON FOR THIS EXAMINATION:\\n assess position\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Nasogastric tube placement.\\n\\n FINDINGS: In comparison with the study of , there has been placement of a\\n nasogastric tube that extends well into the body of the stomach. Continued\\n low lung volumes with probable atelectatic changes at the left base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111551,\n \"text\": \" 1:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess ett location\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman intubated\\n REASON FOR THIS EXAMINATION:\\n assess ett location\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Assessment for ETT location.\\n\\n COMPARISON: .\\n\\n FINDINGS: Newly inserted endotracheal tube, the tip of the tube projects 1 cm\\n above the carina. The tube could be pulled back by 1 to 2 cm. No evidence of\\n complication, notably no pneumothorax.\\n\\n Unchanged course of the nasogastric tube.\\n\\n Unchanged right PICC line. Low lung volumes with borderline size of the\\n cardiac silhouette and minimal increase in diameter of the pulmonary\\n vasculature, potentially indicative of mild overhydration. No focal\\n parenchymal opacity suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1111239,\n \"text\": \" 7:19 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for cardiopulmonary disease\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with altered mental status\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulmonary disease\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman with altered mental status.\\n\\n COMPARISON: .\\n\\n AP AND LATERAL VIEWS OF THE CHEST: Lung volumes are low, resulting in\\n vascular crowding. However, there is no consolidation or pleural effusion.\\n There is no pneumothorax. The cardiomediastinal silhouette is stable,\\n demonstrating an unfolded aorta. There is no hilar or mediastinal\\n enlargement, although the right hilus remains prominent. Pulmonary\\n vascularity is normal.\\n\\n Right upper quadrant clips are consistent with cholecystectomy.\\n\\n IMPRESSIONS: No acute cardiopulmonary abnormality. Low lung volumes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-25 00:00:00.000\",\n \"description\": \"P BILAT LOWER EXT VEINS PORT\",\n \"row_id\": 1111764,\n \"text\": \" 9:23 AM\\n BILAT LOWER EXT VEINS PORT Clip # \\n Reason: SWOLLEN LEGS WHILE INTUBATED. EVAL FOR CLOT AND PE\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with swollen legs, while intubated\\n REASON FOR THIS EXAMINATION:\\n rule out PE\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 71-year-old female with swollen legs. Evaluate for DVT.\\n\\n COMPARISON: No previous exam for comparison.\\n\\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\\n superficial femoral, popliteal and tibial veins were performed. Note is made\\n that the right peroneal vein could not be identified. There is normal flow,\\n compression and augmentation seen in all of the vessels.\\n\\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1111498,\n \"text\": \" 3:12 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Pt had a right sided picc line placed 46cm and needs tip con\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with new picc who needs cxry to confirm tip location.\\n REASON FOR THIS EXAMINATION:\\n Pt had a right sided picc line placed 46cm and needs tip confirmation please\\n page at with wet read,thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old female with new PICC.\\n\\n COMPARISON: Chest radiograph available from .\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The patient is status post placement of a\\n PICC terminating within the low SVC. The cardiac and mediastinal contours are\\n unchanged. There is a nasogastric tube with side port located within the\\n stomach and the termination point beyond the scope of this examination. There\\n is no pneumothorax or pleural effusion.\\n\\n IMPRESSION: Status post placement of a right-sided PICC terminating within\\n the low SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111893,\n \"text\": \" 5:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NG tube position\\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with status\\n REASON FOR THIS EXAMINATION:\\n NG tube position\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: NG tube placement.\\n\\n One portable view. Comparison with the previous study done .\\n\\n There is continued evidence for mild pulmonary vascular congestion. The heart\\n and mediastinal structures are unchanged. The patient has been extubated. A\\n nasogastric tube remains in place, terminating well below the diaphragm.\\n\\n IMPRESSION: No significant change post-extubation.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24985,"cells":{"subject_id":{"kind":"number","value":124,"string":"124"},"hadm_id":{"kind":"number","value":112906,"string":"112,906"},"target_text":{"kind":"string","value":"As stated above, Mr. was admitted to the ICU for blood pressure control on an esmolol drip. He remained without recurrent chest pain and he had a MRI/MRA done of his chest to further delineate his anatomy. Of note, there were two small outpouchings of contrast from the lumen of the inferior portion of the aortic arch surrounded by large thrombus component with some thickening of the aortic wall and no evidence of active bleeding or free fluid. There were additionally multiple irregularities in the aortic wall throughout the entire thoracic and abdominal aorta that was visualized. This was thought to represent an unusual appearance of a penetrating ulcer with a large thrombus component. He additionally had a cardiac catheterization to evaluate for any underlying coronary artery disease should he need operative repair. This revealed 90 percent stenosis of his right coronary artery, saphenous vein graft with patent vein grafts to the OM and patent LIMA to the LAD with diffuse disease in the distal LAD. A Heparin-coated stent was placed in the vein graft to the right coronary artery. Other findings from his catheterization revealed an 80 percent instent stenosis of the left vertebral artery and an 80 percent right brachiocephalic ostial lesion. He tolerated the procedure well and there were no bleeding or groin complications. He returned to the Intensive Care Unit for continued blood pressure monitoring and his esmolol drip was eventually weaned off. Given the patient's multiple medical problems including his severe pulmonary disease, underlying coronary artery disease, and overall debilitated condition, the decision was made to proceed with medical management as the postoperative management of this likely penetrating ulcer. He was transitioned to oral agents. His diltiazem dose was increased and Lopressor was added for additional rate control. He remained off drips for greater than 48 hours. Decision was made to send him home with close followup. Of note, his hematocrit remained stable. His creatinine remained within its baseline of around 1.4 and he was tolerating a regular diet and able to ambulate without difficulty. Of note, because of his complaint of cough, a sputum sample was sent, which grew out Pseudomonas that was , he was started on ciprofloxacin on . Follow-up chest x-ray revealed bilateral lower lobe changes concerning for pneumonia. He remained afebrile with normal white count."},"extractive_notes_summ":{"kind":"string","value":"Normal ascending aorta diameter. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:1. Left ventricular function.Height: (in) 69Weight (lb): 160BSA (m2): 1.88 m2BP (mm Hg): 149/46HR (bpm): 77Status: InpatientDate/Time: at 11:47Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. Mild mitral annularcalcification. TECHNIQUE: PA & lateral chest. Trivial mitralregurgitation is seen. There are unchanged interstitial changes of both lungs, most marked at the bases. The pulmonary vasculature is not engorged. The mediastinal and hilar contours are within normal limit. Diffuse emphysematous changes. The vague hyperattenuated signal within the lower aspect of the aortic arch surrounding the ulcers is of uncertain significance. Otherwise, no diagnosticinterim change.TRACING #1 no c/o chest pain. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). The left ventricular cavity size is normal. FINDINGS: Within the inferior portion of the aortic arch, there are two different small outpouchings of contrast from the lumen, the anterior one is at the level of the left subclavian and measures 6 mm, and the second one is 1 cm posterior to this one and measures 9 x 9 mm. Cardiac and mediastinal contours are stable and within normal limits. Linear atelectasis at right lung base. Limited evaluation of the upper abdomen reveals no gross abnormalities. Otherwise, no significant change in previously seen abnormalities. FINDINGS: The patient is S/P CABG with median sternotomy. IMPRESSION: Two small areas of contrast outpouching from the aortic lumen at the inferior portion of the aortic arch, surrounded by a large polylobulated thrombus extending downwards to the level of the pulmonary artery. Mild stenosis in the origin of the left carotid artery and moderate stenosis in the origin of the left subclavian artery. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to theprevious tracing of the rate has slowed. PT DENIES ANY PAIN. Low limb lead voltage. Low limb lead voltage. AM LOPRESSOR AND HYDRALIZINE HELD. CT CHEST WITHOUT AND WITH IV CONTRAST: The opacified pulmonary arterial tree does not demonstrate any filling defects indicative of pulmonary embolus to the level of the subsegmental pulmonary arteries bilaterally. There is flattening of the diaphragms secondary to emphysema. No diagnostic interim change.TRACING #2 Normal tracing as on . Suboptimal technical quality, a focalLV wall motion abnormality cannot be fully excluded. COMPARISON: CTA dated . FINDINGS: Sternal wires and mediastinal clips are again noted. His TAA volume is 173.8cc. The lung fields demonstrate diffuse emphysematous changes. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Since the previous tracing of the heart rate hasdecreased. Heart size is normal. IMPRESSION: No evidence of pneumonia. The heart, pulmonary arteries and veins are unremarkable. These inferior outpouchings of contrast are surrounded by large polylobulated thrombus component, measuring 4 x 3 x 2.5 cm. L/S clear course @ bases.GI: Taking PO's well.GU: Having adequate u/o, per foley.ID: no temps.Neuro: A&Ox3. intermittent epidose to Sats 80's with wheezes recieved AlB neb and routine inhalers with improvement.cv: HR 72-82,NSR, no ectopy, A-BP 80-120 labile, BP differant R side from L side by 40 points, off ESMOLOL, recieved PO DILTIAZEM and HYDROCHLORTIASIDE, goal SBP> 100 MAPS >60. Remains on PO Dilt and HCT.Respir: O2L NP with O2 sats 97-100%, L/S clear no wheezes noted but does have occ congested sounding cough. NIRIDE off from , recieved 1 dose IV LOPRESSOR 10mg/HYDRALISINE 10mg d/t A-BP 140 w/respons, A-BP 90-130/50-60. cardiac US done--> pnd.has weak peripheral pulses.RESPwearing 2 litres nasal cannula, no c/o SOB.lungs sound clear anteriorally.sats are >95%.GI-abd is soft with positive bowel sounds. NPN MICU-B 7AM-3PMS/O: C/V: Continues on Nipride Gtt titrating to keep BP 80-100's as per A-line, @ present is on .75mcq/kq/min. Cough productive/strongcv: HR 76-91, NSR, no ectopy. NPN MICU-B 7AM-7PMS/O: C/V: Remains off of Esmolol Gtt with BP's 100-136/60, HR 70-80's SR with no ectopy noted. labs morning pendinggu/gi: foley, u/o >60cc/hr, abd soft, +BS, no BM. NPN MICU-B 7AM-7PMS/O: C/V: Remains off of Esmolol Gtt, with BP 90-128/55-68, HR-60-80's SR with no ectopy noted. Plan: manage SBP 90-100.cath on not shown aortic aneurism, but intramural trombus,that not operable by surgery,medical managment, performed PTCA to RCAgu/gi: foley,u/o >60cc/hr. Pedal pulses + by doppler, extrems warm, no edema.Resp: 2l n/p w/ 02 sat 98%, lung sound diminished throu-all fields. pain managment: c/o back pain, recieved TYLENOL w/relief.resp: NC 2L, sat96-99%, LS clear to wheezing w/respons to albut. Awaiting cath on Monday.Respir: O2 sats on 2lPN 98-100%, L/S clear to diminished @ bases. BP TITRTAED WITH NIPRIDE TO KEEP IN 80-100 RANGE VIA A-LINE. Pain Managment: c/o lower back pain, recieved po TYLENOL 650mg w/reliefresp: RR 18-24 NC 2L, sat 98-99%, LS clear, cough strong/productivecv: HR 65-85 NSR, no ectopy. Nipride currently at .7mcg/kgmin w/ SBP 100/63. No neuro deficits noted.Resp: 2L NC on, resp easy and regular, O2sat 93-97%, Lungs clear with bibasilar diminished BS. IV D5 w/KCL @ 60cc/hr, recieved routine DILT/HTZ. Abd soft, + BS.id: afebrile.social:full code,no call from family this shift.plan: monitoring SBP 90-100, wean NIPRIDE gtt transfer to the floor Heparin SQ .GU/GI: Abd round soft + BS, pt c/o of hunger and thrist/remains NPO. Full codeA/P: Continue to attempt to wean and d/c Nipride Gtt, monitor BP keep 80-100 as per A-line, is 40mm lower then L arm NBP, due to stenosis. L arm site has + pulses, also has + pedal pulses noted with doppler.Respir: Has congested cough but not productive, is on 2L NP with O2sats 95-99%, does desat with activity to 88-90%. PT IS AFEBRILE.GI: PT ON HOUSE DIET, ONLY LIQUIDS OVERNIGHT. pmicu nursing progress 7a-7preview of systemsCV-hr has been stable without ectopy noted.continues on esmolol at 80 mcgs/kg/min,this has not been changed, maintaining bp (via a-line) at ~100-120/.no c/o chest pain."},"n_notes":{"kind":"number","value":25,"string":"25"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2161-12-18 00:00:00.000","description":"Report","row_id":60860,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. S/p CABG .Evaulate aorta for evidence of pseudoaneurysm. Left ventricular function.\nHeight: (in) 69\nWeight (lb): 160\nBSA (m2): 1.88 m2\nBP (mm Hg): 149/46\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:47\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n2. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n"},{"category":"Radiology","chartdate":"2161-12-22 00:00:00.000","description":"MMS SUGICAL PLANNING SERVICE","row_id":847661,"text":" 2:07 PM\n MMS SUGICAL PLANNING SERVICE Clip # \n Reason: please send images of CTA and MRA done on , to MMS, p\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with possible aortic arch pseudoaneurysm\n REASON FOR THIS EXAMINATION:\n please send images of CTA and MRA done on \n to MMS, patient in house\n ______________________________________________________________________________\n FINAL REPORT\n This report is for reference only, generated by Medical Metrx Services, For\n primary diagnosis please see CT Exam dated12/2/04\n\n , DOB: (Age 71) TAA\n Date of Service: \n Physician : \n\n\n was last scanned on and is a pre-operative TAA\n patient. His TAA volume is 173.8cc. His TAA diameter is 6.2cm.\n\n Mr. currently has the following alerts triggered in PEMS:\n His Max TAA-Diameter measurement is greater than 60.0mm. This alert has not\n been acknowledged.\n Nb: This note was automatically generated.\n\n"},{"category":"Radiology","chartdate":"2161-12-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":847792,"text":" 12:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pseudomonas on sputum culture\n\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with pseudomonas of sputum culture. Pneumonia.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The patient is S/P CABG with median sternotomy. The heart is\n normal in size. The mediastinal and hilar contours are within normal limit.\n Again note is made of patchy consolidation in bilateral lower lobes medially,\n slightly increased compared to the prior study. There is no evidence of\n congestive heart failure.\n\n IMPRESSION: Increased bilateral lower lobe patchy consolidation, representing\n pneumonia.\n\n"},{"category":"Radiology","chartdate":"2161-12-17 00:00:00.000","description":"MRI CHEST/MEDIASTINUM W/O & W/CONTRAST","row_id":847134,"text":" 8:35 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please evaluate aortic arch aneurysm\n Admitting Diagnosis: CHEST PAIN,R/O MI\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71m vasculopath with 3cm pseudoaneurysm on CTA\n REASON FOR THIS EXAMINATION:\n please evaluate aortic arch aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old man with suspected aneurysm on aortic CTA.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained prior to and\n after administration of IV gadolinium.\n\n Multiplanar reconstructions were obtained and viewed on a different\n workstation.\n\n COMPARISON: CTA dated .\n\n FINDINGS: Within the inferior portion of the aortic arch, there are two\n different small outpouchings of contrast from the lumen, the anterior one is\n at the level of the left subclavian and measures 6 mm, and the second one is 1\n cm posterior to this one and measures 9 x 9 mm. These inferior outpouchings\n of contrast are surrounded by large polylobulated thrombus component,\n measuring 4 x 3 x 2.5 cm. There is some thickening of the aortic wall at the\n inferior portion of the arch around this outpouching. There is no evidence of\n active bleeding, or free fluid. There are multiple irregularities in the\n aortic wall throughout the entire thoracic and visualized portions of the\n abdominal aorta.\n\n The arch vessels are patent. There is severe stenosis in the origin of the\n brachiocephalic artery. Mild stenosis in the origin of the left carotid\n artery and moderate stenosis in the origin of the left subclavian artery.\n\n The heart, pulmonary arteries and veins are unremarkable. There is no\n significant lymphadenopathy.\n\n IMPRESSION: Two small areas of contrast outpouching from the aortic lumen at\n the inferior portion of the aortic arch, surrounded by a large polylobulated\n thrombus extending downwards to the level of the pulmonary artery. This most\n likely represents an unusual appearance of a penetrating ulcer with large\n exophytic thrombus component. There is no evidence of active bleeding or\n leakage.\n\n The vague hyperattenuated signal within the lower aspect of the aortic arch\n surrounding the ulcers is of uncertain significance. Blood products cannot be\n definitely seen but small intramural hematoma cannot be excluded.\n\n (Over)\n\n 8:35 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please evaluate aortic arch aneurysm\n Admitting Diagnosis: CHEST PAIN,R/O MI\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2161-12-17 00:00:00.000","description":"CTA CHEST W&W/O C &RECONS","row_id":847008,"text":" 1:59 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ro pe\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cp, sob. cough and elevated d-dimer with no acute process\n on cxray but chronic interstitial changes-\n REASON FOR THIS EXAMINATION:\n ro pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:50 AM\n no pe; aortic pseudoaneurysm; emphysema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 71-year-old male with chest pain, shortness of breath,\n and cough.\n\n TECHNIQUE: Multidetector CT images of the chest prior to and following the\n administration of 150 cc of Optiray. Non-ionic contrast was used due to the\n rapid bolus infusion required for the CTA technique.\n\n Multiplanar reformatted images were created.\n\n CT CHEST WITHOUT AND WITH IV CONTRAST: The opacified pulmonary arterial tree\n does not demonstrate any filling defects indicative of pulmonary embolus to\n the level of the subsegmental pulmonary arteries bilaterally. There are\n extensive atherosclerotic changes of the aorta, as well as a complex,\n predominantly thrombosed 3.3 x 2.2 cm pseudoaneurysm or penetrating ulcer of\n the aortic arch. There is no evidence of leak. The heart is normal in size.\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\n identified. The lung fields demonstrate diffuse emphysematous changes.\n Limited evaluation of the upper abdomen reveals no gross abnormalities.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. 3 cm partially thrombosed pseudoaneurysm or penetrating ulcer of the aortic\n arch 2.5 cm distal to the left SCA.\n 3. Diffuse emphysematous changes.\n\n"},{"category":"ECG","chartdate":"2161-12-22 00:00:00.000","description":"Report","row_id":115231,"text":"Sinus rhythm with increase in rate as compared to the previous tracing\nof . Low limb lead voltage. No diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2161-12-21 00:00:00.000","description":"Report","row_id":115232,"text":"Sinus rhythm. Low limb lead voltage. Technically limited study. Compared to the\nprevious tracing of the rate has slowed. Otherwise, no diagnostic\ninterim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2161-12-17 00:00:00.000","description":"Report","row_id":115233,"text":"Sinus rhythm. Since the previous tracing of the heart rate has\ndecreased. Otherwise, no significant change in previously seen abnormalities.\n\n"},{"category":"ECG","chartdate":"2161-12-16 00:00:00.000","description":"Report","row_id":115234,"text":"Sinus rhythm. Normal tracing as on .\n\n"},{"category":"Radiology","chartdate":"2161-12-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":847316,"text":" 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n History of chest pain.\n\n Status post CABG. Heart size is normal. No evidence for CHF. There is\n flattening of the diaphragms secondary to emphysema. Linear atelectasis at\n right lung base. No new pulmonary consolidation or pleural effusion.\n\n IMPRESSION: Emphysema and right basilar atelectasis but no evidence for\n pneumonia or CHF.\n\n"},{"category":"Radiology","chartdate":"2161-12-16 00:00:00.000","description":"CHEST (PA & LAT)","row_id":846990,"text":" 9:01 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with productive cough and cp and sob ? xray 1 week pta\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71 y/o male with cough, chest pain, and shortness of breath.\n\n TECHNIQUE: PA & lateral chest.\n\n COMPARISON: .\n\n FINDINGS: Sternal wires and mediastinal clips are again noted. Cardiac and\n mediastinal contours are stable and within normal limits. The pulmonary\n vasculature is not engorged. There are unchanged interstitial changes of both\n lungs, most marked at the bases. There are no pleural effusions. Osseous\n structures are unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n"},{"category":"Nursing/other","chartdate":"2161-12-24 00:00:00.000","description":"Report","row_id":1261811,"text":"NURSING MICU NOTE 11P-7A\n\nPT 3, MAE, FOLLWOWS COMMANDS. PT DENIES ANY PAIN. PT C/O MILD HEARTBURN FROM DINNER. PT GIVEN 2 TUMS. PT SLEEP OUT MOST OF NIGHT. HR 80-90'S NSR. SBP 90-120'S PER NBP. AM LOPRESSOR AND HYDRALIZINE HELD. PT ALINE DAMPENED, 20POINT LOWER THAN NBP IN SAME ARM.\nPT IS CALLED OUT TO FLOOR, TELE BED. AWAITINGBED ASSIGNMENT. PT IS A FULL CODE.\n"},{"category":"Nursing/other","chartdate":"2161-12-18 00:00:00.000","description":"Report","row_id":1261800,"text":"pmicu nursing progress 7p-11p addendum\n\npt was finally permitted to eat and enjoyed a .his bp began to increase however and the esmolol was titrated up gradually to a max dose of 116 mcgs/kg/min (from 80), bp was still in the 120's-130/with pt dozing. no c/o chest pain. bp then dipped to the 90's and i've started to wean esmolol back down- goal bp is 100-110/ to protect aneurysm. pt is sleeping.plan is for cardiac cath on monday.\n"},{"category":"Nursing/other","chartdate":"2161-12-19 00:00:00.000","description":"Report","row_id":1261801,"text":"MICU Nursing Progress Note\n Cardiac: on esomol infusion titrating to keep SBP 100-120 however it was requiring to increase esomol infusion without effecting the SBP which was running 120-136/... requiring doses of 150mcg/kg/min. Notified Dr. , Order from Dr. to give 10 mg of IV hydralazine, quickly weaned esomol then needed to stop IVF at 3am as BP down to 70/. slowly came up to 90/ during this time pt was fully mentating, producing urine from 70-90cc/hr. double checking BP with diamapp showed art line correctly BP in the right arm. there is a 40point difference between arms, left>right. Pt was on D5NS at 75cc/hr. stopped at 2 am. then restarted at 4:30 am to help BP will stop again once BP up above 100SBP. Pt denied feeling any CP, SOB, did c/o of back pain though with futher assessment pain located at the base of his spine, reliefed with change in position.\n Respiratory: on Nasal cannula at 2 liters/min. BS diminshed at bases otherwise fine.\n GI: abd soft, + BS no stool, able to take some POS will need to be NPO again for midnight on Sunday night for cath on monday.\n GU: foley in place and draining well. urine yellow.\n ID: afribile.\n Neuro: A&O x 3, able to move in bed, on bedrest. no ambulating., clear speech. cooperative, pleasant gentleman.\n IV access: two perpheral IV;s\n Social: no contact with the family during the night.\n Plan: to monitor closely, goal is to keep SBP 100-120/ cath on monday.\n\n\n"},{"category":"Nursing/other","chartdate":"2161-12-18 00:00:00.000","description":"Report","row_id":1261798,"text":"1900-0700\n\nNeuro: Pt awake/alert/oriented, follows commands well. MAEs. equal and reactive. No neuro deficits noted.\n\nResp: 2L NC on, resp easy and regular, O2sat 93-97%, Lungs clear with bibasilar diminished BS. Denies any SOB. No exertional dsypnea noted.\n\nCV: NSR without ectopy alarms on. HR 70-80, SBP controlled 90-115, MAP 60-70. Esmolol drip titrated prn, currently infusing @ 80 mcg/kg/min. Pt denies CP. MRI completed awaiting results for aortic arch aneurysm. Pulses to ext weak acquired with doppler. A line to R radial positional. No edema noted. Skin warm/dry/intact. Heparin SQ .\n\nGU/GI: Abd round soft + BS, pt c/o of hunger and thrist/remains NPO. No N/V. Protonix IV given. Foley to BSD draining yellow clear urine.\n\nIV: PIV x2, Lt hand, LLa.\n\neview MRI results, await consult of Dr. , ? surgery. Continue Esmolol for BP control.\n"},{"category":"Nursing/other","chartdate":"2161-12-21 00:00:00.000","description":"Report","row_id":1261806,"text":"FULL CODE Contact Precautions \n\n\nNeuro: AAOx3, MAEx4 spont/command, moves self well in bed.\n\nCV: Pt had cardiac cath today, films reviewed by Drs and . They feel it's an intramural thrombu and not a pseudoanyeurysm and surgery is not required - follow medically. Pt has significant steonis in R brachial ceph artery attributing to the difference in the blood pressures in each arm. Based on central pressures during the procedure, a-line is 40mm lower than actual pressures. Nipride started to maintain SBP <120s, then surgical team rounded and want a-line SBP in 100s. Nipride currently at .7mcg/kgmin w/ SBP 100/63. Cath was done via L radial site and pressure clamp in place - to be removed at 1830. Good perfusion to L hand, 02sat monitor probe on L hand w/ good pleth. Pedal pulses + by doppler, extrems warm, no edema.\n\nResp: 2l n/p w/ 02 sat 98%, lung sound diminished throu-all fields. Congested cough, but non-productive.\n\nGI/GU: Abd soft, +BS, no BM. Taking cardiac diet. On H2B Foley cath w/ clear yellow urine.\n\nPain: No c/o discomfort.\n\nSkin: intact\n\nID: afebrile. No antibx\n\nAccess: PIV x3. R rad a-line\n\nSocial: Wife at bedside. Numerous family members have called.\n\nPlan: Nipride to maintain ABP in 100s. Clamp on L wrist to be d/c'd at 1830. Pain med prn for comfort.\n"},{"category":"Nursing/other","chartdate":"2161-12-22 00:00:00.000","description":"Report","row_id":1261807,"text":"NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED X 3 AND MAE. C/O HA AND WAS WITH TYLENOL. NO C/O CHEST PAIN.\n\nRESP: PT HAS EXTREMELY CONGESTED COUGH AND LUNG SOUNDS COARSE THROUGHOUT. PT'S O2 SAT'S WHILE AWAKE ARE IN THE HIGH 90'S BUT WILL DROP TO THE HIGH 80'S WHEN ASLEEP. NC INCREASED WHILE SLEEPING TO 4L.\nPT TAKES INHALERS SELF.\n\nCV: PT'S HR IN NSR WITHOUT ECTOPY WITH RATES IN THE 70'S TO THE 90'S. BP TITRTAED WITH NIPRIDE TO KEEP IN 80-100 RANGE VIA A-LINE. PT HAS RIGHT RADIAL ALINE WHICH IS WORKING WELL. LEFT RADIAL CATH SITE HAS DRESSING WHICH IS DRY AND INTACT. PT HAS PULSES. LEFT HAND ELEVATED ON PILLOW. PT IS AFEBRILE.\n\nGI: PT ON HOUSE DIET, ONLY LIQUIDS OVERNIGHT. ABD SOFT NONTENDER WITH POSITIVE BOWEL SOUNDS.\n\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF PINK TINGED TO YELLOW URINE WITH OCCASIONAL CLOTS.\n\nSKIN: INTACT.\n\nSOCIAL: WIFE VISITED AND CALLED OVERNIGHT AND HAS BEEN UPDATED. PT IS FULL CODE.\n"},{"category":"Nursing/other","chartdate":"2161-12-22 00:00:00.000","description":"Report","row_id":1261808,"text":"NPN MICU-B 7AM-3PM\nS/O: C/V: Continues on Nipride Gtt titrating to keep BP 80-100's as per A-line, @ present is on .75mcq/kq/min. Hydralazine increased to 50mg qd which was given @ 11am but with no effect as yet. HR- 70-80 SR with no ectopy noted. No c/'o's CP. L arm site has + pulses, also has + pedal pulses noted with doppler.\n\nRespir: Has congested cough but not productive, is on 2L NP with O2sats 95-99%, does desat with activity to 88-90%. L/S clear course @ bases.\n\nGI: Taking PO's well.\n\nGU: Having adequate u/o, per foley.\n\nID: no temps.\n\nNeuro: A&Ox3. Full code\n\nA/P: Continue to attempt to wean and d/c Nipride Gtt, monitor BP keep 80-100 as per A-line, is 40mm lower then L arm NBP, due to stenosis. Monitor I&O's.\n"},{"category":"Nursing/other","chartdate":"2161-12-23 00:00:00.000","description":"Report","row_id":1261809,"text":"micu 1900-0700 rn notes\n\nneuro: A/Ox3,open eyes spont, MAE, follows commands. pain managment: c/o back pain, recieved TYLENOL w/relief.\n\nresp: NC 2L, sat96-99%, LS clear to wheezing w/respons to albut. Cough productive/strong\n\ncv: HR 76-91, NSR, no ectopy. NIRIDE off from , recieved 1 dose IV LOPRESSOR 10mg/HYDRALISINE 10mg d/t A-BP 140 w/respons, A-BP 90-130/50-60. Given PO DILTASEM 360mg. Plan: manage SBP 90-100.\ncath on not shown aortic aneurism, but intramural trombus,that not operable by surgery,medical managment, performed PTCA to RCA\n\ngu/gi: foley,u/o >60cc/hr. Abd soft, + BS.\n\nid: afebrile.\n\nsocial:full code,no call from family this shift.\n\nplan: monitoring SBP 90-100, wean NIPRIDE gtt\n transfer to the floor\n"},{"category":"Nursing/other","chartdate":"2161-12-18 00:00:00.000","description":"Report","row_id":1261799,"text":"pmicu nursing progress 7a-7p\nreview of systems\nCV-hr has been stable without ectopy noted.continues on esmolol at 80 mcgs/kg/min,this has not been changed, maintaining bp (via a-line) at ~100-120/.no c/o chest pain. cardiac US done--> pnd.has weak peripheral pulses.\n\nRESP_wearing 2 litres nasal cannula, no c/o SOB.lungs sound clear anteriorally.sats are >95%.\n\nGI-abd is soft with positive bowel sounds. pt is hungry! on famotidine.no stool today. has been npo for ? surgery.\n\nID-afebrile.wbc=11.3. no new cultures sent.\n\nNEURO-is alert and oriented x 3,cooperative. sleeping in naps.\n\nCOMFORT-c/o R \"tennis elbow\" pain.propped up on pillows with relief.\n\nF/E- maintainence ivf at 75/hr. has had an adequate urinary output of clear yellow urine.no peripheral edema noted.\n\nIV ACCESS-has peripheral heplocks and an a-line R wrist.\n\nSOCIAL-wife in room all day awaiting decision about possible surgery.has been updated with info as i know it.\n\na-stable.uneventful day\n\nP-will keep npo for now. awaiting cardiac to give word regarding possible surgery.continue with esmolol to keep bp <110.\n"},{"category":"Nursing/other","chartdate":"2161-12-23 00:00:00.000","description":"Report","row_id":1261810,"text":"MICU NPN 11AM-7PM:\nPt is called out to the floor and may have his a-line d/c'd before transfer unless he goes to VICU bed where he may have the a-line transduced. See call out note for full report.\n\nNeuro: Pt denies pain. OOB to chair with minimal assist with lines/tubes. Denies pain.\n\nCV: Some BP meds held at some doses according to hold parameters. Pt began on PO lopressor 12.5mg PO BID at noon. His hydrochlorathiazide was held today as well as his 8AM and 8PM dose of hydralizine. He did get the 2PM dose of hydralizine but BP did get below 90 at times and UO dropped after this so hold parameter is 110. We are to follow his BP on his right arm.\n\nResp: Pt wanted to see if he could be off his O2 so he has spent the day on room air with O2 sats 92-95%. He does get DOE and has wheezes at times.\n\nGI: Appetite if only fair. No stool today.\n\nGU: UO dropped to 5cc/hr for two hours and pt given 500cc bolus NS at 6PM with some effect. Will follow UO closely and encourage PO's this evening. There is an order to d/c foley at midnight tonight in transfer to floor orders but this will need to be evaluated according to how well pt is urinating and if pt gets bed.\n\nPlan: Pt awaiting a bed assignment on the floor. Initially pt was to go to VICU bed but after discussion with the accepting team it was decided he could be transferred to the floor with telemetry. He is awaiting bed availability at present and will be transferred when it becomes available.\n"},{"category":"Nursing/other","chartdate":"2161-12-19 00:00:00.000","description":"Report","row_id":1261802,"text":"NPN MICU-B 7AM-7PM\nS/O: C/V: Remains off of Esmolol Gtt, with BP 90-128/55-68, HR-60-80's SR with no ectopy noted. No c/o's CP. Still a 40pt in BP difference between Left arm and R arm, with Left arm being greater. Team is aware and is going by the A-line which is in the Right arm. Has +pulses and lower extremities are warm and dry. Awaiting cath on Monday.\n\nRespir: O2 sats on 2lPN 98-100%, L/S clear to diminished @ bases. RR 20-26, no c/o's SOB.\n\nGI: Taking PO's with just mild appetite. On IFV's D5NS @ 75cc/hr. soft with +BS's.\n\nGU: U/O very adequate. No c/o's.\n\nNeuro: A&Ox3. C/O back pain this AM from lying in bed, rec'd Tylenol with relief.\n\nSocial: Family in visiting all day, very pleasant and supportive.\n\nA/P: Monitor BP maintain between 100-120/60, assess I&O's, assess c/o's CP. Prepare cath on Monday.\n"},{"category":"Nursing/other","chartdate":"2161-12-20 00:00:00.000","description":"Report","row_id":1261803,"text":"micu 1900-0700 RN notes\n\nneuro: AOx3, open eyes spont, follows commands. PERL. pain management: c/o back pain recieved PO TYLENOL 650mg w/relief\n\nresp: NC 2L, sat 95-99%, RR 16-20, LS coarse/clear, productive cough w/secretion. sputum sent to culture. intermittent epidose to Sats 80's with wheezes recieved AlB neb and routine inhalers with improvement.\n\ncv: HR 72-82,NSR, no ectopy, A-BP 80-120 labile, BP differant R side from L side by 40 points, off ESMOLOL, recieved PO DILTIAZEM and HYDROCHLORTIASIDE, goal SBP> 100 MAPS >60. Morning labs pending\n\ngu/gi: foley, u/o>60/hr. abd soft ,+BS\n\nsocial: full code status, family visites, updates\n\nplan:cath on Monday\n surgery on Tuesday\n monitoring BP>100\n"},{"category":"Nursing/other","chartdate":"2161-12-20 00:00:00.000","description":"Report","row_id":1261804,"text":"NPN MICU-B 7AM-7PM\nS/O: C/V: Remains off of Esmolol Gtt with BP's 100-136/60, HR 70-80's SR with no ectopy noted. No c/o's CP. Started on IVF D5 with 20KCL @ 60cc/hr. C/O back pain due to lying in bed, relieved with Tylenol 650mg PO. Awaiting cath in the AM. Remains on PO Dilt and HCT.\n\nRespir: O2L NP with O2 sats 97-100%, L/S clear no wheezes noted but does have occ congested sounding cough. No SOB.\n\nGI: Taking PO's in small amts, to be NPO this evening for cath in the AM. Had very lrge soft brown OB neg stool.\n\nGU: U/O very good, clear yellow urine.\n\nNeuro: A&Ox3.\n\nIV lines: New # 18 angio placed in Left A/C, with 3d old #20 remains in Left wrist. A-line still in R arm.\n\nA/P: Continue to monitor BP, attempt to keep >130. Prepare for Cath. Monitor I&O's, keep NPO after MN.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2161-12-21 00:00:00.000","description":"Report","row_id":1261805,"text":"micu 1900-0700 RN notes\n\nneuro: A/Ox3, MAE,PERL. Pain Managment: c/o lower back pain, recieved po TYLENOL 650mg w/relief\n\nresp: RR 18-24 NC 2L, sat 98-99%, LS clear, cough strong/productive\n\ncv: HR 65-85 NSR, no ectopy. A-BP 80-140/50-60, (40 point discrepancy NBP L-R). Remain off ESMOLOL. IV D5 w/KCL @ 60cc/hr, recieved routine DILT/HTZ. recieved Acetylcystein 600mg @0600 for cath. labs morning pending\n\ngu/gi: foley, u/o >60cc/hr, abd soft, +BS, no BM. NPO from midnight\n\nid: afebrile, Tmax 98.9\n\nsocial: full code. Wife called/updated\n\nplan: cath in the AM, plan for surgery on \n pre/post cath ACETYLCESTEIN 600mg\n monitoring BP\n\n\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2161-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 60860,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease. S/p CABG .Evaulate aorta for evidence of pseudoaneurysm. Left ventricular function.\\nHeight: (in) 69\\nWeight (lb): 160\\nBSA (m2): 1.88 m2\\nBP (mm Hg): 149/46\\nHR (bpm): 77\\nStatus: Inpatient\\nDate/Time: at 11:47\\nTest: Portable TTE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\n1. The left ventricular cavity size is normal. Due to suboptimal technical\\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\\nleft ventricular systolic function is normal (LVEF>55%).\\n2. The mitral valve leaflets are mildly thickened. Trivial mitral\\nregurgitation is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-22 00:00:00.000\",\n \"description\": \"MMS SUGICAL PLANNING SERVICE\",\n \"row_id\": 847661,\n \"text\": \" 2:07 PM\\n MMS SUGICAL PLANNING SERVICE Clip # \\n Reason: please send images of CTA and MRA done on , to MMS, p\\n Admitting Diagnosis: CHEST PAIN,R/O MI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with possible aortic arch pseudoaneurysm\\n REASON FOR THIS EXAMINATION:\\n please send images of CTA and MRA done on \\n to MMS, patient in house\\n ______________________________________________________________________________\\n FINAL REPORT\\n This report is for reference only, generated by Medical Metrx Services, For\\n primary diagnosis please see CT Exam dated12/2/04\\n\\n , DOB: (Age 71) TAA\\n Date of Service: \\n Physician : \\n\\n\\n was last scanned on and is a pre-operative TAA\\n patient. His TAA volume is 173.8cc. His TAA diameter is 6.2cm.\\n\\n Mr. currently has the following alerts triggered in PEMS:\\n His Max TAA-Diameter measurement is greater than 60.0mm. This alert has not\\n been acknowledged.\\n Nb: This note was automatically generated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 847792,\n \"text\": \" 12:04 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for infiltrate\\n Admitting Diagnosis: CHEST PAIN,R/O MI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with pseudomonas on sputum culture\\n\\n REASON FOR THIS EXAMINATION:\\n Eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old man with pseudomonas of sputum culture. Pneumonia.\\n\\n TECHNIQUE: Portable AP chest radiograph.\\n\\n The comparison is made with the prior chest radiograph dated .\\n\\n FINDINGS: The patient is S/P CABG with median sternotomy. The heart is\\n normal in size. The mediastinal and hilar contours are within normal limit.\\n Again note is made of patchy consolidation in bilateral lower lobes medially,\\n slightly increased compared to the prior study. There is no evidence of\\n congestive heart failure.\\n\\n IMPRESSION: Increased bilateral lower lobe patchy consolidation, representing\\n pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-17 00:00:00.000\",\n \"description\": \"MRI CHEST/MEDIASTINUM W/O & W/CONTRAST\",\n \"row_id\": 847134,\n \"text\": \" 8:35 PM\\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n Reason: please evaluate aortic arch aneurysm\\n Admitting Diagnosis: CHEST PAIN,R/O MI\\n Contrast: MAGNEVIST Amt: 40CC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71m vasculopath with 3cm pseudoaneurysm on CTA\\n REASON FOR THIS EXAMINATION:\\n please evaluate aortic arch aneurysm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71 year old man with suspected aneurysm on aortic CTA.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained prior to and\\n after administration of IV gadolinium.\\n\\n Multiplanar reconstructions were obtained and viewed on a different\\n workstation.\\n\\n COMPARISON: CTA dated .\\n\\n FINDINGS: Within the inferior portion of the aortic arch, there are two\\n different small outpouchings of contrast from the lumen, the anterior one is\\n at the level of the left subclavian and measures 6 mm, and the second one is 1\\n cm posterior to this one and measures 9 x 9 mm. These inferior outpouchings\\n of contrast are surrounded by large polylobulated thrombus component,\\n measuring 4 x 3 x 2.5 cm. There is some thickening of the aortic wall at the\\n inferior portion of the arch around this outpouching. There is no evidence of\\n active bleeding, or free fluid. There are multiple irregularities in the\\n aortic wall throughout the entire thoracic and visualized portions of the\\n abdominal aorta.\\n\\n The arch vessels are patent. There is severe stenosis in the origin of the\\n brachiocephalic artery. Mild stenosis in the origin of the left carotid\\n artery and moderate stenosis in the origin of the left subclavian artery.\\n\\n The heart, pulmonary arteries and veins are unremarkable. There is no\\n significant lymphadenopathy.\\n\\n IMPRESSION: Two small areas of contrast outpouching from the aortic lumen at\\n the inferior portion of the aortic arch, surrounded by a large polylobulated\\n thrombus extending downwards to the level of the pulmonary artery. This most\\n likely represents an unusual appearance of a penetrating ulcer with large\\n exophytic thrombus component. There is no evidence of active bleeding or\\n leakage.\\n\\n The vague hyperattenuated signal within the lower aspect of the aortic arch\\n surrounding the ulcers is of uncertain significance. Blood products cannot be\\n definitely seen but small intramural hematoma cannot be excluded.\\n\\n (Over)\\n\\n 8:35 PM\\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n Reason: please evaluate aortic arch aneurysm\\n Admitting Diagnosis: CHEST PAIN,R/O MI\\n Contrast: MAGNEVIST Amt: 40CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-17 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C &RECONS\",\n \"row_id\": 847008,\n \"text\": \" 1:59 AM\\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: ro pe\\n Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with cp, sob. cough and elevated d-dimer with no acute process\\n on cxray but chronic interstitial changes-\\n REASON FOR THIS EXAMINATION:\\n ro pe\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 2:50 AM\\n no pe; aortic pseudoaneurysm; emphysema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: A 71-year-old male with chest pain, shortness of breath,\\n and cough.\\n\\n TECHNIQUE: Multidetector CT images of the chest prior to and following the\\n administration of 150 cc of Optiray. Non-ionic contrast was used due to the\\n rapid bolus infusion required for the CTA technique.\\n\\n Multiplanar reformatted images were created.\\n\\n CT CHEST WITHOUT AND WITH IV CONTRAST: The opacified pulmonary arterial tree\\n does not demonstrate any filling defects indicative of pulmonary embolus to\\n the level of the subsegmental pulmonary arteries bilaterally. There are\\n extensive atherosclerotic changes of the aorta, as well as a complex,\\n predominantly thrombosed 3.3 x 2.2 cm pseudoaneurysm or penetrating ulcer of\\n the aortic arch. There is no evidence of leak. The heart is normal in size.\\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\\n identified. The lung fields demonstrate diffuse emphysematous changes.\\n Limited evaluation of the upper abdomen reveals no gross abnormalities.\\n\\n IMPRESSION:\\n\\n 1. No evidence of pulmonary embolism.\\n 2. 3 cm partially thrombosed pseudoaneurysm or penetrating ulcer of the aortic\\n arch 2.5 cm distal to the left SCA.\\n 3. Diffuse emphysematous changes.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 115231,\n \"text\": \"Sinus rhythm with increase in rate as compared to the previous tracing\\nof . Low limb lead voltage. No diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 115232,\n \"text\": \"Sinus rhythm. Low limb lead voltage. Technically limited study. Compared to the\\nprevious tracing of the rate has slowed. Otherwise, no diagnostic\\ninterim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 115233,\n \"text\": \"Sinus rhythm. Since the previous tracing of the heart rate has\\ndecreased. Otherwise, no significant change in previously seen abnormalities.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 115234,\n \"text\": \"Sinus rhythm. Normal tracing as on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 847316,\n \"text\": \" 12:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n Admitting Diagnosis: CHEST PAIN,R/O MI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n History of chest pain.\\n\\n Status post CABG. Heart size is normal. No evidence for CHF. There is\\n flattening of the diaphragms secondary to emphysema. Linear atelectasis at\\n right lung base. No new pulmonary consolidation or pleural effusion.\\n\\n IMPRESSION: Emphysema and right basilar atelectasis but no evidence for\\n pneumonia or CHF.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-12-16 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 846990,\n \"text\": \" 9:01 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o pneumonia\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with productive cough and cp and sob ? xray 1 week pta\\n\\n REASON FOR THIS EXAMINATION:\\n r/o pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 71 y/o male with cough, chest pain, and shortness of breath.\\n\\n TECHNIQUE: PA & lateral chest.\\n\\n COMPARISON: .\\n\\n FINDINGS: Sternal wires and mediastinal clips are again noted. Cardiac and\\n mediastinal contours are stable and within normal limits. The pulmonary\\n vasculature is not engorged. There are unchanged interstitial changes of both\\n lungs, most marked at the bases. There are no pleural effusions. Osseous\\n structures are unremarkable.\\n\\n IMPRESSION: No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261811,\n \"text\": \"NURSING MICU NOTE 11P-7A\\n\\nPT 3, MAE, FOLLWOWS COMMANDS. PT DENIES ANY PAIN. PT C/O MILD HEARTBURN FROM DINNER. PT GIVEN 2 TUMS. PT SLEEP OUT MOST OF NIGHT. HR 80-90'S NSR. SBP 90-120'S PER NBP. AM LOPRESSOR AND HYDRALIZINE HELD. PT ALINE DAMPENED, 20POINT LOWER THAN NBP IN SAME ARM.\\nPT IS CALLED OUT TO FLOOR, TELE BED. AWAITINGBED ASSIGNMENT. PT IS A FULL CODE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261800,\n \"text\": \"pmicu nursing progress 7p-11p addendum\\n\\npt was finally permitted to eat and enjoyed a .his bp began to increase however and the esmolol was titrated up gradually to a max dose of 116 mcgs/kg/min (from 80), bp was still in the 120's-130/with pt dozing. no c/o chest pain. bp then dipped to the 90's and i've started to wean esmolol back down- goal bp is 100-110/ to protect aneurysm. pt is sleeping.plan is for cardiac cath on monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261801,\n \"text\": \"MICU Nursing Progress Note\\n Cardiac: on esomol infusion titrating to keep SBP 100-120 however it was requiring to increase esomol infusion without effecting the SBP which was running 120-136/... requiring doses of 150mcg/kg/min. Notified Dr. , Order from Dr. to give 10 mg of IV hydralazine, quickly weaned esomol then needed to stop IVF at 3am as BP down to 70/. slowly came up to 90/ during this time pt was fully mentating, producing urine from 70-90cc/hr. double checking BP with diamapp showed art line correctly BP in the right arm. there is a 40point difference between arms, left>right. Pt was on D5NS at 75cc/hr. stopped at 2 am. then restarted at 4:30 am to help BP will stop again once BP up above 100SBP. Pt denied feeling any CP, SOB, did c/o of back pain though with futher assessment pain located at the base of his spine, reliefed with change in position.\\n Respiratory: on Nasal cannula at 2 liters/min. BS diminshed at bases otherwise fine.\\n GI: abd soft, + BS no stool, able to take some POS will need to be NPO again for midnight on Sunday night for cath on monday.\\n GU: foley in place and draining well. urine yellow.\\n ID: afribile.\\n Neuro: A&O x 3, able to move in bed, on bedrest. no ambulating., clear speech. cooperative, pleasant gentleman.\\n IV access: two perpheral IV;s\\n Social: no contact with the family during the night.\\n Plan: to monitor closely, goal is to keep SBP 100-120/ cath on monday.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261798,\n \"text\": \"1900-0700\\n\\nNeuro: Pt awake/alert/oriented, follows commands well. MAEs. equal and reactive. No neuro deficits noted.\\n\\nResp: 2L NC on, resp easy and regular, O2sat 93-97%, Lungs clear with bibasilar diminished BS. Denies any SOB. No exertional dsypnea noted.\\n\\nCV: NSR without ectopy alarms on. HR 70-80, SBP controlled 90-115, MAP 60-70. Esmolol drip titrated prn, currently infusing @ 80 mcg/kg/min. Pt denies CP. MRI completed awaiting results for aortic arch aneurysm. Pulses to ext weak acquired with doppler. A line to R radial positional. No edema noted. Skin warm/dry/intact. Heparin SQ .\\n\\nGU/GI: Abd round soft + BS, pt c/o of hunger and thrist/remains NPO. No N/V. Protonix IV given. Foley to BSD draining yellow clear urine.\\n\\nIV: PIV x2, Lt hand, LLa.\\n\\neview MRI results, await consult of Dr. , ? surgery. Continue Esmolol for BP control.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261806,\n \"text\": \"FULL CODE Contact Precautions \\n\\n\\nNeuro: AAOx3, MAEx4 spont/command, moves self well in bed.\\n\\nCV: Pt had cardiac cath today, films reviewed by Drs and . They feel it's an intramural thrombu and not a pseudoanyeurysm and surgery is not required - follow medically. Pt has significant steonis in R brachial ceph artery attributing to the difference in the blood pressures in each arm. Based on central pressures during the procedure, a-line is 40mm lower than actual pressures. Nipride started to maintain SBP <120s, then surgical team rounded and want a-line SBP in 100s. Nipride currently at .7mcg/kgmin w/ SBP 100/63. Cath was done via L radial site and pressure clamp in place - to be removed at 1830. Good perfusion to L hand, 02sat monitor probe on L hand w/ good pleth. Pedal pulses + by doppler, extrems warm, no edema.\\n\\nResp: 2l n/p w/ 02 sat 98%, lung sound diminished throu-all fields. Congested cough, but non-productive.\\n\\nGI/GU: Abd soft, +BS, no BM. Taking cardiac diet. On H2B Foley cath w/ clear yellow urine.\\n\\nPain: No c/o discomfort.\\n\\nSkin: intact\\n\\nID: afebrile. No antibx\\n\\nAccess: PIV x3. R rad a-line\\n\\nSocial: Wife at bedside. Numerous family members have called.\\n\\nPlan: Nipride to maintain ABP in 100s. Clamp on L wrist to be d/c'd at 1830. Pain med prn for comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261807,\n \"text\": \"NURSING PROGRESS NOTE:\\nNEURO: PT ALERT AND ORIENTED X 3 AND MAE. C/O HA AND WAS WITH TYLENOL. NO C/O CHEST PAIN.\\n\\nRESP: PT HAS EXTREMELY CONGESTED COUGH AND LUNG SOUNDS COARSE THROUGHOUT. PT'S O2 SAT'S WHILE AWAKE ARE IN THE HIGH 90'S BUT WILL DROP TO THE HIGH 80'S WHEN ASLEEP. NC INCREASED WHILE SLEEPING TO 4L.\\nPT TAKES INHALERS SELF.\\n\\nCV: PT'S HR IN NSR WITHOUT ECTOPY WITH RATES IN THE 70'S TO THE 90'S. BP TITRTAED WITH NIPRIDE TO KEEP IN 80-100 RANGE VIA A-LINE. PT HAS RIGHT RADIAL ALINE WHICH IS WORKING WELL. LEFT RADIAL CATH SITE HAS DRESSING WHICH IS DRY AND INTACT. PT HAS PULSES. LEFT HAND ELEVATED ON PILLOW. PT IS AFEBRILE.\\n\\nGI: PT ON HOUSE DIET, ONLY LIQUIDS OVERNIGHT. ABD SOFT NONTENDER WITH POSITIVE BOWEL SOUNDS.\\n\\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF PINK TINGED TO YELLOW URINE WITH OCCASIONAL CLOTS.\\n\\nSKIN: INTACT.\\n\\nSOCIAL: WIFE VISITED AND CALLED OVERNIGHT AND HAS BEEN UPDATED. PT IS FULL CODE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261808,\n \"text\": \"NPN MICU-B 7AM-3PM\\nS/O: C/V: Continues on Nipride Gtt titrating to keep BP 80-100's as per A-line, @ present is on .75mcq/kq/min. Hydralazine increased to 50mg qd which was given @ 11am but with no effect as yet. HR- 70-80 SR with no ectopy noted. No c/'o's CP. L arm site has + pulses, also has + pedal pulses noted with doppler.\\n\\nRespir: Has congested cough but not productive, is on 2L NP with O2sats 95-99%, does desat with activity to 88-90%. L/S clear course @ bases.\\n\\nGI: Taking PO's well.\\n\\nGU: Having adequate u/o, per foley.\\n\\nID: no temps.\\n\\nNeuro: A&Ox3. Full code\\n\\nA/P: Continue to attempt to wean and d/c Nipride Gtt, monitor BP keep 80-100 as per A-line, is 40mm lower then L arm NBP, due to stenosis. Monitor I&O's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261809,\n \"text\": \"micu 1900-0700 rn notes\\n\\nneuro: A/Ox3,open eyes spont, MAE, follows commands. pain managment: c/o back pain, recieved TYLENOL w/relief.\\n\\nresp: NC 2L, sat96-99%, LS clear to wheezing w/respons to albut. Cough productive/strong\\n\\ncv: HR 76-91, NSR, no ectopy. NIRIDE off from , recieved 1 dose IV LOPRESSOR 10mg/HYDRALISINE 10mg d/t A-BP 140 w/respons, A-BP 90-130/50-60. Given PO DILTASEM 360mg. Plan: manage SBP 90-100.\\ncath on not shown aortic aneurism, but intramural trombus,that not operable by surgery,medical managment, performed PTCA to RCA\\n\\ngu/gi: foley,u/o >60cc/hr. Abd soft, + BS.\\n\\nid: afebrile.\\n\\nsocial:full code,no call from family this shift.\\n\\nplan: monitoring SBP 90-100, wean NIPRIDE gtt\\n transfer to the floor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261799,\n \"text\": \"pmicu nursing progress 7a-7p\\nreview of systems\\nCV-hr has been stable without ectopy noted.continues on esmolol at 80 mcgs/kg/min,this has not been changed, maintaining bp (via a-line) at ~100-120/.no c/o chest pain. cardiac US done--> pnd.has weak peripheral pulses.\\n\\nRESP_wearing 2 litres nasal cannula, no c/o SOB.lungs sound clear anteriorally.sats are >95%.\\n\\nGI-abd is soft with positive bowel sounds. pt is hungry! on famotidine.no stool today. has been npo for ? surgery.\\n\\nID-afebrile.wbc=11.3. no new cultures sent.\\n\\nNEURO-is alert and oriented x 3,cooperative. sleeping in naps.\\n\\nCOMFORT-c/o R \\\"tennis elbow\\\" pain.propped up on pillows with relief.\\n\\nF/E- maintainence ivf at 75/hr. has had an adequate urinary output of clear yellow urine.no peripheral edema noted.\\n\\nIV ACCESS-has peripheral heplocks and an a-line R wrist.\\n\\nSOCIAL-wife in room all day awaiting decision about possible surgery.has been updated with info as i know it.\\n\\na-stable.uneventful day\\n\\nP-will keep npo for now. awaiting cardiac to give word regarding possible surgery.continue with esmolol to keep bp <110.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261810,\n \"text\": \"MICU NPN 11AM-7PM:\\nPt is called out to the floor and may have his a-line d/c'd before transfer unless he goes to VICU bed where he may have the a-line transduced. See call out note for full report.\\n\\nNeuro: Pt denies pain. OOB to chair with minimal assist with lines/tubes. Denies pain.\\n\\nCV: Some BP meds held at some doses according to hold parameters. Pt began on PO lopressor 12.5mg PO BID at noon. His hydrochlorathiazide was held today as well as his 8AM and 8PM dose of hydralizine. He did get the 2PM dose of hydralizine but BP did get below 90 at times and UO dropped after this so hold parameter is 110. We are to follow his BP on his right arm.\\n\\nResp: Pt wanted to see if he could be off his O2 so he has spent the day on room air with O2 sats 92-95%. He does get DOE and has wheezes at times.\\n\\nGI: Appetite if only fair. No stool today.\\n\\nGU: UO dropped to 5cc/hr for two hours and pt given 500cc bolus NS at 6PM with some effect. Will follow UO closely and encourage PO's this evening. There is an order to d/c foley at midnight tonight in transfer to floor orders but this will need to be evaluated according to how well pt is urinating and if pt gets bed.\\n\\nPlan: Pt awaiting a bed assignment on the floor. Initially pt was to go to VICU bed but after discussion with the accepting team it was decided he could be transferred to the floor with telemetry. He is awaiting bed availability at present and will be transferred when it becomes available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261802,\n \"text\": \"NPN MICU-B 7AM-7PM\\nS/O: C/V: Remains off of Esmolol Gtt, with BP 90-128/55-68, HR-60-80's SR with no ectopy noted. No c/o's CP. Still a 40pt in BP difference between Left arm and R arm, with Left arm being greater. Team is aware and is going by the A-line which is in the Right arm. Has +pulses and lower extremities are warm and dry. Awaiting cath on Monday.\\n\\nRespir: O2 sats on 2lPN 98-100%, L/S clear to diminished @ bases. RR 20-26, no c/o's SOB.\\n\\nGI: Taking PO's with just mild appetite. On IFV's D5NS @ 75cc/hr. soft with +BS's.\\n\\nGU: U/O very adequate. No c/o's.\\n\\nNeuro: A&Ox3. C/O back pain this AM from lying in bed, rec'd Tylenol with relief.\\n\\nSocial: Family in visiting all day, very pleasant and supportive.\\n\\nA/P: Monitor BP maintain between 100-120/60, assess I&O's, assess c/o's CP. Prepare cath on Monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261803,\n \"text\": \"micu 1900-0700 RN notes\\n\\nneuro: AOx3, open eyes spont, follows commands. PERL. pain management: c/o back pain recieved PO TYLENOL 650mg w/relief\\n\\nresp: NC 2L, sat 95-99%, RR 16-20, LS coarse/clear, productive cough w/secretion. sputum sent to culture. intermittent epidose to Sats 80's with wheezes recieved AlB neb and routine inhalers with improvement.\\n\\ncv: HR 72-82,NSR, no ectopy, A-BP 80-120 labile, BP differant R side from L side by 40 points, off ESMOLOL, recieved PO DILTIAZEM and HYDROCHLORTIASIDE, goal SBP> 100 MAPS >60. Morning labs pending\\n\\ngu/gi: foley, u/o>60/hr. abd soft ,+BS\\n\\nsocial: full code status, family visites, updates\\n\\nplan:cath on Monday\\n surgery on Tuesday\\n monitoring BP>100\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261804,\n \"text\": \"NPN MICU-B 7AM-7PM\\nS/O: C/V: Remains off of Esmolol Gtt with BP's 100-136/60, HR 70-80's SR with no ectopy noted. No c/o's CP. Started on IVF D5 with 20KCL @ 60cc/hr. C/O back pain due to lying in bed, relieved with Tylenol 650mg PO. Awaiting cath in the AM. Remains on PO Dilt and HCT.\\n\\nRespir: O2L NP with O2 sats 97-100%, L/S clear no wheezes noted but does have occ congested sounding cough. No SOB.\\n\\nGI: Taking PO's in small amts, to be NPO this evening for cath in the AM. Had very lrge soft brown OB neg stool.\\n\\nGU: U/O very good, clear yellow urine.\\n\\nNeuro: A&Ox3.\\n\\nIV lines: New # 18 angio placed in Left A/C, with 3d old #20 remains in Left wrist. A-line still in R arm.\\n\\nA/P: Continue to monitor BP, attempt to keep >130. Prepare for Cath. Monitor I&O's, keep NPO after MN.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2161-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1261805,\n \"text\": \"micu 1900-0700 RN notes\\n\\nneuro: A/Ox3, MAE,PERL. Pain Managment: c/o lower back pain, recieved po TYLENOL 650mg w/relief\\n\\nresp: RR 18-24 NC 2L, sat 98-99%, LS clear, cough strong/productive\\n\\ncv: HR 65-85 NSR, no ectopy. A-BP 80-140/50-60, (40 point discrepancy NBP L-R). Remain off ESMOLOL. IV D5 w/KCL @ 60cc/hr, recieved routine DILT/HTZ. recieved Acetylcystein 600mg @0600 for cath. labs morning pending\\n\\ngu/gi: foley, u/o >60cc/hr, abd soft, +BS, no BM. NPO from midnight\\n\\nid: afebrile, Tmax 98.9\\n\\nsocial: full code. Wife called/updated\\n\\nplan: cath in the AM, plan for surgery on \\n pre/post cath ACETYLCESTEIN 600mg\\n monitoring BP\\n\\n\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24986,"cells":{"subject_id":{"kind":"number","value":31809,"string":"31,809"},"hadm_id":{"kind":"number","value":138978,"string":"138,978"},"target_text":{"kind":"string","value":"Patient is a 39 yo male with a h/o Lyme disease who presents with fevers, chest tightness, abdominal pain, and shortness of breath, and was found to have cardiac tamponade. . # Pericardial Effusion: Patient presented with chest tightness and shortness of breath. CXR demonstrated enlarged cardiac silhouette, and subsequent TTE showed a large pericardial effusion with right atrial collapse. Patient had a pericardialcentesis with 900 cc fluid drained. Fluid was sent for analysis and was found to have 4600 WBC. Gm stain and cultures were all negative. Labs were sent for TB, , ds-DNA, Lyme, and Babesiosis, which were all negative. Thyroid hormones were also within normal limits. The patient had two repeat ECHOs during this hospitalization, which both showed resolution of the tamponade physiology. The patient was discharged with close outpatient follow-up in the clinic. . # Fevers: Patient had persistent fevers since the end of . Serologies for Lyme, Borellia, and Histoplamosis were all negative. Patient's fevers were persistently ~ 102 F prior to admission. During this admission, the patient spiked a fever on day of admission but was afebrile 24 hours prior to discharge. He was discharged with close outpatient follow-up."},"extractive_notes_summ":{"kind":"string","value":"Marked diffuse adrenal enlargement. Marked diffuse adrenal enlargement. Physiologic TR.PERICARDIUM: Small to moderate pericardial effusion. Moderate pericardial effusion with enhancing pericardium. Moderate pericardial effusion with enhancing pericardium. Sustained RA diastolic collapse, c/wlow filling pressures or early tamponade.Conclusions:The left atrium is moderately dilated. Small left and tiny right pleural effusions. Small left and tiny right pleural effusions. Small left and tiny right pleural effusions. Normal ascending aorta diameter. There is atrivial/physiologic pericardial effusion. There is a small pericardial effusion. Noechocardiographic signs of tamponade.GENERAL COMMENTS: Left pleural effusion.Conclusions:Regional left ventricular wall motion is normal. There are noechocardiographic signs of tamponade.Compared with the prior study (images reviewed) of , the findings aresimilar. No AR.PERICARDIUM: Small pericardial effusion. No echocardiographic signs oftamponade.Conclusions:The left atrium is mildly dilated. There is a small to moderate sized pericardialeffusion. FINAL REPORT REASON FOR EXAM: Pericardial effusion. Prominentmoderator band/trabeculations are noted in the RV apex.AORTIC VALVE: No AR.MITRAL VALVE: Normal mitral valve leaflets. Trivialmitral regurgitation is seen. doxycyline d/c'd - ? The aortic root is mildly dilated at the sinus level. There is noventricular septal defect. Left lower lobe atelectasis or pneumonic consolidation. No tamponade.Compared with the prior study (images reviewed) of , the largepericardial effusion has nearly resolved. Enlarged cardiac silhouette has slightly decreased. Enlarged cardiac silhouette has slightly decreased. Small right and moderate left pleural effusions are unchanged. Small right and moderate left pleural effusions are unchanged. The aortic root ismildly dilated at the sinus level. Anterior to the right atrium and distalright ventricular free wall, it measures up to 0.8 cm in diameter. Pleural effusions are small on the left and tiny on the right, with adjacent atelectasis. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. FINAL REPORT REASON FOR EXAM: PERICARDIAL AND PLEURAL EFFUSIONS in followup Cardiac silhouette has slightly decreased in size. Marked adrenal hyperplasia. The left upper lung and right lung are well aerated. venous cath site with small dime sized soft hematoma. Serial evaluation 18 hrs s/p pericardiocentesis.Height: (in) 68Weight (lb): 160BSA (m2): 1.86 m2BP (mm Hg): 116/74HR (bpm): 88Status: InpatientDate/Time: at 09:00Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No PS.Physiologic PR.PERICARDIUM: Large pericardial effusion. appearing slightly dyspneic when talking.ID: TM 102po. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Small and large bowel have a normal caliber. Sinus tachycardia. effusion req. The pericardium enhances diffusely. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Contrast reaches the colon. Small right and small-to-moderate left pleural effusions are stable. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 68Weight (lb): 180BSA (m2): 1.96 m2BP (mm Hg): 112/68HR (bpm): 88Status: InpatientDate/Time: at 13:37Test: Portable TTE (Focused views)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal regional LV systolic function. Moderate to large pericardial effusion with pericardial enhancement, a finding that suggests infectious, inflammatory, or neoplastic cause. A few tiny calcified nodules are seen in the atelectatic portions of the lung at the bases. Improved left lower lobe atelectasis. Left lower lobe retrocardiac opacity likely atelectasis has worsened. Left lower lobe retrocardiac opacity likely atelectasis has worsened. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). There is sustained rightatrial collapse, consistent with low filling pressures or early tamponade.IMPRESSION: Large pericardial effusion with echocardiographic signs of earlytamponade.Cardiology consult team was present at the time of study interpretation. The aorta demonstrates a normal course and caliber. FINDINGS: CHEST: A pericardial effusion is moderate to large in size. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Normal aortic valve leaflets (3). Febrile; History of Lyme.Height: (in) 68Weight (lb): 185BSA (m2): 1.98 m2BP (mm Hg): 135/71HR (bpm): 100Status: InpatientDate/Time: at 15:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%decrease during respiration (estimated RA pressure (10-20mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. pulses palp. This is worrisome for pericardial effusion. Admitting Diagnosis: PERICARDIAL TAMPONADE Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated. SC heparin .A/P: s/p pericard. S/P pericardiocentesis.Height: (in) 68Weight (lb): 160BSA (m2): 1.86 m2BP (mm Hg): 107/80HR (bpm): 106Status: InpatientDate/Time: at 19:19Test: TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Trivial/physiologic pericardial effusion. had chest tightness and SOB, worsening- went to ED.ED CXR showing markedly enlarged silhouette. There has been interval increase in small right and moderate left pleural effusion. Right ventricular chamber size and free wall motionare normal. sat up to void. Increased bilateral pleural effusions are small on the right, moderate on the left. Increased bilateral pleural effusions are small on the right, moderate on the left. Possible PR segment depression seen in leads II and V5.Poor R wave progression across the precordium. IMPRESSION: Striking interval enlargement of the cardiac silhouette, concerning for pericardial effusion. There is mild symmetric left ventricular hypertrophy with normalcavity size and regional/global systolic function (LVEF>55%). Soft tissue attenuation infiltrates the anterior mediastinum, without evidence of mass effect. BP 110-120's/ c/o chest pain only with deep inspiration. placed on antibiotics but contin."},"n_notes":{"kind":"number","value":16,"string":"16"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2179-10-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1029840,"text":" 12:25 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\n effusions\n REASON FOR THIS EXAMINATION:\n please assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 5:23 PM\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\n right and moderate left pleural effusions are unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: PERICARDIAL AND PLEURAL EFFUSIONS in followup\n\n Cardiac silhouette has slightly decreased in size. Improved left lower lobe\n atelectasis. Small right and small-to-moderate left pleural effusions are\n stable. No overt CHF or pneumonia.\n\n DR. \n"},{"category":"Radiology","chartdate":"2179-10-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1029841,"text":", H. 12:25 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\n effusions\n REASON FOR THIS EXAMINATION:\n please assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\n right and moderate left pleural effusions are unchanged.\n\n"},{"category":"Echo","chartdate":"2179-10-01 00:00:00.000","description":"Report","row_id":84039,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Serial evaluation 18 hrs s/p pericardiocentesis.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 116/74\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 09:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. There is a small pericardial effusion. The effusion\nis echo dense, consistent with blood, inflammation or other cellular elements.\nThere are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"},{"category":"Echo","chartdate":"2179-10-02 00:00:00.000","description":"Report","row_id":84030,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 112/68\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 13:37\nTest: Portable TTE (Focused views)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion echo dense, c/w\nblood, inflammation or other cellular elements. Effusion is loculated.\nStranding is visualized within the pericardial space c/w organization. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is a small to moderate sized pericardial\neffusion. The effusion is echo dense, consistent with blood, inflammation or\nother cellular elements. The effusion is largest adjacent to the basal to mid\ninferolateral wall (measures 1.4 cm). Anterior to the right atrium and distal\nright ventricular free wall, it measures up to 0.8 cm in diameter. Stranding\nis visualized within the pericardial space c/w organization. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"},{"category":"Echo","chartdate":"2179-09-30 00:00:00.000","description":"Report","row_id":84031,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Febrile; History of Lyme.\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 135/71\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%\ndecrease during respiration (estimated RA pressure (10-20mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. Sustained RA diastolic collapse, c/w\nlow filling pressures or early tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and regional/global systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is a large pericardial effusion. There is sustained right\natrial collapse, consistent with low filling pressures or early tamponade.\n\nIMPRESSION: Large pericardial effusion with echocardiographic signs of early\ntamponade.\n\nCardiology consult team was present at the time of study interpretation.\n\n\n"},{"category":"Echo","chartdate":"2179-09-30 00:00:00.000","description":"Report","row_id":84040,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/P pericardiocentesis.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 107/80\nHR (bpm): 106\nStatus: Inpatient\nDate/Time: at 19:19\nTest: TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Emergency study performed\nby the cardiology fellow on call.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There is a\ntrivial/physiologic pericardial effusion. There are no echocardiographic signs\nof tamponade.\n\nIMPRESSION: Trivial pericardial effusion. No tamponade.\n\nCompared with the prior study (images reviewed) of , the large\npericardial effusion has nearly resolved.\n\n\n"},{"category":"Radiology","chartdate":"2179-09-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1029186,"text":" 1:34 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with fever for weeks\n REASON FOR THIS EXAMINATION:\n eval for acute change\n ______________________________________________________________________________\n WET READ: 2:17 PM\n Striking increase in heart size since , w/increased retrocardiac\n opacity, concerning for pericardial effusion/\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man with fever for weeks.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: Since the prior radiograph, there has been\n a striking enlargement in heart size, with an increase in retrocardiac\n opacity. This is worrisome for pericardial effusion. There is also\n increased opacity at the left lung base, which could represent left lower\n lobe atelectasis or a pneumonic consolidation.\n\n There is no right pleural effusion. The left upper lung and right lung are\n well aerated. There is no pneumothorax. There does not appear to be hilar\n enlargement. Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Striking interval enlargement of the cardiac silhouette,\n concerning for pericardial effusion. Echocardiogram is recommended, and\n cross- sectional imaging could provide further information. Left lower lobe\n atelectasis or pneumonic consolidation.\n\n"},{"category":"Radiology","chartdate":"2179-10-02 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1029622,"text":" 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion\n REASON FOR THIS EXAMINATION:\n Please assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 3:11 PM\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\n opacity likely atelectasis has worsened. Increased bilateral pleural\n effusions are small on the right, moderate on the left.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Pericardial effusion.\n\n Comparison is made with prior study, .\n\n Increased cardiac silhouette is stable. There has been interval increase in\n small right and moderate left pleural effusion. Left lower lobe retrocardiac\n atelectasis has increased.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2179-10-02 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1029623,"text":", H. 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion\n REASON FOR THIS EXAMINATION:\n Please assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\n opacity likely atelectasis has worsened. Increased bilateral pleural\n effusions are small on the right, moderate on the left.\n\n\n"},{"category":"Radiology","chartdate":"2179-10-02 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1029668,"text":" 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with several months of intermittant fevers, presenting with\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n please evaluate for malignancy, lymph node changes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWic SAT 8:55 PM\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\n would include infectious, inflammatory, and neoplastic etiologies.\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\n adrenal infiltration, for example secondary to tuberculosis, other\n granulomatous diseases, or rare disease such as Erdheim- disease.\n 3. Small left and tiny right pleural effusions.\n 4. Several calcified granulomata in the lung bases.\n 5. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding from adjacent pericarditis or residual thymus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male with fever and pericardial effusion.\n\n TECHNIQUE: CT images were acquired through the chest, abdomen, and pelvis\n after the administration of intravenous contrast. No priors available for\n comparison.\n\n FINDINGS:\n\n CHEST: A pericardial effusion is moderate to large in size. The pericardium\n enhances diffusely. Pleural effusions are small on the left and tiny on the\n right, with adjacent atelectasis. A few tiny calcified nodules are seen in\n the atelectatic portions of the lung at the bases. Soft tissue attenuation\n infiltrates the anterior mediastinum, without evidence of mass effect.\n Mediastinal and axillary lymph nodes are not enlarged by CT criteria. The\n aorta demonstrates a normal course and caliber. No large or central pulmonary\n emboli are demonstrated.\n\n ABDOMEN: A 7-mm low-attenuation lesion in segment VIII (image 2:46) of the\n liver is too small to further characterize. The spleen, pancreas,\n gallbladder, and kidneys demonstrate no focal lesions. The adrenal glands are\n markedly enlarged bilaterally and diffusely. Small and large bowel have a\n normal caliber. Retroperitoneal lymph nodes are not enlarged by CT criteria.\n\n PELVIS: The prostate, seminal vesicles, and urinary bladder appear within\n normal limits. Contrast reaches the colon. Pelvic and inguinal lymph nodes\n are not enlarged.\n (Over)\n\n 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated.\n\n IMPRESSION:\n 1. Moderate to large pericardial effusion with pericardial enhancement, a\n finding that suggests infectious, inflammatory, or neoplastic cause.\n 2. Small left and tiny right pleural effusions.\n 3. Marked adrenal hyperplasia. The differential diagnosis would include\n congenital adrenal hyperplasia, and, in the setting of the associated findings\n described above, other entities such as tuberculosis, other granulomatous\n disease, or rare entities such as Erdheim- disease.\n 4. Several tiny calcified granulomata in the lung bases, consistent with\n prior granulomatous disease such as tuberculosis.\n 5. Tiny hepatic lesions, too small to further characterize.\n 6. Stranding in the subcutaneous fat of the right groin, likely due to prior\n percutaneous vascular access.\n 7. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding, perhaps secondary to adjacent pericarditis. Residual\n thymus may also contribute.\n\n"},{"category":"Radiology","chartdate":"2179-10-02 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1029669,"text":", H. 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with several months of intermittant fevers, presenting with\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n please evaluate for malignancy, lymph node changes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\n would include infectious, inflammatory, and neoplastic etiologies.\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\n adrenal infiltration, for example secondary to tuberculosis, other\n granulomatous diseases, or rare disease such as Erdheim- disease.\n 3. Small left and tiny right pleural effusions.\n 4. Several calcified granulomata in the lung bases.\n 5. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding from adjacent pericarditis or residual thymus.\n\n"},{"category":"Nursing/other","chartdate":"2179-10-01 00:00:00.000","description":"Report","row_id":1666632,"text":"CCU NPN 1900-0700\nS: \" I can tell my temp is up \"\nO: 39 yo male admitted from cath lab s/p pericardiocentesis.\ndeveloped fevers, joint aches in . placed on antibiotics but contin. with fevers (hx of lyme dz)- lyme serology neg. In - fevers up to 102, neck stiffness, palps. doxycyline d/c'd - ? reaction. This week, pt. had chest tightness and SOB, worsening- went to ED.\nED CXR showing markedly enlarged silhouette. echo- showing large pericardial effusion and RA collapse. cath lab - 1L SS fluid removed.\n\nArrived to CCU ~ 1900. awake, alert. Ox3. c/o chest pain with deep inspiration.\nCV: pericardial drain mid chest- site D/I. transparent dressing intact. bag to gravity drainage. aspirated 1-4 cc seroussang fluid q4hr. ~ 75cc in bag at MN.\nHR 90's ST. no VEA. BP 110-120's/ c/o chest pain only with deep inspiration. no palps.\n\nright fem. venous cath site with small dime sized soft hematoma. pt. sat up to void. no change in site. pulses palp. no pain in area or in back.\n\nResp: LS diminished bases. sats 91-95% on RA. pt. appearing slightly dyspneic when talking.\nID: TM 102po. tylenol q6hr. BC, pericardial cultures pnd. ID consult planned.\n\nGU: voiding with urinal.\nGI: drinking water and snacking on cookies he had in bag from home.\naccess: PIV x1. SC heparin .\nA/P: s/p pericard. effusion req. drain - ID to follow. follow up on cultures, tylenol prn. follow fever curve. PPD to be placed.\n\n"},{"category":"Nursing/other","chartdate":"2179-10-01 00:00:00.000","description":"Report","row_id":1666633,"text":"CCU NURSING NOTE 0700-1900\nS/O: SEE TRANSFER SUMMARY/SEE CCU FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nCV: VSS, PERICARDIAL DRAIN W/O SIGNIFICANT DRAINAGE THROUGHOUT DAY, PULSUS PARADOX 8 THIS AM, ECHO DONE W/O SIG CHANGE, PERICARDIAL DRAIN D/C'D AT 1400, TOLERATED WELL, PT CONTINUES TO HAVE DISCOMFORT IN CHEST WHICH HAS PERSISTED SINCE PRIOR TO ADMISSION, DOES NOT FEEL HE IS NEED OF PAIN MEDICATION; TAKING TYLENOL FOR TEMPERATURES UP TO 100.4 PO; ID FOLLOWING PATIENT, NOT ON ANTIBX PRESENTLY; AWAITING LAB RESULTS ON PERICARDIAL FLUID/BLOOD/URINE. OOB TO CHAIR AFTER DRAIN PULLED, TOLERATED WELL, R FEM SHEATH SITE, DRAIN SITE D+I, PERIPH PULSES PALP BILAT; MOTHER CALLED FROM - WILL CALL PT LATER THIS EVENING, PT CALLED OUT, AWAITING BED AVAILABILITY FOR TRANSFER TO 3.\n\n\n"},{"category":"ECG","chartdate":"2179-10-01 00:00:00.000","description":"Report","row_id":226648,"text":"No significant change compared to tracing #2.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2179-09-30 00:00:00.000","description":"Report","row_id":226649,"text":"No significant change compared to tracing #1 except for taller R waves in\nleads V4-V6, possibly again related to lead placement.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2179-09-30 00:00:00.000","description":"Report","row_id":226650,"text":"Sinus tachycardia. Possible PR segment depression seen in leads II and V5.\nPoor R wave progression across the precordium. No previous tracing available\nfor comparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1029840,\n \"text\": \" 12:25 PM\\n CHEST (PA & LAT) Clip # \\n Reason: please assess interval change\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\\n effusions\\n REASON FOR THIS EXAMINATION:\\n please assess interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 5:23 PM\\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\\n right and moderate left pleural effusions are unchanged.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: PERICARDIAL AND PLEURAL EFFUSIONS in followup\\n\\n Cardiac silhouette has slightly decreased in size. Improved left lower lobe\\n atelectasis. Small right and small-to-moderate left pleural effusions are\\n stable. No overt CHF or pneumonia.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1029841,\n \"text\": \", H. 12:25 PM\\n CHEST (PA & LAT) Clip # \\n Reason: please assess interval change\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\\n effusions\\n REASON FOR THIS EXAMINATION:\\n please assess interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\\n right and moderate left pleural effusions are unchanged.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2179-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84039,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. Serial evaluation 18 hrs s/p pericardiocentesis.\\nHeight: (in) 68\\nWeight (lb): 160\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 116/74\\nHR (bpm): 88\\nStatus: Inpatient\\nDate/Time: at 09:00\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\\ninflammation or other cellular elements. No echocardiographic signs of\\ntamponade.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF >55%). There is no\\nventricular septal defect. Right ventricular chamber size and free wall motion\\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\\nno aortic regurgitation. There is a small pericardial effusion. The effusion\\nis echo dense, consistent with blood, inflammation or other cellular elements.\\nThere are no echocardiographic signs of tamponade.\\n\\nCompared with the prior study (images reviewed) of , no change.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2179-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84030,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion.\\nHeight: (in) 68\\nWeight (lb): 180\\nBSA (m2): 1.96 m2\\nBP (mm Hg): 112/68\\nHR (bpm): 88\\nStatus: Inpatient\\nDate/Time: at 13:37\\nTest: Portable TTE (Focused views)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\\n(>55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\\nmoderator band/trabeculations are noted in the RV apex.\\n\\nAORTIC VALVE: No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\\n\\nPERICARDIUM: Small to moderate pericardial effusion. Effusion echo dense, c/w\\nblood, inflammation or other cellular elements. Effusion is loculated.\\nStranding is visualized within the pericardial space c/w organization. No\\nechocardiographic signs of tamponade.\\n\\nGENERAL COMMENTS: Left pleural effusion.\\n\\nConclusions:\\nRegional left ventricular wall motion is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\\nfree wall motion are normal. No aortic regurgitation is seen. The mitral valve\\nleaflets are structurally normal. There is no mitral valve prolapse. Trivial\\nmitral regurgitation is seen. There is a small to moderate sized pericardial\\neffusion. The effusion is echo dense, consistent with blood, inflammation or\\nother cellular elements. The effusion is largest adjacent to the basal to mid\\ninferolateral wall (measures 1.4 cm). Anterior to the right atrium and distal\\nright ventricular free wall, it measures up to 0.8 cm in diameter. Stranding\\nis visualized within the pericardial space c/w organization. There are no\\nechocardiographic signs of tamponade.\\n\\nCompared with the prior study (images reviewed) of , the findings are\\nsimilar.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2179-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84031,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. Febrile; History of Lyme.\\nHeight: (in) 68\\nWeight (lb): 185\\nBSA (m2): 1.98 m2\\nBP (mm Hg): 135/71\\nHR (bpm): 100\\nStatus: Inpatient\\nDate/Time: at 15:55\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%\\ndecrease during respiration (estimated RA pressure (10-20mmHg).\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\\nsystolic function (LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Large pericardial effusion. Sustained RA diastolic collapse, c/w\\nlow filling pressures or early tamponade.\\n\\nConclusions:\\nThe left atrium is moderately dilated. The estimated right atrial pressure is\\n10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal\\ncavity size and regional/global systolic function (LVEF>55%). Right\\nventricular chamber size and free wall motion are normal. The aortic root is\\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\\nstructurally normal with good leaflet excursion and no aortic regurgitation.\\nThe mitral valve appears structurally normal with trivial mitral\\nregurgitation. There is a large pericardial effusion. There is sustained right\\natrial collapse, consistent with low filling pressures or early tamponade.\\n\\nIMPRESSION: Large pericardial effusion with echocardiographic signs of early\\ntamponade.\\n\\nCardiology consult team was present at the time of study interpretation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2179-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84040,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. S/P pericardiocentesis.\\nHeight: (in) 68\\nWeight (lb): 160\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 107/80\\nHR (bpm): 106\\nStatus: Inpatient\\nDate/Time: at 19:19\\nTest: TTE (Focused views)\\nDoppler: No Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT VENTRICLE: Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\\nsigns of tamponade.\\n\\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Emergency study performed\\nby the cardiology fellow on call.\\n\\nConclusions:\\nOverall left ventricular systolic function is normal (LVEF>55%). Right\\nventricular chamber size and free wall motion are normal. There is a\\ntrivial/physiologic pericardial effusion. There are no echocardiographic signs\\nof tamponade.\\n\\nIMPRESSION: Trivial pericardial effusion. No tamponade.\\n\\nCompared with the prior study (images reviewed) of , the large\\npericardial effusion has nearly resolved.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-09-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1029186,\n \"text\": \" 1:34 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for acute change\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with fever for weeks\\n REASON FOR THIS EXAMINATION:\\n eval for acute change\\n ______________________________________________________________________________\\n WET READ: 2:17 PM\\n Striking increase in heart size since , w/increased retrocardiac\\n opacity, concerning for pericardial effusion/\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 39-year-old man with fever for weeks.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL VIEWS OF THE CHEST: Since the prior radiograph, there has been\\n a striking enlargement in heart size, with an increase in retrocardiac\\n opacity. This is worrisome for pericardial effusion. There is also\\n increased opacity at the left lung base, which could represent left lower\\n lobe atelectasis or a pneumonic consolidation.\\n\\n There is no right pleural effusion. The left upper lung and right lung are\\n well aerated. There is no pneumothorax. There does not appear to be hilar\\n enlargement. Soft tissue and osseous structures are unremarkable.\\n\\n IMPRESSION: Striking interval enlargement of the cardiac silhouette,\\n concerning for pericardial effusion. Echocardiogram is recommended, and\\n cross- sectional imaging could provide further information. Left lower lobe\\n atelectasis or pneumonic consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-02 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1029622,\n \"text\": \" 9:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Please assess interval change\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with pericardial effusion\\n REASON FOR THIS EXAMINATION:\\n Please assess interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 3:11 PM\\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\\n opacity likely atelectasis has worsened. Increased bilateral pleural\\n effusions are small on the right, moderate on the left.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Pericardial effusion.\\n\\n Comparison is made with prior study, .\\n\\n Increased cardiac silhouette is stable. There has been interval increase in\\n small right and moderate left pleural effusion. Left lower lobe retrocardiac\\n atelectasis has increased.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-02 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1029623,\n \"text\": \", H. 9:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Please assess interval change\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with pericardial effusion\\n REASON FOR THIS EXAMINATION:\\n Please assess interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\\n opacity likely atelectasis has worsened. Increased bilateral pleural\\n effusions are small on the right, moderate on the left.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-02 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1029668,\n \"text\": \" 1:53 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: please evaluate for malignancy, lymph node changes.\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with several months of intermittant fevers, presenting with\\n pericardial effusion.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for malignancy, lymph node changes.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWic SAT 8:55 PM\\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\\n would include infectious, inflammatory, and neoplastic etiologies.\\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\\n adrenal infiltration, for example secondary to tuberculosis, other\\n granulomatous diseases, or rare disease such as Erdheim- disease.\\n 3. Small left and tiny right pleural effusions.\\n 4. Several calcified granulomata in the lung bases.\\n 5. Soft tissue attenuation in the anterior mediastinum may represent\\n inflammatory stranding from adjacent pericarditis or residual thymus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 39-year-old male with fever and pericardial effusion.\\n\\n TECHNIQUE: CT images were acquired through the chest, abdomen, and pelvis\\n after the administration of intravenous contrast. No priors available for\\n comparison.\\n\\n FINDINGS:\\n\\n CHEST: A pericardial effusion is moderate to large in size. The pericardium\\n enhances diffusely. Pleural effusions are small on the left and tiny on the\\n right, with adjacent atelectasis. A few tiny calcified nodules are seen in\\n the atelectatic portions of the lung at the bases. Soft tissue attenuation\\n infiltrates the anterior mediastinum, without evidence of mass effect.\\n Mediastinal and axillary lymph nodes are not enlarged by CT criteria. The\\n aorta demonstrates a normal course and caliber. No large or central pulmonary\\n emboli are demonstrated.\\n\\n ABDOMEN: A 7-mm low-attenuation lesion in segment VIII (image 2:46) of the\\n liver is too small to further characterize. The spleen, pancreas,\\n gallbladder, and kidneys demonstrate no focal lesions. The adrenal glands are\\n markedly enlarged bilaterally and diffusely. Small and large bowel have a\\n normal caliber. Retroperitoneal lymph nodes are not enlarged by CT criteria.\\n\\n PELVIS: The prostate, seminal vesicles, and urinary bladder appear within\\n normal limits. Contrast reaches the colon. Pelvic and inguinal lymph nodes\\n are not enlarged.\\n (Over)\\n\\n 1:53 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: please evaluate for malignancy, lymph node changes.\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated.\\n\\n IMPRESSION:\\n 1. Moderate to large pericardial effusion with pericardial enhancement, a\\n finding that suggests infectious, inflammatory, or neoplastic cause.\\n 2. Small left and tiny right pleural effusions.\\n 3. Marked adrenal hyperplasia. The differential diagnosis would include\\n congenital adrenal hyperplasia, and, in the setting of the associated findings\\n described above, other entities such as tuberculosis, other granulomatous\\n disease, or rare entities such as Erdheim- disease.\\n 4. Several tiny calcified granulomata in the lung bases, consistent with\\n prior granulomatous disease such as tuberculosis.\\n 5. Tiny hepatic lesions, too small to further characterize.\\n 6. Stranding in the subcutaneous fat of the right groin, likely due to prior\\n percutaneous vascular access.\\n 7. Soft tissue attenuation in the anterior mediastinum may represent\\n inflammatory stranding, perhaps secondary to adjacent pericarditis. Residual\\n thymus may also contribute.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2179-10-02 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1029669,\n \"text\": \", H. 1:53 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: please evaluate for malignancy, lymph node changes.\\n Admitting Diagnosis: PERICARDIAL TAMPONADE\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old man with several months of intermittant fevers, presenting with\\n pericardial effusion.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for malignancy, lymph node changes.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\\n would include infectious, inflammatory, and neoplastic etiologies.\\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\\n adrenal infiltration, for example secondary to tuberculosis, other\\n granulomatous diseases, or rare disease such as Erdheim- disease.\\n 3. Small left and tiny right pleural effusions.\\n 4. Several calcified granulomata in the lung bases.\\n 5. Soft tissue attenuation in the anterior mediastinum may represent\\n inflammatory stranding from adjacent pericarditis or residual thymus.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1666632,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" I can tell my temp is up \\\"\\nO: 39 yo male admitted from cath lab s/p pericardiocentesis.\\ndeveloped fevers, joint aches in . placed on antibiotics but contin. with fevers (hx of lyme dz)- lyme serology neg. In - fevers up to 102, neck stiffness, palps. doxycyline d/c'd - ? reaction. This week, pt. had chest tightness and SOB, worsening- went to ED.\\nED CXR showing markedly enlarged silhouette. echo- showing large pericardial effusion and RA collapse. cath lab - 1L SS fluid removed.\\n\\nArrived to CCU ~ 1900. awake, alert. Ox3. c/o chest pain with deep inspiration.\\nCV: pericardial drain mid chest- site D/I. transparent dressing intact. bag to gravity drainage. aspirated 1-4 cc seroussang fluid q4hr. ~ 75cc in bag at MN.\\nHR 90's ST. no VEA. BP 110-120's/ c/o chest pain only with deep inspiration. no palps.\\n\\nright fem. venous cath site with small dime sized soft hematoma. pt. sat up to void. no change in site. pulses palp. no pain in area or in back.\\n\\nResp: LS diminished bases. sats 91-95% on RA. pt. appearing slightly dyspneic when talking.\\nID: TM 102po. tylenol q6hr. BC, pericardial cultures pnd. ID consult planned.\\n\\nGU: voiding with urinal.\\nGI: drinking water and snacking on cookies he had in bag from home.\\naccess: PIV x1. SC heparin .\\nA/P: s/p pericard. effusion req. drain - ID to follow. follow up on cultures, tylenol prn. follow fever curve. PPD to be placed.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2179-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1666633,\n \"text\": \"CCU NURSING NOTE 0700-1900\\nS/O: SEE TRANSFER SUMMARY/SEE CCU FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\\n\\nCV: VSS, PERICARDIAL DRAIN W/O SIGNIFICANT DRAINAGE THROUGHOUT DAY, PULSUS PARADOX 8 THIS AM, ECHO DONE W/O SIG CHANGE, PERICARDIAL DRAIN D/C'D AT 1400, TOLERATED WELL, PT CONTINUES TO HAVE DISCOMFORT IN CHEST WHICH HAS PERSISTED SINCE PRIOR TO ADMISSION, DOES NOT FEEL HE IS NEED OF PAIN MEDICATION; TAKING TYLENOL FOR TEMPERATURES UP TO 100.4 PO; ID FOLLOWING PATIENT, NOT ON ANTIBX PRESENTLY; AWAITING LAB RESULTS ON PERICARDIAL FLUID/BLOOD/URINE. OOB TO CHAIR AFTER DRAIN PULLED, TOLERATED WELL, R FEM SHEATH SITE, DRAIN SITE D+I, PERIPH PULSES PALP BILAT; MOTHER CALLED FROM - WILL CALL PT LATER THIS EVENING, PT CALLED OUT, AWAITING BED AVAILABILITY FOR TRANSFER TO 3.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-10-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 226648,\n \"text\": \"No significant change compared to tracing #2.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 226649,\n \"text\": \"No significant change compared to tracing #1 except for taller R waves in\\nleads V4-V6, possibly again related to lead placement.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2179-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 226650,\n \"text\": \"Sinus tachycardia. Possible PR segment depression seen in leads II and V5.\\nPoor R wave progression across the precordium. No previous tracing available\\nfor comparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":24987,"cells":{"subject_id":{"kind":"number","value":43774,"string":"43,774"},"hadm_id":{"kind":"number","value":105720,"string":"105,720"},"target_text":{"kind":"string","value":"The patient arrived in the ED on . On primary and secondary survey, the patient was intoxicated but was otherwise hemodynamically stable and following commands with a GCS of 15. Imaging studies ultimately revealed the following injuries: Comminuted L femur fx Open right ankle fx / near amputation R lateral 2nd and 3rd rib fxs The patient's admission labs also revealed pancreatitis with a lipase of 427 and an alcohol level greater than 400. The patient was admitted to the trauma service. The orthopedic team was consulted and the patient was brought to the OR for washout and ex fix placement of the R ankle. He was started on lovenox. Ortho intended to take the patient back to the OR for ORIF of his R tib/fib fractures. However, on POD1, the patient was noted to have fevers and tachycardia. He was also diaphoretic, agitated and disoriented. He was put on CIWA protocol for alcohol withdrawal and later transferred to the ICU on because he was developing delirium tremens. While in the ICU, the patient required large amounts of valium. He was also receiving haldol and dilaudid with little effect. An NGT was used to decompress his stomach and reduce the risk of aspiration. Because of his worsening progression and increased somnolence, he was later intubated by the SICU team . He was noted to have a Hct of 21 and was therefore received 4 units of pRBCs. On , the patient was again brought to the OR for ORIF of his left femur fracture. At the same time, an IVC filter was placed by the trauma surgery service. Post-op, the patient was left intubated and transferred back to the SICU. He was noted to have fevers overnight and was therefore pancultured and started on broad-spectrum antibiotics. His sputum eventually grew out GNRs. His antibiotics were adjusted appropriately. The patient was eventually started on tube feeds. His vent was weaned and he was extubated . He continued to have altered mental status, delirium and agitation, which was controlled with Zyprexa. He was seen by physical therapy, who recommended discharge to rehab. On , ortho again took the patient to the OR for washout of the right ankle, adjustment of the ex fix, and closed reduction of the tib fib fractures. He was intubated a few hours prior to the OR for increased agitation. It was determined to keep the patient intubated post-op and obtain a head CT to assess for any potential etiology of his prolonged agitation and delirium. This was ultimately negative. The patient was then extubated and transferred to the floor. After this, the patient's mental status was noted to improve markedly. He was then transferred to the orthopedics service for continued management. On , he was confused and agitated for most of the day. He received many doses of haldol, zyprexa, valium with no avail. He tried to get OOB many times and despite mutiple restraints, he fell onto his left side suffering a small left eyebrow abrasion. Xrays were taken of his left femur. The hardware was intact, with slighly more displacement compared to the fluoroscopic images taken in the OR. He was transferred back to the SICU for more close supervision an medical management of his agitation/delirium. He became stable and oriented thereafter. In the AM of he was alert and oriented to person, time, and place. All antibiotics and IV medications were stopped prior to discharge. He is being discharged to today in stable condition, with a knee immoblizer on his left leg and an ex-fix to the right. His staples from his left leg were removed just prior to discharge."},"extractive_notes_summ":{"kind":"string","value":"d/c valium addiction RN recommendation HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 28. GNR on sputum and febrile -> started on Vanc/ Zosyn/ Cipro. Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. GNR on sputum and febril -> started on Vanc/ Zosyn/ Cipro. CVS: On clonidine patch. Albuterol 0.083% Neb Soln 7. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Monitor for QT prolognation (haldol and quinolone). Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 1316 27. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. Pain: dilaudid prn, Tylenol prn. RENAL: Foley, monitor UOP HEME: Hct monitoring,transfuse as required ENDO: RISS ID: Cefazolin 2gm IV q8hr () Other: Social work/ Addictions consult TLD: Foley, PIV.NGT,ETT IVF: thiamine, d5, folate CONSULTS: ortho, trauma BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas GLYCEMIC CONTROL: RISS PROPHYLAXIS: PPI DVT Lovenox 30 q12hr. NEURO: Recovering from ETOH w/d. NEURO: Recovering from ETOH w/d. GNR on sputum and febril -> started on Vanc/ Zosyn/ Cipro. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Monitor for QT prolognation (haldol and quinolone). Will wean sedation to attempt vent wean CVS: Tachycardic/ HTN likely secondary to withdrawal. Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 15. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. Sputum: GNR Other: Social work/ Addictions consult TLD: Foley, PIV.NGT,ETT, aline IVF: thiamine, d5, folate Wound: L femur, R ankle - watch compartments CONSULTS: ortho, trauma BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp Failure GLYCEMIC CONTROL: RISS PROPHYLAXIS: PPI DVT SQH STRESS ULCER H2B VAP BUNDLE yes COMMUNICATIONS: ICU Consent: pending CODE STATUS: full DISPOSITION: SICU Total time: 32 min Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. Endocrine: RISS. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. Intubated dt's and w/d from etoh. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 28. Will wean sedation to attempt vent wean CVS: Tachycardic/ HTN likely secondary to withdrawal. Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 15. Pain: dilaudid prn, Tylenol prn. Chief Complaint: HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and washout R ankle and IVC filter, POD 0 washout RLE. Monitor for QT prolognation (haldol and quinolone). ENDO: RISS ID: Cefazolin 2gm IV q8hr (). hospital course c/b hypertension,agitation/delirium, and tachycardia c/w EtOH withdrawal. Alcohol withdrawal with DTs, now intubated after increased somnolence. d/c valium addiction RN recommendation CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. NEURO: Alcohol withdrawal/DT. CXR: left base in the retrocardiac region, likely atelectasis Microbiology: Ucx P Assessment and Plan TRAUMA, S/P ALCOHOL ABUSE with active withdrawal and disorientation NEURO: awake, alert, neuro intact, following commands, A&O x1. Will wean off prop to attempt vent wean CVS: Tachycardic/ HTN likely secodary to withdrawal. Pain: dilaudid PCA, Tylenol prn. Neuro checks Q: 1 Pain: dilaudid PCA, Tylenol prn. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal GI: Regular. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal GI: Regular. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal. CVS: On clonidine patch. CVS: On clonidine patch. CVS: On clonidine patch. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. CVS: Tachycardic/ HTN likely secondary to withdrawal. HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE washout/ Ex-fix revision Chief complaint: PMHx: ETOH abuse,Varicose veins Current medications: . On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. Leukocytosis noted . Leukocytosis noted . Leukocytosis noted . HEME: Hct 29 on . HEME: Hct 29 on . HEME: Hct 29 on . Post-op course c/b severe etoh withdrawal. ENDO: RISS. ENDO: RISS. ENDO: RISS. WBC 12.1 Pt afebrile and satting well on RA. -ATC and prn IV Haldol. -ATC and prn IV Haldol. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. There is a nondisplaced fracture of the left fibular head (501B:36). Views demonstrate steps related to fixation of a comminuted distal femoral fracture, side not indicated. Small Right pleural effusion and associated atelectasis. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: EX/FIX RIGHT TIBIA Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES FINAL REPORT HISTORY: ORIF FINDINGS: Multiple views from the operating suite show what appear to be external fixation devices in the tibia."},"n_notes":{"kind":"number","value":170,"string":"170"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2146-01-07 00:00:00.000","description":"Nursing Progress Note","row_id":505291,"text":"Trauma, s/p\n Assessment:\n Temp 100.7 to 98.8 po\n HR 90\ns nsr\n Sbp 140-150\ns when calm, hypertensive to 180\ns with stimulation such\n as suctioning\n Breath sounds clear but diminished in bases\n Suctioned for copious amounts thick yellow secretions\n Abd soft with + bowel sounds\n TF on hold for possible extubation\n Action:\n hemodynamics monitored\n suctioned q1-2 hrs for copious amounts thick yellow secretions\n suctioned for large amounts orally\n Response:\n pt remains lethargic\n arousable only when suctioned then quiets\n placed back on cpap with 10 ips/ 5 peep\n Plan:\n rest overnight\n attempt extubation in am\n resume propofol only if patient becomes agitated\n suction prn\n tube feedings resumed at 1600\n Alcohol abuse\n Assessment:\n Propofol off at 0900\n Very lethargic\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\n No visible sweats or tremors\n Action:\n CIWA scale done\n No valium given this shift\n Response:\n No evidence of DT\n Plan:\n Continue to monitor for DT\n ? d/c valium addiction RN recommendation\n"},{"category":"Physician ","chartdate":"2146-01-13 00:00:00.000","description":"Intensivist Note","row_id":506680,"text":"TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/ h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\n RSBI 30s this AM.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation. Pt\n following commands on Precedex, but seems confused at times, will plan\n to extubate this AM. Please avoid benzos\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\n prolognation (haldol and quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\n hospitalization. s/p IVC filter.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n () x 14 day course.\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\n Wounds: Soft compartments, will monitor.\n Imaging: None planned\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Addiction Med\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n please d/c as no indication\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 32 mins\n"},{"category":"Physician ","chartdate":"2146-01-07 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505093,"text":"TITLE:\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\n auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n URINE CULTURE - At 08:30 PM\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 12:34 AM\n FEVER - 102.1\nF - 09:00 PM\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Vancomycin - 07:49 PM\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\n Ciprofloxacin - 10:27 PM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:00 AM\n Metoprolol - 01:00 PM\n Hydromorphone (Dilaudid) - 03:49 PM\n Pantoprazole (Protonix) - 07:49 PM\n Heparin Sodium (Prophylaxis) - 07:49 PM\n Other medications:\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\n Heparin 5000 UNIT SC BID\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Metoprolol Tartrate 5 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Nicotine Patch 14 mg TD DAILY\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\n Pantoprazole 40 mg IV Q24H\n Cyanocobalamin 50 mcg PO/NG DAILY\n Piperacillin-Tazobactam 4.5 g IV Q8H\n Potassium Phosphate IV Sliding Scale\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Folic Acid/Multivitamin/Thiamine-1000mL NS\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Flowsheet Data as of 12:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.7\nC (99.8\n HR: 93 (82 - 101) bpm\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\n RR: 27 (18 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,921 mL\n 40 mL\n PO:\n TF:\n 277 mL\n 14 mL\n IVF:\n 2,585 mL\n 26 mL\n Blood products:\n Total out:\n 2,275 mL\n 0 mL\n Urine:\n 1,775 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 646 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 494 (466 - 605) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.46/40/155/28/5\n Ve: 12.2 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Rash: left axilla, bruising right chest\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n WBC\n 8.7\n 9.7\n Hct\n 28.7\n 26.8\n 28.1\n Plt\n 169\n 169\n Cr\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n 26\n 29\n Glucose\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n Microbiology: Ucx Negative.\n Sputum: GNR\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Transfer Note","row_id":506815,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n"},{"category":"Nursing","chartdate":"2146-01-07 00:00:00.000","description":"Nursing Progress Note","row_id":505149,"text":"Trauma, s/p pedestrian struck, bilateral leg fractures and rib\n fractures\n Assessment:\n Low grade temps 100.7\n HR 80\ns, BP ~120-140\n Fluid balance MN -0500: +370cc\ns. Remains 9 liters\n positive for length of stay.\n Dopplerable pedal pulses bilat\n Left leg with knee immobilizer, ace wrap with DSD under with\n old sero-sang drg.\n Right leg with external fixator, draining yellow fluid from\n heel pin sites, dressing changed.\n Ls clear with suctioning, tan sputum\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\n Not showing signs of ETOH withdrawal, no valium given this\n shift per CIWA scale\n Dilaudid x 1 this shift in preparation for pin care and\n bathing with good effect\n Action:\n VAP protocol\n Pin care\n Repositioned q 2-3 hours\n ABX as ordered\n Tube feeds stopped in preparation for possible extubation.\n Response:\n HR and vitals acceptable\n Remains with low grade fever\n Concerning sputum\n HCT 25.3, no S+S of active bleeding.\n Plan:\n Continue to monitor respiratory status, wean to extubated if\n appropriate\n Continue to monitor for S+S of ETOH withdrawal\n Continue ABX as ordered, follow up on pending culture\n results.\n"},{"category":"Respiratory ","chartdate":"2146-01-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":505165,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Remain on minimal PSV,\n increased briefly on IPS of 10 cmh20, back down.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: on minimal propofol. ? precedex.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~54. ? elective extubation.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Transfer Note","row_id":506816,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n : washout RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506058,"text":"Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - Minimal response from zyprexa\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n"},{"category":"Respiratory ","chartdate":"2146-01-07 00:00:00.000","description":"Respiratory Care Shift Note","row_id":505327,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchron\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Plan to extubate in am.\n"},{"category":"General","chartdate":"2146-01-17 00:00:00.000","description":"Generic Note","row_id":507540,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent after valium.\n Agitated with awake. Previosly in DT - needed excessive valium. Now\n still delirious. Need frequent re-orientation with restriants. Haldol\n PO and IV prn Ativan. ? Withdrawal from benzos. Will ask psych to\n evaluate and input in the management of patient.\n CVS: On clonidine patch. Beta blockade. HD stable.\n PULM: room air saturating well. h/o HAP likely aspiration. Cx w/ H.\n nflu and Shewanella completed course of levaquin. h/o Intubation \n for altered mental status from withdrawal.\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley. Otherwise no issues\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS with adequate glucose control. Keep < 150 Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505397,"text":"pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"},{"category":"Physician ","chartdate":"2146-01-10 00:00:00.000","description":"Intensivist Note","row_id":505909,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Trauma, alcohol intoxicated\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown.\n Current medications:\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\n Temporary central access (ICU) Location: Left Subclavian, Date\n inserted: Order date: @ 1336 16. IV access request:\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\n line Order date: @ 1454 17. Insulin SC (per Insulin\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\n Q24H Order date: @ 1316\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1316\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\n 1406\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n Extubated. Minimized narcotics. More awake. Agitated at night req\n restraints and zyprexa.\n Post operative day:\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\n Ciprofloxacin - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:04 PM\n Metoprolol - 12:40 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 79 (72 - 82) bpm\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\n RR: 20 (14 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: -2 (-2 - 12) mmHg\n Total In:\n 3,520 mL\n 592 mL\n PO:\n Tube feeding:\n 1,440 mL\n 309 mL\n IV Fluid:\n 2,020 mL\n 283 mL\n Blood products:\n Total out:\n 3,500 mL\n 1,280 mL\n Urine:\n 3,435 mL\n 1,280 mL\n NG:\n 65 mL\n Stool:\n Drains:\n Balance:\n 20 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Creatinine\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\n for w/drawal. Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent: 35 min\n"},{"category":"Respiratory ","chartdate":"2146-01-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":505370,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt remain stable on PSV settings with no issues this shift.\n Pt tidal volumes, Resp rate, oxygen saturations all within normal\n range. Pt had clear lung sounds, with a strong cough. Pt is off all\n IV sedation, and is being monitored for improving mental status and\n awareness. Pt to be assessed by MD team for possible extubation.\n BEDSIDE RSBI- 76\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":505911,"text":"Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused and agitated most of night, oriented to self,\n continually tries to get out of bed, says:\nI have to go to \nI need my money\n. Hard to redirect. When told he is in the hospital\n patient looks shocked. Consistently putting legs over side rail.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Given 5 mg Olanzapine for agitation.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night, more calm after olanzapine given.\n Plan:\n Continue to monitor, reorient frequently.\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505576,"text":"pt is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n - to return to OR for procedure on RLE Tuesday ?\n"},{"category":"Nursing","chartdate":"2146-01-09 00:00:00.000","description":"Nursing Progress Note","row_id":505812,"text":"Trauma, s/p\n Assessment:\n - pt more alert today, compared with yesterday\ns assessment by this\n nurse. Oriented X 1, better able to understand speech, confused,\n oriented at times, needs frequent re-orientation and re-direction\n - lungs clear, rhonchorous at times but clear with coughing\n - strong productive cough, absent gag\n - yellow drainage on pad of RLE\n - face tent 35% humidified\n Action:\n - mouth swabs to moisten oral cavity\n - encouraged coughing and deep breathing\n - OOB to chair\n - did not try pt on clear liquids at this time, uncooperative at times,\n absent gag reflex.\n - frequent pin care as needed\n Response:\n - expectorating lg amts of white secretions\n - slid pt over to stretcher chair with careful movement of legs, pt sat\n up in chair with head elevated and legs out straight at a slight angle\n for approx 2 hrs\n - tolerating TF at goal, 15cc residual\n - sm brown soft formed BM X 1\n - sats 97-100% throughout shift\n Plan:\n - continue turning/repositioning, encourage coughing, deep breathing\n - monitor respiratory status, face tent 35% for humidification of\n secretions\n - frequently re-orient pt as needed\n - to Return to OR Tuessay ? for internal fixation of R leg\n"},{"category":"Nutrition","chartdate":"2146-01-10 00:00:00.000","description":"Clinical Nutrition Note","row_id":506045,"text":"Subjective: patient delirious, confused, A&O x1.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 95.3 kg ( 12:00 AM)\n 28.2\n Pertinent medications: normal saline @ 55mL/hr, ABx,\n cyanocobalamin, protonix, heparin, multivitamin, folic acid, thiamine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 01:53 AM\n Glucose Finger Stick\n 120\n 10:00 PM\n BUN\n 13 mg/dL\n 01:53 AM\n Creatinine\n 0.6 mg/dL\n 01:53 AM\n Sodium\n 142 mEq/L\n 01:53 AM\n Potassium\n 3.9 mEq/L\n 01:53 AM\n Chloride\n 107 mEq/L\n 01:53 AM\n TCO2\n 26 mEq/L\n 01:53 AM\n PO2 (arterial)\n 162 mm Hg\n 02:50 AM\n PCO2 (arterial)\n 37 mm Hg\n 02:50 AM\n pH (arterial)\n 7.47 units\n 02:50 AM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:50 AM\n Calcium non-ionized\n 8.4 mg/dL\n 01:53 AM\n Phosphorus\n 3.1 mg/dL\n 01:53 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.1 mg/dL\n 01:53 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 7.1 K/uL\n 01:53 AM\n Hgb\n 9.0 g/dL\n 01:53 AM\n Hematocrit\n 27.0 %\n 01:53 AM\n Current diet order / nutrition support: Tube Feeds: Replete with fiber\n @ 60mL/hr (1440kcals, 89g protien)\\\n Diet: NPO\n GI: abd soft, bowel sounds present\n Assessment of Nutritional Status\n 50 y.o. Male ped vs auto with multiple orthopedic injuries s/p RLE\n ExFix, rib fractures, s/p L femur ORIF, right ankle external fixation\n removal + ORIF. s/p IVC filter. Patient also with alcohol withdrawal\n with DTs, initially intubated after increased somnolence, now extubated\n as of . Patient is receiving tube feeds via NGT for nutrition;\n current tube feeds do not meet nutritional needs. Recommend increasing\n goal rate to meet 100% of est. calorie and protein needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend increasing tube feed goal to 95mL/hr (2280kcals,\n 141g protein).\n Monitor tolerance with abd exam and residual checks.\n Monitor lytes and hydration.\n Following - #\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505423,"text":"pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil move slowly.\n Hct 26 .6\n Vanco level 4.8\n Suctioned for copiius amts of thick tan\nyellow sputum.\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n On iv vanco, pipercillin and cipro.\n Response:\n Vital signs stable\n Remains off all sedation.\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"},{"category":"Physician ","chartdate":"2146-01-08 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505428,"text":"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n MULTI LUMEN - START 01:30 PM\n FEVER - 101.6\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Ciprofloxacin - 09:56 AM\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:54 PM\n Pantoprazole (Protonix) - 08:32 PM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Flowsheet Data as of 01:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.9\nC (100.3\n HR: 91 (83 - 100) bpm\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\n RR: 28 (21 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (11 - 16)mmHg\n Total In:\n 2,933 mL\n 109 mL\n PO:\n TF:\n 454 mL\n 52 mL\n IVF:\n 2,479 mL\n 57 mL\n Blood products:\n Total out:\n 2,930 mL\n 0 mL\n Urine:\n 2,930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (411 - 624) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.45/45/132/27/7\n Ve: 10.7 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: bases)\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 199 K/uL\n 8.5 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 25.3 %\n 8.0 K/uL\n [image002.jpg]\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n WBC\n 9.7\n 8.0\n Hct\n 26.8\n 28.1\n 25.3\n Plt\n 169\n 199\n Cr\n 0.7\n 0.6\n 0.6\n TCO2\n 28\n 27\n 29\n 26\n 29\n 32\n Glucose\n 87\n 104\n 121\n 128\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febrile -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\n Fiber (Full) - 04:00 PM 50 mL/hour\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Total time spent: 32 min\n"},{"category":"Respiratory ","chartdate":"2146-01-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":505560,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments:\n Pt weaned and extubated without complications.\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505562,"text":" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n -\n Action:\n - extubated at approx 1330\n -\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505573,"text":" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505574,"text":" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506035,"text":"Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n Action:\n - removed restraints, constant observation, frequent\n re-orienting and re-directing\n - encouraged coughing/deep breathing\n - OOB to chair\n - zyprexa order changed to TID, given as ordered\n Response:\n - pt continues to be delirious\n - slid pt using slide board over to stretcher chair, sat\n upright with\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506310,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"},{"category":"Nursing","chartdate":"2146-01-09 00:00:00.000","description":"Nursing Progress Note","row_id":505809,"text":"Trauma, s/p\n Assessment:\n - pt more alert today, compared with yesterday\ns assessment by this\n nurse. Oriented X 1, better able to understand speech, confused,\n oriented at times, needs frequent re-orientation and re-direction\n - lungs clear, rhonchorous at times but clear with coughing\n - strong productive cough, absent gag\n -\n Action:\n - mouth swabs to moisten oral cavity\n - encouraged coughing and deep breathing\n - OOB to chair\n Response:\n - expectorating lg amts of white secretions\n - slid pt over to stretcher chair with careful movement of legs, pt sat\n up in chair with head elevated and legs out straight at a slight angle\n for approx 2 hrs\n -\n Plan:\n -\n"},{"category":"Respiratory ","chartdate":"2146-01-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":504623,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust\n Min. ventilation to control pH, Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved; Comments: Pt remains on PSV settings\n with no changes this shift. Pt remains stable as per tidal volumes,\n RR, SpO2 and airway pressures. Pt had no significant issues this\n shift. Pt to OR today and plan of care to be determined by MD team.\n BEDSIDE RSBI- 72\n"},{"category":"Nursing","chartdate":"2146-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":506422,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, continuously\n trying to get OOB, very hard of hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Pt partially pulled out NGT. NGT found halfway in so it was\n re-inserted, chest xray done which showed it was in too far. NGT was\n drawn back. Now awaiting repeat chest xray\n - 0.5mg Ativan X 1 for agitation due to inability to give PO\n zyprexa\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n - on soft formed brown BM, used bedpan\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - follow up with repeat chest xray\n - OR today for RLE washout and internal fixation ? OR time\n"},{"category":"Nursing","chartdate":"2146-01-09 00:00:00.000","description":"Nursing Progress Note","row_id":505613,"text":"Trauma, s/p\n Assessment:\n Patient is extubated and oriented x 1. Confused and believes he is in\n , constantly says he has to leave, trying to pull at lines and\n NG when unrestrained, able to redirect.\n Serous output from pin site on R leg, pin sites clean.\n L knee immobilizer in place, incision clean and dry.\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\n to touch.\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\n patient able to clear on own, sating 95-100% on 40% face tent.\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\n Action:\n Turned and repositioned for comfort,\n Pin care done q 4 hours during shift,\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\n breathe.\n Response:\n Patient continues to be confused, able to state name only.\n Plan:\n Continue to monitor, pulm. Toilet.\n"},{"category":"Physician ","chartdate":"2146-01-09 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505703,"text":"24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Ciprofloxacin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:52 PM\n Metoprolol - 06:02 AM\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.4\nC (99.4\n HR: 81 (75 - 99) bpm\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\n RR: 20 (19 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 6 (0 - 14)mmHg\n Total In:\n 2,912 mL\n 844 mL\n PO:\n TF:\n 972 mL\n 388 mL\n IVF:\n 1,880 mL\n 456 mL\n Blood products:\n Total out:\n 2,950 mL\n 1,050 mL\n Urine:\n 2,920 mL\n 1,020 mL\n NG:\n 30 mL\n 30 mL\n Stool:\n Drains:\n Balance:\n -38 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/162/27/4\n Ve: 11.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: Sedated but follows commands, reluctantly\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 307 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 104 mEq/L\n 137 mEq/L\n 25.4 %\n 7.8 K/uL\n [image002.jpg]\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n Plt\n 199\n 226\n 259\n 307\n Cr\n 0.6\n 0.5\n 0.6\n TCO2\n 29\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Recovering from ETOH w/d.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, s/p resp\n failure\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n : Time spent 32 min\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506106,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve psychiatric services\n"},{"category":"Nursing","chartdate":"2146-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":506369,"text":"Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, very hard of\n hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - OR today for RLE washout and internal fixation\n"},{"category":"Nursing","chartdate":"2146-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":506370,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, continuously\n trying to get OOB, very hard of hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - OR today for RLE washout and internal fixation ? OR time\n"},{"category":"Nursing","chartdate":"2146-01-09 00:00:00.000","description":"Nursing Progress Note","row_id":505669,"text":"Trauma, s/p\n Assessment:\n Patient is extubated and oriented x 1. Confused and believes he is in\n , constantly says he has to leave, trying to pull at lines and\n NG when unrestrained, able to redirect.\n Serous output from pin site on R leg, pin sites clean.\n L knee immobilizer in place, incision clean and dry.\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\n to touch.\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\n patient able to clear on own, sating 95-100% on 40% face tent.\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\n Action:\n Turned and repositioned for comfort,\n Pin care done q 4 hours during shift,\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\n breathe.\n Response:\n Patient continues to be confused, able to state name only.\n Plan:\n Continue to monitor, pulm. Toilet.\n"},{"category":"Physician ","chartdate":"2146-01-09 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505676,"text":"24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Ciprofloxacin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:52 PM\n Metoprolol - 06:02 AM\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.4\nC (99.4\n HR: 81 (75 - 99) bpm\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\n RR: 20 (19 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 6 (0 - 14)mmHg\n Total In:\n 2,912 mL\n 844 mL\n PO:\n TF:\n 972 mL\n 388 mL\n IVF:\n 1,880 mL\n 456 mL\n Blood products:\n Total out:\n 2,950 mL\n 1,050 mL\n Urine:\n 2,920 mL\n 1,020 mL\n NG:\n 30 mL\n 30 mL\n Stool:\n Drains:\n Balance:\n -38 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/162/27/4\n Ve: 11.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: Sedated but follows commands, reluctantly\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 307 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 104 mEq/L\n 137 mEq/L\n 25.4 %\n 7.8 K/uL\n [image002.jpg]\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n Plt\n 199\n 226\n 259\n 307\n Cr\n 0.6\n 0.5\n 0.6\n TCO2\n 29\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Recovering from ETOH w/d.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n :\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506108,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse, social work\n notified. Pts family states last name is spelt , admitting\n notified and change made in system\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n - mother and sister will be staying with friend\n locally, will be in to visit pt in the morning. Able to reach them\n if needed at number: \n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve psychiatric services.\n"},{"category":"Physician ","chartdate":"2146-01-05 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504708,"text":"Pt with multiple injuries and DTs\n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct monitoring,transfuse as required\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent 32 min\n"},{"category":"Respiratory ","chartdate":"2146-01-12 00:00:00.000","description":"Respiratory Care Shift Note","row_id":506541,"text":"Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Pt intubated several hours pre-op for increased agitation. To OR for\n washout and maneuvering of fixation devices. CT tonight. Probable\n extubation in AM.\n"},{"category":"Physician ","chartdate":"2146-01-05 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504675,"text":"24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct 36 -> 26 -> 21, s/p 2u pRBC --> 25.5 --> 2u PRBC prior to\n going to OR per anesthesia request --> HCT 29.8 --> 28.7\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n"},{"category":"Physician ","chartdate":"2146-01-05 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504682,"text":"24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct monitoring,transfuse as required\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n"},{"category":"Physician ","chartdate":"2146-01-06 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504936,"text":".\n HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Post operative day:\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Pantoprazole (Protonix) - 08:02 PM\n Hydromorphone (Dilaudid) - 08:02 PM\n Diazepam (Valium) - 10:50 PM\n Metoprolol - 12:15 AM\n Other medications:\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1316 19.\n Metoprolol Tartrate 5 mg IV Q6H\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\n DAILY Order date: @ 1316\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\n Order date: @ 1316\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\n TO SEDATION Order date: @ 1316\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\n hold oral thiamine, folate and multivitamins. Order date: \n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.5\nC (101.3\n HR: 96 (72 - 101) bpm\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\n RR: 25 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 5,831 mL\n 655 mL\n PO:\n TF:\n IVF:\n 5,831 mL\n 655 mL\n Blood products:\n Total out:\n 2,520 mL\n 425 mL\n Urine:\n 1,580 mL\n 425 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 3,311 mL\n 230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 530) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI: 72\n PIP: 21 cmH2O\n Plateau: 25 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/43/120/28/3\n Ve: 14.3 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Clubbing\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n WBC\n 8.7\n 7.5\n 8.7\n 9.7\n Hct\n 29.5\n 29.8\n 28.7\n 26.8\n 28.1\n Plt\n 141\n 154\n 169\n 169\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n Glucose\n 97\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean sedation to attempt vent wean\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\n check NG tube position\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: D/CCefazolin 2gm IV q8hr (). Febrile - pan cultured. Change to\n Zosyn. Sputum: GNR\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch compartments\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\n Failure\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Total time: 32 min\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":504951,"text":"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2146-01-13 00:00:00.000","description":"Respiratory Care Shift Note","row_id":506775,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n :\n Respiratory Care Shift Procedures\n Comments: pt extubated to 70% cool aerosol, now on nasal cannula. Pt is\n tolerating well. Meds : alb nebs q6 prn.\n"},{"category":"Nursing","chartdate":"2146-01-05 00:00:00.000","description":"Nursing Progress Note","row_id":504643,"text":"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Trauma, s/p\n Assessment:\n Remains intubated and sedated on propofol gtt.\n Diaphoretic break through during the nite\n Breath sounds rhonchous\n Pupils #2 and reacts briskly.\n Moves upper extremities on the bed.\n No movement in lower extremites\n Suctioned for thick yellow sputum.\n Hct 28.7\n Action:\n Suctioned prn\n Vap mouth care as ordered\n Npo for or today.\n On propofol gtt and infusing at 40mcg/hr.\n Iv lactatated ringers at 100cc/hr.\n Valium 10mg iv prn given\n Hydromorphone 1mg iv prn given.\n Pin care done to right foot and foot draining serous drainage.\n Type and screen specimen sent to the blood bank.\n Response:\n Patient remains intubated and sedated.\n Npo for the or today.\n Plan:\n Monitor condition closely.\n To or for femur repair\n Update cousin of patient\ns condition.\n"},{"category":"Respiratory ","chartdate":"2146-01-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":504764,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Fully sedated @ present time\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n 50 yr old male ped vs auto with\n( femur tib and bilateral rib fx.\n Patient went to OR for repair. Upon his return patient is placed on\n mechanical ventilation sedated with good ABG. CXR persitent low lung\n volume with atelectasis @ bases. BS diminished suctioned for small\n white thick secretion\n"},{"category":"Nursing","chartdate":"2146-01-05 00:00:00.000","description":"Nursing Progress Note","row_id":504766,"text":"Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors,\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-05 00:00:00.000","description":"Nursing Progress Note","row_id":504770,"text":"Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors, diaphoretic.\n Action:\n Taken to OR for internal fixation of right fib/tib fx (unable to do\n because of swelling) and repair of L femur fx.\n L knee immobilizer on and original dsg with ace bandage over it from\n OR. Sanginous drainage noted.\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\n Banana bag given,\n Pin care and incision care done on R leg .\n Response:\n Patient continues on prop and intubated on CMV.\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-05 00:00:00.000","description":"Nursing Progress Note","row_id":504776,"text":"Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors, diaphoretic.\n Action:\n Taken to OR for internal fixation of right fib/tib fx (unable to do\n because of swelling) and repair of L femur fx. Also placement of IVC\n filter.\n L knee immobilizer on and original dsg with ace bandage over it from\n OR. Sanginous drainage noted.\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\n Banana bag given,\n Pin care and incision care done on R leg .\n Response:\n Patient continues on prop and intubated on CMV. HR 80\ns-90\ns NSR, SBP\n 100-120.\n Plan:\n Continue to monitor.\n Alcohol abuse\n Assessment:\n Patient has hx of alcohol abuse (admitted to 12 beers/day) Came in to\n ED with alcohol blood level of 400). Continues to be\n sedated on prop, when woken up patient is unable to follow commands,\n face very red, bites on tube, tremors, diaphoretic.\n Action:\n Given 10 mg IV valium per CIWA scale q 1-2 hours.\n Response:\n Vital signs stable, SBP 100-120, HR 80\ns-90\ns, patient appears\n comfortable after valium given.\n Plan:\n Continue to monitor, continue with CIWA scale.\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":505058,"text":"HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements lungs clear upper lobes diminished in lower lobes\n suctioned for thick tan secretions, and copious amounts of thin oral\n secretions abd soft + bowel sounds + flatus no bm Foley patent\n draining amber urine pin care done + pulses by Doppler + cap refill. T\n max 99.0 heart rate 80-90\ns sinus rhythm systolic 90-120\n over 60\n Action:\n Tube feeding replete with fiber started through NG tube patient started\n on vancomycin, cipro for VAP central line placed for access confirmed\n by x-ray. Ventilator settings changed to 10/10 then weaned to \n Response:\n Patient tolerating vent settings remains stable at this time.\n Plan:\n Continue with current plan of care provide comfort and support as\n needed notify team of any changes\n"},{"category":"Respiratory ","chartdate":"2146-01-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":505061,"text":"Day of mechanical ventilation: 4\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Weaned to CSV, eventually to with good ABG\ns. Possible extubation\n in AM.\n"},{"category":"Respiratory ","chartdate":"2146-01-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":504844,"text":"Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 80.7\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":504887,"text":"Trauma, s/p leg fractures\n Assessment:\n Febrile to 102\n Tachycardic to low 100\ns with PVC\n Diaphoretic\n Sedated on Propofol\n Period of hypotension\n HCT and electrolytes checked\n Adequate urine output 45-100 cc\ns/hr.\n Dopplerable pulses bilateral lower extremities\n Action:\n X1 peripheral BC, U/A, C+S, and sputum samples sent\n Valium x1 given\n Dilaudid x1 given\n LR 500 cc fluid bolus for hypotension\n Magnesium and calcium repleated\n Propofol stopped for daily wakeup, patient biting on ETT, no\n other purposeful movement noted, unable to finish exam before having to\n restart sedation.\n Suctioned for copious amounts of tan sputum @ ~ 0530\n VAP protocol\n Pin care done\n Left knee remains in immobilizer with visible sero-sang\n drainage on original dressing.\n Response:\n Fluid balance for + 3 liters\n No further signs of DT\ns / tremors after valium given\n Remains febrile\n Hypotension resolved\n Plan:\n Continue to monitor for S+S of DT\n Continue to check and correct electrolyte imbalances\n Wean ventilator\n Follow up on culture results\n Follow up with ortho on plans for future surgeries\n"},{"category":"Physician ","chartdate":"2146-01-07 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505197,"text":"TITLE:\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\n auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n URINE CULTURE - At 08:30 PM\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 12:34 AM\n FEVER - 102.1\nF - 09:00 PM\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Vancomycin - 07:49 PM\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\n Ciprofloxacin - 10:27 PM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:00 AM\n Metoprolol - 01:00 PM\n Hydromorphone (Dilaudid) - 03:49 PM\n Pantoprazole (Protonix) - 07:49 PM\n Heparin Sodium (Prophylaxis) - 07:49 PM\n Other medications:\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\n Heparin 5000 UNIT SC BID\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Metoprolol Tartrate 5 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Nicotine Patch 14 mg TD DAILY\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\n Pantoprazole 40 mg IV Q24H\n Cyanocobalamin 50 mcg PO/NG DAILY\n Piperacillin-Tazobactam 4.5 g IV Q8H\n Potassium Phosphate IV Sliding Scale\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Folic Acid/Multivitamin/Thiamine-1000mL NS\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Flowsheet Data as of 12:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.7\nC (99.8\n HR: 93 (82 - 101) bpm\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\n RR: 27 (18 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,921 mL\n 40 mL\n PO:\n TF:\n 277 mL\n 14 mL\n IVF:\n 2,585 mL\n 26 mL\n Blood products:\n Total out:\n 2,275 mL\n 0 mL\n Urine:\n 1,775 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 646 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 494 (466 - 605) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.46/40/155/28/5\n Ve: 12.2 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Rash: left axilla, bruising right chest\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n WBC\n 8.7\n 9.7\n Hct\n 28.7\n 26.8\n 28.1\n Plt\n 169\n 169\n Cr\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n 26\n 29\n Glucose\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n Microbiology: Ucx Negative.\n Sputum: GNR\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\n Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 min\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Transfer Note","row_id":506820,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n : washout RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n PEDESRTRIAN STRUCK, LEG FRACTURES\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 94.5 kg\n Daily weight:\n 91.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\n withdrawing from alcholol and requiring q1hr valium. heart rate\n 130-140's. very agitated and requiring constant watch. npo for or on\n monday to repair left femur.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:68\n Temperature:\n 100.7\n Arterial BP:\n S:123\n D:83\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,938 mL\n 24h total out:\n 2,265 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:30 AM\n Potassium:\n 4.4 mEq/L\n 02:30 AM\n Chloride:\n 110 mEq/L\n 02:30 AM\n CO2:\n 26 mEq/L\n 02:30 AM\n BUN:\n 12 mg/dL\n 02:30 AM\n Creatinine:\n 0.8 mg/dL\n 02:30 AM\n Glucose:\n 95 mg/dL\n 02:30 AM\n Hematocrit:\n 29.1 %\n 08:13 AM\n Finger Stick Glucose:\n 95\n 07:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: cc6\n Date & time of Transfer: 09:00 PM\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":505033,"text":"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":505041,"text":"HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements lungs clear upper lobes diminished in lower lobes\n suctioned for thick tan secretions, and copious amounts of thin oral\n secretions abd soft + bowel sounds + flatus no bm Foley patent\n draining amber urine pin care done + pulses by Doppler + cap refill. T\n max 99.0 heart rate 80-90\ns sinus rhythm systolic 90-120\n over 60\n Action:\n Tube feeding replete with fiber started through NG tube patient started\n on vancomycin, cipro for VAP central line placed for access confirmed\n by x-ray. Ventilator settings changed to 10/10 then weaned to \n Response:\n Patient tolerating vent settings remains stable at this time.\n Plan:\n Continue with current plan of care provide comfort and support as\n needed notify team of any changes\n"},{"category":"Physician ","chartdate":"2146-01-13 00:00:00.000","description":"Intensivist Note","row_id":506589,"text":"TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/24 h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS)\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation.\n Consider LP or further imaging for continued AMS.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: Extubate today, HAP likely aspiration. Cx w/ H.influ and\n Shewanella. Now on Levaquin (). Intubated for altered mental\n status from withdrawal. Reintubated for increasing agitation and in\n prep for OR. Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter.\n Endocrine: RISS\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC\n Wounds:\n Imaging:\n Fluids: D5NS\n Consults: Trauma surgery, Ortho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":506651,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n Alcohol abuse\n Assessment:\n Propofol gtt for sedation till after head CT as above then precedex\n started and propofol transiently weaned to off, pt given dilaudid PRN\n for pain management\n Action:\n Precedex titrated up as needed\n Response:\n Pt awoke with a bang while on just precdeax\n Plan:\n Team requests pt be resedated on propofol at this time, will attempt to\n lighten again later this AM after rounds and ? extubated at that time.\n"},{"category":"Physician ","chartdate":"2146-01-10 00:00:00.000","description":"Intensivist Note","row_id":505964,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Trauma, alcohol intoxicated\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown.\n Current medications:\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\n Temporary central access (ICU) Location: Left Subclavian, Date\n inserted: Order date: @ 1336 16. IV access request:\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\n line Order date: @ 1454 17. Insulin SC (per Insulin\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\n Q24H Order date: @ 1316\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1316\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\n 1406\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n Extubated. Minimized narcotics. More awake. Agitated at night req\n restraints and zyprexa.\n Post operative day:\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\n Ciprofloxacin - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:04 PM\n Metoprolol - 12:40 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 79 (72 - 82) bpm\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\n RR: 20 (14 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: -2 (-2 - 12) mmHg\n Total In:\n 3,520 mL\n 592 mL\n PO:\n Tube feeding:\n 1,440 mL\n 309 mL\n IV Fluid:\n 2,020 mL\n 283 mL\n Blood products:\n Total out:\n 3,500 mL\n 1,280 mL\n Urine:\n 3,435 mL\n 1,280 mL\n NG:\n 65 mL\n Stool:\n Drains:\n Balance:\n 20 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Creatinine\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\n for w/drawal. Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley,, NGT, ,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent:\n"},{"category":"Physician ","chartdate":"2146-01-11 00:00:00.000","description":"Physician Surgical Progress Note","row_id":506144,"text":"24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n : agitated despite zyprexa,responded to haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\n Ciprofloxacin - 09:22 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 08:50 PM\n Haloperidol (Haldol) - 10:17 PM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 90 (76 - 96) bpm\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 9 (-2 - 16)mmHg\n Total In:\n 3,706 mL\n 210 mL\n PO:\n TF:\n 1,658 mL\n 190 mL\n IVF:\n 1,908 mL\n 20 mL\n Blood products:\n Total out:\n 4,140 mL\n 170 mL\n Urine:\n 4,140 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Agitated and disoriented.\n Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\n Lines:\n Multi Lumen - 01:30 PM\n Disposition:\n Total time spent:\n"},{"category":"Rehab Services","chartdate":"2146-01-13 00:00:00.000","description":"Physical Therapy Progress Note","row_id":506750,"text":"Subjective:\n I will try to get OOB\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise\n Updated medical status: s/p Wash out of RLE c ext fix\n manipulation. Head CT - . Extubated this AM.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NT\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n for RLE\n\n\n\n T\n\n\n Transfer:\n T Transfer Bed to Chair\n\n\n\n T\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 83\n 112/62\n 16\n 100% 2LO2\n Activity\n Sit\n 86\n 102/60\n 24\n 95 RA\n Recovery\n Sit\n 82\n 98/50\n 20\n 100% 2LO2\n Total distance walked:\n Minutes:\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\n 1 UE support.\n Education / Communication: c RN RE Pt Status\n Pt RE Rehab Process\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\n ROM L knee 0-40 c hard end-feel\n Pain: B LE c mobility\n MS . Able to follow commands. Reported date at .\n Orientated to self and .\n HOH\n Assessment: Pt is a 51M with multiple fractures presents with continued\n limitations in mobility. Pt is functioning well below baseline and\n will require STR when medically stable.\n Anticipated Discharge: Rehab\n Plan: Progress transfers ?slideboard\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506074,"text":"\n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from zyprexa\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n - OR tomorrow for R internal fixation ?\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506075,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from zyprexa\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n - OR tomorrow for R internal fixation ?\n"},{"category":"Physician ","chartdate":"2146-01-11 00:00:00.000","description":"Physician Surgical Progress Note","row_id":506230,"text":"24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n : agitated despite zyprexa,responded to haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\n Ciprofloxacin - 09:22 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 08:50 PM\n Haloperidol (Haldol) - 10:17 PM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 90 (76 - 96) bpm\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 9 (-2 - 16)mmHg\n Total In:\n 3,706 mL\n 210 mL\n PO:\n TF:\n 1,658 mL\n 190 mL\n IVF:\n 1,908 mL\n 20 mL\n Blood products:\n Total out:\n 4,140 mL\n 170 mL\n Urine:\n 4,140 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Agitated and disoriented.\n Started zyprexa. Restraints prn Additional Haldol.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment ? OR tomorrow.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\n Lines:\n Multi Lumen - 01:30 PM\n Disposition:\n Total time spent:\n"},{"category":"Physician ","chartdate":"2146-01-13 00:00:00.000","description":"Intensivist Note","row_id":506649,"text":"TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/24 h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\n RSBI 30s this AM.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation. Pt\n following commands on precidex, but seems confused at times, will plan\n to extubate this AM.\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\n prolognation (haldol and quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\n hospitalization. s/p IVC filter.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n () x 14 day course.\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\n Wounds: Soft compartments, will monitor.\n Imaging: None planned\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Addiction Med\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 32 mins\n"},{"category":"Rehab Services","chartdate":"2146-01-13 00:00:00.000","description":"Physical Therapy Progress Note","row_id":506746,"text":"Subjective:\n I will try to get OOB\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise\n Updated medical status: s/p Wash out of RLE c ext fix\n manipulation. Head CT - . Extubated this AM.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NT\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n for RLE\n\n\n\n T\n\n\n Transfer:\n T Transfer Bed to Chair\n\n\n\n T\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 83\n 112/62\n 16\n 100% 2LO2\n Activity\n Sit\n 86\n 102/60\n 24\n 95 RA\n Recovery\n Sit\n 82\n 98/50\n 20\n 100% 2LO2\n Total distance walked:\n Minutes:\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\n 1 UE support.\n Education / Communication: c RN RE Pt Status\n Pt RE Rehab Process\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\n ROM L knee 0-40 c hard endfeel\n Pain: B LE c mobility\n MS . Able to follow commands. Reported date at .\n Orientated to self and .\n HOH\n Assessment: Pt is a 51M with multiple fractures presents with continues\n limitations in mobility.\n Anticipated Discharge: Rehab\n Plan:\n"},{"category":"Rehab Services","chartdate":"2146-01-13 00:00:00.000","description":"Physical Therapy Initial Evaluation","row_id":506755,"text":"TITLE: Rehab Services Physical Therapy Evaluation \n Attending Physician:\n date: \n Medical Diagnosis / ICD 9: 959.9 /\n Reason of : eval and treat\n History of Present Illness / Subjective Complaint: 50 m adm from osh\n s/p ped struck by car sustaining R open ankle fx, L distal femur fx and\n 2nd and 3rd rib fractures. -LOC, +ETOH. Intubated dt's and w/d from\n etoh. OR for ORIF L femur, ex fix placement R ankle, IVC filter\n placed. Extubated . Plan for return to OR in near future for ORIF\n RLE.\n Past Medical / Surgical History: unclear\n Medications: Acetaminophen\n Pantoprazole\n Glucagon\n Cyanocobalamin\n Nicotine Patch\n Metoprolol Tartrate\n Heparin\n HYDROmorphone (Dilaudid)\n Piperacillin-Tazobactam\n Ciprofloxacin\n Clonidine Patch\n Thiamine\n FoLIC Acid\n Multivitamins\n Olanzapine\n Radiology: Five views of the right tibia and fibula and ankle show\n comminuted\n oblique fractures of the distal tibia and fibula. There is lateral and\n anterior subluxation of the distal tibia and fibula as well as foot\n relative\n to the proximal lower extremity. The talar dome is smooth. The distal\n fibula\n is slightly medially displaced, projecting over the ankle mortise.\n Limited\n views of the knee joint are unremarkable. There is no radiopaque\n foreign\n body.\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as\n above.\n Four views of the left femur reveal a comminuted fracture of the distal\n femoral diaphysis. There is posterior and slight lateral displacement\n of the\n distal femur relative to the proximal. There is no evidence of\n intra-articular extension. A faint lucency seen at the fibular head\n suggests\n a non-displaced fracture in that location as well. A small of\n bone at\n the lateral margin of the proximal tibia suggests avulsion injury.\n There is\n no radiopaque foreign body.\n Labs:\n 32.9\n 11.7\n 161\n 8.0\n Other labs:\n Activity Orders: NWB RLE, TDWB LLE, unlocked, ROM ok. oob to\n chair.\n Social / Occupational History: ? homeless.\n Living Environment: difficult to obtain history confusion\n Prior Functional Status / Activity Level: presumed I.\n Objective Test\n Arousal / Attention / Cognition / Communication: Awake, speaking\n non-sensically t/o eval. Inconsistently following commands but with\n limited attention span.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 80\n 130/82\n 16\n 97% RA\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: even coordinated breathing pattern\n Integumentary / Vascular: R LE with ex fix, large incision at joint\n line medially, healing well. L LE with brace, DSD, no drainage.\n +edema B feet. NGT, foley, central line\n Sensory Integrity: difficult to assess formally. responds to touch in\n all extremities\n Pain / Limiting Symptoms: c/o pain but then laughing as I ranged his L\n knee. otherwise no c/o pain\n Posture: received supine in bed\n Range of Motion\n Muscle Performance\n WFL x: R ankle ex fix, L knee range 0-25degrees. + guarding\n BUE >/= \n moving R LE against gravity, moves B toes, guarding with L knee/quads,\n able to slr B\n Motor Function: isolates through function. not following commands to\n formally test. ? clonus LLE\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total A to roll and slide to stretcher chair to sit\n up. RN, pt moving on his own in the bed, but not to command\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: deferred\n Education / Communication: pt ed: role of PT, importance of ROM\n case discussed with RN and MD\n Intervention: ROM L knee\n Other:\n Diagnosis:\n 1.\n Knowledge, Impaired\n 2.\n Muscle Performace, Impaired\n 3.\n Range of Motion, Impaired\n 4.\n Transfers, Impaired\n Clinical impression / Prognosis: 50 m s/p ped struck with multiple LE\n injuries presents with above associated with fracture. His current\n situation is limited by confusion and inabiliyt to follow commands\n consistently. Given his age and lack of UE involvement feel that he has\n good potential to be I at a w/c level until his WB status is progressed\n provided his mental status clears a bit. Overall he ahs good potential\n to return to functional ambulation in weeks given success of\n internal fixation, young age and lack of other apparent comorbiidiites.\n This will all depend on resolution of cognitive function. The patient\n will require inpatient rehab to maximize function although ? if\n insurance constraints will prohibit this? rec OT consult.\n Goals\n Time frame: 1 week\n 1.\n increase ROM L knee 0-65\n 2.\n follow 50% simple commands\n 3.\n sit eob iwth max a\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 4-6x/wk\n ROM L knee\n eob activity\n d/c planning\n pt ed: rom, therex\n strengthening/ exercises for LE's with coop student (therex, rom)\n consult OT\n w/c training\n time: 10:15-10:45\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":506814,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":506744,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506312,"text":"51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506321,"text":"51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 with sitter\n"},{"category":"Physician ","chartdate":"2146-01-12 00:00:00.000","description":"Physician Surgical Progress Note","row_id":506382,"text":"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\n w/d.\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 07:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Metoprolol - 12:37 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 93 (76 - 100) bpm\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\n RR: 13 (13 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 39 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 39 mL\n Blood products:\n Total out:\n 3,795 mL\n 215 mL\n Urine:\n 3,795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n -176 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\n agitation\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 390 K/uL\n 9.1 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 107 mEq/L\n 140 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n Plt\n 199\n 226\n 259\n \n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n TCO2\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\n s-levofloxacin,meropenem,cefipime and H.influenzae\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n"},{"category":"Physician ","chartdate":"2146-01-12 00:00:00.000","description":"Physician Surgical Progress Note","row_id":506474,"text":"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\n w/d.\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 07:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Metoprolol - 12:37 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 93 (76 - 100) bpm\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\n RR: 13 (13 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 39 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 39 mL\n Blood products:\n Total out:\n 3,795 mL\n 215 mL\n Urine:\n 3,795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n -176 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\n agitation\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 390 K/uL\n 9.1 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 107 mEq/L\n 140 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n Plt\n 199\n 226\n 259\n \n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n TCO2\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\n s-levofloxacin,meropenem,cefipime and H.influenzae\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-13 00:00:00.000","description":"Nursing Progress Note","row_id":506738,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Transfer Note","row_id":506313,"text":"51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"},{"category":"Physician ","chartdate":"2146-01-12 00:00:00.000","description":"Physician Surgical Admission Note","row_id":506554,"text":"Chief Complaint: HD12 POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix\n right ankle ORIF left femur , now s/p ORIF L distal femur fx and\n IVC filter . S/p washout .\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter . S/p\n washout .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Other medications:\n Clonidine Patch\n Precedex\n Dilaudid\n Haldol\n Past medical history:\n Family / Social history:\n PMH:ETOH abuse,Varicose veins, o/w unknown.\n PSH:Ex fix/ wahout right ankle\n :Unk\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\n Flowsheet Data as of 08:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 76 (69 - 106) bpm\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\n RR: 16 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 2,689 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 2,689 mL\n Blood products:\n Total out:\n 3,795 mL\n 1,705 mL\n Urine:\n 3,795 mL\n 1,555 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress, Sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 455 K/uL\n 9.7 g/dL\n 125 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 30.2 %\n 12.3 K/uL\n [image002.jpg]\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n Plt\n 199\n 226\n 259\n \n 455\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n TCO2\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n 125\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Needs frequent re-orientation\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\n intubated.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Gastrointestinal: NGT feeding.\n Renal: Foley, monitor UOP\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Endocrine: RISS. Euthyroid\n Fluids: thiamine, d5, folate\n Electrolytes:\n Nutrition: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n General:\n ICU Care\n Nutrition:\n Comments: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2146-01-12 00:00:00.000","description":"Physician Surgical Admission Note","row_id":506555,"text":"Chief Complaint: HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7 \n plate left femur and washout R ankle and IVC filter, POD 0 washout RLE.\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 0 washout RLE.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Other medications:\n Clonidine Patch\n Precedex\n Dilaudid\n Haldol\n Past medical history:\n Family / Social history:\n PMH:ETOH abuse,Varicose veins, o/w unknown.\n PSH:Ex fix/ wahout right ankle\n :Unk\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\n Flowsheet Data as of 08:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 76 (69 - 106) bpm\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\n RR: 16 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 2,689 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 2,689 mL\n Blood products:\n Total out:\n 3,795 mL\n 1,705 mL\n Urine:\n 3,795 mL\n 1,555 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress, Sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 455 K/uL\n 9.7 g/dL\n 125 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 30.2 %\n 12.3 K/uL\n [image002.jpg]\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n Plt\n 199\n 226\n 259\n \n 455\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n TCO2\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n 125\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Needs frequent re-orientation\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\n intubated.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Gastrointestinal: NGT feeding.\n Renal: Foley, monitor UOP\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Endocrine: RISS. Euthyroid\n Fluids: thiamine, d5, folate\n Electrolytes:\n Nutrition: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n General:\n ICU Care\n Nutrition:\n Comments: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Rehab Services","chartdate":"2146-01-13 00:00:00.000","description":"Bedside Swallowing Evaluation","row_id":506729,"text":"TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 51 y/o male who initially\npresented to OSH s/p being an intoxicated pedestrian struck by a\ncar at unknown speed, ?+LOC. Patient found with open tib/fib fx,\nL distal femur fx. Patient was transferred to on \nfor further management and underwent irrigation and debridement\nof soft tissue, muscle including bone of the right distal tibia\nopen fracture and application of multiplanar external fixator to\nthe right lower extremity. Patient underwent inferior vena caval\nfilter placed by the right femoral route and open reduction,\ninternal fixation of left supracondylar femur fracture on\n. hospital course c/b hypertension,\nagitation/delirium, and tachycardia c/w EtOH withdrawal. Patient\nwas successfully extubated this am and we were consulted to\nevaluate patient's oral and pharyngeal swallowing function and\nr/o aspiration while eating and drinking. RN reported patient was\nnoted with coughing on water this am following extubation.\nPMH: unknown\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the TSICU.\nCognition, language, speech, voice: Patient was sleeping upon\narrival, easily aroused to voice, however remained fatigued and\nwas able to fall asleep instantly when not stimulated. Patient\nwas oriented to self and \" Hospital\" when asked but\nwas noted with confusion when he later asked a question about\nwhere he was and asked other nonsensical questions. Patient was\nable to follow most basic commands with max cues and models.\nSpeech was fluent and somewhat unintelligible for long\nutterances. Voice was significantly hoarse and ? close to\nbaseline.\nTeeth: poor sparse dentition remaining, no dentures\nSecretions: dry oral cavity, productive baseline cough\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual ROM, and\nbuccal tone. Mildly reduced lingual strength. Palatal elevation\nwas symmetrical. Gag deferred to maintain rapport.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp), nectar thick\nliquids via straw, bites of puree, ground solid, and a bite of \n cracker. Oral phase was remarkable for prolonged, however\nfunctional mastication of regular solid poor dentition, with\nnormal oral residue remaining. Laryngeal elevation felt adequate\nto palpation. Immediate wet vocal quality and delayed coughing\nnoted on ice chips and thin liquid trials. One delayed cough was\nnoted on regular solids followed by nectar thick liquid. No\nfurther throat clearing, coughing, or choking noted. O2 sats\nremained stable at 96%. Patient denied the sensation of PO stuck\nin his throat.\nSUMMARY / IMPRESSION:\nMr. presents with confusion and lethargy and overt s/sx of\naspiration on thin liquids as evidenced by wet vocal quality and\ndelayed coughing, consistent with symptoms usually seen\nimmediately post-extubation. Patient's mastication of regular\nsolids was prolonged poor dentition and he was noted with\ncoughing on the dry, crumbly solid when followed by nectar thick\nliquids. Recommend initiating a PO diet of nectar thick liquids\nand ground solids at this time with 1:1 supervision and only when\npatient is most awake and alert. We will return tomorrow to\nrepeat the evaluation to determine if patient's diet may be\nupgraded given more time to recover from acute extubation.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 5 out of 7.\nRECOMMENDATIONS:\n1. PO diet of nectar thick liquids and ground solids.\n2. Pills whole or crushed with puree.\n3. 1:1 supervision with POs, please give only when most awake and\nalert, seated upright in bed.\n4. Q6 oral care.\n5. We will return tomorrow to repeat the evaluation to determine\nif patient's diet may be upgraded given more time to recover from\nacute extubation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1335-1350\nTotal time: 50 minutes\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":505896,"text":"Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused and agitated most of night, oriented to self,\n continually tries to get out of bed, says:\nI have to go to \nI need my money\n. Hard to redirect. When told he is in the hospital\n patient looks shocked. Consistently putting legs over side rail.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Given 5 mg Olanzapine for agitation.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night, more calm after olanzapine given.\n Plan:\n Continue to monitor, reorient frequently.\n"},{"category":"Respiratory ","chartdate":"2146-01-13 00:00:00.000","description":"Respiratory Care Shift Note","row_id":506616,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Nutrition","chartdate":"2146-01-13 00:00:00.000","description":"Clinical Nutrition Note","row_id":506709,"text":"Subjective\n on facemask\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 91.1 kg ( 03:00 AM)\n 28.2\n Pertinent medications: Dextrose 5 normal saline with KCl, IV abx, folic\n acid, Vit B12, multivitamin, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 95 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 148\n 08:00 AM\n BUN\n 12 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 142 mEq/L\n 02:30 AM\n Potassium\n 4.4 mEq/L\n 02:30 AM\n Chloride\n 110 mEq/L\n 02:30 AM\n TCO2\n 26 mEq/L\n 02:30 AM\n PO2 (arterial)\n 184 mm Hg\n 10:45 PM\n PCO2 (arterial)\n 40 mm Hg\n 10:45 PM\n pH (arterial)\n 7.43 units\n 10:45 PM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 10:45 PM\n Calcium non-ionized\n 8.2 mg/dL\n 02:30 AM\n Phosphorus\n 3.1 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.1 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 9.6 K/uL\n 02:30 AM\n Hgb\n 8.8 g/dL\n 02:30 AM\n Hematocrit\n 29.1 %\n 08:13 AM\n Current diet order / nutrition support: Replete with Fiber @ 95 ml/hr =\n 2280 kcals/ 141 g protein\n GI: soft, +bowel sounds\n Assessment of Nutritional Status\n Specifics: Patient s/p washout RLE and internal fixation on .\n Patient received tube feeding over night, held for extubation this\n morning and currently running at 50 ml/hr and plan to advance to goal\n which provides 100% of nutritional needs. SLP consulted for swallow\n eval. If patient passes SLP eval he will likely need tube feedings as\n patient is delirious and will not meet needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance to goal Replete with Fiber @ 95 ml/hr\n 2. Implement any SLP recommendations\n 3. Check chemistry 10 daily and replete prn\n 4. Will follow page with questions\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":506098,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve nursing services at\n"},{"category":"Social Work","chartdate":"2146-01-13 00:00:00.000","description":"Social Work Progress Note","row_id":506708,"text":"Social Work:\n Rec\nd POE on this 51 yr-old man adm s/p ped struck. Pt w/R leg fx, s/p\n ORIF and IVC filter placement. +ETOH w/BAL=275 upon admit. Pt is\n homeless by report, 1 cousin locally (please see note by \n , LICSW, for family info). Mother, sisters in , but\n none involved in his care.\n Unable to interview pt today to his being somnolent and confused.\n Also, his RN, , pt scheduled for another surgery soon. At\n this point, his needs unclear & he is unable to participate in\n interview.\n SW will follow & assess coping, address substance abuse issue and offer\n resources around latter. If pt does not need or qualify for rehab, will\n assess options & provide info re: shelters. Please page PRN.\n , LICSW\n #\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506278,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0\n Action:\n Continue with oral zyprexa and prn haldol an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho ? callout tomorrow if agitation is better\n"},{"category":"Rehab Services","chartdate":"2146-01-11 00:00:00.000","description":"Physical Therapy Progress Note","row_id":506286,"text":"Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for other:\n Updated medical status: no new imaging\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 74\n 120/67\n 96% on RA\n Activity\n 86\n /\n 94% on RA\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Gait: not assessed\n Balance: not assessed\n Education / Communication: Patient lethargic, sleeping throughout tx\n session. Communicated with nsg re: status.\n Other: L knee PROM 0-30 in \n Patient stirring but not awakening with ROM\n Assessment: 57 yo M pedestrian struck with multiple fxs, making minimal\n progress in PT, today limited by lethargy and not participatory in PT\n session. Tolerated ROM to L knee, mobility not assessed. D/c plan\n remains tentative given his cognition at this time, PT to continue to\n follow to progress as able.\n Anticipated Discharge: Rehab\n Plan: continue with POC\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507596,"text":"S/P MVA, was hit by car , s/p external fixation of right leg\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\n DT\ns from ETOH.\n Code purple called on CC6 0300 this am.\n Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixation device against side rails.\n Oriented only to himself, believes he is at a church, or outside with\n his\nbuddies\n asking for cigarettes and beer, believes he hasn\nt been\n in the hospital. Agitated and combative.\n Action:\n Security called for assistance this am, patient fighting to get out of\n restraints,\n Patient calmly reassured and reoriented frequently,\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\n initiated,\n Psych in to assess, Psych CNS ( ) in to assess (valium and\n ativan d/c\nd, will give haldol for psychosis although QT has been\n 0.40-0.47, it is normally in this range for patient)\n QTC checked twice\n during shift.\n Turned and repositioned for comfort, offered food, liquids.\n Response:\n Haldol effective, patient able to nap after given.\n Continues to be confused and wake up agitated,\n QTC < 0.50.\n Plan:\n Continue to monitor, do not give benzo\ns, treat agitation with haldol,\n check QTC frequently. Daily EKG\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507584,"text":"S/P MVA, was hit by car , s/p external fixation of right leg\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\n DT\ns from ETOH.\n Code purple called on CC6 0300 this am.\n Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixation device against side rails.\n Oriented only to himself, believes he is at a church, or outside with\n his\nbuddies\n asking for cigarettes and beer, believes he hasn\nt been\n in the hospital. Agitated and combative.\n Action:\n Security called for assistance this am, patient fighting to get out of\n restraints,\n Patient calmly reassured and reoriented frequently,\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\n initiated,\n Psych in to assess, Psych CNS ( ) in to assess (valium and\n ativan d/c\nd, will give haldol for psychosis although QT has been\n 0.40-0.47, it is normally in this range for patient)\n QTC checked twice\n during shift.\n Turned and repositioned for comfort, offered food, liquids.\n Response:\n Haldol effective, patient able to nap after given.\n Continues to be confused and wake up agitated,\n QTC < 0.50.\n Plan:\n Continue to monitor, do not give benzo\ns, treat agitation with haldol,\n check QTC frequently. Daily EKG\n"},{"category":"Nursing","chartdate":"2146-01-10 00:00:00.000","description":"Nursing Progress Note","row_id":505860,"text":"Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused, oriented to self, continually tries to get out of\n bed, says:\nI have to go to \nI need my money\n. Hard to\n redirect at times. When told he is in the hospital patient looks\n shocked.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night.\n Plan:\n Continue to monitor.\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506155,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - remains delirious and agitated\n - oriented to person only but unable to answer any orientation\n questions and speech is mostly nonsensical\n - speech at times sounds slurred but clears when patient\n coughs and clears secretions\n - + congested cough, @ times able to clear independently but\n occasionally requiring subglottal suctioning\n - tube feeds at goal\n - right lower extremitie with insision weeping sangounous\n fluid\n - right pin site leaking serous fluid\n - + cms to bil lower extremities\n Action:\n - reoriented\n - restraints applied, 1:1 sitter at bedside, haldol given in\n addition to standing and prn Zyprexa\n - ivf changed to kvo\n - dressing applied to leaking pin site\n - primary team aware of drainage to right lower extremity\n Response:\n - minimal effect with reorientation\n - at times calmer after haldol but lasting for only short\n periods of time\n Plan:\n - continue to monitor mental status and maintain safety\n - continue on iv abx for pneumonia\n - or for internal fixation of right lower extremity later this\n week\n"},{"category":"Nursing","chartdate":"2146-01-11 00:00:00.000","description":"Nursing Progress Note","row_id":506271,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-12 00:00:00.000","description":"Nursing Progress Note","row_id":506525,"text":"50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix and L\n femur ORIF and s/p IVC filter. Hospital course c/b ETOH w/d.\n Trauma, s/p\n Assessment:\n Pt to go to OR today for wash out of RLE & manipulation of external\n fixation device, pt npo after MN for OR, pt with increased agitation\n last noc & pulled out NGT, 0600 dose of po zyprexa not given d/t\n pending CXR to confirm placement after NGT re-inserted, pt with minimal\n c/o pain but increased agitation noted throughout day, agitation not\n controlled by prn IM zyprexa, pt on RA with RA sat 95-97, afebrile &\n VSS\n Action:\n Ho aware of increased agitation, NGT placement ok per cxr & po ATC\n zyprexa given, psych nurse called & up to eval pt d/t\n dilerium/psychosis, 5 mg iv haldol given x 2 with minimal sedative\n effect, po ATC haldol started, pt intubated @ bedside @ 1400 prior to\n OR d/t increased agitation, propofol gtt started, post intubation cxr\n done\n Response:\n Sedated on 40 mic/kg/min propofol gtt, pt off to OR @ 1630\n Plan:\n Keep intubated post op in order to keep pt sedated for head ct this PM\n to eval mental status change, transfer to TSICU from OR, post op care,\n ? extubation tomorrow\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504206,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Action:\n Ciwa scale q1hr\n Valium iv q1hr.\n Response:\n Alcohol withdrawal continues.\n Plan:\n Continue with ciwa scale\n Valium iv as ordered.\n Maintain safe environment.\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Ciwa scale q1hr\n Valium 10mg q1 hr\n Iv lactated ringers at 125cc/hr.\n Npo aftermidnoc for or today.\n Pedal pulses check q 2hrs on right and left feet.\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"},{"category":"Nursing","chartdate":"2146-01-06 00:00:00.000","description":"Nursing Progress Note","row_id":504871,"text":"Trauma, s/p leg fractures\n Assessment:\n Febrile to 102\n Tachycardic to low 100\ns with PVC\n Diaphoretic\n Sedated on Propofol\n Period of hypotension\n HCT and electrolytes checked\n Adequate urine output 45-100 cc\ns/hr.\n Dopplerable pulses bilateral lower extremities\n Action:\n X1 peripheral BC, U/A, C+S, and sputum samples sent\n Valium x1 given\n Dilaudid x1 given\n Lr 500 cc fluid bolus for hypotension\n Magnesium and calcium repleated\n Propofol stopped for daily wakeup, patient biting on ETT, no other\n purposeful movement noted.\n Response:\n Fluid balance for + 3 liters\n No further signs of DT\ns / tremors after valium given\n Plan:\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504309,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Patient bilateral legs pulses by Doppler left leg in traction with\n pin sites right leg femur fracture with leg brace on + csm multiple\n scrapes and bruising.\n Action:\n Pin site cleaning done with\n normal saline and peroxide.\n Response:\n Patient remains stable\n Plan:\n Continue to monitor notify team of any changes provide comfort and\n support as needed\n Alcohol abuse\n Assessment:\n Patient alert and orientated X1\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2146-01-06 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504865,"text":"24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Post operative day:\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Pantoprazole (Protonix) - 08:02 PM\n Hydromorphone (Dilaudid) - 08:02 PM\n Diazepam (Valium) - 10:50 PM\n Metoprolol - 12:15 AM\n Other medications:\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1316 19.\n Metoprolol Tartrate 5 mg IV Q6H\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\n DAILY Order date: @ 1316\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\n Order date: @ 1316\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\n TO SEDATION Order date: @ 1316\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\n hold oral thiamine, folate and multivitamins. Order date: \n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.5\nC (101.3\n HR: 96 (72 - 101) bpm\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\n RR: 25 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 5,831 mL\n 655 mL\n PO:\n TF:\n IVF:\n 5,831 mL\n 655 mL\n Blood products:\n Total out:\n 2,520 mL\n 425 mL\n Urine:\n 1,580 mL\n 425 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 3,311 mL\n 230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 530) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI: 72\n PIP: 21 cmH2O\n Plateau: 25 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/43/120/28/3\n Ve: 14.3 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Clubbing\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n WBC\n 8.7\n 7.5\n 8.7\n 9.7\n Hct\n 29.5\n 29.8\n 28.7\n 26.8\n 28.1\n Plt\n 141\n 154\n 169\n 169\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n Glucose\n 97\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean sedation to attempt vent wean\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr (). Febrile - pan cultured.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Total time: 35 min\n"},{"category":"Physician ","chartdate":"2146-01-04 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504369,"text":"24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:00 PM\n Metoprolol - 03:59 PM\n Haloperidol (Haldol) - 05:00 PM\n Pantoprazole (Protonix) - 08:20 PM\n Enoxaparin (Lovenox) - 09:00 PM\n Hydromorphone (Dilaudid) - 09:30 PM\n Diazepam (Valium) - 12:00 AM\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 75 (73 - 144) bpm\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\n RR: 16 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,909 mL\n 30 mL\n PO:\n TF:\n IVF:\n 3,909 mL\n 30 mL\n Blood products:\n Total out:\n 2,450 mL\n 40 mL\n Urine:\n 2,450 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,459 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 602 (502 - 602) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.45/43/454/28/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 1,135\n Physical Examination\n General Appearance: No acute distress, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 102 mEq/L\n 138 mEq/L\n 26.0 %\n 9.3 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n WBC\n 8.9\n 9.3\n Hct\n 35.1\n 26.0\n Plt\n 204\n 152\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n Glucose\n 120\n 129\n 124\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments.\n Neuro:sedated with propofol\n Pain: dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx.Intubated \n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n ICU Care\n Lines:\n 20 Gauge - 07:10 PM\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-01 00:00:00.000","description":"Nursing Progress Note","row_id":503913,"text":"Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p pedestrian struck\n Assessment:\n Pt admitted from ED overnight, pedestrian struck, not intubated, GCS\n 15. Multiple ortho injuries. Vss, O2 sats 97%. Rt leg splinted, left\n knee with immobilizer on.\n Action:\n Pulse checks/Csm, turn and reposition.\n Response:\n No changes, pt stable, good pulses, csm\n Plan:\n Cont to monitor, OR in a.m. to repair open tib/fib on rt.\n Alcohol abuse\n Assessment:\n Pt with long hx of ETOH abuse. Per pt 12 pack a day of beer. Etoh\n levels in the 400\n Action:\n Ciwa checks/valium ATC.\n Response:\n Pt doing ok, was diaphoretic and had a high ciwa scale this a.m. valium\n given.\n Plan:\n Cont to monitor, medicate prn\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504200,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"},{"category":"Nursing","chartdate":"2146-01-07 00:00:00.000","description":"Nursing Progress Note","row_id":505245,"text":"Trauma, s/p\n Assessment:\n Temp 100.7 to 98.8 po\n HR 90\ns nsr\n Sbp 140-150\ns when calm, hypertensive to 180\ns with stimulation such\n as suctioning\n Breath sounds clear but diminished in bases\n Suctioned for copious amounts thick yellow secretions\n Abd soft with + bowel sounds\n TF on hold for possible extubation\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Propofol off at 0900\n Very lethargic\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\n No visible sweats or tremors\n Action:\n CIWA scale done\n No valium given this shift\n Response:\n No evidence of DT\n Plan:\n Continue to monitor for DT\n ? d/c valium addiction RN recommendation\n"},{"category":"Nursing","chartdate":"2146-01-07 00:00:00.000","description":"Nursing Progress Note","row_id":505144,"text":"Trauma, s/p pedestrian struck, bilateral leg fractures and rib\n fractures\n Assessment:\n Low grade temps 100.7\n HR 80\ns, BP ~120-140\n Fluid balance MN -0500: Remains positive for length of stay.\n Dopplerable pedal pulses bilat\n Left leg with knee immobilizer, ace wrap with DSD under with old\n sero-sang drg.\n Ls clear with suctioning, tan sputum\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\n Not showing signs of ETOH withdrawl, no valium given this shift per\n CIWA scale\n Action:\n VAP protocol\n Pin care\n Repositioned q 2-3 hours\n ABX as ordered\n Tube feeds stopped in preparation for possible extubation.\n Response:\n HR and vitals acceptable\n Remains with low grade fever\n Concerning sputum\n HCT 25.3, no S+S of active bleeding.\n Plan:\n Wean to extubate\n"},{"category":"Nursing","chartdate":"2146-01-01 00:00:00.000","description":"Nursing Progress Note","row_id":503895,"text":"Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"},{"category":"Nursing","chartdate":"2146-01-01 00:00:00.000","description":"Nursing Progress Note","row_id":503897,"text":"Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"},{"category":"Nursing","chartdate":"2146-01-01 00:00:00.000","description":"Nursing Progress Note","row_id":503909,"text":"Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"},{"category":"Social Work","chartdate":"2146-01-03 00:00:00.000","description":"Social Work Progress Note","row_id":504294,"text":"Social Work:\n Consult received from team.\n Pt is sicu this pm; pt is agitated, not able to communicate clearly\n this am. He is trying to get out of bed, etc.\n According to record pt is 51 y/o man admitted from \n after sustaining injuries after being hit by a car. Pt reported to\n that he was homeless and stayed in , MA.\n Pt\ns cousin, came to hospital this pm. He states he\n was contact by orthopedic team and updated recently. Today pt is\n unable to clearly communicate relationship to cousin.\n Met w/ cousin separately. Mr. reports the following:\n Pt\ns name is spelled , not \n Pt has been living in shelters in area for many years,\n he most recently has been staying w/ a friend\n\n but family has no\n other information.\n Pt has a mother, and two sisters and \n all of whom live in . Another sister lives out of the\n country. Pt was married and divorced has two children but has had no\n contact w/ them for many years.\n Pt has had long hx of substance abuse according to cousin, primarily\n alcohol of late. Cousin believes that he has been at Highpointe in\n past for substance abuse treatment.\n Pt\ns cousin, can be reached at (cell #).\n He and his sister, left note for pt. They understand\n that we will be in touch w/ pt permission.\n Will follow.\n , licsw\n Pager \n"},{"category":"Physician ","chartdate":"2146-01-01 00:00:00.000","description":"Intensivist Note","row_id":503827,"text":"TITLE: Admission note/daily ICU progress note\n TSICU\n HPI:\n 50y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. B/l rib fx. No ptx. Questionable lesion on CT ? mass vs pna on R.\n VSS. Intoxicated with ETOH in 400's at Hospital. Denies PMHx,\n but intoxicated.\n Chief complaint:\n b/l LE fractures, intoxication\n PMHx:\n unk - denies\n Current medications:\n denies\n 24 Hour Events:\n admitted to TSICU\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n 1. 1000 mL LR 2. CefazoLIN 3. Diazepam 4. Famotidine 5. FoLIC Acid 6.\n Gentamicin 7. Heparin 8. Morphine Sulfate\n 9. Multivitamins 10. Thiamine\n Other medications:\n Flowsheet Data as of 03:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 36.3\nC (97.3\n HR: 87 (87 - 93) bpm\n BP: 110/69(79) {110/69(79) - 120/73(84)} mmHg\n RR: 12 (9 - 14) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 420 mL\n Urine:\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -420 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: R posterior)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, patient intoxicated.\n Labs / Radiology\n [image002.jpg]\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: pending\n Assessment and Plan\n Assessment and Plan: 50y M ped vs auto with multiple orthopedic\n injuries, rib fractures. Intoxicated, unclear medical history.\n Neurologic: awake, alert, neuro intact, following commands. Denies\n seizure history with withdrawl. Valium CIWA prn.\n Cardiovascular: stable, to monitor\n Pulmonary: stable on nasal cannula. rib fx but no ptx.\n Gastrointestinal / Abdomen: NPO for OR tomorrow\n Nutrition: thiamine, folate IV\n Renal: foley, monitor UOP\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: s/p gent/zosyn/ancef. wash out in OR by ortho\n planned for am.\n Wounds: R tib/fib open fracture with dressing in place. Will be removed\n in OR.\n Imaging:\n Fluids: LR\n Consults: Ortho\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:09 AM\n 18 Gauge - 03:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"},{"category":"Physician ","chartdate":"2146-01-03 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504188,"text":"TITLE:\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 01:39 AM\n Other medications:\n Enoxaparin Sodium 30 mg SC Q12H\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n CloniDINE 0.3 mg PO TID\n Cyanocobalamin 50 mcg PO/NG DAILY\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Flowsheet Data as of 02:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.8\nC (100\n HR: 150 (124 - 150) bpm\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,280 mL\n 279 mL\n PO:\n TF:\n IVF:\n 1,280 mL\n 279 mL\n Blood products:\n Total out:\n 105 mL\n 150 mL\n Urine:\n 105 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,175 mL\n 129 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\n agitated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\n dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Absent, ex fix right leg, left leg in splint\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR: left base in the retrocardiac region, likely\n atelectasis\n Microbiology: U cx P\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments.\n Neuro checks Q: 1\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal:\n ICU Care\n Nutrition:\n Comments: Npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:53 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504271,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2146-01-08 00:00:00.000","description":"Physician Surgical Progress Note","row_id":505353,"text":"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n MULTI LUMEN - START 01:30 PM\n FEVER - 101.6\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Ciprofloxacin - 09:56 AM\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:54 PM\n Pantoprazole (Protonix) - 08:32 PM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Flowsheet Data as of 01:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.9\nC (100.3\n HR: 91 (83 - 100) bpm\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\n RR: 28 (21 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (11 - 16)mmHg\n Total In:\n 2,933 mL\n 109 mL\n PO:\n TF:\n 454 mL\n 52 mL\n IVF:\n 2,479 mL\n 57 mL\n Blood products:\n Total out:\n 2,930 mL\n 0 mL\n Urine:\n 2,930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (411 - 624) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.45/45/132/27/7\n Ve: 10.7 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: bases)\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 199 K/uL\n 8.5 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 25.3 %\n 8.0 K/uL\n [image002.jpg]\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n WBC\n 9.7\n 8.0\n Hct\n 26.8\n 28.1\n 25.3\n Plt\n 169\n 199\n Cr\n 0.7\n 0.6\n 0.6\n TCO2\n 28\n 27\n 29\n 26\n 29\n 32\n Glucose\n 87\n 104\n 121\n 128\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\n Fiber (Full) - 04:00 PM 50 mL/hour\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505419,"text":"pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil move slowly.\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Remains off all sedation.\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505408,"text":"pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"},{"category":"Physician ","chartdate":"2146-01-02 00:00:00.000","description":"Physician Surgical Admission Note","row_id":504170,"text":"TITLE:\n Chief Complaint: Withdrawal from ETOH\n HPI:\n 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: ETOH abuse,Varicose veins, othewise unk\n PSH: Ex fix/ wahout right ankle\n Meds at home: Denies\n All: Denies\n SH: homeless history of ETOH 12 beers/ day but denies withdrawal\n seizures ( per prior notes)\n FH:unk\n Flowsheet Data as of 09:56 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.3\nC (100.9\n HR: 124 (124 - 124) bpm\n BP: 134/87(98) {134/87(98) - 134/87(98)} mmHg\n RR: 27 (27 - 27) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 729 mL\n PO:\n TF:\n IVF:\n 729 mL\n Blood products:\n Total out:\n 1,150 mL\n 30 mL\n Urine:\n 1,150 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n -421 mL\n -30 mL\n Respiratory support\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Anxious, Diaphoretic, Confused\n Eyes / Conjunctiva: injected conjunctiva\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Tachycardic to 120-130s\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), Bilateral\n DP dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Trace, LEft leg in brace, Right ankle with ex fix in place\n bialteral feet warm with intact sensation\n Skin: Warm, flushed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x1 to self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n Microbiology: Ucx P\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE with active withdrawal and disorientation\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn.\n Neuro checks Q: 1\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines: PIV x 2\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: NA\n Need for restraints reviewed Y\n Comments:\n Communication: Comments: ICU consent deferred due to poor MS\n status: Full code\n Disposition: ICU\n Total time spent:\n"},{"category":"Physician ","chartdate":"2146-01-03 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504251,"text":"TITLE:\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\n s/p Ex-fix R tib/fib ID and ex fix right ankle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 01:39 AM\n Other medications:\n Enoxaparin Sodium 30 mg SC Q12H\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n CloniDINE 0.3 mg PO TID\n Cyanocobalamin 50 mcg PO/NG DAILY\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Flowsheet Data as of 02:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.8\nC (100\n HR: 150 (124 - 150) bpm\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,280 mL\n 279 mL\n PO:\n TF:\n IVF:\n 1,280 mL\n 279 mL\n Blood products:\n Total out:\n 105 mL\n 150 mL\n Urine:\n 105 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,175 mL\n 129 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\n agitated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\n dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Absent, ex fix right leg, left leg in splint\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR: left base in the retrocardiac region, likely\n atelectasis\n Microbiology: U cx P\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments. Neuro checks Q 1hr. Restrained.\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Start beta blockade\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n thiamine, folate for protection\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal:\n ICU Care\n Nutrition:\n Comments: Npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:53 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 35\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2146-01-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":504350,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: periods of agitation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2146-01-08 00:00:00.000","description":"Nursing Progress Note","row_id":505406,"text":"pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504335,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Patient bilateral legs pulses by Doppler left leg in traction with\n pin sites right leg femur fracture with leg brace on + csm multiple\n scrapes and bruising.\n Action:\n Pin site cleaning done with\n normal saline and peroxide.\n Response:\n Patient remains stable\n Plan:\n Continue to monitor notify team of any changes provide comfort and\n support as needed\n Alcohol abuse\n Assessment:\n Patient alert and orientated X1 very agitated not appropriate trying\n to climb out of bed heart to 120-130\ns b/p 140\ns over 80\n Action:\n Giving valium 10-20mg IV haldol X 1 and dilaudid with little effect\n patient intubated for increased agitation and DT\ns @ 1700\n Response:\n Patient less agitated and comfortable\n Plan:\n Continue with current plan of care notify team of any changes\n Please see social service note\n"},{"category":"Nursing","chartdate":"2146-01-04 00:00:00.000","description":"Nursing Progress Note","row_id":504490,"text":"Trauma, s/p\n Assessment:\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\n Patient is intubated and sedated on Propofol.\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\n am.\n Vital signs stable (HR 60-70, SBP 90\ns-100)\n When off prop patient tremulous, diaphoretic, inconsistently follow\n commands, able to move upper extremities.\n Action:\n Turned and repositioned for comfort.\n Pin care done, incisional dsg on right leg changed, moderate serosang\n drainage noted.\n Given 2 units PRBC.\n Given 1 mg Dilaudid q 4 hours for pain.\n Response:\n Patient continues to be intubated and sedated,\n Post transfusion HCT up to 25.5,\n Plan:\n Patient to go to OR for ORIF right tibia and left femur, 3 plates,\n and placement of IVC filter.\n Alcohol abuse\n Assessment:\n Last drink : Patient on CIWA scale despite being intubated and\n sedated. Moderate diaphoresis noted.\n Off sedation patient very tremulous, unable to follow commands\n consistently, agitated.\n Action:\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\n Response:\n Patient not as diaphoretic,\n Plan:\n Continue to monitor.\n"},{"category":"Nursing","chartdate":"2146-01-03 00:00:00.000","description":"Nursing Progress Note","row_id":504208,"text":"Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Patient has a long history of alcholol abuse. Patient drinks 12 beers\n /day\n Diaphoretic with heart rate 120-140\n Bp 140-150\ns syst.\n Action:\n Ciwa scale q1hr\n Valium iv q1hr.\n Response:\n Alcohol withdrawal continues.\n Ciwa scale\n Continue with valium iv .\n Plan:\n Continue with ciwa scale\n Valium iv as ordered.\n Maintain safe environment.\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Ciwa scale q1hr\n Valium 10mg q1 hr\n Iv lactated ringers at 125cc/hr.\n Npo aftermidnoc for or today.\n Pedal pulses check q 2hrs on right and left feet.\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"},{"category":"Nursing","chartdate":"2146-01-05 00:00:00.000","description":"Nursing Progress Note","row_id":504594,"text":"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Trauma, s/p\n Assessment:\n Action:\n Suctioned prn\n Vap mouth care as ordered\n On propofol gtt and infusing at 40mcg/hr.\n Iv lactatated ringers at 100cc/hr.\n Valium 10mg iv prn given\n Hydromorphone 1mg iv prn given.\n Response:\n Plan:\n Monitor condition closely.\n To or for femur repair\n Update cousin of patient\ns condition.\n"},{"category":"Physician ","chartdate":"2146-01-04 00:00:00.000","description":"Physician Surgical Progress Note","row_id":504438,"text":"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:00 PM\n Metoprolol - 03:59 PM\n Haloperidol (Haldol) - 05:00 PM\n Pantoprazole (Protonix) - 08:20 PM\n Enoxaparin (Lovenox) - 09:00 PM\n Hydromorphone (Dilaudid) - 09:30 PM\n Diazepam (Valium) - 12:00 AM\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 75 (73 - 144) bpm\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\n RR: 16 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,909 mL\n 30 mL\n PO:\n TF:\n IVF:\n 3,909 mL\n 30 mL\n Blood products:\n Total out:\n 2,450 mL\n 40 mL\n Urine:\n 2,450 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,459 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 602 (502 - 602) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.45/43/454/28/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 1,135\n Physical Examination\n General Appearance: No acute distress, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 102 mEq/L\n 138 mEq/L\n 26.0 %\n 9.3 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n WBC\n 8.9\n 9.3\n Hct\n 35.1\n 26.0\n Plt\n 204\n 152\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n Glucose\n 120\n 129\n 124\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\n .\n NEURO: Sedation with propofol. Significant valium requirements for ETOH\n withdrawal. Cpap/ PS.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx.Intubated \n GI: Npo will feed post procedure. Thiamine, folate, MVI via banana bag\n Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: Transfuse 2 unit preoperatively for hct 21. Check post hct.\n ENDO: RISS\n ID: Wash out in OR by ortho planned for am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n ICU Care\n Lines:\n 20 Gauge - 07:10 PM\n Total time spent: 32 min Delirium Tremens\n"},{"category":"Nursing","chartdate":"2146-01-04 00:00:00.000","description":"Nursing Progress Note","row_id":504430,"text":"Alcohol abuse\n Assessment:\n pt intubated and on propofol drip, pt is sedate but continues to have\n profound diaphoresis.\n Action:\n spoke with dr valium iv given. LR bolus 500 cc times one\n Response:\n decreased daphoresis with valium doses\n Plan:\n Assess for underlying symptoms of with drawal ie diphoresis,\n twitching, tremors and medicate prn. Please give medication for pain\n periodically.\n Trauma, s/p\n Assessment:\n rlower leg draining sero-sanguinous,left leg with knee brace in place\n Action:\n npo for OR ot day for repair . medicated for pain times 4 with .5 mg\n iv\n Response:\n difficult to evaluate for pain so medicate for pain periodically\n Plan:\n NPo for or today. hold enoxaprin sodium but if OR cancelled pt should\n receive doses.\n"},{"category":"Nutrition","chartdate":"2146-01-04 00:00:00.000","description":"Clinical Nutrition Note","row_id":504474,"text":"Subjective\n Unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 28.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 117%\n unknown\n Diagnosis: pedestrian struck, leg fractures\n PMHx: patient denies, per report drinks 12 beers/day\n Food allergies and intolerances: none noted\n Pertinent medications: Propofol drip, RISS, Pantoprazole, vitamin B12,\n Banana bag, KPhos 15mmol\n Labs:\n Value\n Date\n Glucose\n 83 mg/dL\n 04:13 AM\n Glucose Finger Stick\n 115\n 10:00 AM\n BUN\n 13 mg/dL\n 04:13 AM\n Creatinine\n 0.6 mg/dL\n 04:13 AM\n Sodium\n 137 mEq/L\n 04:13 AM\n Potassium\n 5.1 mEq/L\n 04:13 AM\n Chloride\n 105 mEq/L\n 04:13 AM\n TCO2\n 28 mEq/L\n 04:13 AM\n PO2 (arterial)\n 454 mm Hg\n 07:42 PM\n PCO2 (arterial)\n 43 mm Hg\n 07:42 PM\n pH (arterial)\n 7.45 units\n 07:42 PM\n CO2 (Calc) arterial\n 31 mEq/L\n 07:42 PM\n Calcium non-ionized\n 7.4 mg/dL\n 04:13 AM\n Phosphorus\n 4.3 mg/dL\n 04:13 AM\n Magnesium\n 2.2 mg/dL\n 04:13 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 8.3 K/uL\n 11:04 AM\n Hgb\n 8.4 g/dL\n 11:04 AM\n Hematocrit\n 25.5 %\n 11:04 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, (+) bowel sounds; OGT to low continuous suction\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NP, trauma, Etoh use PTA\n Estimated Nutritional Needs\n Calories: 2270-2455 (24-26 cal/kg)\n Protein: 113-142 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 51 YO homless male admitted to Hospital after struck by a car\n while walking intoxicated. Injuries including an open tibia/fibia on\n right and comminuted femur fracture on left; right rib fractures\n 2nd/3rd/ 12th. Questionable lesion on CT question mass versus pna on\n right. Transferred to for further management. Hypertension,\n change in MS, and tachycardia consistent with etoh withdrawal requiring\n >10 mg valium every hr prompting admission to ICU. Intubated for\n airway protection. Plan for OR today for ORIF right tibia/fibia, left\n femur. Remains NPO; propofol providing 750 calories. Questionable\n nutrition status PTA given homeless, report of Etoh use.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n NPO\n Multivitamin / Mineral supplement: continue current;\n multi-vitamin via enteral nutrition\n Tube feeding recommendations: When able begin nutrition\n support\n o Replete with Fiber @ 20ml/hr, advance as tolerated to goal of\n 65ml/hr + 15g Beneprotein = 1615 calories and 120g protein while\n propofol running\n o If propofol discontinued, can advance tube feed goal to\n 95ml/hr = 2280 calories and 141g protein\n o Check residuals, hold tube feed if greater than 200ml\n Check chemistry 10 panel daily\n o Replete lytes PRN\n BS management\n Will follow, page if questions *\n"},{"category":"Nursing","chartdate":"2146-01-04 00:00:00.000","description":"Nursing Progress Note","row_id":504524,"text":"Trauma, s/p\n Assessment:\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\n Patient is intubated and sedated on Propofol.\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\n am.\n Vital signs stable (HR 60-70, SBP 90\ns-100)\n When off prop patient tremulous, diaphoretic, unable to follow\n commands, able to move upper extremities.\n Action:\n Turned and repositioned for comfort.\n Pin care done, incisional dsg on right leg changed, moderate serosang\n drainage noted.\n Given 2 units PRBC.\n Given 1 mg Dilaudid q 4 hours for pain.\n Response:\n Patient continues to be intubated and sedated,\n Post transfusion HCT up to 25.5, given 2 more units PRBC.\n Plan:\n Patient to go to OR for ORIF right tibia and left femur , 3 \n plates, and placement of IVC filter tomorrow.\n Alcohol abuse\n Assessment:\n Last drink : Patient on CIWA scale despite being intubated and\n sedated. Moderate diaphoresis noted.\n Off sedation patient very tremulous, unable to follow commands\n consistently, agitated.\n Action:\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\n Response:\n Patient not as diaphoretic,\n Plan:\n Continue to monitor.\n"},{"category":"Respiratory ","chartdate":"2146-01-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":504526,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness not resolved\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507576,"text":"Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixationdevise against side rails.\n Oriented only to himself, believes he is at a church,\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2146-01-17 00:00:00.000","description":"Intensivist Note","row_id":507449,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Need frequent re-orientation\n with restriants. Haldol PO and IV prn.Ativan prn.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal. Reintubated for increasing\n agitation and in prep for OR\n GI: Regular.\n Nutrition: Thiamine, folate, MVI.\n RENAL:\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n :\n :\n"},{"category":"Physician ","chartdate":"2146-01-17 00:00:00.000","description":"Intensivist Note","row_id":507522,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\n - needed excessive valium. Now still delirious. Need frequent\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley.\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n :\n :\n"},{"category":"Physician ","chartdate":"2146-01-17 00:00:00.000","description":"Intensivist Note","row_id":507541,"text":"SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\n - needed excessive valium. Now still delirious. Need frequent\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley.\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n :\n :\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 10:46 ------\n"},{"category":"Nursing","chartdate":"2146-01-18 00:00:00.000","description":"Nursing Transfer Note","row_id":507811,"text":"HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"},{"category":"Nursing","chartdate":"2146-01-18 00:00:00.000","description":"Nursing Transfer Note","row_id":507813,"text":"HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n Demographics\n Attending MD:\n K.\n Admit diagnosis:\n PEDESRTRIAN STRUCK, LEG FRACTURES\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 94.5 kg\n Daily weight:\n 91.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\n withdrawing from alchohol and requiring q1hr valium. heart rate\n 130-140's. very agitated and requiring constant watch. npo for or on\n monday to repair left femur.\n -pt back to sicu from CC6 after causing \"code purple\" d/t severe\n agitation and delerium\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:68\n Temperature:\n 97.5\n Arterial BP:\n S:123\n D:83\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,066 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:31 AM\n Potassium:\n 4.1 mEq/L\n 04:31 AM\n Chloride:\n 109 mEq/L\n 04:31 AM\n CO2:\n 24 mEq/L\n 04:31 AM\n BUN:\n 10 mg/dL\n 04:31 AM\n Creatinine:\n 0.7 mg/dL\n 04:31 AM\n Glucose:\n 111 mg/dL\n 04:31 AM\n Hematocrit:\n 30.6 %\n 04:31 AM\n Finger Stick Glucose:\n 95\n 07:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: notebook\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: CC 6\n Date & time of Transfer: 12:00 AM\n"},{"category":"Nutrition","chartdate":"2146-01-18 00:00:00.000","description":"Clinical Nutrition Note","row_id":507810,"text":"Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 91.1 kg ( 03:00 AM)\n 28.2\n Pertinent medications: Dextrose 5% with 1/2 normal saline with KCl @\n 10mL/hr, Haldol, others noted\n Labs:\n Value\n Date\n Glucose\n 111 mg/dL\n 04:31 AM\n Glucose Finger Stick\n 95\n 07:00 PM\n BUN\n 10 mg/dL\n 04:31 AM\n Creatinine\n 0.7 mg/dL\n 04:31 AM\n Sodium\n 141 mEq/L\n 04:31 AM\n Potassium\n 4.1 mEq/L\n 04:31 AM\n Chloride\n 109 mEq/L\n 04:31 AM\n TCO2\n 24 mEq/L\n 04:31 AM\n PO2 (arterial)\n 184 mm Hg\n 10:45 PM\n PCO2 (arterial)\n 40 mm Hg\n 10:45 PM\n pH (arterial)\n 7.43 units\n 10:45 PM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 10:45 PM\n Calcium non-ionized\n 8.8 mg/dL\n 04:31 AM\n Phosphorus\n 3.7 mg/dL\n 04:31 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.4 mg/dL\n 04:31 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 6.7 K/uL\n 04:31 AM\n Hgb\n 10.1 g/dL\n 04:31 AM\n Hematocrit\n 30.6 %\n 04:31 AM\n Current diet order / nutrition support: Diet: Regular\n Assessment of Nutritional Status\n Patient was extubated and passed for a ground diet and nectar\n thick liquids per SLP on . Patient was re-evaluated and was\n upgraded to a regular diet. Patient was transferred to ICU o/n due to\n a code purple. Patient is now much more calm and oriented, and is\n tolerating a regular diet well RN. Will continue to follow and\n monitor po intake.\n #\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507512,"text":"Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507514,"text":"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507510,"text":"Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -keep pt safe\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"},{"category":"Nursing","chartdate":"2146-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":507511,"text":"Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -keep pt safe\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"},{"category":"Physician ","chartdate":"2146-01-18 00:00:00.000","description":"Physician Surgical Progress Note","row_id":507666,"text":"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\n amounts of valium. Now still disoriented, requiring frequent\n re-orientation with restriants. Evaluated by psych. Will avoid BDZs for\n now.\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC.\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent:\n"},{"category":"Nursing","chartdate":"2146-01-18 00:00:00.000","description":"Nursing Progress Note","row_id":507672,"text":"Delirium / confusion\n Assessment:\n Pt with delirium, very confused when wakes up, believes he is at \n beach, constantly asking for alcohol and cigarettes.\n Action:\n Medicated with Haldol overnight.\n No Benzos given.\n Response:\n Pt able to sleep for good periods, was oriented x3 at one point, but\n now confused as to place etc. No further periods of agitation.\n Plan:\n Continue to medicate with Haldol for agitation, re-orient pt as needed.\n c/o to floor.\n"},{"category":"Rehab Services","chartdate":"2146-01-18 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":507740,"text":"Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: trauma / 959.9\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 51 yo M admitted\n as pedestrian struck, sustained R open tibia/fibula fx and L\n comminuted supracondylar fx with several R-sided rib fractures.\n Underwent open fixation and ex. fix placement of R ankle, and L knee\n ORIF. Post-op course c/b severe etoh withdrawal.\n Past Medical / Surgical History: See initial eval\n Medications: tylenol, heparin, metoprolol, oxycodone, haloperidol\n Radiology: L knee XR- There is a comminuted fracture of the distal\n femur. There is apparent increase in the space/gap between the plate\n and the largest fragment in the distal diaphysis\n Labs:\n 30.6\n 10.1\n 474\n 6.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist, TDWB B LE's\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert and oriented,\n follows all simple commands. hard of hearing.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 76\n 132/80\n 97% on RA\n Activity\n 88\n /\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lungs cta, non-labored breathing, no cough noted.\n Integumentary / Vascular: L knee with staples intact, in place\n and locked in extension. R ex.fix in place.\n Sensory Integrity: B LE's intact to light touch\n Pain / Limiting Symptoms: c/o 8/10 L knee pain with ROM\n Posture: WNL\n Range of Motion\n Muscle Performance\n L knee ext-flex \n L ankle to neutral\n R hip/knee WNL\n B LE's at least t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: not assessed\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: not assessed, patient in 4-point restraints during eval.\n Education / Communication: Reviewed PT , positioning and use of\n brace. Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired ROM/strength\n Clinical impression / Prognosis: 51 yo M s/p B LE fractures p/w above\n impairments a/w bony surgery. He is most limited by L knee pain and\n decreased ROM at this time, as well as B weight-bearing restrictions.\n He has also had episodes of agitation and has required sedation and\n restraints. He is below his baseline level, but anticipate good rehab\n potential given his strength and level of mobility. PT to continue to\n follow daily for ROM, and mobility when appropriate.\n Goals\n Time frame: 1 week\n 1.\n Min A transfers bed-to-chair\n 2.\n Tolerate OOB >/= 3 hours/day\n 3.\n Tolerate daily LE ROM/strength, L knee ROM 0-90\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily\n transfers, ambulation, balance, endurance, education, strengthening,\n ROM\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Physician ","chartdate":"2146-01-18 00:00:00.000","description":"Physician Surgical Progress Note","row_id":507741,"text":"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\n BDZs for now.\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\n Off abx.\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent: 35 minutes\n"},{"category":"Physician ","chartdate":"2146-01-18 00:00:00.000","description":"Physician Surgical Progress Note","row_id":507750,"text":"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previously in DT - requiring intubation and large\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\n BDZs for now per psych\ns recs and will use Haldol around the clock and\n prn for agitation. Overall, pt is doing better\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H. influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\n Off abx.\n Pt afebrile and saturating well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds. Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20minutes\n"},{"category":"Nursing","chartdate":"2146-01-18 00:00:00.000","description":"Nursing Transfer Note","row_id":507777,"text":"Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"},{"category":"Nursing","chartdate":"2146-01-18 00:00:00.000","description":"Nursing Transfer Note","row_id":507779,"text":"HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"},{"category":"ECG","chartdate":"2146-01-18 00:00:00.000","description":"Report","row_id":233207,"text":"Sinus rhythm. Lead V2 is missing. Otherwise, tracing is within normal limits.\nCompared to the previous tracing of there is no significant change.\n\n"},{"category":"ECG","chartdate":"2146-01-17 00:00:00.000","description":"Report","row_id":233208,"text":"Baseline artifact. Normal sinus rhythm, rate 93 beats per minute. Possible left\natrial abnormality. Compared to the previous tracing of heart rate is\nfaster. QTc interval is not prolonged.\n\n"},{"category":"ECG","chartdate":"2146-01-14 00:00:00.000","description":"Report","row_id":233209,"text":"Sinus rhythm. Since the previous tracing of no significant change.\n\n"},{"category":"ECG","chartdate":"2146-01-12 00:00:00.000","description":"Report","row_id":233210,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrate has slowed. Otherwise, there is no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2146-01-02 00:00:00.000","description":"Report","row_id":233211,"text":"Sinus tachycardia. Otherwise, probably normal tracing but unstable baseline in\nthe precordial leads makes assessment difficult. Since the previous tracing\nof sinus tachycardia is now present but otherwise, probably no\nsignificant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2146-01-01 00:00:00.000","description":"Report","row_id":233212,"text":"Sinus rhythm. Probably normal tracing but unstable baseline in the precordial\nleads makes assessment difficult. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2146-01-16 00:00:00.000","description":"LP KNEE (2 VIEWS) LEFT PORT","row_id":1113015,"text":" 1:40 PM\n KNEE (2 VIEWS) LEFT PORT Clip # \n Reason: assess for hardware movement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with fall from chair today. s/p ORIF L distal femur\n REASON FOR THIS EXAMINATION:\n assess for hardware movement\n ______________________________________________________________________________\n FINAL REPORT\n LEFT KNEE, TWO VIEWS\n\n REASON FOR EXAM: Trauma, assess for hardware displacement.\n\n Comparison is made with prior study fluoroscopic views performed in the O.R.\n on .\n\n There is a comminuted fracture of the distal femur. There is apparent\n increase in the space/gap between the plate and the largest fragment in the\n distal diaphysis.\n\n There is no dislocation. There is joint effusion. Skin staples are present.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111208,"text":" 9:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NC tube position,ETT position\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ETOH WITHDRAWL\n REASON FOR THIS EXAMINATION:\n NC tube position,ETT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube position.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube now measures approximately 3.5 cm above the carina.\n Persistent low lung volumes with atelectatic changes at the bases.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-12 00:00:00.000","description":"OR ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT","row_id":1112510,"text":" 6:01 PM\n ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: RIGHT ANKLE EXFIXATOR ADJUSTMENT\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n WET READ: SPfc WED 6:35 PM\n Intraoperative views of the right ankle redemonstrate comminuted fractures of\n the distal tibia and fibula. See operative note for complete details.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Right ankle external fixator adjustment.\n\n COMPARISON: Right ankle intraoperative radiograph .\n\n FINDINGS: Eight intraoperative fluoroscopic images were acquired without the\n radiologist present, using a fluoro time of 43.6 seconds. The images\n demonstrate a comminuted distal tibial fracture with extension into the distal\n tibiotalar joint. There is a comminuted distal fibular fracture with minimal\n distraction of the fracture fragments. An external fixator is seen in situ.\n There is mild widening of the ankle mortise superiorly and medially. Please\n refer to the operative note for further details of surgery.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2146-01-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111542,"text":" 9:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess location\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ett tube repositioned\n REASON FOR THIS EXAMINATION:\n assess location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: ETT repositioning.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the position of the\n endotracheal tube has not substantially changed. On today's examination, the\n tip of the tube projects approximately 6.5 cm above the carina. Normal course\n and position of the nasogastric tube. The pre-existing bilateral areas of\n atelectasis have decreased in extent. No newly appeared focal parenchymal\n opacities. Unchanged size and shape of the cardiac silhouette.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-06 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1111647,"text":" 2:04 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx, line position\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh wothdrawal s/p new left subclavian\n REASON FOR THIS EXAMINATION:\n ptx, line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, status post new\n subclavian line.\n\n UPRIGHT AP VIEW OF THE CHEST:\n The patient is status post placement of a central venous catheter via a left\n subclavian approach, with the tip terminating within the mid SVC. An\n endotracheal tube terminates 6.8 cm above the level of the carina. The\n cardiac and mediastinal contours are unchanged in comparison to the prior\n chest radiograph from . There is no evidence of pneumothorax\n or pleural effusion.\n\n IMPRESSION: Status post placement of a new subclavian central venous catheter\n terminating within the mid SVC.\n\n"},{"category":"Radiology","chartdate":"2146-01-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112016,"text":" 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with PNA and ETOH withdrawal. Extubated .\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Pneumonia, extubated, question interval change.\n\n FINDINGS: The ET tube has been removed. NG tube tip is in the stomach. Left\n subclavian line is in the SVC, unchanged. There are some patchy areas of\n volume loss in both lower lobes but no focal infiltrate.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1110794,"text":" 12:51 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck pedestrian\n\n Frontal bedside view of the chest is obtained with the patient placed on a\n trauma board. Lung volumes are low and there is bibasilar atelectasis. There\n is mild cardiomegaly, which may be related to technique. Mediastinal and\n hilar contours are unremarkable. There is no definite pneumothorax. Left rib\n fractures are visualized involving the sixth and seventh ribs and a right rib\n fracture is seen in the second rib (please see CT of the Torso for full\n fracture characterization).\n\n A frontal view of the pelvis obtained with the patient on a trauma board shows\n no fracture or dislocation. Bowel gas pattern is unremarkable. Contrast is\n seen within both ureters as well as in the urinary bladder, which contains a\n small amount of gas, presumably sequelae of previous contrast as well as Foley\n catheter placement. There is no radiopaque foreign body.\n\n IMPRESSION: Rib fractures as above.\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1110795,"text":" 12:57 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n ?injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 1:40 AM\n Acute right rib fractures involving the 2nd, 3rd and likely 12th ribs. No\n pneumothorax. Dependant atelectasis bilaterally and a more nodular right\n upper lobe opacity. This may be aspiration, though followup when clinically\n stable is recommended to document resolution and exclude underlying pulmonary\n nodule.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck pedestrian.\n\n TECHNIQUE: Axial CT images were acquired through the torso following the\n administration of 120 cc of intravenous Optiray contrast.\n\n COMPARISON: Radiographs from the same day.\n\n CT CHEST WITH CONTRAST: Airways are patent to subsegmental levels\n bilaterally. There is no pneumothorax. Dependent atelectasis is visualized\n bilaterally, and there is a focus in the right upper lobe of poorly marginated\n 15 x 15mm opacity, with hazy margins. The heart and great vessels are\n unremarkable. There is no mediastinal or axillary lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: The stomach, duodenum, spleen, pancreas, adrenal\n glands, gallbladder, kidneys, and liver are unremarkable. There is no free\n gas or fluid in the abdomen. Regional vascular structures are notable for\n scattered atherosclerotic calcification of the aorta in the absence of\n aneurysmal dilation.\n\n CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter and a\n small amount of gas. Dense contrast reflects the previous study. The\n prostate, seminal vesicles, rectum, colon, and appendix are unremarkable.\n There is no free gas or fluid in the pelvis. There is no pelvic or inguinal\n lymphadenopathy.\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n Note is made of bilateral spondylolysis at L5, without associated\n spondylolisthesis. Acute fractures are visualized with mild displacement on\n the right involving the second and third ribs laterally (2:19). Chronic\n fracture deformities are also visualized on the right, involving the sixth rib\n laterally. An additional acute fracture is seen posteriorly in the twelfth on\n the right. On the left, chronic fracture deformities are visualized involving\n the fifth, sixth, seventh, and eighth ribs.\n\n (Over)\n\n 12:57 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Rib fractures, appearing both chronic and with acute rib fractures seen at\n the second and third ribs on the right as well as in the twelfth rib. There\n is no pneumothorax.\n 2. Bilateral spondylolysis, without spondylolisthesis at L5.\n 3. Bilateral dependent atelectasis as well as a poorly marginated opacity in\n the right upper lobe. Considerations for the latter finding include nodule\n or, less likely aspiration. Followup is recommended to document\n resolution/progression when clinically stable.\n\n Results and recommendations were reviewed in person at the time of image\n acquisition with Dr. from surgery.\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"L CT LOW EXT W/O C LEFT","row_id":1110797,"text":" 1:23 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: L knee CT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n L knee CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 8:47 AM\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\n evidence of intra-articular extension. The largest distal fracture fragment\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\n proximal femur. In addition, there is a non-displaced fracture of the\n proximal fibula (500b:39). Finally, a small osseous near the lateral\n proximal tibia suggests an avulsion injury (Segond fracture) which raises\n concern for internal ligamentous injury to the knee.\n WET READ VERSION #1 SPfc SAT 1:44 AM\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\n evidence of intra-articular extension. The largest distal fracture fragment\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\n proximal femur. In addition, there is a non-displaced fracture of the\n proximal fibula (500b:39).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left femur fracture.\n\n COMPARISON: Radiograph .\n\n TECHNIQUE: MDCT axial images through the left knee were obtained without\n intravenous contrast and displayed with multiplanar reformats.\n\n FINDINGS:\n\n There is a markedly comminuted fracture through the left distal femoral\n metadiaphysis with multiple large fracture fragments. There is apex-posterior\n angulation as well as one shaft width posterior and lateral displacement of\n the distal fracture fragment. There is no intra-articular extension of the\n fracture line.\n\n There is a nondisplaced fracture of the left fibular head (501B:36). A -\n like 2.4-mm osseous fragment arises from the proximal lateral tibial epiphysis\n and may represent a Segond fracture.\n\n There is a small lipohemarthrosis as well as expected soft tissue and\n intramuscular edema. Prominent varicose veins are identified. While the\n anterior cruciate ligament is visualized, given the Segond fracture, there is\n high suspicion for ACL injury.\n\n IMPRESSION:\n\n 1. Comminuted displaced left distal femur fracture without intra-articular\n (Over)\n\n 1:23 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: L knee CT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n extension.\n\n 2. Segond fracture concerning for anterior cruciate ligament injury.\n\n 3. Fracture through the fibular head which may signify posterolateral corner\n injury. Further evaluation can be performed with MRI if indicated.\n\n\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"L FEMUR (AP & LAT) LEFT","row_id":1110798,"text":" 1:35 AM\n FEMUR (AP & LAT) LEFT Clip # \n Reason: ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pedestrian versus car trauma.\n\n Four views of the left femur reveal a comminuted fracture of the distal\n femoral diaphysis. There is posterior and slight lateral displacement of the\n distal femur relative to the proximal. There is no evidence of\n intra-articular extension. A faint lucency seen at the fibular head suggests\n a non-displaced fracture in that location as well. A small of bone at\n the lateral margin of the proximal tibia suggests avulsion injury. There is\n no radiopaque foreign body.\n\n IMPRESSION: Comminuted left femoral fracture, nondisplaced proximal fibular\n fracture and possible avulsed tibial fracture fragment (Segond fracture) which\n raises concern for internal ligamentous injury.\n\n"},{"category":"Radiology","chartdate":"2146-01-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111590,"text":" 9:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh withdrawal\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Alcohol withdrawal. NG tube placement.\n\n COMPARISON: Chest radiograph from .\n\n FRONTAL VIEW OF THE CHEST AND UPPER ABDOMEN: Previous NG tube has been\n advanced into the stomach and appears to be at the antrum of the stomach.\n Endotracheal tube at the level of the clavicles is stable. EKG leads\n overlying the patient limit evaluation. Within these limitations, there is no\n evidence of pneumothorax. There is small right pleural effusion and\n associated atelectasis. Right lateral pleural thickening is secondary to prior\n rib fractures and has decreased. There is no evidence of congestive heart\n failure. Heart is not enlarged. Aortic arch is obscured by overlying EKG\n lead.\n\n IMPRESSION:\n 1. NG tube in the stomach.\n 2. Small Right pleural effusion and associated atelectasis.\n\n"},{"category":"Radiology","chartdate":"2146-01-05 00:00:00.000","description":"LO FEMUR (AP & LAT) LEFT IN O.R.","row_id":1111446,"text":" 11:35 AM\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: TRUAMA, FX, ORIF LEFT FEMUR\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH WED 1:26 PM\n Fluoroscopic assistance provided to the surgeon in the OR.\n ______________________________________________________________________________\n FINAL REPORT\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Twelve spot views obtained. Views demonstrate steps\n related to fixation of a comminuted distal femoral fracture, side not\n indicated. Fluoro time recorded as 224 seconds on the electronic requisition.\n Correlation with real-time findings, and when appropriate, conventional\n radiographs is recommended for full assessment.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-05 00:00:00.000","description":"LO FEMUR (AP & LAT) LEFT IN O.R.","row_id":1111447,"text":", T. SICU-A 11:35 AM\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: TRUAMA, FX, ORIF LEFT FEMUR\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n PFI REPORT\n Fluoroscopic assistance provided to the surgeon in the OR.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-05 00:00:00.000","description":"O ABDOMEN, SINGLE VIEW IN O.R.","row_id":1111449,"text":" 11:36 AM\n ABDOMEN, SINGLE VIEW IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n -77 BY DIFFERENT PHYSICIAN\n : IVC FILTER INSERTION\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male status post IVC filter insertion.\n\n STUDY: Single spot radiograph in the upper lumbar spine region.\n\n FINDINGS: An IVC filter is in appropriately positioned, projecting just\n lateral to the L2 vertebral body.\n\n"},{"category":"Radiology","chartdate":"2146-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112401,"text":" 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, NGT placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ETOH w/d, pulled out NGT which was reinserted\n REASON FOR THIS EXAMINATION:\n interval change, NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, reinserted NG tube.\n\n COMPARISON: Chest radiographs available from .\n\n SEMI-ERECT AP VIEW OF THE CHEST: The patient is status post placement of a\n nasogastric tube, which terminates beyond the scope of the study. The side\n port is also excluded. There is a central venous catheter, via a left\n subclavian approach, which terminates at the mid SVC. The cardiac and\n mediastinal contours are unchanged since the prior examination from , . There is no pneumothorax or pleural effusion.\n\n IMPRESSION: Status post placement of a nasogastric tube, which extends to at\n least the level of the stomach, however the side port and tip are both\n excluded from the study.\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"RO ANKLE (2 VIEWS) RIGHT IN O.R.","row_id":1110831,"text":" 8:55 AM\n ANKLE (2 VIEWS) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: EX/FIX RIGHT TIBIA\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF\n\n FINDINGS: Multiple views from the operating suite show what appear to be\n external fixation devices in the tibia. Further information can be gathered\n from the operative report.\n\n"},{"category":"Radiology","chartdate":"2146-01-12 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1112530,"text":" 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with continued agitation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc WED 10:16 PM\n No acute intracranial abnormality. Paranasal sinus disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Continued agitation.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial CT images were acquired through the head in the\n absence of intravenous contrast.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarction. The ventricles and sulci are normal in size\n and in configuration. Extracranial soft tissue structures reveal a small\n subcutaneous nodule overlying the occipital bone on the left as well as the\n frontal bone on the left. There is no fracture. The mastoid air cells are\n clear. The paranasal sinuses reveal circumferential mucosal thickening at the\n right frontoethmoidal recess extending into the ethmoidal air cells\n bilaterally, the sphenoid sinus as well as both maxillary sinuses.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Paranasal sinus disease.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation, but\n note that tthere is a chronic-appearing defect in the maxilla, primarily right\n of midline, but extending to the left. This has sclerotic margins, implying a\n chronic process. This may be related to dental disease with a periapical cyst\n or related to paranasal sinus inflammatory disease.\n\n"},{"category":"Radiology","chartdate":"2146-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112476,"text":" 2:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess ETT location\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man now intubated\n REASON FOR THIS EXAMINATION:\n assess ETT location\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for ETT location.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the patient has now been\n intubated. The tip of the endotracheal tube projects 11 cm above the carina,\n the tube could be advanced by 3-4 cm. The nasogastric tube and the left\n subclavian catheter are unchanged. Also unchanged is the appearance of the\n lung parenchyma and the size of the cardiac silhouette. No evidence of\n complications, notably no pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2146-01-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1110958,"text":" 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with trauma\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-trauma, to evaluate for aspiration.\n\n FINDINGS: No previous images. The cardiac silhouette is within normal limits\n and there is no vascular congestion or pleural effusion. Suggestion of some\n increased opacification at the left base in the retrocardiac region, which\n most likely represents atelectasis. The possibility of early aspiration\n cannot be definitely excluded. If clinical symptoms persist, followup\n radiograph would be indicated.\n\n\n"},{"category":"Radiology","chartdate":"2146-01-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1113227,"text":" 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hospital acquired PNA, ETOH w/d.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hospital acquired pneumonia. ETOH withdrawal.\n\n Comparison is made with prior study .\n\n Cardiac size is top normal. Lines and tubes have been removed. There are\n multiple opacities that are consistent with atelectasis in the lower lobes\n bilaterally and in the left upper lobe. There are no new lung abnormalities.\n There is no pleural effusion or pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2146-01-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1111191,"text":" 6:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with bilateral fractures of legs\n REASON FOR THIS EXAMINATION:\n et tube placement\n ______________________________________________________________________________\n WET READ: RSRc MON 7:50 PM\n Post-intubation, with ETT 6 cm above carina but below thoracic inlet.\n Worsening left retrocardiac opacification suggests developing pneumonia, and\n new small left effusion. 7:45 p .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:54 P.M., \n\n HISTORY: Bilateral leg fractures, check ET tube placement.\n\n IMPRESSION: AP chest compared to , 8:19 a.m.:\n\n Tip of the newly placed endotracheal tube is above the upper margin of the\n clavicles, more than 6 cm from the carina, 3-4 cm above standard placement.\n This may account for lower lung volumes and new bibasilar atelectasis. Low\n lung volumes in turn may explain in part increase in heart size, though\n increased caliber of mediastinal veins suggests increased intravascular\n volume. No pneumothorax. Small bilateral pleural effusions may be present.\n Despite identification to the contrary this radiograph may have been taken\n with the patient in supine position, contributing to heart size and caliber of\n mediastinal capacitance vessels.\n\n An acute fracture through the lateral aspect of the right second rib is\n slightly more displaced than it was earlier today, but there has been no\n change in the small adjacent extrapleural hematoma.\n\n Findings were discussed by teleophone with Dr at 9:30AM.\n\n"},{"category":"Radiology","chartdate":"2146-01-01 00:00:00.000","description":"R TIB/FIB (AP & LAT) RIGHT","row_id":1110799,"text":" 1:35 AM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: ?injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck-pedestrian trauma.\n\n FINDINGS: Five views of the right tibia and fibula and ankle show comminuted\n oblique fractures of the distal tibia and fibula. There is lateral and\n anterior subluxation of the distal tibia and fibula as well as foot relative\n to the proximal lower extremity. The talar dome is smooth. The distal fibula\n is slightly medially displaced, projecting over the ankle mortise. Limited\n views of the knee joint are unremarkable. There is no radiopaque foreign\n body.\n\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as above.\n\n"},{"category":"Radiology","chartdate":"2146-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1112433,"text":" 9:11 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement.\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh w/d. pulled out his ngt, placed back in. took CXR\n this am but could not identify tip. pulled ngt back more, please repeat CXR.\n REASON FOR THIS EXAMINATION:\n NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, status post pulling of\n NG tube, with consequent replacement.\n\n COMPARISON: Chest radiographs available from at 5:15 a.m.\n\n SUPINE AP VIEW OF THE CHEST: The patient is status post placement of a\n nasogastric tube, which extends to at least the level of the stomach, with the\n tip excluded from the study. The side port is also excluded. A left-sided\n central venous catheter via subclavian approach terminates at the mid SVC.\n The cardiac and mediastinal contours are unchanged since prior exam. There is\n no pneumothorax or pleural effusion.\n\n IMPRESSION: Nasogastric tube extends to at least the level of the stomach,\n however the side port and tip are both excluded from the study.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505291,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Temp 100.7 to 98.8 po\\n HR 90\\ns nsr\\n Sbp 140-150\\ns when calm, hypertensive to 180\\ns with stimulation such\\n as suctioning\\n Breath sounds clear but diminished in bases\\n Suctioned for copious amounts thick yellow secretions\\n Abd soft with + bowel sounds\\n TF on hold for possible extubation\\n Action:\\n hemodynamics monitored\\n suctioned q1-2 hrs for copious amounts thick yellow secretions\\n suctioned for large amounts orally\\n Response:\\n pt remains lethargic\\n arousable only when suctioned then quiets\\n placed back on cpap with 10 ips/ 5 peep\\n Plan:\\n rest overnight\\n attempt extubation in am\\n resume propofol only if patient becomes agitated\\n suction prn\\n tube feedings resumed at 1600\\n Alcohol abuse\\n Assessment:\\n Propofol off at 0900\\n Very lethargic\\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\\n No visible sweats or tremors\\n Action:\\n CIWA scale done\\n No valium given this shift\\n Response:\\n No evidence of DT\\n Plan:\\n Continue to monitor for DT\\n ? d/c valium addiction RN recommendation\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 506680,\n \"text\": \"TSICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Clonidine Patch 0.3 mg/ h\\n Cyanocobalamin\\n Dexmedetomidine\\n FoLIC Acid\\n HYDROmorphone (Dilaudid)\\n Haloperidol\\n Metoprolol Tartrate\\n Pantoprazole\\n 24 Hour Events:\\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\\n RSBI 30s this AM.\\n Post operative day:\\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\\n washout R ankle and IVC filter, POD 1 washout RLE\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\\n Ciprofloxacin - 10:02 AM\\n Levofloxacin - 01:03 PM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\\n Other ICU medications:\\n Metoprolol - 06:00 AM\\n Lorazepam (Ativan) - 07:00 AM\\n Hydromorphone (Dilaudid) - 12:02 AM\\n Other medications:\\n Flowsheet Data as of 04:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.5\\n T current: 38.1\\nC (100.5\\n HR: 95 (66 - 106) bpm\\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SPO2: 84%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 88.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,093 mL\\n 561 mL\\n PO:\\n Tube feeding:\\n 58 mL\\n IV Fluid:\\n 3,093 mL\\n 503 mL\\n Blood products:\\n Total out:\\n 2,100 mL\\n 590 mL\\n Urine:\\n 1,950 mL\\n 440 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 993 mL\\n -26 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n RR (Set): 16\\n RR (Spontaneous): 4\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 14 cmH2O\\n SPO2: 84%\\n ABG: 7.43/40/184/26/2\\n Ve: 10 L/min\\n PaO2 / FiO2: 368\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Sedated\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 27.2 %\\n 9.6 K/uL\\n [image002.jpg]\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n WBC\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n Plt\\n 27\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Imaging: : CT torso: Acute right rib fractures involving the\\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\\n bilaterally and a more nodular right upper lobe opacity. This may be\\n aspiration, though followup when clinically stable is recommended to\\n document resolution and exclude underlying pulmonary nodule.\\n : CT L leg: Markedly comminuted fracture or the distal femoral\\n diaphysis. There is no evidence of intra-articular extension. In\\n addition, there is a non-displaced fracture of the prox fibula.\\n : R tib/fib films: Comminuted fractures of the distal tibia and\\n fibula.\\n CXR: left base in the retrocardiac region, likely atelectasis\\n :Worsening left retrocardiac opacification suggests developing\\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\\n lung volumes.\\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\\n CXR: ETT 11cm above carina\\n Head CT: no acute intracranial process\\n Microbiology: Ucx Negative.\\n Bcx Negative.\\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\\n still delerious when off sedation. Continue to wean sedation. Pt\\n following commands on Precedex, but seems confused at times, will plan\\n to extubate this AM. Please avoid benzos\\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\\n prolognation (haldol and quinolone).\\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\\n on Levaquin (). Intubated for altered mental status from\\n withdrawal. Reintubated for increasing agitation and in prep for OR.\\n Wean to extubate today.\\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\\n Nutrition: Tube feeding, Thiamine, folate, MVI.\\n Renal: Foley, Adequate UO\\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\\n hospitalization. s/p IVC filter.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\\n () x 14 day course.\\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\\n Wounds: Soft compartments, will monitor.\\n Imaging: None planned\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Addiction Med\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Comments: Foley, PIV, NGT, left subclavian TLC\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n please d/c as no indication\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n Total time spent: 32 mins\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505093,\n \"text\": \"TITLE:\\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\\n auto. B/L LE injuries including an open tib/fib on R and comminuted\\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\\n prompting admission to ICU.\\n URINE CULTURE - At 08:30 PM\\n BLOOD CULTURED - At 09:00 PM\\n SPUTUM CULTURE - At 12:34 AM\\n FEVER - 102.1\\nF - 09:00 PM\\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Vancomycin - 07:49 PM\\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\\n Ciprofloxacin - 10:27 PM\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 09:00 AM\\n Metoprolol - 01:00 PM\\n Hydromorphone (Dilaudid) - 03:49 PM\\n Pantoprazole (Protonix) - 07:49 PM\\n Heparin Sodium (Prophylaxis) - 07:49 PM\\n Other medications:\\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\\n Heparin 5000 UNIT SC BID\\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\\n Insulin SC (per Insulin Flowsheet)Sliding Scale\\n Calcium Gluconate IV Sliding Scale\\n Magnesium Sulfate IV Sliding Scale\\n Metoprolol Tartrate 5 mg IV Q6H\\n Ciprofloxacin 400 mg IV Q12H\\n Nicotine Patch 14 mg TD DAILY\\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\\n Pantoprazole 40 mg IV Q24H\\n Cyanocobalamin 50 mcg PO/NG DAILY\\n Piperacillin-Tazobactam 4.5 g IV Q8H\\n Potassium Phosphate IV Sliding Scale\\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\\n Folic Acid/Multivitamin/Thiamine-1000mL NS\\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\\n Flowsheet Data as of 12:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.7\\nC (101.6\\n Tcurrent: 37.7\\nC (99.8\\n HR: 93 (82 - 101) bpm\\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\\n RR: 27 (18 - 28) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 97 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 11 (10 - 12)mmHg\\n Total In:\\n 2,921 mL\\n 40 mL\\n PO:\\n TF:\\n 277 mL\\n 14 mL\\n IVF:\\n 2,585 mL\\n 26 mL\\n Blood products:\\n Total out:\\n 2,275 mL\\n 0 mL\\n Urine:\\n 1,775 mL\\n NG:\\n 500 mL\\n Stool:\\n Drains:\\n Balance:\\n 646 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 600 (600 - 600) mL\\n Vt (Spontaneous): 494 (466 - 605) mL\\n PS : 5 cmH2O\\n RR (Set): 20\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 100%\\n ABG: 7.46/40/155/28/5\\n Ve: 12.2 L/min\\n PaO2 / FiO2: 388\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: 1+\\n Skin: Not assessed, Rash: left axilla, bruising right chest\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.1 g/dL\\n 121 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.0 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 9.7 K/uL\\n [image002.jpg]\\n 08:36 PM\\n 02:17 AM\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n WBC\\n 8.7\\n 9.7\\n Hct\\n 28.7\\n 26.8\\n 28.1\\n Plt\\n 169\\n 169\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n TCO2\\n 30\\n 28\\n 27\\n 29\\n 26\\n 29\\n Glucose\\n 104\\n 87\\n 104\\n 121\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\\n Microbiology: Ucx Negative.\\n Sputum: GNR\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs, now intubated after increased\\n somnolence. Going to OR today for L femur ORIF, right ankle external\\n fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean off prop to attempt vent wean\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febril -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 10:00 AM\\n Multi Lumen - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 506815,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505149,\n \"text\": \"Trauma, s/p pedestrian struck, bilateral leg fractures and rib\\n fractures\\n Assessment:\\n Low grade temps 100.7\\n HR 80\\ns, BP ~120-140\\n Fluid balance MN -0500: +370cc\\ns. Remains 9 liters\\n positive for length of stay.\\n Dopplerable pedal pulses bilat\\n Left leg with knee immobilizer, ace wrap with DSD under with\\n old sero-sang drg.\\n Right leg with external fixator, draining yellow fluid from\\n heel pin sites, dressing changed.\\n Ls clear with suctioning, tan sputum\\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\\n Not showing signs of ETOH withdrawal, no valium given this\\n shift per CIWA scale\\n Dilaudid x 1 this shift in preparation for pin care and\\n bathing with good effect\\n Action:\\n VAP protocol\\n Pin care\\n Repositioned q 2-3 hours\\n ABX as ordered\\n Tube feeds stopped in preparation for possible extubation.\\n Response:\\n HR and vitals acceptable\\n Remains with low grade fever\\n Concerning sputum\\n HCT 25.3, no S+S of active bleeding.\\n Plan:\\n Continue to monitor respiratory status, wean to extubated if\\n appropriate\\n Continue to monitor for S+S of ETOH withdrawal\\n Continue ABX as ordered, follow up on pending culture\\n results.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 505165,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 5\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Tan / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Remain on minimal PSV,\\n increased briefly on IPS of 10 cmh20, back down.\\n Assessment of breathing comfort: No response (sleeping / sedated);\\n Comments: on minimal propofol. ? precedex.\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\\n RSBI done ~54. ? elective extubation.\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 506816,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n : washout RLE\\n Trauma, s/p\\n Assessment:\\n Pt weaned and extubated this am without difficulty. Pt alert and\\n orientated. At times, pt makes comments that do not make sense.\\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\\n complains of pain to BLE.\\n Action:\\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\\n for pain.\\n Response:\\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\\n able to have nectar thick liquids and ground solids per speech therapy.\\n Plan:\\n Transfer to floor this evening.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506058,\n \"text\": \"Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - Minimal response from zyprexa\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa as ordered\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 505327,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 5\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing,\\n Tachypneic (RR> 35 b/min)\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchron\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed\\n Respiratory Care Shift Procedures\\n Plan to extubate in am.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 507540,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.subsequently discharged to floor on .code purple\\n on -transferred to SICU.\\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\\n washout/ Ex-fix revision\\n Chief complaint:\\n PMHx:\\n ETOH abuse,Varicose veins\\n Current medications:\\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\\n Release\\n 24 Hour Events:\\n agitated on floor not responding to haldol/valium/zyprexa\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 03:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 103 (103 - 103) bpm\\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\\n RR: 17 (17 - 17) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: Anxious, agitated/delerius\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Skin: RLE EX fix\\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\\n agitated and deleriuous\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 29.1 %\\n 9.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n WBC\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n Plt\\n 259\\n 307\\n 327\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\\n floor.Transferred to ICU\\n NEURO: Delirious, awake but disoriented and somnolent after valium.\\n Agitated with awake. Previosly in DT - needed excessive valium. Now\\n still delirious. Need frequent re-orientation with restriants. Haldol\\n PO and IV prn Ativan. ? Withdrawal from benzos. Will ask psych to\\n evaluate and input in the management of patient.\\n CVS: On clonidine patch. Beta blockade. HD stable.\\n PULM: room air saturating well. h/o HAP likely aspiration. Cx w/ H.\\n nflu and Shewanella completed course of levaquin. h/o Intubation \\n for altered mental status from withdrawal.\\n GI: Regular. Not taking pos now.\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Place foley. Otherwise no issues\\n HEME: Hct 29 on . On SQH for prophylaxis.\\n ENDO: RISS with adequate glucose control. Keep < 150 Euthyroid\\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\\n levaquin.\\n Other: Social work/ Addictions consult\\n TLD: PIV\\n IVF: KVO\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL:\\n PROPHYLAXIS:\\n DVT SQH/IVC filter\\n STRESS ULCER\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent: 35 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505397,\n \"text\": \"pt he is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Monitor patient\\ns condition closely.\\n Provide emotional support to patient.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 505909,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Trauma, alcohol intoxicated\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown.\\n Current medications:\\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\\n Temporary central access (ICU) Location: Left Subclavian, Date\\n inserted: Order date: @ 1336 16. IV access request:\\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\\n line Order date: @ 1454 17. Insulin SC (per Insulin\\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\\n Q24H Order date: @ 1316\\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\\n flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 1316\\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\\n 1406\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:39 AM\\n Extubated. Minimized narcotics. More awake. Agitated at night req\\n restraints and zyprexa.\\n Post operative day:\\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:32 PM\\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\\n Ciprofloxacin - 11:00 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 09:04 PM\\n Metoprolol - 12:40 AM\\n Other medications:\\n Flowsheet Data as of 05:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 36.3\\nC (97.3\\n HR: 79 (72 - 82) bpm\\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\\n RR: 20 (14 - 32) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 95.3 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: -2 (-2 - 12) mmHg\\n Total In:\\n 3,520 mL\\n 592 mL\\n PO:\\n Tube feeding:\\n 1,440 mL\\n 309 mL\\n IV Fluid:\\n 2,020 mL\\n 283 mL\\n Blood products:\\n Total out:\\n 3,500 mL\\n 1,280 mL\\n Urine:\\n 3,435 mL\\n 1,280 mL\\n NG:\\n 65 mL\\n Stool:\\n Drains:\\n Balance:\\n 20 mL\\n -688 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 98%\\n ABG: ///26/\\n Physical Examination\\n Labs / Radiology\\n 327 K/uL\\n 9.0 g/dL\\n 119 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 142 mEq/L\\n 27.0 %\\n 7.1 K/uL\\n [image002.jpg]\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n Plt\\n 199\\n 226\\n 259\\n 307\\n 327\\n Creatinine\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\\n for w/drawal. Started zyprexa. Restraints prn\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\\n prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV, NGT, aline,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Time spent: 35 min\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 505370,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Cannot manage secretions;\\n Comments: Pt remain stable on PSV settings with no issues this shift.\\n Pt tidal volumes, Resp rate, oxygen saturations all within normal\\n range. Pt had clear lung sounds, with a strong cough. Pt is off all\\n IV sedation, and is being monitored for improving mental status and\\n awareness. Pt to be assessed by MD team for possible extubation.\\n BEDSIDE RSBI- 76\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505911,\n \"text\": \"Trauma, s/p\\n Assessment:\\n External fixation device in place on right leg, Left Knee immbolizer\\n on,\\n Pin sites slightly red and clean, draining serous fluid,\\n Dopplerable pulses, legs warm, good cap refill.\\n Patient is confused and agitated most of night, oriented to self,\\n continually tries to get out of bed, says:\\nI have to go to \\nI need my money\\n. Hard to redirect. When told he is in the hospital\\n patient looks shocked. Consistently putting legs over side rail.\\n Coughing up secretions.\\n Action:\\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\\n frequently, calmly reassured.\\n Pin care done x 2,\\n Turned and repositioned for comfort.\\n Given 5 mg Olanzapine for agitation.\\n Response:\\n Patient continues to be confused and hard to redirect, tries to get\\n OOB. Patient hardly slept all night, more calm after olanzapine given.\\n Plan:\\n Continue to monitor, reorient frequently.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505576,\n \"text\": \"pt is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\\n ORIF L distal femur fx and IVC filter \\n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\\n hct 26.8. febrile\\n pan cultured\\n Trauma, s/p\\n Assessment:\\n - appears sedated at start of shift, slightly opening eyes to\\n voice/stimulation\\n - slowly waking up throughout the morning, pt wide awake\\n sitting up in bed mouthing words and nodding head inconsistently,\\n following simple commands\\n Action:\\n - extubated at approx 1330\\n - coughing/deep breathing, chest pt, repositioning\\n - pin care and changed dressing frequently\\n Response:\\n - tolerating extubation well, strong productive cough, pt will\\n spit secretions, wear mask. Needs lg amt of encouragement to\\n cough/deep breathe\\n - difficult to understand what pt is saying, garbled,\\n congested speech\\n - sm-mod amt of yellow drainage from RLE pins\\n Plan:\\n - face tent with humidified O2\\n - aggressive pulmonary toileting, coughing/deep breathing,\\n chest PT\\n - monitor neuro status, reoirient as needed\\n - pin care as needed\\n - to return to OR for procedure on RLE Tuesday ?\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505812,\n \"text\": \"Trauma, s/p\\n Assessment:\\n - pt more alert today, compared with yesterday\\ns assessment by this\\n nurse. Oriented X 1, better able to understand speech, confused,\\n oriented at times, needs frequent re-orientation and re-direction\\n - lungs clear, rhonchorous at times but clear with coughing\\n - strong productive cough, absent gag\\n - yellow drainage on pad of RLE\\n - face tent 35% humidified\\n Action:\\n - mouth swabs to moisten oral cavity\\n - encouraged coughing and deep breathing\\n - OOB to chair\\n - did not try pt on clear liquids at this time, uncooperative at times,\\n absent gag reflex.\\n - frequent pin care as needed\\n Response:\\n - expectorating lg amts of white secretions\\n - slid pt over to stretcher chair with careful movement of legs, pt sat\\n up in chair with head elevated and legs out straight at a slight angle\\n for approx 2 hrs\\n - tolerating TF at goal, 15cc residual\\n - sm brown soft formed BM X 1\\n - sats 97-100% throughout shift\\n Plan:\\n - continue turning/repositioning, encourage coughing, deep breathing\\n - monitor respiratory status, face tent 35% for humidification of\\n secretions\\n - frequently re-orient pt as needed\\n - to Return to OR Tuessay ? for internal fixation of R leg\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 506045,\n \"text\": \"Subjective: patient delirious, confused, A&O x1.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 183 cm\\n 94.5 kg\\n 95.3 kg ( 12:00 AM)\\n 28.2\\n Pertinent medications: normal saline @ 55mL/hr, ABx,\\n cyanocobalamin, protonix, heparin, multivitamin, folic acid, thiamine,\\n others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 119 mg/dL\\n 01:53 AM\\n Glucose Finger Stick\\n 120\\n 10:00 PM\\n BUN\\n 13 mg/dL\\n 01:53 AM\\n Creatinine\\n 0.6 mg/dL\\n 01:53 AM\\n Sodium\\n 142 mEq/L\\n 01:53 AM\\n Potassium\\n 3.9 mEq/L\\n 01:53 AM\\n Chloride\\n 107 mEq/L\\n 01:53 AM\\n TCO2\\n 26 mEq/L\\n 01:53 AM\\n PO2 (arterial)\\n 162 mm Hg\\n 02:50 AM\\n PCO2 (arterial)\\n 37 mm Hg\\n 02:50 AM\\n pH (arterial)\\n 7.47 units\\n 02:50 AM\\n pH (urine)\\n 6.0 units\\n 08:56 PM\\n CO2 (Calc) arterial\\n 28 mEq/L\\n 02:50 AM\\n Calcium non-ionized\\n 8.4 mg/dL\\n 01:53 AM\\n Phosphorus\\n 3.1 mg/dL\\n 01:53 AM\\n Ionized Calcium\\n 1.11 mmol/L\\n 02:21 AM\\n Magnesium\\n 2.1 mg/dL\\n 01:53 AM\\n ALT\\n 25 IU/L\\n 04:50 AM\\n Alkaline Phosphate\\n 60 IU/L\\n 04:50 AM\\n AST\\n 46 IU/L\\n 04:50 AM\\n Amylase\\n 27 IU/L\\n 04:50 AM\\n Total Bilirubin\\n 1.0 mg/dL\\n 04:50 AM\\n WBC\\n 7.1 K/uL\\n 01:53 AM\\n Hgb\\n 9.0 g/dL\\n 01:53 AM\\n Hematocrit\\n 27.0 %\\n 01:53 AM\\n Current diet order / nutrition support: Tube Feeds: Replete with fiber\\n @ 60mL/hr (1440kcals, 89g protien)\\\\\\n Diet: NPO\\n GI: abd soft, bowel sounds present\\n Assessment of Nutritional Status\\n 50 y.o. Male ped vs auto with multiple orthopedic injuries s/p RLE\\n ExFix, rib fractures, s/p L femur ORIF, right ankle external fixation\\n removal + ORIF. s/p IVC filter. Patient also with alcohol withdrawal\\n with DTs, initially intubated after increased somnolence, now extubated\\n as of . Patient is receiving tube feeds via NGT for nutrition;\\n current tube feeds do not meet nutritional needs. Recommend increasing\\n goal rate to meet 100% of est. calorie and protein needs.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Recommend increasing tube feed goal to 95mL/hr (2280kcals,\\n 141g protein).\\n Monitor tolerance with abd exam and residual checks.\\n Monitor lytes and hydration.\\n Following - #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505423,\n \"text\": \"pt he is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Pupils #3 and reasts briskly\\n Moves upper extremtites off the bed.\\n Move right leg back and forth but has some difficulty moving off the\\n bed due to the metal apparatus.\\n Does not move left leg freely and only wiil move slowly.\\n Hct 26 .6\\n Vanco level 4.8\\n Suctioned for copiius amts of thick tan\\nyellow sputum.\\n Action:\\n Neuro signs q2hrs\\n Pin care to right leg and foot\\n Suctioned prn\\n Vap mouth care\\n Iv 1/2ns at 55cc/hr\\n Tube fdg at goal\\n On iv vanco, pipercillin and cipro.\\n Response:\\n Vital signs stable\\n Remains off all sedation.\\n Slowly waking and following simple commands\\n Hct stable at 26\\n Continues to be suctioned for copius amts of thick white/yellow sputum.\\n Plan:\\n Monitor patient\\ns condition closely.\\n Provide emotional support to patient.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505428,\n \"text\": \"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n MULTI LUMEN - START 01:30 PM\\n FEVER - 101.6\\nF - 08:00 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Ciprofloxacin - 09:56 AM\\n Vancomycin - 08:32 PM\\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 05:54 PM\\n Pantoprazole (Protonix) - 08:32 PM\\n Heparin Sodium (Prophylaxis) - 08:32 PM\\n Other medications:\\n Flowsheet Data as of 01:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.7\\n Tcurrent: 37.9\\nC (100.3\\n HR: 91 (83 - 100) bpm\\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\\n RR: 28 (21 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 98 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 11 (11 - 16)mmHg\\n Total In:\\n 2,933 mL\\n 109 mL\\n PO:\\n TF:\\n 454 mL\\n 52 mL\\n IVF:\\n 2,479 mL\\n 57 mL\\n Blood products:\\n Total out:\\n 2,930 mL\\n 0 mL\\n Urine:\\n 2,930 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3 mL\\n 109 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 624 (411 - 624) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 50\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: 7.45/45/132/27/7\\n Ve: 10.7 L/min\\n PaO2 / FiO2: 330\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\\n Bronchial: bases)\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 199 K/uL\\n 8.5 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 142 mEq/L\\n 25.3 %\\n 8.0 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n WBC\\n 9.7\\n 8.0\\n Hct\\n 26.8\\n 28.1\\n 25.3\\n Plt\\n 169\\n 199\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 28\\n 27\\n 29\\n 26\\n 29\\n 32\\n Glucose\\n 87\\n 104\\n 121\\n 128\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\\n PO4:2.7 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. Going to OR today for L femur\\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean off prop to attempt vent wean\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febrile -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\\n Fiber (Full) - 04:00 PM 50 mL/hour\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Lines:\\n Arterial Line - 10:00 AM\\n Multi Lumen - 01:30 PM\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 505560,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Expectorated / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Comments:\\n Pt weaned and extubated without complications.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505562,\n \"text\": \" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\\n ORIF L distal femur fx and IVC filter \\n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\\n hct 26.8. febrile\\n pan cultured\\n Trauma, s/p\\n Assessment:\\n - appears sedated at start of shift, slightly opening eyes to\\n voice/stimulation\\n - slowly waking up throughout the morning, pt wide awake\\n sitting up in bed mouthing words and nodding head inconsistently,\\n following simple commands\\n -\\n Action:\\n - extubated at approx 1330\\n -\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505573,\n \"text\": \" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\\n ORIF L distal femur fx and IVC filter \\n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\\n hct 26.8. febrile\\n pan cultured\\n Trauma, s/p\\n Assessment:\\n - appears sedated at start of shift, slightly opening eyes to\\n voice/stimulation\\n - slowly waking up throughout the morning, pt wide awake\\n sitting up in bed mouthing words and nodding head inconsistently,\\n following simple commands\\n Action:\\n - extubated at approx 1330\\n - coughing/deep breathing, chest pt, repositioning\\n - pin care and changed dressing frequently\\n Response:\\n - tolerating extubation well, strong productive cough, pt will\\n spit secretions, wear mask. Needs lg amt of encouragement to\\n cough/deep breathe\\n - difficult to understand what pt is saying, garbled,\\n congested speech\\n - sm-mod amt of yellow drainage from RLE pins\\n Plan:\\n - face tent with humidified O2\\n - aggressive pulmonary toileting, coughing/deep breathing,\\n chest PT\\n - monitor neuro status, reoirient as needed\\n - pin care as needed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505574,\n \"text\": \" s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\\n ORIF L distal femur fx and IVC filter \\n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\\n hct 26.8. febrile\\n pan cultured\\n Trauma, s/p\\n Assessment:\\n - appears sedated at start of shift, slightly opening eyes to\\n voice/stimulation\\n - slowly waking up throughout the morning, pt wide awake\\n sitting up in bed mouthing words and nodding head inconsistently,\\n following simple commands\\n Action:\\n - extubated at approx 1330\\n - coughing/deep breathing, chest pt, repositioning\\n - pin care and changed dressing frequently\\n Response:\\n - tolerating extubation well, strong productive cough, pt will\\n spit secretions, wear mask. Needs lg amt of encouragement to\\n cough/deep breathe\\n - difficult to understand what pt is saying, garbled,\\n congested speech\\n - sm-mod amt of yellow drainage from RLE pins\\n Plan:\\n - face tent with humidified O2\\n - aggressive pulmonary toileting, coughing/deep breathing,\\n chest PT\\n - monitor neuro status, reoirient as needed\\n - pin care as needed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506035,\n \"text\": \"Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n Action:\\n - removed restraints, constant observation, frequent\\n re-orienting and re-directing\\n - encouraged coughing/deep breathing\\n - OOB to chair\\n - zyprexa order changed to TID, given as ordered\\n Response:\\n - pt continues to be delirious\\n - slid pt using slide board over to stretcher chair, sat\\n upright with\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506310,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Patient alert confused agitated garbled speech this am gave 1mg haldol\\n and zyprexa IM heart rate 70-80\\ns sinus rhythm systolic b/p 120-140\\n over 70\\ns lungs diminished in bases but clear upper fields respirations\\n unlabored 20\\ns O2 sat 95% suctioned for thick tan secretions abd soft\\n but firm + bowel sounds + flatus incision sutures intact + pp by\\n Doppler external fixation intact T max 100.0 Patient has soft limb\\n restraints\\n Action:\\n Continue with oral zyprexa and prn haldol dc\\ndl an IM zyprexa\\n Response:\\n Patient remains stable at this time\\n Plan:\\n No OR in the am per ortho called out today to CC6 if agitation is\\n better\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505809,\n \"text\": \"Trauma, s/p\\n Assessment:\\n - pt more alert today, compared with yesterday\\ns assessment by this\\n nurse. Oriented X 1, better able to understand speech, confused,\\n oriented at times, needs frequent re-orientation and re-direction\\n - lungs clear, rhonchorous at times but clear with coughing\\n - strong productive cough, absent gag\\n -\\n Action:\\n - mouth swabs to moisten oral cavity\\n - encouraged coughing and deep breathing\\n - OOB to chair\\n Response:\\n - expectorating lg amts of white secretions\\n - slid pt over to stretcher chair with careful movement of legs, pt sat\\n up in chair with head elevated and legs out straight at a slight angle\\n for approx 2 hrs\\n -\\n Plan:\\n -\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 504623,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Copious\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust\\n Min. ventilation to control pH, Increase ventilatory support at night\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Cannot manage secretions,\\n Underlying illness not resolved; Comments: Pt remains on PSV settings\\n with no changes this shift. Pt remains stable as per tidal volumes,\\n RR, SpO2 and airway pressures. Pt had no significant issues this\\n shift. Pt to OR today and plan of care to be determined by MD team.\\n BEDSIDE RSBI- 72\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506422,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - pt alert, oriented X , confused/agitated, continuously\\n trying to get OOB, very hard of hearing\\n - lungs clear, rhonchorous at times, clearing with strong\\n productive cough\\n Action:\\n - zyprexa PO TID\\n - Zyprexa IM X 1\\n - Constant reorienting, redirecting, monitoring pt for high\\n fall risk\\n - Pt partially pulled out NGT. NGT found halfway in so it was\\n re-inserted, chest xray done which showed it was in too far. NGT was\\n drawn back. Now awaiting repeat chest xray\\n - 0.5mg Ativan X 1 for agitation due to inability to give PO\\n zyprexa\\n - Antibiotics given as ordered\\n - Pin care and dressing changed PRN\\n Response:\\n - minimal response from zyprexa doses, pt continues to be\\n confused/agitated\\n - pt awake throughout shift, SICU and trauma teams aware\\n - on soft formed brown BM, used bedpan\\n Plan:\\n - continue to monitor neuro status, frequent reorienting and\\n redirecting\\n - pt will require sitter when transferred to CC6 for\\n agitation, confusion, high fall risk, and risk of injuring lower\\n extremities\\n - follow up with repeat chest xray\\n - OR today for RLE washout and internal fixation ? OR time\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505613,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient is extubated and oriented x 1. Confused and believes he is in\\n , constantly says he has to leave, trying to pull at lines and\\n NG when unrestrained, able to redirect.\\n Serous output from pin site on R leg, pin sites clean.\\n L knee immobilizer in place, incision clean and dry.\\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\\n to touch.\\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\\n patient able to clear on own, sating 95-100% on 40% face tent.\\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\\n Action:\\n Turned and repositioned for comfort,\\n Pin care done q 4 hours during shift,\\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\\n breathe.\\n Response:\\n Patient continues to be confused, able to state name only.\\n Plan:\\n Continue to monitor, pulm. Toilet.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505703,\n \"text\": \"24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\\n prompting admission to ICU.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:32 PM\\n Ciprofloxacin - 11:00 PM\\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:06 PM\\n Heparin Sodium (Prophylaxis) - 08:52 PM\\n Metoprolol - 06:02 AM\\n Other medications:\\n Flowsheet Data as of 06:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.4\\nC (99.4\\n HR: 81 (75 - 99) bpm\\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\\n RR: 20 (19 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 6 (0 - 14)mmHg\\n Total In:\\n 2,912 mL\\n 844 mL\\n PO:\\n TF:\\n 972 mL\\n 388 mL\\n IVF:\\n 1,880 mL\\n 456 mL\\n Blood products:\\n Total out:\\n 2,950 mL\\n 1,050 mL\\n Urine:\\n 2,920 mL\\n 1,020 mL\\n NG:\\n 30 mL\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n -38 mL\\n -206 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 550 (550 - 550) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 35%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: 7.47/37/162/27/4\\n Ve: 11.1 L/min\\n PaO2 / FiO2: 463\\n Physical Examination\\n General Appearance: Sedated but follows commands, reluctantly\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\\n Labs / Radiology\\n 307 K/uL\\n 8.7 g/dL\\n 124 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 25.4 %\\n 7.8 K/uL\\n [image002.jpg]\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n Plt\\n 199\\n 226\\n 259\\n 307\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n TCO2\\n 29\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.3 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Recovering from ETOH w/d.\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febril -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, s/p resp\\n failure\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n : Time spent 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506106,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - zyprexa IM PRN given at 1730\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - Minimal response from PO zyprexa, IM zyprexa with good\\n effect, pt calm and resting\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa qtc and PRN as needed\\n - OR tomorrow for R internal fixation ?\\n - ? transfer to floor tomorrow with distinct plan for fall\\n high risk in order prior to transfer. Involve psychiatric services\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506369,\n \"text\": \"Trauma, s/p\\n Assessment:\\n - pt alert, oriented X , confused/agitated, very hard of\\n hearing\\n - lungs clear, rhonchorous at times, clearing with strong\\n productive cough\\n Action:\\n - zyprexa PO TID\\n - Zyprexa IM X 1\\n - Constant reorienting, redirecting, monitoring pt for high\\n fall risk\\n - Antibiotics given as ordered\\n - Pin care and dressing changed PRN\\n Response:\\n - minimal response from zyprexa doses, pt continues to be\\n confused/agitated\\n - pt awake throughout shift, SICU and trauma teams aware\\n Plan:\\n - continue to monitor neuro status, frequent reorienting and\\n redirecting\\n - pt will require sitter when transferred to CC6 for\\n agitation, confusion, high fall risk, and risk of injuring lower\\n extremities\\n - OR today for RLE washout and internal fixation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506370,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - pt alert, oriented X , confused/agitated, continuously\\n trying to get OOB, very hard of hearing\\n - lungs clear, rhonchorous at times, clearing with strong\\n productive cough\\n Action:\\n - zyprexa PO TID\\n - Zyprexa IM X 1\\n - Constant reorienting, redirecting, monitoring pt for high\\n fall risk\\n - Antibiotics given as ordered\\n - Pin care and dressing changed PRN\\n Response:\\n - minimal response from zyprexa doses, pt continues to be\\n confused/agitated\\n - pt awake throughout shift, SICU and trauma teams aware\\n Plan:\\n - continue to monitor neuro status, frequent reorienting and\\n redirecting\\n - pt will require sitter when transferred to CC6 for\\n agitation, confusion, high fall risk, and risk of injuring lower\\n extremities\\n - OR today for RLE washout and internal fixation ? OR time\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505669,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient is extubated and oriented x 1. Confused and believes he is in\\n , constantly says he has to leave, trying to pull at lines and\\n NG when unrestrained, able to redirect.\\n Serous output from pin site on R leg, pin sites clean.\\n L knee immobilizer in place, incision clean and dry.\\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\\n to touch.\\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\\n patient able to clear on own, sating 95-100% on 40% face tent.\\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\\n Action:\\n Turned and repositioned for comfort,\\n Pin care done q 4 hours during shift,\\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\\n breathe.\\n Response:\\n Patient continues to be confused, able to state name only.\\n Plan:\\n Continue to monitor, pulm. Toilet.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505676,\n \"text\": \"24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\\n prompting admission to ICU.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:32 PM\\n Ciprofloxacin - 11:00 PM\\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:06 PM\\n Heparin Sodium (Prophylaxis) - 08:52 PM\\n Metoprolol - 06:02 AM\\n Other medications:\\n Flowsheet Data as of 06:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 37.4\\nC (99.4\\n HR: 81 (75 - 99) bpm\\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\\n RR: 20 (19 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 94.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 6 (0 - 14)mmHg\\n Total In:\\n 2,912 mL\\n 844 mL\\n PO:\\n TF:\\n 972 mL\\n 388 mL\\n IVF:\\n 1,880 mL\\n 456 mL\\n Blood products:\\n Total out:\\n 2,950 mL\\n 1,050 mL\\n Urine:\\n 2,920 mL\\n 1,020 mL\\n NG:\\n 30 mL\\n 30 mL\\n Stool:\\n Drains:\\n Balance:\\n -38 mL\\n -206 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 550 (550 - 550) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 35%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: 7.47/37/162/27/4\\n Ve: 11.1 L/min\\n PaO2 / FiO2: 463\\n Physical Examination\\n General Appearance: Sedated but follows commands, reluctantly\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\\n Labs / Radiology\\n 307 K/uL\\n 8.7 g/dL\\n 124 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 12 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 25.4 %\\n 7.8 K/uL\\n [image002.jpg]\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n Plt\\n 199\\n 226\\n 259\\n 307\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n TCO2\\n 29\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.3 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Recovering from ETOH w/d.\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febril -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n :\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506108,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - zyprexa IM PRN given at 1730\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse, social work\\n notified. Pts family states last name is spelt , admitting\\n notified and change made in system\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - Minimal response from PO zyprexa, IM zyprexa with good\\n effect, pt calm and resting\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n - mother and sister will be staying with friend\\n locally, will be in to visit pt in the morning. Able to reach them\\n if needed at number: \\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa qtc and PRN as needed\\n - OR tomorrow for R internal fixation ?\\n - ? transfer to floor tomorrow with distinct plan for fall\\n high risk in order prior to transfer. Involve psychiatric services.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504708,\n \"text\": \"Pt with multiple injuries and DTs\\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n No major events.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:39 AM\\n Infusions:\\n Propofol - 40 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:13 PM\\n Enoxaparin (Lovenox) - 08:16 PM\\n Diazepam (Valium) - 07:30 AM\\n Hydromorphone (Dilaudid) - 07:38 AM\\n Flowsheet Data as of 08:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.6\\nC (99.6\\n HR: 83 (70 - 86) bpm\\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\\n RR: 23 (10 - 28) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 72 Inch\\n Total In:\\n 4,497 mL\\n 1,104 mL\\n PO:\\n TF:\\n IVF:\\n 3,022 mL\\n 1,104 mL\\n Blood products:\\n 1,475 mL\\n Total out:\\n 1,730 mL\\n 1,210 mL\\n Urine:\\n 1,730 mL\\n 510 mL\\n NG:\\n 700 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,767 mL\\n -106 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (384 - 753) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 72\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/155/27/3\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 388\\n Physical Examination\\n General Appearance: Diaphoretic\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: RRR\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present\\n Extremities: Right lower extremity edema: 3+, Left lower extremity\\n edema: 2+, Right ankle external fixation\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 8.7 K/uL\\n [image002.jpg]\\n 07:11 PM\\n 04:50 AM\\n 01:15 PM\\n 07:42 PM\\n 04:13 AM\\n 11:04 AM\\n 06:45 PM\\n 08:17 PM\\n 08:36 PM\\n 02:17 AM\\n WBC\\n 9.3\\n 6.6\\n 8.3\\n 8.7\\n 7.5\\n 8.7\\n Hct\\n 26.0\\n 21.3\\n 25.5\\n 29.5\\n 29.8\\n 28.7\\n Plt\\n 152\\n 153\\n 164\\n 141\\n 154\\n 169\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n TCO2\\n 32\\n 31\\n 30\\n Glucose\\n 124\\n 83\\n 97\\n 104\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs, now intubated after increased\\n somnolence. Going to OR today for L femur ORIF, right ankle external\\n fixation removal + ORIF. ?IVC filter.\\n .\\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\\n dilaudid prn, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal.\\n GI: Npo. Will use NGT feeding after surgery.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Hct monitoring,transfuse as required\\n ENDO: RISS\\n ID: Cefazolin 2gm IV q8hr ()\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT\\n IVF: thiamine, d5, folate\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT Lovenox 30 q12hr. Held this AM for surgery.\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Time spent 32 min\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 506541,\n \"text\": \"Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Pt intubated several hours pre-op for increased agitation. To OR for\\n washout and maneuvering of fixation devices. CT tonight. Probable\\n extubation in AM.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504675,\n \"text\": \"24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n No major events.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:39 AM\\n Infusions:\\n Propofol - 40 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:13 PM\\n Enoxaparin (Lovenox) - 08:16 PM\\n Diazepam (Valium) - 07:30 AM\\n Hydromorphone (Dilaudid) - 07:38 AM\\n Other medications:\\n Flowsheet Data as of 08:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.6\\nC (99.6\\n HR: 83 (70 - 86) bpm\\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\\n RR: 23 (10 - 28) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 72 Inch\\n Total In:\\n 4,497 mL\\n 1,104 mL\\n PO:\\n TF:\\n IVF:\\n 3,022 mL\\n 1,104 mL\\n Blood products:\\n 1,475 mL\\n Total out:\\n 1,730 mL\\n 1,210 mL\\n Urine:\\n 1,730 mL\\n 510 mL\\n NG:\\n 700 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,767 mL\\n -106 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (384 - 753) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 72\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/155/27/3\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 388\\n Physical Examination\\n General Appearance: Diaphoretic\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: RRR\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present\\n Extremities: Right lower extremity edema: 3+, Left lower extremity\\n edema: 2+, Right ankle external fixation\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 8.7 K/uL\\n [image002.jpg]\\n 07:11 PM\\n 04:50 AM\\n 01:15 PM\\n 07:42 PM\\n 04:13 AM\\n 11:04 AM\\n 06:45 PM\\n 08:17 PM\\n 08:36 PM\\n 02:17 AM\\n WBC\\n 9.3\\n 6.6\\n 8.3\\n 8.7\\n 7.5\\n 8.7\\n Hct\\n 26.0\\n 21.3\\n 25.5\\n 29.5\\n 29.8\\n 28.7\\n Plt\\n 152\\n 153\\n 164\\n 141\\n 154\\n 169\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n TCO2\\n 32\\n 31\\n 30\\n Glucose\\n 124\\n 83\\n 97\\n 104\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs, now intubated after increased\\n somnolence. Going to OR today for L femur ORIF, right ankle external\\n fixation removal + ORIF. ?IVC filter.\\n .\\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\\n dilaudid prn, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal.\\n GI: Npo. Will use NGT feeding after surgery.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Hct 36 -> 26 -> 21, s/p 2u pRBC --> 25.5 --> 2u PRBC prior to\\n going to OR per anesthesia request --> HCT 29.8 --> 28.7\\n ENDO: RISS\\n ID: Cefazolin 2gm IV q8hr ()\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT\\n IVF: thiamine, d5, folate\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT Lovenox 30 q12hr. Held this AM for surgery.\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504682,\n \"text\": \"24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n No major events.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:39 AM\\n Infusions:\\n Propofol - 40 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:13 PM\\n Enoxaparin (Lovenox) - 08:16 PM\\n Diazepam (Valium) - 07:30 AM\\n Hydromorphone (Dilaudid) - 07:38 AM\\n Other medications:\\n Flowsheet Data as of 08:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37.6\\nC (99.6\\n HR: 83 (70 - 86) bpm\\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\\n RR: 23 (10 - 28) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 72 Inch\\n Total In:\\n 4,497 mL\\n 1,104 mL\\n PO:\\n TF:\\n IVF:\\n 3,022 mL\\n 1,104 mL\\n Blood products:\\n 1,475 mL\\n Total out:\\n 1,730 mL\\n 1,210 mL\\n Urine:\\n 1,730 mL\\n 510 mL\\n NG:\\n 700 mL\\n Stool:\\n Drains:\\n Balance:\\n 2,767 mL\\n -106 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 384 (384 - 753) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 72\\n PIP: 16 cmH2O\\n SpO2: 98%\\n ABG: 7.41/45/155/27/3\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 388\\n Physical Examination\\n General Appearance: Diaphoretic\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: RRR\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present\\n Extremities: Right lower extremity edema: 3+, Left lower extremity\\n edema: 2+, Right ankle external fixation\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.9 g/dL\\n 104 mg/dL\\n 0.7 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.7 %\\n 8.7 K/uL\\n [image002.jpg]\\n 07:11 PM\\n 04:50 AM\\n 01:15 PM\\n 07:42 PM\\n 04:13 AM\\n 11:04 AM\\n 06:45 PM\\n 08:17 PM\\n 08:36 PM\\n 02:17 AM\\n WBC\\n 9.3\\n 6.6\\n 8.3\\n 8.7\\n 7.5\\n 8.7\\n Hct\\n 26.0\\n 21.3\\n 25.5\\n 29.5\\n 29.8\\n 28.7\\n Plt\\n 152\\n 153\\n 164\\n 141\\n 154\\n 169\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n TCO2\\n 32\\n 31\\n 30\\n Glucose\\n 124\\n 83\\n 97\\n 104\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs, now intubated after increased\\n somnolence. Going to OR today for L femur ORIF, right ankle external\\n fixation removal + ORIF. ?IVC filter.\\n .\\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\\n dilaudid prn, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal.\\n GI: Npo. Will use NGT feeding after surgery.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Hct monitoring,transfuse as required\\n ENDO: RISS\\n ID: Cefazolin 2gm IV q8hr ()\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT\\n IVF: thiamine, d5, folate\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT Lovenox 30 q12hr. Held this AM for surgery.\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504936,\n \"text\": \".\\n HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Post operative day:\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\\n femur , now s/p ORIF L distal femur fx and IVC filter \\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 02:07 PM\\n Pantoprazole (Protonix) - 08:02 PM\\n Hydromorphone (Dilaudid) - 08:02 PM\\n Diazepam (Valium) - 10:50 PM\\n Metoprolol - 12:15 AM\\n Other medications:\\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\\n patient is on mechanical ventilation. Order date: @ 1316 19.\\n Metoprolol Tartrate 5 mg IV Q6H\\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\\n DAILY Order date: @ 1316\\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \\n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\\n Order date: @ 1316\\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\\n TO SEDATION Order date: @ 1316\\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\\n hold oral thiamine, folate and multivitamins. Order date: \\n Flowsheet Data as of 04:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.9\\nC (102.1\\n Tcurrent: 38.5\\nC (101.3\\n HR: 96 (72 - 101) bpm\\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\\n RR: 25 (16 - 26) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 97 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 5,831 mL\\n 655 mL\\n PO:\\n TF:\\n IVF:\\n 5,831 mL\\n 655 mL\\n Blood products:\\n Total out:\\n 2,520 mL\\n 425 mL\\n Urine:\\n 1,580 mL\\n 425 mL\\n NG:\\n 700 mL\\n Stool:\\n Drains:\\n Balance:\\n 3,311 mL\\n 230 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n Vt (Spontaneous): 0 (0 - 530) mL\\n PS : 10 cmH2O\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI: 72\\n PIP: 21 cmH2O\\n Plateau: 25 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.42/43/120/28/3\\n Ve: 14.3 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\\n tube, NG tube\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+, Clubbing\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Paralyzed, Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.1 g/dL\\n 121 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.0 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 9.7 K/uL\\n [image002.jpg]\\n 06:45 PM\\n 08:17 PM\\n 08:36 PM\\n 02:17 AM\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n WBC\\n 8.7\\n 7.5\\n 8.7\\n 9.7\\n Hct\\n 29.5\\n 29.8\\n 28.7\\n 26.8\\n 28.1\\n Plt\\n 141\\n 154\\n 169\\n 169\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n 0.6\\n TCO2\\n 30\\n 28\\n 27\\n 29\\n Glucose\\n 97\\n 104\\n 87\\n 104\\n 121\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. Going to OR today for L femur\\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean sedation to attempt vent wean\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal.\\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\\n check NG tube position\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: D/CCefazolin 2gm IV q8hr (). Febrile - pan cultured. Change to\\n Zosyn. Sputum: GNR\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch compartments\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\\n Failure\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Total time: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504951,\n \"text\": \"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Trauma, s/p\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 506775,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Insp Wheeze\\n LUL Lung Sounds: Insp Wheeze\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n :\\n Respiratory Care Shift Procedures\\n Comments: pt extubated to 70% cool aerosol, now on nasal cannula. Pt is\\n tolerating well. Meds : alb nebs q6 prn.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504643,\n \"text\": \"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n .\\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\\n developing pneumonia, and new small left effusion\\n : Intubated for airway protection\\n Trauma, s/p\\n Assessment:\\n Remains intubated and sedated on propofol gtt.\\n Diaphoretic break through during the nite\\n Breath sounds rhonchous\\n Pupils #2 and reacts briskly.\\n Moves upper extremities on the bed.\\n No movement in lower extremites\\n Suctioned for thick yellow sputum.\\n Hct 28.7\\n Action:\\n Suctioned prn\\n Vap mouth care as ordered\\n Npo for or today.\\n On propofol gtt and infusing at 40mcg/hr.\\n Iv lactatated ringers at 100cc/hr.\\n Valium 10mg iv prn given\\n Hydromorphone 1mg iv prn given.\\n Pin care done to right foot and foot draining serous drainage.\\n Type and screen specimen sent to the blood bank.\\n Response:\\n Patient remains intubated and sedated.\\n Npo for the or today.\\n Plan:\\n Monitor condition closely.\\n To or for femur repair\\n Update cousin of patient\\ns condition.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 504764,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 24 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Fully sedated @ present time\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n 50 yr old male ped vs auto with\\n( femur tib and bilateral rib fx.\\n Patient went to OR for repair. Upon his return patient is placed on\\n mechanical ventilation sedated with good ABG. CXR persitent low lung\\n volume with atelectasis @ bases. BS diminished suctioned for small\\n white thick secretion\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504766,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\\n Right leg has external fixation in place, pins look pinkish, serosang\\n drainage from pin sites and incision, L knee immobilizer on.\\n Intubated and sedated on propofol.\\n When woken up patient unable to follow commands, face very red, bites\\n on tube, tremors,\\n Action:\\n Response:\\n Plan:\\n Alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504770,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\\n Right leg has external fixation in place, pins look pinkish, serosang\\n drainage from pin sites and incision, L knee immobilizer on.\\n Intubated and sedated on propofol.\\n When woken up patient unable to follow commands, face very red, bites\\n on tube, tremors, diaphoretic.\\n Action:\\n Taken to OR for internal fixation of right fib/tib fx (unable to do\\n because of swelling) and repair of L femur fx.\\n L knee immobilizer on and original dsg with ace bandage over it from\\n OR. Sanginous drainage noted.\\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\\n Banana bag given,\\n Pin care and incision care done on R leg .\\n Response:\\n Patient continues on prop and intubated on CMV.\\n Plan:\\n Alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504776,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\\n Right leg has external fixation in place, pins look pinkish, serosang\\n drainage from pin sites and incision, L knee immobilizer on.\\n Intubated and sedated on propofol.\\n When woken up patient unable to follow commands, face very red, bites\\n on tube, tremors, diaphoretic.\\n Action:\\n Taken to OR for internal fixation of right fib/tib fx (unable to do\\n because of swelling) and repair of L femur fx. Also placement of IVC\\n filter.\\n L knee immobilizer on and original dsg with ace bandage over it from\\n OR. Sanginous drainage noted.\\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\\n Banana bag given,\\n Pin care and incision care done on R leg .\\n Response:\\n Patient continues on prop and intubated on CMV. HR 80\\ns-90\\ns NSR, SBP\\n 100-120.\\n Plan:\\n Continue to monitor.\\n Alcohol abuse\\n Assessment:\\n Patient has hx of alcohol abuse (admitted to 12 beers/day) Came in to\\n ED with alcohol blood level of 400). Continues to be\\n sedated on prop, when woken up patient is unable to follow commands,\\n face very red, bites on tube, tremors, diaphoretic.\\n Action:\\n Given 10 mg IV valium per CIWA scale q 1-2 hours.\\n Response:\\n Vital signs stable, SBP 100-120, HR 80\\ns-90\\ns, patient appears\\n comfortable after valium given.\\n Plan:\\n Continue to monitor, continue with CIWA scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505058,\n \"text\": \"HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Trauma, s/p\\n Assessment:\\n Patient vented and sedated when sedation lightened patient has\\n purposeful movements lungs clear upper lobes diminished in lower lobes\\n suctioned for thick tan secretions, and copious amounts of thin oral\\n secretions abd soft + bowel sounds + flatus no bm Foley patent\\n draining amber urine pin care done + pulses by Doppler + cap refill. T\\n max 99.0 heart rate 80-90\\ns sinus rhythm systolic 90-120\\n over 60\\n Action:\\n Tube feeding replete with fiber started through NG tube patient started\\n on vancomycin, cipro for VAP central line placed for access confirmed\\n by x-ray. Ventilator settings changed to 10/10 then weaned to \\n Response:\\n Patient tolerating vent settings remains stable at this time.\\n Plan:\\n Continue with current plan of care provide comfort and support as\\n needed notify team of any changes\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 505061,\n \"text\": \"Day of mechanical ventilation: 4\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Crackles\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Weaned to CSV, eventually to with good ABG\\ns. Possible extubation\\n in AM.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 504844,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 4\\n Ideal body weight: 80.7\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Adjust Min. ventilation to control pH\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504887,\n \"text\": \"Trauma, s/p leg fractures\\n Assessment:\\n Febrile to 102\\n Tachycardic to low 100\\ns with PVC\\n Diaphoretic\\n Sedated on Propofol\\n Period of hypotension\\n HCT and electrolytes checked\\n Adequate urine output 45-100 cc\\ns/hr.\\n Dopplerable pulses bilateral lower extremities\\n Action:\\n X1 peripheral BC, U/A, C+S, and sputum samples sent\\n Valium x1 given\\n Dilaudid x1 given\\n LR 500 cc fluid bolus for hypotension\\n Magnesium and calcium repleated\\n Propofol stopped for daily wakeup, patient biting on ETT, no\\n other purposeful movement noted, unable to finish exam before having to\\n restart sedation.\\n Suctioned for copious amounts of tan sputum @ ~ 0530\\n VAP protocol\\n Pin care done\\n Left knee remains in immobilizer with visible sero-sang\\n drainage on original dressing.\\n Response:\\n Fluid balance for + 3 liters\\n No further signs of DT\\ns / tremors after valium given\\n Remains febrile\\n Hypotension resolved\\n Plan:\\n Continue to monitor for S+S of DT\\n Continue to check and correct electrolyte imbalances\\n Wean ventilator\\n Follow up on culture results\\n Follow up with ortho on plans for future surgeries\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505197,\n \"text\": \"TITLE:\\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\\n auto. B/L LE injuries including an open tib/fib on R and comminuted\\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\\n prompting admission to ICU.\\n URINE CULTURE - At 08:30 PM\\n BLOOD CULTURED - At 09:00 PM\\n SPUTUM CULTURE - At 12:34 AM\\n FEVER - 102.1\\nF - 09:00 PM\\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Vancomycin - 07:49 PM\\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\\n Ciprofloxacin - 10:27 PM\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 09:00 AM\\n Metoprolol - 01:00 PM\\n Hydromorphone (Dilaudid) - 03:49 PM\\n Pantoprazole (Protonix) - 07:49 PM\\n Heparin Sodium (Prophylaxis) - 07:49 PM\\n Other medications:\\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\\n Heparin 5000 UNIT SC BID\\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\\n Insulin SC (per Insulin Flowsheet)Sliding Scale\\n Calcium Gluconate IV Sliding Scale\\n Magnesium Sulfate IV Sliding Scale\\n Metoprolol Tartrate 5 mg IV Q6H\\n Ciprofloxacin 400 mg IV Q12H\\n Nicotine Patch 14 mg TD DAILY\\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\\n Pantoprazole 40 mg IV Q24H\\n Cyanocobalamin 50 mcg PO/NG DAILY\\n Piperacillin-Tazobactam 4.5 g IV Q8H\\n Potassium Phosphate IV Sliding Scale\\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\\n Folic Acid/Multivitamin/Thiamine-1000mL NS\\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\\n Flowsheet Data as of 12:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.7\\nC (101.6\\n Tcurrent: 37.7\\nC (99.8\\n HR: 93 (82 - 101) bpm\\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\\n RR: 27 (18 - 28) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 97 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 11 (10 - 12)mmHg\\n Total In:\\n 2,921 mL\\n 40 mL\\n PO:\\n TF:\\n 277 mL\\n 14 mL\\n IVF:\\n 2,585 mL\\n 26 mL\\n Blood products:\\n Total out:\\n 2,275 mL\\n 0 mL\\n Urine:\\n 1,775 mL\\n NG:\\n 500 mL\\n Stool:\\n Drains:\\n Balance:\\n 646 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 600 (600 - 600) mL\\n Vt (Spontaneous): 494 (466 - 605) mL\\n PS : 5 cmH2O\\n RR (Set): 20\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 100%\\n ABG: 7.46/40/155/28/5\\n Ve: 12.2 L/min\\n PaO2 / FiO2: 388\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: 1+\\n Skin: Not assessed, Rash: left axilla, bruising right chest\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.1 g/dL\\n 121 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.0 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 9.7 K/uL\\n [image002.jpg]\\n 08:36 PM\\n 02:17 AM\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n WBC\\n 8.7\\n 9.7\\n Hct\\n 28.7\\n 26.8\\n 28.1\\n Plt\\n 169\\n 169\\n Cr\\n 0.7\\n 0.7\\n 0.6\\n TCO2\\n 30\\n 28\\n 27\\n 29\\n 26\\n 29\\n Glucose\\n 104\\n 87\\n 104\\n 121\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\\n Microbiology: Ucx Negative.\\n Sputum: GNR\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs, now intubated after increased\\n somnolence. Going to OR today for L femur ORIF, right ankle external\\n fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean off prop to attempt vent wean\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febril -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\\n Failure\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 10:00 AM\\n Multi Lumen - 01:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: SICU\\n Total time spent: 32 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 506820,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n : washout RLE\\n Trauma, s/p\\n Assessment:\\n Pt weaned and extubated this am without difficulty. Pt alert and\\n orientated. At times, pt makes comments that do not make sense.\\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\\n complains of pain to BLE.\\n Action:\\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\\n for pain.\\n Response:\\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\\n able to have nectar thick liquids and ground solids per speech therapy.\\n Plan:\\n Transfer to floor this evening.\\n Demographics\\n Attending MD:\\n W.\\n Admit diagnosis:\\n PEDESRTRIAN STRUCK, LEG FRACTURES\\n Code status:\\n Full code\\n Height:\\n 72 Inch\\n Admission weight:\\n 94.5 kg\\n Daily weight:\\n 91.1 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Eu Critical AKA DOB \\n Per pt no PMH/PSH . Per report Hep C but pt denies.\\n Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\\n withdrawing from alcholol and requiring q1hr valium. heart rate\\n 130-140's. very agitated and requiring constant watch. npo for or on\\n monday to repair left femur.\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:122\\n D:68\\n Temperature:\\n 100.7\\n Arterial BP:\\n S:123\\n D:83\\n Respiratory rate:\\n 19 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 1,938 mL\\n 24h total out:\\n 2,265 mL\\n Pertinent Lab Results:\\n Sodium:\\n 142 mEq/L\\n 02:30 AM\\n Potassium:\\n 4.4 mEq/L\\n 02:30 AM\\n Chloride:\\n 110 mEq/L\\n 02:30 AM\\n CO2:\\n 26 mEq/L\\n 02:30 AM\\n BUN:\\n 12 mg/dL\\n 02:30 AM\\n Creatinine:\\n 0.8 mg/dL\\n 02:30 AM\\n Glucose:\\n 95 mg/dL\\n 02:30 AM\\n Hematocrit:\\n 29.1 %\\n 08:13 AM\\n Finger Stick Glucose:\\n 95\\n 07:00 PM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: \\n Transferred to: cc6\\n Date & time of Transfer: 09:00 PM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505033,\n \"text\": \"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Trauma, s/p\\n Assessment:\\n Patient vented and sedated when sedation lightened patient has\\n purposeful movements\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505041,\n \"text\": \"HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Trauma, s/p\\n Assessment:\\n Patient vented and sedated when sedation lightened patient has\\n purposeful movements lungs clear upper lobes diminished in lower lobes\\n suctioned for thick tan secretions, and copious amounts of thin oral\\n secretions abd soft + bowel sounds + flatus no bm Foley patent\\n draining amber urine pin care done + pulses by Doppler + cap refill. T\\n max 99.0 heart rate 80-90\\ns sinus rhythm systolic 90-120\\n over 60\\n Action:\\n Tube feeding replete with fiber started through NG tube patient started\\n on vancomycin, cipro for VAP central line placed for access confirmed\\n by x-ray. Ventilator settings changed to 10/10 then weaned to \\n Response:\\n Patient tolerating vent settings remains stable at this time.\\n Plan:\\n Continue with current plan of care provide comfort and support as\\n needed notify team of any changes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 506589,\n \"text\": \"TSICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Clonidine Patch 0.3 mg/24 h\\n Cyanocobalamin\\n Dexmedetomidine\\n FoLIC Acid\\n HYDROmorphone (Dilaudid)\\n Haloperidol\\n Metoprolol Tartrate\\n Pantoprazole\\n 24 Hour Events:\\n s/p washout RLE by Ortho, Head CT normal (recent AMS)\\n Post operative day:\\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\\n washout R ankle and IVC filter, POD 1 washout RLE\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\\n Ciprofloxacin - 10:02 AM\\n Levofloxacin - 01:03 PM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\\n Other ICU medications:\\n Metoprolol - 06:00 AM\\n Lorazepam (Ativan) - 07:00 AM\\n Hydromorphone (Dilaudid) - 12:02 AM\\n Other medications:\\n Flowsheet Data as of 04:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.5\\n T current: 38.1\\nC (100.5\\n HR: 95 (66 - 106) bpm\\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SPO2: 84%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 88.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,093 mL\\n 561 mL\\n PO:\\n Tube feeding:\\n 58 mL\\n IV Fluid:\\n 3,093 mL\\n 503 mL\\n Blood products:\\n Total out:\\n 2,100 mL\\n 590 mL\\n Urine:\\n 1,950 mL\\n 440 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 993 mL\\n -26 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n RR (Set): 16\\n RR (Spontaneous): 4\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 14 cmH2O\\n SPO2: 84%\\n ABG: 7.43/40/184/26/2\\n Ve: 10 L/min\\n PaO2 / FiO2: 368\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Sedated\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 27.2 %\\n 9.6 K/uL\\n [image002.jpg]\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n WBC\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n Plt\\n 27\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Imaging: : CT torso: Acute right rib fractures involving the\\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\\n bilaterally and a more nodular right upper lobe opacity. This may be\\n aspiration, though followup when clinically stable is recommended to\\n document resolution and exclude underlying pulmonary nodule.\\n : CT L leg: Markedly comminuted fracture or the distal femoral\\n diaphysis. There is no evidence of intra-articular extension. In\\n addition, there is a non-displaced fracture of the prox fibula.\\n : R tib/fib films: Comminuted fractures of the distal tibia and\\n fibula.\\n CXR: left base in the retrocardiac region, likely atelectasis\\n :Worsening left retrocardiac opacification suggests developing\\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\\n lung volumes.\\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\\n CXR: ETT 11cm above carina\\n Head CT: no acute intracranial process\\n Microbiology: Ucx Negative.\\n Bcx Negative.\\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\\n still delerious when off sedation. Continue to wean sedation.\\n Consider LP or further imaging for continued AMS.\\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\\n quinolone).\\n Pulmonary: Extubate today, HAP likely aspiration. Cx w/ H.influ and\\n Shewanella. Now on Levaquin (). Intubated for altered mental\\n status from withdrawal. Reintubated for increasing agitation and in\\n prep for OR. Wean to extubate today.\\n Gastrointestinal / Abdomen: NGT feeding\\n Nutrition: Tube feeding, Thiamine, folate, MVI.\\n Renal: Foley, Adequate UO\\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter.\\n Endocrine: RISS\\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\\n ().\\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC\\n Wounds:\\n Imaging:\\n Fluids: D5NS\\n Consults: Trauma surgery, Ortho\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Comments: Foley, PIV, NGT, left subclavian TLC\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506651,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n Trauma, s/p\\n Assessment:\\n Pt admitted from OR post-op washout of RLE and reconfiguration of\\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\\n for head CT while sedated and post transferred from propofol to\\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\\n stable, pulses weakly palpable in LE\\ns, dopplerable in both Poterior\\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\\n in distal extremities, sepicially hands very cyanotic and cool yet\\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\\n Tube feeds restarted via NGT as ordered.\\n Action:\\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\\n monitored closely with IVF as ordered.\\n Response:\\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\\n Plan:\\n Plan to con\\nt to lighten as tolerated and wean and extubated today\\n Alcohol abuse\\n Assessment:\\n Propofol gtt for sedation till after head CT as above then precedex\\n started and propofol transiently weaned to off, pt given dilaudid PRN\\n for pain management\\n Action:\\n Precedex titrated up as needed\\n Response:\\n Pt awoke with a bang while on just precdeax\\n Plan:\\n Team requests pt be resedated on propofol at this time, will attempt to\\n lighten again later this AM after rounds and ? extubated at that time.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 505964,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Trauma, alcohol intoxicated\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown.\\n Current medications:\\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\\n Temporary central access (ICU) Location: Left Subclavian, Date\\n inserted: Order date: @ 1336 16. IV access request:\\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\\n line Order date: @ 1454 17. Insulin SC (per Insulin\\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\\n Q24H Order date: @ 1316\\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\\n flush\\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\\n Order date: @ 1316\\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\\n 1406\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:39 AM\\n Extubated. Minimized narcotics. More awake. Agitated at night req\\n restraints and zyprexa.\\n Post operative day:\\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 08:32 PM\\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\\n Ciprofloxacin - 11:00 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 09:04 PM\\n Metoprolol - 12:40 AM\\n Other medications:\\n Flowsheet Data as of 05:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.1\\nC (98.8\\n T current: 36.3\\nC (97.3\\n HR: 79 (72 - 82) bpm\\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\\n RR: 20 (14 - 32) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 95.3 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: -2 (-2 - 12) mmHg\\n Total In:\\n 3,520 mL\\n 592 mL\\n PO:\\n Tube feeding:\\n 1,440 mL\\n 309 mL\\n IV Fluid:\\n 2,020 mL\\n 283 mL\\n Blood products:\\n Total out:\\n 3,500 mL\\n 1,280 mL\\n Urine:\\n 3,435 mL\\n 1,280 mL\\n NG:\\n 65 mL\\n Stool:\\n Drains:\\n Balance:\\n 20 mL\\n -688 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SPO2: 98%\\n ABG: ///26/\\n Physical Examination\\n Labs / Radiology\\n 327 K/uL\\n 9.0 g/dL\\n 119 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 142 mEq/L\\n 27.0 %\\n 7.1 K/uL\\n [image002.jpg]\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n Plt\\n 199\\n 226\\n 259\\n 307\\n 327\\n Creatinine\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\\n for w/drawal. Started zyprexa. Restraints prn\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\\n prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley,, NGT, ,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 506144,\n \"text\": \"24 Hour Events:\\n ARTERIAL LINE - STOP 11:39 AM\\n : agitated despite zyprexa,responded to haldol\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\\n Ciprofloxacin - 09:22 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 PM\\n Heparin Sodium (Prophylaxis) - 08:50 PM\\n Haloperidol (Haldol) - 10:17 PM\\n Metoprolol - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 02:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.2\\n Tcurrent: 37.9\\nC (100.2\\n HR: 90 (76 - 96) bpm\\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\\n RR: 23 (18 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90.6 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 9 (-2 - 16)mmHg\\n Total In:\\n 3,706 mL\\n 210 mL\\n PO:\\n TF:\\n 1,658 mL\\n 190 mL\\n IVF:\\n 1,908 mL\\n 20 mL\\n Blood products:\\n Total out:\\n 4,140 mL\\n 170 mL\\n Urine:\\n 4,140 mL\\n 170 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -434 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 327 K/uL\\n 9.0 g/dL\\n 119 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 142 mEq/L\\n 27.0 %\\n 7.1 K/uL\\n [image002.jpg]\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n Plt\\n 199\\n 226\\n 259\\n 307\\n 327\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Agitated and disoriented.\\n Started zyprexa. Restraints prn\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\\n prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV, NGT, left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\\n Lines:\\n Multi Lumen - 01:30 PM\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 506750,\n \"text\": \"Subjective:\\n I will try to get OOB\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, therapeutic exercise\\n Updated medical status: s/p Wash out of RLE c ext fix\\n manipulation. Head CT - . Extubated this AM.\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n NT\\n\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n for RLE\\n\\n\\n\\n T\\n\\n\\n Transfer:\\n T Transfer Bed to Chair\\n\\n\\n\\n T\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 83\\n 112/62\\n 16\\n 100% 2LO2\\n Activity\\n Sit\\n 86\\n 102/60\\n 24\\n 95 RA\\n Recovery\\n Sit\\n 82\\n 98/50\\n 20\\n 100% 2LO2\\n Total distance walked:\\n Minutes:\\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\\n 1 UE support.\\n Education / Communication: c RN RE Pt Status\\n Pt RE Rehab Process\\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\\n ROM L knee 0-40 c hard end-feel\\n Pain: B LE c mobility\\n MS . Able to follow commands. Reported date at .\\n Orientated to self and .\\n HOH\\n Assessment: Pt is a 51M with multiple fractures presents with continued\\n limitations in mobility. Pt is functioning well below baseline and\\n will require STR when medically stable.\\n Anticipated Discharge: Rehab\\n Plan: Progress transfers ?slideboard\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506074,\n \"text\": \"\\n adm to from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - Minimal response from zyprexa\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa as ordered\\n - OR tomorrow for R internal fixation ?\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506075,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - Minimal response from zyprexa\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa as ordered\\n - OR tomorrow for R internal fixation ?\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 506230,\n \"text\": \"24 Hour Events:\\n ARTERIAL LINE - STOP 11:39 AM\\n : agitated despite zyprexa,responded to haldol\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\\n Ciprofloxacin - 09:22 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:46 PM\\n Heparin Sodium (Prophylaxis) - 08:50 PM\\n Haloperidol (Haldol) - 10:17 PM\\n Metoprolol - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 02:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.2\\n Tcurrent: 37.9\\nC (100.2\\n HR: 90 (76 - 96) bpm\\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\\n RR: 23 (18 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90.6 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 9 (-2 - 16)mmHg\\n Total In:\\n 3,706 mL\\n 210 mL\\n PO:\\n TF:\\n 1,658 mL\\n 190 mL\\n IVF:\\n 1,908 mL\\n 20 mL\\n Blood products:\\n Total out:\\n 4,140 mL\\n 170 mL\\n Urine:\\n 4,140 mL\\n 170 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -434 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 327 K/uL\\n 9.0 g/dL\\n 119 mg/dL\\n 0.6 mg/dL\\n 26 mEq/L\\n 3.9 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 142 mEq/L\\n 27.0 %\\n 7.1 K/uL\\n [image002.jpg]\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n Plt\\n 199\\n 226\\n 259\\n 307\\n 327\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n TCO2\\n 26\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. s/p L femur ORIF, right ankle\\n external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Agitated and disoriented.\\n Started zyprexa. Restraints prn Additional Haldol.\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\\n prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV, NGT, left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment ? OR tomorrow.\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\\n Lines:\\n Multi Lumen - 01:30 PM\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 506649,\n \"text\": \"TSICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Current medications:\\n Chlorhexidine Gluconate 0.12% Oral Rinse\\n Clonidine Patch 0.3 mg/24 h\\n Cyanocobalamin\\n Dexmedetomidine\\n FoLIC Acid\\n HYDROmorphone (Dilaudid)\\n Haloperidol\\n Metoprolol Tartrate\\n Pantoprazole\\n 24 Hour Events:\\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\\n RSBI 30s this AM.\\n Post operative day:\\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\\n washout R ankle and IVC filter, POD 1 washout RLE\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\\n Ciprofloxacin - 10:02 AM\\n Levofloxacin - 01:03 PM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\\n Other ICU medications:\\n Metoprolol - 06:00 AM\\n Lorazepam (Ativan) - 07:00 AM\\n Hydromorphone (Dilaudid) - 12:02 AM\\n Other medications:\\n Flowsheet Data as of 04:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.5\\n T current: 38.1\\nC (100.5\\n HR: 95 (66 - 106) bpm\\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\\n RR: 18 (13 - 32) insp/min\\n SPO2: 84%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 88.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,093 mL\\n 561 mL\\n PO:\\n Tube feeding:\\n 58 mL\\n IV Fluid:\\n 3,093 mL\\n 503 mL\\n Blood products:\\n Total out:\\n 2,100 mL\\n 590 mL\\n Urine:\\n 1,950 mL\\n 440 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 993 mL\\n -26 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n RR (Set): 16\\n RR (Spontaneous): 4\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 14 cmH2O\\n SPO2: 84%\\n ABG: 7.43/40/184/26/2\\n Ve: 10 L/min\\n PaO2 / FiO2: 368\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: Sedated\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 27.2 %\\n 9.6 K/uL\\n [image002.jpg]\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n WBC\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n Plt\\n 27\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Imaging: : CT torso: Acute right rib fractures involving the\\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\\n bilaterally and a more nodular right upper lobe opacity. This may be\\n aspiration, though followup when clinically stable is recommended to\\n document resolution and exclude underlying pulmonary nodule.\\n : CT L leg: Markedly comminuted fracture or the distal femoral\\n diaphysis. There is no evidence of intra-articular extension. In\\n addition, there is a non-displaced fracture of the prox fibula.\\n : R tib/fib films: Comminuted fractures of the distal tibia and\\n fibula.\\n CXR: left base in the retrocardiac region, likely atelectasis\\n :Worsening left retrocardiac opacification suggests developing\\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\\n lung volumes.\\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\\n CXR: ETT 11cm above carina\\n Head CT: no acute intracranial process\\n Microbiology: Ucx Negative.\\n Bcx Negative.\\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\\n still delerious when off sedation. Continue to wean sedation. Pt\\n following commands on precidex, but seems confused at times, will plan\\n to extubate this AM.\\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\\n prolognation (haldol and quinolone).\\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\\n on Levaquin (). Intubated for altered mental status from\\n withdrawal. Reintubated for increasing agitation and in prep for OR.\\n Wean to extubate today.\\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\\n Nutrition: Tube feeding, Thiamine, folate, MVI.\\n Renal: Foley, Adequate UO\\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\\n hospitalization. s/p IVC filter.\\n Endocrine: RISS, goal BS<150, adequate control.\\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\\n () x 14 day course.\\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\\n Wounds: Soft compartments, will monitor.\\n Imaging: None planned\\n Fluids: KVO\\n Consults: Trauma surgery, Ortho, Addiction Med\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Comments: Foley, PIV, NGT, left subclavian TLC\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n Total time spent: 32 mins\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 506746,\n \"text\": \"Subjective:\\n I will try to get OOB\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for balance training, therapeutic exercise\\n Updated medical status: s/p Wash out of RLE c ext fix\\n manipulation. Head CT - . Extubated this AM.\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n NT\\n\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n for RLE\\n\\n\\n\\n T\\n\\n\\n Transfer:\\n T Transfer Bed to Chair\\n\\n\\n\\n T\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 83\\n 112/62\\n 16\\n 100% 2LO2\\n Activity\\n Sit\\n 86\\n 102/60\\n 24\\n 95 RA\\n Recovery\\n Sit\\n 82\\n 98/50\\n 20\\n 100% 2LO2\\n Total distance walked:\\n Minutes:\\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\\n 1 UE support.\\n Education / Communication: c RN RE Pt Status\\n Pt RE Rehab Process\\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\\n ROM L knee 0-40 c hard endfeel\\n Pain: B LE c mobility\\n MS . Able to follow commands. Reported date at .\\n Orientated to self and .\\n HOH\\n Assessment: Pt is a 51M with multiple fractures presents with continues\\n limitations in mobility.\\n Anticipated Discharge: Rehab\\n Plan:\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Physical Therapy Initial Evaluation\",\n \"row_id\": 506755,\n \"text\": \"TITLE: Rehab Services Physical Therapy Evaluation \\n Attending Physician:\\n date: \\n Medical Diagnosis / ICD 9: 959.9 /\\n Reason of : eval and treat\\n History of Present Illness / Subjective Complaint: 50 m adm from osh\\n s/p ped struck by car sustaining R open ankle fx, L distal femur fx and\\n 2nd and 3rd rib fractures. -LOC, +ETOH. Intubated dt's and w/d from\\n etoh. OR for ORIF L femur, ex fix placement R ankle, IVC filter\\n placed. Extubated . Plan for return to OR in near future for ORIF\\n RLE.\\n Past Medical / Surgical History: unclear\\n Medications: Acetaminophen\\n Pantoprazole\\n Glucagon\\n Cyanocobalamin\\n Nicotine Patch\\n Metoprolol Tartrate\\n Heparin\\n HYDROmorphone (Dilaudid)\\n Piperacillin-Tazobactam\\n Ciprofloxacin\\n Clonidine Patch\\n Thiamine\\n FoLIC Acid\\n Multivitamins\\n Olanzapine\\n Radiology: Five views of the right tibia and fibula and ankle show\\n comminuted\\n oblique fractures of the distal tibia and fibula. There is lateral and\\n anterior subluxation of the distal tibia and fibula as well as foot\\n relative\\n to the proximal lower extremity. The talar dome is smooth. The distal\\n fibula\\n is slightly medially displaced, projecting over the ankle mortise.\\n Limited\\n views of the knee joint are unremarkable. There is no radiopaque\\n foreign\\n body.\\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as\\n above.\\n Four views of the left femur reveal a comminuted fracture of the distal\\n femoral diaphysis. There is posterior and slight lateral displacement\\n of the\\n distal femur relative to the proximal. There is no evidence of\\n intra-articular extension. A faint lucency seen at the fibular head\\n suggests\\n a non-displaced fracture in that location as well. A small of\\n bone at\\n the lateral margin of the proximal tibia suggests avulsion injury.\\n There is\\n no radiopaque foreign body.\\n Labs:\\n 32.9\\n 11.7\\n 161\\n 8.0\\n Other labs:\\n Activity Orders: NWB RLE, TDWB LLE, unlocked, ROM ok. oob to\\n chair.\\n Social / Occupational History: ? homeless.\\n Living Environment: difficult to obtain history confusion\\n Prior Functional Status / Activity Level: presumed I.\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Awake, speaking\\n non-sensically t/o eval. Inconsistently following commands but with\\n limited attention span.\\n Hemodynamic Response\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2 ]sat\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Supine\\n /\\n Rest\\n /\\n Sit\\n 80\\n 130/82\\n 16\\n 97% RA\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n /\\n Total distance walked:\\n Minutes:\\n Pulmonary Status: even coordinated breathing pattern\\n Integumentary / Vascular: R LE with ex fix, large incision at joint\\n line medially, healing well. L LE with brace, DSD, no drainage.\\n +edema B feet. NGT, foley, central line\\n Sensory Integrity: difficult to assess formally. responds to touch in\\n all extremities\\n Pain / Limiting Symptoms: c/o pain but then laughing as I ranged his L\\n knee. otherwise no c/o pain\\n Posture: received supine in bed\\n Range of Motion\\n Muscle Performance\\n WFL x: R ankle ex fix, L knee range 0-25degrees. + guarding\\n BUE >/= \\n moving R LE against gravity, moves B toes, guarding with L knee/quads,\\n able to slr B\\n Motor Function: isolates through function. not following commands to\\n formally test. ? clonus LLE\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: total A to roll and slide to stretcher chair to sit\\n up. RN, pt moving on his own in the bed, but not to command\\n Rolling:\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: deferred\\n Education / Communication: pt ed: role of PT, importance of ROM\\n case discussed with RN and MD\\n Intervention: ROM L knee\\n Other:\\n Diagnosis:\\n 1.\\n Knowledge, Impaired\\n 2.\\n Muscle Performace, Impaired\\n 3.\\n Range of Motion, Impaired\\n 4.\\n Transfers, Impaired\\n Clinical impression / Prognosis: 50 m s/p ped struck with multiple LE\\n injuries presents with above associated with fracture. His current\\n situation is limited by confusion and inabiliyt to follow commands\\n consistently. Given his age and lack of UE involvement feel that he has\\n good potential to be I at a w/c level until his WB status is progressed\\n provided his mental status clears a bit. Overall he ahs good potential\\n to return to functional ambulation in weeks given success of\\n internal fixation, young age and lack of other apparent comorbiidiites.\\n This will all depend on resolution of cognitive function. The patient\\n will require inpatient rehab to maximize function although ? if\\n insurance constraints will prohibit this? rec OT consult.\\n Goals\\n Time frame: 1 week\\n 1.\\n increase ROM L knee 0-65\\n 2.\\n follow 50% simple commands\\n 3.\\n sit eob iwth max a\\n 4.\\n 5.\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: 4-6x/wk\\n ROM L knee\\n eob activity\\n d/c planning\\n pt ed: rom, therex\\n strengthening/ exercises for LE's with coop student (therex, rom)\\n consult OT\\n w/c training\\n time: 10:15-10:45\\n Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506814,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n Trauma, s/p\\n Assessment:\\n Pt weaned and extubated this am without difficulty. Pt alert and\\n orientated. At times, pt makes comments that do not make sense.\\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\\n complains of pain to BLE.\\n Action:\\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\\n for pain.\\n Response:\\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\\n able to have nectar thick liquids and ground solids per speech therapy.\\n Plan:\\n Transfer to floor this evening.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506744,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n Trauma, s/p\\n Assessment:\\n Pt admitted from OR post-op washout of RLE and reconfiguration of\\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\\n for head CT while sedated and post transferred from propofol to\\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\\n stable, pulses weakly palpable in LE\\ns, dopplerable in both Poterior\\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\\n in distal extremities, sepicially hands very cyanotic and cool yet\\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\\n Tube feeds restarted via NGT as ordered.\\n Action:\\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\\n monitored closely with IVF as ordered.\\n Response:\\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\\n Plan:\\n Plan to con\\nt to lighten as tolerated and wean and extubated today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506312,\n \"text\": \"51M transfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Patient alert confused agitated garbled speech this am gave 1mg haldol\\n and zyprexa IM heart rate 70-80\\ns sinus rhythm systolic b/p 120-140\\n over 70\\ns lungs diminished in bases but clear upper fields respirations\\n unlabored 20\\ns O2 sat 95% suctioned for thick tan secretions abd soft\\n but firm + bowel sounds + flatus incision sutures intact + pp by\\n Doppler external fixation intact T max 100.0 Patient has soft limb\\n restraints\\n Action:\\n Continue with oral zyprexa and prn haldol dc\\ndl an IM zyprexa\\n Response:\\n Patient remains stable at this time\\n Plan:\\n No OR in the am per ortho called out today to CC6 if agitation is\\n better\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506321,\n \"text\": \"51M transfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Patient alert confused agitated garbled speech this am gave 1mg haldol\\n and zyprexa IM heart rate 70-80\\ns sinus rhythm systolic b/p 120-140\\n over 70\\ns lungs diminished in bases but clear upper fields respirations\\n unlabored 20\\ns O2 sat 95% suctioned for thick tan secretions abd soft\\n but firm + bowel sounds + flatus incision sutures intact + pp by\\n Doppler external fixation intact T max 100.0 Patient has soft limb\\n restraints\\n Action:\\n Continue with oral zyprexa and prn haldol dc\\ndl an IM zyprexa\\n Response:\\n Patient remains stable at this time\\n Plan:\\n No OR in the am per ortho called out today to CC6 with sitter\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 506382,\n \"text\": \"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\\n w/d.\\n No major events.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\\n Ciprofloxacin - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 07:00 AM\\n Pantoprazole (Protonix) - 08:00 PM\\n Heparin Sodium (Prophylaxis) - 08:00 PM\\n Metoprolol - 12:37 AM\\n Other medications:\\n Flowsheet Data as of 04:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.5\\n Tcurrent: 37.3\\nC (99.1\\n HR: 93 (76 - 100) bpm\\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\\n RR: 13 (13 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90.6 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,278 mL\\n 39 mL\\n PO:\\n TF:\\n 2,247 mL\\n IVF:\\n 850 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,795 mL\\n 215 mL\\n Urine:\\n 3,795 mL\\n 215 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -517 mL\\n -176 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\\n agitation\\n Eyes / Conjunctiva: PERRL\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: 1+\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 390 K/uL\\n 9.1 g/dL\\n 126 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 27.7 %\\n 8.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n Plt\\n 199\\n 226\\n 259\\n \\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n TCO2\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n 126\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\\n s-levofloxacin,meropenem,cefipime and H.influenzae\\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV, NGT, left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 506474,\n \"text\": \"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\\n w/d.\\n No major events.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\\n Ciprofloxacin - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Haloperidol (Haldol) - 07:00 AM\\n Pantoprazole (Protonix) - 08:00 PM\\n Heparin Sodium (Prophylaxis) - 08:00 PM\\n Metoprolol - 12:37 AM\\n Other medications:\\n Flowsheet Data as of 04:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.5\\n Tcurrent: 37.3\\nC (99.1\\n HR: 93 (76 - 100) bpm\\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\\n RR: 13 (13 - 28) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 90.6 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,278 mL\\n 39 mL\\n PO:\\n TF:\\n 2,247 mL\\n IVF:\\n 850 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,795 mL\\n 215 mL\\n Urine:\\n 3,795 mL\\n 215 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -517 mL\\n -176 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ////\\n Physical Examination\\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\\n agitation\\n Eyes / Conjunctiva: PERRL\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: 1+\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 390 K/uL\\n 9.1 g/dL\\n 126 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 27.7 %\\n 8.6 K/uL\\n [image002.jpg]\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n Plt\\n 199\\n 226\\n 259\\n \\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n TCO2\\n 29\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n 126\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\\n PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\\n for altered mental status from withdrawal. GNR on sputum with\\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\\n s-levofloxacin,meropenem,cefipime and H.influenzae\\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV, NGT, left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506738,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n Trauma, s/p\\n Assessment:\\n Pt admitted from OR post-op washout of RLE and reconfiguration of\\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\\n for head CT while sedated and post transferred from propofol to\\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\\n stable, pulses weakly palpable in LE\\ns, dopplerable in both Poterior\\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\\n in distal extremities, sepicially hands very cyanotic and cool yet\\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\\n Tube feeds restarted via NGT as ordered.\\n Action:\\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\\n monitored closely with IVF as ordered.\\n Response:\\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\\n Plan:\\n Plan to con\\nt to lighten as tolerated and wean and extubated today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 506313,\n \"text\": \"51M transfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Patient alert confused agitated garbled speech this am gave 1mg haldol\\n and zyprexa IM heart rate 70-80\\ns sinus rhythm systolic b/p 120-140\\n over 70\\ns lungs diminished in bases but clear upper fields respirations\\n unlabored 20\\ns O2 sat 95% suctioned for thick tan secretions abd soft\\n but firm + bowel sounds + flatus incision sutures intact + pp by\\n Doppler external fixation intact T max 100.0 Patient has soft limb\\n restraints\\n Action:\\n Continue with oral zyprexa and prn haldol dc\\ndl an IM zyprexa\\n Response:\\n Patient remains stable at this time\\n Plan:\\n No OR in the am per ortho called out today to CC6 if agitation is\\n better\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Physician Surgical Admission Note\",\n \"row_id\": 506554,\n \"text\": \"Chief Complaint: HD12 POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix\\n right ankle ORIF left femur , now s/p ORIF L distal femur fx and\\n IVC filter . S/p washout .\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Post operative day:\\n POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\\n femur , now s/p ORIF L distal femur fx and IVC filter . S/p\\n washout .\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\\n Ciprofloxacin - 10:02 AM\\n Levofloxacin - 01:03 PM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Other ICU medications:\\n Metoprolol - 06:00 AM\\n Lorazepam (Ativan) - 07:00 AM\\n Other medications:\\n Clonidine Patch\\n Precedex\\n Dilaudid\\n Haldol\\n Past medical history:\\n Family / Social history:\\n PMH:ETOH abuse,Varicose veins, o/w unknown.\\n PSH:Ex fix/ wahout right ankle\\n :Unk\\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\\n Flowsheet Data as of 08:43 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 36.6\\nC (97.8\\n HR: 76 (69 - 106) bpm\\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\\n RR: 16 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 88.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,278 mL\\n 2,689 mL\\n PO:\\n TF:\\n 2,247 mL\\n IVF:\\n 850 mL\\n 2,689 mL\\n Blood products:\\n Total out:\\n 3,795 mL\\n 1,705 mL\\n Urine:\\n 3,795 mL\\n 1,555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -517 mL\\n 984 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n RR (Set): 16\\n RR (Spontaneous): 8\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SpO2: 100%\\n ABG: ///25/\\n Ve: 11.9 L/min\\n Physical Examination\\n General Appearance: No acute distress, Sedated\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 455 K/uL\\n 9.7 g/dL\\n 125 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 4.4 mEq/L\\n 16 mg/dL\\n 109 mEq/L\\n 143 mEq/L\\n 30.2 %\\n 12.3 K/uL\\n [image002.jpg]\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n Plt\\n 199\\n 226\\n 259\\n \\n 455\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n TCO2\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n 126\\n 125\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P\\n ALCOHOL ABUSE\\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\\n excessive valium. Now still delirious. Needs frequent re-orientation\\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\\n intubated.\\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\\n quinolone).\\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\\n on Levaquin (). Intubated for altered mental status from\\n withdrawal. Reintubated for increasing agitation and in prep for OR.\\n Gastrointestinal: NGT feeding.\\n Renal: Foley, monitor UOP\\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\\n ().\\n Endocrine: RISS. Euthyroid\\n Fluids: thiamine, d5, folate\\n Electrolytes:\\n Nutrition: Replete with fiber Full strength;\\n Goal rate: 95 ml/hr\\n General:\\n ICU Care\\n Nutrition:\\n Comments: Replete with fiber Full strength;\\n Goal rate: 95 ml/hr\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Comments: Foley, PIV, NGT, left subclavian TLC\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care\\n Need for restraints reviewed\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Physician Surgical Admission Note\",\n \"row_id\": 506555,\n \"text\": \"Chief Complaint: HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7 \\n plate left femur and washout R ankle and IVC filter, POD 0 washout RLE.\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Post operative day:\\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\\n washout R ankle and IVC filter, POD 0 washout RLE.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\\n Ciprofloxacin - 10:02 AM\\n Levofloxacin - 01:03 PM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Other ICU medications:\\n Metoprolol - 06:00 AM\\n Lorazepam (Ativan) - 07:00 AM\\n Other medications:\\n Clonidine Patch\\n Precedex\\n Dilaudid\\n Haldol\\n Past medical history:\\n Family / Social history:\\n PMH:ETOH abuse,Varicose veins, o/w unknown.\\n PSH:Ex fix/ wahout right ankle\\n :Unk\\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\\n Flowsheet Data as of 08:43 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 36.6\\nC (97.8\\n HR: 76 (69 - 106) bpm\\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\\n RR: 16 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 88.5 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 3,278 mL\\n 2,689 mL\\n PO:\\n TF:\\n 2,247 mL\\n IVF:\\n 850 mL\\n 2,689 mL\\n Blood products:\\n Total out:\\n 3,795 mL\\n 1,705 mL\\n Urine:\\n 3,795 mL\\n 1,555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -517 mL\\n 984 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 550 (550 - 550) mL\\n RR (Set): 16\\n RR (Spontaneous): 8\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 20 cmH2O\\n SpO2: 100%\\n ABG: ///25/\\n Ve: 11.9 L/min\\n Physical Examination\\n General Appearance: No acute distress, Sedated\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 455 K/uL\\n 9.7 g/dL\\n 125 mg/dL\\n 0.8 mg/dL\\n 25 mEq/L\\n 4.4 mEq/L\\n 16 mg/dL\\n 109 mEq/L\\n 143 mEq/L\\n 30.2 %\\n 12.3 K/uL\\n [image002.jpg]\\n 02:08 AM\\n 02:21 AM\\n 01:03 AM\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n WBC\\n 8.0\\n 8.0\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n Hct\\n 25.3\\n 25.8\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n Plt\\n 199\\n 226\\n 259\\n \\n 455\\n Cr\\n 0.6\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n TCO2\\n 32\\n 29\\n 28\\n Glucose\\n 128\\n 120\\n 124\\n 119\\n 126\\n 125\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P\\n ALCOHOL ABUSE\\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\\n excessive valium. Now still delirious. Needs frequent re-orientation\\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\\n intubated.\\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\\n quinolone).\\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\\n on Levaquin (). Intubated for altered mental status from\\n withdrawal. Reintubated for increasing agitation and in prep for OR.\\n Gastrointestinal: NGT feeding.\\n Renal: Foley, monitor UOP\\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\\n prophylaxis.\\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\\n ().\\n Endocrine: RISS. Euthyroid\\n Fluids: thiamine, d5, folate\\n Electrolytes:\\n Nutrition: Replete with fiber Full strength;\\n Goal rate: 95 ml/hr\\n General:\\n ICU Care\\n Nutrition:\\n Comments: Replete with fiber Full strength;\\n Goal rate: 95 ml/hr\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Comments: Foley, PIV, NGT, left subclavian TLC\\n Prophylaxis:\\n DVT: SQ UF Heparin, IVC filter\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation, Mouth care\\n Need for restraints reviewed\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Bedside Swallowing Evaluation\",\n \"row_id\": 506729,\n \"text\": \"TITLE: BEDSIDE SWALLOWING EVALUATION:\\nHISTORY:\\nThank you for consulting on this 51 y/o male who initially\\npresented to OSH s/p being an intoxicated pedestrian struck by a\\ncar at unknown speed, ?+LOC. Patient found with open tib/fib fx,\\nL distal femur fx. Patient was transferred to on \\nfor further management and underwent irrigation and debridement\\nof soft tissue, muscle including bone of the right distal tibia\\nopen fracture and application of multiplanar external fixator to\\nthe right lower extremity. Patient underwent inferior vena caval\\nfilter placed by the right femoral route and open reduction,\\ninternal fixation of left supracondylar femur fracture on\\n. hospital course c/b hypertension,\\nagitation/delirium, and tachycardia c/w EtOH withdrawal. Patient\\nwas successfully extubated this am and we were consulted to\\nevaluate patient's oral and pharyngeal swallowing function and\\nr/o aspiration while eating and drinking. RN reported patient was\\nnoted with coughing on water this am following extubation.\\nPMH: unknown\\nEVALUATION:\\nThe examination was performed while the patient was seated\\nupright in the bed on the TSICU.\\nCognition, language, speech, voice: Patient was sleeping upon\\narrival, easily aroused to voice, however remained fatigued and\\nwas able to fall asleep instantly when not stimulated. Patient\\nwas oriented to self and \\\" Hospital\\\" when asked but\\nwas noted with confusion when he later asked a question about\\nwhere he was and asked other nonsensical questions. Patient was\\nable to follow most basic commands with max cues and models.\\nSpeech was fluent and somewhat unintelligible for long\\nutterances. Voice was significantly hoarse and ? close to\\nbaseline.\\nTeeth: poor sparse dentition remaining, no dentures\\nSecretions: dry oral cavity, productive baseline cough\\nORAL MOTOR EXAM:\\nTongue protruded midline. Functional labial and lingual ROM, and\\nbuccal tone. Mildly reduced lingual strength. Palatal elevation\\nwas symmetrical. Gag deferred to maintain rapport.\\nSWALLOWING ASSESSMENT:\\nPO trials included ice chips, thin liquids (tsp), nectar thick\\nliquids via straw, bites of puree, ground solid, and a bite of \\n cracker. Oral phase was remarkable for prolonged, however\\nfunctional mastication of regular solid poor dentition, with\\nnormal oral residue remaining. Laryngeal elevation felt adequate\\nto palpation. Immediate wet vocal quality and delayed coughing\\nnoted on ice chips and thin liquid trials. One delayed cough was\\nnoted on regular solids followed by nectar thick liquid. No\\nfurther throat clearing, coughing, or choking noted. O2 sats\\nremained stable at 96%. Patient denied the sensation of PO stuck\\nin his throat.\\nSUMMARY / IMPRESSION:\\nMr. presents with confusion and lethargy and overt s/sx of\\naspiration on thin liquids as evidenced by wet vocal quality and\\ndelayed coughing, consistent with symptoms usually seen\\nimmediately post-extubation. Patient's mastication of regular\\nsolids was prolonged poor dentition and he was noted with\\ncoughing on the dry, crumbly solid when followed by nectar thick\\nliquids. Recommend initiating a PO diet of nectar thick liquids\\nand ground solids at this time with 1:1 supervision and only when\\npatient is most awake and alert. We will return tomorrow to\\nrepeat the evaluation to determine if patient's diet may be\\nupgraded given more time to recover from acute extubation.\\nThis swallowing pattern correlates to a Functional Oral Intake\\nScale (FOIS) rating of level 5 out of 7.\\nRECOMMENDATIONS:\\n1. PO diet of nectar thick liquids and ground solids.\\n2. Pills whole or crushed with puree.\\n3. 1:1 supervision with POs, please give only when most awake and\\nalert, seated upright in bed.\\n4. Q6 oral care.\\n5. We will return tomorrow to repeat the evaluation to determine\\nif patient's diet may be upgraded given more time to recover from\\nacute extubation.\\nThese recommendations were shared with the patient, nurse and\\nmedical team.\\n____________________________________\\n , M.S., CCC-SLP\\nPager #\\nFace time: 1335-1350\\nTotal time: 50 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505896,\n \"text\": \"Trauma, s/p\\n Assessment:\\n External fixation device in place on right leg, Left Knee immbolizer\\n on,\\n Pin sites slightly red and clean, draining serous fluid,\\n Dopplerable pulses, legs warm, good cap refill.\\n Patient is confused and agitated most of night, oriented to self,\\n continually tries to get out of bed, says:\\nI have to go to \\nI need my money\\n. Hard to redirect. When told he is in the hospital\\n patient looks shocked. Consistently putting legs over side rail.\\n Coughing up secretions.\\n Action:\\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\\n frequently, calmly reassured.\\n Pin care done x 2,\\n Turned and repositioned for comfort.\\n Given 5 mg Olanzapine for agitation.\\n Response:\\n Patient continues to be confused and hard to redirect, tries to get\\n OOB. Patient hardly slept all night, more calm after olanzapine given.\\n Plan:\\n Continue to monitor, reorient frequently.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 506616,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 22 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 506709,\n \"text\": \"Subjective\\n on facemask\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 183 cm\\n 94.5 kg\\n 91.1 kg ( 03:00 AM)\\n 28.2\\n Pertinent medications: Dextrose 5 normal saline with KCl, IV abx, folic\\n acid, Vit B12, multivitamin, heparin, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 95 mg/dL\\n 02:30 AM\\n Glucose Finger Stick\\n 148\\n 08:00 AM\\n BUN\\n 12 mg/dL\\n 02:30 AM\\n Creatinine\\n 0.8 mg/dL\\n 02:30 AM\\n Sodium\\n 142 mEq/L\\n 02:30 AM\\n Potassium\\n 4.4 mEq/L\\n 02:30 AM\\n Chloride\\n 110 mEq/L\\n 02:30 AM\\n TCO2\\n 26 mEq/L\\n 02:30 AM\\n PO2 (arterial)\\n 184 mm Hg\\n 10:45 PM\\n PCO2 (arterial)\\n 40 mm Hg\\n 10:45 PM\\n pH (arterial)\\n 7.43 units\\n 10:45 PM\\n pH (urine)\\n 6.0 units\\n 08:56 PM\\n CO2 (Calc) arterial\\n 27 mEq/L\\n 10:45 PM\\n Calcium non-ionized\\n 8.2 mg/dL\\n 02:30 AM\\n Phosphorus\\n 3.1 mg/dL\\n 02:30 AM\\n Ionized Calcium\\n 1.11 mmol/L\\n 02:21 AM\\n Magnesium\\n 2.1 mg/dL\\n 02:30 AM\\n ALT\\n 25 IU/L\\n 04:50 AM\\n Alkaline Phosphate\\n 60 IU/L\\n 04:50 AM\\n AST\\n 46 IU/L\\n 04:50 AM\\n Amylase\\n 27 IU/L\\n 04:50 AM\\n Total Bilirubin\\n 1.0 mg/dL\\n 04:50 AM\\n WBC\\n 9.6 K/uL\\n 02:30 AM\\n Hgb\\n 8.8 g/dL\\n 02:30 AM\\n Hematocrit\\n 29.1 %\\n 08:13 AM\\n Current diet order / nutrition support: Replete with Fiber @ 95 ml/hr =\\n 2280 kcals/ 141 g protein\\n GI: soft, +bowel sounds\\n Assessment of Nutritional Status\\n Specifics: Patient s/p washout RLE and internal fixation on .\\n Patient received tube feeding over night, held for extubation this\\n morning and currently running at 50 ml/hr and plan to advance to goal\\n which provides 100% of nutritional needs. SLP consulted for swallow\\n eval. If patient passes SLP eval he will likely need tube feedings as\\n patient is delirious and will not meet needs.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Advance to goal Replete with Fiber @ 95 ml/hr\\n 2. Implement any SLP recommendations\\n 3. Check chemistry 10 daily and replete prn\\n 4. Will follow page with questions\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506098,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - alert, oriented X 1, delirious, confused, but oriented at\\n times\\n - lifting legs over side rails, sitting straight up in bed and\\n trying to hold on to R ex-fix, high fall risk\\n - MAE, pulses dopplerable\\n - Strong, productive cough, lungs rhonchorous at times, clear\\n after coughing\\n - Family in to visit patient\\n Action:\\n - removed restraints, constant observation, frequent\\n reorienting and redirecting\\n - encouraged coughing/deep breathing, chest PT\\n - OOB to chair\\n - Pin care as needed, dressing changed X 3\\n - zyprexa order changed to TID, given as ordered\\n - zyprexa IM PRN given at 1730\\n - family identified by patient, Identification process done by\\n nurse , witnessed by this nurse\\n Response:\\n - pt continues to be delirious, trying to get OOB, moments of\\n clarity\\n - requires constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - RLE seeping yellow drainage from medial pin site\\n - slid pt using slide board over to stretcher chair, sat\\n upright with legs at slight angle for approx 2 hours with constant\\n observation\\n - Minimal response from PO zyprexa, IM zyprexa with good\\n effect, pt calm and resting\\n - pt able to cough up secretions, spitting up secretions,\\n nurse able to oral suction secretions before pt spits at times\\n Plan:\\n - continue constant redirecting, reorienting and constant\\n observation for high fall risk and high risk for self injury\\n - continue pin care PRN, monitor drainage\\n - encourage coughing/deep breathing, chest PT\\n - continue Zyprexa qtc and PRN as needed\\n - OR tomorrow for R internal fixation ?\\n - ? transfer to floor tomorrow with distinct plan for fall\\n high risk in order prior to transfer. Involve nursing services at\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2146-01-13 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 506708,\n \"text\": \"Social Work:\\n Rec\\nd POE on this 51 yr-old man adm s/p ped struck. Pt w/R leg fx, s/p\\n ORIF and IVC filter placement. +ETOH w/BAL=275 upon admit. Pt is\\n homeless by report, 1 cousin locally (please see note by \\n , LICSW, for family info). Mother, sisters in , but\\n none involved in his care.\\n Unable to interview pt today to his being somnolent and confused.\\n Also, his RN, , pt scheduled for another surgery soon. At\\n this point, his needs unclear & he is unable to participate in\\n interview.\\n SW will follow & assess coping, address substance abuse issue and offer\\n resources around latter. If pt does not need or qualify for rehab, will\\n assess options & provide info re: shelters. Please page PRN.\\n , LICSW\\n #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506278,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Patient alert confused agitated garbled speech this am gave 1mg haldol\\n and zyprexa IM heart rate 70-80\\ns sinus rhythm systolic b/p 120-140\\n over 70\\ns lungs diminished in bases but clear upper fields respirations\\n unlabored 20\\ns O2 sat 95% suctioned for thick tan secretions abd soft\\n but firm + bowel sounds + flatus incision sutures intact + pp by\\n Doppler external fixation intact T max 100.0\\n Action:\\n Continue with oral zyprexa and prn haldol an IM zyprexa\\n Response:\\n Patient remains stable at this time\\n Plan:\\n No OR in the am per ortho ? callout tomorrow if agitation is better\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 506286,\n \"text\": \"Subjective:\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for other:\\n Updated medical status: no new imaging\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 74\\n 120/67\\n 96% on RA\\n Activity\\n 86\\n /\\n 94% on RA\\n Recovery\\n /\\n Total distance walked: 0\\n Minutes:\\n Gait: not assessed\\n Balance: not assessed\\n Education / Communication: Patient lethargic, sleeping throughout tx\\n session. Communicated with nsg re: status.\\n Other: L knee PROM 0-30 in \\n Patient stirring but not awakening with ROM\\n Assessment: 57 yo M pedestrian struck with multiple fxs, making minimal\\n progress in PT, today limited by lethargy and not participatory in PT\\n session. Tolerated ROM to L knee, mobility not assessed. D/c plan\\n remains tentative given his cognition at this time, PT to continue to\\n follow to progress as able.\\n Anticipated Discharge: Rehab\\n Plan: continue with POC\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507596,\n \"text\": \"S/P MVA, was hit by car , s/p external fixation of right leg\\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\\n DT\\ns from ETOH.\\n Code purple called on CC6 0300 this am.\\n Delirium / confusion\\n Assessment:\\n Patient extremely agitated this am, trying to get out of bed, banging\\n right external fixation device against side rails.\\n Oriented only to himself, believes he is at a church, or outside with\\n his\\nbuddies\\n asking for cigarettes and beer, believes he hasn\\nt been\\n in the hospital. Agitated and combative.\\n Action:\\n Security called for assistance this am, patient fighting to get out of\\n restraints,\\n Patient calmly reassured and reoriented frequently,\\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\\n initiated,\\n Psych in to assess, Psych CNS ( ) in to assess (valium and\\n ativan d/c\\nd, will give haldol for psychosis although QT has been\\n 0.40-0.47, it is normally in this range for patient)\\n QTC checked twice\\n during shift.\\n Turned and repositioned for comfort, offered food, liquids.\\n Response:\\n Haldol effective, patient able to nap after given.\\n Continues to be confused and wake up agitated,\\n QTC < 0.50.\\n Plan:\\n Continue to monitor, do not give benzo\\ns, treat agitation with haldol,\\n check QTC frequently. Daily EKG\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507584,\n \"text\": \"S/P MVA, was hit by car , s/p external fixation of right leg\\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\\n DT\\ns from ETOH.\\n Code purple called on CC6 0300 this am.\\n Delirium / confusion\\n Assessment:\\n Patient extremely agitated this am, trying to get out of bed, banging\\n right external fixation device against side rails.\\n Oriented only to himself, believes he is at a church, or outside with\\n his\\nbuddies\\n asking for cigarettes and beer, believes he hasn\\nt been\\n in the hospital. Agitated and combative.\\n Action:\\n Security called for assistance this am, patient fighting to get out of\\n restraints,\\n Patient calmly reassured and reoriented frequently,\\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\\n initiated,\\n Psych in to assess, Psych CNS ( ) in to assess (valium and\\n ativan d/c\\nd, will give haldol for psychosis although QT has been\\n 0.40-0.47, it is normally in this range for patient)\\n QTC checked twice\\n during shift.\\n Turned and repositioned for comfort, offered food, liquids.\\n Response:\\n Haldol effective, patient able to nap after given.\\n Continues to be confused and wake up agitated,\\n QTC < 0.50.\\n Plan:\\n Continue to monitor, do not give benzo\\ns, treat agitation with haldol,\\n check QTC frequently. Daily EKG\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505860,\n \"text\": \"Trauma, s/p\\n Assessment:\\n External fixation device in place on right leg, Left Knee immbolizer\\n on,\\n Pin sites slightly red and clean, draining serous fluid,\\n Dopplerable pulses, legs warm, good cap refill.\\n Patient is confused, oriented to self, continually tries to get out of\\n bed, says:\\nI have to go to \\nI need my money\\n. Hard to\\n redirect at times. When told he is in the hospital patient looks\\n shocked.\\n Coughing up secretions.\\n Action:\\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\\n frequently, calmly reassured.\\n Pin care done x 2,\\n Turned and repositioned for comfort.\\n Response:\\n Patient continues to be confused and hard to redirect, tries to get\\n OOB. Patient hardly slept all night.\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506155,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n - remains delirious and agitated\\n - oriented to person only but unable to answer any orientation\\n questions and speech is mostly nonsensical\\n - speech at times sounds slurred but clears when patient\\n coughs and clears secretions\\n - + congested cough, @ times able to clear independently but\\n occasionally requiring subglottal suctioning\\n - tube feeds at goal\\n - right lower extremitie with insision weeping sangounous\\n fluid\\n - right pin site leaking serous fluid\\n - + cms to bil lower extremities\\n Action:\\n - reoriented\\n - restraints applied, 1:1 sitter at bedside, haldol given in\\n addition to standing and prn Zyprexa\\n - ivf changed to kvo\\n - dressing applied to leaking pin site\\n - primary team aware of drainage to right lower extremity\\n Response:\\n - minimal effect with reorientation\\n - at times calmer after haldol but lasting for only short\\n periods of time\\n Plan:\\n - continue to monitor mental status and maintain safety\\n - continue on iv abx for pneumonia\\n - or for internal fixation of right lower extremity later this\\n week\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506271,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n \\n adm to trauma unit from \\n \\n Irrigation debridement of soft tissue muscle and bone of R\\n distal tibia, open Fixation\\n - external fixation of RLE\\n - to floor postop\\n \\n adm to sicu for severe withdrawal, given high doses valium\\n \\n electively intubated\\n \\n IVC filter via R groin for increased risk for thrmoboembolism\\n - open reduction, internal fixation, L supracondylar femur\\n fracture\\n \\n extubated\\n Trauma, s/p\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 506525,\n \"text\": \"50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix and L\\n femur ORIF and s/p IVC filter. Hospital course c/b ETOH w/d.\\n Trauma, s/p\\n Assessment:\\n Pt to go to OR today for wash out of RLE & manipulation of external\\n fixation device, pt npo after MN for OR, pt with increased agitation\\n last noc & pulled out NGT, 0600 dose of po zyprexa not given d/t\\n pending CXR to confirm placement after NGT re-inserted, pt with minimal\\n c/o pain but increased agitation noted throughout day, agitation not\\n controlled by prn IM zyprexa, pt on RA with RA sat 95-97, afebrile &\\n VSS\\n Action:\\n Ho aware of increased agitation, NGT placement ok per cxr & po ATC\\n zyprexa given, psych nurse called & up to eval pt d/t\\n dilerium/psychosis, 5 mg iv haldol given x 2 with minimal sedative\\n effect, po ATC haldol started, pt intubated @ bedside @ 1400 prior to\\n OR d/t increased agitation, propofol gtt started, post intubation cxr\\n done\\n Response:\\n Sedated on 40 mic/kg/min propofol gtt, pt off to OR @ 1630\\n Plan:\\n Keep intubated post op in order to keep pt sedated for head ct this PM\\n to eval mental status change, transfer to TSICU from OR, post op care,\\n ? extubation tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504206,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Alcohol abuse\\n Assessment:\\n Action:\\n Ciwa scale q1hr\\n Valium iv q1hr.\\n Response:\\n Alcohol withdrawal continues.\\n Plan:\\n Continue with ciwa scale\\n Valium iv as ordered.\\n Maintain safe environment.\\n Trauma, s/p\\n Assessment:\\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\\n climb oob,\\n Diaphoretic and slight ly tremorous.\\n Yelling out and not making any sense.\\n Pulling at the bedclothes and sheets.\\n Eyes open wide.\\n Unable to answer where he is, unable to name month or year.\\n Patient is able to state his own name.\\n Heart rate up to the 130-140\\n Left leg has immobilizer on . good pedal pulses.\\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\\n place/\\n Patient moving right leg despite pins and bracket. Patient does yell\\n out wnen moving leg.\\n Iv lactated ringers at 125 cc/hr\\n Fluid bolus x2 with lactated ringers iv given.\\n Breath sounds clear\\n Action:\\n Ciwa scale q1hr\\n Valium 10mg q1 hr\\n Iv lactated ringers at 125cc/hr.\\n Npo aftermidnoc for or today.\\n Pedal pulses check q 2hrs on right and left feet.\\n Response:\\n Continues to have alcholol withdrawal\\n Ciwa scale q1hr maintained.\\n Valium iv q1 hr.\\n Plan:\\n Monitor very closely\\n Continue with ciwa scale.\\n To or for femur repair.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504871,\n \"text\": \"Trauma, s/p leg fractures\\n Assessment:\\n Febrile to 102\\n Tachycardic to low 100\\ns with PVC\\n Diaphoretic\\n Sedated on Propofol\\n Period of hypotension\\n HCT and electrolytes checked\\n Adequate urine output 45-100 cc\\ns/hr.\\n Dopplerable pulses bilateral lower extremities\\n Action:\\n X1 peripheral BC, U/A, C+S, and sputum samples sent\\n Valium x1 given\\n Dilaudid x1 given\\n Lr 500 cc fluid bolus for hypotension\\n Magnesium and calcium repleated\\n Propofol stopped for daily wakeup, patient biting on ETT, no other\\n purposeful movement noted.\\n Response:\\n Fluid balance for + 3 liters\\n No further signs of DT\\ns / tremors after valium given\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504309,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Patient bilateral legs pulses by Doppler left leg in traction with\\n pin sites right leg femur fracture with leg brace on + csm multiple\\n scrapes and bruising.\\n Action:\\n Pin site cleaning done with\\n normal saline and peroxide.\\n Response:\\n Patient remains stable\\n Plan:\\n Continue to monitor notify team of any changes provide comfort and\\n support as needed\\n Alcohol abuse\\n Assessment:\\n Patient alert and orientated X1\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504865,\n \"text\": \"24 Hour Events:\\n ARTERIAL LINE - START 10:00 AM\\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\\n Postop Hct 26.8. Febrile - pan cultured.\\n Post operative day:\\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\\n femur , now s/p ORIF L distal femur fx and IVC filter \\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Infusions:\\n Propofol - 30 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 02:07 PM\\n Pantoprazole (Protonix) - 08:02 PM\\n Hydromorphone (Dilaudid) - 08:02 PM\\n Diazepam (Valium) - 10:50 PM\\n Metoprolol - 12:15 AM\\n Other medications:\\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\\n patient is on mechanical ventilation. Order date: @ 1316 19.\\n Metoprolol Tartrate 5 mg IV Q6H\\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\\n DAILY Order date: @ 1316\\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \\n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\\n Order date: @ 1316\\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\\n TO SEDATION Order date: @ 1316\\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\\n hold oral thiamine, folate and multivitamins. Order date: \\n Flowsheet Data as of 04:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.9\\nC (102.1\\n Tcurrent: 38.5\\nC (101.3\\n HR: 96 (72 - 101) bpm\\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\\n RR: 25 (16 - 26) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 97 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 5,831 mL\\n 655 mL\\n PO:\\n TF:\\n IVF:\\n 5,831 mL\\n 655 mL\\n Blood products:\\n Total out:\\n 2,520 mL\\n 425 mL\\n Urine:\\n 1,580 mL\\n 425 mL\\n NG:\\n 700 mL\\n Stool:\\n Drains:\\n Balance:\\n 3,311 mL\\n 230 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n Vt (Spontaneous): 0 (0 - 530) mL\\n PS : 10 cmH2O\\n RR (Set): 20\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 60%\\n RSBI: 72\\n PIP: 21 cmH2O\\n Plateau: 25 cmH2O\\n Compliance: 42.3 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.42/43/120/28/3\\n Ve: 14.3 L/min\\n PaO2 / FiO2: 200\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\\n tube, NG tube\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: 2+, Left lower extremity\\n edema: 2+, Clubbing\\n Musculoskeletal: Unable to stand\\n Skin: Warm\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Paralyzed, Tone: Not assessed\\n Labs / Radiology\\n 169 K/uL\\n 9.1 g/dL\\n 121 mg/dL\\n 0.6 mg/dL\\n 28 mEq/L\\n 4.0 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 141 mEq/L\\n 28.1 %\\n 9.7 K/uL\\n [image002.jpg]\\n 06:45 PM\\n 08:17 PM\\n 08:36 PM\\n 02:17 AM\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n WBC\\n 8.7\\n 7.5\\n 8.7\\n 9.7\\n Hct\\n 29.5\\n 29.8\\n 28.7\\n 26.8\\n 28.1\\n Plt\\n 141\\n 154\\n 169\\n 169\\n Cr\\n 0.6\\n 0.7\\n 0.7\\n 0.6\\n TCO2\\n 30\\n 28\\n 27\\n 29\\n Glucose\\n 97\\n 104\\n 87\\n 104\\n 121\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. Going to OR today for L femur\\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean sedation to attempt vent wean\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal.\\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Cefazolin 2gm IV q8hr (). Febrile - pan cultured.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Total time: 35 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504369,\n \"text\": \"24 Hour Events: :Worsening left retrocardiac opacification suggests\\n developing pneumonia, and new small left effusion\\n : Intubated for airway protection\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 04:49 AM\\n Gentamicin - 07:26 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 03:00 PM\\n Metoprolol - 03:59 PM\\n Haloperidol (Haldol) - 05:00 PM\\n Pantoprazole (Protonix) - 08:20 PM\\n Enoxaparin (Lovenox) - 09:00 PM\\n Hydromorphone (Dilaudid) - 09:30 PM\\n Diazepam (Valium) - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 12:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.7\\n Tcurrent: 37\\nC (98.6\\n HR: 75 (73 - 144) bpm\\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\\n RR: 16 (15 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,909 mL\\n 30 mL\\n PO:\\n TF:\\n IVF:\\n 3,909 mL\\n 30 mL\\n Blood products:\\n Total out:\\n 2,450 mL\\n 40 mL\\n Urine:\\n 2,450 mL\\n 40 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,459 mL\\n -10 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 602 (502 - 602) mL\\n PS : 10 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.45/43/454/28/5\\n Ve: 8.2 L/min\\n PaO2 / FiO2: 1,135\\n Physical Examination\\n General Appearance: No acute distress, Diaphoretic\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 152 K/uL\\n 8.7 g/dL\\n 124 mg/dL\\n 0.7 mg/dL\\n 28 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 102 mEq/L\\n 138 mEq/L\\n 26.0 %\\n 9.3 K/uL\\n [image002.jpg]\\n 04:17 AM\\n 05:00 AM\\n 07:11 PM\\n 04:50 AM\\n 01:15 PM\\n 07:42 PM\\n WBC\\n 8.9\\n 9.3\\n Hct\\n 35.1\\n 26.0\\n Plt\\n 204\\n 152\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n TCO2\\n 32\\n 31\\n Glucose\\n 120\\n 129\\n 124\\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\\n .\\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\\n seizure history with withdrawl. Valium CIWA prn. Significant valium\\n requirments.\\n Neuro:sedated with propofol\\n Pain: dilaudid prn, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx.Intubated \\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\\n RENAL: Foley, monitor UOP\\n HEME: stable\\n ENDO: RISS\\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\\n am.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT\\n IVF: LR @125 mL/hr.\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT Lovenox 30 q12\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n ICU Care\\n Lines:\\n 20 Gauge - 07:10 PM\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 503913,\n \"text\": \"Eu Critical AKA DOB \\n Per pt no PMH/PSH . Per report Hep C but pt denies.\\n Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p pedestrian struck\\n Assessment:\\n Pt admitted from ED overnight, pedestrian struck, not intubated, GCS\\n 15. Multiple ortho injuries. Vss, O2 sats 97%. Rt leg splinted, left\\n knee with immobilizer on.\\n Action:\\n Pulse checks/Csm, turn and reposition.\\n Response:\\n No changes, pt stable, good pulses, csm\\n Plan:\\n Cont to monitor, OR in a.m. to repair open tib/fib on rt.\\n Alcohol abuse\\n Assessment:\\n Pt with long hx of ETOH abuse. Per pt 12 pack a day of beer. Etoh\\n levels in the 400\\n Action:\\n Ciwa checks/valium ATC.\\n Response:\\n Pt doing ok, was diaphoretic and had a high ciwa scale this a.m. valium\\n given.\\n Plan:\\n Cont to monitor, medicate prn\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504200,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Trauma, s/p\\n Assessment:\\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\\n climb oob,\\n Diaphoretic and slight ly tremorous.\\n Yelling out and not making any sense.\\n Pulling at the bedclothes and sheets.\\n Eyes open wide.\\n Unable to answer where he is, unable to name month or year.\\n Patient is able to state his own name.\\n Heart rate up to the 130-140\\n Left leg has immobilizer on . good pedal pulses.\\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\\n place/\\n Patient moving right leg despite pins and bracket. Patient does yell\\n out wnen moving leg.\\n Iv lactated ringers at 125 cc/hr\\n Fluid bolus x2 with lactated ringers iv given.\\n Breath sounds clear\\n Action:\\n Response:\\n Continues to have alcholol withdrawal\\n Ciwa scale q1hr maintained.\\n Valium iv q1 hr.\\n Plan:\\n Monitor very closely\\n Continue with ciwa scale.\\n To or for femur repair.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505245,\n \"text\": \"Trauma, s/p\\n Assessment:\\n Temp 100.7 to 98.8 po\\n HR 90\\ns nsr\\n Sbp 140-150\\ns when calm, hypertensive to 180\\ns with stimulation such\\n as suctioning\\n Breath sounds clear but diminished in bases\\n Suctioned for copious amounts thick yellow secretions\\n Abd soft with + bowel sounds\\n TF on hold for possible extubation\\n Action:\\n Response:\\n Plan:\\n Alcohol abuse\\n Assessment:\\n Propofol off at 0900\\n Very lethargic\\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\\n No visible sweats or tremors\\n Action:\\n CIWA scale done\\n No valium given this shift\\n Response:\\n No evidence of DT\\n Plan:\\n Continue to monitor for DT\\n ? d/c valium addiction RN recommendation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505144,\n \"text\": \"Trauma, s/p pedestrian struck, bilateral leg fractures and rib\\n fractures\\n Assessment:\\n Low grade temps 100.7\\n HR 80\\ns, BP ~120-140\\n Fluid balance MN -0500: Remains positive for length of stay.\\n Dopplerable pedal pulses bilat\\n Left leg with knee immobilizer, ace wrap with DSD under with old\\n sero-sang drg.\\n Ls clear with suctioning, tan sputum\\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\\n Not showing signs of ETOH withdrawl, no valium given this shift per\\n CIWA scale\\n Action:\\n VAP protocol\\n Pin care\\n Repositioned q 2-3 hours\\n ABX as ordered\\n Tube feeds stopped in preparation for possible extubation.\\n Response:\\n HR and vitals acceptable\\n Remains with low grade fever\\n Concerning sputum\\n HCT 25.3, no S+S of active bleeding.\\n Plan:\\n Wean to extubate\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 503895,\n \"text\": \"Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 503897,\n \"text\": \"Eu Critical AKA DOB \\n Per pt no PMH/PSH . Per report Hep C but pt denies.\\n Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 503909,\n \"text\": \"Eu Critical AKA DOB \\n Per pt no PMH/PSH . Per report Hep C but pt denies.\\n Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 504294,\n \"text\": \"Social Work:\\n Consult received from team.\\n Pt is sicu this pm; pt is agitated, not able to communicate clearly\\n this am. He is trying to get out of bed, etc.\\n According to record pt is 51 y/o man admitted from \\n after sustaining injuries after being hit by a car. Pt reported to\\n that he was homeless and stayed in , MA.\\n Pt\\ns cousin, came to hospital this pm. He states he\\n was contact by orthopedic team and updated recently. Today pt is\\n unable to clearly communicate relationship to cousin.\\n Met w/ cousin separately. Mr. reports the following:\\n Pt\\ns name is spelled , not \\n Pt has been living in shelters in area for many years,\\n he most recently has been staying w/ a friend\\n\\n but family has no\\n other information.\\n Pt has a mother, and two sisters and \\n all of whom live in . Another sister lives out of the\\n country. Pt was married and divorced has two children but has had no\\n contact w/ them for many years.\\n Pt has had long hx of substance abuse according to cousin, primarily\\n alcohol of late. Cousin believes that he has been at Highpointe in\\n past for substance abuse treatment.\\n Pt\\ns cousin, can be reached at (cell #).\\n He and his sister, left note for pt. They understand\\n that we will be in touch w/ pt permission.\\n Will follow.\\n , licsw\\n Pager \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 503827,\n \"text\": \"TITLE: Admission note/daily ICU progress note\\n TSICU\\n HPI:\\n 50y M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. B/l rib fx. No ptx. Questionable lesion on CT ? mass vs pna on R.\\n VSS. Intoxicated with ETOH in 400's at Hospital. Denies PMHx,\\n but intoxicated.\\n Chief complaint:\\n b/l LE fractures, intoxication\\n PMHx:\\n unk - denies\\n Current medications:\\n denies\\n 24 Hour Events:\\n admitted to TSICU\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n 1. 1000 mL LR 2. CefazoLIN 3. Diazepam 4. Famotidine 5. FoLIC Acid 6.\\n Gentamicin 7. Heparin 8. Morphine Sulfate\\n 9. Multivitamins 10. Thiamine\\n Other medications:\\n Flowsheet Data as of 03:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.3\\nC (97.3\\n T current: 36.3\\nC (97.3\\n HR: 87 (87 - 93) bpm\\n BP: 110/69(79) {110/69(79) - 120/73(84)} mmHg\\n RR: 12 (9 - 14) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 420 mL\\n Urine:\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -420 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress, Well nourished\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : , Diminished: R posterior)\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\\n pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\\n Moves all extremities, patient intoxicated.\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: : CT torso: Acute right rib fractures involving the\\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\\n bilaterally and a more nodular right upper lobe opacity. This may be\\n aspiration, though followup when clinically stable is recommended to\\n document resolution and exclude underlying pulmonary nodule.\\n : CT L leg: Markedly comminuted fracture or the distal femoral\\n diaphysis. There is no evidence of intra-articular extension. In\\n addition, there is a non-displaced fracture of the prox fibula.\\n : R tib/fib films: pending\\n Assessment and Plan\\n Assessment and Plan: 50y M ped vs auto with multiple orthopedic\\n injuries, rib fractures. Intoxicated, unclear medical history.\\n Neurologic: awake, alert, neuro intact, following commands. Denies\\n seizure history with withdrawl. Valium CIWA prn.\\n Cardiovascular: stable, to monitor\\n Pulmonary: stable on nasal cannula. rib fx but no ptx.\\n Gastrointestinal / Abdomen: NPO for OR tomorrow\\n Nutrition: thiamine, folate IV\\n Renal: foley, monitor UOP\\n Hematology: Serial Hct\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: s/p gent/zosyn/ancef. wash out in OR by ortho\\n planned for am.\\n Wounds: R tib/fib open fracture with dressing in place. Will be removed\\n in OR.\\n Imaging:\\n Fluids: LR\\n Consults: Ortho\\n Billing Diagnosis: Multiple injuries (Trauma)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 03:09 AM\\n 18 Gauge - 03:09 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504188,\n \"text\": \"TITLE:\\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 04:49 AM\\n Gentamicin - 07:26 AM\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 01:39 AM\\n Other medications:\\n Enoxaparin Sodium 30 mg SC Q12H\\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\\n Insulin SC (per Insulin Flowsheet)Sliding Scale\\n CloniDINE 0.3 mg PO TID\\n Cyanocobalamin 50 mcg PO/NG DAILY\\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\\n Flowsheet Data as of 02:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.8\\nC (100\\n HR: 150 (124 - 150) bpm\\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\\n RR: 23 (19 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 1,280 mL\\n 279 mL\\n PO:\\n TF:\\n IVF:\\n 1,280 mL\\n 279 mL\\n Blood products:\\n Total out:\\n 105 mL\\n 150 mL\\n Urine:\\n 105 mL\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,175 mL\\n 129 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\\n agitated\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\\n dopplerable\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: Absent, ex fix right leg, left leg in splint\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 204 K/uL\\n 11.5 g/dL\\n 129\\n 0.6 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 11 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 35.1 %\\n 8.9 K/uL\\n [image002.jpg]\\n 04:17 AM\\n 05:00 AM\\n 07:11 PM\\n WBC\\n 8.9\\n Hct\\n 35.1\\n Plt\\n 204\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 120\\n 129\\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\\n Imaging: CXR: left base in the retrocardiac region, likely\\n atelectasis\\n Microbiology: U cx P\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs.\\n .\\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\\n seizure history with withdrawl. Valium CIWA prn. Significant valium\\n requirments.\\n Neuro checks Q: 1\\n Pain: dilaudid PCA, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\\n PULM: stable on nasal cannula. Right rib fx but no ptx.\\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\\n RENAL: Foley, monitor UOP\\n HEME: stable\\n ENDO: RISS\\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\\n am.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.\\n IVF: LR @125 mL/hr.\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal:\\n ICU Care\\n Nutrition:\\n Comments: Npo\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 10:53 PM\\n Prophylaxis:\\n DVT: Boots, LMW Heparin\\n Stress ulcer: PPI\\n VAP:\\n Need for restraints reviewed\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n Total time spent:\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504271,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alcohol abuse\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 505353,\n \"text\": \"HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\\n \\n 24 Hour Events:\\n MULTI LUMEN - START 01:30 PM\\n FEVER - 101.6\\nF - 08:00 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 02:13 AM\\n Ciprofloxacin - 09:56 AM\\n Vancomycin - 08:32 PM\\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 05:54 PM\\n Pantoprazole (Protonix) - 08:32 PM\\n Heparin Sodium (Prophylaxis) - 08:32 PM\\n Other medications:\\n Flowsheet Data as of 01:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.7\\n Tcurrent: 37.9\\nC (100.3\\n HR: 91 (83 - 100) bpm\\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\\n RR: 28 (21 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 98 kg (admission): 94.5 kg\\n Height: 72 Inch\\n CVP: 11 (11 - 16)mmHg\\n Total In:\\n 2,933 mL\\n 109 mL\\n PO:\\n TF:\\n 454 mL\\n 52 mL\\n IVF:\\n 2,479 mL\\n 57 mL\\n Blood products:\\n Total out:\\n 2,930 mL\\n 0 mL\\n Urine:\\n 2,930 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3 mL\\n 109 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 624 (411 - 624) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 22\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 50\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: 7.45/45/132/27/7\\n Ve: 10.7 L/min\\n PaO2 / FiO2: 330\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\\n Bronchial: bases)\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n 199 K/uL\\n 8.5 g/dL\\n 128 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 108 mEq/L\\n 142 mEq/L\\n 25.3 %\\n 8.0 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 03:27 PM\\n 08:16 PM\\n 10:00 PM\\n 01:55 AM\\n 02:03 AM\\n 09:24 AM\\n 06:07 PM\\n 02:08 AM\\n 02:21 AM\\n WBC\\n 9.7\\n 8.0\\n Hct\\n 26.8\\n 28.1\\n 25.3\\n Plt\\n 169\\n 199\\n Cr\\n 0.7\\n 0.6\\n 0.6\\n TCO2\\n 28\\n 27\\n 29\\n 26\\n 29\\n 32\\n Glucose\\n 87\\n 104\\n 121\\n 128\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\\n PO4:2.7 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\\n intubated after increased somnolence. Going to OR today for L femur\\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\\n .\\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\\n prn, Tylenol prn. Will wean off prop to attempt vent wean\\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx. Intubated for altered mental\\n status from withdrawal. GNR on sputum and febril -> started on\\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\\n GI: NGT feeding.\\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\\n Fiber (Full) - 04:00 PM 50 mL/hour\\n RENAL: Foley, monitor UOP\\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\\n ENDO: RISS\\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\\n IVF: thiamine, d5, folate\\n Wound: L femur, R ankle - watch for compartment\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT SQH\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n Lines:\\n Arterial Line - 10:00 AM\\n Multi Lumen - 01:30 PM\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505419,\n \"text\": \"pt he is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Pupils #3 and reasts briskly\\n Moves upper extremtites off the bed.\\n Move right leg back and forth but has some difficulty moving off the\\n bed due to the metal apparatus.\\n Does not move left leg freely and only wiil move slowly.\\n Action:\\n Neuro signs q2hrs\\n Pin care to right leg and foot\\n Suctioned prn\\n Vap mouth care\\n Iv 1/2ns at 55cc/hr\\n Tube fdg at goal\\n Response:\\n Vital signs stable\\n Remains off all sedation.\\n Slowly waking and following simple commands\\n Hct stable at 26\\n Continues to be suctioned for copius amts of thick white/yellow sputum.\\n Plan:\\n Monitor patient\\ns condition closely.\\n Provide emotional support to patient.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505408,\n \"text\": \"pt he is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Pupils #3 and reasts briskly\\n Moves upper extremtites off the bed.\\n Move right leg back and forth but has some difficulty moving off the\\n bed due to the metal apparatus.\\n Does not move left leg freely and only wiil\\n Action:\\n Neuro signs q2hrs\\n Pin care to right leg and foot\\n Suctioned prn\\n Vap mouth care\\n Iv 1/2ns at 55cc/hr\\n Tube fdg at goal\\n Response:\\n Vital signs stable\\n Slowly waking and following simple commands\\n Hct stable at 26\\n Continues to be suctioned for copius amts of thick white/yellow sputum.\\n Plan:\\n Monitor patient\\ns condition closely.\\n Provide emotional support to patient.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-02 00:00:00.000\",\n \"description\": \"Physician Surgical Admission Note\",\n \"row_id\": 504170,\n \"text\": \"TITLE:\\n Chief Complaint: Withdrawal from ETOH\\n HPI:\\n 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Post operative day:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 04:49 AM\\n Gentamicin - 07:26 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family / Social history:\\n PMH: ETOH abuse,Varicose veins, othewise unk\\n PSH: Ex fix/ wahout right ankle\\n Meds at home: Denies\\n All: Denies\\n SH: homeless history of ETOH 12 beers/ day but denies withdrawal\\n seizures ( per prior notes)\\n FH:unk\\n Flowsheet Data as of 09:56 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 38.3\\nC (100.9\\n HR: 124 (124 - 124) bpm\\n BP: 134/87(98) {134/87(98) - 134/87(98)} mmHg\\n RR: 27 (27 - 27) insp/min\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 729 mL\\n PO:\\n TF:\\n IVF:\\n 729 mL\\n Blood products:\\n Total out:\\n 1,150 mL\\n 30 mL\\n Urine:\\n 1,150 mL\\n 30 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -421 mL\\n -30 mL\\n Respiratory support\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress, Anxious, Diaphoretic, Confused\\n Eyes / Conjunctiva: injected conjunctiva\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), Tachycardic to 120-130s\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), Bilateral\\n DP dopplerable\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Non-tender, Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: Trace, LEft leg in brace, Right ankle with ex fix in place\\n bialteral feet warm with intact sensation\\n Skin: Warm, flushed\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Oriented (to): x1 to self, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 204 K/uL\\n 11.5 g/dL\\n 129\\n 0.6 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 11 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 35.1 %\\n 8.9 K/uL\\n [image002.jpg]\\n 04:17 AM\\n 05:00 AM\\n 07:11 PM\\n WBC\\n 8.9\\n Hct\\n 35.1\\n Plt\\n 204\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 120\\n 129\\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\\n Imaging: : CT torso: Acute right rib fractures involving the\\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\\n bilaterally and a more nodular right upper lobe opacity. This may be\\n aspiration, though followup when clinically stable is recommended to\\n document resolution and exclude underlying pulmonary nodule.\\n : CT L leg: Markedly comminuted fracture or the distal femoral\\n diaphysis. There is no evidence of intra-articular extension. In\\n addition, there is a non-displaced fracture of the prox fibula.\\n : R tib/fib films: Comminuted fractures of the distal tibia and\\n fibula.\\n CXR: left base in the retrocardiac region, likely atelectasis\\n Microbiology: Ucx P\\n Assessment and Plan\\n TRAUMA, S/P\\n ALCOHOL ABUSE with active withdrawal and disorientation\\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\\n seizure history with withdrawl. Valium CIWA prn.\\n Neuro checks Q: 1\\n Pain: dilaudid PCA, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\\n PULM: stable on nasal cannula. Right rib fx but no ptx.\\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\\n RENAL: Foley, monitor UOP\\n HEME: stable\\n ENDO: RISS\\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\\n am.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.\\n IVF: LR @125 mL/hr.\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal\\n ICU Care\\n Nutrition: NPO\\n Glycemic Control: Regular insulin sliding scale\\n Lines: PIV x 2\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\\n Stress ulcer: PPI\\n VAP: NA\\n Need for restraints reviewed Y\\n Comments:\\n Communication: Comments: ICU consent deferred due to poor MS\\n status: Full code\\n Disposition: ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504251,\n \"text\": \"TITLE:\\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\\n s/p Ex-fix R tib/fib ID and ex fix right ankle\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 04:49 AM\\n Gentamicin - 07:26 AM\\n Infusions:\\n Other ICU medications:\\n Diazepam (Valium) - 01:39 AM\\n Other medications:\\n Enoxaparin Sodium 30 mg SC Q12H\\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\\n Insulin SC (per Insulin Flowsheet)Sliding Scale\\n CloniDINE 0.3 mg PO TID\\n Cyanocobalamin 50 mcg PO/NG DAILY\\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\\n Flowsheet Data as of 02:27 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (100.9\\n Tcurrent: 37.8\\nC (100\\n HR: 150 (124 - 150) bpm\\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\\n RR: 23 (19 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 1,280 mL\\n 279 mL\\n PO:\\n TF:\\n IVF:\\n 1,280 mL\\n 279 mL\\n Blood products:\\n Total out:\\n 105 mL\\n 150 mL\\n Urine:\\n 105 mL\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,175 mL\\n 129 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\\n agitated\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\\n dopplerable\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Bowel sounds present, Distended\\n Extremities: Right lower extremity edema: 1+, Left lower extremity\\n edema: Absent, ex fix right leg, left leg in splint\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 204 K/uL\\n 11.5 g/dL\\n 129\\n 0.6 mg/dL\\n 26 mEq/L\\n 4.3 mEq/L\\n 11 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 35.1 %\\n 8.9 K/uL\\n [image002.jpg]\\n 04:17 AM\\n 05:00 AM\\n 07:11 PM\\n WBC\\n 8.9\\n Hct\\n 35.1\\n Plt\\n 204\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 120\\n 129\\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\\n Imaging: CXR: left base in the retrocardiac region, likely\\n atelectasis\\n Microbiology: U cx P\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\\n fractures. Alcohol withdrawal with DTs.\\n .\\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\\n seizure history with withdrawl. Valium CIWA prn. Significant valium\\n requirments. Neuro checks Q 1hr. Restrained.\\n Pain: dilaudid PCA, Tylenol prn.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Start beta blockade\\n PULM: stable on nasal cannula. Right rib fx but no ptx.\\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\\n RENAL: Foley, monitor UOP\\n HEME: stable\\n ENDO: RISS\\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\\n am.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.\\n IVF: LR @125 mL/hr.\\n thiamine, folate for protection\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal:\\n ICU Care\\n Nutrition:\\n Comments: Npo\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 10:53 PM\\n Prophylaxis:\\n DVT: Boots, LMW Heparin\\n Stress ulcer: PPI\\n VAP:\\n Need for restraints reviewed\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n Total time spent: 35\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 504350,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 22 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: periods of agitation\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Maintain PEEP at current level and reduce FiO2 as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 505406,\n \"text\": \"pt he is homeless and lives in . 12 beer a day drinker/smokes\\n cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Action:\\n Neuro signs q2hrs\\n Pin care to right leg and foot\\n Suctioned prn\\n Vap mouth care\\n Iv 1/2ns at 55cc/hr\\n Tube fdg at goal\\n Response:\\n Vital signs stable\\n Slowly waking and following simple commands\\n Hct stable at 26\\n Continues to be suctioned for copius amts of thick white/yellow sputum.\\n Plan:\\n Monitor patient\\ns condition closely.\\n Provide emotional support to patient.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504335,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Trauma, s/p\\n Assessment:\\n Patient bilateral legs pulses by Doppler left leg in traction with\\n pin sites right leg femur fracture with leg brace on + csm multiple\\n scrapes and bruising.\\n Action:\\n Pin site cleaning done with\\n normal saline and peroxide.\\n Response:\\n Patient remains stable\\n Plan:\\n Continue to monitor notify team of any changes provide comfort and\\n support as needed\\n Alcohol abuse\\n Assessment:\\n Patient alert and orientated X1 very agitated not appropriate trying\\n to climb out of bed heart to 120-130\\ns b/p 140\\ns over 80\\n Action:\\n Giving valium 10-20mg IV haldol X 1 and dilaudid with little effect\\n patient intubated for increased agitation and DT\\ns @ 1700\\n Response:\\n Patient less agitated and comfortable\\n Plan:\\n Continue with current plan of care notify team of any changes\\n Please see social service note\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504490,\n \"text\": \"Trauma, s/p\\n Assessment:\\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\\n Patient is intubated and sedated on Propofol.\\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\\n am.\\n Vital signs stable (HR 60-70, SBP 90\\ns-100)\\n When off prop patient tremulous, diaphoretic, inconsistently follow\\n commands, able to move upper extremities.\\n Action:\\n Turned and repositioned for comfort.\\n Pin care done, incisional dsg on right leg changed, moderate serosang\\n drainage noted.\\n Given 2 units PRBC.\\n Given 1 mg Dilaudid q 4 hours for pain.\\n Response:\\n Patient continues to be intubated and sedated,\\n Post transfusion HCT up to 25.5,\\n Plan:\\n Patient to go to OR for ORIF right tibia and left femur, 3 plates,\\n and placement of IVC filter.\\n Alcohol abuse\\n Assessment:\\n Last drink : Patient on CIWA scale despite being intubated and\\n sedated. Moderate diaphoresis noted.\\n Off sedation patient very tremulous, unable to follow commands\\n consistently, agitated.\\n Action:\\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\\n Response:\\n Patient not as diaphoretic,\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504208,\n \"text\": \"Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\\n facility when he went to cross the street he got hit by a car.Pt\\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\\n Injuries include: Open tib/fib to right (per osh reports hanging by a\\n thread), Lt comminuted femur fx, bilateral rib fxs\\n Alcohol abuse\\n Assessment:\\n Patient has a long history of alcholol abuse. Patient drinks 12 beers\\n /day\\n Diaphoretic with heart rate 120-140\\n Bp 140-150\\ns syst.\\n Action:\\n Ciwa scale q1hr\\n Valium iv q1hr.\\n Response:\\n Alcohol withdrawal continues.\\n Ciwa scale\\n Continue with valium iv .\\n Plan:\\n Continue with ciwa scale\\n Valium iv as ordered.\\n Maintain safe environment.\\n Trauma, s/p\\n Assessment:\\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\\n climb oob,\\n Diaphoretic and slight ly tremorous.\\n Yelling out and not making any sense.\\n Pulling at the bedclothes and sheets.\\n Eyes open wide.\\n Unable to answer where he is, unable to name month or year.\\n Patient is able to state his own name.\\n Heart rate up to the 130-140\\n Left leg has immobilizer on . good pedal pulses.\\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\\n place/\\n Patient moving right leg despite pins and bracket. Patient does yell\\n out wnen moving leg.\\n Iv lactated ringers at 125 cc/hr\\n Fluid bolus x2 with lactated ringers iv given.\\n Breath sounds clear\\n Action:\\n Ciwa scale q1hr\\n Valium 10mg q1 hr\\n Iv lactated ringers at 125cc/hr.\\n Npo aftermidnoc for or today.\\n Pedal pulses check q 2hrs on right and left feet.\\n Response:\\n Continues to have alcholol withdrawal\\n Ciwa scale q1hr maintained.\\n Valium iv q1 hr.\\n Plan:\\n Monitor very closely\\n Continue with ciwa scale.\\n To or for femur repair.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504594,\n \"text\": \"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n .\\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\\n developing pneumonia, and new small left effusion\\n : Intubated for airway protection\\n Trauma, s/p\\n Assessment:\\n Action:\\n Suctioned prn\\n Vap mouth care as ordered\\n On propofol gtt and infusing at 40mcg/hr.\\n Iv lactatated ringers at 100cc/hr.\\n Valium 10mg iv prn given\\n Hydromorphone 1mg iv prn given.\\n Response:\\n Plan:\\n Monitor condition closely.\\n To or for femur repair\\n Update cousin of patient\\ns condition.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 504438,\n \"text\": \"HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n .\\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\\n developing pneumonia, and new small left effusion\\n : Intubated for airway protection\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Cefazolin - 04:49 AM\\n Gentamicin - 07:26 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 03:00 PM\\n Metoprolol - 03:59 PM\\n Haloperidol (Haldol) - 05:00 PM\\n Pantoprazole (Protonix) - 08:20 PM\\n Enoxaparin (Lovenox) - 09:00 PM\\n Hydromorphone (Dilaudid) - 09:30 PM\\n Diazepam (Valium) - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 12:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.7\\n Tcurrent: 37\\nC (98.6\\n HR: 75 (73 - 144) bpm\\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\\n RR: 16 (15 - 29) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,909 mL\\n 30 mL\\n PO:\\n TF:\\n IVF:\\n 3,909 mL\\n 30 mL\\n Blood products:\\n Total out:\\n 2,450 mL\\n 40 mL\\n Urine:\\n 2,450 mL\\n 40 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,459 mL\\n -10 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 550 (550 - 550) mL\\n Vt (Spontaneous): 602 (502 - 602) mL\\n PS : 10 cmH2O\\n RR (Set): 16\\n RR (Spontaneous): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 16 cmH2O\\n Plateau: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.45/43/454/28/5\\n Ve: 8.2 L/min\\n PaO2 / FiO2: 1,135\\n Physical Examination\\n General Appearance: No acute distress, Diaphoretic\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Tone: Not assessed\\n Labs / Radiology\\n 152 K/uL\\n 8.7 g/dL\\n 124 mg/dL\\n 0.7 mg/dL\\n 28 mEq/L\\n 3.8 mEq/L\\n 9 mg/dL\\n 102 mEq/L\\n 138 mEq/L\\n 26.0 %\\n 9.3 K/uL\\n [image002.jpg]\\n 04:17 AM\\n 05:00 AM\\n 07:11 PM\\n 04:50 AM\\n 01:15 PM\\n 07:42 PM\\n WBC\\n 8.9\\n 9.3\\n Hct\\n 35.1\\n 26.0\\n Plt\\n 204\\n 152\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n TCO2\\n 32\\n 31\\n Glucose\\n 120\\n 129\\n 124\\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\\n .\\n NEURO: Sedation with propofol. Significant valium requirements for ETOH\\n withdrawal. Cpap/ PS.\\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\\n patch. Beta blockade.\\n PULM: Right rib fx but no ptx.Intubated \\n GI: Npo will feed post procedure. Thiamine, folate, MVI via banana bag\\n Electrolyte repletion\\n RENAL: Foley, monitor UOP\\n HEME: Transfuse 2 unit preoperatively for hct 21. Check post hct.\\n ENDO: RISS\\n ID: Wash out in OR by ortho planned for am.\\n Other: Social work/ Addictions consult\\n TLD: Foley, PIV.NGT,ETT\\n IVF: LR @125 mL/hr.\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal\\n GLYCEMIC CONTROL: RISS\\n PROPHYLAXIS: PPI\\n DVT Lovenox 30 q12\\n STRESS ULCER H2B\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU\\n ICU Care\\n Lines:\\n 20 Gauge - 07:10 PM\\n Total time spent: 32 min Delirium Tremens\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504430,\n \"text\": \"Alcohol abuse\\n Assessment:\\n pt intubated and on propofol drip, pt is sedate but continues to have\\n profound diaphoresis.\\n Action:\\n spoke with dr valium iv given. LR bolus 500 cc times one\\n Response:\\n decreased daphoresis with valium doses\\n Plan:\\n Assess for underlying symptoms of with drawal ie diphoresis,\\n twitching, tremors and medicate prn. Please give medication for pain\\n periodically.\\n Trauma, s/p\\n Assessment:\\n rlower leg draining sero-sanguinous,left leg with knee brace in place\\n Action:\\n npo for OR ot day for repair . medicated for pain times 4 with .5 mg\\n iv\\n Response:\\n difficult to evaluate for pain so medicate for pain periodically\\n Plan:\\n NPo for or today. hold enoxaprin sodium but if OR cancelled pt should\\n receive doses.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 504474,\n \"text\": \"Subjective\\n Unable to assess due to intubation\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 183 cm\\n 94.5 kg\\n 28.2\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 80.7 kg\\n 117%\\n unknown\\n Diagnosis: pedestrian struck, leg fractures\\n PMHx: patient denies, per report drinks 12 beers/day\\n Food allergies and intolerances: none noted\\n Pertinent medications: Propofol drip, RISS, Pantoprazole, vitamin B12,\\n Banana bag, KPhos 15mmol\\n Labs:\\n Value\\n Date\\n Glucose\\n 83 mg/dL\\n 04:13 AM\\n Glucose Finger Stick\\n 115\\n 10:00 AM\\n BUN\\n 13 mg/dL\\n 04:13 AM\\n Creatinine\\n 0.6 mg/dL\\n 04:13 AM\\n Sodium\\n 137 mEq/L\\n 04:13 AM\\n Potassium\\n 5.1 mEq/L\\n 04:13 AM\\n Chloride\\n 105 mEq/L\\n 04:13 AM\\n TCO2\\n 28 mEq/L\\n 04:13 AM\\n PO2 (arterial)\\n 454 mm Hg\\n 07:42 PM\\n PCO2 (arterial)\\n 43 mm Hg\\n 07:42 PM\\n pH (arterial)\\n 7.45 units\\n 07:42 PM\\n CO2 (Calc) arterial\\n 31 mEq/L\\n 07:42 PM\\n Calcium non-ionized\\n 7.4 mg/dL\\n 04:13 AM\\n Phosphorus\\n 4.3 mg/dL\\n 04:13 AM\\n Magnesium\\n 2.2 mg/dL\\n 04:13 AM\\n ALT\\n 25 IU/L\\n 04:50 AM\\n Alkaline Phosphate\\n 60 IU/L\\n 04:50 AM\\n AST\\n 46 IU/L\\n 04:50 AM\\n Amylase\\n 27 IU/L\\n 04:50 AM\\n Total Bilirubin\\n 1.0 mg/dL\\n 04:50 AM\\n WBC\\n 8.3 K/uL\\n 11:04 AM\\n Hgb\\n 8.4 g/dL\\n 11:04 AM\\n Hematocrit\\n 25.5 %\\n 11:04 AM\\n Current diet order / nutrition support: Diet: NPO\\n GI: soft, (+) bowel sounds; OGT to low continuous suction\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Patient at risk due to: NP, trauma, Etoh use PTA\\n Estimated Nutritional Needs\\n Calories: 2270-2455 (24-26 cal/kg)\\n Protein: 113-142 (1.2-1.5 g/kg)\\n Fluid: per team\\n Calculations based on: Admit weight\\n Estimation of previous intake: unknown\\n Estimation of current intake: Inadequate due to NPO\\n Specifics:\\n 51 YO homless male admitted to Hospital after struck by a car\\n while walking intoxicated. Injuries including an open tibia/fibia on\\n right and comminuted femur fracture on left; right rib fractures\\n 2nd/3rd/ 12th. Questionable lesion on CT question mass versus pna on\\n right. Transferred to for further management. Hypertension,\\n change in MS, and tachycardia consistent with etoh withdrawal requiring\\n >10 mg valium every hr prompting admission to ICU. Intubated for\\n airway protection. Plan for OR today for ORIF right tibia/fibia, left\\n femur. Remains NPO; propofol providing 750 calories. Questionable\\n nutrition status PTA given homeless, report of Etoh use.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Current diet / nutrition support is appropriate: Continue\\n NPO\\n Multivitamin / Mineral supplement: continue current;\\n multi-vitamin via enteral nutrition\\n Tube feeding recommendations: When able begin nutrition\\n support\\n o Replete with Fiber @ 20ml/hr, advance as tolerated to goal of\\n 65ml/hr + 15g Beneprotein = 1615 calories and 120g protein while\\n propofol running\\n o If propofol discontinued, can advance tube feed goal to\\n 95ml/hr = 2280 calories and 141g protein\\n o Check residuals, hold tube feed if greater than 200ml\\n Check chemistry 10 panel daily\\n o Replete lytes PRN\\n BS management\\n Will follow, page if questions *\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 504524,\n \"text\": \"Trauma, s/p\\n Assessment:\\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\\n Patient is intubated and sedated on Propofol.\\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\\n am.\\n Vital signs stable (HR 60-70, SBP 90\\ns-100)\\n When off prop patient tremulous, diaphoretic, unable to follow\\n commands, able to move upper extremities.\\n Action:\\n Turned and repositioned for comfort.\\n Pin care done, incisional dsg on right leg changed, moderate serosang\\n drainage noted.\\n Given 2 units PRBC.\\n Given 1 mg Dilaudid q 4 hours for pain.\\n Response:\\n Patient continues to be intubated and sedated,\\n Post transfusion HCT up to 25.5, given 2 more units PRBC.\\n Plan:\\n Patient to go to OR for ORIF right tibia and left femur , 3 \\n plates, and placement of IVC filter tomorrow.\\n Alcohol abuse\\n Assessment:\\n Last drink : Patient on CIWA scale despite being intubated and\\n sedated. Moderate diaphoresis noted.\\n Off sedation patient very tremulous, unable to follow commands\\n consistently, agitated.\\n Action:\\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\\n Response:\\n Patient not as diaphoretic,\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2146-01-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 504526,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 80.7 None\\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Pending procedure / OR, Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507576,\n \"text\": \"Delirium / confusion\\n Assessment:\\n Patient extremely agitated this am, trying to get out of bed, banging\\n right external fixationdevise against side rails.\\n Oriented only to himself, believes he is at a church,\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 507449,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.subsequently discharged to floor on .code purple\\n on -transferred to SICU.\\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\\n washout/ Ex-fix revision\\n Chief complaint:\\n PMHx:\\n ETOH abuse,Varicose veins\\n Current medications:\\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\\n Release\\n 24 Hour Events:\\n agitated on floor not responding to haldol/valium/zyprexa\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 03:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 103 (103 - 103) bpm\\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\\n RR: 17 (17 - 17) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: Anxious, agitated/delerius\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Skin: RLE EX fix\\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\\n agitated and deleriuous\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 29.1 %\\n 9.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n WBC\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n Plt\\n 259\\n 307\\n 327\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\\n floor.Transferred to ICU\\n NEURO: Delirious, awake but disoriented. Previosly in DT - needed\\n excessive valium. Now still delirious. Need frequent re-orientation\\n with restriants. Haldol PO and IV prn.Ativan prn.\\n CVS: On clonidine patch. Beta blockade.\\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \\n for altered mental status from withdrawal. Reintubated for increasing\\n agitation and in prep for OR\\n GI: Regular.\\n Nutrition: Thiamine, folate, MVI.\\n RENAL:\\n HEME: Hct 29 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\\n levaquin.\\n Other: Social work/ Addictions consult\\n TLD: PIV\\n IVF: KVO\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL:\\n PROPHYLAXIS:\\n DVT SQH/IVC filter\\n STRESS ULCER\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent:\\n :\\n :\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 507522,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.subsequently discharged to floor on .code purple\\n on -transferred to SICU.\\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\\n washout/ Ex-fix revision\\n Chief complaint:\\n PMHx:\\n ETOH abuse,Varicose veins\\n Current medications:\\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\\n Release\\n 24 Hour Events:\\n agitated on floor not responding to haldol/valium/zyprexa\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 03:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 103 (103 - 103) bpm\\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\\n RR: 17 (17 - 17) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: Anxious, agitated/delerius\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Skin: RLE EX fix\\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\\n agitated and deleriuous\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 29.1 %\\n 9.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n WBC\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n Plt\\n 259\\n 307\\n 327\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\\n floor.Transferred to ICU\\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\\n - needed excessive valium. Now still delirious. Need frequent\\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\\n CVS: On clonidine patch. Beta blockade.\\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \\n for altered mental status from withdrawal\\n GI: Regular. Not taking pos now.\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Place foley.\\n HEME: Hct 29 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\\n levaquin.\\n Other: Social work/ Addictions consult\\n TLD: PIV\\n IVF: KVO\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL:\\n PROPHYLAXIS:\\n DVT SQH/IVC filter\\n STRESS ULCER\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent: 35 min\\n :\\n :\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 507541,\n \"text\": \"SICU\\n HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.subsequently discharged to floor on .code purple\\n on -transferred to SICU.\\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\\n washout/ Ex-fix revision\\n Chief complaint:\\n PMHx:\\n ETOH abuse,Varicose veins\\n Current medications:\\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\\n Release\\n 24 Hour Events:\\n agitated on floor not responding to haldol/valium/zyprexa\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 03:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 103 (103 - 103) bpm\\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\\n RR: 17 (17 - 17) insp/min\\n SPO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: Anxious, agitated/delerius\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Skin: RLE EX fix\\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\\n agitated and deleriuous\\n Labs / Radiology\\n 433 K/uL\\n 8.8 g/dL\\n 95 mg/dL\\n 0.8 mg/dL\\n 26 mEq/L\\n 4.4 mEq/L\\n 12 mg/dL\\n 110 mEq/L\\n 142 mEq/L\\n 29.1 %\\n 9.6 K/uL\\n [image002.jpg]\\n 05:00 AM\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n WBC\\n 8.1\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n Hct\\n 26.6\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n Plt\\n 259\\n 307\\n 327\\n 390\\n 455\\n 433\\n Creatinine\\n 0.5\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 120\\n 124\\n 119\\n 126\\n 125\\n 95\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n TRAUMA, S/P, ALCOHOL ABUSE\\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\\n floor.Transferred to ICU\\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\\n - needed excessive valium. Now still delirious. Need frequent\\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\\n CVS: On clonidine patch. Beta blockade.\\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \\n for altered mental status from withdrawal\\n GI: Regular. Not taking pos now.\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Place foley.\\n HEME: Hct 29 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\\n levaquin.\\n Other: Social work/ Addictions consult\\n TLD: PIV\\n IVF: KVO\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n GLYCEMIC CONTROL:\\n PROPHYLAXIS:\\n DVT SQH/IVC filter\\n STRESS ULCER\\n VAP BUNDLE yes\\n COMMUNICATIONS:\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n Total time spent: 35 min\\n :\\n :\\n ------ Protected Section------\\n ------ Protected Section Error Entered By: , MD\\n on: 10:46 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 507811,\n \"text\": \"HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Delirium / confusion\\n Assessment:\\n S/P code purple called on at 0300, patient is now not agitated,\\n alert, oriented to self and place, unsure of date. Able to follow\\n commands, was not trying to get out of bed, able to use call bell for\\n help.\\n Action:\\n Continued on standing dose of haldol (all benzo\\ns d/c\\nd yesterday per\\n psych recommendation),\\n PT in to work with patient, offered to get OOB to chair,\\n Response:\\n Patient continues to be calm, a little confused at times.\\n Plan:\\n Continue to monitor, no benzo\\ns per pysch.\\n Trauma, s/p\\n Assessment:\\n S/P internal fixation of right fibula, repair of L femur fx,\\n External fixation in place, draining serous fluid from pin sites, pin\\n sites look clean.\\n Action:\\n Pin care x 2 today,\\n Dsg changed,\\n PT in to work with patient.\\n Response:\\n Patient c/o of some pain after working with PT, given Tylenol with good\\n effect.\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 507813,\n \"text\": \"HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Delirium / confusion\\n Assessment:\\n S/P code purple called on at 0300, patient is now not agitated,\\n alert, oriented to self and place, unsure of date. Able to follow\\n commands, was not trying to get out of bed, able to use call bell for\\n help.\\n Action:\\n Continued on standing dose of haldol (all benzo\\ns d/c\\nd yesterday per\\n psych recommendation),\\n PT in to work with patient, offered to get OOB to chair,\\n Response:\\n Patient continues to be calm, a little confused at times.\\n Plan:\\n Continue to monitor, no benzo\\ns per pysch.\\n Trauma, s/p\\n Assessment:\\n S/P internal fixation of right fibula, repair of L femur fx,\\n External fixation in place, draining serous fluid from pin sites, pin\\n sites look clean.\\n Action:\\n Pin care x 2 today,\\n Dsg changed,\\n PT in to work with patient.\\n Response:\\n Patient c/o of some pain after working with PT, given Tylenol with good\\n effect.\\n Plan:\\n Continue to monitor.\\n Demographics\\n Attending MD:\\n K.\\n Admit diagnosis:\\n PEDESRTRIAN STRUCK, LEG FRACTURES\\n Code status:\\n Full code\\n Height:\\n 72 Inch\\n Admission weight:\\n 94.5 kg\\n Daily weight:\\n 91.1 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Eu Critical AKA DOB \\n Per pt no PMH/PSH . Per report Hep C but pt denies.\\n Per pt he is homeless and lives in . 12 beer a day\\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\\n withdrawing from alchohol and requiring q1hr valium. heart rate\\n 130-140's. very agitated and requiring constant watch. npo for or on\\n monday to repair left femur.\\n -pt back to sicu from CC6 after causing \\\"code purple\\\" d/t severe\\n agitation and delerium\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:115\\n D:68\\n Temperature:\\n 97.5\\n Arterial BP:\\n S:123\\n D:83\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 59 bpm\\n Heart rhythm:\\n SB (Sinus Bradycardia)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 99% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 1,066 mL\\n 24h total out:\\n 650 mL\\n Pertinent Lab Results:\\n Sodium:\\n 141 mEq/L\\n 04:31 AM\\n Potassium:\\n 4.1 mEq/L\\n 04:31 AM\\n Chloride:\\n 109 mEq/L\\n 04:31 AM\\n CO2:\\n 24 mEq/L\\n 04:31 AM\\n BUN:\\n 10 mg/dL\\n 04:31 AM\\n Creatinine:\\n 0.7 mg/dL\\n 04:31 AM\\n Glucose:\\n 111 mg/dL\\n 04:31 AM\\n Hematocrit:\\n 30.6 %\\n 04:31 AM\\n Finger Stick Glucose:\\n 95\\n 07:00 PM\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables: notebook\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: SICU A\\n Transferred to: CC 6\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 507810,\n \"text\": \"Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 183 cm\\n 94.5 kg\\n 91.1 kg ( 03:00 AM)\\n 28.2\\n Pertinent medications: Dextrose 5% with 1/2 normal saline with KCl @\\n 10mL/hr, Haldol, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 111 mg/dL\\n 04:31 AM\\n Glucose Finger Stick\\n 95\\n 07:00 PM\\n BUN\\n 10 mg/dL\\n 04:31 AM\\n Creatinine\\n 0.7 mg/dL\\n 04:31 AM\\n Sodium\\n 141 mEq/L\\n 04:31 AM\\n Potassium\\n 4.1 mEq/L\\n 04:31 AM\\n Chloride\\n 109 mEq/L\\n 04:31 AM\\n TCO2\\n 24 mEq/L\\n 04:31 AM\\n PO2 (arterial)\\n 184 mm Hg\\n 10:45 PM\\n PCO2 (arterial)\\n 40 mm Hg\\n 10:45 PM\\n pH (arterial)\\n 7.43 units\\n 10:45 PM\\n pH (urine)\\n 6.0 units\\n 08:56 PM\\n CO2 (Calc) arterial\\n 27 mEq/L\\n 10:45 PM\\n Calcium non-ionized\\n 8.8 mg/dL\\n 04:31 AM\\n Phosphorus\\n 3.7 mg/dL\\n 04:31 AM\\n Ionized Calcium\\n 1.11 mmol/L\\n 02:21 AM\\n Magnesium\\n 2.4 mg/dL\\n 04:31 AM\\n ALT\\n 25 IU/L\\n 04:50 AM\\n Alkaline Phosphate\\n 60 IU/L\\n 04:50 AM\\n AST\\n 46 IU/L\\n 04:50 AM\\n Amylase\\n 27 IU/L\\n 04:50 AM\\n Total Bilirubin\\n 1.0 mg/dL\\n 04:50 AM\\n WBC\\n 6.7 K/uL\\n 04:31 AM\\n Hgb\\n 10.1 g/dL\\n 04:31 AM\\n Hematocrit\\n 30.6 %\\n 04:31 AM\\n Current diet order / nutrition support: Diet: Regular\\n Assessment of Nutritional Status\\n Patient was extubated and passed for a ground diet and nectar\\n thick liquids per SLP on . Patient was re-evaluated and was\\n upgraded to a regular diet. Patient was transferred to ICU o/n due to\\n a code purple. Patient is now much more calm and oriented, and is\\n tolerating a regular diet well RN. Will continue to follow and\\n monitor po intake.\\n #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507512,\n \"text\": \"Delirium / confusion\\n Assessment:\\n -pt arrived from floor to sicu after causing\\ncode purple\\n due to\\n delirium and extreme agitation\\n -pt arrived with security escorts, sitting upright in bed, hollering\\n out . Pt unable to answer questions appropriately and appeared to be\\n having hallucinations at times\\n -pt at high risk to fall as he was flipping legs over edge of bed and\\n pulling at restraints\\n Action:\\n -pt given 1mg IV haldol without effect\\n -pt subsequently given 10mg IV valium\\n Response:\\n -pt fell asleep after valium administration\\n Plan:\\n -frequent safety checks to maintain safety\\n -?consult psych to manage pt meds for better treatment of\\n delirium/agitation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507514,\n \"text\": \"51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.subsequently discharged to floor on .code purple\\n on -transferred to SICU.\\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\\n washout/ Ex-fix revision\\n Delirium / confusion\\n Assessment:\\n -pt arrived from floor to sicu after causing\\ncode purple\\n due to\\n delirium and extreme agitation\\n -pt arrived with security escorts, sitting upright in bed, hollering\\n out . Pt unable to answer questions appropriately and appeared to be\\n having hallucinations at times\\n -pt at high risk to fall as he was flipping legs over edge of bed and\\n pulling at restraints\\n Action:\\n -pt given 1mg IV haldol without effect\\n -pt subsequently given 10mg IV valium\\n Response:\\n -pt fell asleep after valium administration\\n Plan:\\n -frequent safety checks to maintain safety\\n -?consult psych to manage pt meds for better treatment of\\n delirium/agitation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507510,\n \"text\": \"Delirium / confusion\\n Assessment:\\n -pt arrived from floor to sicu after causing\\ncode purple\\n due to\\n delirium and extreme agitation\\n -pt arrived with security escorts, sitting upright in bed, hollering\\n out . Pt unable to answer questions appropriately and appeared to be\\n having hallucinations at times\\n -pt at high risk to fall as he was flipping legs over edge of bed and\\n pulling at restraints\\n Action:\\n -pt given 1mg IV haldol without effect\\n -pt subsequently given 10mg IV valium\\n Response:\\n -pt fell asleep after valium administration\\n Plan:\\n -keep pt safe\\n -frequent safety checks to maintain safety\\n -?consult psych to manage pt meds for better treatment of\\n delirium/agitation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507511,\n \"text\": \"Delirium / confusion\\n Assessment:\\n -pt arrived from floor to sicu after causing\\ncode purple\\n due to\\n delirium and extreme agitation\\n -pt arrived with security escorts, sitting upright in bed, hollering\\n out . Pt unable to answer questions appropriately and appeared to be\\n having hallucinations at times\\n -pt at high risk to fall as he was flipping legs over edge of bed and\\n pulling at restraints\\n Action:\\n -pt given 1mg IV haldol without effect\\n -pt subsequently given 10mg IV valium\\n Response:\\n -pt fell asleep after valium administration\\n Plan:\\n -keep pt safe\\n -frequent safety checks to maintain safety\\n -?consult psych to manage pt meds for better treatment of\\n delirium/agitation\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 507666,\n \"text\": \"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\\n been d/c'd to floor and returns to SICU code purple 12/21AM.\\n No major events overnight. Pt's agitation improved with haldol,\\n however, pt remains disoriented.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 12:39 PM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 04:00 AM\\n Diazepam (Valium) - 05:13 AM\\n Heparin Sodium (Prophylaxis) - 07:58 PM\\n Haloperidol (Haldol) - 12:00 AM\\n Metoprolol - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 02:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.9\\nC (98.5\\n HR: 72 (70 - 116) bpm\\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 1,953 mL\\n 209 mL\\n PO:\\n 480 mL\\n 120 mL\\n TF:\\n IVF:\\n 1,473 mL\\n 89 mL\\n Blood products:\\n Total out:\\n 1,600 mL\\n 0 mL\\n Urine:\\n 1,600 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 353 mL\\n 209 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 504 K/uL\\n 9.8 g/dL\\n 105 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 138 mEq/L\\n 29.8 %\\n 12.1 K/uL\\n [image002.jpg]\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n 03:44 AM\\n WBC\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n 12.1\\n Hct\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n 29.8\\n Plt\\n 55\\n 433\\n 504\\n Cr\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 124\\n 119\\n 126\\n 125\\n 95\\n 105\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n DELIRIUM / CONFUSION, TRAUMA, S/P\\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\\n early 12/21AM. Transferred to ICU\\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\\n amounts of valium. Now still disoriented, requiring frequent\\n re-orientation with restriants. Evaluated by psych. Will avoid BDZs for\\n now.\\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC.\\n -Nicotine patch.\\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\\n QTC 437.\\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\\n CXR in AM.\\n GI: Regular diet\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Cr 0.8; No foley.\\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1\\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\\n Other: Social work/ Addictions consult/Psych\\n TLD: PIV\\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\\n taking pills.\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n DVT SQH/IVC filter\\n STRESS ULCER: regular diet\\n VAP BUNDLE N/A\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n ICU Care\\n Nutrition: Regular diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 04:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: regular diet\\n VAP: n/a\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Need to obtain ICU consent.\\n Code status: Full code\\n Disposition:Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 507672,\n \"text\": \"Delirium / confusion\\n Assessment:\\n Pt with delirium, very confused when wakes up, believes he is at \\n beach, constantly asking for alcohol and cigarettes.\\n Action:\\n Medicated with Haldol overnight.\\n No Benzos given.\\n Response:\\n Pt able to sleep for good periods, was oriented x3 at one point, but\\n now confused as to place etc. No further periods of agitation.\\n Plan:\\n Continue to medicate with Haldol for agitation, re-orient pt as needed.\\n c/o to floor.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 507740,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: trauma / 959.9\\n Reason of referral: Re-Eval\\n History of Present Illness / Subjective Complaint: 51 yo M admitted\\n as pedestrian struck, sustained R open tibia/fibula fx and L\\n comminuted supracondylar fx with several R-sided rib fractures.\\n Underwent open fixation and ex. fix placement of R ankle, and L knee\\n ORIF. Post-op course c/b severe etoh withdrawal.\\n Past Medical / Surgical History: See initial eval\\n Medications: tylenol, heparin, metoprolol, oxycodone, haloperidol\\n Radiology: L knee XR- There is a comminuted fracture of the distal\\n femur. There is apparent increase in the space/gap between the plate\\n and the largest fragment in the distal diaphysis\\n Labs:\\n 30.6\\n 10.1\\n 474\\n 6.7\\n [image002.jpg]\\n Other labs:\\n Activity Orders: OOB with assist, TDWB B LE's\\n Social / Occupational History: see initial eval\\n Living Environment: see initial eval\\n Prior Functional Status / Activity Level: see initial eval\\n Objective Test\\n Arousal / Attention / Cognition / Communication: alert and oriented,\\n follows all simple commands. hard of hearing.\\n Aerobic Capacity\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n 76\\n 132/80\\n 97% on RA\\n Activity\\n 88\\n /\\n Recovery\\n /\\n Total distance walked: 0\\n Minutes:\\n Pulmonary Status: lungs cta, non-labored breathing, no cough noted.\\n Integumentary / Vascular: L knee with staples intact, in place\\n and locked in extension. R ex.fix in place.\\n Sensory Integrity: B LE's intact to light touch\\n Pain / Limiting Symptoms: c/o 8/10 L knee pain with ROM\\n Posture: WNL\\n Range of Motion\\n Muscle Performance\\n L knee ext-flex \\n L ankle to neutral\\n R hip/knee WNL\\n B LE's at least t/o\\n Motor Function: no abnormal movement patterns\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Gait, Locomotion: not assessed\\n Rolling:\\n\\n T\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n T\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: not assessed, patient in 4-point restraints during eval.\\n Education / Communication: Reviewed PT , positioning and use of\\n brace. Communicated with nsg re: status.\\n Intervention:\\n Diagnosis:\\n 1.\\n Impaired functional mobility\\n 2.\\n Impaired endurance\\n 3.\\n Impaired ROM/strength\\n Clinical impression / Prognosis: 51 yo M s/p B LE fractures p/w above\\n impairments a/w bony surgery. He is most limited by L knee pain and\\n decreased ROM at this time, as well as B weight-bearing restrictions.\\n He has also had episodes of agitation and has required sedation and\\n restraints. He is below his baseline level, but anticipate good rehab\\n potential given his strength and level of mobility. PT to continue to\\n follow daily for ROM, and mobility when appropriate.\\n Goals\\n Time frame: 1 week\\n 1.\\n Min A transfers bed-to-chair\\n 2.\\n Tolerate OOB >/= 3 hours/day\\n 3.\\n Tolerate daily LE ROM/strength, L knee ROM 0-90\\n 4.\\n 5.\\n 6.\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: daily\\n transfers, ambulation, balance, endurance, education, strengthening,\\n ROM\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 507741,\n \"text\": \"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\\n been d/c'd to floor and returns to SICU code purple 12/21AM.\\n No major events overnight. Pt's agitation improved with haldol,\\n however, pt remains disoriented.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 12:39 PM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 04:00 AM\\n Diazepam (Valium) - 05:13 AM\\n Heparin Sodium (Prophylaxis) - 07:58 PM\\n Haloperidol (Haldol) - 12:00 AM\\n Metoprolol - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 02:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.9\\nC (98.5\\n HR: 72 (70 - 116) bpm\\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 1,953 mL\\n 209 mL\\n PO:\\n 480 mL\\n 120 mL\\n TF:\\n IVF:\\n 1,473 mL\\n 89 mL\\n Blood products:\\n Total out:\\n 1,600 mL\\n 0 mL\\n Urine:\\n 1,600 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 353 mL\\n 209 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 504 K/uL\\n 9.8 g/dL\\n 105 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 138 mEq/L\\n 29.8 %\\n 12.1 K/uL\\n [image002.jpg]\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n 03:44 AM\\n WBC\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n 12.1\\n Hct\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n 29.8\\n Plt\\n 55\\n 433\\n 504\\n Cr\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 124\\n 119\\n 126\\n 125\\n 95\\n 105\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n DELIRIUM / CONFUSION, TRAUMA, S/P\\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\\n early 12/21AM. Transferred to ICU\\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\\n BDZs for now.\\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\\n -Nicotine patch.\\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\\n QTC 437.\\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\\n CXR in AM.\\n GI: Regular diet\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Cr 0.8; No foley.\\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\\n Off abx.\\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\\n Other: Social work/ Addictions consult/Psych\\n TLD: PIV\\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\\n taking pills.\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n DVT SQH/IVC filter\\n STRESS ULCER: regular diet\\n VAP BUNDLE N/A\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n ICU Care\\n Nutrition: Regular diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 04:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: regular diet\\n VAP: n/a\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Need to obtain ICU consent.\\n Code status: Full code\\n Disposition:Transfer to floor\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Physician Surgical Progress Note\",\n \"row_id\": 507750,\n \"text\": \"24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\\n been d/c'd to floor and returns to SICU code purple 12/21AM.\\n No major events overnight. Pt's agitation improved with haldol,\\n however, pt remains disoriented.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 12:39 PM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 04:00 AM\\n Diazepam (Valium) - 05:13 AM\\n Heparin Sodium (Prophylaxis) - 07:58 PM\\n Haloperidol (Haldol) - 12:00 AM\\n Metoprolol - 12:00 AM\\n Other medications:\\n Flowsheet Data as of 02:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.9\\nC (98.5\\n HR: 72 (70 - 116) bpm\\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 91.1 kg (admission): 94.5 kg\\n Height: 72 Inch\\n Total In:\\n 1,953 mL\\n 209 mL\\n PO:\\n 480 mL\\n 120 mL\\n TF:\\n IVF:\\n 1,473 mL\\n 89 mL\\n Blood products:\\n Total out:\\n 1,600 mL\\n 0 mL\\n Urine:\\n 1,600 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 353 mL\\n 209 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 504 K/uL\\n 9.8 g/dL\\n 105 mg/dL\\n 0.8 mg/dL\\n 23 mEq/L\\n 4.2 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 138 mEq/L\\n 29.8 %\\n 12.1 K/uL\\n [image002.jpg]\\n 12:59 PM\\n 02:41 AM\\n 02:50 AM\\n 01:53 AM\\n 01:50 AM\\n 10:58 AM\\n 10:45 PM\\n 02:30 AM\\n 08:13 AM\\n 03:44 AM\\n WBC\\n 7.8\\n 7.1\\n 8.6\\n 12.3\\n 9.6\\n 12.1\\n Hct\\n 25.4\\n 27.0\\n 27.7\\n 30.2\\n 27.2\\n 29.1\\n 29.8\\n Plt\\n 55\\n 433\\n 504\\n Cr\\n 0.6\\n 0.6\\n 0.8\\n 0.8\\n 0.8\\n 0.8\\n TCO2\\n 29\\n 28\\n 27\\n Glucose\\n 124\\n 119\\n 126\\n 125\\n 95\\n 105\\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n DELIRIUM / CONFUSION, TRAUMA, S/P\\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\\n early 12/21AM. Transferred to ICU\\n NEURO: Disoriented. Previously in DT - requiring intubation and large\\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\\n BDZs for now per psych\\ns recs and will use Haldol around the clock and\\n prn for agitation. Overall, pt is doing better\\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\\n -Nicotine patch.\\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\\n QTC 437.\\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\\n CXR in AM.\\n GI: Regular diet\\n Nutrition: Thiamine, folate, MVI.\\n RENAL: Cr 0.8; No foley.\\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\\n ENDO: RISS. Euthyroid\\n ID: HAP. SHEWANELLA SPECIES, H. influenzae, and proteus vulgaris on\\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\\n Off abx.\\n Pt afebrile and saturating well on RA. CXR in AM. Trend WBC.\\n Other: Social work/ Addictions consult/Psych\\n TLD: PIV\\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\\n taking pills.\\n Wound: L femur, R ankle\\n CONSULTS: ortho, trauma\\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\\n DVT SQH/IVC filter\\n STRESS ULCER: regular diet\\n VAP BUNDLE N/A\\n ICU Consent: pending\\n CODE STATUS: full\\n DISPOSITION: SICU-floor\\n ICU Care\\n Nutrition: Regular diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 04:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin, IVC filter\\n Stress ulcer: regular diet\\n VAP: n/a\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds. Comments:\\n Need to obtain ICU consent.\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 20minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 507777,\n \"text\": \"Delirium / confusion\\n Assessment:\\n S/P code purple called on at 0300, patient is now not agitated,\\n alert, oriented to self and place, unsure of date. Able to follow\\n commands, was not trying to get out of bed, able to use call bell for\\n help.\\n Action:\\n Continued on standing dose of haldol (all benzo\\ns d/c\\nd yesterday per\\n psych recommendation),\\n PT in to work with patient, offered to get OOB to chair,\\n Response:\\n Patient continues to be calm, a little confused at times.\\n Plan:\\n Continue to monitor, no benzo\\n Trauma, s/p\\n Assessment:\\n S/P internal fixation of right fibula, repair of L femur fx,\\n External fixation in place, draining serous fluid from pin sites, pin\\n sites look clean.\\n Action:\\n Pin care x 2 today,\\n Dsg changed,\\n PT in to work with patient.\\n Response:\\n Patient c/o of some pain after working with PT, given Tylenol with good\\n effect.\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 507779,\n \"text\": \"HPI:\\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\\n injuries including an open tib/fib on R and comminuted femur fracture\\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\\n admission to ICU.\\n Chief complaint:\\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\\n plate left femur and washout R ankle and IVC filter, POD 1 washout\\n RLE\\n PMHx:\\n ETOH abuse,Varicose veins, o/w unknown\\n Delirium / confusion\\n Assessment:\\n S/P code purple called on at 0300, patient is now not agitated,\\n alert, oriented to self and place, unsure of date. Able to follow\\n commands, was not trying to get out of bed, able to use call bell for\\n help.\\n Action:\\n Continued on standing dose of haldol (all benzo\\ns d/c\\nd yesterday per\\n psych recommendation),\\n PT in to work with patient, offered to get OOB to chair,\\n Response:\\n Patient continues to be calm, a little confused at times.\\n Plan:\\n Continue to monitor, no benzo\\ns per pysch.\\n Trauma, s/p\\n Assessment:\\n S/P internal fixation of right fibula, repair of L femur fx,\\n External fixation in place, draining serous fluid from pin sites, pin\\n sites look clean.\\n Action:\\n Pin care x 2 today,\\n Dsg changed,\\n PT in to work with patient.\\n Response:\\n Patient c/o of some pain after working with PT, given Tylenol with good\\n effect.\\n Plan:\\n Continue to monitor.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233207,\n \"text\": \"Sinus rhythm. Lead V2 is missing. Otherwise, tracing is within normal limits.\\nCompared to the previous tracing of there is no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233208,\n \"text\": \"Baseline artifact. Normal sinus rhythm, rate 93 beats per minute. Possible left\\natrial abnormality. Compared to the previous tracing of heart rate is\\nfaster. QTc interval is not prolonged.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233209,\n \"text\": \"Sinus rhythm. Since the previous tracing of no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233210,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing of the\\nrate has slowed. Otherwise, there is no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233211,\n \"text\": \"Sinus tachycardia. Otherwise, probably normal tracing but unstable baseline in\\nthe precordial leads makes assessment difficult. Since the previous tracing\\nof sinus tachycardia is now present but otherwise, probably no\\nsignificant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 233212,\n \"text\": \"Sinus rhythm. Probably normal tracing but unstable baseline in the precordial\\nleads makes assessment difficult. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-16 00:00:00.000\",\n \"description\": \"LP KNEE (2 VIEWS) LEFT PORT\",\n \"row_id\": 1113015,\n \"text\": \" 1:40 PM\\n KNEE (2 VIEWS) LEFT PORT Clip # \\n Reason: assess for hardware movement\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with fall from chair today. s/p ORIF L distal femur\\n REASON FOR THIS EXAMINATION:\\n assess for hardware movement\\n ______________________________________________________________________________\\n FINAL REPORT\\n LEFT KNEE, TWO VIEWS\\n\\n REASON FOR EXAM: Trauma, assess for hardware displacement.\\n\\n Comparison is made with prior study fluoroscopic views performed in the O.R.\\n on .\\n\\n There is a comminuted fracture of the distal femur. There is apparent\\n increase in the space/gap between the plate and the largest fragment in the\\n distal diaphysis.\\n\\n There is no dislocation. There is joint effusion. Skin staples are present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111208,\n \"text\": \" 9:44 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: NC tube position,ETT position\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with ETOH WITHDRAWL\\n REASON FOR THIS EXAMINATION:\\n NC tube position,ETT position\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ET tube position.\\n\\n FINDINGS: In comparison with the earlier study of this date, the tip of the\\n endotracheal tube now measures approximately 3.5 cm above the carina.\\n Persistent low lung volumes with atelectatic changes at the bases.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"OR ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT\",\n \"row_id\": 1112510,\n \"text\": \" 6:01 PM\\n ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \\n Reason: RIGHT ANKLE EXFIXATOR ADJUSTMENT\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n WET READ: SPfc WED 6:35 PM\\n Intraoperative views of the right ankle redemonstrate comminuted fractures of\\n the distal tibia and fibula. See operative note for complete details.\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Right ankle external fixator adjustment.\\n\\n COMPARISON: Right ankle intraoperative radiograph .\\n\\n FINDINGS: Eight intraoperative fluoroscopic images were acquired without the\\n radiologist present, using a fluoro time of 43.6 seconds. The images\\n demonstrate a comminuted distal tibial fracture with extension into the distal\\n tibiotalar joint. There is a comminuted distal fibular fracture with minimal\\n distraction of the fracture fragments. An external fixator is seen in situ.\\n There is mild widening of the ankle mortise superiorly and medially. Please\\n refer to the operative note for further details of surgery.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111542,\n \"text\": \" 9:07 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess location\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with ett tube repositioned\\n REASON FOR THIS EXAMINATION:\\n assess location\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: ETT repositioning.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the position of the\\n endotracheal tube has not substantially changed. On today's examination, the\\n tip of the tube projects approximately 6.5 cm above the carina. Normal course\\n and position of the nasogastric tube. The pre-existing bilateral areas of\\n atelectasis have decreased in extent. No newly appeared focal parenchymal\\n opacities. Unchanged size and shape of the cardiac silhouette.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1111647,\n \"text\": \" 2:04 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: ptx, line position\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with etoh wothdrawal s/p new left subclavian\\n REASON FOR THIS EXAMINATION:\\n ptx, line position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old male with alcohol withdrawal, status post new\\n subclavian line.\\n\\n UPRIGHT AP VIEW OF THE CHEST:\\n The patient is status post placement of a central venous catheter via a left\\n subclavian approach, with the tip terminating within the mid SVC. An\\n endotracheal tube terminates 6.8 cm above the level of the carina. The\\n cardiac and mediastinal contours are unchanged in comparison to the prior\\n chest radiograph from . There is no evidence of pneumothorax\\n or pleural effusion.\\n\\n IMPRESSION: Status post placement of a new subclavian central venous catheter\\n terminating within the mid SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112016,\n \"text\": \" 4:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with PNA and ETOH withdrawal. Extubated .\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON \\n\\n HISTORY: Pneumonia, extubated, question interval change.\\n\\n FINDINGS: The ET tube has been removed. NG tube tip is in the stomach. Left\\n subclavian line is in the SVC, unchanged. There are some patchy areas of\\n volume loss in both lower lobes but no focal infiltrate.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1110794,\n \"text\": \" 12:51 AM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Struck pedestrian\\n\\n Frontal bedside view of the chest is obtained with the patient placed on a\\n trauma board. Lung volumes are low and there is bibasilar atelectasis. There\\n is mild cardiomegaly, which may be related to technique. Mediastinal and\\n hilar contours are unremarkable. There is no definite pneumothorax. Left rib\\n fractures are visualized involving the sixth and seventh ribs and a right rib\\n fracture is seen in the second rib (please see CT of the Torso for full\\n fracture characterization).\\n\\n A frontal view of the pelvis obtained with the patient on a trauma board shows\\n no fracture or dislocation. Bowel gas pattern is unremarkable. Contrast is\\n seen within both ureters as well as in the urinary bladder, which contains a\\n small amount of gas, presumably sequelae of previous contrast as well as Foley\\n catheter placement. There is no radiopaque foreign body.\\n\\n IMPRESSION: Rib fractures as above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1110795,\n \"text\": \" 12:57 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: ?injuries\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man s/p ped struck\\n REASON FOR THIS EXAMINATION:\\n ?injuries\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SPfc SAT 1:40 AM\\n Acute right rib fractures involving the 2nd, 3rd and likely 12th ribs. No\\n pneumothorax. Dependant atelectasis bilaterally and a more nodular right\\n upper lobe opacity. This may be aspiration, though followup when clinically\\n stable is recommended to document resolution and exclude underlying pulmonary\\n nodule.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Struck pedestrian.\\n\\n TECHNIQUE: Axial CT images were acquired through the torso following the\\n administration of 120 cc of intravenous Optiray contrast.\\n\\n COMPARISON: Radiographs from the same day.\\n\\n CT CHEST WITH CONTRAST: Airways are patent to subsegmental levels\\n bilaterally. There is no pneumothorax. Dependent atelectasis is visualized\\n bilaterally, and there is a focus in the right upper lobe of poorly marginated\\n 15 x 15mm opacity, with hazy margins. The heart and great vessels are\\n unremarkable. There is no mediastinal or axillary lymphadenopathy.\\n\\n CT ABDOMEN WITH CONTRAST: The stomach, duodenum, spleen, pancreas, adrenal\\n glands, gallbladder, kidneys, and liver are unremarkable. There is no free\\n gas or fluid in the abdomen. Regional vascular structures are notable for\\n scattered atherosclerotic calcification of the aorta in the absence of\\n aneurysmal dilation.\\n\\n CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter and a\\n small amount of gas. Dense contrast reflects the previous study. The\\n prostate, seminal vesicles, rectum, colon, and appendix are unremarkable.\\n There is no free gas or fluid in the pelvis. There is no pelvic or inguinal\\n lymphadenopathy.\\n\\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\\n Note is made of bilateral spondylolysis at L5, without associated\\n spondylolisthesis. Acute fractures are visualized with mild displacement on\\n the right involving the second and third ribs laterally (2:19). Chronic\\n fracture deformities are also visualized on the right, involving the sixth rib\\n laterally. An additional acute fracture is seen posteriorly in the twelfth on\\n the right. On the left, chronic fracture deformities are visualized involving\\n the fifth, sixth, seventh, and eighth ribs.\\n\\n (Over)\\n\\n 12:57 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: ?injuries\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION:\\n 1. Rib fractures, appearing both chronic and with acute rib fractures seen at\\n the second and third ribs on the right as well as in the twelfth rib. There\\n is no pneumothorax.\\n 2. Bilateral spondylolysis, without spondylolisthesis at L5.\\n 3. Bilateral dependent atelectasis as well as a poorly marginated opacity in\\n the right upper lobe. Considerations for the latter finding include nodule\\n or, less likely aspiration. Followup is recommended to document\\n resolution/progression when clinically stable.\\n\\n Results and recommendations were reviewed in person at the time of image\\n acquisition with Dr. from surgery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"L CT LOW EXT W/O C LEFT\",\n \"row_id\": 1110797,\n \"text\": \" 1:23 AM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: L knee CT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man s/p ped struck\\n REASON FOR THIS EXAMINATION:\\n L knee CT\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SPfc SAT 8:47 AM\\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\\n evidence of intra-articular extension. The largest distal fracture fragment\\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\\n proximal femur. In addition, there is a non-displaced fracture of the\\n proximal fibula (500b:39). Finally, a small osseous near the lateral\\n proximal tibia suggests an avulsion injury (Segond fracture) which raises\\n concern for internal ligamentous injury to the knee.\\n WET READ VERSION #1 SPfc SAT 1:44 AM\\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\\n evidence of intra-articular extension. The largest distal fracture fragment\\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\\n proximal femur. In addition, there is a non-displaced fracture of the\\n proximal fibula (500b:39).\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Left femur fracture.\\n\\n COMPARISON: Radiograph .\\n\\n TECHNIQUE: MDCT axial images through the left knee were obtained without\\n intravenous contrast and displayed with multiplanar reformats.\\n\\n FINDINGS:\\n\\n There is a markedly comminuted fracture through the left distal femoral\\n metadiaphysis with multiple large fracture fragments. There is apex-posterior\\n angulation as well as one shaft width posterior and lateral displacement of\\n the distal fracture fragment. There is no intra-articular extension of the\\n fracture line.\\n\\n There is a nondisplaced fracture of the left fibular head (501B:36). A -\\n like 2.4-mm osseous fragment arises from the proximal lateral tibial epiphysis\\n and may represent a Segond fracture.\\n\\n There is a small lipohemarthrosis as well as expected soft tissue and\\n intramuscular edema. Prominent varicose veins are identified. While the\\n anterior cruciate ligament is visualized, given the Segond fracture, there is\\n high suspicion for ACL injury.\\n\\n IMPRESSION:\\n\\n 1. Comminuted displaced left distal femur fracture without intra-articular\\n (Over)\\n\\n 1:23 AM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: L knee CT\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n extension.\\n\\n 2. Segond fracture concerning for anterior cruciate ligament injury.\\n\\n 3. Fracture through the fibular head which may signify posterolateral corner\\n injury. Further evaluation can be performed with MRI if indicated.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"L FEMUR (AP & LAT) LEFT\",\n \"row_id\": 1110798,\n \"text\": \" 1:35 AM\\n FEMUR (AP & LAT) LEFT Clip # \\n Reason: ?injuries\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pedestrian versus car trauma.\\n\\n Four views of the left femur reveal a comminuted fracture of the distal\\n femoral diaphysis. There is posterior and slight lateral displacement of the\\n distal femur relative to the proximal. There is no evidence of\\n intra-articular extension. A faint lucency seen at the fibular head suggests\\n a non-displaced fracture in that location as well. A small of bone at\\n the lateral margin of the proximal tibia suggests avulsion injury. There is\\n no radiopaque foreign body.\\n\\n IMPRESSION: Comminuted left femoral fracture, nondisplaced proximal fibular\\n fracture and possible avulsed tibial fracture fragment (Segond fracture) which\\n raises concern for internal ligamentous injury.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111590,\n \"text\": \" 9:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NGT placement\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with etoh withdrawal\\n REASON FOR THIS EXAMINATION:\\n NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Alcohol withdrawal. NG tube placement.\\n\\n COMPARISON: Chest radiograph from .\\n\\n FRONTAL VIEW OF THE CHEST AND UPPER ABDOMEN: Previous NG tube has been\\n advanced into the stomach and appears to be at the antrum of the stomach.\\n Endotracheal tube at the level of the clavicles is stable. EKG leads\\n overlying the patient limit evaluation. Within these limitations, there is no\\n evidence of pneumothorax. There is small right pleural effusion and\\n associated atelectasis. Right lateral pleural thickening is secondary to prior\\n rib fractures and has decreased. There is no evidence of congestive heart\\n failure. Heart is not enlarged. Aortic arch is obscured by overlying EKG\\n lead.\\n\\n IMPRESSION:\\n 1. NG tube in the stomach.\\n 2. Small Right pleural effusion and associated atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"LO FEMUR (AP & LAT) LEFT IN O.R.\",\n \"row_id\": 1111446,\n \"text\": \" 11:35 AM\\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \\n Reason: TRUAMA, FX, ORIF LEFT FEMUR\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH WED 1:26 PM\\n Fluoroscopic assistance provided to the surgeon in the OR.\\n ______________________________________________________________________________\\n FINAL REPORT\\n Fluoroscopic assistance provided to the surgeon in the OR without the\\n radiologist present. Twelve spot views obtained. Views demonstrate steps\\n related to fixation of a comminuted distal femoral fracture, side not\\n indicated. Fluoro time recorded as 224 seconds on the electronic requisition.\\n Correlation with real-time findings, and when appropriate, conventional\\n radiographs is recommended for full assessment.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"LO FEMUR (AP & LAT) LEFT IN O.R.\",\n \"row_id\": 1111447,\n \"text\": \", T. SICU-A 11:35 AM\\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \\n Reason: TRUAMA, FX, ORIF LEFT FEMUR\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n PFI REPORT\\n Fluoroscopic assistance provided to the surgeon in the OR.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-05 00:00:00.000\",\n \"description\": \"O ABDOMEN, SINGLE VIEW IN O.R.\",\n \"row_id\": 1111449,\n \"text\": \" 11:36 AM\\n ABDOMEN, SINGLE VIEW IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \\n -77 BY DIFFERENT PHYSICIAN\\n : IVC FILTER INSERTION\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 51-year-old male status post IVC filter insertion.\\n\\n STUDY: Single spot radiograph in the upper lumbar spine region.\\n\\n FINDINGS: An IVC filter is in appropriately positioned, projecting just\\n lateral to the L2 vertebral body.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112401,\n \"text\": \" 5:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change, NGT placement\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with ETOH w/d, pulled out NGT which was reinserted\\n REASON FOR THIS EXAMINATION:\\n interval change, NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old male with alcohol withdrawal, reinserted NG tube.\\n\\n COMPARISON: Chest radiographs available from .\\n\\n SEMI-ERECT AP VIEW OF THE CHEST: The patient is status post placement of a\\n nasogastric tube, which terminates beyond the scope of the study. The side\\n port is also excluded. There is a central venous catheter, via a left\\n subclavian approach, which terminates at the mid SVC. The cardiac and\\n mediastinal contours are unchanged since the prior examination from , . There is no pneumothorax or pleural effusion.\\n\\n IMPRESSION: Status post placement of a nasogastric tube, which extends to at\\n least the level of the stomach, however the side port and tip are both\\n excluded from the study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"RO ANKLE (2 VIEWS) RIGHT IN O.R.\",\n \"row_id\": 1110831,\n \"text\": \" 8:55 AM\\n ANKLE (2 VIEWS) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \\n Reason: EX/FIX RIGHT TIBIA\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ORIF\\n\\n FINDINGS: Multiple views from the operating suite show what appear to be\\n external fixation devices in the tibia. Further information can be gathered\\n from the operative report.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1112530,\n \"text\": \" 9:18 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with continued agitation\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SPfc WED 10:16 PM\\n No acute intracranial abnormality. Paranasal sinus disease.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Continued agitation.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Contiguous axial CT images were acquired through the head in the\\n absence of intravenous contrast.\\n\\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\\n vascular territorial infarction. The ventricles and sulci are normal in size\\n and in configuration. Extracranial soft tissue structures reveal a small\\n subcutaneous nodule overlying the occipital bone on the left as well as the\\n frontal bone on the left. There is no fracture. The mastoid air cells are\\n clear. The paranasal sinuses reveal circumferential mucosal thickening at the\\n right frontoethmoidal recess extending into the ethmoidal air cells\\n bilaterally, the sphenoid sinus as well as both maxillary sinuses.\\n\\n IMPRESSION:\\n 1. No acute intracranial abnormality.\\n 2. Paranasal sinus disease.\\n\\n NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation, but\\n note that tthere is a chronic-appearing defect in the maxilla, primarily right\\n of midline, but extending to the left. This has sclerotic margins, implying a\\n chronic process. This may be related to dental disease with a periapical cyst\\n or related to paranasal sinus inflammatory disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112476,\n \"text\": \" 2:13 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: assess ETT location\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man now intubated\\n REASON FOR THIS EXAMINATION:\\n assess ETT location\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n CHEST RADIOGRAPH\\n\\n INDICATION: Assessment for ETT location.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous examination, the patient has now been\\n intubated. The tip of the endotracheal tube projects 11 cm above the carina,\\n the tube could be advanced by 3-4 cm. The nasogastric tube and the left\\n subclavian catheter are unchanged. Also unchanged is the appearance of the\\n lung parenchyma and the size of the cardiac silhouette. No evidence of\\n complications, notably no pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1110958,\n \"text\": \" 7:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? aspiration\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with trauma\\n REASON FOR THIS EXAMINATION:\\n ? aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Post-trauma, to evaluate for aspiration.\\n\\n FINDINGS: No previous images. The cardiac silhouette is within normal limits\\n and there is no vascular congestion or pleural effusion. Suggestion of some\\n increased opacification at the left base in the retrocardiac region, which\\n most likely represents atelectasis. The possibility of early aspiration\\n cannot be definitely excluded. If clinical symptoms persist, followup\\n radiograph would be indicated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1113227,\n \"text\": \" 4:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hospital acquired PNA, ETOH w/d.\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Hospital acquired pneumonia. ETOH withdrawal.\\n\\n Comparison is made with prior study .\\n\\n Cardiac size is top normal. Lines and tubes have been removed. There are\\n multiple opacities that are consistent with atelectasis in the lower lobes\\n bilaterally and in the left upper lobe. There are no new lung abnormalities.\\n There is no pleural effusion or pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1111191,\n \"text\": \" 6:28 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: et tube placement\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with bilateral fractures of legs\\n REASON FOR THIS EXAMINATION:\\n et tube placement\\n ______________________________________________________________________________\\n WET READ: RSRc MON 7:50 PM\\n Post-intubation, with ETT 6 cm above carina but below thoracic inlet.\\n Worsening left retrocardiac opacification suggests developing pneumonia, and\\n new small left effusion. 7:45 p .\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 6:54 P.M., \\n\\n HISTORY: Bilateral leg fractures, check ET tube placement.\\n\\n IMPRESSION: AP chest compared to , 8:19 a.m.:\\n\\n Tip of the newly placed endotracheal tube is above the upper margin of the\\n clavicles, more than 6 cm from the carina, 3-4 cm above standard placement.\\n This may account for lower lung volumes and new bibasilar atelectasis. Low\\n lung volumes in turn may explain in part increase in heart size, though\\n increased caliber of mediastinal veins suggests increased intravascular\\n volume. No pneumothorax. Small bilateral pleural effusions may be present.\\n Despite identification to the contrary this radiograph may have been taken\\n with the patient in supine position, contributing to heart size and caliber of\\n mediastinal capacitance vessels.\\n\\n An acute fracture through the lateral aspect of the right second rib is\\n slightly more displaced than it was earlier today, but there has been no\\n change in the small adjacent extrapleural hematoma.\\n\\n Findings were discussed by teleophone with Dr at 9:30AM.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-01 00:00:00.000\",\n \"description\": \"R TIB/FIB (AP & LAT) RIGHT\",\n \"row_id\": 1110799,\n \"text\": \" 1:35 AM\\n TIB/FIB (AP & LAT) RIGHT Clip # \\n Reason: ?injuries\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man s/p ped struck\\n REASON FOR THIS EXAMINATION:\\n ?injuries\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Struck-pedestrian trauma.\\n\\n FINDINGS: Five views of the right tibia and fibula and ankle show comminuted\\n oblique fractures of the distal tibia and fibula. There is lateral and\\n anterior subluxation of the distal tibia and fibula as well as foot relative\\n to the proximal lower extremity. The talar dome is smooth. The distal fibula\\n is slightly medially displaced, projecting over the ankle mortise. Limited\\n views of the knee joint are unremarkable. There is no radiopaque foreign\\n body.\\n\\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2146-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1112433,\n \"text\": \" 9:11 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: NGT placement.\\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with etoh w/d. pulled out his ngt, placed back in. took CXR\\n this am but could not identify tip. pulled ngt back more, please repeat CXR.\\n REASON FOR THIS EXAMINATION:\\n NGT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old male with alcohol withdrawal, status post pulling of\\n NG tube, with consequent replacement.\\n\\n COMPARISON: Chest radiographs available from at 5:15 a.m.\\n\\n SUPINE AP VIEW OF THE CHEST: The patient is status post placement of a\\n nasogastric tube, which extends to at least the level of the stomach, with the\\n tip excluded from the study. The side port is also excluded. A left-sided\\n central venous catheter via subclavian approach terminates at the mid SVC.\\n The cardiac and mediastinal contours are unchanged since prior exam. There is\\n no pneumothorax or pleural effusion.\\n\\n IMPRESSION: Nasogastric tube extends to at least the level of the stomach,\\n however the side port and tip are both excluded from the study.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":24988,"cells":{"subject_id":{"kind":"number","value":11228,"string":"11,228"},"hadm_id":{"kind":"number","value":167826,"string":"167,826"},"target_text":{"kind":"string","value":"Shortly after arrival in the intensive care unit the patient's right internal jugular catheter was immediately exchanged for a catheter capable of accepting a Swan. The Swan was floated successfully showing mild cardiogenic shock and dehydration. Preparations were made at that time for additional inotropic support as well as CVVHD. Initial evaluation at that time by the transplant team concluded that the patient's presentation was most consistent with resolving sepsis, acute renal failure and possibly adult respiratory distress syndrome. It was felt given that the family still was quite interested in possible transplant candidacy it was felt that additional work up was necessary. Effort during the next several days thus surrounded transplant work up as well as stabilization of his multiple medical problems. Infectious disease consultation felt that the patient had multiple possible sources for sepsis and final antibiotic course regimen including Vancomycin, meropenum, caspofungin was selected. At that time HIV testing was necessary to assess patient's candidacy for transplant. Ethics consult was requested and per recommendations of that consult HIV testing was performed. At that time neurologic function was questionable at best. Patient responded to some basic commands, however, was never oriented to person, place or time. Ammonia level check shortly after arrival in the Intensive Care Unit showed ammonia to be 69. Hospital days 2 through 4 patient's pressor requirements continued to increasing including Neo-Synephrine drip which at that time was 1.25. A delicate balance had to be maintained for diuresis and dialysis needs which were maintained using CVVHD and Neo-Synephrine for blood pressure maintenance. Despite expansion of the antibiotic regimen patient's white count continued to increase peaking at 24.6 on hospital day 4. Repeated culturing and imaging failed to reveal any undiagnosed sources for this infection. By hospital day 8 or , patient's condition had continued to deteriorate. His blood pressure was refractory to additional pressors. Over the course of several family discussions including the chief resident and Dr. family began to inquire about changing the patient's status to Do Not Resuscitate, Do No Intubate. Given the patient's increasing coagulopathy, sepsis and circulatory collapse he was not longer being considered a good candidate for liver recipient and the family's request was thought to not be unreasonable. On or hospital day 10, with patient's white blood cell count at 36.1, pressor support maxed out, patient's family including his mother, the designated health care proxy, requested that he be made Do Not Resuscitate, Do Not Intubate and life support be gradually withdrawn. In accordance with their request pressors were withdrawn and ventilator settings were changed to room air. Patient expired shortly thereafter. Per the patient's family's request patient was submitted for autopsy. , MD, PHD Dictated By: MEDQUIST36 D: 14:30:54 T: 15:36:05 Job#: "},"extractive_notes_summ":{"kind":"string","value":"Left-sided stable pleural effusion is noted. Thereis a trivial/physiologic pericardial effusion. Mild (1+) mitral regurgitation is seen. Withdraws slightly when PPF d/c'd. Stable left pleural effusion. Stable left pleural effusion. Bibasilar atelectasis and small left pleural effusion. Stable left-sided pleural effusion with left lower lobe atelectasis is seen. Thereis moderate mitral stenosis. essentially anuric. Right ventricular chamber size and free wall motion appear normal.The aortic root is mildly dilated. There isa minimally increased gradient consistent with trivial mitral stenosis. Hypo BS. Persistent right middle lobe and lower lobe atelectasis/consolidation. There is persistent right middle lobe and lower lobe atelectasis/consolidation. Small to moderate left pleural effusion with adjacent opacity at the left base consistent with atelectasis versus consolidation. FINDINGS: An endotracheal tube is in place at the level of the thoracic inlet with tip terminating 7.1 cm from the carina. There is mild cardiomegaly. TECHNIQUE: Single AP portable supine chest. TECHNIQUE: Single AP portable supine chest. There is mild pulmonary artery systolic hypertension. FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from the carina. TECHNIQUE: AP single view of the abdomen. Bilateral pleural effusions. There is bilateral upper lobe improved aeration consistent with decreasing edema. Non-specificrepolarization changes. Withdraws to sternal rub, shaking head slightly when off gtt. There is generalized subcutaneous edema noted bilaterally extending down to and below the popliteal level. Mild pulmonary edema. Since the examination dated , the right internal jugular venous access catheter has been replaced with a sheath containing a catheter, which is poorly visualized beyond the level of the right atrium. Mild PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. There is a normal portal venous wave form. The heart is upper limits of normal in size. PPF gtt for sedation and comfort. CONCLUSION: 1. There is mild prominence of the pulmonary vasculature consistent with pulmonary edema. pboots ordered.GI: Abd large soft distended. tpn infusing. tpn infusing. TPN infusing. cvvhdf tol well. D/C CRRT D/T LABILE BP'S. Hypothermic, Bair Hugger in place. +Anasarca, faintly palpable pulses bilaterally. +anasarca throughout. filter clotted x1. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT SEDATED ON PROPOFOL GTT. repeat fio2 84. wbc 30.0 on iv caspofungin and merepenum. care note - Pt. care note - Pt. Neo weaned to off. on iv reglan and iv protonix. Resp. Resp. WHEN ATTEMPTED TO SET PFR TO MAINTAIN FLUID BALANCE EVEN, PT BECAME AGAIN. reinitiated.action: suctioned prn. level done this am.cardiac: remains in nsr. ABGs WNL. CONT FLUID BOLUSES AS ORDERED. iv calicium gluconate given. CXR done.CV: Remains slightly hypothermic, Bair Hugger worn. inr 6.9 2 units of ffp given. START LEVO OR VASOPRESSIN IN LIEU OF NEO. vanco iv given. lg amt of oral secretitions. CRRT SET TO 0 PFR. Bolused and given Albumin x1. -BS. neo down to 2.5mcg.gI abd soft ngt draining lg amt of , pink drainage. and UEs. Echo done.GI: Abdomen large, +ascites. calicum gluconate iv given.response: monitor closely MD'S AND INFORMED. MD'S AND INFORMED. +pp. TFs held for high residuals, NGT to suction.GU/RENAL: Foley patent minimal amount icteric urine. on neo gtt and titrated to keep bp > 100syst. 2 ffp given. US done and abdomen tapped for small amount ascites by Dr. @ bedside, sent for cx. clotted. Nursing note:NEURO: Arouses to verbal stimulation, moves UEs. repeat 2.1 post hct 31.3, k 3.5. bp up to > 100syst. PT 2 500CC NS BOLUSES AS ORDERED WITH TRANSIENT IMPROVEMENT IN SBP. 2 units prbc given. 2 units prbc given. Continue current plan of care. Changed to PCV, ABGs acceptable. 1 liter of ns given. Begin CVVHD.ENDO: Glucose stable, given SSRI PRN.SKIN: Breakdown to coccyx noted, Tegaderm in place, no drainage. PADs 24-30. Will cont to monitor. BS coarse bil. PERRLA 3 and brisk. Scrotal area edematous with dry chapped areas, Edematous throughtout, skin tears in folds of upper thighs, cloth heel protecters on.PLAN: Start CVVH in the AM, Continue with hepatic work-up, Attempt to wean vent, Provide extra comfort. TPN INFUSING.GU: CVVHDF INFUSING OK. propofol and neo gtt maintained. tpn infusing. cvvhdf being tol. care note - Pt. care note - Pt. total tonite.action: suctioned prn. Resp. Resp. TUBE FDGS ON HOLD. TUBE FDGS ON HOLD. Noted status is DNR. PT NOW DNR. on caspofungin. abg's. FLUID BOLUS ORDERED AND GIVEN BY MD . HR- occ PVC'S. LEVEL DRAWN THIS AM. LEVO WEANED SLIGHTLY TO INPROVE HR. CREAT 1.5 AND BUN 65ACTION: SUCTIONED PRN. ABG'S GOOD.CARDIAC: REMAINS IN NSR. MD' , , AND INFORMED. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: SEDATED ON PROPOFOL GTT. TACHYCARDIC TO 130S WITH TEMP. for further workup of ESLD.Remains on current vent settings. STATUSD: VSS SEE FLOW SHEET..REMAINS ON LEVO/INSULIN/PROPOFOL GTT'S.. ABG's WNL. MD INFORMED.CV: LABILE BP. lg amt of oral secretitions. LG AMT OF ORAL SECRETITIONS. DNR. CRRT RESTARTED WITH SOME HYPOTENSION. moves head back and forth.resp: remains vented. AM ABGs WNL. focus hemodydnmicsdata: neuro: on propofol gtt. albumin 2.8.tube fdgs cont to be held. Plan to continue with vent support at this time. ABGs WNL, Plan to continue with vent support at this time. Plan to continue with mech. CMP TO BE FURTHER DISCUSSED.PLAN: CONT PER CURRENT MGMT FOR NOW. PT'S PROGNOSIS DISCUSSED. cvvhdf being tolerated. ON NEO GTT. AIR WAY IN PLACE AND REMOVED TO CLEANSE MOUTH. Bil breath sounds clear t/o. ON IV CASPOFUNGIN AND VANCOMYCIN 1GM IV GIVEN. guiac post stool. labs as ordered. LABS AS ORDERED. k 3.3-3.4 k via ccvvh fluid. on a neo gtt. ventilation at this time. PROPOFOL GTT INFUSING TO MAINTAIN QUIET. CATHETER NOT WEDGED.GI ABD SOFFT. creat 2.7 and bun 55.gI abd soft and distended. Suctioned for sml amts thick bld tinged secretions. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: UNCHANGED.RESP: NO VENT CHANGED. BP SYST 110-120. FOCUS HEMODYNMICSDATA: NEURO: PERLA # AND REACTS BRISKLY. See vent flow sheet for details. perla # and reacts briskly. Resp Care Note, Pt from MED CTR. I AND O NEGATIVE."},"n_notes":{"kind":"number","value":46,"string":"46"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2193-06-19 00:00:00.000","description":"Report","row_id":79636,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 330\nBSA (m2): 2.58 m2\nBP (mm Hg): 129/62\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 16:19\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: No AS.\n\nMITRAL VALVE: Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may\nbe significantly UNDERestimated.]\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function appears normal\n(LVEF>55%). Right ventricular chamber size and free wall motion appear normal.\nThe aortic root is mildly dilated. There is no aortic valve stenosis. There is\na minimally increased gradient consistent with trivial mitral stenosis. There\nis moderate mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is mild pulmonary artery systolic hypertension. There\nis a trivial/physiologic pericardial effusion.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":873415,"text":" 1:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT PLACEMENT\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n S/p tranfer in\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure, status post ET tube placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place at the level of the thoracic inlet\n with tip terminating 7.1 cm from the carina. There is a right internal\n jugular venous access catheter with tip terminating in the mid SVC. Left\n internal jugular venous access catheter with tip in the distal SVC near the\n SVC/RA junction. The heart is upper limits of normal in size. The\n mediastinal contours appear within normal limits. There is mild prominence of\n the pulmonary vasculature consistent with pulmonary edema. Small to moderate\n left pleural effusion with adjacent opacity at the left base consistent with\n atelectasis versus consolidation. Additional patchy opacity at the right base\n may also represent atelectasis versus consolidation or component of pulmonary\n edema. The right costophrenic angle is excluded from the radiograph. The\n osseous structures appear within normal limits.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n 2. Bibasilar atelectasis and small left pleural effusion.\n 3. Mild pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-20 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":873557,"text":" 12:53 AM\n PORTABLE ABDOMEN Clip # \n Reason: s/p NGT\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n s/p NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of liver failure, status post NG tube placement.\n\n COMPARISON: None.\n\n PORTABLE ABDOMINAL RADIOGRAPHS: The study is somewhat limited secondary to\n motion and technique. An NG tube is seen with the tip positioned within the\n stomach. Air can be seen within the small bowel. Evaluation of the lung\n fields is limited secondary to motion. An ET tube and central venous\n catheters are seen overlying the mediastinal contour.\n\n IMPRESSION: NG tube is seen with the tip in the stomach. The remainder of\n the study is limited secondary to motion.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-20 00:00:00.000","description":"US ABD LIMIT, SINGLE ORGAN","row_id":873595,"text":" 10:17 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ASCITES. PLEASE MARK FOR PERITONEAL TAP\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD\n\n REASON FOR THIS EXAMINATION:\n Please mark for peritoneal tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old with endstage liver disease, assess for ascites and\n mark the spot.\n\n Using ultrasound guidance, a spot was marked in the left lower quadrant for\n paracentesis to be performed by the clinical team. The distance from the skin\n to intraperitoneal fluid is approximately 4 cm.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":873592,"text":" 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: routine\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n\n REASON FOR THIS EXAMINATION:\n routine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with liver failure and decreased O2 sats.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: There is cardiomegaly and perihilar haziness and pulmonary edema.\n These findings are consistent with CHF. There are also bilateral pleural\n effusions. There are new patchy opacities in the bilateral mid lung zones\n that could represent pneumonia or aspiration. The ET tube is in good\n position. There is an NG tube extending below the limits of the radiograph.\n\n IMPRESSION:\n 1. Cardiomegaly and findings consistent with CHF with pulmonary edema.\n 2. Bilateral pleural effusions.\n 3. New patchy opacities in bilateral mid lung zones most likely represent\n pneumonia versus aspiration.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":874331,"text":" 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, etc\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n REASON FOR THIS EXAMINATION:\n assess for PNA, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure with decreased oxygen sats.\n\n X-ray, chest AP portable view.\n\n COMPARISON: .\n\n The quality of the radiograph is poor due to patient body habitus.\n\n There is persistent right middle lobe and lower lobe\n atelectasis/consolidation. Stable left-sided pleural effusion with left lower\n lobe atelectasis is seen. The mediastinal and hilar contours are stable.\n\n IMPRESSION:\n 1. Persistent right middle lobe and lower lobe atelectasis/consolidation.\n 2. Stable left pleural effusion.\n 3. Stable CHF.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-19 00:00:00.000","description":"P ABDOMEN U.S. (COMPLETE STUDY) PORT","row_id":873449,"text":" 9:08 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: Liver failure pre transplant\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n Liver failure pre transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old with end stage liver disease pre-transplant.\n\n No prior studies.\n\n The study is technically limited due to patient body habitus and difficulties\n in positioning the patient. The liver is coarse and heterogeneous in\n architecture consistent with the history of cirrhosis. No focal mass is\n identified. The gallbladder is normal without stones or sludge. The common\n bile duct measures 3 mm. There is no intrahepatic ductal dilation. The right\n kidney measures 11.8 cm. No mass, hydronephrosis, or stone is seen in the\n right kidney. The pancreas, left kidney, and spleen were not visualized.\n There is a moderate amount of ascites seen throughout the abdomen.\n\n Pulse color Doppler imaging demonstrates normal hepatopetal flow within the\n main portal vein, which is widely patent. There is a normal portal venous\n wave form.\n\n IMPRESSION:\n\n Cirrhotic appearing liver with ascites. Patent portal vein. The study is\n technically limited.\n\n\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2193-06-25 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":874132,"text":" 1:58 PM\n PORTABLE ABDOMEN Clip # \n Reason: asses NG placement\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n\n REASON FOR THIS EXAMINATION:\n asses NG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISONS: Comparison is made to . Comparison is also made to\n chest radiograph performed one day earlier.\n\n TECHNIQUE: AP single view of the abdomen.\n\n FINDINGS: The images are slightly limited due to motion. Also, the images do\n not include the entire abdomen.\n\n There is interval placement of NG tube with the tip in the second portion of\n the duodenum. There is again noted left pleural effusion with associated\n atelectasis which was not completely imaged in this study.\n\n IMPRESSION: NG tube tip is located within duodenum.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":873974,"text":" 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates?\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\n\n REASON FOR THIS EXAMINATION:\n infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with liver failure and decreased oxygen sats.\n\n COMPARISON: .\n\n There is mild cardiomegaly. There is bilateral hilar prominence. There is\n persistent right middle lobe collapse. Left-sided stable pleural effusion is\n noted. There is bilateral upper lobe improved aeration consistent with\n decreasing edema.\n\n The ET tube is 4 cm from the carina. The central venous catheter tip is in\n the SVC.\n\n IMPRESSION:\n 1. Persistent right middle lobe collapse.\n 2. Stable left pleural effusion.\n 3. Improving CHF.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":873471,"text":" 11:36 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assexssx ETT placement\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n REASON FOR THIS EXAMINATION:\n Assexssx ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure and decreased O2 sat, assess ET tube placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from\n the carina. Since the examination dated , the right internal\n jugular venous access catheter has been replaced with a sheath containing a\n catheter, which is poorly visualized beyond the level of the right atrium. The\n left internal jugular venous access catheter appears in unchanged position,\n with tip located at the RA/SVC junction. The heart size and mediastinal\n contours are unchanged. There is moderate left pleural effusion and increase\n in bibasilar parenchymal opacities, probably related to atelectasis versus\n consolidation.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-19 00:00:00.000","description":"P BILAT LOWER EXT VEINS PORT","row_id":873469,"text":" 11:17 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILATERAL SWELLING, PLEASE ASSESS FOR DVT IN BOTH LEGS\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with leg swelling\n REASON FOR THIS EXAMINATION:\n please assess for DVT in bilaterally\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER LIMB DOPPLER VENOUS ULTRASOUND.\n\n CLINICAL DETAILS: Query lower limb DVT.\n\n FINDINGS: The right and left lower limb veins are patent and compressible\n along their length, normal phasic venous flow and increased venous return with\n calf compression on color Doppler.\n\n There is generalized subcutaneous edema noted bilaterally extending down to\n and below the popliteal level.\n\n CONCLUSION:\n 1. No right or left lower limb DVT demonstrated.\n\n\n"},{"category":"Radiology","chartdate":"2193-06-23 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":873905,"text":" 1:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line please\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\n\n REASON FOR THIS EXAMINATION:\n assess line please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased O2 sats. Assess line placement.\n\n CHEST PORTABLE: The endotracheal tube is 5 cm above the carina. The\n nasogastric tube tip is not seen since the abdomen is cut off the film. There\n is a right central line, which has its tip in the right atrium. The left\n central catheter has its tip in the distal SVC. There is no pneumothorax.\n Persistent and worsening pulmonary atelectasis and effusions are noted.\n\n IMPRESSION: Life support lines in good position. Increasing atelectasis and\n pulmonary infiltrates.\n\n"},{"category":"ECG","chartdate":"2193-06-19 00:00:00.000","description":"Report","row_id":210023,"text":"Normal sinus rhythm, rate 82. Borderline low voltage. Non-specific\nrepolarization changes. No previous tracing available for comparison.\n\n"},{"category":"Nursing/other","chartdate":"2193-06-24 00:00:00.000","description":"Report","row_id":1410229,"text":"Nursing note:\nNEURO: Sedated on Propofol gtt, no spont. movement noted. PERRLA 3mm and brisk. Withdraws to sternal rub, shaking head slightly when off gtt. Withdraws slightly when PPF d/c'd. Does move UEs slightly when off gtt, no movement to LEs noted. Grimacing with interventions.\nRESP: Lung sounds coarse, suctioned for thick tan secretions and occ. plugs. Occ. moving mouth and biting on ETT. No vent changes made.\nCV: SR-SB, occ. PVCs. Afebrile, hypothermic at times, warm blankets on. Neo gtt to maintain SBP >100. CVP 13-17. Pt. very weepy from all open areas and total body anasarca. Dopplerable pulses.\nGI: Abdomen large, +ascites. Hypo BS. NGT to sxn for copious amounts -pink liquid. NPO otherwise. TPN infusing.\nENDO: Insulin gtt titrated to keep glucose <120.\nGU/RENAL: Foley patent small amount icteric urine, pt. essentially anuric. running to keep pt. even, clotted filter x1 and changed.\nSOCIAL: mother called and given update. Will not be in until Wednesday.\nSKIN: Breakdown to coccyx, Duoderm intact, no drainage. Scrotum w/abrasion noted to underside, cleaned w/wound cleanser and DSD applied. Heels reddened, R. heel w/small dark area noted, kept off bed. MPBs ordered. Mult. old tap and line sites weepy to UEs, covered w/surgicel and occlusive dressings.\n\nA/P: Continues w/labile SBP on Neo gtt, to keep pt even. Rising WBCs, ID following for recs. PPF gtt for sedation and comfort. Insulin gtt to keep <120.\nWorsening overall status. Continue current plan of care, awaiting some improvement in status in order to be considered for liver/kidney tx.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-06-24 00:00:00.000","description":"Report","row_id":1410230,"text":"Resp Care: Pt remains intubated/sedated. BS clear @apices, sl decreased w/ few scatt rales @ bases. ABG WNL, (PaO2= 81 on FiO2=.6, and 8cm PEEP). Pt having periods of subtle discoordination w/ vent (actively exhaling @ times). Pip/plat= 36/21. No vent changes made this shift. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2193-06-25 00:00:00.000","description":"Report","row_id":1410231,"text":"Resp Care\nPt remains intubated on AC, no vent changes made during noc. Pt sx'd for sm tan secretions, bil breath sounds clear. ABG's WNL. Plan to continue with vent support at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-25 00:00:00.000","description":"Report","row_id":1410232,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED ON PROPOFOL GTT. WITH GTT OFF FOR SHORT PERIOD , PT WITHDREW ALL EXTREMITIES TO PAINFUL STIMULI, OPENED EYUES TO VOICE.\nRESP: SCANT SECRETIONS VIA ET SUCTION. NO VENT CHANGES. ABG STABLE.\nCV: BAIR HUGGER FOR HYPOTHERMIA. CRRT RUNNING IN ATTEMPT TO KEEP PT EVEN, BUT PT . NEO REQUIRMENT INCREASING THROUGH NOC, CURRENTLY AT MAX OF 5MCG/KG/MIN. MD'S AND INFORMED. PT 2 500CC NS BOLUSES AS ORDERED WITH TRANSIENT IMPROVEMENT IN SBP. CRRT SET TO 0 PFR. WHEN ATTEMPTED TO SET PFR TO MAINTAIN FLUID BALANCE EVEN, PT BECAME AGAIN. UNABLE TO MAINTAIN SBP 100 THIS AM, CURRENTLY 80S. MD'S AND INFORMED. TRANSPLANT TEAM TO COME AND PT. MD INFORMED OF AM LABS, HCT, INR, PLT.\nGI: LG AMTS PINK NG O/P.\nGU: ANEURIC.\nENDO: INSULIN GTT TITRATED PER RISS.\nPLAN: MAINTAIN SBP > 100. ? START LEVO OR VASOPRESSIN IN LIEU OF NEO. CONT FLUID BOLUSES AS ORDERED. ? D/C CRRT D/T LABILE BP'S. AWAIT INPUT FROM TRANSPLANT TEAM.\n"},{"category":"Nursing/other","chartdate":"2193-06-25 00:00:00.000","description":"Report","row_id":1410233,"text":"Nursing note:\nNEURO: Sedated on PPF gtt, attempting to open eyes and withdraws w/UEs when off gtt briefly this am. PERRLA 4-5mm and brisk. No movement to LEs noted, no spont. movement. Moves head when less sedated.\nCV: SR-SB, no ectopy. Hypothermic, Bair Hugger in place. Neo weaned to off. SBP kept >100 w/increasing Levophed requirements, ICU and tx. teams aware. SBP to 50-70s w/turning and interventions, slow to recover. Bolused 250cc NS x1 and given 250cc 5% albumin x1 w/some improvment. CVP 9-15. +Anasarca, weepy areas to abd. and UEs. Dopplerable pulses bilaterally.\nRESP: Lung sounds coarse, suctioned for thick blood-tinged sputum. Poor PO2, Fi02 increased to 70% and TV to 700 w/some improvement in oxygenation.\nGI: Abdomen distended, +ascites. +BS, NGT to drainage for pink to bile tinged drainage in lg. amounts. TPN infusing. Insulin gtt titrated to keep glucose <120.\nGU/RENAL: Foley patent, essentially anuric. Attempting to run to keep pt. even in am, running @ PFR 0/hr as pt's pressor requirments have increased.\nSKIN: See Carevue for skin care details.\n\nA/P: Increasing Levophed requirements, labile SBP, unable to tolerate fluid removal during and turning for care. Bolused and given Albumin x1. Oxygenation poor.\n\nGenerally worsening status in this 46 year old man with ESLD/ARF, will continue current plan of care and monitor closely.\n\n"},{"category":"Nursing/other","chartdate":"2193-06-23 00:00:00.000","description":"Report","row_id":1410226,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB/ASSESSMENT\nPATIENT GENERALLY WORSE TODAY THAN YESTERDAY. UNABLE TO WEAN NEO, INCREASINGLY NEO DEPENDEDNT, NEEDS BETWEEN 2-3 MCG TO MAINTAIN SBP>100. PA LINE TO TLC THIS AFTERNOON, TIPS SENT FOR CULTURES.\nTRENDING LOWER PO2 AND INCREASING PIPS, HO AWARE, PEEP TO 8, WILL RECHECK GASES.\nCONTINUES WITH LARGE AMOUNTS OF NGT DRAINAGE.\n TO RUN EVEN,\nFAMILY IN, REPORT GIVEN.\nHO AND ICU TEAM AWARE OF ABOVE. WILL CONTINUE TO AGGRESSIVELY SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2193-06-24 00:00:00.000","description":"Report","row_id":1410227,"text":"focus hemodymmics\ndata: neuro: on propofol gtt at 20mcg/kg/min. gtt off for neuro assessment. pt moves head back and forth. perla # and reacts briskly.\n\nresp: suctioned for thick tan sputum. lg amt of oral secretitions. po2 74 and fio2 increased to 60%. repeat fio2 84. wbc 30.0 on iv caspofungin and merepenum. vanco iv given. level done this am.\n\ncardiac: remains in nsr. on neo gtt and titrated to keep bp > 100syst. episode of bp dropping to the 70's. neo titrated up to 4mcg. clotted. 1 liter of ns given. 2 units prbc given. iv calicium gluconate given. inr 6.9 2 units of ffp given. vitamin k 10mg sc given. repeat 2.1 post hct 31.3, k 3.5. bp up to > 100syst. neo down to 2.5mcg.\n\ngI abd soft ngt draining lg amt of , pink drainage. on iv reglan and iv protonix. tpn infusing. total bili 40.3.\n\ngU: foley patent and no urine out. cvvhdf tol well. filter clotted x1. reinitiated.\n\naction: suctioned prn. labs as ordered. on iv neo and titrated to keep bp> 100. on iv propofol. iv insulin gtt infusing with q1 blood sugars. fio2 incresased to 60%. tpn infusing. 2 units prbc given. 2 ffp given. 10mg vit k given. cvvhdf tol ok and goal to remain even. calicum gluconate iv given.\n\nresponse: monitor closely\n"},{"category":"Nursing/other","chartdate":"2193-06-24 00:00:00.000","description":"Report","row_id":1410228,"text":"Resp Care\nPt remains on AC during noc, fio2 increased to 60%. Bil breath sounds clear, sx'd for mod thick tan secretions. ABGs WNL. Plan to continue vent support at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-19 00:00:00.000","description":"Report","row_id":1410209,"text":"Nursing Note--B shift\nPlease see Carevue for complete assessment and specifics.\n\nNEURO: Opens eyes briefly to loud voice. PERRLA 3 and brisk. Occ nods and shakes head to questions asked. Follows very simple commands with BUE but needs lots of encouragement. Does not follow commands with BLE, withdraws minimally to noxious stimuli.\n\nCARDIAC: Afebrile. HR 80's NSR with occ pvc's. SBP 120-140's. +pp. pboots ordered.\n\nGI: Abd large soft distended. BS absent. Rectal tube intact draining black liquid.\n\nGU: Foley intact draining 15cc/hr of dark amber urine.\n\nRESP: Tol vent settings. Deep sxn for small amts of thick white sputum.\n\nEndo: FS 87\n\nInteg: Area on coccyx erethematous with serosang drainage, 2x2 with tegaderm, skin care rn notified. Scrotal area edematous with dry chapped areas, Edematous throughtout, skin tears in folds of upper thighs, cloth heel protecters on.\n\nPLAN: Start CVVH in the AM, Continue with hepatic work-up, Attempt to wean vent, Provide extra comfort.\n\n"},{"category":"Nursing/other","chartdate":"2193-06-20 00:00:00.000","description":"Report","row_id":1410212,"text":"resp care\nPt initially on pcv but sats and volumes so pt was changed to a/c. Currently pt is on a/c 600x20 50% 5peep with peak/plat 35/24. BS coarse bil. Suct for sml amt of blood tinged sput.Pt appears mich more comfortable on a/c mode of ventilation. Will cont to monitor.\n"},{"category":"Nursing/other","chartdate":"2193-06-20 00:00:00.000","description":"Report","row_id":1410213,"text":"Resp. care note - Pt. remaines intubated and vente, no vent changes made at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-19 00:00:00.000","description":"Report","row_id":1410210,"text":"Nursing note:\nNEURO: Arouses to verbal stimulation, moves UEs. Agitated at times, given Fentanyl for c/o's pain, begun on low dose PPF gtt. PERRLA 3mm and brisk. Does nod to ?s.\nRESP: Lung sounds coarse, dim to bases. Suctioned infrequently for blood-tinged secretions. Changed to PCV, ABGs acceptable. Biting down on ETT at times, dropping sats and TVs, bite block in place.\nCV: Hypothermic @95, warm blankets on. SR w/occ PVCs in 80s. CVP 17-24. PADs 20-26. PA catheter advanced slightly by Dr. to 51 cm. Given platelets for plt count 36, oozing from mult. line sites and mouth/gums. +anasarca throughout. Echo done.\nGI: Abdomen large, +ascites. +liquid black tarry stool, sent for cdiff and cxs. -BS. US done of liver and of LEs.\nGU: Foley patent minimal amount cloudy amber urine. ? Begin CVVHD.\nENDO: Glucose stable, given SSRI PRN.\nSKIN: Breakdown to coccyx noted, Tegaderm in place, no drainage. Leaking ascites from mult. sites.\nSOCIAL: pt's mother updated by team, will be in this evening.\n\nA/P: Hemodynamically stable pt. w/ESLD and likely hepatorenal syndrome undergoing ? tx work-up.\nContinue to monitor closely, ? CVVHD, frequent labs.\n"},{"category":"Nursing/other","chartdate":"2193-06-20 00:00:00.000","description":"Report","row_id":1410211,"text":"46 year old male ESLD, sepsis, with ARF, CVVHDF started, NGT placed and Nephro started, SBP labile neo gtt started, melena stool out, sx oral and ETT for bld tinged, Plts, FFP, PRBC given,\n\nNeuro-pt grimace and biting on ett moves upper extrem weakly with draws LE, fentanly given x1 and propofol gtt increased, PERLLA\nCV-MP SR occass PVC, pt hypothermic bair hugger on, hyperdynamic, pitting anasarca, SCDS on, palp pulses neo drip started for SBP>90\nResp-LS dim at bases coarse upper lobes, bite block in due to biting, changed from PCV to AC, due to desats and decrease TV currently on AC and improved ventilation sx q3 hours for thick bld tinged\nGI-abd acites, large obese, neg BS, NGT placed by MD started, BS>200 ?need for insulin gtt, cont on D51/2 ns at 100cc/hr\nGU-anuric, foley changed, CVVHDF started and running even to negative 100cc/hr, following lytes and ABG\nHeme/monitoring HCT, plt and coags, and LFTS\n\nPlan- cont prop, PRN fentanly,CVVHDF running negativ, follow lytes, ABG, and plt, HCT, plts, coags, cont TF, monitor stool out, ?need for insulin gtt, and d/c IVF, cont ABX\n"},{"category":"Nursing/other","chartdate":"2193-06-20 00:00:00.000","description":"Report","row_id":1410214,"text":"Nursing note:\nNEURO: Sedated on PPF gtt, appears comfortable. Awakens to stimulation when off gtt, grimaces and bites on ETT. Does not follow commands, moving UEs, not noted to move LEs. Shaking head back and forth at times. PERRLA 3mm and brisk.\nRESP: Lung sounds coarse, suctioned for blood-tinged secretions frequently. No vent changes made, ABGs acceptable. Oozing from mouth and gums. Bite block in place. CXR done.\nCV: Remains slightly hypothermic, Bair Hugger worn. SR in 70s-80s, no ectopy. MAP >70 w/Neo gtt. +Anasarca, faintly palpable pulses bilaterally. CVP 13-18. PADs 24-30. CO/CI per Carevue, remains hyperdynamic.\nSKIN: Weeping from all open areas, all dressed w/Aquacel/Tegaderm. Duoderm intact to coccyx. Skin care RN in to see pt, will write recs. tomorrow. Recommends skin care gel to scrotal abrasion and DSD.\nGI: Abdomen large, +ascites. -BS, +dark black stool via Mushroom catheter. Stool for 3rd O&P sent. US done and abdomen tapped for small amount ascites by Dr. @ bedside, sent for cx. TFs held for high residuals, NGT to suction.\nGU/RENAL: Foley patent minimal amount icteric urine. CVVHD running -50cc/hr, clotted x1 and filter changed.\nENDO: Insulin gtt @2-6U/hr, D10 infusing as well. Glucose stable, checked hourly.\n\nA/P: ESLD/hepatorenal syndrome on CVVHD, worsening LFTs.\nNeo gtt for MAP >70, PPF gtt for sedation/comfort, frequent labs, CVVHD for 50cc/hr negative. Continue current plan of care.\n\n\n"},{"category":"Nursing/other","chartdate":"2193-06-21 00:00:00.000","description":"Report","row_id":1410215,"text":"Neuro-prop turned off to assess neuro, pt shakes head side to side, biting on ETT and bite block noted chewing motion of mouth, does not follow commands, minimal movement of upper extrem withdraws to stimuli intermitently, does not withdraw LE, grimace, PERRLA, prop restarted for comfort and ventilation due to biting on ETT\nCV-MP SR occass PAC, doppler DP/PT, + pitting edema, anasarca, neo gtt for MAP>70, remains hyperdyanamic and requires bair hugger to maintain temp\nResp-LS grossly dim, coarse upper lobes sx for thick tan, remains on AC\nGI-TPN, Insulin gtt, neq BS, reglan and protonix for GI motility, mushroom cath with melena out,\nGU-CVVHDF running neg 50cc/hr, anuric, lytes, ABG, followed\nHeme-HCT, coags, plts, followed, and pt monitored for bleeding\nID-cont on ABX\n\nPlan-cont to run CVVHDF even, follow all labs, monitor neuro, maintain pts comfort, cont TPN, and insulin, wean neo as SBP tolerates, ?amonia, please see carvue\n"},{"category":"Nursing/other","chartdate":"2193-06-21 00:00:00.000","description":"Report","row_id":1410216,"text":"Resp Care\nPt remains intubated during noc, no vent changes made, ABG's WNL. Bil breath sounds, sx'd mod thick yellow secretions. Plan to continue vent support at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-21 00:00:00.000","description":"Report","row_id":1410217,"text":"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-27 00:00:00.000","description":"Report","row_id":1410240,"text":"STATUS\nD: ON PROPOFOL/LEVO/INSULIN GTT'S..NEURO UNCHANGED..LABILE BP..CVVH FILTER CLOTTED\nA: FAMILY HERE SPOKE WITH DR PT NOW .. NOT RESTARTED .. LEVO/INSULIN GTT'S DC'D..STARTED ON FENTANYL GTT FOR COMFORT..PT HR V FIB/FLUTTER>>ASYSTOLE..FAMILY WITH PT..DR ? POST\n\n"},{"category":"Nursing/other","chartdate":"2193-06-21 00:00:00.000","description":"Report","row_id":1410218,"text":"status\nD: REMAINS ON PROPOFOL/NEO GTT'S & ON & OFF INSULIN GTT..CVVHDF RUNNING..PLTS DROPPING..COAG'S CLIMBING..CA+ DOWN(REPLETED)\nA: NO VENT CHANGES..ADQUATE ABG'S & SAT'S..CVVHDF FILTER CHANGED X1..REPLACEMENT INCREASED TO 2L/H..FLUID REMOVAL INCREASED TO 200CC/H..PLACED ON ROTATING BARI BIG BOY BED..CONTINUES WITH LGE AMT NG DRAINAGE.. MULTIPLE AREAS OF BLISTERS & ABRASIONS OOZING LGE AMT SEROUS..MUSHROOM CATH WITH SM AMT CLEAR/BLACK FLECKED STOOL..MIN AMBER URINE\nR: CONTINUES WITH HEPATO-RENAL SYNDROME\nP: CONTINUE TO CLOSELY MONITOR Q6H LABS REPLETE AS NEEDED\n"},{"category":"Nursing/other","chartdate":"2193-06-22 00:00:00.000","description":"Report","row_id":1410219,"text":"Resp Care\nPt remains intubated on AC during noc, no changes made. BIl breath sounds, sx'd mod thick tan secretions. ABG's WNL. Plan to continue with mech. ventilation at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-22 00:00:00.000","description":"Report","row_id":1410220,"text":"FOCUS HEMODYNMICS\nDATA: NEURO: PERLA # AND REACTS BRISKLY. MOVES UPPER ARMS BUT DOES NOT FOLLOW COMMANDS. WITHDRAWS TO PAINFUL STIMULI. DID NOT MOVE LEGS ON THE BED. LEGS EDEMATOUS. PROPOFOL GTT ON AND OFF FOR NEURO ASSESSMENT.\n\nRESP: SUCTIONED FOR THICK BROWN SPUTUM. LG AMT OF ORAL SECRETITIONS. AIR WAY IN PLACE AND REMOVED TO CLEANSE MOUTH. ABG'S GOOD.\n\nCARDIAC: REMAINS IN NSR. ON NEO GTT. AT 1.25MCG/KG//MIN. GOAL OF MAP > 65. BP SYST 110-120. INR 2.5 PT 19.6 AND PTT 50.5. HCT 30 K 3.3-3.4 KCL IN CCVH FLUID. DDR PALASTRAIN NOTIFIED OF RESULTS THIS AM DURING HIS ROUNDS. CO CI 3 AND SVR 300-450. CATHETER NOT WEDGED.\n\nGI ABD SOFFT. MUSHROOM CATHETER IN PLACE AND REMOVED Q2 HRS. GUIAC POS BLACK STOOL. SKIN JAUNDICED. TUBE FDGS ON HOLD. TPN INFUSING.\n\nGU: CVVHDF INFUSING OK. I AND O NEGATIVE. CREAT 1.5 AND BUN 65\n\nACTION: SUCTIONED PRN. LABS AS ORDERED. ON IV CASPOFUNGIN AND VANCOMYCIN 1GM IV GIVEN. LEVEL DRAWN THIS AM. CVVHDF TOL WELL GOAL 200CC /HR. I AND O NEGATIVE. INSULIN GTT ON INFUSING BLOOD SUGARS Q1HRS. NEO GTT TITRATED TO KEEP MAP > 65. PROPOFOL GTT INFUSING TO MAINTAIN QUIET. TUBE FDGS ON HOLD. MUSHROOM CATHETER IN PLACE AND REMOVED TO REST RECTUM. VENODLYNES ON FAMILLY IN TO SEE PT TODAY AND UPDATE GIVEN.\n\nRSPONSE: MONITOR CLOSELY.\n"},{"category":"Nursing/other","chartdate":"2193-06-22 00:00:00.000","description":"Report","row_id":1410221,"text":"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-22 00:00:00.000","description":"Report","row_id":1410222,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFICS.\nREMAINS ON , DR. , RUN TO KEEP EVEN AND TRY TO GET NEO OFF, YET IS VERY DEPENDENT ON NEO.\nRECEIVED 2 U FFP TODAY OR INR OF 2.8, UNCHANGED AFTER FFP INFUSED.\nVERY OOZY WITH TOTAL BODY ANASARCA.\nWILL START SLIDING SCALE CALCIUM DRIP PER RENAL SINCE IONIZED CA REMAINS LOW.\nDIALYASATE AND REPLACEMENT FLUIDS CHANGED DURING THIS SHIFT FOR LOWER K/CA.\nNGT CONTINUES WITH A LARGE AMOUNT OF DRAINAGE.\nTAKEN OF POPOFOL THIS AM, DID NOT FOLLOW COMMANDS, BUT MINIMAL MOVEMENT OF ALL 4 EXTREMITIES NOTED.\nTRANSPLANT TEAM AND ICU TEAM AWARE OF ABOVE AND ALL FLOW SHEET VALUES.\nFAMILY IN, VERY SUPPORTIVE,\nWILL CONTINUE WITH AGGRESSIVE CARE.\n"},{"category":"Nursing/other","chartdate":"2193-06-23 00:00:00.000","description":"Report","row_id":1410223,"text":"Resp Care\nPt remains intubated on AC, no vent changes made during noc. Pt has bil breath sounds clear, sx'd for mod thick brown secretions. AM ABGs WNL. Plan to continue with vent support at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-19 00:00:00.000","description":"Report","row_id":1410208,"text":"Resp Care Note, Pt from MED CTR. for further workup of ESLD.Remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions. HR- occ PVC'S. RSBI done on 0 peep/5 ips-10 Will cont to monitor resp status for further weaning.\n"},{"category":"Nursing/other","chartdate":"2193-06-26 00:00:00.000","description":"Report","row_id":1410234,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: SEDATED ON PROPOFOL GTT. NO CHANGES.\nRESP: NO VENT CHANGES. ABG STABLE.\nCV: FEBRILE THIS EVE TO 101.7. MD' , , AND INFORMED. TACHYCARDIC TO 130S WITH TEMP. LEVO WEANED SLIGHTLY TO INPROVE HR. CRRT RESTARTED WITH SOME HYPOTENSION. FLUID BOLUS ORDERED AND GIVEN BY MD . TACHYCARDIA AND TEMPERATURE IMPROVED. LEVO GTT TITRATED TO MAINTAIN SBP >100. CRRT RUNNING WITH NO PFR.\nGI: NGT TO LCWS WITH PINK O/P, MOD AMTS. MUSHROOM CATH INTACT WITH SCANT CLEAR LIQUID O/P.\nGU: ANEURIC.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: PT WITH MULTIPLE OPEN SKIN LESIONS AT ARMS WITH LG AMTS SEROUS DRG, CLEANED WITH SOAP AND H2O, COVERED WITH AQUACEL AND TEGADERM IN ATTEMPT TO KEEP PT'S SKIN DRY. ANTIFUNGAL LOTION APPLIES TO SKIN FOLDS AT PANNUS. R HEEL BLISTER CLEARNED WITH WOUND SPRAY WITH DSD APPLIED, NO DRG, ELEVATED FROM BED. SCROTAL WOUND CLEANED WITH WOUND CLEANSER AND COVERED WITH DOUDERM GEL, ADAPTIC, AND SPFTSORB.\nSOC: FAMILY MEETING THIS EVE WITH RN, PT'S MOTHER, , RN AND MD . PT'S PROGNOSIS DISCUSSED. PT NOW DNR. CMP TO BE FURTHER DISCUSSED.\nPLAN: CONT PER CURRENT MGMT FOR NOW. DNR. EMOTIONAL SUPPORT TO FAMILY.\n"},{"category":"Nursing/other","chartdate":"2193-06-26 00:00:00.000","description":"Report","row_id":1410235,"text":"REsp Care\nPt remians intubated , no vent changes made. Bil breath sounds clear t/o. Pt sx'd for mod thick blood tinged secretions. ABGs WNL, Plan to continue with vent support at this time.\n"},{"category":"Nursing/other","chartdate":"2193-06-26 00:00:00.000","description":"Report","row_id":1410236,"text":"Respiratory Care Note:\n Patient remains on A/C of 20 x 700cc, 70% and 8 PEEP. BS=bilat, decreased bilat lower lobes. Suctioned for moderate amounts of thick blood tinged sputum. He is sedated on propofol. CVVH continues and he remains on levo and insulin infusions. Plan to continue with supportive care. Noted status is DNR.\n"},{"category":"Nursing/other","chartdate":"2193-06-26 00:00:00.000","description":"Report","row_id":1410237,"text":"STATUS\nD: VSS SEE FLOW SHEET..REMAINS ON LEVO/INSULIN/PROPOFOL GTT'S.. ESSENTIALLY UNRESPONSIVE..WILL WITHDRAW ARMS TO PAINFUL STIMULI BUT DOESN'T FOLLOW COMMANDS\nA: REMAINS ON CVVHDF..FILTER CLOTTED X1 REPLACED..MIN HUO & STOOL.. CONTINUES TO OOZE SEROUS FROM MULTIPLE AREAS ON ARMS/SCROTUM.. DR SPOKE WITH FAMILY RE CMO..MOTHER WILL SPEAK WITH PT'S CHILDREN & WILL MAKE DECISION IN AM\nR: ESSENTIALLY UNCHANGED\nP: CONTINUE WITH FULL SUPPORT..AWAITING FAMILY DECISION\n"},{"category":"Nursing/other","chartdate":"2193-06-27 00:00:00.000","description":"Report","row_id":1410238,"text":"Respiratory Care:\nPt has been on all noc. No vent changes. PaO2 = 67; on FiO2\nOf 70%. Will follow\n"},{"category":"Nursing/other","chartdate":"2193-06-27 00:00:00.000","description":"Report","row_id":1410239,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: UNCHANGED.\nRESP: NO VENT CHANGED. PO2 DOWN TO 67. MD INFORMED.\nCV: LABILE BP. LEVO GTT TITRATED TO SBP >100. CRRT WITH NO PFR D/T OVERALL INCREASING LEVO REQUIREMENT.\nGI: PINK TO YELLOW NGT O/P. SCANT AMT LIQUID STOOL.\nGU: ANEURIC.\nSKIN: SEE FLOWSHEET.\nENDO: INSULIN GTT TITRATED TO RISS.\nSOC: MULT FAMILY MEMBERS IN TO VISIT IN EVE. REQUEST FOR PRIEST THIS AM BY SISTER.\nPLAN: CONT PER CURRENT MGMT. AWAIT FAM MTG TO DISCUSS POSSIBLE CMO. ARRANGE FOR PRIEST.\n"},{"category":"Nursing/other","chartdate":"2193-06-23 00:00:00.000","description":"Report","row_id":1410224,"text":"focus hemodydnmics\ndata: neuro: on propofol gtt. at 20mcg/kg/min. perla # and reacts briskly. moves upper extremities but does not move lower extremties. propofol off for neuro exam. moves head back and forth.\n\nresp: remains vented. suctioned for thick tan sputum with some plugs present. lg amt of oral secretitions. abg's. good. no vent changes tonite.\n\ncardiac: remains in nsr. occasional pvc. k 3.3-3.4 k via ccvvh fluid. on a neo gtt. goal to keep map 65-70/ 1unit of prbc given for hct 26 post hct 30.1. inr 2.2. pt 18.4. 2 bags of plts given tonite.\n\ngU foley patent and no urine . cvvhdf being tolerated. goal is to be even. creat 2.7 and bun 55.\n\ngI abd soft and distended. mushroom catheter in place. guiac post stool. albumin 2.8.tube fdgs cont to be held. ngt draining brown drainage. > 1000cc. total tonite.\n\naction: suctioned prn. labs as ordered. insulin gtt and blood sugars q1hr. propofol and neo gtt maintained. cvvhdf being tol. tpn infusing. on caspofungin. vanco iv held due to high level.\n\nresponse: monitor closely\n"},{"category":"Nursing/other","chartdate":"2193-06-23 00:00:00.000","description":"Report","row_id":1410225,"text":"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79636,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 70\\nWeight (lb): 330\\nBSA (m2): 2.58 m2\\nBP (mm Hg): 129/62\\nHR (bpm): 86\\nStatus: Inpatient\\nDate/Time: at 16:19\\nTest: Portable TTE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic root.\\n\\nAORTIC VALVE: No AS.\\n\\nMITRAL VALVE: Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may\\nbe significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild PA systolic\\nhypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\\nfully excluded. Overall left ventricular systolic function appears normal\\n(LVEF>55%). Right ventricular chamber size and free wall motion appear normal.\\nThe aortic root is mildly dilated. There is no aortic valve stenosis. There is\\na minimally increased gradient consistent with trivial mitral stenosis. There\\nis moderate mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to\\nacoustic shadowing, the severity of mitral regurgitation may be significantly\\nUNDERestimated.] There is mild pulmonary artery systolic hypertension. There\\nis a trivial/physiologic pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 873415,\n \"text\": \" 1:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT PLACEMENT\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure\\n REASON FOR THIS EXAMINATION:\\n S/p tranfer in\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver failure, status post ET tube placement.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Single AP portable supine chest.\\n\\n FINDINGS: An endotracheal tube is in place at the level of the thoracic inlet\\n with tip terminating 7.1 cm from the carina. There is a right internal\\n jugular venous access catheter with tip terminating in the mid SVC. Left\\n internal jugular venous access catheter with tip in the distal SVC near the\\n SVC/RA junction. The heart is upper limits of normal in size. The\\n mediastinal contours appear within normal limits. There is mild prominence of\\n the pulmonary vasculature consistent with pulmonary edema. Small to moderate\\n left pleural effusion with adjacent opacity at the left base consistent with\\n atelectasis versus consolidation. Additional patchy opacity at the right base\\n may also represent atelectasis versus consolidation or component of pulmonary\\n edema. The right costophrenic angle is excluded from the radiograph. The\\n osseous structures appear within normal limits.\\n\\n IMPRESSION:\\n 1. Lines and tubes in satisfactory position.\\n 2. Bibasilar atelectasis and small left pleural effusion.\\n 3. Mild pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 873557,\n \"text\": \" 12:53 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: s/p NGT\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure\\n REASON FOR THIS EXAMINATION:\\n s/p NGT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of liver failure, status post NG tube placement.\\n\\n COMPARISON: None.\\n\\n PORTABLE ABDOMINAL RADIOGRAPHS: The study is somewhat limited secondary to\\n motion and technique. An NG tube is seen with the tip positioned within the\\n stomach. Air can be seen within the small bowel. Evaluation of the lung\\n fields is limited secondary to motion. An ET tube and central venous\\n catheters are seen overlying the mediastinal contour.\\n\\n IMPRESSION: NG tube is seen with the tip in the stomach. The remainder of\\n the study is limited secondary to motion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"US ABD LIMIT, SINGLE ORGAN\",\n \"row_id\": 873595,\n \"text\": \" 10:17 AM\\n US ABD LIMIT, SINGLE ORGAN Clip # \\n Reason: ASCITES. PLEASE MARK FOR PERITONEAL TAP\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with ESLD\\n\\n REASON FOR THIS EXAMINATION:\\n Please mark for peritoneal tap\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old with endstage liver disease, assess for ascites and\\n mark the spot.\\n\\n Using ultrasound guidance, a spot was marked in the left lower quadrant for\\n paracentesis to be performed by the clinical team. The distance from the skin\\n to intraperitoneal fluid is approximately 4 cm.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 873592,\n \"text\": \" 9:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: routine\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure, decreased O2 sats\\n\\n REASON FOR THIS EXAMINATION:\\n routine\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old male with liver failure and decreased O2 sats.\\n\\n COMPARISONS: Comparison is made to .\\n\\n TECHNIQUE: AP supine single view of the chest.\\n\\n FINDINGS: There is cardiomegaly and perihilar haziness and pulmonary edema.\\n These findings are consistent with CHF. There are also bilateral pleural\\n effusions. There are new patchy opacities in the bilateral mid lung zones\\n that could represent pneumonia or aspiration. The ET tube is in good\\n position. There is an NG tube extending below the limits of the radiograph.\\n\\n IMPRESSION:\\n 1. Cardiomegaly and findings consistent with CHF with pulmonary edema.\\n 2. Bilateral pleural effusions.\\n 3. New patchy opacities in bilateral mid lung zones most likely represent\\n pneumonia versus aspiration.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 874331,\n \"text\": \" 5:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for PNA, etc\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure, decreased O2 sats\\n REASON FOR THIS EXAMINATION:\\n assess for PNA, etc\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver failure with decreased oxygen sats.\\n\\n X-ray, chest AP portable view.\\n\\n COMPARISON: .\\n\\n The quality of the radiograph is poor due to patient body habitus.\\n\\n There is persistent right middle lobe and lower lobe\\n atelectasis/consolidation. Stable left-sided pleural effusion with left lower\\n lobe atelectasis is seen. The mediastinal and hilar contours are stable.\\n\\n IMPRESSION:\\n 1. Persistent right middle lobe and lower lobe atelectasis/consolidation.\\n 2. Stable left pleural effusion.\\n 3. Stable CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"P ABDOMEN U.S. (COMPLETE STUDY) PORT\",\n \"row_id\": 873449,\n \"text\": \" 9:08 AM\\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \\n Reason: Liver failure pre transplant\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with ESLD\\n REASON FOR THIS EXAMINATION:\\n Liver failure pre transplant\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old with end stage liver disease pre-transplant.\\n\\n No prior studies.\\n\\n The study is technically limited due to patient body habitus and difficulties\\n in positioning the patient. The liver is coarse and heterogeneous in\\n architecture consistent with the history of cirrhosis. No focal mass is\\n identified. The gallbladder is normal without stones or sludge. The common\\n bile duct measures 3 mm. There is no intrahepatic ductal dilation. The right\\n kidney measures 11.8 cm. No mass, hydronephrosis, or stone is seen in the\\n right kidney. The pancreas, left kidney, and spleen were not visualized.\\n There is a moderate amount of ascites seen throughout the abdomen.\\n\\n Pulse color Doppler imaging demonstrates normal hepatopetal flow within the\\n main portal vein, which is widely patent. There is a normal portal venous\\n wave form.\\n\\n IMPRESSION:\\n\\n Cirrhotic appearing liver with ascites. Patent portal vein. The study is\\n technically limited.\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-25 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 874132,\n \"text\": \" 1:58 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: asses NG placement\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure\\n\\n REASON FOR THIS EXAMINATION:\\n asses NG placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: NG tube placement.\\n\\n COMPARISONS: Comparison is made to . Comparison is also made to\\n chest radiograph performed one day earlier.\\n\\n TECHNIQUE: AP single view of the abdomen.\\n\\n FINDINGS: The images are slightly limited due to motion. Also, the images do\\n not include the entire abdomen.\\n\\n There is interval placement of NG tube with the tip in the second portion of\\n the duodenum. There is again noted left pleural effusion with associated\\n atelectasis which was not completely imaged in this study.\\n\\n IMPRESSION: NG tube tip is located within duodenum.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 873974,\n \"text\": \" 8:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrates?\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\\n\\n REASON FOR THIS EXAMINATION:\\n infiltrates?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old man with liver failure and decreased oxygen sats.\\n\\n COMPARISON: .\\n\\n There is mild cardiomegaly. There is bilateral hilar prominence. There is\\n persistent right middle lobe collapse. Left-sided stable pleural effusion is\\n noted. There is bilateral upper lobe improved aeration consistent with\\n decreasing edema.\\n\\n The ET tube is 4 cm from the carina. The central venous catheter tip is in\\n the SVC.\\n\\n IMPRESSION:\\n 1. Persistent right middle lobe collapse.\\n 2. Stable left pleural effusion.\\n 3. Improving CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 873471,\n \"text\": \" 11:36 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Assexssx ETT placement\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure, decreased O2 sats\\n REASON FOR THIS EXAMINATION:\\n Assexssx ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver failure and decreased O2 sat, assess ET tube placement.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Single AP portable supine chest.\\n\\n FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from\\n the carina. Since the examination dated , the right internal\\n jugular venous access catheter has been replaced with a sheath containing a\\n catheter, which is poorly visualized beyond the level of the right atrium. The\\n left internal jugular venous access catheter appears in unchanged position,\\n with tip located at the RA/SVC junction. The heart size and mediastinal\\n contours are unchanged. There is moderate left pleural effusion and increase\\n in bibasilar parenchymal opacities, probably related to atelectasis versus\\n consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"P BILAT LOWER EXT VEINS PORT\",\n \"row_id\": 873469,\n \"text\": \" 11:17 AM\\n BILAT LOWER EXT VEINS PORT Clip # \\n Reason: BILATERAL SWELLING, PLEASE ASSESS FOR DVT IN BOTH LEGS\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with leg swelling\\n REASON FOR THIS EXAMINATION:\\n please assess for DVT in bilaterally\\n ______________________________________________________________________________\\n FINAL REPORT\\n BILATERAL LOWER LIMB DOPPLER VENOUS ULTRASOUND.\\n\\n CLINICAL DETAILS: Query lower limb DVT.\\n\\n FINDINGS: The right and left lower limb veins are patent and compressible\\n along their length, normal phasic venous flow and increased venous return with\\n calf compression on color Doppler.\\n\\n There is generalized subcutaneous edema noted bilaterally extending down to\\n and below the popliteal level.\\n\\n CONCLUSION:\\n 1. No right or left lower limb DVT demonstrated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-06-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 873905,\n \"text\": \" 1:46 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: assess line please\\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\\n\\n REASON FOR THIS EXAMINATION:\\n assess line please\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Decreased O2 sats. Assess line placement.\\n\\n CHEST PORTABLE: The endotracheal tube is 5 cm above the carina. The\\n nasogastric tube tip is not seen since the abdomen is cut off the film. There\\n is a right central line, which has its tip in the right atrium. The left\\n central catheter has its tip in the distal SVC. There is no pneumothorax.\\n Persistent and worsening pulmonary atelectasis and effusions are noted.\\n\\n IMPRESSION: Life support lines in good position. Increasing atelectasis and\\n pulmonary infiltrates.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 210023,\n \"text\": \"Normal sinus rhythm, rate 82. Borderline low voltage. Non-specific\\nrepolarization changes. No previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410229,\n \"text\": \"Nursing note:\\nNEURO: Sedated on Propofol gtt, no spont. movement noted. PERRLA 3mm and brisk. Withdraws to sternal rub, shaking head slightly when off gtt. Withdraws slightly when PPF d/c'd. Does move UEs slightly when off gtt, no movement to LEs noted. Grimacing with interventions.\\nRESP: Lung sounds coarse, suctioned for thick tan secretions and occ. plugs. Occ. moving mouth and biting on ETT. No vent changes made.\\nCV: SR-SB, occ. PVCs. Afebrile, hypothermic at times, warm blankets on. Neo gtt to maintain SBP >100. CVP 13-17. Pt. very weepy from all open areas and total body anasarca. Dopplerable pulses.\\nGI: Abdomen large, +ascites. Hypo BS. NGT to sxn for copious amounts -pink liquid. NPO otherwise. TPN infusing.\\nENDO: Insulin gtt titrated to keep glucose <120.\\nGU/RENAL: Foley patent small amount icteric urine, pt. essentially anuric. running to keep pt. even, clotted filter x1 and changed.\\nSOCIAL: mother called and given update. Will not be in until Wednesday.\\nSKIN: Breakdown to coccyx, Duoderm intact, no drainage. Scrotum w/abrasion noted to underside, cleaned w/wound cleanser and DSD applied. Heels reddened, R. heel w/small dark area noted, kept off bed. MPBs ordered. Mult. old tap and line sites weepy to UEs, covered w/surgicel and occlusive dressings.\\n\\nA/P: Continues w/labile SBP on Neo gtt, to keep pt even. Rising WBCs, ID following for recs. PPF gtt for sedation and comfort. Insulin gtt to keep <120.\\nWorsening overall status. Continue current plan of care, awaiting some improvement in status in order to be considered for liver/kidney tx.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410230,\n \"text\": \"Resp Care: Pt remains intubated/sedated. BS clear @apices, sl decreased w/ few scatt rales @ bases. ABG WNL, (PaO2= 81 on FiO2=.6, and 8cm PEEP). Pt having periods of subtle discoordination w/ vent (actively exhaling @ times). Pip/plat= 36/21. No vent changes made this shift. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410231,\n \"text\": \"Resp Care\\nPt remains intubated on AC, no vent changes made during noc. Pt sx'd for sm tan secretions, bil breath sounds clear. ABG's WNL. Plan to continue with vent support at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410232,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: PT SEDATED ON PROPOFOL GTT. WITH GTT OFF FOR SHORT PERIOD , PT WITHDREW ALL EXTREMITIES TO PAINFUL STIMULI, OPENED EYUES TO VOICE.\\nRESP: SCANT SECRETIONS VIA ET SUCTION. NO VENT CHANGES. ABG STABLE.\\nCV: BAIR HUGGER FOR HYPOTHERMIA. CRRT RUNNING IN ATTEMPT TO KEEP PT EVEN, BUT PT . NEO REQUIRMENT INCREASING THROUGH NOC, CURRENTLY AT MAX OF 5MCG/KG/MIN. MD'S AND INFORMED. PT 2 500CC NS BOLUSES AS ORDERED WITH TRANSIENT IMPROVEMENT IN SBP. CRRT SET TO 0 PFR. WHEN ATTEMPTED TO SET PFR TO MAINTAIN FLUID BALANCE EVEN, PT BECAME AGAIN. UNABLE TO MAINTAIN SBP 100 THIS AM, CURRENTLY 80S. MD'S AND INFORMED. TRANSPLANT TEAM TO COME AND PT. MD INFORMED OF AM LABS, HCT, INR, PLT.\\nGI: LG AMTS PINK NG O/P.\\nGU: ANEURIC.\\nENDO: INSULIN GTT TITRATED PER RISS.\\nPLAN: MAINTAIN SBP > 100. ? START LEVO OR VASOPRESSIN IN LIEU OF NEO. CONT FLUID BOLUSES AS ORDERED. ? D/C CRRT D/T LABILE BP'S. AWAIT INPUT FROM TRANSPLANT TEAM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410233,\n \"text\": \"Nursing note:\\nNEURO: Sedated on PPF gtt, attempting to open eyes and withdraws w/UEs when off gtt briefly this am. PERRLA 4-5mm and brisk. No movement to LEs noted, no spont. movement. Moves head when less sedated.\\nCV: SR-SB, no ectopy. Hypothermic, Bair Hugger in place. Neo weaned to off. SBP kept >100 w/increasing Levophed requirements, ICU and tx. teams aware. SBP to 50-70s w/turning and interventions, slow to recover. Bolused 250cc NS x1 and given 250cc 5% albumin x1 w/some improvment. CVP 9-15. +Anasarca, weepy areas to abd. and UEs. Dopplerable pulses bilaterally.\\nRESP: Lung sounds coarse, suctioned for thick blood-tinged sputum. Poor PO2, Fi02 increased to 70% and TV to 700 w/some improvement in oxygenation.\\nGI: Abdomen distended, +ascites. +BS, NGT to drainage for pink to bile tinged drainage in lg. amounts. TPN infusing. Insulin gtt titrated to keep glucose <120.\\nGU/RENAL: Foley patent, essentially anuric. Attempting to run to keep pt. even in am, running @ PFR 0/hr as pt's pressor requirments have increased.\\nSKIN: See Carevue for skin care details.\\n\\nA/P: Increasing Levophed requirements, labile SBP, unable to tolerate fluid removal during and turning for care. Bolused and given Albumin x1. Oxygenation poor.\\n\\nGenerally worsening status in this 46 year old man with ESLD/ARF, will continue current plan of care and monitor closely.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410226,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB/ASSESSMENT\\nPATIENT GENERALLY WORSE TODAY THAN YESTERDAY. UNABLE TO WEAN NEO, INCREASINGLY NEO DEPENDEDNT, NEEDS BETWEEN 2-3 MCG TO MAINTAIN SBP>100. PA LINE TO TLC THIS AFTERNOON, TIPS SENT FOR CULTURES.\\nTRENDING LOWER PO2 AND INCREASING PIPS, HO AWARE, PEEP TO 8, WILL RECHECK GASES.\\nCONTINUES WITH LARGE AMOUNTS OF NGT DRAINAGE.\\n TO RUN EVEN,\\nFAMILY IN, REPORT GIVEN.\\nHO AND ICU TEAM AWARE OF ABOVE. WILL CONTINUE TO AGGRESSIVELY SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410227,\n \"text\": \"focus hemodymmics\\ndata: neuro: on propofol gtt at 20mcg/kg/min. gtt off for neuro assessment. pt moves head back and forth. perla # and reacts briskly.\\n\\nresp: suctioned for thick tan sputum. lg amt of oral secretitions. po2 74 and fio2 increased to 60%. repeat fio2 84. wbc 30.0 on iv caspofungin and merepenum. vanco iv given. level done this am.\\n\\ncardiac: remains in nsr. on neo gtt and titrated to keep bp > 100syst. episode of bp dropping to the 70's. neo titrated up to 4mcg. clotted. 1 liter of ns given. 2 units prbc given. iv calicium gluconate given. inr 6.9 2 units of ffp given. vitamin k 10mg sc given. repeat 2.1 post hct 31.3, k 3.5. bp up to > 100syst. neo down to 2.5mcg.\\n\\ngI abd soft ngt draining lg amt of , pink drainage. on iv reglan and iv protonix. tpn infusing. total bili 40.3.\\n\\ngU: foley patent and no urine out. cvvhdf tol well. filter clotted x1. reinitiated.\\n\\naction: suctioned prn. labs as ordered. on iv neo and titrated to keep bp> 100. on iv propofol. iv insulin gtt infusing with q1 blood sugars. fio2 incresased to 60%. tpn infusing. 2 units prbc given. 2 ffp given. 10mg vit k given. cvvhdf tol ok and goal to remain even. calicum gluconate iv given.\\n\\nresponse: monitor closely\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410228,\n \"text\": \"Resp Care\\nPt remains on AC during noc, fio2 increased to 60%. Bil breath sounds clear, sx'd for mod thick tan secretions. ABGs WNL. Plan to continue vent support at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410209,\n \"text\": \"Nursing Note--B shift\\nPlease see Carevue for complete assessment and specifics.\\n\\nNEURO: Opens eyes briefly to loud voice. PERRLA 3 and brisk. Occ nods and shakes head to questions asked. Follows very simple commands with BUE but needs lots of encouragement. Does not follow commands with BLE, withdraws minimally to noxious stimuli.\\n\\nCARDIAC: Afebrile. HR 80's NSR with occ pvc's. SBP 120-140's. +pp. pboots ordered.\\n\\nGI: Abd large soft distended. BS absent. Rectal tube intact draining black liquid.\\n\\nGU: Foley intact draining 15cc/hr of dark amber urine.\\n\\nRESP: Tol vent settings. Deep sxn for small amts of thick white sputum.\\n\\nEndo: FS 87\\n\\nInteg: Area on coccyx erethematous with serosang drainage, 2x2 with tegaderm, skin care rn notified. Scrotal area edematous with dry chapped areas, Edematous throughtout, skin tears in folds of upper thighs, cloth heel protecters on.\\n\\nPLAN: Start CVVH in the AM, Continue with hepatic work-up, Attempt to wean vent, Provide extra comfort.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410212,\n \"text\": \"resp care\\nPt initially on pcv but sats and volumes so pt was changed to a/c. Currently pt is on a/c 600x20 50% 5peep with peak/plat 35/24. BS coarse bil. Suct for sml amt of blood tinged sput.Pt appears mich more comfortable on a/c mode of ventilation. Will cont to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410213,\n \"text\": \"Resp. care note - Pt. remaines intubated and vente, no vent changes made at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410210,\n \"text\": \"Nursing note:\\nNEURO: Arouses to verbal stimulation, moves UEs. Agitated at times, given Fentanyl for c/o's pain, begun on low dose PPF gtt. PERRLA 3mm and brisk. Does nod to ?s.\\nRESP: Lung sounds coarse, dim to bases. Suctioned infrequently for blood-tinged secretions. Changed to PCV, ABGs acceptable. Biting down on ETT at times, dropping sats and TVs, bite block in place.\\nCV: Hypothermic @95, warm blankets on. SR w/occ PVCs in 80s. CVP 17-24. PADs 20-26. PA catheter advanced slightly by Dr. to 51 cm. Given platelets for plt count 36, oozing from mult. line sites and mouth/gums. +anasarca throughout. Echo done.\\nGI: Abdomen large, +ascites. +liquid black tarry stool, sent for cdiff and cxs. -BS. US done of liver and of LEs.\\nGU: Foley patent minimal amount cloudy amber urine. ? Begin CVVHD.\\nENDO: Glucose stable, given SSRI PRN.\\nSKIN: Breakdown to coccyx noted, Tegaderm in place, no drainage. Leaking ascites from mult. sites.\\nSOCIAL: pt's mother updated by team, will be in this evening.\\n\\nA/P: Hemodynamically stable pt. w/ESLD and likely hepatorenal syndrome undergoing ? tx work-up.\\nContinue to monitor closely, ? CVVHD, frequent labs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410211,\n \"text\": \"46 year old male ESLD, sepsis, with ARF, CVVHDF started, NGT placed and Nephro started, SBP labile neo gtt started, melena stool out, sx oral and ETT for bld tinged, Plts, FFP, PRBC given,\\n\\nNeuro-pt grimace and biting on ett moves upper extrem weakly with draws LE, fentanly given x1 and propofol gtt increased, PERLLA\\nCV-MP SR occass PVC, pt hypothermic bair hugger on, hyperdynamic, pitting anasarca, SCDS on, palp pulses neo drip started for SBP>90\\nResp-LS dim at bases coarse upper lobes, bite block in due to biting, changed from PCV to AC, due to desats and decrease TV currently on AC and improved ventilation sx q3 hours for thick bld tinged\\nGI-abd acites, large obese, neg BS, NGT placed by MD started, BS>200 ?need for insulin gtt, cont on D51/2 ns at 100cc/hr\\nGU-anuric, foley changed, CVVHDF started and running even to negative 100cc/hr, following lytes and ABG\\nHeme/monitoring HCT, plt and coags, and LFTS\\n\\nPlan- cont prop, PRN fentanly,CVVHDF running negativ, follow lytes, ABG, and plt, HCT, plts, coags, cont TF, monitor stool out, ?need for insulin gtt, and d/c IVF, cont ABX\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410214,\n \"text\": \"Nursing note:\\nNEURO: Sedated on PPF gtt, appears comfortable. Awakens to stimulation when off gtt, grimaces and bites on ETT. Does not follow commands, moving UEs, not noted to move LEs. Shaking head back and forth at times. PERRLA 3mm and brisk.\\nRESP: Lung sounds coarse, suctioned for blood-tinged secretions frequently. No vent changes made, ABGs acceptable. Oozing from mouth and gums. Bite block in place. CXR done.\\nCV: Remains slightly hypothermic, Bair Hugger worn. SR in 70s-80s, no ectopy. MAP >70 w/Neo gtt. +Anasarca, faintly palpable pulses bilaterally. CVP 13-18. PADs 24-30. CO/CI per Carevue, remains hyperdynamic.\\nSKIN: Weeping from all open areas, all dressed w/Aquacel/Tegaderm. Duoderm intact to coccyx. Skin care RN in to see pt, will write recs. tomorrow. Recommends skin care gel to scrotal abrasion and DSD.\\nGI: Abdomen large, +ascites. -BS, +dark black stool via Mushroom catheter. Stool for 3rd O&P sent. US done and abdomen tapped for small amount ascites by Dr. @ bedside, sent for cx. TFs held for high residuals, NGT to suction.\\nGU/RENAL: Foley patent minimal amount icteric urine. CVVHD running -50cc/hr, clotted x1 and filter changed.\\nENDO: Insulin gtt @2-6U/hr, D10 infusing as well. Glucose stable, checked hourly.\\n\\nA/P: ESLD/hepatorenal syndrome on CVVHD, worsening LFTs.\\nNeo gtt for MAP >70, PPF gtt for sedation/comfort, frequent labs, CVVHD for 50cc/hr negative. Continue current plan of care.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410215,\n \"text\": \"Neuro-prop turned off to assess neuro, pt shakes head side to side, biting on ETT and bite block noted chewing motion of mouth, does not follow commands, minimal movement of upper extrem withdraws to stimuli intermitently, does not withdraw LE, grimace, PERRLA, prop restarted for comfort and ventilation due to biting on ETT\\nCV-MP SR occass PAC, doppler DP/PT, + pitting edema, anasarca, neo gtt for MAP>70, remains hyperdyanamic and requires bair hugger to maintain temp\\nResp-LS grossly dim, coarse upper lobes sx for thick tan, remains on AC\\nGI-TPN, Insulin gtt, neq BS, reglan and protonix for GI motility, mushroom cath with melena out,\\nGU-CVVHDF running neg 50cc/hr, anuric, lytes, ABG, followed\\nHeme-HCT, coags, plts, followed, and pt monitored for bleeding\\nID-cont on ABX\\n\\nPlan-cont to run CVVHDF even, follow all labs, monitor neuro, maintain pts comfort, cont TPN, and insulin, wean neo as SBP tolerates, ?amonia, please see carvue\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410216,\n \"text\": \"Resp Care\\nPt remains intubated during noc, no vent changes made, ABG's WNL. Bil breath sounds, sx'd mod thick yellow secretions. Plan to continue vent support at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410217,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410240,\n \"text\": \"STATUS\\nD: ON PROPOFOL/LEVO/INSULIN GTT'S..NEURO UNCHANGED..LABILE BP..CVVH FILTER CLOTTED\\nA: FAMILY HERE SPOKE WITH DR PT NOW .. NOT RESTARTED .. LEVO/INSULIN GTT'S DC'D..STARTED ON FENTANYL GTT FOR COMFORT..PT HR V FIB/FLUTTER>>ASYSTOLE..FAMILY WITH PT..DR ? POST\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410218,\n \"text\": \"status\\nD: REMAINS ON PROPOFOL/NEO GTT'S & ON & OFF INSULIN GTT..CVVHDF RUNNING..PLTS DROPPING..COAG'S CLIMBING..CA+ DOWN(REPLETED)\\nA: NO VENT CHANGES..ADQUATE ABG'S & SAT'S..CVVHDF FILTER CHANGED X1..REPLACEMENT INCREASED TO 2L/H..FLUID REMOVAL INCREASED TO 200CC/H..PLACED ON ROTATING BARI BIG BOY BED..CONTINUES WITH LGE AMT NG DRAINAGE.. MULTIPLE AREAS OF BLISTERS & ABRASIONS OOZING LGE AMT SEROUS..MUSHROOM CATH WITH SM AMT CLEAR/BLACK FLECKED STOOL..MIN AMBER URINE\\nR: CONTINUES WITH HEPATO-RENAL SYNDROME\\nP: CONTINUE TO CLOSELY MONITOR Q6H LABS REPLETE AS NEEDED\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410219,\n \"text\": \"Resp Care\\nPt remains intubated on AC during noc, no changes made. BIl breath sounds, sx'd mod thick tan secretions. ABG's WNL. Plan to continue with mech. ventilation at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410220,\n \"text\": \"FOCUS HEMODYNMICS\\nDATA: NEURO: PERLA # AND REACTS BRISKLY. MOVES UPPER ARMS BUT DOES NOT FOLLOW COMMANDS. WITHDRAWS TO PAINFUL STIMULI. DID NOT MOVE LEGS ON THE BED. LEGS EDEMATOUS. PROPOFOL GTT ON AND OFF FOR NEURO ASSESSMENT.\\n\\nRESP: SUCTIONED FOR THICK BROWN SPUTUM. LG AMT OF ORAL SECRETITIONS. AIR WAY IN PLACE AND REMOVED TO CLEANSE MOUTH. ABG'S GOOD.\\n\\nCARDIAC: REMAINS IN NSR. ON NEO GTT. AT 1.25MCG/KG//MIN. GOAL OF MAP > 65. BP SYST 110-120. INR 2.5 PT 19.6 AND PTT 50.5. HCT 30 K 3.3-3.4 KCL IN CCVH FLUID. DDR PALASTRAIN NOTIFIED OF RESULTS THIS AM DURING HIS ROUNDS. CO CI 3 AND SVR 300-450. CATHETER NOT WEDGED.\\n\\nGI ABD SOFFT. MUSHROOM CATHETER IN PLACE AND REMOVED Q2 HRS. GUIAC POS BLACK STOOL. SKIN JAUNDICED. TUBE FDGS ON HOLD. TPN INFUSING.\\n\\nGU: CVVHDF INFUSING OK. I AND O NEGATIVE. CREAT 1.5 AND BUN 65\\n\\nACTION: SUCTIONED PRN. LABS AS ORDERED. ON IV CASPOFUNGIN AND VANCOMYCIN 1GM IV GIVEN. LEVEL DRAWN THIS AM. CVVHDF TOL WELL GOAL 200CC /HR. I AND O NEGATIVE. INSULIN GTT ON INFUSING BLOOD SUGARS Q1HRS. NEO GTT TITRATED TO KEEP MAP > 65. PROPOFOL GTT INFUSING TO MAINTAIN QUIET. TUBE FDGS ON HOLD. MUSHROOM CATHETER IN PLACE AND REMOVED TO REST RECTUM. VENODLYNES ON FAMILLY IN TO SEE PT TODAY AND UPDATE GIVEN.\\n\\nRSPONSE: MONITOR CLOSELY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410221,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410222,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFICS.\\nREMAINS ON , DR. , RUN TO KEEP EVEN AND TRY TO GET NEO OFF, YET IS VERY DEPENDENT ON NEO.\\nRECEIVED 2 U FFP TODAY OR INR OF 2.8, UNCHANGED AFTER FFP INFUSED.\\nVERY OOZY WITH TOTAL BODY ANASARCA.\\nWILL START SLIDING SCALE CALCIUM DRIP PER RENAL SINCE IONIZED CA REMAINS LOW.\\nDIALYASATE AND REPLACEMENT FLUIDS CHANGED DURING THIS SHIFT FOR LOWER K/CA.\\nNGT CONTINUES WITH A LARGE AMOUNT OF DRAINAGE.\\nTAKEN OF POPOFOL THIS AM, DID NOT FOLLOW COMMANDS, BUT MINIMAL MOVEMENT OF ALL 4 EXTREMITIES NOTED.\\nTRANSPLANT TEAM AND ICU TEAM AWARE OF ABOVE AND ALL FLOW SHEET VALUES.\\nFAMILY IN, VERY SUPPORTIVE,\\nWILL CONTINUE WITH AGGRESSIVE CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410223,\n \"text\": \"Resp Care\\nPt remains intubated on AC, no vent changes made during noc. Pt has bil breath sounds clear, sx'd for mod thick brown secretions. AM ABGs WNL. Plan to continue with vent support at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410208,\n \"text\": \"Resp Care Note, Pt from MED CTR. for further workup of ESLD.Remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions. HR- occ PVC'S. RSBI done on 0 peep/5 ips-10 Will cont to monitor resp status for further weaning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410234,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: SEDATED ON PROPOFOL GTT. NO CHANGES.\\nRESP: NO VENT CHANGES. ABG STABLE.\\nCV: FEBRILE THIS EVE TO 101.7. MD' , , AND INFORMED. TACHYCARDIC TO 130S WITH TEMP. LEVO WEANED SLIGHTLY TO INPROVE HR. CRRT RESTARTED WITH SOME HYPOTENSION. FLUID BOLUS ORDERED AND GIVEN BY MD . TACHYCARDIA AND TEMPERATURE IMPROVED. LEVO GTT TITRATED TO MAINTAIN SBP >100. CRRT RUNNING WITH NO PFR.\\nGI: NGT TO LCWS WITH PINK O/P, MOD AMTS. MUSHROOM CATH INTACT WITH SCANT CLEAR LIQUID O/P.\\nGU: ANEURIC.\\nENDO: INSULIN GTT TITRATED TO FSBG.\\nSKIN: PT WITH MULTIPLE OPEN SKIN LESIONS AT ARMS WITH LG AMTS SEROUS DRG, CLEANED WITH SOAP AND H2O, COVERED WITH AQUACEL AND TEGADERM IN ATTEMPT TO KEEP PT'S SKIN DRY. ANTIFUNGAL LOTION APPLIES TO SKIN FOLDS AT PANNUS. R HEEL BLISTER CLEARNED WITH WOUND SPRAY WITH DSD APPLIED, NO DRG, ELEVATED FROM BED. SCROTAL WOUND CLEANED WITH WOUND CLEANSER AND COVERED WITH DOUDERM GEL, ADAPTIC, AND SPFTSORB.\\nSOC: FAMILY MEETING THIS EVE WITH RN, PT'S MOTHER, , RN AND MD . PT'S PROGNOSIS DISCUSSED. PT NOW DNR. CMP TO BE FURTHER DISCUSSED.\\nPLAN: CONT PER CURRENT MGMT FOR NOW. DNR. EMOTIONAL SUPPORT TO FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410235,\n \"text\": \"REsp Care\\nPt remians intubated , no vent changes made. Bil breath sounds clear t/o. Pt sx'd for mod thick blood tinged secretions. ABGs WNL, Plan to continue with vent support at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410236,\n \"text\": \"Respiratory Care Note:\\n Patient remains on A/C of 20 x 700cc, 70% and 8 PEEP. BS=bilat, decreased bilat lower lobes. Suctioned for moderate amounts of thick blood tinged sputum. He is sedated on propofol. CVVH continues and he remains on levo and insulin infusions. Plan to continue with supportive care. Noted status is DNR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410237,\n \"text\": \"STATUS\\nD: VSS SEE FLOW SHEET..REMAINS ON LEVO/INSULIN/PROPOFOL GTT'S.. ESSENTIALLY UNRESPONSIVE..WILL WITHDRAW ARMS TO PAINFUL STIMULI BUT DOESN'T FOLLOW COMMANDS\\nA: REMAINS ON CVVHDF..FILTER CLOTTED X1 REPLACED..MIN HUO & STOOL.. CONTINUES TO OOZE SEROUS FROM MULTIPLE AREAS ON ARMS/SCROTUM.. DR SPOKE WITH FAMILY RE CMO..MOTHER WILL SPEAK WITH PT'S CHILDREN & WILL MAKE DECISION IN AM\\nR: ESSENTIALLY UNCHANGED\\nP: CONTINUE WITH FULL SUPPORT..AWAITING FAMILY DECISION\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410238,\n \"text\": \"Respiratory Care:\\nPt has been on all noc. No vent changes. PaO2 = 67; on FiO2\\nOf 70%. Will follow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410239,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: UNCHANGED.\\nRESP: NO VENT CHANGED. PO2 DOWN TO 67. MD INFORMED.\\nCV: LABILE BP. LEVO GTT TITRATED TO SBP >100. CRRT WITH NO PFR D/T OVERALL INCREASING LEVO REQUIREMENT.\\nGI: PINK TO YELLOW NGT O/P. SCANT AMT LIQUID STOOL.\\nGU: ANEURIC.\\nSKIN: SEE FLOWSHEET.\\nENDO: INSULIN GTT TITRATED TO RISS.\\nSOC: MULT FAMILY MEMBERS IN TO VISIT IN EVE. REQUEST FOR PRIEST THIS AM BY SISTER.\\nPLAN: CONT PER CURRENT MGMT. AWAIT FAM MTG TO DISCUSS POSSIBLE CMO. ARRANGE FOR PRIEST.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410224,\n \"text\": \"focus hemodydnmics\\ndata: neuro: on propofol gtt. at 20mcg/kg/min. perla # and reacts briskly. moves upper extremities but does not move lower extremties. propofol off for neuro exam. moves head back and forth.\\n\\nresp: remains vented. suctioned for thick tan sputum with some plugs present. lg amt of oral secretitions. abg's. good. no vent changes tonite.\\n\\ncardiac: remains in nsr. occasional pvc. k 3.3-3.4 k via ccvvh fluid. on a neo gtt. goal to keep map 65-70/ 1unit of prbc given for hct 26 post hct 30.1. inr 2.2. pt 18.4. 2 bags of plts given tonite.\\n\\ngU foley patent and no urine . cvvhdf being tolerated. goal is to be even. creat 2.7 and bun 55.\\n\\ngI abd soft and distended. mushroom catheter in place. guiac post stool. albumin 2.8.tube fdgs cont to be held. ngt draining brown drainage. > 1000cc. total tonite.\\n\\naction: suctioned prn. labs as ordered. insulin gtt and blood sugars q1hr. propofol and neo gtt maintained. cvvhdf being tol. tpn infusing. on caspofungin. vanco iv held due to high level.\\n\\nresponse: monitor closely\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2193-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1410225,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\\n\"\n }\n]"}}},{"rowIdx":24989,"cells":{"subject_id":{"kind":"number","value":22217,"string":"22,217"},"hadm_id":{"kind":"number","value":136274,"string":"136,274"},"target_text":{"kind":"string","value":"The patient was taken immediately to the operating room for bladder repair. There was gross blood in the abdomen. The spleen had a small tear at the capsule of the inferior pole. Spleen was initially packed and then the packing was removed, possible abrasion. A 12 cm bladder laceration was identified and sutured with Urology present. The left thigh was debrided and washed out. For further details, please see the operative report of . The patient was transferred to the Trauma SICU after the procedure for close hemodynamic monitoring. He remained stable and was extubated on hospital day three. On , the patient returned to the operating room with Orthopedics for ORIF with plate and screws to the left forearm. The pelvic fracture was deemed nonoperative. The patient progressed well after his surgery and Addiction consult was obtained, and patient was counseled on his alcohol use. The patient was cleared for home with services on . The patient was tolerating p.o. without nausea or vomiting, was passing flatus. Was able to walk using the walker and crutches with Physical Therapy, and was able to perform stairs independently. The patient was discharged home with VNA for dressing changes wet-to-dry on the left thigh and bladder bag care and teaching, and home OT for his left wrist."},"extractive_notes_summ":{"kind":"string","value":"There is a small amount of hemorrhage layering posteriorly in the occipital of the left lateral ventricle, which in retrospect, is not changed from the prior study. There is a tiny amount of hemorrhage layering posteriorly in the occipital of the left lateral ventricle. The surrounding osseous and soft tissue structures are within normal limits, aside from mild mucosal thickening in the sphenoid sinus. TECHNIQUE: Non-contrast head CT was obtained. There is a vertical fracture through the body of S1 extending to the left incompletely visualized. FINDINGS: There is suspicion of a small amount of subarachnoid blood along the left posterior parietal convexity surface superiorly. There is a left superior and inferior pubic ramus fracture. CONCLUSION: No definite intracranial hemorrhage. PELVIS: Single view of the pelvis is limited by overlying trauma board. CONCLUSION: Suspected small amount of subarachnoid hemorrhage with other findings as noted above. TECHNIQUE: Routine non-contrast head CT. TECHNIQUE: Non-contrast head CT scan was obtained. IMPRESSION: Angulated fracture of the distal radial shaft associated with positive ulnar variance as described above. Carpal rows are intact although there is positive ulnar variance. ADDENDUM: There is a mild degree of scalp soft tissue swelling in the left parietal vertex region of the skull. IMPRESSION: Left pubis fracture. There also is a focus of decreased attenuation in the left occipital lobe, which appears slightly more prominent than on the prior study. of c-spine irreg on OSH films REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast FINAL REPORT INDICATIONS: Question of C-spine irregularity on outside films. COMMENT: There is loss of visualization of the airway, likely due to intubation. FINDINGS: This exam is limited by the overlying trauma board. A vague irregular linear lucency overlying the portion of the upper sacrum is difficult to evaluate on this study.No prior studies for review. The heart size is stable, given differences in technique. FINDINGS: The small focus of increased attenuation overlying the left parietal region seen on the examination is not appreciated today. There is moderate mucosal thickening of the visualized portions of the left maxillary sinus. There is moderate mucosal thickening within the maxillary and ethmoid sinuses, with a minor degree of mucosal thickening in the sphenoid sinus. There is a moderate degree of soft tissue swelling within the scalp bilaterally, most notably near the vertex of the skull. IMPRESSION: 1) No evidence for subarachnoid hemorrhage. No diastasis of the sacroiliac joints. There is probable moderate thickening of the posterior superior nasopharyngeal soft tissues. vert injury on OSH films/CT REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast FINAL REPORT INDICATIONS: High speed MVA. MG+ REPLETED.ENDO: STABLEID: LOW GRADE TEMP - 100.3, IV ABX D/C'D .SKIN: BACK/BUTTOCKS INTACT, MIDLINE ABD.INC WNL - COVERED W/OCCLUSIVE PRIMARY DSG, D/I. wbc=7.3 from 10.2. left upper leg redressed for moderate serosanguineous drainage. SKIN PIN/WARM/DRY - HEPARIN AND PB'S FOR DVT PROPHYLAXIS.HEME: HCT 32.4(33.1)RESP: LUNG SOUNDS CLEAR, DIMINISHED AT BASES B/L. Lung sounds ess clear dim R base. SOFT TISSUE SENSITIVITY TO BE PERFORMED THIS PM UPON INCREASED ALERT STATUS.CV: HR 110 ST. BP 160/70 LOPRESSOR 5MG X 1 PULSES EASILY PALPABLE THROUGOUT.RESP: EXTUBATED LUNG SOUNDS CLEAR DIMINISHED AT BASES. R THIGH W/W->D DSG DRAINING SCANT AMT SEROUS FLUID. after a.m. care, slightly pink-tinged.heme=continues on q 6hr hcts--no change.endo=no issues.id=temp. POST EXTUBATION ABG PENDING.GI: NPO ABSENT BOWEL SOUNDS OGT D/C'D. PULSES EASILY PALPABLE THROUGHOUT.RESP: LUNG SOUNDS CLEAR DIMINISHED AT BASES. Nasal airway placed as Pt intermittantly with partial airway obstruction. DENIES N/V.GU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/ADEQUATE HOURLY VOLUME OUT. nsg note ROS: CV:OCCASIONALLY TACKY AND HYPERTENSIVE DEPENDING ON AMT OF PAIN.HE WAS STARTED ON DILAUDID PCA WHICH IS EFFECTIVE. GU:EXCELLENT UO,NO BLD NOTED.IV AT KVO GI:STARTED ON CLEAR LIQUIDS,CAN ADVANCE AS TOLERATED. CLEARANCE OF C-SPINE, DECREASE SEDATION.P: PROVIDE PAIN CONTROL, FOLLOW WND, FOLLOW TEMPS, PULM TOLIETING FREQUENTLY, SUPPORT FAMILY, ADV DIET D/C TO FLOOR. RR 16-24 AT REST.GI: ABD SOFT, APPROPRIATELY TENDER W/(+)HYPOACTIVE BS, NO RF/BM. Pt sedated on propofol, plan to cont vent support. sats cocsistently 100%.gi=orogastric tube to low wall suction. Once cleared, sedation stopped and Pt placed on CPAP/PSV. Resp Care Note:Pt cont intub sedated on mech vent as per Carevue. suctioned for thick slightly tan secretions--scant amts. PT'S UPPER LIP SWOLLEN, SLIGHTLY IMPROVED FROM PREVIOUS DAY.SOCIAL: NO FAMILY CONTACT OVER .A/P: STABLE S/P MVC, TOLERATED EXTUBATION. AP, neutral, and axillary views of the left shoulder show AC joint separation. BUN 9 CREAT .09HEME: CYCLE HCT 33.2 (33.4) CONT TO FOLLOW TREND.ID: TMAX 100.9 WBC 9 FLAGYL, KEFZOL.SKIN: ABD INCISION WITH STAPLES C/D/I MODERATE SEROUS STAINING ON PRIMARY DRESSING. Continues tachycardic and relatively hypertensive.P:Continue to answer pt's questions. BS equal bilat, slight decreased to bases. k+ to be repleted--awaiting mix from phcy.pulm=ventilated on simv 16-40%-700-5 cm peep and 5 cm pressure support. Care NotePt received intubated, sedated and vented on settings SIMV 700x 16x 40% peep 5 psv 5. also sedated with alternating doses of mso4 and dilaudid for pain.cv=monitor=st with no ectopy noted. SUCTIONED FOR MINIMUM SECRETIONS.GI: NPO OGT TO LWS WITH MINIMAL OUTPUT FAMOTIDINE ABSENT BOWEL SOUNDS.GU: URINE OUTPUT 100-200 CC CLEAR YELLOW URINE VIA FOLEY CATHETER LYTES REPLEATED. WRAPPED IN KERLEX. FAMOTIDINE DENIES NAUSEA.GU: URINE OUTPUT 100-150CC CLEAR YELLOW URINE VIA FOLEY CATH.SKIN: ABD INCISION C/D/I MINIMAL SEROUS STAINING STAPLES WELL APPROXIMATED. NT SUCTION FOR MINIMAL TNA SECRETIONS NASAL TRUMPET INTACT FOR ACCESS. npns=orally intubated and sedated.o=sedated, responds to painful stimuli only. Pt arrived to T-SICU and placed on vent with initial settings of SIMV 700x 12x 100% peep 5 and psv 5."},"n_notes":{"kind":"number","value":23,"string":"23"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2123-05-18 00:00:00.000","description":"CT T-SPINE W/ CONTRAST","row_id":792352,"text":" 8:19 AM\n CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High speed MVA.\n\n TECHNIQUE: Contiguous axial images with reformatted images.\n\n FINDINGS: This is a survey examination and the reformatted images are quite\n limited. No definite evidence of fracture or malalignment. If there is a\n specific issue regarding one area of the thoracic spine, a more focused\n examination is recommended. Note is made of parenchymal opacifications in the\n posterior aspect of the lungs.\n\n IMPRESSION: Limited survey examination showing no evidence of fracture or\n malalignment.\n\n"},{"category":"Radiology","chartdate":"2123-05-18 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":792351,"text":" 8:19 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? of c-spine irreg on OSH films\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Question of C-spine irregularity on outside films.\n\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\n\n FINDINGS: There is no evidence of fracture or malalignment. Disc spaces are\n preserved. Orogastric and orotracheal tubes are in place.\n\n IMPRESSION: No evidence of fracture.\n\n"},{"category":"Radiology","chartdate":"2123-05-18 00:00:00.000","description":"CT RECONSTRUCTION","row_id":792353,"text":" 8:19 AM\n CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High speed MVA.\n\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\n\n FINDINGS: There is a fracture of the transverse process of L5 on the left, a\n fracture of the inferior articular facet of L5 on the left and the superior\n articular facet of S1 on the left. There is a vertical fracture through the\n body of S1 extending to the left incompletely visualized. There is a fracture\n of the lamina of S1 as well.\n\n IMPRESSION: Fractures of L5 and S1 with features as discussed above.\n\n"},{"category":"Radiology","chartdate":"2123-05-19 00:00:00.000","description":"P PELVIS (AP ONLY) PORT","row_id":792480,"text":" 9:58 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: please evaluate for s1 type 2 fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with sacral fracture\n REASON FOR THIS EXAMINATION:\n please evaluate for s1 type 2 fracture\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS, SINGLE FILM:\n\n History of sacral fracture.\n\n No definite fracture is not identified on this film. The upper iliac crests\n are not included on the film. No diastasis of the sacroiliac joints. A vague\n irregular linear lucency overlying the portion of the upper sacrum is\n difficult to evaluate on this study.No prior studies for review.\n\n"},{"category":"Radiology","chartdate":"2123-05-20 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":792602,"text":" 11:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval interval for subarachnoid bleed\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,\n REASON FOR THIS EXAMINATION:\n please eval interval for subarachnoid bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC, evaluate for subarachnoid hemorrhage.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n COMPARISON: and .\n\n FINDINGS: The small focus of increased attenuation overlying the left\n parietal region seen on the examination is not appreciated today.\n There is a small amount of hemorrhage layering posteriorly in the occipital\n of the left lateral ventricle, which in retrospect, is not changed from\n the prior study. No other areas of hemorrhage are appreciated. There is no\n mass effect or shift of normally midline structures. There also is a focus of\n decreased attenuation in the left occipital lobe, which appears slightly more\n prominent than on the prior study. This may represent an area of developing\n encephalomalacia. The -white matter differentiation is preserved. There\n is no hydrocephalus.\n\n There is moderate mucosal thickening of the visualized portions of the left\n maxillary sinus. There is also mild mucosal thickening within the ethmoid and\n sphenoid sinuses. There may be an air fluid level in the left and right\n sphenoid air cells. No fractures are identified.\n\n IMPRESSION:\n\n 1) No evidence for subarachnoid hemorrhage. There is a tiny amount of\n hemorrhage layering posteriorly in the occipital of the left lateral\n ventricle.\n 2) Probable area of developing encephalomalacia in the left occipital lobe.\n 3) Mucosal sinus disease as described.\n\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"LP HIP UNILAT MIN 2 VIEWS LEFT PORT","row_id":792282,"text":" 1:35 PM\n HIP UNILAT MIN 2 VIEWS LEFT PORT Clip # \n Reason: eval fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 year old status post motor vehicle accident.\n\n A single oblique view of the pelvis shows a fracture through the left pubic\n bone and left inferior pubic rami bone. No other fractures are seen. The hip\n joints are intact. Surgical staples are seen overlying the lower abdomen,\n vertically.\n\n IMPRESSION: Left inferior pubic rami fracture, and left pubic bone fracture.\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"LP FEMUR (AP & LAT) LEFT PORT","row_id":792283,"text":" 1:35 PM\n FEMUR (AP & LAT) LEFT PORT; KNEE (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle accident.\n\n AP and lateral views of the left femur and knee again demonstrate a fracture\n through the left pubic bone and left inferior pubic ramus bone. The left hip\n joint is intact. No fracture of the left femur or knee is seen. The knee joint\n space is intact. No knee joint effusion seen. Knee joint space is preserved.\n subcutaneous air within the soft tissues of the medial is appreciated, maybe\n be related to trauma or prior intervention.\n\n IMPRESSION: As described previously, fracture through the left inferior pubic\n ramus bone and left pubic bone.\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":792281,"text":" 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries, now post-op ex-lap\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple injuries, MVC, evaluate for pneumothorax.\n\n Comparison is made to the AP chest radiograph from approximately five hours\n earlier.\n\n AP CHEST RADIOGRAPH: Again seen are an ET tube in satisfactory position\n several cm above the carina and an NG tube with tip below the diaphragm. The\n heart size is stable, given differences in technique. Again seen is a sharply\n demarcated prominence of the superior mediastinum, which is stable in\n appearance. There is slight increase in opacity in the left upper lung zone.\n No pleural effusions or pneumonic consolidations are present. No pneumothorax\n is seen. Osseous structures are unchanged.\n\n IMPRESSION: No evidence of pneumothorax. Increased opacity in left upper\n lung zone.\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"LP WRIST(3 + VIEWS) LEFT PORT","row_id":792318,"text":" 6:05 PM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: left radius\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n left forearm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 23 year old male status post motor vehicle collision.\n\n TECHNIQUE: AP, lateral, and oblique views of the left wrist were obtained.\n\n COMPARISON: Exam performed five hours earlier.\n\n FINDINGS: There is a comminuted fracture of the distal third of the radial\n shaft with volar angulation of the distal fracture fragment. Carpal rows are\n intact although there is positive ulnar variance.\n\n IMPRESSION: Angulated fracture of the distal radial shaft associated with\n positive ulnar variance as described above.\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":792218,"text":" 7:54 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: MVA. Assess ET tube placement and pelvic fracture.\n\n FINDINGS: This exam is limited by the overlying trauma board.\n ET tube is several cm above the carina in good position. NG tube tip is\n within the stomach. Cardiac and mediastinal contours are unremarkable. There\n is no pulmonary vascular congestion, pleural effusion, focal infiltrate or\n pneumothorax.\n\n PELVIS: Single view of the pelvis is limited by overlying trauma board. There\n is a left superior and inferior pubic ramus fracture. No other displaced\n fractures are seen.\n\n IMPRESSION: Left pubis fracture. Tubes and lines in good position.\n\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":792222,"text":" 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n MVC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN:\n\n HISTORY: MVA collision.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no sign of an intraparenchymal hemorrhage, mass effect or\n shift of midline structures. There is slight increased density of the falx\n cerebri and tentorium cerebelli, which in a patient of this age is probably\n within normal limits. The surrounding osseous and soft tissue structures are\n within normal limits, aside from mild mucosal thickening in the sphenoid\n sinus. There is probable moderate thickening of the posterior superior\n nasopharyngeal soft tissues. In a patient of this age, this finding could\n represent enlarged adenoids.\n\n CONCLUSION: No definite intracranial hemorrhage.\n\n ADDENDUM: There is a mild degree of scalp soft tissue swelling in the left\n parietal vertex region of the skull. Presumably this is post traumatic in\n origin.\n\n The nasogastric and endotracheal tubes are seen on the lateral scout image.\n\n\n"},{"category":"Radiology","chartdate":"2123-05-18 00:00:00.000","description":"CT HEAD W/ CONTRAST","row_id":792347,"text":" 7:50 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: MVC\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with mvc\n REASON FOR THIS EXAMINATION:\n rule out any bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN:\n\n HISTORY: Motor vehicle accident. Assess for intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan was obtained.\n\n FINDINGS: There is suspicion of a small amount of subarachnoid blood along\n the left posterior parietal convexity surface superiorly. There is no other\n definite accumulation of intracranial hemorrhage identified. There is no mass\n effect or shift of normally midline structures. There is a moderate degree of\n soft tissue swelling within the scalp bilaterally, most notably near the\n vertex of the skull. There is moderate mucosal thickening within the\n maxillary and ethmoid sinuses, with a minor degree of mucosal thickening in\n the sphenoid sinus. The sinus abnormalities could represent an allergic or\n some other type of inflammatory process.\n\n CONCLUSION:\n\n Suspected small amount of subarachnoid hemorrhage with other findings as noted\n above.\n\n COMMENT: There is loss of visualization of the airway, likely due to\n intubation.\n\n\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"OL FEMUR (AP & LAT) IN O.R. LEFT","row_id":792251,"text":" 10:46 AM\n FEMUR (AP & LAT) IN O.R. LEFT Clip # \n Reason: H/O TRAUMA, OPEN WOUND LEFT FEMUR, ASSESS FOR FX\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: H/O trauma, open wound in left femur. Assess for skeletal\n injury.\n\n AP FILM OF LEFT FEMUR INCLUDED IN TRAUMA SERIES: Single view covers only a\n distal two-thirds of the femur where there is no conclusive evidence of the\n traumatic bony injury. A subcutaneous wound is noted in the lateral aspect\n of the mid-thigh.\n\n\n\n"},{"category":"Radiology","chartdate":"2123-05-17 00:00:00.000","description":"LP SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT","row_id":792284,"text":" 1:35 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT; ELBOW (AP, LAT & OBLIQUE) LEFT PORTClip # \n WRIST(3 + VIEWS) LEFT PORT\n Reason: r/o fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P motor vehicle accident.\n\n AP, neutral, and axillary views of the left shoulder show AC joint separation.\n No shoulder joint dislocation seen. The AC joint separation measures\n approximately 1.6 cm.\n\n Two views of the left elbow show no fracture or dislocation. A lateral view\n of the elbow is not provided, and therefore no elbow joint effusion can be\n assessed.\n\n Two views of the distal radius and ulna/wrist on the left show a comminuted\n fracture through the distal of the radial shaft, with minimal\n displacement. Note is also made of a small foreign body with the appearance\n typical for glass seen within the soft tissues adjacent to the proximal ulna.\n\n IMPRESSION: Left AC joint separation, fracture through the distal radial\n shaft, and small foreign body within the soft tissues adjacent to the proximal\n ulna.\n\n"},{"category":"Nursing/other","chartdate":"2123-05-17 00:00:00.000","description":"Report","row_id":1553183,"text":"Resp. Care Note\nPt arrived in ER intubated with 8.0 ETT secured at 25cm. BS equal bilat, slight decreased to bases. Pt transported to ER CT scanner and then to OR for E. Lap. Pt arrived to T-SICU and placed on vent with initial settings of SIMV 700x 12x 100% peep 5 and psv 5. Combined acidosis on ABG so minute ventilation increased and FiO2 weaned down. Current settings SIMV 700x 18x 40% 5/5. Last ABG 7.41/37/153/24 on 50%. Pt sedated on propofol, plan to cont vent support.\n"},{"category":"Nursing/other","chartdate":"2123-05-17 00:00:00.000","description":"Report","row_id":1553184,"text":"TSICU ADMIT NOTE\n23 S/P MVC +ETOH PMH PEDIATRIC BURN WITH GRAFT REPAIRS.\nTRANSFERRED TO FROM OSH.\nINJURIES:\nRUPTURED BLADDER, LEFT SUPERIOR AND INFERIOR PUBIC RAMI FX (NON-DISPLACED), LEFT FOREARM FX, ?LUMBER FRACTURES, SPLENIC PERIPLEURAL TEAR, LEFT THIGH ABRASION\n\nOR: S/P EX LAP REPAIR BLADDER RUPTURE DEBRIDEMENT LEFT THIGH WOUND.\nCRYST 4000\nEBL 300\nU/O 400\n\nNEURO: INTUBATED AND SEDATED WITH PROPOFOL, MORPHINE AND DILAUDID. OPENS EYES TO PAINFUL STIMULI DOES NOT FOLLOW COMMANDS, MOVES EXTREMITIES WITH EXCEPTION OF LEFT UPPER EXTREMITITY WHICH REMAINS STABILIZED IN A SPLINT. COUGH/GAG INTACT PUPILS 3MM/BRISK. HEAD CT INDICATES NO SIGNS OF BLEED/SHIFT.\n\nCV: HR 120'S ST NO ECTOPY. BP 140/70'S. LR @ 100/HR. PULSES EASILY PALPABLE THROUGHOUT.\n\nRESP: LUNG SOUNDS CLEAR DIMINISHED AT BASES. SATS 100% SIMV 18/700 PEEP 5 PS 5 FIO2 40%. ABG INDICATE ADEQUATE V/Q CONT TO FOLLOW. SUCTIONED FOR MINIMUM SECRETIONS.\n\nGI: NPO OGT TO LWS WITH MINIMAL OUTPUT FAMOTIDINE ABSENT BOWEL SOUNDS.\n\n\nGU: URINE OUTPUT 100-200 CC CLEAR YELLOW URINE VIA FOLEY CATHETER LYTES REPLEATED. BUN 9 CREAT .09\n\nHEME: CYCLE HCT 33.2 (33.4) CONT TO FOLLOW TREND.\n\nID: TMAX 100.9 WBC 9 FLAGYL, KEFZOL.\n\nSKIN: ABD INCISION WITH STAPLES C/D/I MODERATE SEROUS STAINING ON PRIMARY DRESSING. LEFT DEBRIDEMENT WITH LARGE AMTS OF SEROUS OUTPUT. WRAPPED IN KERLEX. LEFT ARM SECURED WITH BRACE. J-COLLAR.\n\nSOCIAL: MOTHER AND GIRLFRIEND AND BEDSIDE PATIENT IS CURRENTLY UNEMPLOYED AND LIVING WITH GIRLFRIEND.\n\nA:S/P TRAUMA FOLLOWING HEMODYNAMICS, FOLLOWING RADIOLOGY REPORTS.\n\nP:ONCE RADIOLOGICALLY CLEAR CHANGE ACT STATUS FOR EXTUBATION, FOLLOW HCTS, FOLLOW SEDATION AND PAIN CONTROL, CHANGE WOUND DRESSINGS, SUPPORT FAMILY, REPLEAT LYTES.\n"},{"category":"Nursing/other","chartdate":"2123-05-19 00:00:00.000","description":"Report","row_id":1553190,"text":"T/SICU NPN 2300-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT/ORIENTED/AFFECT AND QUESTIONS APPROPRIATE. OCCASIONALLY CONFUSED WHEN WAKING FROM SLEEP - REORIENTS WELL. MOVES ALL EXTREMITIES, LIFTS/HOLDS R ARM/LEG, MOVES L ARM/LEG ON BED: CAP REFILL TO ALL EXTREMITIES. GIVEN PRN DILAUDID FOR C/O EXTREMITY AND ABD PAIN W/(+) EFFECT - RESTING COMFORTABLY - SLEPT ON/OFF. C-COLLAR INTACT - AWAITING CLINICAL CLEARANCE OF NECK.\n\nCV: HR ST 110-120'S, BP 140-160'S/80-90'S. BP 130'S WHEN ASLEEP. NO ECTOPY NOTED ON TELEMETRY. PERIPHERAL PULSES EASILY PALPABLE. SKIN PIN/WARM/DRY - HEPARIN AND PB'S FOR DVT PROPHYLAXIS.\n\nHEME: HCT 32.4(33.1)\n\nRESP: LUNG SOUNDS CLEAR, DIMINISHED AT BASES B/L. O2 2L VIA NC AS WELL AS COOL NEB FACE MASK @40% FOR HUMIDITY: SATS 94-97% AT THESE SETTINGS; PT TRENDS DOWN TO 80'S ON RA. DENIES SOB, NORMAL COUGH EFFORT, NEEDS TO SUPPORT ABD FOR COUGH/DEEP BREATH EXERCISES. RR 16-24 AT REST.\n\nGI: ABD SOFT, APPROPRIATELY TENDER W/(+)HYPOACTIVE BS, NO RF/BM. NPO - IVF @KVO RATE. DENIES N/V.\n\nGU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/ADEQUATE HOURLY VOLUME OUT. MG+ REPLETED.\n\nENDO: STABLE\n\nID: LOW GRADE TEMP - 100.3, IV ABX D/C'D .\n\nSKIN: BACK/BUTTOCKS INTACT, MIDLINE ABD.INC WNL - COVERED W/OCCLUSIVE PRIMARY DSG, D/I. L ARM IN SPLINT W/(+)CSM TO FINGERS. R THIGH W/W->D DSG DRAINING SCANT AMT SEROUS FLUID. R ARM W/IV INFILTRATE - (+)EDEMA - BOTH EXTREMITIES ELEVATED ON PILLOWS. CAP REFILL THROUGHOUT. PT'S UPPER LIP SWOLLEN, SLIGHTLY IMPROVED FROM PREVIOUS DAY.\n\nSOCIAL: NO FAMILY CONTACT OVER .\n\nA/P: STABLE S/P MVC, TOLERATED EXTUBATION. LOW GRADE TEMP. CONTINUE PER CURRENT PLAN OF CARE: MONITOR SYSTEMS/LABS FOR CHANGES, REPLETE LYTES AS NEEDED. PAIN MGT - PULMONARY HYGEINE. DSG CHANGES AS ORDERED. F/U W/TEAM TO CLEAR C-SPINE AND REMOVE COLLAR. (?)SLOW DIET ADVANCE. PT LIKELY ABLE TO TRANSFER TO FLOOR IF HE REMAINS STABLE AND BED BECOMES AVAILABLE. FULL SUPPORT/COMFORT/ASSIST.\n"},{"category":"Nursing/other","chartdate":"2123-05-19 00:00:00.000","description":"Report","row_id":1553191,"text":"nsg note\n ROS:\n\n CV:OCCASIONALLY TACKY AND HYPERTENSIVE DEPENDING ON AMT OF PAIN.HE WAS STARTED ON DILAUDID PCA WHICH IS EFFECTIVE. T MAX 99.6.\n\n RESP:STRONG PROD COUGH.ON 2L NP WITH SAT 98\n\n NEURO:AWARE,SLEEPY BUT EASILY AROUSABLE.MOVING R SIDE WELL,DUE TO INJURY NOT MOVING L ARM OR LEG.\n\n GU:EXCELLENT UO,NO BLD NOTED.IV AT KVO\n\n GI:STARTED ON CLEAR LIQUIDS,CAN ADVANCE AS TOLERATED.\n\n SKIN:L THIGH W-D DSD DONE AT 1PM,MIMINAL SS DRAINAGE.\nBACK INTACT.\n\n FAMILY:MOTHER,GIRLFRIEND IN THIS PM.AWARE OF PLANS TO SEND PT TO FLOOR WHEN BED AVAILABLE.\n\n PLAN:TRANSFER TO FLOOR.OR FOR ORIF L WRIST.\n"},{"category":"Nursing/other","chartdate":"2123-05-18 00:00:00.000","description":"Report","row_id":1553187,"text":"TSICU PROGRESS NOTE\nNEURO: APTIETN IS ALERT AND ORIENTED X 3 SLIGHTLY CLOUDY WHEN FIRST AWAKE BUT REORIENTS QUICKLY. FOLLOWING ALL COMMANDS, COUGH/GAG INTACT, PUPILS 3 , , DILAUDID PRN FOR DISCOMFORT, ENIES NUMBNESS AND TINGLING THROUGHOUT. HEAD/NECK LUMBAR/THORACIC CT PERFORMED THIS AM. L5 WITH NON-OPERABLE FRACTURE. LOGROLL PRECAUTIONS DISCONTINUED. J COLLAR REMIANS INTACT. SOFT TISSUE SENSITIVITY TO BE PERFORMED THIS PM UPON INCREASED ALERT STATUS.\n\nCV: HR 110 ST. BP 160/70 LOPRESSOR 5MG X 1 PULSES EASILY PALPABLE THROUGOUT.\n\nRESP: EXTUBATED LUNG SOUNDS CLEAR DIMINISHED AT BASES. ENCOURAGE COUGH AND DEEP BREATHE. FREQUENT PULMONARY TOLIETING. NT SUCTION FOR MINIMAL TNA SECRETIONS NASAL TRUMPET INTACT FOR ACCESS. SATS 95 5 ON 40% FACE MASK. POST EXTUBATION ABG PENDING.\n\nGI: NPO ABSENT BOWEL SOUNDS OGT D/C'D. FAMOTIDINE DENIES NAUSEA.\n\nGU: URINE OUTPUT 100-150CC CLEAR YELLOW URINE VIA FOLEY CATH.\n\nSKIN: ABD INCISION C/D/I MINIMAL SEROUS STAINING STAPLES WELL APPROXIMATED. LEFT LEG INCISION W->D DRESSING WITH+ GRANULATION.\n\nID: TMAX 101.3 WBC 7 KEFZOL/FLAGYL DISCONTINUED.\n\nHEME: HCT 33.4 HEPARIN P-BOOTS.\n\nSOCIAL:GIRLFRIEND AND MOTHER IN ROOM SOCIAL WORK FOLLOWING.\n\nA: RESP STATUS POST-EXTUBATION. CLEARANCE OF C-SPINE, DECREASE SEDATION.\n\nP: PROVIDE PAIN CONTROL, FOLLOW WND, FOLLOW TEMPS, PULM TOLIETING FREQUENTLY, SUPPORT FAMILY, ADV DIET D/C TO FLOOR.\n"},{"category":"Nursing/other","chartdate":"2123-05-18 00:00:00.000","description":"Report","row_id":1553188,"text":"Resp. Care Note\nPt received intubated, sedated and vented on settings SIMV 700x 16x 40% peep 5 psv 5. Pt transported to CT scan of head and for spine clearance. Once cleared, sedation stopped and Pt placed on CPAP/PSV. Weaned quickly to and extubated without incident. Nasal airway placed as Pt intermittantly with partial airway obstruction. Follows commands for deep breathing and coughing. Face tent at 40%.\n"},{"category":"Nursing/other","chartdate":"2123-05-18 00:00:00.000","description":"Report","row_id":1553189,"text":"T-SICU Nsg Note\nNeuro - pt frequently asks what happened to him, wanting to hear his list of injuries. Does not remember car accident, but can repeat that was in a car accident. Follows commands, purposeful. Good strength R arm & R leg. L leg painful to move, L arm splinted, but good movement of fingers, L fingers warm cap refill. O x 3, arouses to voice when sleeping. 2mg Hydromorphone IVP for pain with sleep ensuing.\n\nCV - remains tachycardic to 130, sinus tach. BP often 150-160 sys.\n\nResp - regular, non-labored breathing. Weak cough when asked to cough, dry. O2 sats fall into 80's without supplemental O2. With face tent & cool neb at 40%, O2 sats 93-96%.\n\nGU - urine is clear yellow, no hematuria. QS u/o.\n\nGI - no bowel sounds heard. abd softly distended, abd dressing with wrinkles in dressing.\n\nL posterior thigh wound beefy red in color, scant serosanguinous drainage. No odor. About kerlix packed into wound.\n\nHct at 21:00 33.1, similar to earlier Hcts today.\n\n mother & SO, went home for night, both supportive of pt and each other.\n\nA; Pt frequently asks what happened to him - short term memory deficit? Continues tachycardic and relatively hypertensive.\n\nP:Continue to answer pt's questions. Informational support to family.\n go to OR Friday to repair L forearm fx.\n"},{"category":"Nursing/other","chartdate":"2123-05-18 00:00:00.000","description":"Report","row_id":1553185,"text":"Resp Care Note:\n\nPt cont intub sedated on mech vent as per Carevue. Lung sounds ess clear dim R base. ABGs stable. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2123-05-18 00:00:00.000","description":"Report","row_id":1553186,"text":"npn\ns=orally intubated and sedated.\n\no=sedated, responds to painful stimuli only. does not open eyes unless moved or suctioned. pupils equal and reactive--left pupil sometimes not in midline. no corneal reflexes noted while sedated on propofol. moves all extremities except left arm. ortho in at start of shift and clamshell splint applied. circulation and color to arm good after application. good cap. refill. propofol decreased at 0600 from 50mkm to 25 mkm in anticipation of extubation. also sedated with alternating doses of mso4 and dilaudid for pain.\n\ncv=monitor=st with no ectopy noted. sbp via right radial a-line= 140--170's. diastolic pressures remain consistently in 90's. md aware. ivf at 100cc/hr. propofol as noted above. mgso4 repleted. k+ to be repleted--awaiting mix from phcy.\n\npulm=ventilated on simv 16-40%-700-5 cm peep and 5 cm pressure support. resp. rate overnight 16--did not overbreathe vent. at all. breath sounds clear bilaterally to bases except decreased at right base. suctioned for thick slightly tan secretions--scant amts. sats cocsistently 100%.\n\ngi=orogastric tube to low wall suction. patent for green gastric contents--50cc. absent bowel sounds. abdomen soft, slightly distended. dressing to abdomen with previously marked serosanguineous staining--no increase in size throughout shift.\n\ngu=foley patent for clear yellow urine, at times with sediment. after a.m. care, slightly pink-tinged.\n\nheme=continues on q 6hr hcts--no change.\n\nendo=no issues.\n\nid=temp. remains afebrile this shift. wbc=7.3 from 10.2. left upper leg redressed for moderate serosanguineous drainage. edges clean, non-odorous. continues on antibiotics as ordered.\n\nskin=small abrasions at left shoulder and left upper chest laterally. no drainage.\n\nsocial=no family contact this shift.\n\na=continues tachycardic and hypertensive while sedated on propofol, mso4 and dilaudid. becomes agitated when disturbed.\n\np=plan to extubate today.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"CT T-SPINE W/ CONTRAST\",\n \"row_id\": 792352,\n \"text\": \" 8:19 AM\\n CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o fx\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: High speed MVA.\\n\\n TECHNIQUE: Contiguous axial images with reformatted images.\\n\\n FINDINGS: This is a survey examination and the reformatted images are quite\\n limited. No definite evidence of fracture or malalignment. If there is a\\n specific issue regarding one area of the thoracic spine, a more focused\\n examination is recommended. Note is made of parenchymal opacifications in the\\n posterior aspect of the lungs.\\n\\n IMPRESSION: Limited survey examination showing no evidence of fracture or\\n malalignment.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 792351,\n \"text\": \" 8:19 AM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o fx\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with h/o high mech MVC ? of c-spine irreg on OSH films\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Question of C-spine irregularity on outside films.\\n\\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\\n\\n FINDINGS: There is no evidence of fracture or malalignment. Disc spaces are\\n preserved. Orogastric and orotracheal tubes are in place.\\n\\n IMPRESSION: No evidence of fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"CT RECONSTRUCTION\",\n \"row_id\": 792353,\n \"text\": \" 8:19 AM\\n CT RECONSTRUCTION Clip # \\n Reason: r/o fx\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: High speed MVA.\\n\\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\\n\\n FINDINGS: There is a fracture of the transverse process of L5 on the left, a\\n fracture of the inferior articular facet of L5 on the left and the superior\\n articular facet of S1 on the left. There is a vertical fracture through the\\n body of S1 extending to the left incompletely visualized. There is a fracture\\n of the lamina of S1 as well.\\n\\n IMPRESSION: Fractures of L5 and S1 with features as discussed above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-19 00:00:00.000\",\n \"description\": \"P PELVIS (AP ONLY) PORT\",\n \"row_id\": 792480,\n \"text\": \" 9:58 AM\\n PELVIS (AP ONLY) PORT Clip # \\n Reason: please evaluate for s1 type 2 fracture\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with sacral fracture\\n REASON FOR THIS EXAMINATION:\\n please evaluate for s1 type 2 fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n PELVIS, SINGLE FILM:\\n\\n History of sacral fracture.\\n\\n No definite fracture is not identified on this film. The upper iliac crests\\n are not included on the film. No diastasis of the sacroiliac joints. A vague\\n irregular linear lucency overlying the portion of the upper sacrum is\\n difficult to evaluate on this study.No prior studies for review.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-20 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 792602,\n \"text\": \" 11:50 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please eval interval for subarachnoid bleed\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,\\n REASON FOR THIS EXAMINATION:\\n please eval interval for subarachnoid bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: MVC, evaluate for subarachnoid hemorrhage.\\n\\n TECHNIQUE: Routine non-contrast head CT.\\n\\n COMPARISON: and .\\n\\n FINDINGS: The small focus of increased attenuation overlying the left\\n parietal region seen on the examination is not appreciated today.\\n There is a small amount of hemorrhage layering posteriorly in the occipital\\n of the left lateral ventricle, which in retrospect, is not changed from\\n the prior study. No other areas of hemorrhage are appreciated. There is no\\n mass effect or shift of normally midline structures. There also is a focus of\\n decreased attenuation in the left occipital lobe, which appears slightly more\\n prominent than on the prior study. This may represent an area of developing\\n encephalomalacia. The -white matter differentiation is preserved. There\\n is no hydrocephalus.\\n\\n There is moderate mucosal thickening of the visualized portions of the left\\n maxillary sinus. There is also mild mucosal thickening within the ethmoid and\\n sphenoid sinuses. There may be an air fluid level in the left and right\\n sphenoid air cells. No fractures are identified.\\n\\n IMPRESSION:\\n\\n 1) No evidence for subarachnoid hemorrhage. There is a tiny amount of\\n hemorrhage layering posteriorly in the occipital of the left lateral\\n ventricle.\\n 2) Probable area of developing encephalomalacia in the left occipital lobe.\\n 3) Mucosal sinus disease as described.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"LP HIP UNILAT MIN 2 VIEWS LEFT PORT\",\n \"row_id\": 792282,\n \"text\": \" 1:35 PM\\n HIP UNILAT MIN 2 VIEWS LEFT PORT Clip # \\n Reason: eval fracture\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,mult injuries\\n\\n REASON FOR THIS EXAMINATION:\\n eval fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 23 year old status post motor vehicle accident.\\n\\n A single oblique view of the pelvis shows a fracture through the left pubic\\n bone and left inferior pubic rami bone. No other fractures are seen. The hip\\n joints are intact. Surgical staples are seen overlying the lower abdomen,\\n vertically.\\n\\n IMPRESSION: Left inferior pubic rami fracture, and left pubic bone fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"LP FEMUR (AP & LAT) LEFT PORT\",\n \"row_id\": 792283,\n \"text\": \" 1:35 PM\\n FEMUR (AP & LAT) LEFT PORT; KNEE (AP, LAT & OBLIQUE) LEFT PORT Clip # \\n Reason: r/o fracture\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,mult injuries\\n\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post motor vehicle accident.\\n\\n AP and lateral views of the left femur and knee again demonstrate a fracture\\n through the left pubic bone and left inferior pubic ramus bone. The left hip\\n joint is intact. No fracture of the left femur or knee is seen. The knee joint\\n space is intact. No knee joint effusion seen. Knee joint space is preserved.\\n subcutaneous air within the soft tissues of the medial is appreciated, maybe\\n be related to trauma or prior intervention.\\n\\n IMPRESSION: As described previously, fracture through the left inferior pubic\\n ramus bone and left pubic bone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 792281,\n \"text\": \" 1:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,mult injuries, now post-op ex-lap\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Multiple injuries, MVC, evaluate for pneumothorax.\\n\\n Comparison is made to the AP chest radiograph from approximately five hours\\n earlier.\\n\\n AP CHEST RADIOGRAPH: Again seen are an ET tube in satisfactory position\\n several cm above the carina and an NG tube with tip below the diaphragm. The\\n heart size is stable, given differences in technique. Again seen is a sharply\\n demarcated prominence of the superior mediastinum, which is stable in\\n appearance. There is slight increase in opacity in the left upper lung zone.\\n No pleural effusions or pneumonic consolidations are present. No pneumothorax\\n is seen. Osseous structures are unchanged.\\n\\n IMPRESSION: No evidence of pneumothorax. Increased opacity in left upper\\n lung zone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"LP WRIST(3 + VIEWS) LEFT PORT\",\n \"row_id\": 792318,\n \"text\": \" 6:05 PM\\n WRIST(3 + VIEWS) LEFT PORT Clip # \\n Reason: left radius\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,mult injuries\\n\\n REASON FOR THIS EXAMINATION:\\n left forearm\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: 23 year old male status post motor vehicle collision.\\n\\n TECHNIQUE: AP, lateral, and oblique views of the left wrist were obtained.\\n\\n COMPARISON: Exam performed five hours earlier.\\n\\n FINDINGS: There is a comminuted fracture of the distal third of the radial\\n shaft with volar angulation of the distal fracture fragment. Carpal rows are\\n intact although there is positive ulnar variance.\\n\\n IMPRESSION: Angulated fracture of the distal radial shaft associated with\\n positive ulnar variance as described above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 792218,\n \"text\": \" 7:54 AM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: MVA TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n INDICATION: MVA. Assess ET tube placement and pelvic fracture.\\n\\n FINDINGS: This exam is limited by the overlying trauma board.\\n ET tube is several cm above the carina in good position. NG tube tip is\\n within the stomach. Cardiac and mediastinal contours are unremarkable. There\\n is no pulmonary vascular congestion, pleural effusion, focal infiltrate or\\n pneumothorax.\\n\\n PELVIS: Single view of the pelvis is limited by overlying trauma board. There\\n is a left superior and inferior pubic ramus fracture. No other displaced\\n fractures are seen.\\n\\n IMPRESSION: Left pubis fracture. Tubes and lines in good position.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 792222,\n \"text\": \" 8:10 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: MVC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with\\n REASON FOR THIS EXAMINATION:\\n MVC\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n NON-CONTRAST HEAD CT SCAN:\\n\\n HISTORY: MVA collision.\\n\\n TECHNIQUE: Non-contrast head CT was obtained.\\n\\n FINDINGS: There is no sign of an intraparenchymal hemorrhage, mass effect or\\n shift of midline structures. There is slight increased density of the falx\\n cerebri and tentorium cerebelli, which in a patient of this age is probably\\n within normal limits. The surrounding osseous and soft tissue structures are\\n within normal limits, aside from mild mucosal thickening in the sphenoid\\n sinus. There is probable moderate thickening of the posterior superior\\n nasopharyngeal soft tissues. In a patient of this age, this finding could\\n represent enlarged adenoids.\\n\\n CONCLUSION: No definite intracranial hemorrhage.\\n\\n ADDENDUM: There is a mild degree of scalp soft tissue swelling in the left\\n parietal vertex region of the skull. Presumably this is post traumatic in\\n origin.\\n\\n The nasogastric and endotracheal tubes are seen on the lateral scout image.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"CT HEAD W/ CONTRAST\",\n \"row_id\": 792347,\n \"text\": \" 7:50 AM\\n CT HEAD W/ CONTRAST Clip # \\n Reason: MVC\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with mvc\\n REASON FOR THIS EXAMINATION:\\n rule out any bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n NON-CONTRAST HEAD CT SCAN:\\n\\n HISTORY: Motor vehicle accident. Assess for intracranial hemorrhage.\\n\\n TECHNIQUE: Non-contrast head CT scan was obtained.\\n\\n FINDINGS: There is suspicion of a small amount of subarachnoid blood along\\n the left posterior parietal convexity surface superiorly. There is no other\\n definite accumulation of intracranial hemorrhage identified. There is no mass\\n effect or shift of normally midline structures. There is a moderate degree of\\n soft tissue swelling within the scalp bilaterally, most notably near the\\n vertex of the skull. There is moderate mucosal thickening within the\\n maxillary and ethmoid sinuses, with a minor degree of mucosal thickening in\\n the sphenoid sinus. The sinus abnormalities could represent an allergic or\\n some other type of inflammatory process.\\n\\n CONCLUSION:\\n\\n Suspected small amount of subarachnoid hemorrhage with other findings as noted\\n above.\\n\\n COMMENT: There is loss of visualization of the airway, likely due to\\n intubation.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"OL FEMUR (AP & LAT) IN O.R. LEFT\",\n \"row_id\": 792251,\n \"text\": \" 10:46 AM\\n FEMUR (AP & LAT) IN O.R. LEFT Clip # \\n Reason: H/O TRAUMA, OPEN WOUND LEFT FEMUR, ASSESS FOR FX\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: H/O trauma, open wound in left femur. Assess for skeletal\\n injury.\\n\\n AP FILM OF LEFT FEMUR INCLUDED IN TRAUMA SERIES: Single view covers only a\\n distal two-thirds of the femur where there is no conclusive evidence of the\\n traumatic bony injury. A subcutaneous wound is noted in the lateral aspect\\n of the mid-thigh.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"LP SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT\",\n \"row_id\": 792284,\n \"text\": \" 1:35 PM\\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT; ELBOW (AP, LAT & OBLIQUE) LEFT PORTClip # \\n WRIST(3 + VIEWS) LEFT PORT\\n Reason: r/o fracture\\n Admitting Diagnosis: EXP LAP\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with MVC,mult injuries\\n\\n REASON FOR THIS EXAMINATION:\\n r/o fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P motor vehicle accident.\\n\\n AP, neutral, and axillary views of the left shoulder show AC joint separation.\\n No shoulder joint dislocation seen. The AC joint separation measures\\n approximately 1.6 cm.\\n\\n Two views of the left elbow show no fracture or dislocation. A lateral view\\n of the elbow is not provided, and therefore no elbow joint effusion can be\\n assessed.\\n\\n Two views of the distal radius and ulna/wrist on the left show a comminuted\\n fracture through the distal of the radial shaft, with minimal\\n displacement. Note is also made of a small foreign body with the appearance\\n typical for glass seen within the soft tissues adjacent to the proximal ulna.\\n\\n IMPRESSION: Left AC joint separation, fracture through the distal radial\\n shaft, and small foreign body within the soft tissues adjacent to the proximal\\n ulna.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553183,\n \"text\": \"Resp. Care Note\\nPt arrived in ER intubated with 8.0 ETT secured at 25cm. BS equal bilat, slight decreased to bases. Pt transported to ER CT scanner and then to OR for E. Lap. Pt arrived to T-SICU and placed on vent with initial settings of SIMV 700x 12x 100% peep 5 and psv 5. Combined acidosis on ABG so minute ventilation increased and FiO2 weaned down. Current settings SIMV 700x 18x 40% 5/5. Last ABG 7.41/37/153/24 on 50%. Pt sedated on propofol, plan to cont vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553184,\n \"text\": \"TSICU ADMIT NOTE\\n23 S/P MVC +ETOH PMH PEDIATRIC BURN WITH GRAFT REPAIRS.\\nTRANSFERRED TO FROM OSH.\\nINJURIES:\\nRUPTURED BLADDER, LEFT SUPERIOR AND INFERIOR PUBIC RAMI FX (NON-DISPLACED), LEFT FOREARM FX, ?LUMBER FRACTURES, SPLENIC PERIPLEURAL TEAR, LEFT THIGH ABRASION\\n\\nOR: S/P EX LAP REPAIR BLADDER RUPTURE DEBRIDEMENT LEFT THIGH WOUND.\\nCRYST 4000\\nEBL 300\\nU/O 400\\n\\nNEURO: INTUBATED AND SEDATED WITH PROPOFOL, MORPHINE AND DILAUDID. OPENS EYES TO PAINFUL STIMULI DOES NOT FOLLOW COMMANDS, MOVES EXTREMITIES WITH EXCEPTION OF LEFT UPPER EXTREMITITY WHICH REMAINS STABILIZED IN A SPLINT. COUGH/GAG INTACT PUPILS 3MM/BRISK. HEAD CT INDICATES NO SIGNS OF BLEED/SHIFT.\\n\\nCV: HR 120'S ST NO ECTOPY. BP 140/70'S. LR @ 100/HR. PULSES EASILY PALPABLE THROUGHOUT.\\n\\nRESP: LUNG SOUNDS CLEAR DIMINISHED AT BASES. SATS 100% SIMV 18/700 PEEP 5 PS 5 FIO2 40%. ABG INDICATE ADEQUATE V/Q CONT TO FOLLOW. SUCTIONED FOR MINIMUM SECRETIONS.\\n\\nGI: NPO OGT TO LWS WITH MINIMAL OUTPUT FAMOTIDINE ABSENT BOWEL SOUNDS.\\n\\n\\nGU: URINE OUTPUT 100-200 CC CLEAR YELLOW URINE VIA FOLEY CATHETER LYTES REPLEATED. BUN 9 CREAT .09\\n\\nHEME: CYCLE HCT 33.2 (33.4) CONT TO FOLLOW TREND.\\n\\nID: TMAX 100.9 WBC 9 FLAGYL, KEFZOL.\\n\\nSKIN: ABD INCISION WITH STAPLES C/D/I MODERATE SEROUS STAINING ON PRIMARY DRESSING. LEFT DEBRIDEMENT WITH LARGE AMTS OF SEROUS OUTPUT. WRAPPED IN KERLEX. LEFT ARM SECURED WITH BRACE. J-COLLAR.\\n\\nSOCIAL: MOTHER AND GIRLFRIEND AND BEDSIDE PATIENT IS CURRENTLY UNEMPLOYED AND LIVING WITH GIRLFRIEND.\\n\\nA:S/P TRAUMA FOLLOWING HEMODYNAMICS, FOLLOWING RADIOLOGY REPORTS.\\n\\nP:ONCE RADIOLOGICALLY CLEAR CHANGE ACT STATUS FOR EXTUBATION, FOLLOW HCTS, FOLLOW SEDATION AND PAIN CONTROL, CHANGE WOUND DRESSINGS, SUPPORT FAMILY, REPLEAT LYTES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553190,\n \"text\": \"T/SICU NPN 2300-0700:\\n\\nREVIEW OF SYSTEMS:\\n\\nNEURO: PT ALERT/ORIENTED/AFFECT AND QUESTIONS APPROPRIATE. OCCASIONALLY CONFUSED WHEN WAKING FROM SLEEP - REORIENTS WELL. MOVES ALL EXTREMITIES, LIFTS/HOLDS R ARM/LEG, MOVES L ARM/LEG ON BED: CAP REFILL TO ALL EXTREMITIES. GIVEN PRN DILAUDID FOR C/O EXTREMITY AND ABD PAIN W/(+) EFFECT - RESTING COMFORTABLY - SLEPT ON/OFF. C-COLLAR INTACT - AWAITING CLINICAL CLEARANCE OF NECK.\\n\\nCV: HR ST 110-120'S, BP 140-160'S/80-90'S. BP 130'S WHEN ASLEEP. NO ECTOPY NOTED ON TELEMETRY. PERIPHERAL PULSES EASILY PALPABLE. SKIN PIN/WARM/DRY - HEPARIN AND PB'S FOR DVT PROPHYLAXIS.\\n\\nHEME: HCT 32.4(33.1)\\n\\nRESP: LUNG SOUNDS CLEAR, DIMINISHED AT BASES B/L. O2 2L VIA NC AS WELL AS COOL NEB FACE MASK @40% FOR HUMIDITY: SATS 94-97% AT THESE SETTINGS; PT TRENDS DOWN TO 80'S ON RA. DENIES SOB, NORMAL COUGH EFFORT, NEEDS TO SUPPORT ABD FOR COUGH/DEEP BREATH EXERCISES. RR 16-24 AT REST.\\n\\nGI: ABD SOFT, APPROPRIATELY TENDER W/(+)HYPOACTIVE BS, NO RF/BM. NPO - IVF @KVO RATE. DENIES N/V.\\n\\nGU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/ADEQUATE HOURLY VOLUME OUT. MG+ REPLETED.\\n\\nENDO: STABLE\\n\\nID: LOW GRADE TEMP - 100.3, IV ABX D/C'D .\\n\\nSKIN: BACK/BUTTOCKS INTACT, MIDLINE ABD.INC WNL - COVERED W/OCCLUSIVE PRIMARY DSG, D/I. L ARM IN SPLINT W/(+)CSM TO FINGERS. R THIGH W/W->D DSG DRAINING SCANT AMT SEROUS FLUID. R ARM W/IV INFILTRATE - (+)EDEMA - BOTH EXTREMITIES ELEVATED ON PILLOWS. CAP REFILL THROUGHOUT. PT'S UPPER LIP SWOLLEN, SLIGHTLY IMPROVED FROM PREVIOUS DAY.\\n\\nSOCIAL: NO FAMILY CONTACT OVER .\\n\\nA/P: STABLE S/P MVC, TOLERATED EXTUBATION. LOW GRADE TEMP. CONTINUE PER CURRENT PLAN OF CARE: MONITOR SYSTEMS/LABS FOR CHANGES, REPLETE LYTES AS NEEDED. PAIN MGT - PULMONARY HYGEINE. DSG CHANGES AS ORDERED. F/U W/TEAM TO CLEAR C-SPINE AND REMOVE COLLAR. (?)SLOW DIET ADVANCE. PT LIKELY ABLE TO TRANSFER TO FLOOR IF HE REMAINS STABLE AND BED BECOMES AVAILABLE. FULL SUPPORT/COMFORT/ASSIST.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553191,\n \"text\": \"nsg note\\n ROS:\\n\\n CV:OCCASIONALLY TACKY AND HYPERTENSIVE DEPENDING ON AMT OF PAIN.HE WAS STARTED ON DILAUDID PCA WHICH IS EFFECTIVE. T MAX 99.6.\\n\\n RESP:STRONG PROD COUGH.ON 2L NP WITH SAT 98\\n\\n NEURO:AWARE,SLEEPY BUT EASILY AROUSABLE.MOVING R SIDE WELL,DUE TO INJURY NOT MOVING L ARM OR LEG.\\n\\n GU:EXCELLENT UO,NO BLD NOTED.IV AT KVO\\n\\n GI:STARTED ON CLEAR LIQUIDS,CAN ADVANCE AS TOLERATED.\\n\\n SKIN:L THIGH W-D DSD DONE AT 1PM,MIMINAL SS DRAINAGE.\\nBACK INTACT.\\n\\n FAMILY:MOTHER,GIRLFRIEND IN THIS PM.AWARE OF PLANS TO SEND PT TO FLOOR WHEN BED AVAILABLE.\\n\\n PLAN:TRANSFER TO FLOOR.OR FOR ORIF L WRIST.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553187,\n \"text\": \"TSICU PROGRESS NOTE\\nNEURO: APTIETN IS ALERT AND ORIENTED X 3 SLIGHTLY CLOUDY WHEN FIRST AWAKE BUT REORIENTS QUICKLY. FOLLOWING ALL COMMANDS, COUGH/GAG INTACT, PUPILS 3 , , DILAUDID PRN FOR DISCOMFORT, ENIES NUMBNESS AND TINGLING THROUGHOUT. HEAD/NECK LUMBAR/THORACIC CT PERFORMED THIS AM. L5 WITH NON-OPERABLE FRACTURE. LOGROLL PRECAUTIONS DISCONTINUED. J COLLAR REMIANS INTACT. SOFT TISSUE SENSITIVITY TO BE PERFORMED THIS PM UPON INCREASED ALERT STATUS.\\n\\nCV: HR 110 ST. BP 160/70 LOPRESSOR 5MG X 1 PULSES EASILY PALPABLE THROUGOUT.\\n\\nRESP: EXTUBATED LUNG SOUNDS CLEAR DIMINISHED AT BASES. ENCOURAGE COUGH AND DEEP BREATHE. FREQUENT PULMONARY TOLIETING. NT SUCTION FOR MINIMAL TNA SECRETIONS NASAL TRUMPET INTACT FOR ACCESS. SATS 95 5 ON 40% FACE MASK. POST EXTUBATION ABG PENDING.\\n\\nGI: NPO ABSENT BOWEL SOUNDS OGT D/C'D. FAMOTIDINE DENIES NAUSEA.\\n\\nGU: URINE OUTPUT 100-150CC CLEAR YELLOW URINE VIA FOLEY CATH.\\n\\nSKIN: ABD INCISION C/D/I MINIMAL SEROUS STAINING STAPLES WELL APPROXIMATED. LEFT LEG INCISION W->D DRESSING WITH+ GRANULATION.\\n\\nID: TMAX 101.3 WBC 7 KEFZOL/FLAGYL DISCONTINUED.\\n\\nHEME: HCT 33.4 HEPARIN P-BOOTS.\\n\\nSOCIAL:GIRLFRIEND AND MOTHER IN ROOM SOCIAL WORK FOLLOWING.\\n\\nA: RESP STATUS POST-EXTUBATION. CLEARANCE OF C-SPINE, DECREASE SEDATION.\\n\\nP: PROVIDE PAIN CONTROL, FOLLOW WND, FOLLOW TEMPS, PULM TOLIETING FREQUENTLY, SUPPORT FAMILY, ADV DIET D/C TO FLOOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553188,\n \"text\": \"Resp. Care Note\\nPt received intubated, sedated and vented on settings SIMV 700x 16x 40% peep 5 psv 5. Pt transported to CT scan of head and for spine clearance. Once cleared, sedation stopped and Pt placed on CPAP/PSV. Weaned quickly to and extubated without incident. Nasal airway placed as Pt intermittantly with partial airway obstruction. Follows commands for deep breathing and coughing. Face tent at 40%.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553189,\n \"text\": \"T-SICU Nsg Note\\nNeuro - pt frequently asks what happened to him, wanting to hear his list of injuries. Does not remember car accident, but can repeat that was in a car accident. Follows commands, purposeful. Good strength R arm & R leg. L leg painful to move, L arm splinted, but good movement of fingers, L fingers warm cap refill. O x 3, arouses to voice when sleeping. 2mg Hydromorphone IVP for pain with sleep ensuing.\\n\\nCV - remains tachycardic to 130, sinus tach. BP often 150-160 sys.\\n\\nResp - regular, non-labored breathing. Weak cough when asked to cough, dry. O2 sats fall into 80's without supplemental O2. With face tent & cool neb at 40%, O2 sats 93-96%.\\n\\nGU - urine is clear yellow, no hematuria. QS u/o.\\n\\nGI - no bowel sounds heard. abd softly distended, abd dressing with wrinkles in dressing.\\n\\nL posterior thigh wound beefy red in color, scant serosanguinous drainage. No odor. About kerlix packed into wound.\\n\\nHct at 21:00 33.1, similar to earlier Hcts today.\\n\\n mother & SO, went home for night, both supportive of pt and each other.\\n\\nA; Pt frequently asks what happened to him - short term memory deficit? Continues tachycardic and relatively hypertensive.\\n\\nP:Continue to answer pt's questions. Informational support to family.\\n go to OR Friday to repair L forearm fx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553185,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub sedated on mech vent as per Carevue. Lung sounds ess clear dim R base. ABGs stable. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2123-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1553186,\n \"text\": \"npn\\ns=orally intubated and sedated.\\n\\no=sedated, responds to painful stimuli only. does not open eyes unless moved or suctioned. pupils equal and reactive--left pupil sometimes not in midline. no corneal reflexes noted while sedated on propofol. moves all extremities except left arm. ortho in at start of shift and clamshell splint applied. circulation and color to arm good after application. good cap. refill. propofol decreased at 0600 from 50mkm to 25 mkm in anticipation of extubation. also sedated with alternating doses of mso4 and dilaudid for pain.\\n\\ncv=monitor=st with no ectopy noted. sbp via right radial a-line= 140--170's. diastolic pressures remain consistently in 90's. md aware. ivf at 100cc/hr. propofol as noted above. mgso4 repleted. k+ to be repleted--awaiting mix from phcy.\\n\\npulm=ventilated on simv 16-40%-700-5 cm peep and 5 cm pressure support. resp. rate overnight 16--did not overbreathe vent. at all. breath sounds clear bilaterally to bases except decreased at right base. suctioned for thick slightly tan secretions--scant amts. sats cocsistently 100%.\\n\\ngi=orogastric tube to low wall suction. patent for green gastric contents--50cc. absent bowel sounds. abdomen soft, slightly distended. dressing to abdomen with previously marked serosanguineous staining--no increase in size throughout shift.\\n\\ngu=foley patent for clear yellow urine, at times with sediment. after a.m. care, slightly pink-tinged.\\n\\nheme=continues on q 6hr hcts--no change.\\n\\nendo=no issues.\\n\\nid=temp. remains afebrile this shift. wbc=7.3 from 10.2. left upper leg redressed for moderate serosanguineous drainage. edges clean, non-odorous. continues on antibiotics as ordered.\\n\\nskin=small abrasions at left shoulder and left upper chest laterally. no drainage.\\n\\nsocial=no family contact this shift.\\n\\na=continues tachycardic and hypertensive while sedated on propofol, mso4 and dilaudid. becomes agitated when disturbed.\\n\\np=plan to extubate today.\\n\"\n }\n]"}}},{"rowIdx":24990,"cells":{"subject_id":{"kind":"number","value":25557,"string":"25,557"},"hadm_id":{"kind":"number","value":178001,"string":"178,001"},"target_text":{"kind":"string","value":"SUMMARY 75 yo F with CAD s/p 3V CABG and critical aortic stenosis. She arrived in chest pain that was due to hypertensive emergency (arterial line pressures in excess of 330). She was gradually brought under better control. She was discharged with sBP's of 140-180 and tolerated these pressures without syncope or neurologic deficits. She was evaluated and deemed ineligible for an open AVR. She was discharged to continue optimal medical management of her hypertension, dyslipidemia, cad and AS. She will follow up with Dr. and may receive a percutaneous AVR. BY PROBLEM # Hypertension: Patient presented with hypertensive emergency & chest pain. She was grossly hypertensive in the cath lab with arterial tracings showing systolics in the 330s. She was thought to be chronically hypertensive in setting of medication non-compliance due to financial issues. While outpatient blood pressure checks have SBPs ranging from 110s-140s, she has known left subclavian steal phenomenon and as an inpatient, her cuff pressures underestimate BPs measured via A-line. In the CCU, the patient's blood pressure was initially controlled with Nitroprusside gtt before being transitioned to PO Metoprolol 75mg TID & PO Captopril 100mg TID with resulting sbp's in the 180's-200's initially. Unfortunately, the patient continued to have intermittent SBP's >200 so metoprolol was changed to carvedilol for greater control of blood pressure. She was discharged with sBP's of 140-180 and on a regimen of Carvedilol 25 and Lisinopril 40 . . # Critical AS: Patient with Valve area 0.68 cm^2. Symptomatic with peak gradient of 25 mm Hg. Has symptoms for AS triad (angina, CHF). Cardiac surgery was consulted and accepted the patient for valve replacement surgery. Given her h/o autoimmune hepatitis, she was cleared by hepatology for the procedure. However, given the degree of Aortic Calcification, she was not deemed to be a surgical candidate. Dr. will continue to follow her for percutaneous valve replacement in the spring. . # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain on admission was thought to be demand ischemia in the setting of critical AS and hypertensive emergency as pain resolved with improved bp??????s & patient with negative troponins, no new ischemic EKG changes. Her discharge medications are baby asa, pravastatin, carvedilol and lisinopril . # PUMP: Patient with evidence of acute diastolic congestive heart failure (EF 55% this admission, down from 65% in ), with elevated PCWP. Patient also with R sided PA and RA pressures on R heart cath, indicating evidence of pulmonary hypertension and right-sided heart failure, likely exacerbated in setting of L sided heart failure from critical AS. Her blood pressure was managed as above, avoiding agents that would decrease preload. . # RHYTHM: Patient with history of SVT in 2/. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. She was maintained on Metoprolol and observed on telemetry throughout her stay. . # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line higher than blood pressure cuff, consistent with a diagnosis of PVD. She was maintained on ASA & Pravastatin. . # Carotid artery disease: Patient with history of TIA in (significant R sided ICA stenosis). Carotid US this admission, uchanged from , showed 60-69% stenosis of the right internal carotid artery. Less than 40% stenosis of the left internal carotid artery. Reversed flow in the left vertebral artery, which may correspond to subclavian steal phenomenon. She was maintained on the above beta-blocker, ACE, ASA, statin regimen. . # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11. Patient reportedly on Lipitor but discontinued due to patient concern about cirrhosis and possible liver damage. Patient was prescribed Zetia, but given cost, changed to Pravastatin. . # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8. She was placed on a RISS with FS qACHS during this admission. This were discontinued as her admission hyperglycemia normalized. . # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI at . LFT's were normal during her stay and hepatology cleared patient for cardiac surgery. . # Anemia: Patient with an admission Hct of 30.9 that remained stable throughout her CCU stay. . # History of seizure: Patient was admitted for seizure in . She has been on Keppra, but self-discontinued it because of depression. No further episodes since then or during this CCU stay. **** **** **** **** **** TO BE FOLLOWED 1) Hypertension: Patient discharged on lisinopril 40 after 100 mg of Captopril TID in house. Patient tolerates high blood pressures but becomes weak or dizzy with sBP < 140 2) Medication Managment: Patient with poor compliance due to cost and other issues. The medications were selected with the intention of cost minimization. Her compliance is crucial to the natural history of her present cardiovascular disease. **** **** **** **** **** Medications on Admission: ASA 162 mg daily Cozaar 100 mg daily, Metoprolol XL 100 mg daily . Of note: has been intolerant of statins in the past, has been on Zetia 10 mg PO daily, but also stopped this due to non-compliance. Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart failure Severe Aortic Stenosis Hypertension Hyperlipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had an episode of congestive heart failure and chest pain and was transferred from for a cardiac catherization. You did not have a heart attack. Your blood pressure has been much too high and your aortic valve is very stiff. You were seem by a cardiac surgeon here who thought that you are not a good candidate for a traditional surgical valve replacement. You may be a candidate for a valve replacement done using a cardiac catheterization technique. Dr. will see you at your next cardiologist visit to discuss this further. In the meantime, it is extremely important that you take your blood pressure medicine every day and check your blood pressure at home daily. You need to stay away from salt in your diet. Weigh yourself every morning, call Dr. if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking Cozaar and Metoprolol. 2. Start Carvedilol twice daily to keep your heart rate and blood pressure controlled. 3. Start Lisinopril twice daily to keep your blood pressure controlled. 4. continue aspirin and Pravastatin at the previous dose. Followup Instructions: Cardiology: , Phone: at 9:00am. Please call the office to confirm this appt. . Primary Care: , M. Phone: Date/time: Please keep any previously scheduled appts."},"extractive_notes_summ":{"kind":"string","value":"Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. Aortic stenosis/ Diastolic Heart Failure Assessment: AS- Critical AS per cardiac cath - 0.68cm2. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. - RISS with FS qACHS - check HgA1c . - RISS with FS qACHS - check HgA1c . Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. Response: Plan: Continue ABP management with IV Nipride gtt Aortic stenosis & CHF (Acute Diastolic) Assessment: AS: Cath showing critical AS (the aortic valve area was 0.68 cm2 with a 25mm Hg peak to peak gradient). Action: Response: Plan: Continue ABP management with IV Nipride gtt Aortic stenosis & CHF (Acute Diastolic) Assessment: AS: Cath showing critical AS (the aortic valve area was 0.68 cm2 with a 25mm Hg peak to peak gradient)."},"n_notes":{"kind":"number","value":78,"string":"78"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2127-12-05 00:00:00.000","description":"Report","row_id":84570,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Hypertension. Left ventricular function.\nHeight: (in) 61\nWeight (lb): 149\nBSA (m2): 1.67 m2\nBP (mm Hg): 208/72\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV\nchamber size.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\nannular calcification. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is severe symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. Right ventricular chamber size is normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. There are three\naortic valve leaflets. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area 0.5\ncm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. There is severe mitral annular calcification. Mild to\nmoderate (+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\nhypertrophy with normal global and regional biventricular systolic function.\nMild aortic regurgitation. Mild to moderate mitral regurgitation. Mild\npulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , aortic stenosis\nseverity and degree of LV hypertrophy have progressed. The other findings are\nsimilar.\n\n\n"},{"category":"Physician ","chartdate":"2127-12-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":398752,"text":"Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaterally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely due to demand in setting of critical AS and increased\n afterload from her hypertensive emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\n daily\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 14:48 ------\n"},{"category":"ECG","chartdate":"2127-12-10 00:00:00.000","description":"Report","row_id":206933,"text":"Sinus rhythm with A-V conduction delay. Left atrial abnormality. Right\nbundle-branch block. Left axis deviation may be due to left anterior\nfascicular block. Left ventricular hypertrophy with ST-T wave abnormalities.\nSince the previous tracing of the same date no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2127-12-10 00:00:00.000","description":"Report","row_id":206934,"text":"Sinus rhythm with A-V conduction delay and ventricular premature beat. Left\natrial abnormality. Right bundle-branch block. Left axis deviation may be due\nto left anterior fascicular block. Left ventricular hypertrophy with ST-T wave\nabnormalities. Clinical correlation is suggested. Since the previous tracing\nof ventricular ectopy is present. Otherwise, no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2127-12-04 00:00:00.000","description":"Report","row_id":207170,"text":"Sinus rhythm. The P-R interval is prolonged. Left atrial abnormality. Left\naxis deviation. Right bundle-branch block with left anterior fascicular block.\nLeft ventricular hypertrophy with associated ST-T wave changes, although\nischemia or myocardial infarction cannot be excluded. Compared to the previous\ntracing the P-R interval is longer.\n\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398138,"text":"Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\n pain and progressive DOE as a transfer from \n for cardiac cath on now diagnosed with critical aortic\n stenosis and marked systemic hypertension.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"},{"category":"Physician ","chartdate":"2127-12-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":398140,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: pending\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily and zetia 10mg daily\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will restart losartan today after nitroprusside gtt is discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and losartan today, goal\n sBP 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, consistent with a diagnosis of PVD.\n - continue ASA, Zetia\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - try to obtain carotid U/S records in AM\n - may need carotid U/S here at for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result.\n - continue Zetia 10 mg PO daily\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"},{"category":"Physician ","chartdate":"2127-12-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":398146,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: my read\nno acute cardiopulmonary process\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"},{"category":"Physician ","chartdate":"2127-12-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":398125,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: pending\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily and zetia 10mg daily\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - will restart losartan today\n - treatment of hypertension (see below)\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s. BP\n brought down by nitroprusside gtt overnight in the CCU to SBPs 200.\n Likely chronically hypertensive in setting of medication non-compliance\n due to financial issues. Outpt blood pressure checks have SBPs ranging\n from 110s-140s, but were in the left arm with known L subclavian steal\n phenomenon. Also, cuff pressure seems to underestimate the true BPs\n that are measured via A-line.\n - transition nitroprusside gtt to metoprolol and losartan today\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Critical symptomatic AS (0.7 cm^2)\n with peak to peak gradient of 25 mm Hg. Patient also with R sided PA\n and RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - transition nitroprusside gtt to metoprolol and losartan today\n - no nitroglycerin given critical AS\n - f/u on BNP\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, consistent with a diagnosis of PVD.\n - continue ASA, Zetia\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - try to obtain carotid U/S records in AM\n - may need carotid U/S here at for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result.\n - continue Zetia 10 mg PO daily\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398207,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Action:\n Response:\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398209,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Response:\n No CHF on CXR, adequate UOP. + 300cc at MN.\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398210,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Response:\n No CHF on CXR, adequate UOP. + 300cc at MN.\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n ------ Protected Section ------\n Of note: 02 sat transiently down to 85% then quickly back up to 93%. Pt\n sound asleep. ? sleep apnea. Sat 96-98% when woken up by RN. Denies\n SOB. Pt denies any h/o sleep apnea. Placed on supplemental 2L\n NC\nContinue to monitor.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:16 ------\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398119,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398120,"text":"Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\n pain and progressive DOE as a transfer from \n for cardiac cath on now diagnosed with critical aortic\n stenosis and marked systemic hypertension.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398304,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 190\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.1\n HR: 62 (56 - 76) bpm\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.2 kg (admission): 64.8 kg\n Total In:\n 506 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 266 mL\n Blood products:\n Total out:\n 1,075 mL\n 215 mL\n Urine:\n 1,075 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n -95 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///23/\n Physical Examination\n General: Well nourished, No acute distress\n Neck: supple with JVP 7cm\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\n at LUSB\n Respiratory: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\n Extremities: No LE edema\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, AAOx3\n Labs / Radiology\n 181 K/uL\n 10.3 g/dL\n 150 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 40 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.9 %\n 6.6 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n Plt\n 182\n 186\n 184\n 181\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n 150\n Other labs:\n PT / PTT / INR:12.7/25.5/1.1,\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved but still not at goal of\n 150-160.\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control for goal sBP 150-160\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR.\n - ordered dental consult and panorex\n - per hepatology consult, pt is a good candidate for surgery from liver\n perspective\n - pt will get CTA today. Pt with Contrast allergy to be managed with\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\n - avoid medications that could decrease preload, such as NTG\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA and pravastatin\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - awaiting AVR surgery\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - pt may live at BP around 200, and if BP drop lower pt may experience\n TIA and dizziness. Need to monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, zetia\n changed to pravastatin.\n - continue pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n - per hepatology, pt is a good candidate for AVR from liver stand\n point.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable during this admission.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: regular cardiac-healthy diet\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 07:54 PM\n Prophylaxis:\n DVT: pneumoboots (pt refused sc heparin)\n Stress ulcer: none\n VAP: n/a\n Comments:\n Communication: Comments: husband\n status: Full code\n Disposition: will stay in CCU for BP optimization\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Transfer Note","row_id":398383,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398274,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from Hosp for cardiac cath on . Cath showed\n critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310\n & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/ Nipride gtt--\n DCd -- converted to PO antihypertensives. Diuresed w/ lasix in cath\n lab. R fem venous and art sheaths DCd . OF NOTE: L subclavian steel-\n significant difference in arm BPs, L 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n Pre-contrast prophylactic meds for CT given as ordered\n (allergy to Shellfish/iodine), Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CF management-2L Fluid restruction, low Na+ diet, daily wts,\n strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398275,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\n minimal assist. No c/o dizziness. Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\n for CT given as ordered, Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"},{"category":"General","chartdate":"2127-12-04 00:00:00.000","description":"Generic Note","row_id":398095,"text":"TITLE: Cardiology fellow CCU admit note\n 75 yo woman with CAD s/p CABG in , autoimmune hepatitis, now with\n severe aortic stenosis ( 0.7 cm2) and SEVERE HTN with systolic BPs\n in the 280s and LV systolic pressures in the 320s. Admitted to CCU for\n invasive BP monitoring, intravenous antihypertensives and diuresis.\n Start with nitroprusside with goal SBP of 200 mm Hg. Would also\n administer 10 mg IV furosemide at this time.\n"},{"category":"Physician ","chartdate":"2127-12-05 00:00:00.000","description":"Physician Resident Admission Note","row_id":398101,"text":"Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaerally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n .\n Cardiac cath: :\n Aortic valve area: 0.68 cm^2 and 25 mm Hg peak to peak gradient\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low na, cardiac, diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2127-12-05 00:00:00.000","description":"Physician Resident Admission Note","row_id":398102,"text":"Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaterally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely due to demand in setting of critical AS and increased\n afterload from her hypertensive emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\n daily\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398179,"text":"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by .\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Progress Note","row_id":398367,"text":"Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Progress Note","row_id":398368,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by .\n Response:\n Plan:\n Hyperglycemic\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398181,"text":"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398258,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs persistently > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP mamangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398264,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Emotional support provided\n Get OOB, ^ activity\n as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Progress Note","row_id":398340,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 200\n Action:\n Captopril 100mg TID and Lopressor 75mg TID given as ordered\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. No\n dizziness/lightheadedness\n Plan:\n Continue BP manangement, goal SBP ~150-160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills, I\nve taken 25 pills today\n. Slept well overnight,\n startles when woken up by RN for nsg interventions.\nJust leave me\n alone\n. Emotional support provided\n Get OOB, ^ activity as tolerated.\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Progress Note","row_id":398341,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills, I\nve taken 25 pills today\n. Slept well overnight,\n startles when woken up by RN for nsg interventions.\nJust leave me\n alone\n. Emotional support provided\n Get OOB, ^ activity as tolerated.\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398346,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\n of the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - no CTsurg recs\n - BP great, in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398348,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\n of the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - no CTsurg recs\n - BP great, in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt may be slightly dry today given small rise in Cr. Continue to\n observe, but very conservative fluid management.\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398349,"text":"Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt may be slightly dry today given small rise in Cr. Continue to\n observe, but very conservative fluid management.\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398352,"text":"Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398354,"text":"Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398357,"text":"Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"},{"category":"Physician ","chartdate":"2127-12-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":398358,"text":"Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Will target BP of 150 mm/Hg. Surgery Wed or Friday.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:18 ------\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398243,"text":"is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n Impaired Skin Integrity\n Assessment:\n Gluteal fold/coccyx\n Action:\n Mepilex intact in place pt repositioned several times\n Response:\n Unchanged\n Plan:\n Continue to turn side to side , change positions frequently\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP 130-220, critical AS per cardiac cath\n Action:\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\n pulses dopplerable\n Response:\n Sbp 190\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\n hypotension that she felt sick nausea dizzy once when bp went as low as\n 130sbp and another when pt tried to get oob to use commode pt s bp\n dropped to 160\ns and pt had to quickly get back into bed r/t feeling so\n bad once n bed c legs elevated pt felt better she received zofran for\n nausea, right fem arterial and venous sheaths removed no bleeding at\n site no hematoma\n Plan:\n Monitor hemodynamics closely, po meds will need to be increased as\n needed and tolerated, niprid gtt dc\nd , goal is to decrease bp very\n slowly\n .\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398244,"text":"is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n Impaired Skin Integrity\n Assessment:\n Gluteal fold/coccyx skin tear\n Action:\n Mepilex intact in place pt repositioned several times\n Response:\n Unchanged\n Plan:\n Continue to turn side to side , change positions frequently\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP 130-220, critical AS per cardiac cath\n Action:\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\n pulses dopplerable\n Response:\n Sbp 190\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\n hypotension that she felt sick nausea dizzy once when bp went as low as\n 130sbp and another when pt tried to get oob to use commode pt s bp\n dropped to 160\ns and pt had to quickly get back into bed r/t feeling so\n bad. once n bed c legs elevated pt felt better she received zofran for\n nausea, right fem arterial and venous sheaths removed no bleeding at\n site no hematoma\n Plan:\n Monitor hemodynamics closely, po meds will need to be increased as\n needed and tolerated, niprid gtt dc\nd , goal is to decrease bp very\n slowly\n .\n"},{"category":"Nursing","chartdate":"2127-12-08 00:00:00.000","description":"Nursing Progress Note","row_id":398344,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management--2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx. Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Improving\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: freq\n BP checks and not being able to go to the bathroom in room or shower.\n Stated,\n I am not taking anymore pills, I\nve taken 25 pills today\n Slept well overnight, startles when woken up by RN for nsg\n interventions.\nJust leave me alone\n. Emotional support provided\n Get\n OOB, ^ activity as tolerated. ? DC foley\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398325,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L improvement\n noted.\n Plan:\n Monitor area closely- con\nt skin care.\n Hyperglycemia\n Assessment:\n Blood sugar elevated on admission- glucose range 141- 218 today.\n Action:\n Insulin given as per sliding scale.\n Response:\n Stable.\n Plan:\n Con\nt q6hr fingersticks and Rx as per SS.\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398241,"text":"Impaired Skin Integrity\n Assessment:\n gluteal\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\n tomorrow.\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Con\nt to monitor closely.\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- area open to air.\n Response:\n Unchanged.\n Plan:\n Monitor area closely- con\nt freq repositioning & back care.\n"},{"category":"Physician ","chartdate":"2127-12-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":398223,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n AORTIC STENOSIS\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2127-12-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":398224,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n TTE\n The left atrium is moderately dilated. There is severe symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Regional left ventricular wall motion is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. Right ventricular chamber\n size is normal. The diameters of aorta at the sinus, ascending and arch\n levels are normal. There are three aortic valve leaflets. The aortic\n valve leaflets are severely thickened/deformed. There is critical\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\n regurgitation is seen. The mitral valve leaflets are moderately\n thickened. There is severe mitral annular calcification. Mild to\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\n hypertrophy with normal global and regional biventricular systolic\n function. Mild aortic regurgitation. Mild to moderate mitral\n regurgitation. Mild pulmonary hypertension.\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2127-12-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":398229,"text":"Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n TTE\n The left atrium is moderately dilated. There is severe symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Regional left ventricular wall motion is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. Right ventricular chamber\n size is normal. The diameters of aorta at the sinus, ascending and arch\n levels are normal. There are three aortic valve leaflets. The aortic\n valve leaflets are severely thickened/deformed. There is critical\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\n regurgitation is seen. The mitral valve leaflets are moderately\n thickened. There is severe mitral annular calcification. Mild to\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\n hypertrophy with normal global and regional biventricular systolic\n function. Mild aortic regurgitation. Mild to moderate mitral\n regurgitation. Mild pulmonary hypertension.\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Will further lower blood pressure parenterally for sheath pull. Will\n image thorax per request of interventional cardiology and CT surgery.\n Increase dose of ACE.\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398240,"text":"Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398312,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 250.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem aline) of 200.\n Requested SW consult to discuss financial medication issues.\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weights\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398112,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398110,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Cath showing unchanged 3 VD native LAD 100 %.(patent SVG to LAD &\n patent SVG to RCA) (Occluded SVG to OM, diffuse mid-LAD <40%).\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398111,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398114,"text":"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weights\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398195,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68 cm2 w/ a 25mm Hg peak to\n peak gradient & marked systemic HTN w/ SBP 310 & elevated PA pressures\n w/ PCWP 29. BPs intially tx\nd w/ Nipride gtt, DCd . Diuresed w/\n lasix in cath lab. Echo showed EF >55%.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\n left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Action:\n Response:\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT.\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n"},{"category":"Nursing","chartdate":"2127-12-06 00:00:00.000","description":"Nursing Progress Note","row_id":398196,"text":"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\n left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Action:\n Response:\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"},{"category":"Nursing","chartdate":"2127-12-07 00:00:00.000","description":"Nursing Progress Note","row_id":398276,"text":"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\n minimal assist. No c/o dizziness. Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\n for CT given as ordered, Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398186,"text":"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"},{"category":"Nursing","chartdate":"2127-12-05 00:00:00.000","description":"Nursing Progress Note","row_id":398190,"text":"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\n tomorrow.\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Con\nt to monitor closely.\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- area open to air.\n Response:\n Unchanged.\n Plan:\n Monitor area closely- con\nt freq repositioning & back care.\n"},{"category":"Physician ","chartdate":"2127-12-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":398280,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:00 AM\n SHEATH - STOP 11:00 AM\n - increased captopril to 100 TID\n - used nipride to drop pressure while Aline sheeth is being pulled\n - pressure to 120's with 3 of Nipride, to 176 after decreased to 0.24,\n adjusting to goal fo 150\n - ordered dental consult and panorex\n - hepatology consult: good candidate for surgery from liver perspective\n - CTA: Contrast allergy to be managed with pre-treatment (prednisone,\n ranitidine, benadryl). CTA at 8am Sunday\n - Received Hydralazine 25 mg at 0100 for sBP > 190\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.1\n HR: 62 (56 - 76) bpm\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.2 kg (admission): 64.8 kg\n Total In:\n 506 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 266 mL\n Blood products:\n Total out:\n 1,075 mL\n 215 mL\n Urine:\n 1,075 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n -95 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///23/\n Physical Examination\n General: Well nourished, No acute distress\n Neck: supple with JVP 7cm\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\n at LUSB\n Respiratory: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\n Extremities: No LE edema\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, AAOx3\n Labs / Radiology\n 181 K/uL\n 10.3 g/dL\n 150 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 40 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.9 %\n 6.6 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n Plt\n 182\n 186\n 184\n 181\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n 150\n Other labs:\n PT / PTT / INR:12.7/25.5/1.1,\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved but still not at goal of\n 150-160.\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control for goal sBP 150-160\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR.\n - ordered dental consult and panorex\n - per hepatology consult, pt is a good candidate for surgery from liver\n perspective\n - pt will get CTA today. Pt with Contrast allergy to be managed with\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\n - avoid medications that could decrease preload, such as NTG\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA and pravastatin\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - awaiting AVR surgery\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - pt may live at BP around 200, and if BP drop lower pt may experience\n TIA and dizziness. Need to monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, zetia\n changed to pravastatin.\n - continue pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n - per hepatology, pt is a good candidate for AVR from liver stand\n point.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable during this admission.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: regular cardiac-healthy diet\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 07:54 PM\n Prophylaxis:\n DVT: pneumoboots (pt refused sc heparin)\n Stress ulcer: none\n VAP: n/a\n Comments:\n Communication: Comments: husband\n status: Full code\n Disposition: will stay in CCU for BP optimization\n"},{"category":"Radiology","chartdate":"2127-12-08 00:00:00.000","description":"R VENOUS DUP EXT UNI (MAP/DVT) RIGHT","row_id":1116006,"text":", M. 11:45 AM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring valve replacement surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PFI REPORT\n Patent right greater and lesser saphenous veins with diameters described\n below.\n\n\n"},{"category":"Radiology","chartdate":"2127-12-08 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":1116007,"text":" 11:45 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:24 PM\n PFI:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\n subclavian steal.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with critical AS requiring surgery. Pre-op.\n\n TECHNIQUE: Evaluation of the bilateral extracranial carotid arteries as well\n as vertebral arteries was performed with B-mode, color and spectral Doppler\n ultrasound.\n\n FINDINGS: A mild amount of plaque was seen in the bilateral internal carotid\n arteries, with B-mode ultrasound.\n\n On the right side peak systolic velocities were 187 cm/sec for the internal\n carotid artery and 69 cm/sec for the common carotid artery. The right ICA/CCA\n ratio was 2.7.\n\n On the left side peak systolic velocities were 98 cm/sec for the ICA and 68\n cm/sec for the CCA. The left ICA/CCA ratio was 1.44.\n\n The right vertebral artery presented antegrade flow. The left vertebral\n artery presented with retrograde flow, suggestive of left subclavian steal.\n\n COMPARISON: No change when compared to the carotid duplex scan obtained in\n .\n\n IMPRESSION:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Reverse flow in the left vertebral artery, which may correspond to\n subclavian steal phenomenon.\n\n\n"},{"category":"Radiology","chartdate":"2127-12-08 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":1116008,"text":", M. 11:45 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\n subclavian steal.\n\n\n"},{"category":"Radiology","chartdate":"2127-12-08 00:00:00.000","description":"R VENOUS DUP EXT UNI (MAP/DVT) RIGHT","row_id":1116005,"text":" 11:45 AM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring valve replacement surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:18 PM\n Patent right greater and lesser saphenous veins with diameters described\n below.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with critical AS requiring valve replacement\n surgery. Venous mapping was requested.\n\n The right greater saphenous vein is patent and compressible with diameters\n ranging between 0.25 and 0.31 cm. The right lesser saphenous vein is patent\n and compressible with diameters ranging between 0.21 and 0.29 cm. The left\n greater saphenous vein was not visualized due to previous harvesting.\n\n COMPARISON: None available.\n\n IMPRESSION: Patent right greater and lesser saphenous veins, with diameters\n described above.\n\n\n"},{"category":"Radiology","chartdate":"2127-12-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1115565,"text":" 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary congestion, consolidation\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD, critical AS, elevated PCWP\n REASON FOR THIS EXAMINATION:\n pulmonary congestion, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Pulmonary congestion.\n\n FINDINGS: Cardiac silhouette remains enlarged, and there is unchanged\n tortuosity and calcification of the thoracic aorta. Lungs are grossly clear,\n and there are no pleural effusions or acute skeletal findings.\n\n\n"},{"category":"Radiology","chartdate":"2127-12-07 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1115847,"text":" 9:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with aortic stenosis\n REASON FOR THIS EXAMINATION:\n please evaluate from axillary arteries to common femoral. This is a pre-op\n exam. Please conduct study at 0800 so that her pretreatment schedule is correct\n CONTRAINDICATIONS for IV CONTRAST:\n allergy: Preteated !\n ______________________________________________________________________________\n WET READ: SPfc 11:26 AM\n Extensive atherosclerotic disease with ectasia of the ascending aorta, similar\n to that seen in . Otherwise, incidental note is made of a nodule in the\n left lower lobe of the lungs, appearing slightly larger since . This\n could be followed with a dedicated high-res Chest ct in ~3months\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation in a patient with aortic stenosis.\n\n TECHNIQUE: Axial CT images were acquired through the torso prior to and\n thereafter following the administration of 100 cc of intravenous Optiray 350\n contrast. Coronal and sagittal reformatted images were also reviewed.\n\n CT CHEST WITH AND WITHOUT CONTRAST: The airways are patent to segmental\n levels bilaterally. Heterogeneous attenuation throughout the lungs is likely\n related to air-trapping. There is a small amount of dependent atelectasis\n bilaterally. A nodular opacity posterolaterally in the left lower lobe is 13\n x 9 mm. This correlates to a small nodular opacity, which was described on a\n CT from , and has now grown minimally in size. There is no\n axillary lymphadenopathy. A hypodense pretracheal node is borderline in size,\n measuring 10mm in shortest diameter.\n\n The heart and great vessels are notable for coronary arterial calcification as\n well as aortic valvular calcification. In addition, calcification is\n visualized along the length of the aorta, which is ectatic, unchanged from the\n previous studies, measuring approximately 37 x 38 mm in the ascending aorta.\n Dense calcification is also prominent at the origin of the left subclavian\n artery. The main as well as right pulmonary arteries are prominent in size\n measuring ~29 mm, suggesting pulmonary hypertension. Note is made of\n cardiomegaly, in particular with left atrium appears enlarged.\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: The stomach, duodenum, spleen,\n pancreas, adrenal glands, right kidney, and gallbladder are unremarkable. The\n left kidney contains an 18x18mm hypodensity which is hypodense (~27H.U.) and\n does not enhance, though is new or enlarged. The liver is notable for three\n hypodensities, two in the right lobe and one in the left, all of which are too\n small to characterize though appear unchanged from . There is no free gas\n or free fluid in the abdomen. There is no retroperitoneal or mesenteric\n lymphadenopathy.\n (Over)\n\n 9:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Vascular structures are notable for extensive atherosclerotic calcification\n along the length of the aorta in the absence of aneurysmal dilation.\n Calcification is noted at the origin of the renal arteries bilaterally as well\n as at the origin of the superior mesenteric artery. The celiac trunk is\n notable for a separate origin of the left gastric artery.\n\n CT PELVIS WITH AND WITHOUT CONTRAST: The urinary bladder contains a small\n amount of gas and a Foley catheter. The uterus, right adnexa, and rectum are\n unremarkable. The colon reveals diverticulosis. A punctate calcification in\n the left adnexa is unchanged. There is no free gas or fluid in the pelvis,\n and there is no pelvic sidewall or inguinal lymphadenopathy. Regional\n vascular structures opacify normally. Note is made of scattered injection\n granulomas in the right buttocks region.\n\n OSSEOUS FINDINGS: The patient is status post median sternotomy. There is a\n wedge compression deformity in the mid thoracic spine at the T5 vertebral\n body, which is unchanged since . There is a grade 1 anterolisthesis of L4\n over L5. Degenerative disc disease at that same level with endplate sclerosis\n has progressed since .\n\n IMPRESSION:\n 1. Extensive atherosclerotic disease as well as ectatic dilation of the\n ascending aorta, similar to that seen in .\n 2. Left lower lobe pulmonary nodular opacity, appearing minimally enlarged\n from . Given the size of this lesion, followup with a PET study or\n dedicated CT of the chest within three months, is recommended.\n 3. Diverticulosis\n 4. Left renal hypodensity. While this is likely a cyst, it is new/enlarged\n from the previous study and could be correlated to U/S for further\n characterization.\n 3. Stable hepatic hypodensities too small to characterize but likely cysts.\n 4. Wedge compression deformity in the mid thoracic spine and degenerative\n changes in the remainder of the spine as cataloged above.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84570,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Hypertension. Left ventricular function.\\nHeight: (in) 61\\nWeight (lb): 149\\nBSA (m2): 1.67 m2\\nBP (mm Hg): 208/72\\nHR (bpm): 76\\nStatus: Inpatient\\nDate/Time: at 10:00\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional\\nLV systolic function. Overall normal LVEF (>55%).\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV\\nchamber size.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\\nvalve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\\nannular calcification. No MS. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is severe symmetric left\\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\\nleft ventricular wall motion is normal. Overall left ventricular systolic\\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\\nmotion are normal. Right ventricular chamber size is normal. The diameters of\\naorta at the sinus, ascending and arch levels are normal. There are three\\naortic valve leaflets. The aortic valve leaflets are severely\\nthickened/deformed. There is critical aortic valve stenosis (valve area 0.5\\ncm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\\nmoderately thickened. There is severe mitral annular calcification. Mild to\\nmoderate (+) mitral regurgitation is seen. There is mild pulmonary artery\\nsystolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\\nhypertrophy with normal global and regional biventricular systolic function.\\nMild aortic regurgitation. Mild to moderate mitral regurgitation. Mild\\npulmonary hypertension.\\n\\nCompared with the prior study (images reviewed) of , aortic stenosis\\nseverity and degree of LV hypertrophy have progressed. The other findings are\\nsimilar.\\n\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 398752,\n \"text\": \"Chief Complaint: chest pain, SOB\\n HPI:\\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\\n who presented to an OSH on with acute onset chest pain and\\n progressive DOE, and was transferred to today for cardiac\\n catherization.\\n .\\n Patient reports progressive worsening of DOE since her CABG in .\\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\\n . Her symptoms have progressed to the point where she rarely leaves\\n her house anymore. Denies any associated chest pain prior to this\\n symptoms except on Monday at midnight, when she had sudden onset\\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\\n n/v. No SOB at time due to being at rest. Anginal equivalent is\\n atypical fleeting pain in all areas of her chest, states this\\n particular pain was more severe in nature. Chest pain lasted for 4\\n hours, subsided without intervention. She called her cardiologist's\\n office in the morning and was advised by her cardiologist to go to the\\n ED for immediate evaluation. Poorly compliant with blood pressure\\n medications due to medications prices (ie has been taking some meds\\n daily in order to make them last).\\n .\\n She presented to Hospital for these symptoms on . There,\\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \\n for cardiac cath on .\\n .\\n In the cath lab, patient was noted to have severe AS (valve area of\\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\\n Cardiac cath showed patent grafts unchanged from cath. She was\\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\\n was started on a nitroprusside gtt with good control of her SBPs in the\\n 200s.\\n .\\n On review of systems, s/he denies any prior history of deep venous\\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\\n S/he denies recent fevers, chills or rigors. S/he denies exertional\\n buttock or calf pain. All of the other review of systems were\\n negative.\\n .\\n Patient admitted from: Transfer from other hospital\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n ASA 162 mg daily\\n Cozaar 100 mg daily,\\n Metoprolol XL 100 mg daily\\n .\\n Of note: has been intolerant of statins in the past, has been on Zetia\\n 10 mg PO daily, but also stopped this due to non-compliance.\\n Past medical history:\\n Family history:\\n Social History:\\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\\n 2. CARDIAC HISTORY:\\n Cardiac Catheterization performed for symptoms of unstable\\n angina\\n PTCA to mid LAD\\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\\n -> Left anterior descending, Saphenous vein graft -> Obtuse\\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\\n not used due to retrograde L vertebral flow and concern of future left\\n subclavian artery steal.\\n : Cardiac Cath (performed in setting of chest pain, SVT):\\n patent grafts, SVG-> OM1 occluded. No significant change in graft\\n patency otherwise.\\n .\\n 3. OTHER PAST MEDICAL HISTORY:\\n Hypertension\\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\\n Anemia\\n Aortic stenosis\\n TIA (significant R sided ICA stenosis)\\n Peripheral Vascular Disease\\n Seizure in (oral numbness, followed by R hand/R leg numbness and\\n weakness. has been on Keppra, but was self-discontinued by patient due\\n to symptoms of depression).\\n Carotid artery disease\\n L sided subclavian steal\\n h/o SVT in \\n s/p appendectomy\\n (+) FHx CAD: 5 brothers and sisters all with CAD\\n in 60's\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Retired, married lives with husband and 2 adult children. used\\n to work at for 20 years. denies tobacco or ETOH use\\n Review of systems:\\n Flowsheet Data as of 12:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 75 (75 - 86) bpm\\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\\n RR: 18 (16 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 312 mL\\n 30 mL\\n PO:\\n TF:\\n IVF:\\n 312 mL\\n 30 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 0 mL\\n Urine:\\n 995 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,283 mL\\n 30 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///23/\\n Physical Examination\\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\\n pallor or cyanosis of the oral mucosa. No xanthalesma.\\n NECK: Supple with JVP of 6 cm at 45' angle.\\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\\n systolic crescendo-decrescendo murmur heard throughout the precordium\\n radiating to the carotics. no gallops or rubs.\\n Carotids: III/VI decresencdo murmer radiating to both carotids\\n bilaterally, louder R > L.\\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\\n palpation. No abdominial bruits.\\n EXTREMITIES: No c/c/e. No femoral bruits.\\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\\n PULSES:\\n Right: DP 2+ PT 2+\\n Left: DP 2+ PT 2+\\n Labs / Radiology\\n 182 K/uL\\n 10.2 g/dL\\n 191 mg/dL\\n 0.9 mg/dL\\n 21 mg/dL\\n 23 mEq/L\\n 103 mEq/L\\n 4.0 mEq/L\\n 138 mEq/L\\n 30.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n \\n 2:33 A1/7/ 08:37 PM\\n \\n 10:20 P\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 7.2\\n Hct\\n 30.9\\n Plt\\n 182\\n Cr\\n 0.9\\n Glucose\\n 191\\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\\n mg/dL\\n Fluid analysis / Other labs: ETT: () - normal symptomatic\\n response to adenosie, no significant arythmias, nuclear images neg for\\n ischemia with LVEF of > 60%.\\n .\\n CARDIAC CATH:\\n :\\n 1. Selective coronary angioigraphy of this right-dominant system\\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\\n The LAD had 50% proximal stenosis. The LCX was free from significant\\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\\n disease.\\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\\n occluded SVG-OM.\\n 3. Left ventriculography was deferred due to known dilated ascending\\n aorta and complex > 4 mm aortic plaque per previous TEE.\\n 4. Limited hemodynamic assessment revealed severe systemic arterial\\n hypertension (190/70 mmHg, right arm).\\n .\\n :\\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)\\n .\\n Coronary angiography: right dominant\\n LMCA: non selective injection. No apparent stenosis\\n LAD: 100% proximal occlusion\\n LCX: Patent to tortuous OMB\\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\\n SVG-OMB: occluded\\n .\\n There was marked systemic hypertension (up to 310mmHg) and a pressure\\n difference from the left arm to the right arm consistent with\\n subclavian stenosis.\\n .\\n Assessment and Recommendation:\\n 1. three vessel coronary artery disease\\n 2. Patent SVG to the LAD; Patent SVG to the RCA\\n 3. Occluded SVG to the OMB\\n 4. Severe systemic hypertension\\n 5. Critical aortic stenosis\\n 6. CCU for IV nipride and BP control\\n 7. Aortic valve replacement surgery\\n .\\n FINAL DIAGNOSIS:\\n 1. Two vessel and moderate left main coronary artery disease, unchanged\\n from prior angiogram.\\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\\n 3. Severe hypertension.\\n Hospital Records:\\n Lipid panel:\\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\\n Ferritin: 73 TSH: 3.0\\n Imaging: : (TEE) -\\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\\n There is moderate symmetric left ventricular hypertrophy. Right\\n ventricular chamber size and free wall motion are normal. There are\\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\\n done to confirm no atheroma at cannulation or cross-clamp location.\\n There are simple atheroma in the descending thoracic aorta. The aortic\\n valve leaflets are moderately thickened with relative immobility of the\\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\\n regurgitation is seen. There is severe MAC. There is no pericardial\\n effusion.\\n .\\n Postbypass: - Normal LV systolic function, Normal RV systolic\\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\\n otherwise unchanged from prebypass.\\n .\\n TTE: () per PCP : concentric LVH, post-operative septal\\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\\n .\\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\\n with RBBB. Given LAD, this is indicative of bifascicular block with\\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\\n V1-V3. No significant ST changes.\\n Assessment and Plan\\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\\n with chest pain and progressive DOE, diagnosed with critical aortic\\n stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely due to demand in setting of critical AS and increased\\n afterload from her hypertensive emergency.\\n - continue ASA 325 mg PO daily, zetia\\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\\n - hold losartan for now\\n - treatment of hypertension (see below)\\n .\\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\\n indicating evidence of pulmonary hypertension, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. EF 64% in 3/.\\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\\n restricted diet\\n - continue nitroprusside gtt\\n - if chest pain, start enalaprilat or esmolol gtt\\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\\n -1 L overnight\\n - no nitroglycerin\\n - continue BB\\n - holding for now\\n - check BNP\\n - contact for aortic valve replacement evaluation\\n - CXR, TTE in AM\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\\n the cath lab with arterial tracings showing systolics in the 330s.\\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\\n in the 220s. Likely chronically hypertensive in setting of medication\\n non-compliance due to financial issues. Outpt blood pressure checks\\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\\n evidence of patient's known L subclavian steal phenomenon.\\n - continue nitroprusside gtt goal SBP 200\\n - continue BB\\n - has arterial sheath in place for A-line tracings\\n - holding for now\\n - SW consult for med compliance\\n - consider renal U/S to assess for artery stenosis.\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - needs eval for AVR\\n - avoid medications that could decrease preload\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - check HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at .\\n - trend LFTS\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis)\\n - try to obtain carotid U/S records in AM\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage.\\n - continue Zetia 10 mg PO daily\\n .\\n # Peripheral Vascular Disease: Patient with possible vascular dementia\\n given hx of PVD and TIAs. A-line higher than blood pressure\\n cuff, indicating evidence of PVD.\\n - continue ASA, Zetia\\n .\\n # History of seizure: Patient was admitted for seizure in (has\\n been on Keppra, but was self-discontinued by patient). No further\\n episodes since then. Will continue to monitor.\\n .\\n ICU Care\\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\\n daily\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I have also reviewed the notes of Dr(s). .\\n I would add the following remarks:\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:48 ------\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206933,\n \"text\": \"Sinus rhythm with A-V conduction delay. Left atrial abnormality. Right\\nbundle-branch block. Left axis deviation may be due to left anterior\\nfascicular block. Left ventricular hypertrophy with ST-T wave abnormalities.\\nSince the previous tracing of the same date no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 206934,\n \"text\": \"Sinus rhythm with A-V conduction delay and ventricular premature beat. Left\\natrial abnormality. Right bundle-branch block. Left axis deviation may be due\\nto left anterior fascicular block. Left ventricular hypertrophy with ST-T wave\\nabnormalities. Clinical correlation is suggested. Since the previous tracing\\nof ventricular ectopy is present. Otherwise, no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 207170,\n \"text\": \"Sinus rhythm. The P-R interval is prolonged. Left atrial abnormality. Left\\naxis deviation. Right bundle-branch block with left anterior fascicular block.\\nLeft ventricular hypertrophy with associated ST-T wave changes, although\\nischemia or myocardial infarction cannot be excluded. Compared to the previous\\ntracing the P-R interval is longer.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398138,\n \"text\": \"Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\\n pain and progressive DOE as a transfer from \\n for cardiac cath on now diagnosed with critical aortic\\n stenosis and marked systemic hypertension.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference noted Left arm < Right arm; consistent with left subclavian\\n stenosis.\\n Patient asymptomatic with no c/o h/a or dizziness. Reports\\n non-compliance with cardiac meds financial restrictions.\\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\\n aline SBP > 250. Bounding pedal pulses.\\n Action:\\n Nitroglycerin d/c\\nd- initiated low-dose Nipride gtt with\\n goal SBP (by fem a-line) of 200.\\n 50 mg lopressor given in TID dosing\\n Knee immobilizer to right leg to encourage patient to\\n maintain straight leg and bedrest\\n Patient refused sq heparin\\n MD notified\\n Requested SW consult to discuss financial medication issues.\\n Response:\\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\\n arterial SBP 200 while patient sleeping\\n Patient non-compliant with bedrest condition, keeps\\nforgetting\\n restrictions, but is easily re-oriented and slept\\n comfortably overnight, startles aware to light touch. (? Degree of\\n dementia).\\n SQ heparin d/c\\nd- pneumo boots ordered & placed.\\n SW consult ordered.\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Invasive hemodynamic monitoring- goal currently SBP 200.\\n Maintain safety & integrity of femoral aline and venous\\n sheath\\n SW consult\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n AS: Cath showing critical AS (the aortic valve area was\\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\\n clear/slightly diminished bilateral bases.\\n Received 40 mg IVP lasix in cath lab prior to transfer.\\n Action:\\n 2 liter fluid restrictions; goal 1 liter negative overnight.\\n Completed post-cath fluid D5\\n NS at 75 cc\\ns per hour for\\n 450 cc\\ns total.\\n Monitored output in response to 40 mg IVP lasix given in lab\\n Response:\\n Excellent diuretic response to 40 mg IV- negative 1 liter at\\n midnight.\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Caution with meds that reduce pre-load (ie NTG).\\n Ordered for Cxray and TTE in am\\n Maintain 2 liter fluid restriction, low-salt diet, daily\\n weight.\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered.\\n Hyperglycemia\\n Assessment:\\n Patient denies history of DM. Elevated serum glucose on CCU admission\\n to 191.\\n Action:\\n FSBG elevated to 274 at 10 pm\\n Response:\\n RISS sliding scale coverage ( 8 units at 10 pm) given\\n Plan:\\n Continue to monitor BG levels.\\n Team discussing ordering HgA1c.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398140,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 07:52 PM\\n SHEATH - START 07:56 PM\\n CARDIAC CATH - At 08:08 PM\\n NASAL SWAB - At 12:00 AM\\n Admitted overnight\\n No event overnight\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.7\\nC (98\\n HR: 69 (69 - 86) bpm\\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\\n RR: 17 (16 - 23) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 512 mL\\n 328 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 312 mL\\n 328 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 435 mL\\n Urine:\\n 995 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,083 mL\\n -107 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///23/\\n Physical Examination\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n NECK: Supple, with JVP of 8cm\\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\\n peaking systolic crescendo-decrescendo murmur heard throughout the\\n precordium radiating to the carotics. no gallops or rubs.\\n LUNGS: CTAB\\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\\n guarding, no rebound.\\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\\n at right groin in place (not pulled)\\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\\n (Right DP pulse: 2+), (Left DP pulse: 2+)\\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\\n Neurologic: AOx3, neuro exam grossly normal\\n Labs / Radiology\\n 186 K/uL\\n 9.8 g/dL\\n 180 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 3.6 mEq/L\\n 27 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 28.7 %\\n 4.3 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n WBC\\n 7.2\\n 4.3\\n Hct\\n 30.9\\n 28.7\\n Plt\\n 182\\n 186\\n Cr\\n 0.9\\n 1.1\\n Glucose\\n 191\\n 180\\n Other labs:\\n PT / PTT / INR:12.8/25.5/1.1,\\n CK 31,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\\n proBNP: 2787\\n MICRO: none\\n CXR from today: pending\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily and zetia 10mg daily\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - will restart losartan today after nitroprusside gtt is discontinued\\n - treatment of hypertension (see below)\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP was around 200 overnight on\\n nitroprusside gtt.\\n - transition nitroprusside gtt to metoprolol and losartan today, goal\\n sBP 150 today.\\n - has arterial sheath in place for A-line tracings\\n - SW consult for med compliance\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - f/u CSurg eval for AVR\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. BNP elevated at 2787, consistent with\\n heart failure.\\n - transition nitroprusside gtt to metoprolol and losartan today, as\\n above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - f/u Csurg recs on AVR\\n - f/u on CXR and TTE today\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with possible vascular dementia\\n given hx of PVD and TIAs. A-line higher than blood pressure\\n cuff, consistent with a diagnosis of PVD.\\n - continue ASA, Zetia\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis).\\n - try to obtain carotid U/S records in AM\\n - may need carotid U/S here at for pre-op eval\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result.\\n - continue Zetia 10 mg PO daily\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - f/u HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at .\\n - trend LFTS\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: cardiac healthy low salt low fat diet.\\n Glycemic Control: RISS\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: pneumoboots (pt refusing SQ heparin)\\n Stress ulcer: none\\n VAP: n/a\\n Comments: Bowel regimen with colace and senna prn\\n Communication: Comments: (husband)\\n status: Full code (confirmed with patient)\\n Disposition: CCU for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398146,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 07:52 PM\\n SHEATH - START 07:56 PM\\n CARDIAC CATH - At 08:08 PM\\n NASAL SWAB - At 12:00 AM\\n Admitted overnight\\n No event overnight\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.7\\nC (98\\n HR: 69 (69 - 86) bpm\\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\\n RR: 17 (16 - 23) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 512 mL\\n 328 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 312 mL\\n 328 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 435 mL\\n Urine:\\n 995 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,083 mL\\n -107 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///23/\\n Physical Examination\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n NECK: Supple, with JVP of 8cm\\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\\n peaking systolic crescendo-decrescendo murmur heard throughout the\\n precordium radiating to the carotics. no gallops or rubs.\\n LUNGS: CTAB\\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\\n guarding, no rebound.\\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\\n at right groin in place (not pulled)\\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\\n (Right DP pulse: 2+), (Left DP pulse: 2+)\\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\\n Neurologic: AOx3, neuro exam grossly normal\\n Labs / Radiology\\n 186 K/uL\\n 9.8 g/dL\\n 180 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 3.6 mEq/L\\n 27 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 28.7 %\\n 4.3 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n WBC\\n 7.2\\n 4.3\\n Hct\\n 30.9\\n 28.7\\n Plt\\n 182\\n 186\\n Cr\\n 0.9\\n 1.1\\n Glucose\\n 191\\n 180\\n Other labs:\\n PT / PTT / INR:12.8/25.5/1.1,\\n CK 31,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\\n proBNP: 2787\\n MICRO: none\\n CXR from today: my read\\nno acute cardiopulmonary process\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily\\n - start pravastatin today\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - will start ACEI today while nitroprusside gtt is down-titrated and\\n discontinued\\n - treatment of hypertension (see below)\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP was around 200 overnight on\\n nitroprusside gtt.\\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\\n 150 today.\\n - has arterial sheath in place for A-line tracings\\n - SW consult for med compliance\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - f/u CSurg eval for AVR\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. BNP elevated at 2787, consistent with\\n heart failure.\\n - transition nitroprusside gtt to metoprolol and losartan today, as\\n above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - f/u Csurg recs on AVR\\n - f/u on CXR and TTE today\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA\\n - will start pravastatin today\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis).\\n - may need carotid U/S here for pre-op eval\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result. Zetia is very expensive; given her economic situation, would\\n change to pravastatin.\\n - start pravastatin today\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - f/u HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - trend LFT\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: cardiac healthy low salt low fat diet.\\n Glycemic Control: RISS\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: pneumoboots (pt refusing SQ heparin)\\n Stress ulcer: none\\n VAP: n/a\\n Comments: Bowel regimen with colace and senna prn\\n Communication: Comments: (husband)\\n status: Full code (confirmed with patient)\\n Disposition: CCU for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398125,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 07:52 PM\\n SHEATH - START 07:56 PM\\n CARDIAC CATH - At 08:08 PM\\n NASAL SWAB - At 12:00 AM\\n Admitted overnight\\n No event overnight\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.3 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.7\\nC (98\\n HR: 69 (69 - 86) bpm\\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\\n RR: 17 (16 - 23) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 512 mL\\n 328 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 312 mL\\n 328 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 435 mL\\n Urine:\\n 995 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,083 mL\\n -107 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///23/\\n Physical Examination\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n NECK: Supple, with JVP of 8cm\\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\\n peaking systolic crescendo-decrescendo murmur heard throughout the\\n precordium radiating to the carotics. no gallops or rubs.\\n LUNGS: CTAB\\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\\n guarding, no rebound.\\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\\n at right groin in place (not pulled)\\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\\n (Right DP pulse: 2+), (Left DP pulse: 2+)\\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\\n Neurologic: AOx3, neuro exam grossly normal\\n Labs / Radiology\\n 186 K/uL\\n 9.8 g/dL\\n 180 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 3.6 mEq/L\\n 27 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 28.7 %\\n 4.3 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n WBC\\n 7.2\\n 4.3\\n Hct\\n 30.9\\n 28.7\\n Plt\\n 182\\n 186\\n Cr\\n 0.9\\n 1.1\\n Glucose\\n 191\\n 180\\n Other labs:\\n PT / PTT / INR:12.8/25.5/1.1,\\n CK 31,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\\n proBNP: 2787\\n MICRO: none\\n CXR from today: pending\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily and zetia 10mg daily\\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\\n - will restart losartan today\\n - treatment of hypertension (see below)\\n .\\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\\n the cath lab with arterial tracings showing systolics in the 330s. BP\\n brought down by nitroprusside gtt overnight in the CCU to SBPs 200.\\n Likely chronically hypertensive in setting of medication non-compliance\\n due to financial issues. Outpt blood pressure checks have SBPs ranging\\n from 110s-140s, but were in the left arm with known L subclavian steal\\n phenomenon. Also, cuff pressure seems to underestimate the true BPs\\n that are measured via A-line.\\n - transition nitroprusside gtt to metoprolol and losartan today\\n - has arterial sheath in place for A-line tracings\\n - SW consult for med compliance\\n - consider renal U/S to assess for artery stenosis\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - f/u CSurg eval for AVR\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Critical symptomatic AS (0.7 cm^2)\\n with peak to peak gradient of 25 mm Hg. Patient also with R sided PA\\n and RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. EF 64% in 3/.\\n - transition nitroprusside gtt to metoprolol and losartan today\\n - no nitroglycerin given critical AS\\n - f/u on BNP\\n - f/u Csurg recs on AVR\\n - f/u on CXR and TTE today\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with possible vascular dementia\\n given hx of PVD and TIAs. A-line higher than blood pressure\\n cuff, consistent with a diagnosis of PVD.\\n - continue ASA, Zetia\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis).\\n - try to obtain carotid U/S records in AM\\n - may need carotid U/S here at for pre-op eval\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result.\\n - continue Zetia 10 mg PO daily\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - f/u HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at .\\n - trend LFTS\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: cardiac healthy low salt low fat diet.\\n Glycemic Control: RISS\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: pneumoboots (pt refusing SQ heparin)\\n Stress ulcer: none\\n VAP: n/a\\n Comments: Bowel regimen with colace and senna prn\\n Communication: Comments: (husband)\\n status: Full code (confirmed with patient)\\n Disposition: CCU for now\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398207,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from for cardiac cath on . Cath\\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\\n lower than R arm, c/w left subclavian stenosis.\\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\\n meds financial restrictions\\ns/w consulted and following\\n Action:\\n 50 mg lopressor given in TID dosing\\n Captopril 25mg TID\\n Response:\\n Stable\\n Plan:\\n Continue BP management w/ current med regimen\\ngoal SBP 200\\n ? DC F fem venous and art sheaths\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB.\\n Action:\\n Response:\\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\\n Plan:\\n C- pre-ops\\nwill need carotid u/s (h/o R ICA stenosis),\\n dental panorex, chest CT. ? surgery mid-week\\n CHF management\\n2L fluid restriction, low-salt diet, daily\\n weights, strict I&Os.\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG at 22:00 119\\n Action/Response:\\n FS QID, stable\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- Mepilex placed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown, con\\nt freq\\n repositioning & back care as pt mobility is impaired while bedridden\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398209,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from for cardiac cath on . Cath\\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\\n lower than R arm, c/w left subclavian stenosis.\\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\\n meds financial restrictions\\ns/w consulted and following\\n Action:\\n 50 mg lopressor given in TID dosing\\n Captopril 25mg TID\\n Response:\\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\\n Plan:\\n Continue BP management w/ current med regimen\\ngoal SBP 200\\n ? DC F fem venous and art sheaths\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB.\\n Response:\\n No CHF on CXR, adequate UOP. + 300cc at MN.\\n Plan:\\n C- pre-ops\\nwill need carotid u/s (h/o R ICA stenosis),\\n dental panorex, chest CT. ? surgery mid-week\\n CHF management\\n2L fluid restriction, low-salt diet, daily\\n weights, strict I&Os.\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG at 22:00 119\\n Action/Response:\\n FS QID, stable\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- Mepilex placed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown, con\\nt freq\\n repositioning & back care as pt mobility is impaired while bedridden\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398210,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from for cardiac cath on . Cath\\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\\n lower than R arm, c/w left subclavian stenosis.\\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\\n meds financial restrictions\\ns/w consulted and following\\n Action:\\n 50 mg lopressor given in TID dosing\\n Captopril 25mg TID\\n Response:\\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\\n Plan:\\n Continue BP management w/ current med regimen\\ngoal SBP 200\\n ? DC F fem venous and art sheaths\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB.\\n Response:\\n No CHF on CXR, adequate UOP. + 300cc at MN.\\n Plan:\\n C- pre-ops\\nwill need carotid u/s (h/o R ICA stenosis),\\n dental panorex, chest CT. ? surgery mid-week\\n CHF management\\n2L fluid restriction, low-salt diet, daily\\n weights, strict I&Os.\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG at 22:00 119\\n Action/Response:\\n FS QID, stable\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- Mepilex placed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown, con\\nt freq\\n repositioning & back care as pt mobility is impaired while bedridden\\n ------ Protected Section ------\\n Of note: 02 sat transiently down to 85% then quickly back up to 93%. Pt\\n sound asleep. ? sleep apnea. Sat 96-98% when woken up by RN. Denies\\n SOB. Pt denies any h/o sleep apnea. Placed on supplemental 2L\\n NC\\nContinue to monitor.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 05:16 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398119,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference noted Left arm < Right arm; consistent with left subclavian\\n stenosis.\\n Patient asymptomatic with no c/o h/a or dizziness. Reports\\n non-compliance with cardiac meds financial restrictions.\\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\\n aline SBP > 250. Bounding pedal pulses.\\n Action:\\n Nitroglycerin d/c\\nd- initiated low-dose Nipride gtt with\\n goal SBP (by fem a-line) of 200.\\n 50 mg lopressor given in TID dosing\\n Knee immobilizer to right leg to encourage patient to\\n maintain straight leg and bedrest\\n Patient refused sq heparin\\n MD notified\\n Requested SW consult to discuss financial medication issues.\\n Response:\\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\\n arterial SBP 200 while patient sleeping\\n Patient non-compliant with bedrest condition, keeps\\nforgetting\\n restrictions, but is easily re-oriented and slept\\n comfortably overnight, startles aware to light touch. (? Degree of\\n dementia).\\n SQ heparin d/c\\nd- pneumo boots ordered & placed.\\n SW consult ordered.\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Invasive hemodynamic monitoring- goal currently SBP 200.\\n Maintain safety & integrity of femoral aline and venous\\n sheath\\n SW consult\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n AS: Cath showing critical AS (the aortic valve area was\\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\\n clear/slightly diminished bilateral bases.\\n Received 40 mg IVP lasix in cath lab prior to transfer.\\n Action:\\n 2 liter fluid restrictions; goal 1 liter negative overnight.\\n Completed post-cath fluid D5\\n NS at 75 cc\\ns per hour for\\n 450 cc\\ns total.\\n Monitored output in response to 40 mg IVP lasix given in lab\\n Response:\\n Excellent diuretic response to 40 mg IV- negative 1 liter at\\n midnight.\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Caution with meds that reduce pre-load (ie NTG).\\n Ordered for Cxray and TTE in am\\n Maintain 2 liter fluid restriction, low-salt diet, daily\\n weight.\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered.\\n Hyperglycemia\\n Assessment:\\n Patient denies history of DM. Elevated serum glucose on CCU admission\\n to 191.\\n Action:\\n FSBG elevated to 274 at 10 pm\\n Response:\\n RISS sliding scale coverage ( 8 units at 10 pm) given\\n Plan:\\n Continue to monitor BG levels.\\n Team discussing ordering HgA1c.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398120,\n \"text\": \"Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\\n pain and progressive DOE as a transfer from \\n for cardiac cath on now diagnosed with critical aortic\\n stenosis and marked systemic hypertension.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference noted Left arm < Right arm; consistent with left subclavian\\n stenosis.\\n Patient asymptomatic with no c/o h/a or dizziness. Reports\\n non-compliance with cardiac meds financial restrictions.\\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\\n aline SBP > 250. Bounding pedal pulses.\\n Action:\\n Nitroglycerin d/c\\nd- initiated low-dose Nipride gtt with\\n goal SBP (by fem a-line) of 200.\\n 50 mg lopressor given in TID dosing\\n Knee immobilizer to right leg to encourage patient to\\n maintain straight leg and bedrest\\n Patient refused sq heparin\\n MD notified\\n Requested SW consult to discuss financial medication issues.\\n Response:\\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\\n arterial SBP 200 while patient sleeping\\n Patient non-compliant with bedrest condition, keeps\\nforgetting\\n restrictions, but is easily re-oriented and slept\\n comfortably overnight, startles aware to light touch. (? Degree of\\n dementia).\\n SQ heparin d/c\\nd- pneumo boots ordered & placed.\\n SW consult ordered.\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Invasive hemodynamic monitoring- goal currently SBP 200.\\n Maintain safety & integrity of femoral aline and venous\\n sheath\\n SW consult\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n AS: Cath showing critical AS (the aortic valve area was\\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\\n clear/slightly diminished bilateral bases.\\n Received 40 mg IVP lasix in cath lab prior to transfer.\\n Action:\\n 2 liter fluid restrictions; goal 1 liter negative overnight.\\n Completed post-cath fluid D5\\n NS at 75 cc\\ns per hour for\\n 450 cc\\ns total.\\n Monitored output in response to 40 mg IVP lasix given in lab\\n Response:\\n Excellent diuretic response to 40 mg IV- negative 1 liter at\\n midnight.\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Caution with meds that reduce pre-load (ie NTG).\\n Ordered for Cxray and TTE in am\\n Maintain 2 liter fluid restriction, low-salt diet, daily\\n weight.\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered.\\n Hyperglycemia\\n Assessment:\\n Patient denies history of DM. Elevated serum glucose on CCU admission\\n to 191.\\n Action:\\n FSBG elevated to 274 at 10 pm\\n Response:\\n RISS sliding scale coverage ( 8 units at 10 pm) given\\n Plan:\\n Continue to monitor BG levels.\\n Team discussing ordering HgA1c.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398304,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 190\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.2\\nC (97.1\\n HR: 62 (56 - 76) bpm\\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.2 kg (admission): 64.8 kg\\n Total In:\\n 506 mL\\n 120 mL\\n PO:\\n 240 mL\\n 120 mL\\n TF:\\n IVF:\\n 266 mL\\n Blood products:\\n Total out:\\n 1,075 mL\\n 215 mL\\n Urine:\\n 1,075 mL\\n 215 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -569 mL\\n -95 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 93%\\n ABG: ///23/\\n Physical Examination\\n General: Well nourished, No acute distress\\n Neck: supple with JVP 7cm\\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\\n at LUSB\\n Respiratory: CTAB\\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\\n Extremities: No LE edema\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\\n DP pulses are biphasic and easily extinguished with soft compression\\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\\n Skin: Not assessed\\n Neurologic: Attentive, AAOx3\\n Labs / Radiology\\n 181 K/uL\\n 10.3 g/dL\\n 150 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 5.0 mEq/L\\n 40 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 30.9 %\\n 6.6 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n Other labs:\\n PT / PTT / INR:12.7/25.5/1.1,\\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved but still not at goal of\\n 150-160.\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - continue captopril 100mg TID\\n - may need to add another for BP control for goal sBP 150-160\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR.\\n - ordered dental consult and panorex\\n - per hepatology consult, pt is a good candidate for surgery from liver\\n perspective\\n - pt will get CTA today. Pt with Contrast allergy to be managed with\\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA and pravastatin\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - continue captopril 100mg TID\\n - may need to add another for BP control\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - awaiting AVR surgery\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - pt may live at BP around 200, and if BP drop lower pt may experience\\n TIA and dizziness. Need to monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result. Zetia is very expensive; given her economic situation, zetia\\n changed to pravastatin.\\n - continue pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - trend LFT\\n - per hepatology, pt is a good candidate for AVR from liver stand\\n point.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable during this admission.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: regular cardiac-healthy diet\\n Glycemic Control: RISS\\n Lines:\\n 20 Gauge - 07:54 PM\\n Prophylaxis:\\n DVT: pneumoboots (pt refused sc heparin)\\n Stress ulcer: none\\n VAP: n/a\\n Comments:\\n Communication: Comments: husband\\n status: Full code\\n Disposition: will stay in CCU for BP optimization\\n Cardiology Teaching Physician Note\\n have seen and examined the patient. I have reviewed the above note\\n and plans.\\n I have also reviewed the notes of Dr(s). .\\n I would add the following remarks:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 398383,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given\\n Response:\\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\\n Orthostatics neg.\\n Plan:\\n Continue BP manangement, goal SBP ~ 150-160s.\\n Aortic stenosis\\n Assessment:\\n Pre-op AVR w/u/tests\\n Action:\\n Pre-contrast prophylactic meds for CT given as ordered,\\n Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n Resume diet after CT\\n Needs Panorex and carotids check\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills\\n. Slept well overnight, startles when woken up by\\n RN for nsg interventions.\\nJust leave me alone\\n. Emotional support\\n provided\\n Get OOB, ^ activity as tolerated.\\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\\n placed but pt taking off. Pt encouraged to keep on for the night.\\n continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398274,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from Hosp for cardiac cath on . Cath showed\\n critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310\\n & elevated PA pressures w/ PCWP 29. BPs intially tx\\nd w/ Nipride gtt--\\n DCd -- converted to PO antihypertensives. Diuresed w/ lasix in cath\\n lab. R fem venous and art sheaths DCd . OF NOTE: L subclavian steel-\\n significant difference in arm BPs, L 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given @ 01:00\\n Response:\\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\\n Orthostatics neg.\\n Plan:\\n Continue BP manangement, goal SBP ~160s.\\n Aortic stenosis & CHF (Acute diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\\n Action:\\n Pre-contrast prophylactic meds for CT given as ordered\\n (allergy to Shellfish/iodine), Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n CT scheduled for 8am. Resume diet after CT\\n Needs Panorex and carotids check\\n CF management-2L Fluid restruction, low Na+ diet, daily wts,\\n strict I&Os\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\\n Action/Response:\\n Covered w/ RISS\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS (of\\n note: pt on prednisone)\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length, Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills\\n. Slept well overnight, startles when woken up by\\n RN for nsg interventions.\\nJust leave me alone\\n. Emotional support\\n provided\\n Get OOB, ^ activity as tolerated.\\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\\n placed but pt taking off. Pt encouraged to keep on for the night.\\n continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398275,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given @ 01:00\\n Response:\\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\\n minimal assist. No c/o dizziness. Orthostatics neg.\\n Plan:\\n Continue BP manangement, goal SBP ~160s.\\n Aortic stenosis & CHF (Acute diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\\n Action:\\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\\n for CT given as ordered, Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n CT scheduled for 8am. Resume diet after CT\\n Needs Panorex and carotids check\\n CHF management-2L Fluid restruction, low Na+ diet, daily\\n wts, strict I&Os\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\\n Action/Response:\\n Covered w/ RISS\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS (of\\n note: pt on prednisone)\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length, Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills\\n. Slept well overnight, startles when woken up by\\n RN for nsg interventions.\\nJust leave me alone\\n. Emotional support\\n provided\\n Get OOB, ^ activity as tolerated.\\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\\n placed but pt taking off. Pt encouraged to keep on for the night.\\n continue to monitor\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2127-12-04 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 398095,\n \"text\": \"TITLE: Cardiology fellow CCU admit note\\n 75 yo woman with CAD s/p CABG in , autoimmune hepatitis, now with\\n severe aortic stenosis ( 0.7 cm2) and SEVERE HTN with systolic BPs\\n in the 280s and LV systolic pressures in the 320s. Admitted to CCU for\\n invasive BP monitoring, intravenous antihypertensives and diuresis.\\n Start with nitroprusside with goal SBP of 200 mm Hg. Would also\\n administer 10 mg IV furosemide at this time.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 398101,\n \"text\": \"Chief Complaint: chest pain, SOB\\n HPI:\\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\\n who presented to an OSH on with acute onset chest pain and\\n progressive DOE, and was transferred to today for cardiac\\n catherization.\\n .\\n Patient reports progressive worsening of DOE since her CABG in .\\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\\n . Her symptoms have progressed to the point where she rarely leaves\\n her house anymore. Denies any associated chest pain prior to this\\n symptoms except on Monday at midnight, when she had sudden onset\\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\\n n/v. No SOB at time due to being at rest. Anginal equivalent is\\n atypical fleeting pain in all areas of her chest, states this\\n particular pain was more severe in nature. Chest pain lasted for 4\\n hours, subsided without intervention. She called her cardiologist's\\n office in the morning and was advised by her cardiologist to go to the\\n ED for immediate evaluation. Poorly compliant with blood pressure\\n medications due to medications prices (ie has been taking some meds\\n daily in order to make them last).\\n .\\n She presented to Hospital for these symptoms on . There,\\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \\n for cardiac cath on .\\n .\\n In the cath lab, patient was noted to have severe AS (valve area of\\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\\n Cardiac cath showed patent grafts unchanged from cath. She was\\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\\n was started on a nitroprusside gtt with good control of her SBPs in the\\n 200s.\\n .\\n On review of systems, s/he denies any prior history of deep venous\\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\\n S/he denies recent fevers, chills or rigors. S/he denies exertional\\n buttock or calf pain. All of the other review of systems were\\n negative.\\n .\\n Patient admitted from: Transfer from other hospital\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n ASA 162 mg daily\\n Cozaar 100 mg daily,\\n Metoprolol XL 100 mg daily\\n .\\n Of note: has been intolerant of statins in the past, has been on Zetia\\n 10 mg PO daily, but also stopped this due to non-compliance.\\n Past medical history:\\n Family history:\\n Social History:\\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\\n 2. CARDIAC HISTORY:\\n Cardiac Catheterization performed for symptoms of unstable\\n angina\\n PTCA to mid LAD\\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\\n -> Left anterior descending, Saphenous vein graft -> Obtuse\\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\\n not used due to retrograde L vertebral flow and concern of future left\\n subclavian artery steal.\\n : Cardiac Cath (performed in setting of chest pain, SVT):\\n patent grafts, SVG-> OM1 occluded. No significant change in graft\\n patency otherwise.\\n .\\n 3. OTHER PAST MEDICAL HISTORY:\\n Hypertension\\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\\n Anemia\\n Aortic stenosis\\n TIA (significant R sided ICA stenosis)\\n Peripheral Vascular Disease\\n Seizure in (oral numbness, followed by R hand/R leg numbness and\\n weakness. has been on Keppra, but was self-discontinued by patient due\\n to symptoms of depression).\\n Carotid artery disease\\n L sided subclavian steal\\n h/o SVT in \\n s/p appendectomy\\n (+) FHx CAD: 5 brothers and sisters all with CAD\\n in 60's\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Retired, married lives with husband and 2 adult children. used\\n to work at for 20 years. denies tobacco or ETOH use\\n Review of systems:\\n Flowsheet Data as of 12:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 75 (75 - 86) bpm\\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\\n RR: 18 (16 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 312 mL\\n 30 mL\\n PO:\\n TF:\\n IVF:\\n 312 mL\\n 30 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 0 mL\\n Urine:\\n 995 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,283 mL\\n 30 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///23/\\n Physical Examination\\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\\n pallor or cyanosis of the oral mucosa. No xanthalesma.\\n NECK: Supple with JVP of 6 cm at 45' angle.\\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\\n systolic crescendo-decrescendo murmur heard throughout the precordium\\n radiating to the carotics. no gallops or rubs.\\n Carotids: III/VI decresencdo murmer radiating to both carotids\\n bilaerally, louder R > L.\\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\\n palpation. No abdominial bruits.\\n EXTREMITIES: No c/c/e. No femoral bruits.\\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\\n PULSES:\\n Right: DP 2+ PT 2+\\n Left: DP 2+ PT 2+\\n Labs / Radiology\\n 182 K/uL\\n 10.2 g/dL\\n 191 mg/dL\\n 0.9 mg/dL\\n 21 mg/dL\\n 23 mEq/L\\n 103 mEq/L\\n 4.0 mEq/L\\n 138 mEq/L\\n 30.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n \\n 2:33 A1/7/ 08:37 PM\\n \\n 10:20 P\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 7.2\\n Hct\\n 30.9\\n Plt\\n 182\\n Cr\\n 0.9\\n Glucose\\n 191\\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\\n mg/dL\\n Fluid analysis / Other labs: ETT: () - normal symptomatic\\n response to adenosie, no significant arythmias, nuclear images neg for\\n ischemia with LVEF of > 60%.\\n .\\n CARDIAC CATH:\\n :\\n 1. Selective coronary angioigraphy of this right-dominant system\\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\\n The LAD had 50% proximal stenosis. The LCX was free from significant\\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\\n disease.\\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\\n occluded SVG-OM.\\n 3. Left ventriculography was deferred due to known dilated ascending\\n aorta and complex > 4 mm aortic plaque per previous TEE.\\n 4. Limited hemodynamic assessment revealed severe systemic arterial\\n hypertension (190/70 mmHg, right arm).\\n .\\n :\\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)\\n .\\n Coronary angiography: right dominant\\n LMCA: non selective injection. No apparent stenosis\\n LAD: 100% proximal occlusion\\n LCX: Patent to tortuous OMB\\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\\n SVG-OMB: occluded\\n .\\n There was marked systemic hypertension (up to 310mmHg) and a pressure\\n difference from the left arm to the right arm consistent with\\n subclavian stenosis.\\n .\\n Assessment and Recommendation:\\n 1. three vessel coronary artery disease\\n 2. Patent SVG to the LAD; Patent SVG to the RCA\\n 3. Occluded SVG to the OMB\\n 4. Severe systemic hypertension\\n 5. Critical aortic stenosis\\n 6. CCU for IV nipride and BP control\\n 7. Aortic valve replacement surgery\\n .\\n FINAL DIAGNOSIS:\\n 1. Two vessel and moderate left main coronary artery disease, unchanged\\n from prior angiogram.\\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\\n 3. Severe hypertension.\\n .\\n Cardiac cath: :\\n Aortic valve area: 0.68 cm^2 and 25 mm Hg peak to peak gradient\\n Hospital Records:\\n Lipid panel:\\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\\n Ferritin: 73 TSH: 3.0\\n Imaging: : (TEE) -\\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\\n There is moderate symmetric left ventricular hypertrophy. Right\\n ventricular chamber size and free wall motion are normal. There are\\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\\n done to confirm no atheroma at cannulation or cross-clamp location.\\n There are simple atheroma in the descending thoracic aorta. The aortic\\n valve leaflets are moderately thickened with relative immobility of the\\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\\n regurgitation is seen. There is severe MAC. There is no pericardial\\n effusion.\\n .\\n Postbypass: - Normal LV systolic function, Normal RV systolic\\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\\n otherwise unchanged from prebypass.\\n .\\n TTE: () per PCP : concentric LVH, post-operative septal\\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\\n .\\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\\n with RBBB. Given LAD, this is indicative of bifascicular block with\\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\\n V1-V3. No significant ST changes.\\n Assessment and Plan\\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\\n with chest pain and progressive DOE, diagnosed with critical aortic\\n stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily, zetia\\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\\n - hold losartan for now\\n - treatment of hypertension (see below)\\n .\\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\\n indicating evidence of pulmonary hypertension, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. EF 64% in 3/.\\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\\n restricted diet\\n - continue nitroprusside gtt\\n - if chest pain, start enalaprilat or esmolol gtt\\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\\n -1 L overnight\\n - no nitroglycerin\\n - continue BB\\n - holding for now\\n - check BNP\\n - contact for aortic valve replacement evaluation\\n - CXR, TTE in AM\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\\n the cath lab with arterial tracings showing systolics in the 330s.\\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\\n in the 220s. Likely chronically hypertensive in setting of medication\\n non-compliance due to financial issues. Outpt blood pressure checks\\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\\n evidence of patient's known L subclavian steal phenomenon.\\n - continue nitroprusside gtt goal SBP 200\\n - continue BB\\n - has arterial sheath in place for A-line tracings\\n - holding for now\\n - SW consult for med compliance\\n - consider renal U/S to assess for artery stenosis.\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - needs eval for AVR\\n - avoid medications that could decrease preload\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - check HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at .\\n - trend LFTS\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis)\\n - try to obtain carotid U/S records in AM\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage.\\n - continue Zetia 10 mg PO daily\\n .\\n # Peripheral Vascular Disease: Patient with possible vascular dementia\\n given hx of PVD and TIAs. A-line higher than blood pressure\\n cuff, indicating evidence of PVD.\\n - continue ASA, Zetia\\n .\\n # History of seizure: Patient was admitted for seizure in (has\\n been on Keppra, but was self-discontinued by patient). No further\\n episodes since then. Will continue to monitor.\\n .\\n ICU Care\\n Nutrition: low na, cardiac, diabetic diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 398102,\n \"text\": \"Chief Complaint: chest pain, SOB\\n HPI:\\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\\n who presented to an OSH on with acute onset chest pain and\\n progressive DOE, and was transferred to today for cardiac\\n catherization.\\n .\\n Patient reports progressive worsening of DOE since her CABG in .\\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\\n . Her symptoms have progressed to the point where she rarely leaves\\n her house anymore. Denies any associated chest pain prior to this\\n symptoms except on Monday at midnight, when she had sudden onset\\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\\n n/v. No SOB at time due to being at rest. Anginal equivalent is\\n atypical fleeting pain in all areas of her chest, states this\\n particular pain was more severe in nature. Chest pain lasted for 4\\n hours, subsided without intervention. She called her cardiologist's\\n office in the morning and was advised by her cardiologist to go to the\\n ED for immediate evaluation. Poorly compliant with blood pressure\\n medications due to medications prices (ie has been taking some meds\\n daily in order to make them last).\\n .\\n She presented to Hospital for these symptoms on . There,\\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \\n for cardiac cath on .\\n .\\n In the cath lab, patient was noted to have severe AS (valve area of\\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\\n Cardiac cath showed patent grafts unchanged from cath. She was\\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\\n was started on a nitroprusside gtt with good control of her SBPs in the\\n 200s.\\n .\\n On review of systems, s/he denies any prior history of deep venous\\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\\n S/he denies recent fevers, chills or rigors. S/he denies exertional\\n buttock or calf pain. All of the other review of systems were\\n negative.\\n .\\n Patient admitted from: Transfer from other hospital\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Nitroprusside - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n ASA 162 mg daily\\n Cozaar 100 mg daily,\\n Metoprolol XL 100 mg daily\\n .\\n Of note: has been intolerant of statins in the past, has been on Zetia\\n 10 mg PO daily, but also stopped this due to non-compliance.\\n Past medical history:\\n Family history:\\n Social History:\\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\\n 2. CARDIAC HISTORY:\\n Cardiac Catheterization performed for symptoms of unstable\\n angina\\n PTCA to mid LAD\\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\\n -> Left anterior descending, Saphenous vein graft -> Obtuse\\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\\n not used due to retrograde L vertebral flow and concern of future left\\n subclavian artery steal.\\n : Cardiac Cath (performed in setting of chest pain, SVT):\\n patent grafts, SVG-> OM1 occluded. No significant change in graft\\n patency otherwise.\\n .\\n 3. OTHER PAST MEDICAL HISTORY:\\n Hypertension\\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\\n Anemia\\n Aortic stenosis\\n TIA (significant R sided ICA stenosis)\\n Peripheral Vascular Disease\\n Seizure in (oral numbness, followed by R hand/R leg numbness and\\n weakness. has been on Keppra, but was self-discontinued by patient due\\n to symptoms of depression).\\n Carotid artery disease\\n L sided subclavian steal\\n h/o SVT in \\n s/p appendectomy\\n (+) FHx CAD: 5 brothers and sisters all with CAD\\n in 60's\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Retired, married lives with husband and 2 adult children. used\\n to work at for 20 years. denies tobacco or ETOH use\\n Review of systems:\\n Flowsheet Data as of 12:28 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 75 (75 - 86) bpm\\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\\n RR: 18 (16 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.8 kg (admission): 64.8 kg\\n Total In:\\n 312 mL\\n 30 mL\\n PO:\\n TF:\\n IVF:\\n 312 mL\\n 30 mL\\n Blood products:\\n Total out:\\n 1,595 mL\\n 0 mL\\n Urine:\\n 995 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,283 mL\\n 30 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///23/\\n Physical Examination\\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\\n appropriate.\\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\\n pallor or cyanosis of the oral mucosa. No xanthalesma.\\n NECK: Supple with JVP of 6 cm at 45' angle.\\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\\n systolic crescendo-decrescendo murmur heard throughout the precordium\\n radiating to the carotics. no gallops or rubs.\\n Carotids: III/VI decresencdo murmer radiating to both carotids\\n bilaterally, louder R > L.\\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\\n palpation. No abdominial bruits.\\n EXTREMITIES: No c/c/e. No femoral bruits.\\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\\n PULSES:\\n Right: DP 2+ PT 2+\\n Left: DP 2+ PT 2+\\n Labs / Radiology\\n 182 K/uL\\n 10.2 g/dL\\n 191 mg/dL\\n 0.9 mg/dL\\n 21 mg/dL\\n 23 mEq/L\\n 103 mEq/L\\n 4.0 mEq/L\\n 138 mEq/L\\n 30.9 %\\n 7.2 K/uL\\n [image002.jpg]\\n \\n 2:33 A1/7/ 08:37 PM\\n \\n 10:20 P\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 7.2\\n Hct\\n 30.9\\n Plt\\n 182\\n Cr\\n 0.9\\n Glucose\\n 191\\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\\n mg/dL\\n Fluid analysis / Other labs: ETT: () - normal symptomatic\\n response to adenosie, no significant arythmias, nuclear images neg for\\n ischemia with LVEF of > 60%.\\n .\\n CARDIAC CATH:\\n :\\n 1. Selective coronary angioigraphy of this right-dominant system\\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\\n The LAD had 50% proximal stenosis. The LCX was free from significant\\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\\n disease.\\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\\n occluded SVG-OM.\\n 3. Left ventriculography was deferred due to known dilated ascending\\n aorta and complex > 4 mm aortic plaque per previous TEE.\\n 4. Limited hemodynamic assessment revealed severe systemic arterial\\n hypertension (190/70 mmHg, right arm).\\n .\\n :\\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)\\n .\\n Coronary angiography: right dominant\\n LMCA: non selective injection. No apparent stenosis\\n LAD: 100% proximal occlusion\\n LCX: Patent to tortuous OMB\\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\\n SVG-OMB: occluded\\n .\\n There was marked systemic hypertension (up to 310mmHg) and a pressure\\n difference from the left arm to the right arm consistent with\\n subclavian stenosis.\\n .\\n Assessment and Recommendation:\\n 1. three vessel coronary artery disease\\n 2. Patent SVG to the LAD; Patent SVG to the RCA\\n 3. Occluded SVG to the OMB\\n 4. Severe systemic hypertension\\n 5. Critical aortic stenosis\\n 6. CCU for IV nipride and BP control\\n 7. Aortic valve replacement surgery\\n .\\n FINAL DIAGNOSIS:\\n 1. Two vessel and moderate left main coronary artery disease, unchanged\\n from prior angiogram.\\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\\n 3. Severe hypertension.\\n Hospital Records:\\n Lipid panel:\\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\\n Ferritin: 73 TSH: 3.0\\n Imaging: : (TEE) -\\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\\n There is moderate symmetric left ventricular hypertrophy. Right\\n ventricular chamber size and free wall motion are normal. There are\\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\\n done to confirm no atheroma at cannulation or cross-clamp location.\\n There are simple atheroma in the descending thoracic aorta. The aortic\\n valve leaflets are moderately thickened with relative immobility of the\\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\\n regurgitation is seen. There is severe MAC. There is no pericardial\\n effusion.\\n .\\n Postbypass: - Normal LV systolic function, Normal RV systolic\\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\\n otherwise unchanged from prebypass.\\n .\\n TTE: () per PCP : concentric LVH, post-operative septal\\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\\n .\\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\\n with RBBB. Given LAD, this is indicative of bifascicular block with\\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\\n V1-V3. No significant ST changes.\\n Assessment and Plan\\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\\n with chest pain and progressive DOE, diagnosed with critical aortic\\n stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely due to demand in setting of critical AS and increased\\n afterload from her hypertensive emergency.\\n - continue ASA 325 mg PO daily, zetia\\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\\n - hold losartan for now\\n - treatment of hypertension (see below)\\n .\\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\\n indicating evidence of pulmonary hypertension, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. EF 64% in 3/.\\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\\n restricted diet\\n - continue nitroprusside gtt\\n - if chest pain, start enalaprilat or esmolol gtt\\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\\n -1 L overnight\\n - no nitroglycerin\\n - continue BB\\n - holding for now\\n - check BNP\\n - contact for aortic valve replacement evaluation\\n - CXR, TTE in AM\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\\n the cath lab with arterial tracings showing systolics in the 330s.\\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\\n in the 220s. Likely chronically hypertensive in setting of medication\\n non-compliance due to financial issues. Outpt blood pressure checks\\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\\n evidence of patient's known L subclavian steal phenomenon.\\n - continue nitroprusside gtt goal SBP 200\\n - continue BB\\n - has arterial sheath in place for A-line tracings\\n - holding for now\\n - SW consult for med compliance\\n - consider renal U/S to assess for artery stenosis.\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - needs eval for AVR\\n - avoid medications that could decrease preload\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - check HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at .\\n - trend LFTS\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis)\\n - try to obtain carotid U/S records in AM\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage.\\n - continue Zetia 10 mg PO daily\\n .\\n # Peripheral Vascular Disease: Patient with possible vascular dementia\\n given hx of PVD and TIAs. A-line higher than blood pressure\\n cuff, indicating evidence of PVD.\\n - continue ASA, Zetia\\n .\\n # History of seizure: Patient was admitted for seizure in (has\\n been on Keppra, but was self-discontinued by patient). No further\\n episodes since then. Will continue to monitor.\\n .\\n ICU Care\\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\\n daily\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398179,\n \"text\": \"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID.\\n Response:\\n SBP <200- Nipride gtt weaned and D?C\\n Plan:\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by .\\n Response:\\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\\n Plan:\\n Hyperglycemic\\n Assessment:\\n Glucose range 123-180\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Better glucose control.\\n Plan:\\n Con\\nt fingersticks q6hrs and follow sliding scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398367,\n \"text\": \"Aortic stenosis/ Diastolic Heart Failure\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398368,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L200 this am on Nipride gtt @ .3mcq/kg/min.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID.\\n Response:\\n SBP <200- Nipride gtt weaned and D?C\\n Plan:\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by .\\n Response:\\n Plan:\\n Hyperglycemic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398181,\n \"text\": \"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID.\\n Response:\\n SBP <200- Nipride gtt weaned and D?C\\n Plan:\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by this evening- ? surgery mid week-\\n pre-op orders started.\\n Response:\\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\\n Plan:\\n Hyperglycemic\\n Assessment:\\n Glucose range 123-180\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Better glucose control.\\n Plan:\\n Con\\nt fingersticks q6hrs and follow sliding scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398258,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs persistently > 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given\\n Response:\\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\\n Orthostatics neg.\\n Plan:\\n Continue BP mamangement, goal SBP ~ 150-160s.\\n Aortic stenosis\\n Assessment:\\n Pre-op AVR w/u/tests\\n Action:\\n Pre-contrast prophylactic meds for CT given as ordered,\\n Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n Resume diet after CT\\n Needs Panorex and carotids check\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398264,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs > 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given\\n Response:\\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\\n Orthostatics neg.\\n Plan:\\n Continue BP manangement, goal SBP ~ 150-160s.\\n Aortic stenosis\\n Assessment:\\n Pre-op AVR w/u/tests\\n Action:\\n Pre-contrast prophylactic meds for CT given as ordered,\\n Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n Resume diet after CT\\n Needs Panorex and carotids check\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills\\n. Emotional support provided\\n Get OOB, ^ activity\\n as tolerated.\\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\\n placed but pt taking off. Pt encouraged to keep on for the night.\\n continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398340,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 200\\n Action:\\n Captopril 100mg TID and Lopressor 75mg TID given as ordered\\n Response:\\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. No\\n dizziness/lightheadedness\\n Plan:\\n Continue BP manangement, goal SBP ~150-160s.\\n Aortic stenosis & CHF (Acute diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB\\n Action:\\n . Pre-op AVR w/u in progress\\n Response:\\n Stable overnight\\n Plan:\\n Needs Panorex and carotids check\\n CHF management-2L Fluid restruction, low Na+ diet, daily\\n wts, strict I&Os\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length, Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills, I\\nve taken 25 pills today\\n. Slept well overnight,\\n startles when woken up by RN for nsg interventions.\\nJust leave me\\n alone\\n. Emotional support provided\\n Get OOB, ^ activity as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398341,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L55%. LS clear. No SOB\\n Action:\\n . Pre-op AVR w/u in progress\\n Response:\\n Stable overnight\\n Plan:\\n Needs Panorex and carotids check\\n CHF management-2L Fluid restruction, low Na+ diet, daily\\n wts, strict I&Os\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length, Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills, I\\nve taken 25 pills today\\n. Slept well overnight,\\n startles when woken up by RN for nsg interventions.\\nJust leave me\\n alone\\n. Emotional support provided\\n Get OOB, ^ activity as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398346,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\\n of the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - no CTsurg recs\\n - BP great, in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398348,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\\n of the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - no CTsurg recs\\n - BP great, in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - Pt may be slightly dry today given small rise in Cr. Continue to\\n observe, but very conservative fluid management.\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398349,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\\n the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - SBP in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - Pt may be slightly dry today given small rise in Cr. Continue to\\n observe, but very conservative fluid management.\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398352,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\\n the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - SBP in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\\n conservative fluid management PRN.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition: pending cardiac surgery later this week\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398354,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\\n the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - SBP in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\\n conservative fluid management PRN.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition: pending cardiac surgery later this week\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398357,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\\n the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - SBP in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\\n conservative fluid management PRN.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition: pending cardiac surgery later this week\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398358,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\\n the ascending aorta\\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\\n 100mg TID\\n - SBP in the 160s. Patient was asymptomatic all day.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:01 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36\\nC (96.8\\n HR: 68 (58 - 83) bpm\\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\\n RR: 18 (11 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68 kg (admission): 64.8 kg\\n Total In:\\n 930 mL\\n PO:\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 1,130 mL\\n 265 mL\\n Urine:\\n 1,130 mL\\n 265 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -200 mL\\n -265 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished woman, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\\n peaking systolic murmur loudest at RUSB radiating to carotids\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\\n bilaterally\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 216 K/uL\\n 10.0 g/dL\\n 111 mg/dL\\n 1.2 mg/dL\\n 25 mEq/L\\n 4.8 mEq/L\\n 47 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 30.9 %\\n 11.0 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n 04:06 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n 11.0\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n 216\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n 1.2\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n 111\\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\\n Assessment and Plan\\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\\n later this week.\\n .\\n # Hypertension: Patient presented with hypertensive emergency & chest\\n pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved to sbp\\ns in 160\\ns yesterday\\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\\n - Continue Captopril 100mg TID (goal sbp\\ns 150-170\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\\n preliminary read demonstrated extensive atherosclerotic disease with\\n ectasia of the ascending aorta.\\n - Panorex scheduled for today, will then need dental re-consult\\n - F/U final CTA read.\\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\\n conservative fluid management PRN.\\n - Avoid medications that decrease preload\\n .\\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\\n on admission likely demand ischemia in setting of critical AS and\\n hypertensive emergency as pain resolved with improved bp\\ns & patient\\n with negative troponins, no new ischemic EKG changes.\\n - continue ASA and Pravastatin\\n - continue Metoprolol 75 mg PO TID\\n - continue Captopril 100mg TID\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - No nitroglycerin given critical AS\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue Metoprolol Tartrate 75mg PO TID\\n - Telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and Pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - If BP drop lower than sbp\\ns of 150\\ns-170\\ns, pt may experience TIA and\\n dizziness. Will monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was prescribed\\n Zetia, but given cost, changed to Pravastatin.\\n - continue Pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - Trend LFT\\n - Per hepatology, pt is a good candidate for AVR.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable since admission.\\n - Trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:00 AM\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: none\\n VAP: N/A\\n Communication: Patient & husband, \\n status: Full code\\n Disposition: pending cardiac surgery later this week\\n ------ Protected Section ------\\n Cardiology Teaching Physician Note\\n have seen and examined the patient. I have reviewed the above note\\n and plans.\\n I have also reviewed the notes of Dr(s). .\\n I would add the following remarks:\\n Medical Decision Making\\n Will target BP of 150 mm/Hg. Surgery Wed or Friday.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 10:18 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398243,\n \"text\": \"is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n Impaired Skin Integrity\\n Assessment:\\n Gluteal fold/coccyx\\n Action:\\n Mepilex intact in place pt repositioned several times\\n Response:\\n Unchanged\\n Plan:\\n Continue to turn side to side , change positions frequently\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP 130-220, critical AS per cardiac cath\\n Action:\\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\\n pulses dopplerable\\n Response:\\n Sbp 190\\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\\n hypotension that she felt sick nausea dizzy once when bp went as low as\\n 130sbp and another when pt tried to get oob to use commode pt s bp\\n dropped to 160\\ns and pt had to quickly get back into bed r/t feeling so\\n bad once n bed c legs elevated pt felt better she received zofran for\\n nausea, right fem arterial and venous sheaths removed no bleeding at\\n site no hematoma\\n Plan:\\n Monitor hemodynamics closely, po meds will need to be increased as\\n needed and tolerated, niprid gtt dc\\nd , goal is to decrease bp very\\n slowly\\n .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398244,\n \"text\": \"is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n Impaired Skin Integrity\\n Assessment:\\n Gluteal fold/coccyx skin tear\\n Action:\\n Mepilex intact in place pt repositioned several times\\n Response:\\n Unchanged\\n Plan:\\n Continue to turn side to side , change positions frequently\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP 130-220, critical AS per cardiac cath\\n Action:\\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\\n pulses dopplerable\\n Response:\\n Sbp 190\\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\\n hypotension that she felt sick nausea dizzy once when bp went as low as\\n 130sbp and another when pt tried to get oob to use commode pt s bp\\n dropped to 160\\ns and pt had to quickly get back into bed r/t feeling so\\n bad. once n bed c legs elevated pt felt better she received zofran for\\n nausea, right fem arterial and venous sheaths removed no bleeding at\\n site no hematoma\\n Plan:\\n Monitor hemodynamics closely, po meds will need to be increased as\\n needed and tolerated, niprid gtt dc\\nd , goal is to decrease bp very\\n slowly\\n .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398344,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L55%. LS clear. No SOB\\n Action:\\n . Pre-op AVR w/u in progress\\n Response:\\n Stable overnight\\n Plan:\\n Needs Panorex and carotids check\\n CHF management--2L Fluid restruction, low Na+ diet, daily\\n wts, strict I&Os\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx. Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Improving\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: freq\\n BP checks and not being able to go to the bathroom in room or shower.\\n Stated,\\n I am not taking anymore pills, I\\nve taken 25 pills today\\n Slept well overnight, startles when woken up by RN for nsg\\n interventions.\\nJust leave me alone\\n. Emotional support provided\\n Get\\n OOB, ^ activity as tolerated. ? DC foley\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398325,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L improvement\\n noted.\\n Plan:\\n Monitor area closely- con\\nt skin care.\\n Hyperglycemia\\n Assessment:\\n Blood sugar elevated on admission- glucose range 141- 218 today.\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Stable.\\n Plan:\\n Con\\nt q6hr fingersticks and Rx as per SS.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398241,\n \"text\": \"Impaired Skin Integrity\\n Assessment:\\n gluteal\\n Action:\\n Response:\\n Plan:\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\\n sheaths remain in R fem.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID- R fem site without oozing or hematoma- (-) distal pulses.\\n Response:\\n SBP <200- Nipride gtt weaned and D/C\\nd- captopril increased to 12.5mg\\n TID\\n Plan:\\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\\n tomorrow.\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by this evening- ? surgery mid week-\\n pre-op orders started.\\n Response:\\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\\n Plan:\\n Con\\nt to monitor closely.\\n Hyperglycemic\\n Assessment:\\n Glucose range 123-180\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Better glucose control.\\n Plan:\\n Con\\nt fingersticks q6hrs and follow sliding scale.\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- area open to air.\\n Response:\\n Unchanged.\\n Plan:\\n Monitor area closely- con\\nt freq repositioning & back care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398223,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - According to PCP, previously on statin & ACE, problems with\\n compliance & minor side effects, but no major contraindications\\n - Started on Pravastatin 20mg\\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\\n - Nitroprusside stopped\\n - HgbA1c 5.8%\\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\\n Aorta size and calcification\\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\\n greater degree of LV hypertrophy have progressed compared to prior\\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\\n skeletal findings\\n - seen by SW, attempting medication assistance\\n - Will need Dental/Panorex consult in AM\\n - Will need Hepatology consult with Dr. in AM to clear for\\n surgery\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: uncomfortable\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Numbness / tingling, No(t) Headache\\n Flowsheet Data as of 07:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.2\\nC (97.1\\n HR: 69 (61 - 79) bpm\\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\\n RR: 21 (17 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 67 kg (admission): 64.8 kg\\n Total In:\\n 1,521 mL\\n 77 mL\\n PO:\\n 840 mL\\n TF:\\n IVF:\\n 681 mL\\n 77 mL\\n Blood products:\\n Total out:\\n 1,185 mL\\n 420 mL\\n Urine:\\n 1,185 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 336 mL\\n -344 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL, EOMI\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\\n Crescendo, all fields of precordium/ worst at LUSB\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\\n DP pulses are biphasic and easily extinguished with soft compression\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 184 K/uL\\n 9.9 g/dL\\n 108 mg/dL\\n 1.1 mg/dL\\n 24 mEq/L\\n 4.2 mEq/L\\n 38 mg/dL\\n 106 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 9.4 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n Plt\\n 182\\n 186\\n 184\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n Glucose\\n 191\\n 180\\n 108\\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n IMPAIRED SKIN INTEGRITY\\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n AORTIC STENOSIS\\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398224,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - According to PCP, previously on statin & ACE, problems with\\n compliance & minor side effects, but no major contraindications\\n - Started on Pravastatin 20mg\\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\\n - Nitroprusside stopped\\n - HgbA1c 5.8%\\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\\n Aorta size and calcification\\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\\n greater degree of LV hypertrophy have progressed compared to prior\\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\\n skeletal findings\\n - seen by SW, attempting medication assistance\\n - Will need Dental/Panorex consult in AM\\n - Will need Hepatology consult with Dr. in AM to clear for\\n surgery\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: uncomfortable\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Numbness / tingling, No(t) Headache\\n Flowsheet Data as of 07:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.2\\nC (97.1\\n HR: 69 (61 - 79) bpm\\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\\n RR: 21 (17 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 67 kg (admission): 64.8 kg\\n Total In:\\n 1,521 mL\\n 77 mL\\n PO:\\n 840 mL\\n TF:\\n IVF:\\n 681 mL\\n 77 mL\\n Blood products:\\n Total out:\\n 1,185 mL\\n 420 mL\\n Urine:\\n 1,185 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 336 mL\\n -344 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL, EOMI\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\\n Crescendo, all fields of precordium/ worst at LUSB\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\\n DP pulses are biphasic and easily extinguished with soft compression\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 184 K/uL\\n 9.9 g/dL\\n 108 mg/dL\\n 1.1 mg/dL\\n 24 mEq/L\\n 4.2 mEq/L\\n 38 mg/dL\\n 106 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 9.4 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n Plt\\n 182\\n 186\\n 184\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n Glucose\\n 191\\n 180\\n 108\\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\\n TTE\\n The left atrium is moderately dilated. There is severe symmetric left\\n ventricular hypertrophy. The left ventricular cavity size is normal.\\n Regional left ventricular wall motion is normal. Overall left\\n ventricular systolic function is normal (LVEF>55%). Right ventricular\\n chamber size and free wall motion are normal. Right ventricular chamber\\n size is normal. The diameters of aorta at the sinus, ascending and arch\\n levels are normal. There are three aortic valve leaflets. The aortic\\n valve leaflets are severely thickened/deformed. There is critical\\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\\n regurgitation is seen. The mitral valve leaflets are moderately\\n thickened. There is severe mitral annular calcification. Mild to\\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\\n artery systolic hypertension. There is no pericardial effusion.\\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\\n hypertrophy with normal global and regional biventricular systolic\\n function. Mild aortic regurgitation. Mild to moderate mitral\\n regurgitation. Mild pulmonary hypertension.\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily\\n - start pravastatin today\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - will start ACEI today while nitroprusside gtt is down-titrated and\\n discontinued\\n - treatment of hypertension (see below)\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP was around 200 overnight on\\n nitroprusside gtt.\\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\\n 150 today.\\n - has arterial sheath in place for A-line tracings\\n - SW consult for med compliance\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - f/u CSurg eval for AVR\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. BNP elevated at 2787, consistent with\\n heart failure.\\n - transition nitroprusside gtt to metoprolol and losartan today, as\\n above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - f/u Csurg recs on AVR\\n - f/u on CXR and TTE today\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA\\n - will start pravastatin today\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis).\\n - may need carotid U/S here for pre-op eval\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result. Zetia is very expensive; given her economic situation, would\\n change to pravastatin.\\n - start pravastatin today\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - f/u HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - trend LFT\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398229,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n :\\n - According to PCP, previously on statin & ACE, problems with\\n compliance & minor side effects, but no major contraindications\\n - Started on Pravastatin 20mg\\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\\n - Nitroprusside stopped\\n - HgbA1c 5.8%\\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\\n Aorta size and calcification\\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\\n greater degree of LV hypertrophy have progressed compared to prior\\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\\n skeletal findings\\n - seen by SW, attempting medication assistance\\n - Will need Dental/Panorex consult in AM\\n - Will need Hepatology consult with Dr. in AM to clear for\\n surgery\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: uncomfortable\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Genitourinary: No(t) Dysuria\\n Neurologic: No(t) Numbness / tingling, No(t) Headache\\n Flowsheet Data as of 07:45 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.2\\nC (97.1\\n HR: 69 (61 - 79) bpm\\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\\n RR: 21 (17 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 67 kg (admission): 64.8 kg\\n Total In:\\n 1,521 mL\\n 77 mL\\n PO:\\n 840 mL\\n TF:\\n IVF:\\n 681 mL\\n 77 mL\\n Blood products:\\n Total out:\\n 1,185 mL\\n 420 mL\\n Urine:\\n 1,185 mL\\n 420 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 336 mL\\n -344 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL, EOMI\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\\n Crescendo, all fields of precordium/ worst at LUSB\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\\n DP pulses are biphasic and easily extinguished with soft compression\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\\n Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 184 K/uL\\n 9.9 g/dL\\n 108 mg/dL\\n 1.1 mg/dL\\n 24 mEq/L\\n 4.2 mEq/L\\n 38 mg/dL\\n 106 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 9.4 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n Plt\\n 182\\n 186\\n 184\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n Glucose\\n 191\\n 180\\n 108\\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\\n TTE\\n The left atrium is moderately dilated. There is severe symmetric left\\n ventricular hypertrophy. The left ventricular cavity size is normal.\\n Regional left ventricular wall motion is normal. Overall left\\n ventricular systolic function is normal (LVEF>55%). Right ventricular\\n chamber size and free wall motion are normal. Right ventricular chamber\\n size is normal. The diameters of aorta at the sinus, ascending and arch\\n levels are normal. There are three aortic valve leaflets. The aortic\\n valve leaflets are severely thickened/deformed. There is critical\\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\\n regurgitation is seen. The mitral valve leaflets are moderately\\n thickened. There is severe mitral annular calcification. Mild to\\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\\n artery systolic hypertension. There is no pericardial effusion.\\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\\n hypertrophy with normal global and regional biventricular systolic\\n function. Mild aortic regurgitation. Mild to moderate mitral\\n regurgitation. Mild pulmonary hypertension.\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA 325 mg PO daily\\n - start pravastatin today\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - will start ACEI today while nitroprusside gtt is down-titrated and\\n discontinued\\n - treatment of hypertension (see below)\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP was around 200 overnight on\\n nitroprusside gtt.\\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\\n 150 today.\\n - has arterial sheath in place for A-line tracings\\n - SW consult for med compliance\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\\n - f/u CSurg eval for AVR\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. BNP elevated at 2787, consistent with\\n heart failure.\\n - transition nitroprusside gtt to metoprolol and losartan today, as\\n above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - f/u Csurg recs on AVR\\n - f/u on CXR and TTE today\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA\\n - will start pravastatin today\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis).\\n - may need carotid U/S here for pre-op eval\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result. Zetia is very expensive; given her economic situation, would\\n change to pravastatin.\\n - start pravastatin today\\n .\\n # Hyperglycemia: BS 191 on admission. Patient without history of\\n diabetes.\\n - RISS with FS qACHS\\n - f/u HgA1c\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - trend LFT\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 07:52 PM\\n 20 Gauge - 07:54 PM\\n Sheath - 07:56 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n Cardiology Teaching Physician Note\\n have seen and examined the patient. I have reviewed the above note\\n and plans.\\n I have also reviewed the notes of Dr(s). .\\n I would add the following remarks:\\n Medical Decision Making\\n Will further lower blood pressure parenterally for sheath pull. Will\\n image thorax per request of interventional cardiology and CT surgery.\\n Increase dose of ACE.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398240,\n \"text\": \"Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398312,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 250.\\n Action:\\n Nitroglycerin d/c\\nd- initiated low-dose Nipride gtt with\\n goal SBP (by fem aline) of 200.\\n Requested SW consult to discuss financial medication issues.\\n Response:\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n AS: Cath showing critical AS (the aortic valve area was\\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\\n clear/slightly diminished bilateral bases.\\n Received 40 mg IVP lasix in cath lab prior to transfer.\\n Action:\\n 2 liter fluid restrictions; goal 1 liter negative overnight.\\n Response:\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Caution with meds that reduce pre-load (ie NTG).\\n Ordered for Cxray and TTE in am\\n Maintain 2 liter fluid restriction, low-salt diet, daily\\n weights\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered. Diovan held.\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398112,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference Left arm < Right arm consistent with subclavian stenosis.\\n Action:\\n Response:\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Aortic stenosis\\n Assessment:\\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\\n 25mm Hg peak to peak gradient).\\n Action:\\n Response:\\n Plan:\\n consult for aortic valve replacement surgery\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered. Diovan held.\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\\n PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\\n indicating evidence of pulmonary hypertension, likely exacerbated in\\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\\n with good urine output of -1 L. EF 64% in 3/.\\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\\n restricted diet\\n - continue nitroprusside gtt\\n - if chest pain, start enalaprilat or esmolol gtt\\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\\n -1 L overnight\\n - no nitroglycerin\\n - continue BB\\n - holding for now\\n - check BNP\\n - contact for aortic valve replacement evaluation\\n - CXR, TTE in AM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398110,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference Left arm < Right arm consistent with subclavian stenosis.\\n Action:\\n Response:\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Aortic stenosis\\n Assessment:\\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\\n 25mm Hg peak to peak gradient).\\n Action:\\n Response:\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Cath showing unchanged 3 VD native LAD 100 %.(patent SVG to LAD &\\n patent SVG to RCA) (Occluded SVG to OM, diffuse mid-LAD <40%).\\n Action:\\n Response:\\n Plan:\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398111,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference Left arm < Right arm consistent with subclavian stenosis.\\n Action:\\n Response:\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Aortic stenosis\\n Assessment:\\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\\n 25mm Hg peak to peak gradient).\\n Action:\\n Response:\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered. Diovan held.\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398114,\n \"text\": \"Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n Cath showing\\nmarked systemic HTN\\n (up to 310 mmHG). NIBP\\n difference Left arm < Right arm consistent with subclavian stenosis.\\n Action:\\n Response:\\n Plan:\\n Continue ABP management with IV Nipride gtt\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n AS: Cath showing critical AS (the aortic valve area was\\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\\n clear/slightly diminished bilateral bases.\\n Received 40 mg IVP lasix in cath lab prior to transfer.\\n Action:\\n 2 liter fluid restrictions; goal 1 liter negative overnight.\\n Response:\\n Plan:\\n CSurg consult for aortic valve replacement surgery\\n Ordered for Cxray and TTE in am\\n Maintain 2 liter fluid restriction, low-salt diet, daily\\n weights\\n Coronary artery disease (CAD, ischemic heart disease)\\n Assessment:\\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\\n mid-LAD <40%). No evidence ACS for this admission. CP free.\\n Hypertensive w. management as above. HR 80\\ns, SR, no ectopy noted.\\n Action:\\n Lopressor 50 mg po given in TID dosing.\\n Monitored for c/o CP.\\n Response:\\n Lopressor effective in decreasing HR to 60\\n Remains CP free overnight.\\n Plan:\\n Monitor for c/o CP or discomfort. Medical management with lopressor,\\n asa and zetia as ordered. Diovan held.\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398195,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from for cardiac cath on . Cath\\n showed critical AS w/ aortic valve area 0.68 cm2 w/ a 25mm Hg peak to\\n peak gradient & marked systemic HTN w/ SBP 310 & elevated PA pressures\\n w/ PCWP 29. BPs intially tx\\nd w/ Nipride gtt, DCd . Diuresed w/\\n lasix in cath lab. Echo showed EF >55%.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\\n left subclavian stenosis.\\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\\n meds financial restrictions\\ns/w consulted and following\\n Action:\\n 50 mg lopressor given in TID dosing\\n Captopril 25mg TID\\n Response:\\n Stable\\n Plan:\\n Continue BP management w/ current med regimen\\ngoal SBP 200\\n ? DC F fem venous and art sheaths\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n C- pre-ops\\nwill need carotid u/s (h/o R ICA stenosis),\\n dental panorex, chest CT.\\n CHF management\\n2L fluid restriction, low-salt diet, daily\\n weights, strict I&Os.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398196,\n \"text\": \"75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\\n from for cardiac cath on . Cath\\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab.\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\\n left subclavian stenosis.\\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\\n meds financial restrictions\\ns/w consulted and following\\n Action:\\n 50 mg lopressor given in TID dosing\\n Captopril 25mg TID\\n Response:\\n Stable\\n Plan:\\n Continue BP management w/ current med regimen\\ngoal SBP 200\\n ? DC F fem venous and art sheaths\\n Aortic stenosis & CHF (Acute Diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB.\\n Action:\\n Response:\\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\\n Plan:\\n C- pre-ops\\nwill need carotid u/s (h/o R ICA stenosis),\\n dental panorex, chest CT. ? surgery mid-week\\n CHF management\\n2L fluid restriction, low-salt diet, daily\\n weights, strict I&Os.\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG at 22:00 119\\n Action/Response:\\n FS QID, stable\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- Mepilex placed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown, con\\nt freq\\n repositioning & back care as pt mobility is impaired while bedridden\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398276,\n \"text\": \"75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\\nd w/\\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\\n subclavian steel- significant difference in arm BPs, L 200\\n Action:\\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\\n Additional 1 time dose 25mg PO hydral given @ 01:00\\n Response:\\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\\n minimal assist. No c/o dizziness. Orthostatics neg.\\n Plan:\\n Continue BP manangement, goal SBP ~160s.\\n Aortic stenosis & CHF (Acute diastolic)\\n Assessment:\\n Critical AS per cardiac cath- consulted . Echo showed EF\\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\\n Action:\\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\\n for CT given as ordered, Prednisone, benedryl and ranitidine\\n NPO for CT per techs\\n Response:\\n Stable overnight\\n Plan:\\n CT scheduled for 8am. Resume diet after CT\\n Needs Panorex and carotids check\\n CHF management-2L Fluid restruction, low Na+ diet, daily\\n wts, strict I&Os\\n Hyperglycemic\\n Assessment:\\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\\n Action/Response:\\n Covered w/ RISS\\n Plan:\\n Con\\nt to check FS q6hrs, treat as indicated per SS (of\\n note: pt on prednisone)\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length, Mepilex placed \\n Action:\\n Pt turning self independently in bed\\n Response:\\n Unchanged\\n Plan:\\n Monitor area closely- prevent further breakdown\\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\\n being able to go to the bathroom in room or shower. Stated,\\n I am not\\n taking anymore pills\\n. Slept well overnight, startles when woken up by\\n RN for nsg interventions.\\nJust leave me alone\\n. Emotional support\\n provided\\n Get OOB, ^ activity as tolerated.\\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\\n placed but pt taking off. Pt encouraged to keep on for the night.\\n continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398186,\n \"text\": \"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\\n sheaths remain in R fem.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID- R fem site without oozing or hematoma- (-) distal pulses.\\n Response:\\n SBP <200- Nipride gtt weaned and D/C\\nd- captopril increased to 12.5mg\\n TID\\n Plan:\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by this evening- ? surgery mid week-\\n pre-op orders started.\\n Response:\\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\\n Plan:\\n Hyperglycemic\\n Assessment:\\n Glucose range 123-180\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Better glucose control.\\n Plan:\\n Con\\nt fingersticks q6hrs and follow sliding scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 398190,\n \"text\": \"Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\\n Assessment:\\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\\n sheaths remain in R fem.\\n Action:\\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\\n TID- R fem site without oozing or hematoma- (-) distal pulses.\\n Response:\\n SBP <200- Nipride gtt weaned and D/C\\nd- captopril increased to 12.5mg\\n TID\\n Plan:\\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\\n tomorrow.\\n Aortic stenosis\\n Assessment:\\n Critical AS per cardiac cath- consulted.\\n Action:\\n CXR done- echo done- seen by this evening- ? surgery mid week-\\n pre-op orders started.\\n Response:\\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\\n Plan:\\n Con\\nt to monitor closely.\\n Hyperglycemic\\n Assessment:\\n Glucose range 123-180\\n Action:\\n Insulin given as per sliding scale.\\n Response:\\n Better glucose control.\\n Plan:\\n Con\\nt fingersticks q6hrs and follow sliding scale.\\n Impaired Skin Integrity\\n Assessment:\\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\\n length.\\n Action:\\n Repositioned q2hrs off back- freq back care- area open to air.\\n Response:\\n Unchanged.\\n Plan:\\n Monitor area closely- con\\nt freq repositioning & back care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 398280,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 11:00 AM\\n SHEATH - STOP 11:00 AM\\n - increased captopril to 100 TID\\n - used nipride to drop pressure while Aline sheeth is being pulled\\n - pressure to 120's with 3 of Nipride, to 176 after decreased to 0.24,\\n adjusting to goal fo 150\\n - ordered dental consult and panorex\\n - hepatology consult: good candidate for surgery from liver perspective\\n - CTA: Contrast allergy to be managed with pre-treatment (prednisone,\\n ranitidine, benadryl). CTA at 8am Sunday\\n - Received Hydralazine 25 mg at 0100 for sBP > 190\\n Allergies:\\n Sulfa (Sulfonamides)\\n Anaphylaxis;\\n Shellfish\\n Anaphylaxis;\\n Iodine\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.2\\nC (97.1\\n HR: 62 (56 - 76) bpm\\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\\n RR: 18 (14 - 25) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 64.2 kg (admission): 64.8 kg\\n Total In:\\n 506 mL\\n 120 mL\\n PO:\\n 240 mL\\n 120 mL\\n TF:\\n IVF:\\n 266 mL\\n Blood products:\\n Total out:\\n 1,075 mL\\n 215 mL\\n Urine:\\n 1,075 mL\\n 215 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -569 mL\\n -95 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 93%\\n ABG: ///23/\\n Physical Examination\\n General: Well nourished, No acute distress\\n Neck: supple with JVP 7cm\\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\\n at LUSB\\n Respiratory: CTAB\\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\\n Extremities: No LE edema\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\\n DP pulses are biphasic and easily extinguished with soft compression\\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\\n Skin: Not assessed\\n Neurologic: Attentive, AAOx3\\n Labs / Radiology\\n 181 K/uL\\n 10.3 g/dL\\n 150 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 5.0 mEq/L\\n 40 mg/dL\\n 104 mEq/L\\n 138 mEq/L\\n 30.9 %\\n 6.6 K/uL\\n [image002.jpg]\\n 08:37 PM\\n 04:29 AM\\n 03:56 AM\\n 04:00 AM\\n WBC\\n 7.2\\n 4.3\\n 9.4\\n 6.6\\n Hct\\n 30.9\\n 28.7\\n 30.8\\n 30.9\\n Plt\\n 182\\n 186\\n 184\\n 181\\n Cr\\n 0.9\\n 1.1\\n 1.1\\n 1.1\\n Glucose\\n 191\\n 180\\n 108\\n 150\\n Other labs:\\n PT / PTT / INR:12.7/25.5/1.1,\\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\\n Assessment and Plan\\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\\n .\\n # Hypertension: Patient presented with hypertensive emergency with\\n chest pain. Patient grossly hypertensive in the cath lab with arterial\\n tracings showing systolics in the 330s. BP brought down by\\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\\n hypertensive in setting of medication non-compliance due to financial\\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\\n but were in the left arm with known L subclavian steal phenomenon.\\n Also, cuff pressure seems to underestimate the true BPs that are\\n measured via A-line. Patient\\ns BP improved but still not at goal of\\n 150-160.\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - continue captopril 100mg TID\\n - may need to add another for BP control for goal sBP 150-160\\n .\\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\\n pre-op studies for planned AVR.\\n - ordered dental consult and panorex\\n - per hepatology consult, pt is a good candidate for surgery from liver\\n perspective\\n - pt will get CTA today. Pt with Contrast allergy to be managed with\\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\\n - avoid medications that could decrease preload, such as NTG\\n .\\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\\n pain likely demand ischemia in setting of critical AS and hypertensive\\n emergency.\\n - continue ASA and pravastatin\\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\\n 75mg TID with goal HR 55-60\\n - continue captopril 100mg TID\\n - may need to add another for BP control\\n .\\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\\n 64% in ), with elevated PCWP. Patient also with R sided PA and\\n RA pressures on R heart cath, indicating evidence of pulmonary\\n hypertension and right-sided heart failure, likely exacerbated in\\n setting of L sided heart failure. BNP elevated at 2787, consistent\\n with heart failure.\\n - manage BP as above\\n - Pt appears euvolemic currently. Keep I/O even today\\n - no nitroglycerin given critical AS\\n - awaiting AVR surgery\\n .\\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\\n EKG. Currently HR around 60.\\n - continue BB\\n - telemetry\\n .\\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\\n higher than blood pressure cuff, consistent with a diagnosis of\\n PVD.\\n - continue ASA and pravastatin\\n .\\n # Carotid artery disease: Patient with history of TIA in \\n (significant R sided ICA stenosis). Carotid US from showed\\n 60-69% stenosis of the right internal carotid artery. Less than 40%\\n stenosis of the left internal carotid artery. Reversed flow in the left\\n vertebral artery, which may correspond to subclavian steal phenomenon.\\n - pt may live at BP around 200, and if BP drop lower pt may experience\\n TIA and dizziness. Need to monitor for sx.\\n .\\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\\n Patient reportedly on Lipitor but discontinued due to patient concern\\n about cirrhosis and possible liver damage. Patient was put on zetia as\\n a result. Zetia is very expensive; given her economic situation, zetia\\n changed to pravastatin.\\n - continue pravastatin\\n .\\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\\n - RISS with FS qACHS\\n .\\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\\n at . LFT normal.\\n - trend LFT\\n - per hepatology, pt is a good candidate for AVR from liver stand\\n point.\\n .\\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\\n was 73. Hct stable during this admission.\\n - trend Hct\\n .\\n # History of seizure: Patient was admitted for seizure in . She\\n has been on Keppra, but self-discontinued it because of depression. No\\n further episodes since then. Will continue to monitor.\\n ICU Care\\n Nutrition: regular cardiac-healthy diet\\n Glycemic Control: RISS\\n Lines:\\n 20 Gauge - 07:54 PM\\n Prophylaxis:\\n DVT: pneumoboots (pt refused sc heparin)\\n Stress ulcer: none\\n VAP: n/a\\n Comments:\\n Communication: Comments: husband\\n status: Full code\\n Disposition: will stay in CCU for BP optimization\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"R VENOUS DUP EXT UNI (MAP/DVT) RIGHT\",\n \"row_id\": 1116006,\n \"text\": \", M. 11:45 AM\\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \\n Reason: pre-op\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with critical AS requiring valve replacement surgery\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n PFI REPORT\\n Patent right greater and lesser saphenous veins with diameters described\\n below.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 1116007,\n \"text\": \" 11:45 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: pre-op\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with critical AS requiring surgery\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:24 PM\\n PFI:\\n 1. 60-69% stenosis of the right internal carotid artery.\\n 2. Less than 40% stenosis of the left internal carotid artery.\\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\\n subclavian steal.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 75-year-old woman with critical AS requiring surgery. Pre-op.\\n\\n TECHNIQUE: Evaluation of the bilateral extracranial carotid arteries as well\\n as vertebral arteries was performed with B-mode, color and spectral Doppler\\n ultrasound.\\n\\n FINDINGS: A mild amount of plaque was seen in the bilateral internal carotid\\n arteries, with B-mode ultrasound.\\n\\n On the right side peak systolic velocities were 187 cm/sec for the internal\\n carotid artery and 69 cm/sec for the common carotid artery. The right ICA/CCA\\n ratio was 2.7.\\n\\n On the left side peak systolic velocities were 98 cm/sec for the ICA and 68\\n cm/sec for the CCA. The left ICA/CCA ratio was 1.44.\\n\\n The right vertebral artery presented antegrade flow. The left vertebral\\n artery presented with retrograde flow, suggestive of left subclavian steal.\\n\\n COMPARISON: No change when compared to the carotid duplex scan obtained in\\n .\\n\\n IMPRESSION:\\n 1. 60-69% stenosis of the right internal carotid artery.\\n 2. Less than 40% stenosis of the left internal carotid artery.\\n 3. Reverse flow in the left vertebral artery, which may correspond to\\n subclavian steal phenomenon.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 1116008,\n \"text\": \", M. 11:45 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: pre-op\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with critical AS requiring surgery\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI:\\n 1. 60-69% stenosis of the right internal carotid artery.\\n 2. Less than 40% stenosis of the left internal carotid artery.\\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\\n subclavian steal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-08 00:00:00.000\",\n \"description\": \"R VENOUS DUP EXT UNI (MAP/DVT) RIGHT\",\n \"row_id\": 1116005,\n \"text\": \" 11:45 AM\\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \\n Reason: pre-op\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with critical AS requiring valve replacement surgery\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:18 PM\\n Patent right greater and lesser saphenous veins with diameters described\\n below.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 75-year-old woman with critical AS requiring valve replacement\\n surgery. Venous mapping was requested.\\n\\n The right greater saphenous vein is patent and compressible with diameters\\n ranging between 0.25 and 0.31 cm. The right lesser saphenous vein is patent\\n and compressible with diameters ranging between 0.21 and 0.29 cm. The left\\n greater saphenous vein was not visualized due to previous harvesting.\\n\\n COMPARISON: None available.\\n\\n IMPRESSION: Patent right greater and lesser saphenous veins, with diameters\\n described above.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1115565,\n \"text\": \" 7:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pulmonary congestion, consolidation\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with CAD, critical AS, elevated PCWP\\n REASON FOR THIS EXAMINATION:\\n pulmonary congestion, consolidation\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n COMPARISON: .\\n\\n INDICATION: Pulmonary congestion.\\n\\n FINDINGS: Cardiac silhouette remains enlarged, and there is unchanged\\n tortuosity and calcification of the thoracic aorta. Lungs are grossly clear,\\n and there are no pleural effusions or acute skeletal findings.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-12-07 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1115847,\n \"text\": \" 9:38 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with aortic stenosis\\n REASON FOR THIS EXAMINATION:\\n please evaluate from axillary arteries to common femoral. This is a pre-op\\n exam. Please conduct study at 0800 so that her pretreatment schedule is correct\\n CONTRAINDICATIONS for IV CONTRAST:\\n allergy: Preteated !\\n ______________________________________________________________________________\\n WET READ: SPfc 11:26 AM\\n Extensive atherosclerotic disease with ectasia of the ascending aorta, similar\\n to that seen in . Otherwise, incidental note is made of a nodule in the\\n left lower lobe of the lungs, appearing slightly larger since . This\\n could be followed with a dedicated high-res Chest ct in ~3months\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preoperative evaluation in a patient with aortic stenosis.\\n\\n TECHNIQUE: Axial CT images were acquired through the torso prior to and\\n thereafter following the administration of 100 cc of intravenous Optiray 350\\n contrast. Coronal and sagittal reformatted images were also reviewed.\\n\\n CT CHEST WITH AND WITHOUT CONTRAST: The airways are patent to segmental\\n levels bilaterally. Heterogeneous attenuation throughout the lungs is likely\\n related to air-trapping. There is a small amount of dependent atelectasis\\n bilaterally. A nodular opacity posterolaterally in the left lower lobe is 13\\n x 9 mm. This correlates to a small nodular opacity, which was described on a\\n CT from , and has now grown minimally in size. There is no\\n axillary lymphadenopathy. A hypodense pretracheal node is borderline in size,\\n measuring 10mm in shortest diameter.\\n\\n The heart and great vessels are notable for coronary arterial calcification as\\n well as aortic valvular calcification. In addition, calcification is\\n visualized along the length of the aorta, which is ectatic, unchanged from the\\n previous studies, measuring approximately 37 x 38 mm in the ascending aorta.\\n Dense calcification is also prominent at the origin of the left subclavian\\n artery. The main as well as right pulmonary arteries are prominent in size\\n measuring ~29 mm, suggesting pulmonary hypertension. Note is made of\\n cardiomegaly, in particular with left atrium appears enlarged.\\n\\n CT ABDOMEN WITH AND WITHOUT CONTRAST: The stomach, duodenum, spleen,\\n pancreas, adrenal glands, right kidney, and gallbladder are unremarkable. The\\n left kidney contains an 18x18mm hypodensity which is hypodense (~27H.U.) and\\n does not enhance, though is new or enlarged. The liver is notable for three\\n hypodensities, two in the right lobe and one in the left, all of which are too\\n small to characterize though appear unchanged from . There is no free gas\\n or free fluid in the abdomen. There is no retroperitoneal or mesenteric\\n lymphadenopathy.\\n (Over)\\n\\n 9:38 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\\n Admitting Diagnosis: AORTIC STENOSIS\\\\RIGHT HEART CATH;LEFT HEART CATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Vascular structures are notable for extensive atherosclerotic calcification\\n along the length of the aorta in the absence of aneurysmal dilation.\\n Calcification is noted at the origin of the renal arteries bilaterally as well\\n as at the origin of the superior mesenteric artery. The celiac trunk is\\n notable for a separate origin of the left gastric artery.\\n\\n CT PELVIS WITH AND WITHOUT CONTRAST: The urinary bladder contains a small\\n amount of gas and a Foley catheter. The uterus, right adnexa, and rectum are\\n unremarkable. The colon reveals diverticulosis. A punctate calcification in\\n the left adnexa is unchanged. There is no free gas or fluid in the pelvis,\\n and there is no pelvic sidewall or inguinal lymphadenopathy. Regional\\n vascular structures opacify normally. Note is made of scattered injection\\n granulomas in the right buttocks region.\\n\\n OSSEOUS FINDINGS: The patient is status post median sternotomy. There is a\\n wedge compression deformity in the mid thoracic spine at the T5 vertebral\\n body, which is unchanged since . There is a grade 1 anterolisthesis of L4\\n over L5. Degenerative disc disease at that same level with endplate sclerosis\\n has progressed since .\\n\\n IMPRESSION:\\n 1. Extensive atherosclerotic disease as well as ectatic dilation of the\\n ascending aorta, similar to that seen in .\\n 2. Left lower lobe pulmonary nodular opacity, appearing minimally enlarged\\n from . Given the size of this lesion, followup with a PET study or\\n dedicated CT of the chest within three months, is recommended.\\n 3. Diverticulosis\\n 4. Left renal hypodensity. While this is likely a cyst, it is new/enlarged\\n from the previous study and could be correlated to U/S for further\\n characterization.\\n 3. Stable hepatic hypodensities too small to characterize but likely cysts.\\n 4. Wedge compression deformity in the mid thoracic spine and degenerative\\n changes in the remainder of the spine as cataloged above.\\n\\n\"\n }\n]"}}},{"rowIdx":24991,"cells":{"subject_id":{"kind":"number","value":63552,"string":"63,552"},"hadm_id":{"kind":"number","value":160230,"string":"160,230"},"target_text":{"kind":"string","value":"77 yo female with PMH tracheostomy respiratory failure, subglottic stenosis, Parkinson's and SLE who is s/p rigid bronchoscopy on for removal of granulation tissue who required ICU admission for observation due to tachypnea post extubation. Bronch revealed mild TBM and recidual tracehal stenosis. She has a tegaderm covering her stomal opening, which will stay in place for now. She had normal oxygen saturations throughout her ICU stay. A CT airway was done to evaluate for tracheal stenosis, which showed tracheal and subglottic stenosis as noted above. In terms of Atrial Fibrillation, Currently in sinus rhythm. Maintained on metoprolol. INR was 1.3 on . Warfarin was being held pre-procedure and was restarted on . Healthcare proxy : , (daughter) "},"extractive_notes_summ":{"kind":"string","value":"Focal minimal collection of air is present adjacent to the upper right mediastinum, 4:58, approximately 7 mm in diameter, most likely representing loculated pneumothorax. Small amount of pericardial effusion. There is small amount of pericardial effusion. There is small amount of pericardial effusion. Since theprevious tracing of atrial flutter is now absent. Note is made that the dynamic expiration was suboptimal and does not really represent the expiratory images. FINDINGS: Thin-section images demonstrate the minimal diameter of the airway being 9.5 x 7 mm with a cross-sectional area at this location of 70 mm2 at the level of the thoracic inlet. Sinus bradycardia with probable sinus arrhythmia and a possible non-conductedatrial premature beat. The mid and distal portions of the trachea are well expanded with minimal secretions noted. Focal area of narrowing of the trachea just at the level of the thoracic inlet to be 9 x 7 mm in diameter, 71 mm2, with no significant change during dynamic expiration. The rest of the trachea is unremarkable. Cardiomegaly, moderate. Airways are patent till the level of subsegmental bronchi bilaterally. Areas of ground-glass opacity in the lungs are concerning for infection/aspiration. The imaged portion of the upper abdomen reveals no abnormality . Local collection in the area adjacent to the right upper mediastinum that might represent local pneumothorax. The descending thoracic aorta is mildly enlarged as well, ranging up to 3.2 cm as opposite to maximum of 2.5 cm. Within the limitations of this non-enhanced study, no mediastinal, hilar or axillary lymphadenopathy was present. The aorta is up to 4 mm, borderline. Bibasilar atelectasis is present. In left upper quadrant of the abdomen, there is a 9 mm rounded lesion that most likely represents a splenule given the presence of a similar one adjacent to the spleen and the proximity to spleen. No IV contrast is administered. COMPARISON: Chest radiograph from and . Lateral precordial lead T wave changes are suggestedbut unstable baseline in those leads makes assessemnt difficult. IMPRESSION: 1. TECHNIQUE: MDCT of the chest was obtained from the level of the lower neck to the level of upper abdomen during end inspiration as well as dynamic expiration. Dynamic imaging did not demonstrate significant collapsibility of the airways and in particular, there was no appreciably change in the size of the airway at that specific location (65 mm2). Those areas are highly worrisome for infectious process. Axial images reviewed in conjunction with multiple coronal, sagittal, and 3D volume-rendering reformats. The evaluation of the lung parenchyma demonstrates ground-glass opacity (Over) 9:46 AM CT TRACHEA W/O C W/3D REND Clip # Reason: pls perform airway CT. we are interested in assessing trache Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT FINAL REPORT (Cont) involving the right upper lung with diffuse and more focal components as well as right middle lobe and to a lesser extent right lower lobe. 4. No evidence of fluid accumulation next to this area is noted. 3. The main pulmonary artery is enlarged up to 3.5 cm. Aspiration would be another possibility. There are no bone lesions worrisome for infection or neoplasm within the limitations of this study technique. The heart is enlarged. REASON FOR THIS EXAMINATION: pls perform airway CT. we are interested in assessing tracheal stenosis No contraindications for IV contrast FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy with tracheal stenosis, now with trachea decannulated. 2. No evidence of fluid collection in the area demonstrated to suggest infectious origin of this finding."},"n_notes":{"kind":"number","value":2,"string":"2"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2137-12-10 00:00:00.000","description":"CT TRACHEA W/O C W/3D REND","row_id":1168988,"text":" 9:46 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: pls perform airway CT. we are interested in assessing trache\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with h/o resp failure, s/p trach, tracheal stenosis, now with\n trach decannulated.\n REASON FOR THIS EXAMINATION:\n pls perform airway CT. we are interested in assessing tracheal stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy with\n tracheal stenosis, now with trachea decannulated.\n\n COMPARISON: Chest radiograph from and .\n\n TECHNIQUE: MDCT of the chest was obtained from the level of the lower neck to\n the level of upper abdomen during end inspiration as well as dynamic\n expiration. No IV contrast is administered. Axial images reviewed in\n conjunction with multiple coronal, sagittal, and 3D volume-rendering\n reformats.\n\n Note is made that the dynamic expiration was suboptimal and does not really\n represent the expiratory images.\n\n FINDINGS:\n\n Thin-section images demonstrate the minimal diameter of the airway being 9.5 x\n 7 mm with a cross-sectional area at this location of 70 mm2 at the level of\n the thoracic inlet. Dynamic imaging did not demonstrate significant\n collapsibility of the airways and in particular, there was no appreciably\n change in the size of the airway at that specific location (65 mm2).\n\n The mid and distal portions of the trachea are well expanded with minimal\n secretions noted. Airways are patent till the level of subsegmental bronchi\n bilaterally. Within the limitations of this non-enhanced study, no\n mediastinal, hilar or axillary lymphadenopathy was present. There is small\n amount of pericardial effusion. The main pulmonary artery is enlarged up to\n 3.5 cm. The aorta is up to 4 mm, borderline. The heart is enlarged. There\n is small amount of pericardial effusion.\n\n The descending thoracic aorta is mildly enlarged as well, ranging up to 3.2 cm\n as opposite to maximum of 2.5 cm.\n\n The imaged portion of the upper abdomen reveals no abnormality .\n\n In left upper quadrant of the abdomen, there is a 9 mm rounded lesion that\n most likely represents a splenule given the presence of a similar one adjacent\n to the spleen and the proximity to spleen.\n\n The evaluation of the lung parenchyma demonstrates ground-glass opacity\n (Over)\n\n 9:46 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: pls perform airway CT. we are interested in assessing trache\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n involving the right upper lung with diffuse and more focal components as well\n as right middle lobe and to a lesser extent right lower lobe. Those areas are\n highly worrisome for infectious process. Aspiration would be another\n possibility.\n\n Focal minimal collection of air is present adjacent to the upper right\n mediastinum, 4:58, approximately 7 mm in diameter, most likely representing\n loculated pneumothorax. No evidence of fluid accumulation next to this area\n is noted.\n\n Bibasilar atelectasis is present.\n\n There are no bone lesions worrisome for infection or neoplasm within the\n limitations of this study technique.\n\n IMPRESSION:\n 1. Focal area of narrowing of the trachea just at the level of the thoracic\n inlet to be 9 x 7 mm in diameter, 71 mm2, with no significant change during\n dynamic expiration. The rest of the trachea is unremarkable.\n 2. Local collection in the area adjacent to the right upper mediastinum that\n might represent local pneumothorax. No evidence of fluid collection in the\n area demonstrated to suggest infectious origin of this finding.\n 3. Areas of ground-glass opacity in the lungs are concerning for\n infection/aspiration.\n 4. Cardiomegaly, moderate. Small amount of pericardial effusion.\n\n"},{"category":"ECG","chartdate":"2137-12-09 00:00:00.000","description":"Report","row_id":281325,"text":"Sinus bradycardia with probable sinus arrhythmia and a possible non-conducted\natrial premature beat. Lateral precordial lead T wave changes are suggested\nbut unstable baseline in those leads makes assessemnt difficult. Since the\nprevious tracing of atrial flutter is now absent.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2137-12-10 00:00:00.000\",\n \"description\": \"CT TRACHEA W/O C W/3D REND\",\n \"row_id\": 1168988,\n \"text\": \" 9:46 AM\\n CT TRACHEA W/O C W/3D REND Clip # \\n Reason: pls perform airway CT. we are interested in assessing trache\\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 77 year old woman with h/o resp failure, s/p trach, tracheal stenosis, now with\\n trach decannulated.\\n REASON FOR THIS EXAMINATION:\\n pls perform airway CT. we are interested in assessing tracheal stenosis\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy with\\n tracheal stenosis, now with trachea decannulated.\\n\\n COMPARISON: Chest radiograph from and .\\n\\n TECHNIQUE: MDCT of the chest was obtained from the level of the lower neck to\\n the level of upper abdomen during end inspiration as well as dynamic\\n expiration. No IV contrast is administered. Axial images reviewed in\\n conjunction with multiple coronal, sagittal, and 3D volume-rendering\\n reformats.\\n\\n Note is made that the dynamic expiration was suboptimal and does not really\\n represent the expiratory images.\\n\\n FINDINGS:\\n\\n Thin-section images demonstrate the minimal diameter of the airway being 9.5 x\\n 7 mm with a cross-sectional area at this location of 70 mm2 at the level of\\n the thoracic inlet. Dynamic imaging did not demonstrate significant\\n collapsibility of the airways and in particular, there was no appreciably\\n change in the size of the airway at that specific location (65 mm2).\\n\\n The mid and distal portions of the trachea are well expanded with minimal\\n secretions noted. Airways are patent till the level of subsegmental bronchi\\n bilaterally. Within the limitations of this non-enhanced study, no\\n mediastinal, hilar or axillary lymphadenopathy was present. There is small\\n amount of pericardial effusion. The main pulmonary artery is enlarged up to\\n 3.5 cm. The aorta is up to 4 mm, borderline. The heart is enlarged. There\\n is small amount of pericardial effusion.\\n\\n The descending thoracic aorta is mildly enlarged as well, ranging up to 3.2 cm\\n as opposite to maximum of 2.5 cm.\\n\\n The imaged portion of the upper abdomen reveals no abnormality .\\n\\n In left upper quadrant of the abdomen, there is a 9 mm rounded lesion that\\n most likely represents a splenule given the presence of a similar one adjacent\\n to the spleen and the proximity to spleen.\\n\\n The evaluation of the lung parenchyma demonstrates ground-glass opacity\\n (Over)\\n\\n 9:46 AM\\n CT TRACHEA W/O C W/3D REND Clip # \\n Reason: pls perform airway CT. we are interested in assessing trache\\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n involving the right upper lung with diffuse and more focal components as well\\n as right middle lobe and to a lesser extent right lower lobe. Those areas are\\n highly worrisome for infectious process. Aspiration would be another\\n possibility.\\n\\n Focal minimal collection of air is present adjacent to the upper right\\n mediastinum, 4:58, approximately 7 mm in diameter, most likely representing\\n loculated pneumothorax. No evidence of fluid accumulation next to this area\\n is noted.\\n\\n Bibasilar atelectasis is present.\\n\\n There are no bone lesions worrisome for infection or neoplasm within the\\n limitations of this study technique.\\n\\n IMPRESSION:\\n 1. Focal area of narrowing of the trachea just at the level of the thoracic\\n inlet to be 9 x 7 mm in diameter, 71 mm2, with no significant change during\\n dynamic expiration. The rest of the trachea is unremarkable.\\n 2. Local collection in the area adjacent to the right upper mediastinum that\\n might represent local pneumothorax. No evidence of fluid collection in the\\n area demonstrated to suggest infectious origin of this finding.\\n 3. Areas of ground-glass opacity in the lungs are concerning for\\n infection/aspiration.\\n 4. Cardiomegaly, moderate. Small amount of pericardial effusion.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 281325,\n \"text\": \"Sinus bradycardia with probable sinus arrhythmia and a possible non-conducted\\natrial premature beat. Lateral precordial lead T wave changes are suggested\\nbut unstable baseline in those leads makes assessemnt difficult. Since the\\nprevious tracing of atrial flutter is now absent.\\n\\n\"\n }\n]"}}},{"rowIdx":24992,"cells":{"subject_id":{"kind":"number","value":22734,"string":"22,734"},"hadm_id":{"kind":"number","value":184944,"string":"184,944"},"target_text":{"kind":"string","value":"1. Cardiovascular/respiratory: The patient's respiratory distress accelerated after admission to the Neonatal Intensive Care Unit. She progressed from CPAP to requiring intubation and treatment with Surfactant. She received two doses of surfactant. She was extubated to CPAP by the second hospital day. She uses nasal cannula oxygen by the third day and weaned to room air by the ninth hospital day. Apnea and bradycardia has not been a prominent part of her hospital course. She has not required treatment with Methylxanthine. Murmur consistent with PPS was noted at approximately day 15 of life. 2. Fluid, electrolytes and nutrition: The patient was maintained NPO on intravenous fluids through the second hospital day. At that point feedings were started and progressed easily. She is currently receiving 24 calorie formula at a volume of 150 cc per kilogram per day. The weight at the time of this dictation on is 2150 grams. Discharge weight is 2150grams. 3. Hematologic: The patient's hematocrit on admission was 40.4. A repeat on was 33.6 with a reticulocyte count of 1.4%. 4. Infectious disease: The patient was treated with antibiotics for 48 hour rule out with antibiotics. CBC on admission showed a white blood cell count of 11.1 with 32 polys and 0 bands. Blood culture remained negative and the patient was clinically stable after the discontinuation of antibiotics. 5. Gastrointestinal: The patient's maximum bilirubin was 8.9 on the fourth hospital day. She was treated with phototherapy, which was discontinued by the sixth hospital day. 6. Neurological: The patient manifested normal neurological examination throughout her hospital stay. Head ultrasound on was within normal limits. 7. Routine health care maintenance: The patient passed a hearing screen. Car seat test is passed. Hepatitis B vaccine was administered on . 8. Immunization recommendations: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria, one born at less then 32 weeks, two born between 32 and 35 weeks with two of the three of the following, day care during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or three with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other care givers should be considered for immunization against influenza to protect the infant. Follow up appointment with primary care pediatrician is to be arranged within two days following discharge by the parents. Ferrous sulfate supplementation. , M.D. Dictated By: MEDQUIST36 D: 09:28 T: 09:30 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"Continue to monitorFEN status.DEV: Temps stable, swaddled in OAC. Respiratory O: Pt. Abdexam benign. A: Stable in RA P: Continue to support.#3 FEN S/O: TF 150cc/k/d. noincreased wob noted. A: StableP: Continue to support.#3 FEN S/O: TF 150cc/k/d. mild SC retractions. Mild sc rtxns. Abd soft, +BS. mild subcostal retractions. P: Continue to support.#4 DEV S/O: Infant in OAC, maintaining temps. Comfortab;e appeatring.Wt 2150 up 45. Abdomen benign,voiding and stooling. due this wk. Cl and = BS. A: Pt. A: Pt. Lungs clear, subcostalretractions. Abdomen bneign. A: Stable. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. NeonatologyDoing well. NeonatologyDOing well. Abdomen benign. minimal aspirates. 2 Resp. P: Cont to mtr#3 FENs/o: TF 150cc/k/d-- remains on BM26/PE26. Lungs CTA, =. Cont to moitor. REmains in RA. A: Stable P: Encourage po feeds.#4 DEV S/O: Maintaining temps in OAC. Swaddled w/iboundaries. infant abd exam benign. Resp O/A Rec'dinf in RA. Abd exam benign.Voiding and stooling. Cor nl s1s2 murmur as before. DEV O/A remains in an OAC cobedding with hertwin. Temp stable. Continue to monitorFEN status.DEV: Temps stable, swaddled in OAC. Resp O/A Rec'd inf in RA. Neuro non-focal and age aprpopriate.COntinue current monitoring and nurtitional regimen Skin w/o leisons. DEV O/A remains in an OAC with stable temp. Alt po/pg.Skin w/o leisons. mild subcostal retractions. Inf remains in RA. Inf remains in RA. Settles with paci. MildIC/SC rtx. Infant calmseasily w/ wrapping and pacifier when offered.A: AGAP: Cont dev. neuro non-focal and age appropriate. Remains in R air, BBS clear, equal, mild subcostal/intercostal retractions present, no spells thus far thisshift. Infant remains in RA. A; Feeds tolertaed. BBS clear/=, RR 30-70's, mild transient SCretractions. Settles best onabd. G/D: Temp. Bld cx neg to date. A: stable under single P: COnt. NPN 7p-7aSepsis: Bld cx neg to date. Issueresolved.Resp: Infant remains on Nc 02. fi02 100%. Nested insheepksin with boundries in place. No edema.Stable 02 sat with min 02 requirement.Cont to monitor. A: stable P:Cont. Max aspirate 1.2cc. IVF ofpnd10w via piv. Temps stable in OAC. Occbrief 02 sat drifts, self resolving. Cont to advance feeds as tol.Dev: Temp stable in servo isolette. Am lytespending. Mild ic/sc retractions. Bs+. Bs +. Ic/Sc retractions noted. Respiratory Care NotePt off CPAP today. A: stable in 02, no spellsovernight P: COnt. A;requiredsupplemental o2 to maintain sats P; cont to wean o2 astolerated.#3. to monitor.3infant remains on TF min. stable in servo mode isoeltte. Med spit x 1. 48 Ro/o complete. benign, voiindg/no stool.PN/lipids infusing at 80cc/k, DS stable.A: toleratingadvancement of feeds P: COnt. Settles well inbetween cares. Isolette weaned astolerated. G/D: Temps stable swaddled in off-isolette. Abd exam benign. MildIC/SCR noted. Amlytes stable. Mild rtxns. Started on amp and gent. P- Cont toassess for Resp needs.#3-O/A- TF=140cc/kg/d of BM/PE20 via NGT. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. BBS clear and =. Active, alert in an isolette, AFOF, sutures opposed, good tone. Bili this am=7.0, 0.2. Neonatology-NNP Physical ExamInfant remains in RA. 2. remains in RA, color pink, sl jaundice, RR 30-60,BBS clear, equal, sc retractions, no spells.3. Tolerating NGT feedings well; abd exambenign, no spits, min asp, and AG stable. Voiding qs and nostool noted thus far. AGA. AGA. NPNOte;#2.Remains in R air, BBS clear, equal, mild subcostal /intercostal retractions present, no spells thus far thisshift. Tol well. LS = and clear, no murmur noted, VSS, D/S:72. NPN Days#1 Pt cont on ampi and gent. LS course bilat. CBG (0200): 7.35/ 47/ 46/ 27/ 0. Cl and = BS. one spell this shift. FiO221%. Ext. Pt weaned throughout the am and cbg drawn7.32/56/29/30/0. HUSscheduled for thurs. Currently pt. Cl and = BS> RR40-70s. Pt. Pt. Pt. Pt. Pt. Pt. Pt. nospells so far this shift. was treated with 6.2cc's of Survanta at 2145 and 0400. Br. Lungs CTA, cl and = bilat. d-stick 87. aga. aga. 2+FP. 2+FP. mildsubcostal retractions. updates given. Abd soft, +BS. Tol well. Tol well. +NG. Remains on Amp & Gent.G&D: CGA=32 wk. BCpending. asking appropques. BP 68/35, 46. TF 150 cc/k/day BM26/PE26 po/pg. TF 150 cc/k/day BM/PE26 po/pg. Pt NPO. sucks onpacifier. sucks onpacifier. Mild sc rtxns. Mild sc rtxns. IC SC retrac. NPO. stable girths.gavage fed this shift. Con to monitor. On Ferinsol.DEV: Temps stable in OAC. A: small O2 needpersists P;Follow#3 TF's presently at 95cc/k. LSclear and equal. Ls clr/=.Mild ic/sc retractions. Stable temp in heated isolette. Abd benign. Bili today 11.5/0.2. LS clear/=. Will check bilitonight. AFOF, Caput over occiput. Cont to advance feeds as tol.Dev: Temp stable in servo isolette. BBS clear and =. Remains in R air, BBS clear, equal, mild subcostalretractions present, no spells thus far this shift. Belly benign. snds clear, = bilat.A: Stable in RA w/o spells.P: Cont to monitor for desats or bradys.#3 F/N: Infant continues on 150cc/kg/d PE26/BM 26 w/ promod,47cc q 4 hrs. RRR, without murmur, pulses 2+ and symmetrical. PE26 with PM (45cc Q4hr) PO/PG. Dstick 86.Abd soft. Minimal aspirates. Alt po/pgfeeds. IVf of pnd10w with IL via piv. Mod jaundice under single phototherapy. Mildretractions present. Active bs. Am bili 6.1/.3-downfrom 8.4/.3. A; ,involved.P; cont dev support. Tol feeds gavagedover 1hr20min. P- Cont toassess for Resp needs.#3-O/A- TF=110cc/kg/d of BM/PE20 via NGT. to monitor resp. Infant remainson NCO2. Abd exam benign. Abd exam benign. LSclear and equal. abd benign. P: Cont. P: Cont. P: Cont. wt. MildIC/SCR. Voiding qs and nostool noted thus far. AGA. Temp stable inheated isolette. NPNOte;#2.Remains in R air, BBs clear, equal, mild subcostalretarctions present, no spells, occassional sat drifts tomid 80's noted, QSR. Mild IC/SCretractions. lsc=. Transferred toopen crib, temp stable. mild sc/icretractions. Neonatology-NNP Physical ExamInfant remains in RA. Tolerating feedings well; abd exambenign, min asp, AG stable, and one spit. P- Cont to assess for Respneeds.#3-O/A- TF=150cc/kg/d of BM/PE24 via NGT. Will continue with current plan of care.Dev: Temp stable in low air isolette while swaddled. minimal aspirates.#4 g&dpt in oac with stable temps."},"n_notes":{"kind":"number","value":122,"string":"122"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2152-02-10 00:00:00.000","description":"NEONATAL HEAD PORTABLE","row_id":816466,"text":" 7:04 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: TWIN INFANT BORN AT 32 3/7 WEEKS GESTATION, R/O IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 32 week twin\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with 32 and 3/7th weeks. Twin. R/O intraventricular\n hemorrhage.\n\n FINDINGS: The sulci and gyri of the cerebrum and cerebellum have an appearance\n consistent with the patient's prematurity. An extra-axial fluid collection is\n not seen. The ventricular system size is normal. There is no evidence of a\n subarachnoid or an intraventricular hemorrhage.\n\n IMPRESSION: Premature appearing brain. No bleed.\n\n"},{"category":"Radiology","chartdate":"2152-02-07 00:00:00.000","description":"BABYGRAM (CHEST ONLY)","row_id":816205,"text":" 10:14 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: check placement of ett\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with surfactant deficiency\n REASON FOR THIS EXAMINATION:\n check placement of ett\n ______________________________________________________________________________\n FINAL REPORT\n This is a child with prematurity.\n\n The exam is grossly underexposed and should be repeated at no cost to the\n patient. I can ascertain that the ETT is just at the carina. There is probably\n hyaline membrane disease present.\n\n"},{"category":"Radiology","chartdate":"2152-02-10 00:00:00.000","description":"P BABYGRAM (CHEST ONLY) PORT","row_id":816500,"text":" 11:18 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: 3 day old ex-32 week with worse resp distress\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress\n REASON FOR THIS EXAMINATION:\n 3 day old ex-32 week with worse resp distress\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Infant with respiratory distress.\n\n Single frontal radiographs compared to the only prior demonstrates diffuse\n ground-glass opacities bilaterally with a more focal opacity in the right\n lower lobe and right middle lobe. The enteric catheter tip overlies the\n stomach. Findings are most consistent with RDS and right middle and lower\n lobe subsegmental atelectasis.\n\n"},{"category":"Nursing/other","chartdate":"2152-03-01 00:00:00.000","description":"Report","row_id":1987264,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats thus far this shift.\nlung sounds clear and equal. mild subcostal retractions. no\nincreased wob noted. Rr 50-60's. sats remain in the high\n90%.\n\n3: fen\ncurrent weight 2040gms up 30gms. total fluids remain at\n150cc/kilo/day of pe/bm26 with prom. tolerating feeds well.\none small spit. minimal aspirates. abd soft with no loops.\nvoiding, no stool thus far this shift.stable girths. infant\ntaking full volumes po's at first two cares. will attempt to\npo if and rooting with next care. continue to\nencourage po feedings.\n\n4: dev\ntemps stable in an open crib. and active with cares.\nsleeps well inbetween. waking prior to care time. sucks\nvigorously on pacifier. brings hands to face. aga. continue\nto monitor for developmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-01 00:00:00.000","description":"Report","row_id":1987265,"text":"Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing.\n\nWt 2040 up 30. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Still requiring some gavage. Small amounts of non-bilious spits.\n\nTemp stable in open crib.\n\nHct 33.6 Retic 1.4.\n\nContinue current monitoring and nutritional managfement.\n"},{"category":"Nursing/other","chartdate":"2152-03-01 00:00:00.000","description":"Report","row_id":1987266,"text":"Neonatology - NP Physical Exam\nAwake and alertt with cares, temp stable in o-pen crib. BS clear and equal with mild subcostal retractions, color pink. RRR with soft murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\n"},{"category":"Nursing/other","chartdate":"2152-03-01 00:00:00.000","description":"Report","row_id":1987267,"text":"Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 23.\nWT: 2040 g (+30)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 30.5 cm (~10th to 25th %ile); last: 30 cm\nLN: 44 cm (~10th to 25th %ile); last: 43 cm\nMeds include Fe\n due this wk\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant attempts po's w/ every feed; takes ~ to full volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. due this wk. Learning po feeding skills. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for all parameters. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2152-03-01 00:00:00.000","description":"Report","row_id":1987268,"text":"NPN\n\n\n#2 Resp: infant remains in RA with sats >93%. RR 30-50's,\nBBS clear/=. mild SC retractions. no desats or brady's. cont\nto monitor resp status.\n\n#3 Fluids: infant TF remain 150cc/kg/d PE26+PM. Receiving\nPO/NG feeds 51cc Q4h. Infant took partial feed PO this AM\nand remainder gavaged. Took full volume for 1330 feeding.\nTaking PO's well with good coordination. abd soft, +BS,\nvoiding, stools heme negative. small spit. cont to offer PO\nfeedings when infant eager and interested.\n\n#4 G&D: infant bundled in OC with stable temps. Awake, \nand active, wakes for feedings. cont to provide\ndevelopmental support.\n\n#5 : called this afternoon to say that he will be\nin for 2130 feeding. cont to provide updates and support.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-02 00:00:00.000","description":"Report","row_id":1987269,"text":"NPN 1900-0700\n\n\n#2 RESP S/O: Infant in RA. Lungs clear, subcostal\nretractions. RR 30-70's, O2 sats >95%. No spells or\ndrifting. A: Stable in RA P: Continue to support.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get pe26 with promod,\n51cc q4h po/pg. Infant bottled 47ccx2 tonight so far.\nAbdomen is benign, voiding and stooling. No spits, min\naspirates. A: Tolerating feeds. P: Continue to support.\n\n#4 DEV S/O: Infant in OAC, maintaining temps. and\nactive. Waking before feeds. A: AGA P: Continue to support.\n\n#5 S/O: in tonight. Held infant and bottled her.\nAsked appropriate questions. A: Involved P: Continue to\nsupport and update.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-02 00:00:00.000","description":"Report","row_id":1987270,"text":"Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-60's, no increase work of breathing noted. LS clear/=.\nNo A&B's or de-sats noted this shift thus far. A: Pt. is\nstable in RA. P: Continue to monitor respiratory status.\nMonitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE 26 w/PM =53cc\nQ 4hrs. She has taken all PO's this shift thus far ~55cc Q\nfeed. Pt. tires out a bit toward the end. Abdomen is soft,\npink, +BS, no loops/spits noted. Abdominal girth is 25cm.\nShe is voiding/ stool x1. A: Pt. is tolerating current\nnutritional plan. P: Continue w/ current feeding plan.\nMonitor for s/s of intolerance. Encourage PO feeds.\n\n#4. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. O: Mom in to visit this afternoon for cares.\nShe was udpated at bedside on pt's current status and daily\nplan of care. Mom is active and involved in cares. A:\nFamily is and involved. P: Continue to udpate,\nsupport and educate.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-03 00:00:00.000","description":"Report","row_id":1987271,"text":"NPN 1900-0700\n\n\n#2 RESP S/O: Infant in RA, lungs clear with subcostal\nretractions. RR 40-70's, O2 sats >95%. No spells. A: Stable\nP: Continue to support.\n\n#3 FEN S/O: TF 150cc/k/d. To get pe26, with promod, 53cc\nq4h. Infant bottled 60ccx2 so far tonight. Abdomen benign,\nvoiding and stooling. Getting desitin to bottom. No spits,\nmin aspirates. Nutrition tonight Ca , Phos 7.5, Alk\nPhos 277. A: Stable P: Encourage po feeds.\n\n#4 DEV S/O: Maintaining temps in OAC. and active with\ncares. Waking for some feeds. A: AGA P: Continue to support.\n\n#5 S/O: No contact.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-03 00:00:00.000","description":"Report","row_id":1987272,"text":"Neonatology\nDoing well. RA. No spells. Comfortab;e appeatring.\n\nWt 2150 up 45. All po overnight. Seems much improved with bottling. Abdomen benign. Will dcerease cals to 24 and change from preemie formula.\n\nTemp stable\n\nWill need HBV.\n\nLeft message for mother re potential for dc in coming days.\n\nDC summary dictated.\n"},{"category":"Nursing/other","chartdate":"2152-02-21 00:00:00.000","description":"Report","row_id":1987229,"text":"#2 RESP\ns/o: BS clear and equal. Comfortable wob. Color pink. No\nspells. A: Stable. P: Cont to mtr\n#3 FEN\ns/o: TF 150cc/k/d-- remains on BM26/PE26. Void/stool qs. Abd\nexam benign. Wt up 30 gms to 1755gms tonight A: Gaining on\n26 cal formula. P: cont to mtr tolerance and daily wt\n#4 DEV\ns/o: Temp stable in open crib- with cares. Tone good.\nAwake yet little interest at breast or with po offered. A:\nDev AGA for CGA- 34-3/7 wks. P: cont dev supp cares\n#5 \ns/o: Both in tonight- actively participating in\ncares. A: Invested family P: cont dev supportive cares\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-22 00:00:00.000","description":"Report","row_id":1987230,"text":"2 Resp.\n Infant stable in room air, mild retractions, sats over 92\nmost of the time, 0 spells tonight. Continue to monitor and\nrecord any changes.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\ninfant tolerating feeds well by gavage, bottlee part of feed\nX1 did fair.Voiding, 0 stool. Wt. up 30gms to 1.755.\nContinue present plans.\n5 \n No contact from so far tonight, plan to keep\nfamily updated.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-22 00:00:00.000","description":"Report","row_id":1987231,"text":"Neonatology Attending Note\nExam:\nUnchanged form previously. Resting comfortably in no distress. Pink. AFSF. Lungs CTA, =. CV RRR, soft murmur. Abd soft, +BS. Ext warm, pink and well perfused.\n"},{"category":"Nursing/other","chartdate":"2152-02-22 00:00:00.000","description":"Report","row_id":1987232,"text":"Neonatology Attending Note\nDay 15\nCGA 34 4\n\nRA. Cl and = BS. Mild sc rtxns. RR30-60s. 2 A&Bs past 24 hours. TF 150 -160s. BP 56/44. H/o PPS murmur.\n\nWt 1755, up 30 gms. TF 150 cc/k/day BM/PE26 po/pg. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with aop and immature feeding skills. Cont to moitor. Will add promod supplementation to her feedings. No other changes to current medical plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-27 00:00:00.000","description":"Report","row_id":1987253,"text":"1900-0730 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-98%. RR=20-70's.\nBreath sounds clear and equal, mild SCR noted. No bradys, no\ndesats so far this shift. Will continue to monitor resp\nstatus.\n\nFEN: Weight tonight=1.930kg (+50 grams). TF=150cc/kg/d of\nPE26/BM26 with promod alternating PO/PG q4hr. Infant bottled\n24cc at 2130, remainder gavaged. Abdomen pink, soft, round,\n+BS. no loops, AG=25-26cm. Small spit x1, minimal aspirates.\nVoiding and stooling (guiac negative). Continue to monitor\nFEN status.\n\nDEV: Temps stable, swaddled in OAC. Active and with\ncares, sleeps well in between. Brings hands to face, sucks\non pacifier for comfort. MAE. Continue to support DEV.\n\n: No contact with so far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-27 00:00:00.000","description":"Report","row_id":1987254,"text":"Neonatology Attending\n\nDay 20\n\nRemains in RA. RR 40-60s. Sats > 93%. Clear breath sounds. No bradycardia. HR 130-140s. BP mean 48. Weight gms (+50). On PE/BM 26 with Promod. Learning to bottle. Tolerating gavage feeds. Stable temperature.\n\nImproved feeding but not ready to ad lib feed. Will continue to encourage po feeding. Adequate breathing control. Monitoring closely.\n\n"},{"category":"Nursing/other","chartdate":"2152-02-27 00:00:00.000","description":"Report","row_id":1987255,"text":"NEonatology-NNP PROgress Note\n\nPE: remains in her open crib, nested, in room iar, bbs cl=, rrr s1s2no murmur,abd soft, notender, V&S, afso, active with feedings, gavage tube in place\n\nSee attending note for plan\n"},{"category":"Nursing/other","chartdate":"2152-02-27 00:00:00.000","description":"Report","row_id":1987256,"text":"NEonatology-NNP PROgress Note\nsoft murmur audib,e pulses 2+=, well perfused\n"},{"category":"Nursing/other","chartdate":"2152-02-28 00:00:00.000","description":"Report","row_id":1987259,"text":"Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 1270 up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Alt po/pg.\n\nSkin w/o leisons. Abdomen benign. Cor nl s1s2 murmur as before. neuro non-focal and age appropriate. Moving all 4 ext well.\n\nCOntinue current monitoring and nutritional rx.\n"},{"category":"Nursing/other","chartdate":"2152-02-22 00:00:00.000","description":"Report","row_id":1987233,"text":"Nursing Progress Note\n\n\n2. Resp O/A Rec'dinf in RA. Inf remains in RA. No\ndesats, no spells thus far. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of PE26w/PM. Inf PO fed full\nvol 1X thus far. Tol feeds well, 1X sm spit, min asp thus\nfar. Belly soft, no loops. Inf voiding, no stool thus far.\n P cont to offer PO feeds as tol.\n4. DEV O/A remains in an OAC cobedding with her\ntwin. Temp stable. A/A with cares. P cont to assess dev\nneeds.\n5. O/A No contact thus far. P support, eudcate.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987234,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nRR 30-50's. continue to monitor for resp changes.\n\n3: fluids\ncurrent weight 1790gms up 35. total fluids remain a\nt150cc/kilo/day of pe 26 with prom. tolerating feeds well.\nattempted po feed x'2. infant took 20 and 25cc with\nremainder gavaged. infant abd exam benign. no loops. stable\ngirths. voiding, no stool thus far. no spits.minimal\naspirates. continue to encourage po feeds.\n\n4: dev\ntemps stable in an open crib. co-bedded with sister. \nand active with cares. sleeps well inbetween. sucks on\npacifier. brings hands to face. aga. monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-24 00:00:00.000","description":"Report","row_id":1987240,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats thus far this shift.\nRR 40-70's. sats > 94%. Lung sounds clear and equal. mild\nsubcostal retractions. no increased wob noted. continue to\nmonitor for changes in resp status.\n\n3: fluids\ncurrent weight 1815gms up 25gms. total fluids remain at\n150cc/kilo/day of pe 26 with prom. tolerating feeds well.\nalt po/pg feeds. infant took 30cc's po at 0130. abd exam\nbenign. no spits.minimal aspirates. stable girths. voiding,\nno stool thus far this shift. continues on iron.\n\n4: dev\ntemps stable in an open crib. co-bedded with sister. \nand active with cares. sucks vigorously on pacifier. brings\nhands to face. waking at times prior to cares. aga. continue\nto monitor for developmental milestones.\n\n5: \nmom and in following cpr for very quick visit. \nand intact family. continue to support needs.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-24 00:00:00.000","description":"Report","row_id":1987241,"text":"progress note\nd17 corrected 34 wks\nRA no spells\nlast spell on 22nd\n1815g (up 25)\ntf 150 pe26/PM\nocc spits gets feeds over 1 hour\nalt po/pg\n\nexam:\nafof\nsoft flow murmur\nnl s1/s2\nbs clr\nabd: soft, non distended\n\na/p:\nprematurity\npremature feeding pattern\npassed hearing\ncont to encourage PO\n\n"},{"category":"Nursing/other","chartdate":"2152-02-24 00:00:00.000","description":"Report","row_id":1987242,"text":"progress note\nNeonatology Attending\n\nGrowing preterm infant learning how to po feed. Reviewed and agree with medical plan as outlined by Dr. .\n"},{"category":"Nursing/other","chartdate":"2152-02-27 00:00:00.000","description":"Report","row_id":1987257,"text":"NPN 1500\n\n\n#2 Resp: Infant stable in RA w/ O2sats 98-100%. No drifts or\nspells. RR 40-70, br. snds clear and equal.\nA: Stable in Ra.\nP: Cont to monitor for spells.\n#3 F/N: Infant remains on 26 cal PE/BM w/ promod. Bottled\n40cc X1 this AM. Tolerates gavage w/ occasional small spit.\nAbd soft, bowel snds active. Voiding and stooling.\nA: Learning to po, still requires gavage.\nP: Cont to offer po's X2 per shift.\n#4 Dev.: Infant awake and w/ cares. Swaddled w/i\nboundaries. Extremities flexed to midline. Infant calms\neasily w/ wrapping and pacifier when offered.\nA: AGA\nP: Cont dev. supports.\n#5 : No contact thus far on shift. Mother here\nyesterday at 5pm, br. fed infant. Infant latched on well but\nmother states her milk supply is low and always has been.\nShe is unsure if she will try to increase her supply at this\npoint. Mother handled well.\nA: Invested and involved family.\nP: Cont parent support.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-28 00:00:00.000","description":"Report","row_id":1987258,"text":"1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats 95-100%. RR=20-70's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=1.970kg (+40 grams). TF=150cc/kg/d of\nPE26/BM26 with promod PO/PG q4hr. Infant bottled 46cc at\n2130 and 28cc at 0130, remainder gavaged. Abdomen pink,\nsoft, round, +BS, no loops, AG=26cm. No spits, no aspirates.\nVoiding and stooling (guiac negative). Continue to monitor\nFEN status.\n\nDEV: Temps stable, swaddled in OAC. Active and with\ncares, sleeps well in between. Brings hands to face, MAE.\nContinue to support DEV.\n\n: in for the 2130 care. Involved and .\nUpdated on patient's status/current plan of care by RN.\nContinue to support family.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-28 00:00:00.000","description":"Report","row_id":1987260,"text":"Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\ndrifts, no spells thus far. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of BM or PE26w/PM. Alt PO/PG\nfeeding this shift. Tol feeds well, no spits thus far, min\nasp thus far. Belly soft, no loops. Inf voiding, no stool\nthus far. P cont to offer PO feeds as tol.\n4. DEV O/A remains in an OAC with stable temp. A/A\nw/cares. Sleeping well between cares. Not waking for feeds\nthis shift. P cont to assess dev needs.\n5. O/A Mom called for updates. P support,\neducate. plan to visit later today.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-29 00:00:00.000","description":"Report","row_id":1987261,"text":"NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, no spells thus far this\nshift. no sat drifts noted, soft murmur noted.A;stable in R\nair. P; cont to monitor.\n\n#3. TF=150cc/kg/day, PE26 with promod, po/pg fed\ntolertaed,po fed full volume x1, BS+, no loops, voided,\nstooled, guaic negative. A; Feeds tolertaed. P; cont current\nfeeding plan.\n\n#4. , active with care, temp stable in a open crib,\nswaddled with blanket, MAE.bath given. A; AGA P; cont dev\nsupport.\n\n#5. Mom called for a update, asking app questions.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-29 00:00:00.000","description":"Report","row_id":1987262,"text":"Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing. Soft murmur c/w PPS heard./ Comfortable apeparing on my exam.\n\nWt up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Good weight gain over time.. Abdomen benign.Alternating po/pg.\n\nActive . Skin w/o leisons. Moving all ext. Neuro non-focal and age aprpopriate.\n\nCOntinue current monitoring and nurtitional regimen\n"},{"category":"Nursing/other","chartdate":"2152-02-29 00:00:00.000","description":"Report","row_id":1987263,"text":"NPN\n\n\n#2 Resp: infant remains in RA with sats >95, no desats or\ndrifts. BBS clear/=, RR 30-70's, mild transient SC\nretractions. cont to monitor resp status\n\n#3 Fluids: infant TF remain @150cc/kg/d P26+PM/Br26+PM =50cc\nQ4h. infant alternating PO/NG feeds. Took full volume bottle\nwith Mom this afternoon. abd soft, +BS, voiding, stools dark\nbrown, heme negative. girth stable 25-26cm. X1 small spit.\ncont to monitor feeding tolerance.\n\n#4 G&D: infant bundled in OC, temps stable, awake and ,\nwaking for feeds. PO feeding with good coordination. AGA 35\nweeker. cont to provide developmental support.\n\n#5 : Mom in this afternoon. Met with Lactation to\ndiscuss feeding plans. Updated on infant status and\ndiscussed discharge teaching. Mom states although she has\ntwin#1 at home she is happy to review d/c instructions. cont\nto provide updates and support.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-24 00:00:00.000","description":"Report","row_id":1987243,"text":"Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. No bradys so far this shift. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=150cc/kg/d of BM/PE26w/ProMod. Alt po/pg feeds.\n Taking less than of feeds by bottle. Abd exam benign.\nVoiding and stooling. Tol feeds. P- Cont to assess for\nFEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nopen crib. P- Cont to assess for G&D needs.\n#5-O/A- in to visit with updates given. held\nand bottled infant. P- Cont to enc parental calls and\nvisits.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-25 00:00:00.000","description":"Report","row_id":1987244,"text":"NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 90-97%. RR 30-80's. Mild\nIC/SC rtx. LS clear and equal. TB sxn'd X1 for sm amt of\npale yellow nasal secretions. No spells.\n\nFEN: wt=1855g (up 40g). TF=150cc/kg/d of BM/PE26 with\npromod. Equals 46cc q4hrs, alt PO/PG. Gavaged over 45min.\nTolerating well. Bottled 45cc at 0130. Abdomen soft, +BS, no\nloops, sm spit X1, voiding and stooling. On Fe.\n\nDEV: Temps stable, swaddled with hat in open crib. Cobedding\nwith twin. and active with cares. Sleeps well between.\nWakes ~1hr prior to feeds. Settles with paci.\n\n: No contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-25 00:00:00.000","description":"Report","row_id":1987245,"text":"progress note\nNeonatology Attending\n\nGrowing preterm infant with immature feeding skills. No change to current medical plan.\n\nReviewed and agree with medical plan as outlined by Dr. .\n"},{"category":"Nursing/other","chartdate":"2152-02-25 00:00:00.000","description":"Report","row_id":1987246,"text":"progress note\nd 18 corrected 35 wks\nra\nno spells\n\n1855g (up 40)\npe 26 / pm\npo/pg\n\nexam: afof\nsoft PPS murmur\nbs clr\nabd: soft, no mass\nnl s/1/s2\n\na/p:\nprematurity\npremature feeding pattern\npassed hearing\n\n"},{"category":"Nursing/other","chartdate":"2152-03-03 00:00:00.000","description":"Report","row_id":1987273,"text":"PCA 0700-1500\n\n\n2\ninfant remains in RA, RR 30-70, O2 sats 96-100%, lung sounds\ncl=, mild sc retractions, no desats. P:cont. to monitor.\n\n3\ninfant remains on TF min. 150cc/kg/d, formula was switched\nfrom PE26 with promod to E24=53cc q4h. infant taking all PO\nfeeds, bottling full volume with good coordination, infant\ntires out toward end of feed. abd. soft, bs+, no loops, ag\nstable 27-27.5cm, small spit X1, voiding qs, no stool thus\nfar. P:cont. to support nutritional needs.\n\n4\ninfant remains swaddled in OAC, temp. stable, occ. wakes for\nfeeds, a/a with cares, settles well in between, fontanelles\nsoft/flat, brings hands to face for comfort. P:cont. \nsupport dev. needs.\n\n5\n called to let us know he would be in for the 1730 care.\nP:cont. to update on infant's progress.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-03 00:00:00.000","description":"Report","row_id":1987274,"text":"Nursing NICU Note Addendum\n\n\nI have read the above note written by PCA and\nagree with the information as stated.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-04 00:00:00.000","description":"Report","row_id":1987275,"text":"NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal\nretractions still present,no spells thus far this shift.\nA;stable in R air.P; cont to monitor.\n\n#3. Todays weight=2150, no change, TF= 150cc/ kg /day ,\nEnfamil 24 cal, po fed tolerated, gets tired towards the end\nof po feeds.BS+, no loops, voided, stooled, guaic negative.\nA; Feeds tolertaed.P; cont current feeding plan.\n\n#4. , active with care, temp stable in a open crib,bath\ngiven, swaddled with blanket, MAE. Hep B vaccine given. A;\nAGA P; cont dev support.\n\n#5. No contacts from thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-03-04 00:00:00.000","description":"Report","row_id":1987276,"text":"Newborn Med Attending\n\nDOL#26. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT=2150, no change, on ~150 cc/kg/d BM24 or E24, PO. Passed hearing.\nA/P: Growing infant on full feeds. Tentative D/C home today or in AM.\n"},{"category":"Nursing/other","chartdate":"2152-03-04 00:00:00.000","description":"Report","row_id":1987277,"text":"Nursing Discharge Note\nPt d/c'd to home with at 1845 as ordered by MD. VSS. In RA. No spells. Soft murmur. TF=min 150cc/kg/d of BM24/E24 (53cc Q4hr). Pt bottlefed Q4hr, taking 55-70cc PO at each feeding. Med spit x 1. Abdomen benign. Voiding, stools x 3. On Ferinsol, demonstrated administration to who verbalized understanding. Temps stable in OAC. /active. AGA. Passed car seat test today. D/C teaching reviewed with both who verbalized understanding. Appropriate documentation signed, see chart for details.\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987171,"text":"NPN 7p-7a\n\n\nSepsis: Infant conts amp and gent. Bld cx neg to date. Cont\nto monitor for signs and symptoms of sepsis.\n\nResp: Infant conts on nasal prong cpap 6cm. Fio2 23-25%. RR\n30-50's. Ls clr/=. Ic/Sc retractions noted. No spells or\ndesats so far this shift. Cont to wean 02 as tol.\n\nFen: Wt tonoc 1.480kg (-60gms). Conts on tf 100cc/kg. IVF of\npnd10w via piv. Enteral feeds started at 20cc/kg of pe 20.\nTol feeds well thus far. Abd soft round. Bs +. No spits\nminimal aspirates. Mec stool x1. Voiding with each diaper\nchange. Cont to monitor toleration of feeds.\n\nDev: Temp stable transferred to servo isolette. Alert and\nactive with cares. Sleeps well between. Occasionally sucks\non pacifier. Nested in sheepskin with boundries in place.\nCont to support developmental milestones.\n\nParents: MOm and in this evening with grandfather.\n at bedside. Mom did diaper and temp as well as held\ninfant. still not feeling well. Asking appropriate\nquestions. Cont to support and update.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987172,"text":"Neonatology Attending Progress\nNow day of life 2.\nBaby remains on CPAP of 6 and in RA-24% FIO2.\nRR - 30-50s.\nNo apnea and bradycardia.\nHR - 110-120 77/46 62\n\nWt. 1480gm down 60gm on 100cc/kg/d of TF - PN/IL 80cc/kg/d enteral feedings of PE/MM 20cc/kg/d.\nUO 4.1cc/kg/hr, passing mec.\n\nBili 5.2/0.1\n\nAssessment/plan:\nVery nice progress for this 32 week gestation twin.\nWill give trial off CPAP today.\nFeeding advancement to continue slowly - FT up to 120cc/kg/d.\nFU bili tomorrow.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987173,"text":"Clinical Nutrition\nO:\n32 wk gestational age BG, AGA, now on DOL 2.\nBirth wt: 1540 g (~25th to 50th %ile); current wt: 1480 g (-60)(down ~4% from birth wt)\nHC:: 29.5 cm (~25th to 50th %ile)\nLN: 42 cm (~25th to 50th %ile)\nLabs noted\nNutrition: 120 cc/kg/day TF. Feeds started on DOL 1; currently @ 20 cc/kg/day PE/BM 20,advancing 10 cc/kg/. PN started on DOL 1; lipids being added today. Remainder of fluids as PN via PIV; projected intake for next 24 hrs from PN ~54 kcal/kg/day, ~2.5 g pro/kg/day, and ~1.6 g fat/kg/day. From EN: ~20 kcal/kg/day, ~0.3 to 0.6 g pro/kg/day, and ~1.0 g 1.1 g fat/kg/day. Glucose infusion rate from PN ~5.7 mg/kg/min.\nGI: Abdomen soft and round; overall benign.\n\nA/Goals:\nTolerating feeds without GI problems; advancing cautiously and monitoring closely for tolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Expect PN to be supplemental only to feeds, and to taper as EN advances. Further increases in feeds as per growth and tolerance. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987174,"text":"Respiratory Care Note\nPt off CPAP today. Placed in 50-100cc nasal cannula. BS clear. RR 30-50's. No bradys noted off CPAP.\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987175,"text":"Neonatology-NNP Physical Exam\n\nInfant is currently in NC. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended iwth active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987176,"text":"NPN 7am-7pm\n\n\n1. VSS as charted on flow sheet. Afebrile. Blood cultures\nneg at this time Awaiting 48 hour rule out. Pink, no apnea\nor bradycardia. Cont on antibiotoc therapy.\nStable. No signs or symptoms of infection.\nCheck 48 hour blood culture results tonight.\nCont to monitor.\n2. Received on CPAP6, RA. Weaned to prong nasal cannula at\n1145 and remains at this time in 100%Fi02 at 50cc. Tol well\nwith 02 sats >93%. No apnea or bradycardia this shift. Occ\nbrief 02 sat drifts, self resolving. BBS clear and equal. No\nmurmur. No edema.\nStable 02 sat with min 02 requirement.\nCont to monitor. Wean 02 as tol.\n3.TF currently at 120cc/kg/day. Increased at 1730 feeding.\nCurrently taking 90cc/kg/day via PIV D10W with NaCl and KCl\nadded. Enteral feeds at 30cc/kg/day.PE20/BM20.Currently no\nbreast milk available. Mom is pumping q 3 hours. Abd soft\nactive bowel sounds. A/G 21-21.5cm Voiding qs See flow\nsheet. Mec stool x1.\nAdvancing on ent feeds. Weaning IV.\nCont as planned. Advance 10cc/kg . Next advance due at\n0530.\n4. In Servo isolette maintaining temp, Nested with boundries\nand sheepshin. Sucks on pacifier with feeds. Infant noted to\nbe irritable at times difficult to calm. Settles best on\nabd. Parents in at various times today and held infant. Mom\ndischarged this afternoon. Staying at a hotel in \nwith husband.\nCOnt stress precautions.\n5. Parents involved with infant care. Asking appropriate\nquestions. Had family meeting with team today. Verbalized\nunderstanding of criteria for discharge and plan of care.\nInvolved parents.\nCont to support.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-10 00:00:00.000","description":"Report","row_id":1987177,"text":"NPN 7p-7a\n\n\nSepsis: Bld cx neg to date. 48 Ro/o complete. Issue\nresolved.\n\nResp: Infant remains on Nc 02. fi02 100%. 25-50cc flow. RR\n40-60's. Mild ic/sc retractions. No spells or desats so far\nthis shift. Ls clr/=. Cont to wean 02 as tol.\n\nFen: Wt tonoc 1.445kg (-35gms). Conts on tf 120cc/kg. IVF of\npnd10w with il infusing at 90cc/kg via piv. Enteral feeds at\n30cc/kg of pe20. Increasing 10cc/kg at 05 & 1730. Tol\nfeeds well. Max aspirate 1.2cc. Abd soft. Bs+. No stool thus\nfar. Voiding with each diaper change. Ag stable. Am lytes\npending. Dstick 92. Cont to advance feeds as tol.\n\nDev: Temp stable in servo isolette. Alert and active with\ncares. Irritable at times. Likes pacifier. Nested in\nsheepksin with boundries in place. Cont to support\ndevelopmental milestones.\n\n: No contact from so far this shift.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-10 00:00:00.000","description":"Report","row_id":1987178,"text":"Neonatology Attending Progress Note\nNow day of life 3 for this 32 week gestation twin.\nIN 25cc of nasal cannula O2 - RR - 40-60s. Noted to have increased work of breathing today.\nHR 120-130s 66/36 48\n\nWt. 1445 down 35gm on 140cc/kg/d of TF - feedings up to 30cc/kg/d of MM, 110cc/kg/d of PN/IL.\nFeedings overall well tolerated - 3 cc aspirates noted.\nNormal urine and stool/mec output.\n\nLytes 140 4.7 107 22\nBili 11.5/0.2\n\nHUS - unremarkable - no IVH\n\nSocial - family meeting yesterday to review course. Awaiting further word on father's hepatitis diagnosis.\n\nAssessment/plan:\nMild worsening of respiratory status today - will evaluate with CXR.\nFeedings to be advanced gradually as tolerated.\nDouble phototherapy with FU bili tomorrow.\n\n"},{"category":"Nursing/other","chartdate":"2152-02-10 00:00:00.000","description":"Report","row_id":1987179,"text":"0700- NPN\n\n1 Infant with Potential Sepsis\n\nRESP: Remains in nasal cannula 25cc flow, 100% fi02. Flow\nrate increased to 75cc x1 when infant was positioned in\nsupine position (see flowsheet). LS clear/=; nares suctioned\nx1 for mod amt yellow/blood-tinged secretions. RR 40s-60s,\nmild SC/IC retractions present. No spells.\n\nFEN: TF 140cc/kg/d. IVFs PND10w and IL infusing via PIV at\n100cc/kg/d at this time. Feedings currently at 40cc/kg/d\nPE20, given via gavage q4hrs over 20min, TW. Plan to\nincrease feedings 10cc/kg/d as tolerated. No spits, max\nasp 3cc (nonbilious, partially digested formula). Abdomen\nsoft, round, no loops, active BS. Voiding (UO 3.8cc/kg/hr)\nand mec stooling. Dstick 105.\n\nDEV: Temps stable, nested with sheepskin in servo control\nisolette. MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping between cares. Brings hands to face,\nsucks on pacifier for comfort. AGA.\n\nPARENTING: visiting throughout the day, updated by\nRN. Assisting with cares, asking appropriate questions. Mom\nkangaroo'd this twin for about 1.5hrs today. loving\nand invested.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"},{"category":"Nursing/other","chartdate":"2152-02-11 00:00:00.000","description":"Report","row_id":1987184,"text":"NPNOte\n\n\n#2. remains on nasal cannula 100% 25cc to maintain sats\n>87-94%, BBS clear, equal, mild subcostal/intercostal\nretractions present, no spells thus far this shift, sat\ndrifts noted following shallow respiration. A;required\nsupplemental o2 to maintain sats P; cont to wean o2 as\ntolerated.\n\n#3. Tf=150cc/kg/day, Parentral at 90cc//kg/day,infusing\nPND10 with lipids at PIV, enteral at 60cc/kg/day,PE20 pg fed\ntolerated, BS+, no loops, voided, stooled,D'stix 97. A;\nFeeds tolerated. P; cont to advance feeds 10cc/kg, at\n1.30+1.30.\n\n#4. Alert, active with care, temp stable in a servo control\nisolette, nested in sheepskin, mae. loves pacifier.A; AGA P;\ncont dev support.\n\n#5. visited, asking app questions, states that\nhis lab result status is pending (type of Hep disease)\n wore gown and held the baby, A; P; cont\nparental support and teaching.\n\n#6. MIldly jaundiced, under single phototherapy.A; mildly\njaundiced. p; cont phototherapy as ordered, Bili on Sunday.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-11 00:00:00.000","description":"Report","row_id":1987185,"text":"Neonatology NP Exam Note\nInfant examined, care discussed with team.\nPlease refer to Dr note for detailed evaluation and plan.\n\nPhysical Exam:\nINfant netsled in isolette, under phototherapy. AFOF, eyes clear, nares clean ng in place, MMMP.\nChest is clear, comfortable resp pattern.\nCV: RRR, no murmur, pulses+2=.\nAbd: soft, active BS. Cord dry, NTND.\nGU: immature female genitalia.\nExt: lean. , \nNeuro: active, easliy consoles, primitive reflexes intact and symmetric.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-12 00:00:00.000","description":"Report","row_id":1987186,"text":"NICU NPN\n\n\n2. RESP: Infant remains in 02 via NC 100%, 25-50cc\nthroughout night. Lungs clear/=, breathing comfortable with\nbaseline mild SC/IC retractions. A: stable in 02, no spells\novernight P: COnt. to support and wean as tolerated.\n\n3. Fluids: Infant remains on TF of 150cc/k/d, advancing on\nenteral feeds 10cc/k/d curretnly at 70cc/k of BM/Pe20 taking\n18c q4hours via gavage over 30 min. Infant tolerating well,\nminimal asp, no spits. Abd. benign, voiindg/no stool.\nPN/lipids infusing at 80cc/k, DS stable.A: tolerating\nadvancement of feeds P: COnt. to support current feeding\nplan.\n\n4. G/D: Temp. stable in servo mode isoeltte. Infant\nturned and repositioned q4hours w/ cares, sleeping well\nbetween. A: stable P:Cont. to support G/D.\n\n5. : No contact thus far in shift.\n\n6. BILi: Infant remains under single phototherapy with eye\n on aat. REpeat bili will be checked tomorrow am2/15\nas ordered. A: stable under single P: COnt. to monitor\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-12 00:00:00.000","description":"Report","row_id":1987187,"text":"Neonatology Attending\n\nDOL 5 CGA 33 1/7 weeks\n\nStable in NCO2 25-50 cc. R 50s-60s. No A/B.\n\nN murmur. BP 69/38 mean 51\n\nOn 150 cc/kg/d with PE/BM 20 at 70 cc/kg and PN10/IL at 80 cc/kg. Tolerating feeds and advancing 10 cc/kg q 12. Voiding. Stooling. Wt 1405 grams (down 35).\n\nOn single phototherapy.\n\n visiting and up to date. Father being worked up for hepatitis. Family plans to return to after discharge.\n\nA: Stable. Resolving RDS with small O2 requirement. No spells. Tolerating feed advance. Hyperbili on phototherapy.\n\nP: Monitor\n Wean O2 as tolerated\n Advance feeds\n One more day of PN\n Follow bili\n\n"},{"category":"Nursing/other","chartdate":"2152-02-14 00:00:00.000","description":"Report","row_id":1987193,"text":"NPN 7p-7a\n\n\n#2 In 13cc of O2 via NC. O2 sats 97-100%. RR's ^ 80's at\ntimes. BBS clear and =. No bradys or desats. A: small O2\nrequirement P: Follow resp status\n\n#3 Feeds ^ by 15cc/k to 125cc/k. Receiving 32cc of PE20 q\n4hrs on a pump over 40 mins. No spits or aspirates.\nAbdominal exam unremarkable. Voiding, passing meconium. Am\nlytes stable. DS 87. A: tolerating feeds P: Follow weight\nand tolerance to feeds\n\n#4 Swaddled on sheepskin in air isolette. Isolette weaned as\ntolerated. Pleasantly alert with cares. Sleeps with ease. A:\nAGA P: support developmental needs\n\n#5 No parental contact.\n\n#6 Am rebound bili 7.0/.2. Lights cont. off. Passing stool.\nWorking up on feeds.P: Cont to follow bili level as\nordered.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-14 00:00:00.000","description":"Report","row_id":1987194,"text":"Neonatology Attending Note\nDay 7\nCGA 33 3\n\nNC 100%, 13-25cc. RR30-80s, int tachypneic. No A&Bs. Mild rtxns. No murmur. HR 110-140s.\n\nBili 7.0/0.2 (rebound).\n\nWt 1485, down 15. TF 125 cc/k/day PE/BM20, increasing 15/k/day for a goal of 150 cc/k/day. Tol well. Nl voiding and stooling.\n137/4.6/104/26\n\nIn low heated isolette.\n\nA/P:\nresolving RDS, wean O2 as tol\ncont feeding advance\ntransition to open crib\n"},{"category":"Nursing/other","chartdate":"2152-02-14 00:00:00.000","description":"Report","row_id":1987195,"text":"Social Work:\nMet briefly with . See note in sibling's chart.\n"},{"category":"Nursing/other","chartdate":"2152-02-14 00:00:00.000","description":"Report","row_id":1987196,"text":"Nursing Progress Note\n\n\n#2-O/A- Received infant on NCO2 100% 25cc flow. Infant\nremains on NCO2. No resp distress. No Bradys. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=140cc/kg/d of BM/PE20 via NGT. Will advance to\nTF=150 at 1am. Abd exam benign. Voiding and, no stool so\nfar this shift. Tol feeds. P- Cont to assess for FEN\nneeds.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in low\nheated isolette. Sucks on pacifier. P- Cont to assess for\nG&D needs.\n#5-O/A- in to visit with updates given. held\ninfant with gown and gloves. interaction. P- Cont\nto enc parental calls and visits.\n#6-O/A- Remains off photo. Bili this am=7.0, 0.2. P-\nCont to assess for Hyperbilirubimemia.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-14 00:00:00.000","description":"Report","row_id":1987197,"text":"Neonatology-NNP PRogress Note\n remains in her isolette, nested in room air, bbs cl =, rrr s1s2no murmur, abd soft, nontender V&S, afso, active with care\n\nSee attending note for plan\n"},{"category":"Nursing/other","chartdate":"2152-02-15 00:00:00.000","description":"Report","row_id":1987198,"text":"NPN 1900-0700\n\n6 Bili:\n\n1. Resp: Received infant in NC O2 100% requiring 25 cc flow.\nInfant has been in RA since 2130 maintaining her O2 sats\ngreater than 92%. Lung sounds clear/=. RR 40-70's. Mild\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\nresp. status.\n\n2. FEN: Weight is 1520 gms up 35 gms. TF remain at 150\ncc/kg/day of BM/PE20. Tolerating NGT feedings well; abd\nexam benign, no spits, min asp, AG stable. Voiding qs and\nno stool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in weaning air-controlled\nisolette. Alert and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n4. : No contact thus far this shift.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili:; resolved\n\n"},{"category":"Nursing/other","chartdate":"2152-02-16 00:00:00.000","description":"Report","row_id":1987205,"text":"Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 9.\nWt: 1540 g (+20)(birth wt 1540 g.) Infant has just reachieved birth wt. Average wt gain over past wk ~6 g/kg/day.\nHC: n/a\nLN: n/a\nLabs not due yet.\nNutrition: 150 cc/kg/day BM/PE 24, all pg over 80 min feeds due to spits. Feeds just increased today; projected intake for next 24 hrs ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\nGI: Abdomen benign. Spits w/ q feed overnight.\n\nA/Goals:\nTolerating feeds but w/ frequent large to mod. spits requiring extended gavage times; will monitor spits on longer feeding times. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins except Fe, which will be started tomorrow if infant's spits resolve. Growth should improve now that feeds have reached initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2152-02-16 00:00:00.000","description":"Report","row_id":1987206,"text":"2. remains in RA, color pink, sl jaundice, RR 30-60,\nBBS clear, equal, sc retractions, no spells.\n3. TF 150cc/k/d PE24 39cc q4h pg, abd soft, no loops,\npositive bowel sounds, minimal aspirates, very sm spit x1,\nvoiding and passing guiac neg stool.\n4. temp warm this am, isolette weaned to off, swaddled,\nactive with cares, sucking on pacifier.\n5. here for 1300 cares, held , Mom held\n. Continue to offer support.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-17 00:00:00.000","description":"Report","row_id":1987207,"text":"NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 96%. Lung sounds clear/=. RR 40-70's. M\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\nresp. status.\n\n2. FEN: Weight is 1565 gms up 25 gms. TF remain at 150\ncc/kg/day of PE24. Tolerating NGT feedings well; abd exam\nbenign, no spits, min asp, and AG stable. Voiding qs and no\nstool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in off-isolette. Alert and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support nutritional\nneeds.\n\n4. : No contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-17 00:00:00.000","description":"Report","row_id":1987208,"text":"progress note\nd10 corrected 33 wks\nra\n\n1565g (up 25)\ntf 150 bm/pe24\ngavage\nmin asp\n\nexam: nnp\n\na/p:\npreamturity\npremature feeding pattern\nstart Fe today\n\n"},{"category":"Nursing/other","chartdate":"2152-02-17 00:00:00.000","description":"Report","row_id":1987209,"text":"progress note\nAddendum - Neonatology Attending\nInfant with feeding immaturity. Course over the past 24 hours reviewed with team. I agree with Dr. assessment. Continue to await maturation of oral feeding skills and optimize nutritional intake.\n"},{"category":"Nursing/other","chartdate":"2152-02-17 00:00:00.000","description":"Report","row_id":1987210,"text":"Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-19 00:00:00.000","description":"Report","row_id":1987217,"text":"NICU NPN 1900-0700\n\n\nRESP O: LUNGS ARE CLEAR, O2 SATS 94-100% IN ROOM AIR. NO\nBRADYS THIS SHIFT.\n\nFEN O: GAINING WEIGHT, AND TOLERATING PO.PG FEEDS OF PE26\nWELL. ABDOMINAL EXAM BENIGN, VOIDING AND STOOLING, NO SPITS,\nAND MIN NGT ASPIRATES, AG STABLE.\n\nDEV O: TEMPS ARE STABLE SWADDLED IN CRIB. BABY IS AND\nACTIVE WITH CARES, SLEEPS WELL IN BETWEEN CARES. FONTANELLS\nARE SOFT AND FLAT.\n\nPARENTING O: NO CONTACT OVERNIGHT.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-19 00:00:00.000","description":"Report","row_id":1987218,"text":"DOL 12 for this 34 week infant in RA with immature feeding skills. 1630 up 40 gms on TF of 150 cc/kg/d. Doing well\n\nRRR no m\nClear BS\nSoft abdomen + BS\n+ 2 pulses\n\nA/P: Well appearing infnat with no new medical changes.\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987224,"text":"NPNOte;\n\n\n#2.Remains in R air, BBS clear, equal, mild subcostal /\nintercostal retractions present, no spells thus far this\nshift. A; stable in R air. P; cont to monitor.\n\n#3. TF=150cc/kg/day,On PE26/BM26, pg fed over 1hr 30mts,\ntolerated, BS+, no loops, voided, no stool thus far this\nshift. A;Feeds tolerated.P; cont current feeding plan.\n\n#4. , active with care, temp stbale in a crib,\nco-bedding with sibling, swaddled, mae.A; AGA P;cont dev\nsupport.\n\n#5. will be in later this pm. A; . P;\ncont update and teaching.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987225,"text":"NPNOte;\n visited, asking app questions, wore glove and gown, po fed then held . spell x1 thus far this shift QSR.\n"},{"category":"Nursing/other","chartdate":"2152-02-07 00:00:00.000","description":"Report","row_id":1987159,"text":"NICU Nursing Admission Note:\nInfant admitted from L&D to NICU warmer due to prematurity, respiratory distress, and sepsis work-up. Infat active and alert with eyes open, occasional grunting noted. Sao2's drifted initially to 80's, resolved with BBO2. When BBO2 removed, would con't to drift to 70's and started retracting-> placed on CPAP. LS = and clear, no murmur noted, VSS, D/S:72. CBC w/diff sent, blood culture pending. PIV started at 80cc/k/d of D10W. Started on amp and gent. Voided in DR. in to bedside to visit and was updated (though CPAP will be new to him). Infant presently resting comfortably in 30%, CPAP 6, with Sao2's mid-high 90's.\n"},{"category":"Nursing/other","chartdate":"2152-02-07 00:00:00.000","description":"Report","row_id":1987160,"text":"Neonatology NP Procedure Note\nEndotracheal Intubation\nPremedicated with 3 mcg. of fentanyl\nIndication: need for surfactant administration\n3.0 ETT passed oraly through cords under direct layngoscopy. Tube secured with 8 at upper lip. Equal breath sounds and good chest wall movement present. Infant tolerated procedure well. No compliations.\nCXR pending to confirm placement.\n"},{"category":"Nursing/other","chartdate":"2152-02-07 00:00:00.000","description":"Report","row_id":1987161,"text":"Neonatology Attending Admission Note\n\nDelivering Ob - Dr. primary MD - Dr. \n\nBaby is a 32 week gestation female twin #2 delivered at 17:30.\n\nPregnancy: Mother is 35 old G1 P0-1.\nMedical history is remarkable for maternal polycystic ovary disease. Pregnancy was conceived with IVF/ICSI and was a triplet pregnancy reduced to twins.\nPNS: A pos, Ab neg, HBSAg neg, RPR NR, GBS unkown.\n\nPregnacy was complicated at 28 weeks with maternal preterm labor, cervical shortening, diarrhea and a left shifted cbc on arrival back from living in . She was treated with MGSO4, antibiotics, betamethasone and then nifedipine. She also developed cholestasis of pregnancy and was treated with Actigall.\n\nCultures of stool, urine were negative. Mother was hospitalized for one month until . Father also reportedly has hepatitis? Further history pending.\nToday at 13:00 she developed PROM with preterm labor.\n\nMother was treated with ampicillin prior to delivery.\nDelivery was vaginal for both twins. This twin had vacuum assistance because of decelerations. The baby emerged with no respirator effort or tone. She responded well to bag and mask ventilation after bulb suctioning. She was bagged for approximately 1 minute and then developed a good spontaneous cry and respiratory effort. Apgars 3, 8.\n\nSocial - Both parents work for the State Department in .\n\nPE - Wt. 1540gm(40%) Lt 42cm(40%) HC 29.5cm(40%)\nVS - T 97.9 HR 140 RR 36 BP 57/30 41\nHEENT - AF soft and flat, prominent caput post vacuum, eyes PERL, normal red reflexes\nPalate intact\nResp - lungs equal, decreased air entry in bases, retractions noted after being in NICU for several minutes - improved somewhat on CPAP\nCVS - S1 S2 normal intensity, no murmur, perfusion fair, pulses normal\nAbd - soft, no organomegaly\nGU - normal AGA female\nHips stable.\nNeuro - tone wnl for GA, symmetrical exam\n\nWork of breathing and persistant grunting noted - baby intubated and treated with surfactant.\n\nAssessment/plan:\n32 week gestation female twin with clinical picture consistent with surfactant deficiency/RDS.\nBaby has responded well to intubation and surfactant treatment.\nWill wean vent support as tolerated.\nParents updated at bedside.\nIV antibiotics initiated - at risk for sepsis.\n\n"},{"category":"Nursing/other","chartdate":"2152-02-07 00:00:00.000","description":"Report","row_id":1987162,"text":"nursing\n\n\n#2O: baby Girl received in 28% O2 via prong CPAP 6.\n Intubated with 3.0ETT for increased work of breathing and\nhas received 11 dose of Survanta. Vent settings 24/5 x 20\nin 25% O2. Br. sounds are clear but diminshed and does have\nretractions.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987163,"text":"Respiratory Care Note\nPt. is 32 wker twin #2. Pt. was placed on 6cmH2O of nasal prong CPAP at change of shift. Pt. was requiring 30% FIO2, increased wob. Decision made to intubate and and give surfactant therapy. Pt. was intubated with a 3.0 ett taped at 8.0--gd.position per cxr. Pt. was treated with 6.2cc's of Survanta at 2145 and 0400. Pt. started out on IMV 24/5 R 20. Currently pt. is on 20/5 R 20 and 21%. Last cap gas was on 22/5 R 20 -->7.35/47. Pt. desatted with the surfactant and required hand-bagging. Plan is to obtain another cap gas and continue to wean as tolerated. Pt. improved since being intubated and given Survanta---21%, decreasd wob. To follow.\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987164,"text":"NPN:\n\nRESP: Vent - 24/5 x 20 -> -> 20/5 x 18, 21% 02; last setting change at 0530. CBG (0200): 7.35/ 47/ 46/ 27/ 0. Survanta (dose #2) given at 0400. Sx;d q 4 h for small amt cloudy secretions. BBS =/sl coarse. RR=40-60 with SC retraction. No desats, no A&Bs thus far tonight.\n\nCV: No murmur. HR=116-140. BP means 36-43; BP=66/30 (36). Color pink w/good perfusion.\n\nFEN: Birth wt=1540g. NPO. TF=80cc/kg/d; D-10-W. Dx=117. Abd soft, rounded, hypoactive bs; soft loops noted early in shift, but none at present. Bili & Elec to be done ~ 1700.\n\nID: Blood cx pending. Remains on Amp & Gent.\n\nG&D: CGA=32 wk. Temp stable on warmer w/servo control. Active and alert. Sl fussy w/cares; settles w/containment. Nested in sheepskin and resting well.\n\nSOCIAL: Mother in to visit x 1. Loving and appropriate.\n"},{"category":"Nursing/other","chartdate":"2152-02-19 00:00:00.000","description":"Report","row_id":1987219,"text":"NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, no desats noted thus far\nthis shift. A;no spells. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, PE26/MBM26, po/pg fed tolerated,po fed\n~10cc x1, BS+, no loops, voided, stooled, guaic negative. A;\nfeeds tolerated. P; cont current feeding plan.\n\n#4., active with care, temp stable in a open crib,\nco-bedding with sibling. A; AGA P; cont dev support.\n\n#5. No contacts from thus far this shift. \nare planning to visit this evening.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987220,"text":"npn 1900-0700\ndev: infant with healing scab on scalp.\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987221,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. no spells thus far this shift. no dsats. Rr\n40-70's. Lung sounds clear and equal. mild subcostal\nretractions. no increased wob noted. continue to monitor for\nchanges in resp status.\n\n3: fen\ncurrent weight 1965gms up 55gms. total fluids remain at\n150cc/kilo/day of bm/pe 26. tolerating feeds well. one\nmedium spits. max aspirate 2cc's. voiding, no stool thus\nfar this shift. abd soft with no loops. stable girths.\ngavage fed this shift. infant not showing interest in\nbottling.\n\n4: dev\ntemps stable in an open crib. Infant had a low temp of 97.3\naxillary and 97.5 rectally at 0130 following a spit. infant\nplaced under warming lights. temp increased to 98.1.\nco-bedded with sister. and active with cares. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987222,"text":"Neonatology Attending Note\nExam Note:\nInfant resting comfortably in open crib, co-bedding with twin. AFSF. +NG. Lungs CTA, cl and = bilat. CV RRR, 1/6 SEM heard over axilla and back - c/w PPS. 2+FP. Abd soft, +BS. Ext. warm, pink and well perfused.\n"},{"category":"Nursing/other","chartdate":"2152-02-20 00:00:00.000","description":"Report","row_id":1987223,"text":"Neonatology Attending Note\nDay 13\nCGA 34 2\n\nRA. Cl and = BS> RR40-70s. Mild sc rtxns. No A&Bs. HR 130-160s. No murmur. BP 72/36, 49.\n\nWt 1685, up 55 gms. TF 150 cc/k/day BM26/PE26 po/pg. Tol well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\n - CVR monitoring\n - no change to nutritional plan\n - check bili in am for persistent jaundice\n"},{"category":"Nursing/other","chartdate":"2152-02-21 00:00:00.000","description":"Report","row_id":1987226,"text":"npn 1900-0700\n\n\n2: resp\nremains in ra. one spell this shift. see flow sheet for\nfurther info. RR 30-60's. Lung sounds clear and equal. mild\nsubcostal retractions. no increased wob noted. no dsats.\ncontinue to monitor for changes.\n\n3: fluids:\ncurrent weight 2030gms up 60gms. total fluids remain at\n150cc/kilo/day of pe/bm 26 cals. tolerating feeds well.\nno spits. feeds ran over 1.5 hours for hx of spits. minimal\naspirates. voiding, no stool thus far this shift. stable\ngirths. attempted to po x's 1. infant not showing interest\nin bottling. infant taking only 5cc's.\n\n4: dev\ntemps stable co-bedded with sister. and active with\ncares. sleeps well inbetween. 14 day pku drawn. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-21 00:00:00.000","description":"Report","row_id":1987227,"text":"Neonatology Attending Note\nDay 14\n\nRA. Cl and = BS. RR40-70s. 2 A&B past 24 hrs. Mild sc rtxns. +soft murmur. HR 130-150s. BP 68/35, 46. BP 68/35, 46.\n\nBili 5.2/0.2\n\nWt 1725, up 40 gms. TF 150 cc/k/day BM/PE26 po/pg. Tol well. Nl voiding and stooling (g-).\n\nIn open crib, co-bedding with twin.\n\nExam:\nResting comfortably in open crib. Pink. No distress.\nAFSF.\nLungs CTA, =.\nCV 1-2 SEM at LSB heard also over axilla and back. 2+FP. Pink and well perfused.\nAbd soft, +BS.\nExt warm, pink and well perfused.\n\nA/P:\n - Growing preterm infant with immature cardioresp control and po feeding skills. Con to monitor. No changes to current medical plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-21 00:00:00.000","description":"Report","row_id":1987228,"text":"NPNOte;\n\n\n#2. Remains in Ra ir, BBS clear, equaql, mild subcostal\nretractions present, no spells thus far this shift. A;\nstable in R air. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, Pe26 pg fed tolerated, H/O spits, no\nspits thus far, feeds given over 1hr 30mts,BS+,no loops,\nvoided, no stool thus far this shift. A; Feeds tolerated. p;\ncont current feeding plan.\n\n#4. ,a ctive with acre, temp stable in a open crib,\nco-bedding with sibling, MAE. A; AGA P; cont dev support.\n\n#5. will be visiting this pm.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987235,"text":"Neonatology Attending\nAddendum - Physical Examination\nwell-appearing infant in no distress\nHEENT AFSF\nCHEST no retractionbs; good bs bialt; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM LSB without radiation\nCNS active, resp to stim; tone AGA\nINTEG normal\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987236,"text":"Neonatology Attending\nDOL 16 / CGA 34-5/7 weeks\n\n is in room air with no distress and no bradycardias since .\n\nPPS murmur persists. BP 62/30 (41).\n\nWt 1790 (+35) on TFI 150 cc/kg/day BM26/PE26PM, tolerating well. Bottling up to volume. Abdomen benign. On iron. Voiding and stooling normally.\n\nA&P\n32-3/7 week GA infant with resolving respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Follow murmur clinically\n-No other changes in management\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987237,"text":"CAse Management Note\nReferral called today to VNA in preparation for eventual d'c. is main # and fax is . Will need name of hotel/phone #/room #/address for VNA. Also need name/phone # of Pedi for twins. Will assess w/team if EIP is needed here in USA vs as family expects to relocate back there at some point. Will cont to follow.\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987165,"text":"Neonatology Attending Progress Note\n\nNow day one of life for this 32 week gestation infant with RDS.\nOn vent support of 18 20/5 and RA currently.\nBaby treated with 2 doses of surfactant with nice improvement.\nLast CBG - 7.35/47 prior to wean.\n\nHR 112-140s MAP 36-43 - BP 66/30 36\n\nWt. 1540 BW\nNPO on 80cc/kg/d of IV fluids.\nBS 117\nUO 3.3cc/kg/hr overnight.\n\nID - wbc 11,100 32P 0B 52L plat 264 Hct 40.4%\nOn amp and gent.\n\nAssessment/plan: Preterm infant with nice response to surfactant.\nWill wean vent support and hopefully be able to go to CPAP later today.\nPN to be initiated today.\nWill follow lytes - bili later today.\nWill set up family meeting prior to mother's discharge to home.\nHUS to be scheduled for Thursday.\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987166,"text":"Social Work:\n\nParents of these twins have been known to me from mom's 6s antepartum admission. Please see note in sister's chart for complete social work note.\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987167,"text":"NPN Days\n\n\n#1 Pt cont on ampi and gent. no s/s of infection. BC\npending. P- Will cont to monitor for sepsis.\n#2 Pt received intubated 20/5 with a rate of 18. FiO2\n21%. Pt weaned throughout the am and cbg drawn\n7.32/56/29/30/0. Pt extubated @ 1400 to CPAP. Pt currently\non CPAP 6. FiO2 21%. LS course bilat. IC SC retrac. no\nspells so far this shift. sx for mod cloudy secr from ETT.\nand sm clear from mouth. P- Will cont to monitor resp\nstatus.\n#3 FEN- TF=80cc/kg/d to be increased to 100cc/kg/d after\nlabs this pm. Pt NPO. IV fluids D10W infuising through PIV.\nabd benign voiding and stooling mec. d-stick 87. P- Will\ndraw lytes and bili @ 1700 and cont to monitor FEN.\n#4 G&D- Temp stable on servo warmer. alert and active with\ncares. irritable at times. sucking on pacifier. HUS\nscheduled for thurs. P- Will cont to monitor G&D.\n#5 Parents- Parents visiting throughout the shift. helping\nwith cares. loving and caring. updates given. asking approp\nques. P- Will cont to encourage parental visits and calls.\nSee flowhseet for further details.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987168,"text":"Neonatology NP Exam Note\nInfant eaxmined, care discussed with team.\nPlease refer to Dr note for detailed evaluation and plan.\n\nPhyical exam:\nInfant nested on open warmer, orally intubated. AFOF, Caput over occiput. Sutures overriding.\nChest is clear, equal BS. Good air exchange.\nRRR, nl S1, split S2. Pulses plus 2 and equal.\nAbd: active BS, cord dry.\nGU: immature female genitalia.\nExt: MAE, WWP\nNeuro: equal grasps, symmetric moro\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-08 00:00:00.000","description":"Report","row_id":1987169,"text":"Respiratory Care\nPt recieved on SIMV rate of 18, pressures of 20/5 with the fio2 21%. Pt weaned down on PIP from 20 to 18, pt also weaned down on ventilator rate from 18 to 14. Blood gas results obtained with good results. Pt extubated and place on nasal prong CPAP. Plan is to follow on CPAP.\n"},{"category":"Nursing/other","chartdate":"2152-02-09 00:00:00.000","description":"Report","row_id":1987170,"text":"RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 23-25%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. RR 30-50's stable on Prong CPAP cont to follow.\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987238,"text":"Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 16.\nWT: 1790 g (+35)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~20 g/kg/day.\nHC: 30 cm (~10th to 25th %ile); last: 29.5 cm at birth\nLN: 43 cm (~25th %ile); last: 42 cm at birth\nLabs not due yet.\nMeds include Fe\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant takes ~ to full volume w/ po feeds. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\nGI: Abdomen benign; one small spit\n\nA/Goals:\nTolerating feeds without GI problems except occasional small spit. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. Average HC and LN gains over past 2 wks not meeting recommended ~0.5 to 1 cm/wk for HC gain or ~1 cm/wk for LN gain; expect improvement now that feeds have surpassed initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"},{"category":"Nursing/other","chartdate":"2152-02-23 00:00:00.000","description":"Report","row_id":1987239,"text":"0700- NPN\n\n\nRESP: In RA with RR 30's-60's. LS clear/=. No\nretractions. No A/B spells or desats.\n\nFEN: TF=150cc/kg/d. PE26 with PM (45cc Q4hr) PO/PG. Pt\nbottlefed x 2, taking 22-42cc at each feed. Small and\nmedium spits. Minimal aspirates. Abdomen benign. Voiding,\nsmall stool x 1. On Ferinsol.\n\nDEV: Temps stable in OAC. /active with cares. Sleeps\nbetween cares, waking early for feeds. Sucks pacifier and\nbrings hands to face for comfort. Fontanels soft/flat.\nAGA.\n\nPARENTING: Both in to visit this shift, updated by\nthis RN, asking appropriate questions.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-25 00:00:00.000","description":"Report","row_id":1987247,"text":"NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal\nretractions present, no spells thus far this shift. A;\nstable in R air. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, PE26 with promod, po/pg fed, tolertaed,\nBS+, no loops, voided, stooled. A; Feeds tolerated. P; cont\ncurrent feeding plan.\n\n#4. , active with care, temp stable in a open crib,\nswaddled with blanket, MAE. co-bedding with sibling,A; AGA\nP; cont dev support.\n\n#5. visited, asking app questions. will be\ndischarged home today after car seat screening.A; \n P; cont update and teaching.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-25 00:00:00.000","description":"Report","row_id":1987248,"text":"Social Work:\nMet with . See note in sibling's chart.\n"},{"category":"Nursing/other","chartdate":"2152-02-26 00:00:00.000","description":"Report","row_id":1987249,"text":"NPN NOCS\n\n\n2. Remians in RA. LS clear. O2 sats 91-100%. No drifts, no\nspells. Stable.\n\n3. Wt up 25gms. TF at 150cc/kg of BM/PE26 with PM. Alt po/pg\nfeeds. Gavaged over 50min. Small spits. Abd benign. Voiding,\nno stool. Continue to work on po feed skills.\n\n4. Temp stable in open crib. and active with cares.\nSwaddled. AGA.\n\n5. No contact from thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-26 00:00:00.000","description":"Report","row_id":1987250,"text":"Neonatology Attending Progress Note\n\nNow day of life 19, CA 1/7 weeks.\nIn RA - O2 sast >95%\nRR 30-60s.\nHR 130-150s BP 66/36 46\n\n\nWt. 1880 up 25gm on 150cc/kg/d of PE or MM26 with Promod\nFeedings well tolerated overall.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress overall.\nWill continue with current management.\n\n"},{"category":"Nursing/other","chartdate":"2152-02-11 00:00:00.000","description":"Report","row_id":1987182,"text":"NPN 7p-7a\n\n6 Bili:\n\nResp: Infant remains in NC 02 100% 25-50cc flow. Ls clr/=.\nMild ic/sc retractions. RR 50-60's. No spells or desats so\nfar this shift. Cont to wean 02 as tol.\n\nFEn: Infant's wt tonoc 1.440kg (-5gms). Conts on tf 140cc/kg\nEnteral feeds at 50cc/kg of pe 20. Increasing 10cc/kg at\n0130&1330. IVf of pnd10w with IL via piv. Tol feeds well\ngavaged over 20 mins. No spits minimal aspirates. Dstick 86.\nAbd soft. Active bs. No stool thus far. Voiding with each\ndiaper change. Cont to advance feeds as tol.\n\nDev: Temp stable in servo isolette. Nested in sheepskin with\nboundries in place. Likes pacifier. Irritable at times.\nLikes prone postion. Cont to support developmental\nmilestones.\n\n: No contact from so far this shift.\n\nBili: Infant conts under double phototx. AM bili pending.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili:; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2152-02-11 00:00:00.000","description":"Report","row_id":1987183,"text":"Neonatology Attending Progress Note\n\nNow day of life 4.\nOn 100% 25-50cc of O2 RR 50-80s\nNo apnea and bradycardia.\nHR 120-140, BP 69/38 51\n\nBili 8.9/0.3\n\nWt. 1440gm down 5gm on 140cc/kg/d - 90ml/kg/d of PN/IL - feedings up to 50cc/kg/d of MM or PE - gavage feedings well tolerated so far - occasional non-bilious aspirates noted.\nDS 86\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management with gradual increase of feedings as tolerated.\nMonitoring for apnea/bradycardia.\nAwaiting further word on father's diagnosis of hepatitis.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-12 00:00:00.000","description":"Report","row_id":1987188,"text":"Neonatology-NNP PRogress Note\\\n\nPE: in her isolette, in room air, (recently out of nc) bbs cl=, rrr s1s 2no murmur,abd soft, nontender, cord drying, V&S, nested, peripheral iv and gavage tube in\n\nUpdated at bedside\n\nSee attending note for plan\n"},{"category":"Nursing/other","chartdate":"2152-02-12 00:00:00.000","description":"Report","row_id":1987189,"text":"NPN DAYS\n\n\nRespiratory: Remains on NC 13cc Fio2 100%. Trialed in room\nair x2 hours and failed r/t frequent drifts of sats. LS\nclear and equal. IC/SC retractions. No spells. No caffeine.\nWill continue to monitor.\n\nFluids: TF 150cc/kg/day. 80cc/kg/day PE20/BM20. 70cc/kg/day\nPND10 via PIV in right leg. Increasing feeds by 10cc/kg/.\nTolerating feeds. Belly benign. No spits. Urine output\n3.6cc/kg/day. No stool. D/S 103. Will continue to increase\nfeeds as tolerated.\n\nDevelopment: Temp stable in servo isolette. Awake and alert\nwith cares. Sleeps well between cares. Likes her pacifier.\nWill continue to support developmental needs.\n\n: in for 1pm cares, held baby. Asking\nlots of questions. Will continue to provide teaching and\nsupport.\n\nBili: Remains under single phototherapy. Will check bili\ntonight.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-26 00:00:00.000","description":"Report","row_id":1987251,"text":"Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes, Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"},{"category":"Nursing/other","chartdate":"2152-02-26 00:00:00.000","description":"Report","row_id":1987252,"text":"NPN 1500\n\n\n#2 Resp: Infant remains in RA, no desats or brady spells. RR\n40-70. Br. snds clear, = bilat.\nA: Stable in RA w/o spells.\nP: Cont to monitor for desats or bradys.\n#3 F/N: Infant continues on 150cc/kg/d PE26/BM 26 w/ promod,\n47cc q 4 hrs. Infant bottled well 25cc @ 0930 this AM. Abd\nbenign, voiding well, no stool today. Tolerates gavage feed\nw/o spits.\nA: Tol. feeds, learning to po/breast feed.\nP: Cont to monitor for s/s of feeding intolerance.\n#4 Dev.: Infant maintaining temp well in an open crib. Awake\nand w/ cares. Swaddled and positioned prone.\nA: AGA\nP: Cont dev. supports.\n#5 : No contact thus far on shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-10 00:00:00.000","description":"Report","row_id":1987180,"text":"Neonatology - NNP PRogress Note\n\n is active with good tone. AFOF. Head ultrasound today normal. She is pink, well perfused, no murmur auscultated. She remains in NCO2 25-75ccs/100%. Moderate retractions, breath sounds diminished on left side. CXR today clear.Total fluids @ 140cc/kg/day. PN/IL infusing via PIV. She is tolerating advancing feeds. Abd soft, active bowel sounds, no loops. Voding and stooling. Mod jaundice under single phototherapy. Bili today 11.5/0.2. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-10 00:00:00.000","description":"Report","row_id":1987181,"text":"Rehab/OT\n\nMet at the bedside. Discussed the role of OT, infant stress signals, and ways to maximize infant comfort. Posted care plan at the bedside. Please refer to care plan for recommendations. OT to follow.\n"},{"category":"Nursing/other","chartdate":"2152-02-13 00:00:00.000","description":"Report","row_id":1987190,"text":"NPN 7p-7a\n\n\n#1 Remains in 13cc of 100% O2 via NC. BBS clear and =. Mild\nretractions present. No bradys or desats. A: small O2 need\npersists P;Follow\n\n#3 TF's presently at 95cc/k. IV leaking ~ 0045. NNP\nRivers advance feeds 15cc/k and leave IV out. Receiving\n24cc of PE20 Q 4hrs on a pump over 30 mins. No spits or\naspirates. Abdominal exam unremarkable. Voiding. No stool\npassed overnoc yet. A: tolerating feeds P: Advance feeds\n15cc/k and follow weight\n\n#4 Isolette weaned x 1 for warm temp. Fiesty with cares.\nNested on sheepskin with boundaries in place. Sleeps fairly\nwell. A: AGA P: Support developmental needs\n\n#5 No contact.\n\n#6 Remains under single phototherapy. Am bili 6.1/.3-down\nfrom 8.4/.3. Working up on feeds. No stool. A: bili\ndecreasing P: f/u with team\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-13 00:00:00.000","description":"Report","row_id":1987191,"text":"Atttending Note\nDay of life 6 CGA 33 \nnasal cannula 13-25 cc RR 50-60 mild retractions\nlungs clear\nno murmur 120-140 71/36 mean 55\nbili 6.1/0.3 still on single phototherapy\n1500 up 95 grams on 95 cc/kg/day of enteral adv 15 cc/kg/day\nBM 20 PE 20\nservocontrolled isolette\n\nimp-needs to wean from nasal cannula\nas tolerated\nwill discontinue photo and recheck rebound in am\n\n"},{"category":"Nursing/other","chartdate":"2152-02-13 00:00:00.000","description":"Report","row_id":1987192,"text":"Nursing Progress Note\n\n\n#2-O/A- Recieved infant on NCO2 100% 25cc. Infant remains\non NCO2. No resp distress. No A's or B's. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=110cc/kg/d of BM/PE20 via NGT. Abd exam benign.\n Voiding, no stool so far this shift. Tol feeds. P- Cont\nto assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nheated isolette. Sucks on pacifier. P- Cont to assess for\nG&D needs.\n#5-O/A- in to visit with updates given. Mom held\n. interaction. P- Cont to enc parental calls\nand visits.\n#6-O/A- Photo d/c this am for bili= 6.1, 0.3. Plans to\ncheck bili in am. P- Cont to assess for\nHyperbilirubinemia.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-15 00:00:00.000","description":"Report","row_id":1987199,"text":"progress note\nAgree with note by Dr. .\nDay of life 8 CGA 33 week\ntransition from nasal cannula to room air last night\nno spells\nweight 1520 gram up 35\non 150 cc/kg/day of PE/BM 20 cal/oz\npo/pg\n\nImp-overall making good progress\nwill increase to 24 cal/oz and\ncontinue to encourage po feeds\n"},{"category":"Nursing/other","chartdate":"2152-02-15 00:00:00.000","description":"Report","row_id":1987200,"text":"progress note\nd8 corrected 33 wks\nnc to RA last night - ok\nno spells\n\n57/33 (38)\n1520g (up 35)\ntf 150 pe/ bm 20 gavage\n\n\nexam:\nafof\nbs clr\nno murmur\nabd soft\nwell perfused\npink\nslightly jaundice\n\na/p:\nprematurity\npremature feeding pattern\ninc to 24 cal\nfollow juandice - resolving\n"},{"category":"Nursing/other","chartdate":"2152-02-15 00:00:00.000","description":"Report","row_id":1987201,"text":"NPN DAYS\n\n\nRespiratory: Remains in room air with O2 sats 96-100%. LS\nclear and equal. No desats or spells. Mild IC/SC\nretractions. Continue to monitor closely.\n\nFluids: TF 150cc/kg/day PE22/BM22, gavaging feeds over\n50mins. Belly benign. Spit x2. Voiding and stooling. Minimal\naspirates. Will continue with current plan of care.\n\nDev: Temp stable in low air isolette while swaddled. Awake\nand alert with cares. Kangaroo'd with mom for an hour and\ntolerated well. Will conitnue to support developmental\nneeds.\n\n: in to visit. Mom participated in cares and\nkangaroo'd. Will continue to provide support and teaching.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-16 00:00:00.000","description":"Report","row_id":1987202,"text":"NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 95%. Lung sounds clear/=. RR 30-60's. Mild\nIC/SCR. Infant had one desat to 70 with spit. No bradys\nnoted. P: Cont. to monitor resp. status.\n\n2. FEN: Weight is 1540 gms up 20 gms. TF remain at 150\ncc/kg/day of BM/PE22. Tolerating feedings well; abd exam\nbenign, min asp, AG stable, and one spit. Voiding qs and no\nstool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in air-controlled isolette.\nAlert and active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. ; No contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-16 00:00:00.000","description":"Report","row_id":1987203,"text":"progress note\nd9 corrected 33 wks\nra 30-60's\none desat to 70 with spit.\n\n1540g (up 20)\ntf 150 pe22 - 3 spits - increased feeding time over 1 hr\n\nexam:\nafof\nno murmur\nbs clr\nabd soft\nwell perfused\n\na/p:\nprematurity\npremature feeding pattern\nfeeding over 1 hour 20 mins\ninc 24 cals.\nstart fe tommorrow (.15cc qd)\n\n"},{"category":"Nursing/other","chartdate":"2152-02-16 00:00:00.000","description":"Report","row_id":1987204,"text":"progress note\nAgree with Dr. \n of life 9 CGA 33 \nstable in room air RR 30-60\none dat with feeds\nweight 1540 gram up 20 on\n150 cc/kg/day of BM/PE 22\nvoiding and stooling\n\nImp-overall making progress\nstill have a lot of spits\nwill increase feeding time and\nconsider decreasing total fluid\nwhile at the same time increasing\ncalories.\n\ntoday will increase to 24 cal/oz\nand increase feeds to over 1 hour 20 min\n\n"},{"category":"Nursing/other","chartdate":"2152-02-17 00:00:00.000","description":"Report","row_id":1987211,"text":"Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. No bradys. P- Cont to assess for Resp\nneeds.\n#3-O/A- TF=150cc/kg/d of BM/PE24 via NGT. Abd exam benign.\n Voiding, trace stool so far this shift. Tol feeds gavaged\nover 1hr20min. Started on FeSO4. P- Cont to assess for\nFEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Transferred to\nopen crib, temp stable. Sucks on pacifier. P- Cont to\nassess for G&D needs.\n#5-O/A- called, they plan to visit at 1700. P-\nCont to enc parental calls and visits.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-18 00:00:00.000","description":"Report","row_id":1987212,"text":"npn 1900-0700\n\n\n#2 resp\npt continues in r/a with sats >97%. lsc=. mild sc/ic\nretractions. rr 40-50's. occational drift mid 80's-low\n90's that qsr. no spells thus far this shift.\n#3 fen\ntf 150cc/kg of pe24/bm24 gavaged q4hours. wt. 1.590kg\n(+25gms). abd benign. voiding and stooling qdiaper change\ngreen yellow stools guiac neg. lg fissure noted 6pm,\ndesitin applied with each diaper change. spitting with each\nfeeding small to lg amts. gavage time increased to 1hour and\n40 minutes due to spits. minimal aspirates.\n#4 g&d\npt in oac with stable temps. alert and active with cares.\nmaew. fontanelles soft and flat. sucking on binki.\n#5 parenting\nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-02-18 00:00:00.000","description":"Report","row_id":1987213,"text":"pregress note\nAgree with note by Dr. \n of life 11 CGA 34 0/7 weeks\nstable in room air RR 40-50\nweight 1590 up 25 grams on 150 cc/kg/day\nof BM/PE 24 cal/oz pg\nvoiding and stooling\non iron\n\nImp-overall doing well.\nwill continue to encourage po feeds\nWill advance to 26 cal/oz\n"},{"category":"Nursing/other","chartdate":"2152-02-18 00:00:00.000","description":"Report","row_id":1987214,"text":"pregress note\nd11 corrected 33 wks\nRA 40-50's\n\n1590g (up 25)\ntf 150 bm24/pe24\nmod spits\n\nexam: NNP\n\na/p:\nprematurity\npremature feeding pattern\ninc. to 26 cals\n\n"},{"category":"Nursing/other","chartdate":"2152-02-18 00:00:00.000","description":"Report","row_id":1987215,"text":"Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"},{"category":"Nursing/other","chartdate":"2152-02-18 00:00:00.000","description":"Report","row_id":1987216,"text":"NPNOte;\n\n\n#2.Remains in R air, BBs clear, equal, mild subcostal\nretarctions present, no spells, occassional sat drifts to\nmid 80's noted, QSR. A; No spells P; cont to monitor.\n\n#3. On Tf=150cc/kg/day, MBM26/PE26, po/pg fed , tolerated.\ncal increased today,BS+, no loops, voided, stooled.guaic\nnegative, A; Feeds tolerated. P; cont current feeding plan.\n\n#4. alert,a ctive with care, temp stable open crib,\nco-bedding with sibling.mae. A; AGA P; cont dev support.\n\n#5. visited, held the baby. A; ,\ninvolved.P; cont dev support.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"NEONATAL HEAD PORTABLE\",\n \"row_id\": 816466,\n \"text\": \" 7:04 AM\\n NEONATAL HEAD PORTABLE Clip # \\n Reason: TWIN INFANT BORN AT 32 3/7 WEEKS GESTATION, R/O IVH\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with 32 week twin\\n REASON FOR THIS EXAMINATION:\\n r/o ivh\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Infant with 32 and 3/7th weeks. Twin. R/O intraventricular\\n hemorrhage.\\n\\n FINDINGS: The sulci and gyri of the cerebrum and cerebellum have an appearance\\n consistent with the patient's prematurity. An extra-axial fluid collection is\\n not seen. The ventricular system size is normal. There is no evidence of a\\n subarachnoid or an intraventricular hemorrhage.\\n\\n IMPRESSION: Premature appearing brain. No bleed.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-02-07 00:00:00.000\",\n \"description\": \"BABYGRAM (CHEST ONLY)\",\n \"row_id\": 816205,\n \"text\": \" 10:14 PM\\n BABYGRAM (CHEST ONLY) Clip # \\n Reason: check placement of ett\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with surfactant deficiency\\n REASON FOR THIS EXAMINATION:\\n check placement of ett\\n ______________________________________________________________________________\\n FINAL REPORT\\n This is a child with prematurity.\\n\\n The exam is grossly underexposed and should be repeated at no cost to the\\n patient. I can ascertain that the ETT is just at the carina. There is probably\\n hyaline membrane disease present.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"P BABYGRAM (CHEST ONLY) PORT\",\n \"row_id\": 816500,\n \"text\": \" 11:18 AM\\n BABYGRAM (CHEST ONLY) PORT Clip # \\n Reason: 3 day old ex-32 week with worse resp distress\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with resp distress\\n REASON FOR THIS EXAMINATION:\\n 3 day old ex-32 week with worse resp distress\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Infant with respiratory distress.\\n\\n Single frontal radiographs compared to the only prior demonstrates diffuse\\n ground-glass opacities bilaterally with a more focal opacity in the right\\n lower lobe and right middle lobe. The enteric catheter tip overlies the\\n stomach. Findings are most consistent with RDS and right middle and lower\\n lobe subsegmental atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987264,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells and no dsats thus far this shift.\\nlung sounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. Rr 50-60's. sats remain in the high\\n90%.\\n\\n3: fen\\ncurrent weight 2040gms up 30gms. total fluids remain at\\n150cc/kilo/day of pe/bm26 with prom. tolerating feeds well.\\none small spit. minimal aspirates. abd soft with no loops.\\nvoiding, no stool thus far this shift.stable girths. infant\\ntaking full volumes po's at first two cares. will attempt to\\npo if and rooting with next care. continue to\\nencourage po feedings.\\n\\n4: dev\\ntemps stable in an open crib. and active with cares.\\nsleeps well inbetween. waking prior to care time. sucks\\nvigorously on pacifier. brings hands to face. aga. continue\\nto monitor for developmental milestones.\\n\\n5: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987265,\n \"text\": \"Neonatology\\nDOing well. REmains in RA. No spells. Comfortable apeparing.\\n\\nWt 2040 up 30. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Still requiring some gavage. Small amounts of non-bilious spits.\\n\\nTemp stable in open crib.\\n\\nHct 33.6 Retic 1.4.\\n\\nContinue current monitoring and nutritional managfement.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987266,\n \"text\": \"Neonatology - NP Physical Exam\\nAwake and alertt with cares, temp stable in o-pen crib. BS clear and equal with mild subcostal retractions, color pink. RRR with soft murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987267,\n \"text\": \"Clinical Nutrition\\nO:\\n~35 wk CGA BG on DOL 23.\\nWT: 2040 g (+30)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~18 g/kg/day.\\nHC: 30.5 cm (~10th to 25th %ile); last: 30 cm\\nLN: 44 cm (~10th to 25th %ile); last: 43 cm\\nMeds include Fe\\n due this wk\\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant attempts po's w/ every feed; takes ~ to full volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\\nGI: Abdomen benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems. due this wk. Learning po feeding skills. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for all parameters. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987268,\n \"text\": \"NPN\\n\\n\\n#2 Resp: infant remains in RA with sats >93%. RR 30-50's,\\nBBS clear/=. mild SC retractions. no desats or brady's. cont\\nto monitor resp status.\\n\\n#3 Fluids: infant TF remain 150cc/kg/d PE26+PM. Receiving\\nPO/NG feeds 51cc Q4h. Infant took partial feed PO this AM\\nand remainder gavaged. Took full volume for 1330 feeding.\\nTaking PO's well with good coordination. abd soft, +BS,\\nvoiding, stools heme negative. small spit. cont to offer PO\\nfeedings when infant eager and interested.\\n\\n#4 G&D: infant bundled in OC with stable temps. Awake, \\nand active, wakes for feedings. cont to provide\\ndevelopmental support.\\n\\n#5 : called this afternoon to say that he will be\\nin for 2130 feeding. cont to provide updates and support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987269,\n \"text\": \"NPN 1900-0700\\n\\n\\n#2 RESP S/O: Infant in RA. Lungs clear, subcostal\\nretractions. RR 30-70's, O2 sats >95%. No spells or\\ndrifting. A: Stable in RA P: Continue to support.\\n\\n#3 FEN S/O: TF 150cc/k/d. Infant to get pe26 with promod,\\n51cc q4h po/pg. Infant bottled 47ccx2 tonight so far.\\nAbdomen is benign, voiding and stooling. No spits, min\\naspirates. A: Tolerating feeds. P: Continue to support.\\n\\n#4 DEV S/O: Infant in OAC, maintaining temps. and\\nactive. Waking before feeds. A: AGA P: Continue to support.\\n\\n#5 S/O: in tonight. Held infant and bottled her.\\nAsked appropriate questions. A: Involved P: Continue to\\nsupport and update.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987270,\n \"text\": \"Nursing NICU Note\\n\\n\\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\\n~30-60's, no increase work of breathing noted. LS clear/=.\\nNo A&B's or de-sats noted this shift thus far. A: Pt. is\\nstable in RA. P: Continue to monitor respiratory status.\\nMonitor for A&B's.\\n\\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE 26 w/PM =53cc\\nQ 4hrs. She has taken all PO's this shift thus far ~55cc Q\\nfeed. Pt. tires out a bit toward the end. Abdomen is soft,\\npink, +BS, no loops/spits noted. Abdominal girth is 25cm.\\nShe is voiding/ stool x1. A: Pt. is tolerating current\\nnutritional plan. P: Continue w/ current feeding plan.\\nMonitor for s/s of intolerance. Encourage PO feeds.\\n\\n#4. Growth/Development O: Pt. remains in an open crib,\\nswaddled w/ stable temps. She is and active w/ cares,\\nsleeps well in between. Fontanelle soft/flat. She loves to\\nuse her pacifier, brings hands to face. A: AGA P:\\nContinue to provide environment appropriate for growth and\\ndevelopment.\\n\\n#5. O: Mom in to visit this afternoon for cares.\\nShe was udpated at bedside on pt's current status and daily\\nplan of care. Mom is active and involved in cares. A:\\nFamily is and involved. P: Continue to udpate,\\nsupport and educate.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987271,\n \"text\": \"NPN 1900-0700\\n\\n\\n#2 RESP S/O: Infant in RA, lungs clear with subcostal\\nretractions. RR 40-70's, O2 sats >95%. No spells. A: Stable\\nP: Continue to support.\\n\\n#3 FEN S/O: TF 150cc/k/d. To get pe26, with promod, 53cc\\nq4h. Infant bottled 60ccx2 so far tonight. Abdomen benign,\\nvoiding and stooling. Getting desitin to bottom. No spits,\\nmin aspirates. Nutrition tonight Ca , Phos 7.5, Alk\\nPhos 277. A: Stable P: Encourage po feeds.\\n\\n#4 DEV S/O: Maintaining temps in OAC. and active with\\ncares. Waking for some feeds. A: AGA P: Continue to support.\\n\\n#5 S/O: No contact.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987272,\n \"text\": \"Neonatology\\nDoing well. RA. No spells. Comfortab;e appeatring.\\n\\nWt 2150 up 45. All po overnight. Seems much improved with bottling. Abdomen benign. Will dcerease cals to 24 and change from preemie formula.\\n\\nTemp stable\\n\\nWill need HBV.\\n\\nLeft message for mother re potential for dc in coming days.\\n\\nDC summary dictated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987229,\n \"text\": \"#2 RESP\\ns/o: BS clear and equal. Comfortable wob. Color pink. No\\nspells. A: Stable. P: Cont to mtr\\n#3 FEN\\ns/o: TF 150cc/k/d-- remains on BM26/PE26. Void/stool qs. Abd\\nexam benign. Wt up 30 gms to 1755gms tonight A: Gaining on\\n26 cal formula. P: cont to mtr tolerance and daily wt\\n#4 DEV\\ns/o: Temp stable in open crib- with cares. Tone good.\\nAwake yet little interest at breast or with po offered. A:\\nDev AGA for CGA- 34-3/7 wks. P: cont dev supp cares\\n#5 \\ns/o: Both in tonight- actively participating in\\ncares. A: Invested family P: cont dev supportive cares\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987230,\n \"text\": \"2 Resp.\\n Infant stable in room air, mild retractions, sats over 92\\nmost of the time, 0 spells tonight. Continue to monitor and\\nrecord any changes.\\n3 F/N\\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\\ninfant tolerating feeds well by gavage, bottlee part of feed\\nX1 did fair.Voiding, 0 stool. Wt. up 30gms to 1.755.\\nContinue present plans.\\n5 \\n No contact from so far tonight, plan to keep\\nfamily updated.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987231,\n \"text\": \"Neonatology Attending Note\\nExam:\\nUnchanged form previously. Resting comfortably in no distress. Pink. AFSF. Lungs CTA, =. CV RRR, soft murmur. Abd soft, +BS. Ext warm, pink and well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987232,\n \"text\": \"Neonatology Attending Note\\nDay 15\\nCGA 34 4\\n\\nRA. Cl and = BS. Mild sc rtxns. RR30-60s. 2 A&Bs past 24 hours. TF 150 -160s. BP 56/44. H/o PPS murmur.\\n\\nWt 1755, up 30 gms. TF 150 cc/k/day BM/PE26 po/pg. Nl voiding and stooling.\\n\\nIn open crib.\\n\\nA/P:\\nGrowing preterm infant with aop and immature feeding skills. Cont to moitor. Will add promod supplementation to her feedings. No other changes to current medical plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987253,\n \"text\": \"1900-0730 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats=96-98%. RR=20-70's.\\nBreath sounds clear and equal, mild SCR noted. No bradys, no\\ndesats so far this shift. Will continue to monitor resp\\nstatus.\\n\\nFEN: Weight tonight=1.930kg (+50 grams). TF=150cc/kg/d of\\nPE26/BM26 with promod alternating PO/PG q4hr. Infant bottled\\n24cc at 2130, remainder gavaged. Abdomen pink, soft, round,\\n+BS. no loops, AG=25-26cm. Small spit x1, minimal aspirates.\\nVoiding and stooling (guiac negative). Continue to monitor\\nFEN status.\\n\\nDEV: Temps stable, swaddled in OAC. Active and with\\ncares, sleeps well in between. Brings hands to face, sucks\\non pacifier for comfort. MAE. Continue to support DEV.\\n\\n: No contact with so far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987254,\n \"text\": \"Neonatology Attending\\n\\nDay 20\\n\\nRemains in RA. RR 40-60s. Sats > 93%. Clear breath sounds. No bradycardia. HR 130-140s. BP mean 48. Weight gms (+50). On PE/BM 26 with Promod. Learning to bottle. Tolerating gavage feeds. Stable temperature.\\n\\nImproved feeding but not ready to ad lib feed. Will continue to encourage po feeding. Adequate breathing control. Monitoring closely.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987255,\n \"text\": \"NEonatology-NNP PROgress Note\\n\\nPE: remains in her open crib, nested, in room iar, bbs cl=, rrr s1s2no murmur,abd soft, notender, V&S, afso, active with feedings, gavage tube in place\\n\\nSee attending note for plan\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987256,\n \"text\": \"NEonatology-NNP PROgress Note\\nsoft murmur audib,e pulses 2+=, well perfused\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987259,\n \"text\": \"Neonatology\\nDoing well. Remains in RA. No spells. Comfortable appearing.\\n\\nWt 1270 up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Alt po/pg.\\n\\nSkin w/o leisons. Abdomen benign. Cor nl s1s2 murmur as before. neuro non-focal and age appropriate. Moving all 4 ext well.\\n\\nCOntinue current monitoring and nutritional rx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987233,\n \"text\": \"Nursing Progress Note\\n\\n\\n2. Resp O/A Rec'dinf in RA. Inf remains in RA. No\\ndesats, no spells thus far. P cont to assess resp needs.\\n3. FEN O/A TF=150cc/kg/day of PE26w/PM. Inf PO fed full\\nvol 1X thus far. Tol feeds well, 1X sm spit, min asp thus\\nfar. Belly soft, no loops. Inf voiding, no stool thus far.\\n P cont to offer PO feeds as tol.\\n4. DEV O/A remains in an OAC cobedding with her\\ntwin. Temp stable. A/A with cares. P cont to assess dev\\nneeds.\\n5. O/A No contact thus far. P support, eudcate.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987234,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells and no dsats. lung sounds clear and\\nequal. mild subcostal retractions. no increased wob noted.\\nRR 30-50's. continue to monitor for resp changes.\\n\\n3: fluids\\ncurrent weight 1790gms up 35. total fluids remain a\\nt150cc/kilo/day of pe 26 with prom. tolerating feeds well.\\nattempted po feed x'2. infant took 20 and 25cc with\\nremainder gavaged. infant abd exam benign. no loops. stable\\ngirths. voiding, no stool thus far. no spits.minimal\\naspirates. continue to encourage po feeds.\\n\\n4: dev\\ntemps stable in an open crib. co-bedded with sister. \\nand active with cares. sleeps well inbetween. sucks on\\npacifier. brings hands to face. aga. monitor for\\ndevelopmental milestones.\\n\\n5: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987240,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells and no dsats thus far this shift.\\nRR 40-70's. sats > 94%. Lung sounds clear and equal. mild\\nsubcostal retractions. no increased wob noted. continue to\\nmonitor for changes in resp status.\\n\\n3: fluids\\ncurrent weight 1815gms up 25gms. total fluids remain at\\n150cc/kilo/day of pe 26 with prom. tolerating feeds well.\\nalt po/pg feeds. infant took 30cc's po at 0130. abd exam\\nbenign. no spits.minimal aspirates. stable girths. voiding,\\nno stool thus far this shift. continues on iron.\\n\\n4: dev\\ntemps stable in an open crib. co-bedded with sister. \\nand active with cares. sucks vigorously on pacifier. brings\\nhands to face. waking at times prior to cares. aga. continue\\nto monitor for developmental milestones.\\n\\n5: \\nmom and in following cpr for very quick visit. \\nand intact family. continue to support needs.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987241,\n \"text\": \"progress note\\nd17 corrected 34 wks\\nRA no spells\\nlast spell on 22nd\\n1815g (up 25)\\ntf 150 pe26/PM\\nocc spits gets feeds over 1 hour\\nalt po/pg\\n\\nexam:\\nafof\\nsoft flow murmur\\nnl s1/s2\\nbs clr\\nabd: soft, non distended\\n\\na/p:\\nprematurity\\npremature feeding pattern\\npassed hearing\\ncont to encourage PO\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987242,\n \"text\": \"progress note\\nNeonatology Attending\\n\\nGrowing preterm infant learning how to po feed. Reviewed and agree with medical plan as outlined by Dr. .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987257,\n \"text\": \"NPN 1500\\n\\n\\n#2 Resp: Infant stable in RA w/ O2sats 98-100%. No drifts or\\nspells. RR 40-70, br. snds clear and equal.\\nA: Stable in Ra.\\nP: Cont to monitor for spells.\\n#3 F/N: Infant remains on 26 cal PE/BM w/ promod. Bottled\\n40cc X1 this AM. Tolerates gavage w/ occasional small spit.\\nAbd soft, bowel snds active. Voiding and stooling.\\nA: Learning to po, still requires gavage.\\nP: Cont to offer po's X2 per shift.\\n#4 Dev.: Infant awake and w/ cares. Swaddled w/i\\nboundaries. Extremities flexed to midline. Infant calms\\neasily w/ wrapping and pacifier when offered.\\nA: AGA\\nP: Cont dev. supports.\\n#5 : No contact thus far on shift. Mother here\\nyesterday at 5pm, br. fed infant. Infant latched on well but\\nmother states her milk supply is low and always has been.\\nShe is unsure if she will try to increase her supply at this\\npoint. Mother handled well.\\nA: Invested and involved family.\\nP: Cont parent support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987258,\n \"text\": \"1900-0700 NPN\\n\\n\\nRESP: Infant remains in RA, O2 sats 95-100%. RR=20-70's.\\nBreath sounds clear and equal bilaterally, mild SCR noted.\\nNo bradys, no desats so far this shift. Continue to monitor\\nresp status.\\n\\nFEN: Weight tonight=1.970kg (+40 grams). TF=150cc/kg/d of\\nPE26/BM26 with promod PO/PG q4hr. Infant bottled 46cc at\\n2130 and 28cc at 0130, remainder gavaged. Abdomen pink,\\nsoft, round, +BS, no loops, AG=26cm. No spits, no aspirates.\\nVoiding and stooling (guiac negative). Continue to monitor\\nFEN status.\\n\\nDEV: Temps stable, swaddled in OAC. Active and with\\ncares, sleeps well in between. Brings hands to face, MAE.\\nContinue to support DEV.\\n\\n: in for the 2130 care. Involved and .\\nUpdated on patient's status/current plan of care by RN.\\nContinue to support family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987260,\n \"text\": \"Nursing Progress Note\\n\\n\\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\\ndrifts, no spells thus far. P cont to assess resp needs.\\n3. FEN O/A TF=150cc/kg/day of BM or PE26w/PM. Alt PO/PG\\nfeeding this shift. Tol feeds well, no spits thus far, min\\nasp thus far. Belly soft, no loops. Inf voiding, no stool\\nthus far. P cont to offer PO feeds as tol.\\n4. DEV O/A remains in an OAC with stable temp. A/A\\nw/cares. Sleeping well between cares. Not waking for feeds\\nthis shift. P cont to assess dev needs.\\n5. O/A Mom called for updates. P support,\\neducate. plan to visit later today.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987261,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in R air, BBS clear, equal, mild subcostal/\\nintercostal retractions present, no spells thus far this\\nshift. no sat drifts noted, soft murmur noted.A;stable in R\\nair. P; cont to monitor.\\n\\n#3. TF=150cc/kg/day, PE26 with promod, po/pg fed\\ntolertaed,po fed full volume x1, BS+, no loops, voided,\\nstooled, guaic negative. A; Feeds tolertaed. P; cont current\\nfeeding plan.\\n\\n#4. , active with care, temp stable in a open crib,\\nswaddled with blanket, MAE.bath given. A; AGA P; cont dev\\nsupport.\\n\\n#5. Mom called for a update, asking app questions.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987262,\n \"text\": \"Neonatology\\nDoing well. REmains in RA. No spells. Comfortable apeparing. Soft murmur c/w PPS heard./ Comfortable apeparing on my exam.\\n\\nWt up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Good weight gain over time.. Abdomen benign.Alternating po/pg.\\n\\nActive . Skin w/o leisons. Moving all ext. Neuro non-focal and age aprpopriate.\\n\\nCOntinue current monitoring and nurtitional regimen\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987263,\n \"text\": \"NPN\\n\\n\\n#2 Resp: infant remains in RA with sats >95, no desats or\\ndrifts. BBS clear/=, RR 30-70's, mild transient SC\\nretractions. cont to monitor resp status\\n\\n#3 Fluids: infant TF remain @150cc/kg/d P26+PM/Br26+PM =50cc\\nQ4h. infant alternating PO/NG feeds. Took full volume bottle\\nwith Mom this afternoon. abd soft, +BS, voiding, stools dark\\nbrown, heme negative. girth stable 25-26cm. X1 small spit.\\ncont to monitor feeding tolerance.\\n\\n#4 G&D: infant bundled in OC, temps stable, awake and ,\\nwaking for feeds. PO feeding with good coordination. AGA 35\\nweeker. cont to provide developmental support.\\n\\n#5 : Mom in this afternoon. Met with Lactation to\\ndiscuss feeding plans. Updated on infant status and\\ndiscussed discharge teaching. Mom states although she has\\ntwin#1 at home she is happy to review d/c instructions. cont\\nto provide updates and support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987243,\n \"text\": \"Nursing Progress Note\\n\\n\\n#2-O/A- Received infant in RA. Infant remains in RA. No\\nresp distress. No bradys so far this shift. P- Cont to\\nassess for Resp needs.\\n#3-O/A- TF=150cc/kg/d of BM/PE26w/ProMod. Alt po/pg feeds.\\n Taking less than of feeds by bottle. Abd exam benign.\\nVoiding and stooling. Tol feeds. P- Cont to assess for\\nFEN needs.\\n#4-O/A- cont to be awake and active with cluster\\ncares q4hrs. Sleeps well between cares. Temp stable in\\nopen crib. P- Cont to assess for G&D needs.\\n#5-O/A- in to visit with updates given. held\\nand bottled infant. P- Cont to enc parental calls and\\nvisits.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987244,\n \"text\": \"NPN 1900-0700\\n\\n\\nRESP: Infant remains in RA. O2sat 90-97%. RR 30-80's. Mild\\nIC/SC rtx. LS clear and equal. TB sxn'd X1 for sm amt of\\npale yellow nasal secretions. No spells.\\n\\nFEN: wt=1855g (up 40g). TF=150cc/kg/d of BM/PE26 with\\npromod. Equals 46cc q4hrs, alt PO/PG. Gavaged over 45min.\\nTolerating well. Bottled 45cc at 0130. Abdomen soft, +BS, no\\nloops, sm spit X1, voiding and stooling. On Fe.\\n\\nDEV: Temps stable, swaddled with hat in open crib. Cobedding\\nwith twin. and active with cares. Sleeps well between.\\nWakes ~1hr prior to feeds. Settles with paci.\\n\\n: No contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987245,\n \"text\": \"progress note\\nNeonatology Attending\\n\\nGrowing preterm infant with immature feeding skills. No change to current medical plan.\\n\\nReviewed and agree with medical plan as outlined by Dr. .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987246,\n \"text\": \"progress note\\nd 18 corrected 35 wks\\nra\\nno spells\\n\\n1855g (up 40)\\npe 26 / pm\\npo/pg\\n\\nexam: afof\\nsoft PPS murmur\\nbs clr\\nabd: soft, no mass\\nnl s/1/s2\\n\\na/p:\\nprematurity\\npremature feeding pattern\\npassed hearing\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987273,\n \"text\": \"PCA 0700-1500\\n\\n\\n2\\ninfant remains in RA, RR 30-70, O2 sats 96-100%, lung sounds\\ncl=, mild sc retractions, no desats. P:cont. to monitor.\\n\\n3\\ninfant remains on TF min. 150cc/kg/d, formula was switched\\nfrom PE26 with promod to E24=53cc q4h. infant taking all PO\\nfeeds, bottling full volume with good coordination, infant\\ntires out toward end of feed. abd. soft, bs+, no loops, ag\\nstable 27-27.5cm, small spit X1, voiding qs, no stool thus\\nfar. P:cont. to support nutritional needs.\\n\\n4\\ninfant remains swaddled in OAC, temp. stable, occ. wakes for\\nfeeds, a/a with cares, settles well in between, fontanelles\\nsoft/flat, brings hands to face for comfort. P:cont. \\nsupport dev. needs.\\n\\n5\\n called to let us know he would be in for the 1730 care.\\nP:cont. to update on infant's progress.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987274,\n \"text\": \"Nursing NICU Note Addendum\\n\\n\\nI have read the above note written by PCA and\\nagree with the information as stated.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987275,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in R air, BBS clear, equal, mild subcostal\\nretractions still present,no spells thus far this shift.\\nA;stable in R air.P; cont to monitor.\\n\\n#3. Todays weight=2150, no change, TF= 150cc/ kg /day ,\\nEnfamil 24 cal, po fed tolerated, gets tired towards the end\\nof po feeds.BS+, no loops, voided, stooled, guaic negative.\\nA; Feeds tolertaed.P; cont current feeding plan.\\n\\n#4. , active with care, temp stable in a open crib,bath\\ngiven, swaddled with blanket, MAE. Hep B vaccine given. A;\\nAGA P; cont dev support.\\n\\n#5. No contacts from thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987276,\n \"text\": \"Newborn Med Attending\\n\\nDOL#26. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT=2150, no change, on ~150 cc/kg/d BM24 or E24, PO. Passed hearing.\\nA/P: Growing infant on full feeds. Tentative D/C home today or in AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987277,\n \"text\": \"Nursing Discharge Note\\nPt d/c'd to home with at 1845 as ordered by MD. VSS. In RA. No spells. Soft murmur. TF=min 150cc/kg/d of BM24/E24 (53cc Q4hr). Pt bottlefed Q4hr, taking 55-70cc PO at each feeding. Med spit x 1. Abdomen benign. Voiding, stools x 3. On Ferinsol, demonstrated administration to who verbalized understanding. Temps stable in OAC. /active. AGA. Passed car seat test today. D/C teaching reviewed with both who verbalized understanding. Appropriate documentation signed, see chart for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987171,\n \"text\": \"NPN 7p-7a\\n\\n\\nSepsis: Infant conts amp and gent. Bld cx neg to date. Cont\\nto monitor for signs and symptoms of sepsis.\\n\\nResp: Infant conts on nasal prong cpap 6cm. Fio2 23-25%. RR\\n30-50's. Ls clr/=. Ic/Sc retractions noted. No spells or\\ndesats so far this shift. Cont to wean 02 as tol.\\n\\nFen: Wt tonoc 1.480kg (-60gms). Conts on tf 100cc/kg. IVF of\\npnd10w via piv. Enteral feeds started at 20cc/kg of pe 20.\\nTol feeds well thus far. Abd soft round. Bs +. No spits\\nminimal aspirates. Mec stool x1. Voiding with each diaper\\nchange. Cont to monitor toleration of feeds.\\n\\nDev: Temp stable transferred to servo isolette. Alert and\\nactive with cares. Sleeps well between. Occasionally sucks\\non pacifier. Nested in sheepskin with boundries in place.\\nCont to support developmental milestones.\\n\\nParents: MOm and in this evening with grandfather.\\n at bedside. Mom did diaper and temp as well as held\\ninfant. still not feeling well. Asking appropriate\\nquestions. Cont to support and update.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987172,\n \"text\": \"Neonatology Attending Progress\\nNow day of life 2.\\nBaby remains on CPAP of 6 and in RA-24% FIO2.\\nRR - 30-50s.\\nNo apnea and bradycardia.\\nHR - 110-120 77/46 62\\n\\nWt. 1480gm down 60gm on 100cc/kg/d of TF - PN/IL 80cc/kg/d enteral feedings of PE/MM 20cc/kg/d.\\nUO 4.1cc/kg/hr, passing mec.\\n\\nBili 5.2/0.1\\n\\nAssessment/plan:\\nVery nice progress for this 32 week gestation twin.\\nWill give trial off CPAP today.\\nFeeding advancement to continue slowly - FT up to 120cc/kg/d.\\nFU bili tomorrow.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987173,\n \"text\": \"Clinical Nutrition\\nO:\\n32 wk gestational age BG, AGA, now on DOL 2.\\nBirth wt: 1540 g (~25th to 50th %ile); current wt: 1480 g (-60)(down ~4% from birth wt)\\nHC:: 29.5 cm (~25th to 50th %ile)\\nLN: 42 cm (~25th to 50th %ile)\\nLabs noted\\nNutrition: 120 cc/kg/day TF. Feeds started on DOL 1; currently @ 20 cc/kg/day PE/BM 20,advancing 10 cc/kg/. PN started on DOL 1; lipids being added today. Remainder of fluids as PN via PIV; projected intake for next 24 hrs from PN ~54 kcal/kg/day, ~2.5 g pro/kg/day, and ~1.6 g fat/kg/day. From EN: ~20 kcal/kg/day, ~0.3 to 0.6 g pro/kg/day, and ~1.0 g 1.1 g fat/kg/day. Glucose infusion rate from PN ~5.7 mg/kg/min.\\nGI: Abdomen soft and round; overall benign.\\n\\nA/Goals:\\nTolerating feeds without GI problems; advancing cautiously and monitoring closely for tolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Expect PN to be supplemental only to feeds, and to taper as EN advances. Further increases in feeds as per growth and tolerance. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987174,\n \"text\": \"Respiratory Care Note\\nPt off CPAP today. Placed in 50-100cc nasal cannula. BS clear. RR 30-50's. No bradys noted off CPAP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987175,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\nInfant is currently in NC. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended iwth active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987176,\n \"text\": \"NPN 7am-7pm\\n\\n\\n1. VSS as charted on flow sheet. Afebrile. Blood cultures\\nneg at this time Awaiting 48 hour rule out. Pink, no apnea\\nor bradycardia. Cont on antibiotoc therapy.\\nStable. No signs or symptoms of infection.\\nCheck 48 hour blood culture results tonight.\\nCont to monitor.\\n2. Received on CPAP6, RA. Weaned to prong nasal cannula at\\n1145 and remains at this time in 100%Fi02 at 50cc. Tol well\\nwith 02 sats >93%. No apnea or bradycardia this shift. Occ\\nbrief 02 sat drifts, self resolving. BBS clear and equal. No\\nmurmur. No edema.\\nStable 02 sat with min 02 requirement.\\nCont to monitor. Wean 02 as tol.\\n3.TF currently at 120cc/kg/day. Increased at 1730 feeding.\\nCurrently taking 90cc/kg/day via PIV D10W with NaCl and KCl\\nadded. Enteral feeds at 30cc/kg/day.PE20/BM20.Currently no\\nbreast milk available. Mom is pumping q 3 hours. Abd soft\\nactive bowel sounds. A/G 21-21.5cm Voiding qs See flow\\nsheet. Mec stool x1.\\nAdvancing on ent feeds. Weaning IV.\\nCont as planned. Advance 10cc/kg . Next advance due at\\n0530.\\n4. In Servo isolette maintaining temp, Nested with boundries\\nand sheepshin. Sucks on pacifier with feeds. Infant noted to\\nbe irritable at times difficult to calm. Settles best on\\nabd. Parents in at various times today and held infant. Mom\\ndischarged this afternoon. Staying at a hotel in \\nwith husband.\\nCOnt stress precautions.\\n5. Parents involved with infant care. Asking appropriate\\nquestions. Had family meeting with team today. Verbalized\\nunderstanding of criteria for discharge and plan of care.\\nInvolved parents.\\nCont to support.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987177,\n \"text\": \"NPN 7p-7a\\n\\n\\nSepsis: Bld cx neg to date. 48 Ro/o complete. Issue\\nresolved.\\n\\nResp: Infant remains on Nc 02. fi02 100%. 25-50cc flow. RR\\n40-60's. Mild ic/sc retractions. No spells or desats so far\\nthis shift. Ls clr/=. Cont to wean 02 as tol.\\n\\nFen: Wt tonoc 1.445kg (-35gms). Conts on tf 120cc/kg. IVF of\\npnd10w with il infusing at 90cc/kg via piv. Enteral feeds at\\n30cc/kg of pe20. Increasing 10cc/kg at 05 & 1730. Tol\\nfeeds well. Max aspirate 1.2cc. Abd soft. Bs+. No stool thus\\nfar. Voiding with each diaper change. Ag stable. Am lytes\\npending. Dstick 92. Cont to advance feeds as tol.\\n\\nDev: Temp stable in servo isolette. Alert and active with\\ncares. Irritable at times. Likes pacifier. Nested in\\nsheepksin with boundries in place. Cont to support\\ndevelopmental milestones.\\n\\n: No contact from so far this shift.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987178,\n \"text\": \"Neonatology Attending Progress Note\\nNow day of life 3 for this 32 week gestation twin.\\nIN 25cc of nasal cannula O2 - RR - 40-60s. Noted to have increased work of breathing today.\\nHR 120-130s 66/36 48\\n\\nWt. 1445 down 35gm on 140cc/kg/d of TF - feedings up to 30cc/kg/d of MM, 110cc/kg/d of PN/IL.\\nFeedings overall well tolerated - 3 cc aspirates noted.\\nNormal urine and stool/mec output.\\n\\nLytes 140 4.7 107 22\\nBili 11.5/0.2\\n\\nHUS - unremarkable - no IVH\\n\\nSocial - family meeting yesterday to review course. Awaiting further word on father's hepatitis diagnosis.\\n\\nAssessment/plan:\\nMild worsening of respiratory status today - will evaluate with CXR.\\nFeedings to be advanced gradually as tolerated.\\nDouble phototherapy with FU bili tomorrow.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987179,\n \"text\": \"0700- NPN\\n\\n1 Infant with Potential Sepsis\\n\\nRESP: Remains in nasal cannula 25cc flow, 100% fi02. Flow\\nrate increased to 75cc x1 when infant was positioned in\\nsupine position (see flowsheet). LS clear/=; nares suctioned\\nx1 for mod amt yellow/blood-tinged secretions. RR 40s-60s,\\nmild SC/IC retractions present. No spells.\\n\\nFEN: TF 140cc/kg/d. IVFs PND10w and IL infusing via PIV at\\n100cc/kg/d at this time. Feedings currently at 40cc/kg/d\\nPE20, given via gavage q4hrs over 20min, TW. Plan to\\nincrease feedings 10cc/kg/d as tolerated. No spits, max\\nasp 3cc (nonbilious, partially digested formula). Abdomen\\nsoft, round, no loops, active BS. Voiding (UO 3.8cc/kg/hr)\\nand mec stooling. Dstick 105.\\n\\nDEV: Temps stable, nested with sheepskin in servo control\\nisolette. MAE, fontanels soft and flat. Alert and active\\nwith cares, sleeping between cares. Brings hands to face,\\nsucks on pacifier for comfort. AGA.\\n\\nPARENTING: visiting throughout the day, updated by\\nRN. Assisting with cares, asking appropriate questions. Mom\\nkangaroo'd this twin for about 1.5hrs today. loving\\nand invested.\\n\\nREVISIONS TO PATHWAY:\\n\\n 1 Infant with Potential Sepsis; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987184,\n \"text\": \"NPNOte\\n\\n\\n#2. remains on nasal cannula 100% 25cc to maintain sats\\n>87-94%, BBS clear, equal, mild subcostal/intercostal\\nretractions present, no spells thus far this shift, sat\\ndrifts noted following shallow respiration. A;required\\nsupplemental o2 to maintain sats P; cont to wean o2 as\\ntolerated.\\n\\n#3. Tf=150cc/kg/day, Parentral at 90cc//kg/day,infusing\\nPND10 with lipids at PIV, enteral at 60cc/kg/day,PE20 pg fed\\ntolerated, BS+, no loops, voided, stooled,D'stix 97. A;\\nFeeds tolerated. P; cont to advance feeds 10cc/kg, at\\n1.30+1.30.\\n\\n#4. Alert, active with care, temp stable in a servo control\\nisolette, nested in sheepskin, mae. loves pacifier.A; AGA P;\\ncont dev support.\\n\\n#5. visited, asking app questions, states that\\nhis lab result status is pending (type of Hep disease)\\n wore gown and held the baby, A; P; cont\\nparental support and teaching.\\n\\n#6. MIldly jaundiced, under single phototherapy.A; mildly\\njaundiced. p; cont phototherapy as ordered, Bili on Sunday.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987185,\n \"text\": \"Neonatology NP Exam Note\\nInfant examined, care discussed with team.\\nPlease refer to Dr note for detailed evaluation and plan.\\n\\nPhysical Exam:\\nINfant netsled in isolette, under phototherapy. AFOF, eyes clear, nares clean ng in place, MMMP.\\nChest is clear, comfortable resp pattern.\\nCV: RRR, no murmur, pulses+2=.\\nAbd: soft, active BS. Cord dry, NTND.\\nGU: immature female genitalia.\\nExt: lean. , \\nNeuro: active, easliy consoles, primitive reflexes intact and symmetric.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987186,\n \"text\": \"NICU NPN\\n\\n\\n2. RESP: Infant remains in 02 via NC 100%, 25-50cc\\nthroughout night. Lungs clear/=, breathing comfortable with\\nbaseline mild SC/IC retractions. A: stable in 02, no spells\\novernight P: COnt. to support and wean as tolerated.\\n\\n3. Fluids: Infant remains on TF of 150cc/k/d, advancing on\\nenteral feeds 10cc/k/d curretnly at 70cc/k of BM/Pe20 taking\\n18c q4hours via gavage over 30 min. Infant tolerating well,\\nminimal asp, no spits. Abd. benign, voiindg/no stool.\\nPN/lipids infusing at 80cc/k, DS stable.A: tolerating\\nadvancement of feeds P: COnt. to support current feeding\\nplan.\\n\\n4. G/D: Temp. stable in servo mode isoeltte. Infant\\nturned and repositioned q4hours w/ cares, sleeping well\\nbetween. A: stable P:Cont. to support G/D.\\n\\n5. : No contact thus far in shift.\\n\\n6. BILi: Infant remains under single phototherapy with eye\\n on aat. REpeat bili will be checked tomorrow am2/15\\nas ordered. A: stable under single P: COnt. to monitor\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987187,\n \"text\": \"Neonatology Attending\\n\\nDOL 5 CGA 33 1/7 weeks\\n\\nStable in NCO2 25-50 cc. R 50s-60s. No A/B.\\n\\nN murmur. BP 69/38 mean 51\\n\\nOn 150 cc/kg/d with PE/BM 20 at 70 cc/kg and PN10/IL at 80 cc/kg. Tolerating feeds and advancing 10 cc/kg q 12. Voiding. Stooling. Wt 1405 grams (down 35).\\n\\nOn single phototherapy.\\n\\n visiting and up to date. Father being worked up for hepatitis. Family plans to return to after discharge.\\n\\nA: Stable. Resolving RDS with small O2 requirement. No spells. Tolerating feed advance. Hyperbili on phototherapy.\\n\\nP: Monitor\\n Wean O2 as tolerated\\n Advance feeds\\n One more day of PN\\n Follow bili\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987193,\n \"text\": \"NPN 7p-7a\\n\\n\\n#2 In 13cc of O2 via NC. O2 sats 97-100%. RR's ^ 80's at\\ntimes. BBS clear and =. No bradys or desats. A: small O2\\nrequirement P: Follow resp status\\n\\n#3 Feeds ^ by 15cc/k to 125cc/k. Receiving 32cc of PE20 q\\n4hrs on a pump over 40 mins. No spits or aspirates.\\nAbdominal exam unremarkable. Voiding, passing meconium. Am\\nlytes stable. DS 87. A: tolerating feeds P: Follow weight\\nand tolerance to feeds\\n\\n#4 Swaddled on sheepskin in air isolette. Isolette weaned as\\ntolerated. Pleasantly alert with cares. Sleeps with ease. A:\\nAGA P: support developmental needs\\n\\n#5 No parental contact.\\n\\n#6 Am rebound bili 7.0/.2. Lights cont. off. Passing stool.\\nWorking up on feeds.P: Cont to follow bili level as\\nordered.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987194,\n \"text\": \"Neonatology Attending Note\\nDay 7\\nCGA 33 3\\n\\nNC 100%, 13-25cc. RR30-80s, int tachypneic. No A&Bs. Mild rtxns. No murmur. HR 110-140s.\\n\\nBili 7.0/0.2 (rebound).\\n\\nWt 1485, down 15. TF 125 cc/k/day PE/BM20, increasing 15/k/day for a goal of 150 cc/k/day. Tol well. Nl voiding and stooling.\\n137/4.6/104/26\\n\\nIn low heated isolette.\\n\\nA/P:\\nresolving RDS, wean O2 as tol\\ncont feeding advance\\ntransition to open crib\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987195,\n \"text\": \"Social Work:\\nMet briefly with . See note in sibling's chart.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987196,\n \"text\": \"Nursing Progress Note\\n\\n\\n#2-O/A- Received infant on NCO2 100% 25cc flow. Infant\\nremains on NCO2. No resp distress. No Bradys. P- Cont to\\nassess for Resp needs.\\n#3-O/A- TF=140cc/kg/d of BM/PE20 via NGT. Will advance to\\nTF=150 at 1am. Abd exam benign. Voiding and, no stool so\\nfar this shift. Tol feeds. P- Cont to assess for FEN\\nneeds.\\n#4-O/A- cont to be awake and active with cluster\\ncares q4hrs. Sleeps well between cares. Temp stable in low\\nheated isolette. Sucks on pacifier. P- Cont to assess for\\nG&D needs.\\n#5-O/A- in to visit with updates given. held\\ninfant with gown and gloves. interaction. P- Cont\\nto enc parental calls and visits.\\n#6-O/A- Remains off photo. Bili this am=7.0, 0.2. P-\\nCont to assess for Hyperbilirubimemia.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987197,\n \"text\": \"Neonatology-NNP PRogress Note\\n remains in her isolette, nested in room air, bbs cl =, rrr s1s2no murmur, abd soft, nontender V&S, afso, active with care\\n\\nSee attending note for plan\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987198,\n \"text\": \"NPN 1900-0700\\n\\n6 Bili:\\n\\n1. Resp: Received infant in NC O2 100% requiring 25 cc flow.\\nInfant has been in RA since 2130 maintaining her O2 sats\\ngreater than 92%. Lung sounds clear/=. RR 40-70's. Mild\\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\\nresp. status.\\n\\n2. FEN: Weight is 1520 gms up 35 gms. TF remain at 150\\ncc/kg/day of BM/PE20. Tolerating NGT feedings well; abd\\nexam benign, no spits, min asp, AG stable. Voiding qs and\\nno stool noted thus far. P: Cont. to support nutritional\\nneeds.\\n\\n3. G/D: Temps stable swaddled in weaning air-controlled\\nisolette. Alert and active with cares. Settles well in\\nbetween cares. Appropriately brings hands to face and sucks\\non pacifier to comfort self. AFSF. AGA. P: Cont. to\\nsupport developmental needs.\\n\\n4. : No contact thus far this shift.\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Bili:; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987205,\n \"text\": \"Clinical Nutrition\\nO:\\n~33 wk CGA BG on DOL 9.\\nWt: 1540 g (+20)(birth wt 1540 g.) Infant has just reachieved birth wt. Average wt gain over past wk ~6 g/kg/day.\\nHC: n/a\\nLN: n/a\\nLabs not due yet.\\nNutrition: 150 cc/kg/day BM/PE 24, all pg over 80 min feeds due to spits. Feeds just increased today; projected intake for next 24 hrs ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\\nGI: Abdomen benign. Spits w/ q feed overnight.\\n\\nA/Goals:\\nTolerating feeds but w/ frequent large to mod. spits requiring extended gavage times; will monitor spits on longer feeding times. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins except Fe, which will be started tomorrow if infant's spits resolve. Growth should improve now that feeds have reached initial goal. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987206,\n \"text\": \"2. remains in RA, color pink, sl jaundice, RR 30-60,\\nBBS clear, equal, sc retractions, no spells.\\n3. TF 150cc/k/d PE24 39cc q4h pg, abd soft, no loops,\\npositive bowel sounds, minimal aspirates, very sm spit x1,\\nvoiding and passing guiac neg stool.\\n4. temp warm this am, isolette weaned to off, swaddled,\\nactive with cares, sucking on pacifier.\\n5. here for 1300 cares, held , Mom held\\n. Continue to offer support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987207,\n \"text\": \"NPN 1900-0700\\n\\n\\n1. Resp: Infant remains in RA, maintaining her O2 sats\\ngreater than 96%. Lung sounds clear/=. RR 40-70's. M\\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\\nresp. status.\\n\\n2. FEN: Weight is 1565 gms up 25 gms. TF remain at 150\\ncc/kg/day of PE24. Tolerating NGT feedings well; abd exam\\nbenign, no spits, min asp, and AG stable. Voiding qs and no\\nstool noted thus far. P: Cont. to support nutritional\\nneeds.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Alert and\\nactive with cares. Settles well in between cares.\\nAppropriately brings hands to face and sucks on pacifier to\\ncomfort self. AFSF. AGA. P: Cont. to support nutritional\\nneeds.\\n\\n4. : No contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987208,\n \"text\": \"progress note\\nd10 corrected 33 wks\\nra\\n\\n1565g (up 25)\\ntf 150 bm/pe24\\ngavage\\nmin asp\\n\\nexam: nnp\\n\\na/p:\\npreamturity\\npremature feeding pattern\\nstart Fe today\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987209,\n \"text\": \"progress note\\nAddendum - Neonatology Attending\\nInfant with feeding immaturity. Course over the past 24 hours reviewed with team. I agree with Dr. assessment. Continue to await maturation of oral feeding skills and optimize nutritional intake.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987210,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987217,\n \"text\": \"NICU NPN 1900-0700\\n\\n\\nRESP O: LUNGS ARE CLEAR, O2 SATS 94-100% IN ROOM AIR. NO\\nBRADYS THIS SHIFT.\\n\\nFEN O: GAINING WEIGHT, AND TOLERATING PO.PG FEEDS OF PE26\\nWELL. ABDOMINAL EXAM BENIGN, VOIDING AND STOOLING, NO SPITS,\\nAND MIN NGT ASPIRATES, AG STABLE.\\n\\nDEV O: TEMPS ARE STABLE SWADDLED IN CRIB. BABY IS AND\\nACTIVE WITH CARES, SLEEPS WELL IN BETWEEN CARES. FONTANELLS\\nARE SOFT AND FLAT.\\n\\nPARENTING O: NO CONTACT OVERNIGHT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987218,\n \"text\": \"DOL 12 for this 34 week infant in RA with immature feeding skills. 1630 up 40 gms on TF of 150 cc/kg/d. Doing well\\n\\nRRR no m\\nClear BS\\nSoft abdomen + BS\\n+ 2 pulses\\n\\nA/P: Well appearing infnat with no new medical changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987224,\n \"text\": \"NPNOte;\\n\\n\\n#2.Remains in R air, BBS clear, equal, mild subcostal /\\nintercostal retractions present, no spells thus far this\\nshift. A; stable in R air. P; cont to monitor.\\n\\n#3. TF=150cc/kg/day,On PE26/BM26, pg fed over 1hr 30mts,\\ntolerated, BS+, no loops, voided, no stool thus far this\\nshift. A;Feeds tolerated.P; cont current feeding plan.\\n\\n#4. , active with care, temp stbale in a crib,\\nco-bedding with sibling, swaddled, mae.A; AGA P;cont dev\\nsupport.\\n\\n#5. will be in later this pm. A; . P;\\ncont update and teaching.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987225,\n \"text\": \"NPNOte;\\n visited, asking app questions, wore glove and gown, po fed then held . spell x1 thus far this shift QSR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987159,\n \"text\": \"NICU Nursing Admission Note:\\nInfant admitted from L&D to NICU warmer due to prematurity, respiratory distress, and sepsis work-up. Infat active and alert with eyes open, occasional grunting noted. Sao2's drifted initially to 80's, resolved with BBO2. When BBO2 removed, would con't to drift to 70's and started retracting-> placed on CPAP. LS = and clear, no murmur noted, VSS, D/S:72. CBC w/diff sent, blood culture pending. PIV started at 80cc/k/d of D10W. Started on amp and gent. Voided in DR. in to bedside to visit and was updated (though CPAP will be new to him). Infant presently resting comfortably in 30%, CPAP 6, with Sao2's mid-high 90's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987160,\n \"text\": \"Neonatology NP Procedure Note\\nEndotracheal Intubation\\nPremedicated with 3 mcg. of fentanyl\\nIndication: need for surfactant administration\\n3.0 ETT passed oraly through cords under direct layngoscopy. Tube secured with 8 at upper lip. Equal breath sounds and good chest wall movement present. Infant tolerated procedure well. No compliations.\\nCXR pending to confirm placement.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987161,\n \"text\": \"Neonatology Attending Admission Note\\n\\nDelivering Ob - Dr. primary MD - Dr. \\n\\nBaby is a 32 week gestation female twin #2 delivered at 17:30.\\n\\nPregnancy: Mother is 35 old G1 P0-1.\\nMedical history is remarkable for maternal polycystic ovary disease. Pregnancy was conceived with IVF/ICSI and was a triplet pregnancy reduced to twins.\\nPNS: A pos, Ab neg, HBSAg neg, RPR NR, GBS unkown.\\n\\nPregnacy was complicated at 28 weeks with maternal preterm labor, cervical shortening, diarrhea and a left shifted cbc on arrival back from living in . She was treated with MGSO4, antibiotics, betamethasone and then nifedipine. She also developed cholestasis of pregnancy and was treated with Actigall.\\n\\nCultures of stool, urine were negative. Mother was hospitalized for one month until . Father also reportedly has hepatitis? Further history pending.\\nToday at 13:00 she developed PROM with preterm labor.\\n\\nMother was treated with ampicillin prior to delivery.\\nDelivery was vaginal for both twins. This twin had vacuum assistance because of decelerations. The baby emerged with no respirator effort or tone. She responded well to bag and mask ventilation after bulb suctioning. She was bagged for approximately 1 minute and then developed a good spontaneous cry and respiratory effort. Apgars 3, 8.\\n\\nSocial - Both parents work for the State Department in .\\n\\nPE - Wt. 1540gm(40%) Lt 42cm(40%) HC 29.5cm(40%)\\nVS - T 97.9 HR 140 RR 36 BP 57/30 41\\nHEENT - AF soft and flat, prominent caput post vacuum, eyes PERL, normal red reflexes\\nPalate intact\\nResp - lungs equal, decreased air entry in bases, retractions noted after being in NICU for several minutes - improved somewhat on CPAP\\nCVS - S1 S2 normal intensity, no murmur, perfusion fair, pulses normal\\nAbd - soft, no organomegaly\\nGU - normal AGA female\\nHips stable.\\nNeuro - tone wnl for GA, symmetrical exam\\n\\nWork of breathing and persistant grunting noted - baby intubated and treated with surfactant.\\n\\nAssessment/plan:\\n32 week gestation female twin with clinical picture consistent with surfactant deficiency/RDS.\\nBaby has responded well to intubation and surfactant treatment.\\nWill wean vent support as tolerated.\\nParents updated at bedside.\\nIV antibiotics initiated - at risk for sepsis.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987162,\n \"text\": \"nursing\\n\\n\\n#2O: baby Girl received in 28% O2 via prong CPAP 6.\\n Intubated with 3.0ETT for increased work of breathing and\\nhas received 11 dose of Survanta. Vent settings 24/5 x 20\\nin 25% O2. Br. sounds are clear but diminshed and does have\\nretractions.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987163,\n \"text\": \"Respiratory Care Note\\nPt. is 32 wker twin #2. Pt. was placed on 6cmH2O of nasal prong CPAP at change of shift. Pt. was requiring 30% FIO2, increased wob. Decision made to intubate and and give surfactant therapy. Pt. was intubated with a 3.0 ett taped at 8.0--gd.position per cxr. Pt. was treated with 6.2cc's of Survanta at 2145 and 0400. Pt. started out on IMV 24/5 R 20. Currently pt. is on 20/5 R 20 and 21%. Last cap gas was on 22/5 R 20 -->7.35/47. Pt. desatted with the surfactant and required hand-bagging. Plan is to obtain another cap gas and continue to wean as tolerated. Pt. improved since being intubated and given Survanta---21%, decreasd wob. To follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987164,\n \"text\": \"NPN:\\n\\nRESP: Vent - 24/5 x 20 -> -> 20/5 x 18, 21% 02; last setting change at 0530. CBG (0200): 7.35/ 47/ 46/ 27/ 0. Survanta (dose #2) given at 0400. Sx;d q 4 h for small amt cloudy secretions. BBS =/sl coarse. RR=40-60 with SC retraction. No desats, no A&Bs thus far tonight.\\n\\nCV: No murmur. HR=116-140. BP means 36-43; BP=66/30 (36). Color pink w/good perfusion.\\n\\nFEN: Birth wt=1540g. NPO. TF=80cc/kg/d; D-10-W. Dx=117. Abd soft, rounded, hypoactive bs; soft loops noted early in shift, but none at present. Bili & Elec to be done ~ 1700.\\n\\nID: Blood cx pending. Remains on Amp & Gent.\\n\\nG&D: CGA=32 wk. Temp stable on warmer w/servo control. Active and alert. Sl fussy w/cares; settles w/containment. Nested in sheepskin and resting well.\\n\\nSOCIAL: Mother in to visit x 1. Loving and appropriate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987219,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in R air, BBS clear, equal, mild subcostal/\\nintercostal retractions present, no desats noted thus far\\nthis shift. A;no spells. P; cont to monitor.\\n\\n#3. Tf=150cc/kg/day, PE26/MBM26, po/pg fed tolerated,po fed\\n~10cc x1, BS+, no loops, voided, stooled, guaic negative. A;\\nfeeds tolerated. P; cont current feeding plan.\\n\\n#4., active with care, temp stable in a open crib,\\nco-bedding with sibling. A; AGA P; cont dev support.\\n\\n#5. No contacts from thus far this shift. \\nare planning to visit this evening.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987220,\n \"text\": \"npn 1900-0700\\ndev: infant with healing scab on scalp.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987221,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. no spells thus far this shift. no dsats. Rr\\n40-70's. Lung sounds clear and equal. mild subcostal\\nretractions. no increased wob noted. continue to monitor for\\nchanges in resp status.\\n\\n3: fen\\ncurrent weight 1965gms up 55gms. total fluids remain at\\n150cc/kilo/day of bm/pe 26. tolerating feeds well. one\\nmedium spits. max aspirate 2cc's. voiding, no stool thus\\nfar this shift. abd soft with no loops. stable girths.\\ngavage fed this shift. infant not showing interest in\\nbottling.\\n\\n4: dev\\ntemps stable in an open crib. Infant had a low temp of 97.3\\naxillary and 97.5 rectally at 0130 following a spit. infant\\nplaced under warming lights. temp increased to 98.1.\\nco-bedded with sister. and active with cares. sucks on\\npacifier. brings hands to face. aga. continue to monitor for\\ndevelopmental milestones.\\n\\n5: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987222,\n \"text\": \"Neonatology Attending Note\\nExam Note:\\nInfant resting comfortably in open crib, co-bedding with twin. AFSF. +NG. Lungs CTA, cl and = bilat. CV RRR, 1/6 SEM heard over axilla and back - c/w PPS. 2+FP. Abd soft, +BS. Ext. warm, pink and well perfused.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987223,\n \"text\": \"Neonatology Attending Note\\nDay 13\\nCGA 34 2\\n\\nRA. Cl and = BS> RR40-70s. Mild sc rtxns. No A&Bs. HR 130-160s. No murmur. BP 72/36, 49.\\n\\nWt 1685, up 55 gms. TF 150 cc/k/day BM26/PE26 po/pg. Tol well. Nl voiding and stooling.\\n\\nIn open crib.\\n\\nA/P:\\n - CVR monitoring\\n - no change to nutritional plan\\n - check bili in am for persistent jaundice\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987226,\n \"text\": \"npn 1900-0700\\n\\n\\n2: resp\\nremains in ra. one spell this shift. see flow sheet for\\nfurther info. RR 30-60's. Lung sounds clear and equal. mild\\nsubcostal retractions. no increased wob noted. no dsats.\\ncontinue to monitor for changes.\\n\\n3: fluids:\\ncurrent weight 2030gms up 60gms. total fluids remain at\\n150cc/kilo/day of pe/bm 26 cals. tolerating feeds well.\\nno spits. feeds ran over 1.5 hours for hx of spits. minimal\\naspirates. voiding, no stool thus far this shift. stable\\ngirths. attempted to po x's 1. infant not showing interest\\nin bottling. infant taking only 5cc's.\\n\\n4: dev\\ntemps stable co-bedded with sister. and active with\\ncares. sleeps well inbetween. 14 day pku drawn. sucks on\\npacifier. brings hands to face. aga. continue to monitor for\\ndevelopmental milestones.\\n\\n5: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987227,\n \"text\": \"Neonatology Attending Note\\nDay 14\\n\\nRA. Cl and = BS. RR40-70s. 2 A&B past 24 hrs. Mild sc rtxns. +soft murmur. HR 130-150s. BP 68/35, 46. BP 68/35, 46.\\n\\nBili 5.2/0.2\\n\\nWt 1725, up 40 gms. TF 150 cc/k/day BM/PE26 po/pg. Tol well. Nl voiding and stooling (g-).\\n\\nIn open crib, co-bedding with twin.\\n\\nExam:\\nResting comfortably in open crib. Pink. No distress.\\nAFSF.\\nLungs CTA, =.\\nCV 1-2 SEM at LSB heard also over axilla and back. 2+FP. Pink and well perfused.\\nAbd soft, +BS.\\nExt warm, pink and well perfused.\\n\\nA/P:\\n - Growing preterm infant with immature cardioresp control and po feeding skills. Con to monitor. No changes to current medical plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987228,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in Ra ir, BBS clear, equaql, mild subcostal\\nretractions present, no spells thus far this shift. A;\\nstable in R air. P; cont to monitor.\\n\\n#3. Tf=150cc/kg/day, Pe26 pg fed tolerated, H/O spits, no\\nspits thus far, feeds given over 1hr 30mts,BS+,no loops,\\nvoided, no stool thus far this shift. A; Feeds tolerated. p;\\ncont current feeding plan.\\n\\n#4. ,a ctive with acre, temp stable in a open crib,\\nco-bedding with sibling, MAE. A; AGA P; cont dev support.\\n\\n#5. will be visiting this pm.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987235,\n \"text\": \"Neonatology Attending\\nAddendum - Physical Examination\\nwell-appearing infant in no distress\\nHEENT AFSF\\nCHEST no retractionbs; good bs bialt; no crackles\\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM LSB without radiation\\nCNS active, resp to stim; tone AGA\\nINTEG normal\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987236,\n \"text\": \"Neonatology Attending\\nDOL 16 / CGA 34-5/7 weeks\\n\\n is in room air with no distress and no bradycardias since .\\n\\nPPS murmur persists. BP 62/30 (41).\\n\\nWt 1790 (+35) on TFI 150 cc/kg/day BM26/PE26PM, tolerating well. Bottling up to volume. Abdomen benign. On iron. Voiding and stooling normally.\\n\\nA&P\\n32-3/7 week GA infant with resolving respiratory and feeding immaturity\\n-Continue to await maturation of oral feeding skills and respiratory drive\\n-Follow murmur clinically\\n-No other changes in management\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987237,\n \"text\": \"CAse Management Note\\nReferral called today to VNA in preparation for eventual d'c. is main # and fax is . Will need name of hotel/phone #/room #/address for VNA. Also need name/phone # of Pedi for twins. Will assess w/team if EIP is needed here in USA vs as family expects to relocate back there at some point. Will cont to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987165,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day one of life for this 32 week gestation infant with RDS.\\nOn vent support of 18 20/5 and RA currently.\\nBaby treated with 2 doses of surfactant with nice improvement.\\nLast CBG - 7.35/47 prior to wean.\\n\\nHR 112-140s MAP 36-43 - BP 66/30 36\\n\\nWt. 1540 BW\\nNPO on 80cc/kg/d of IV fluids.\\nBS 117\\nUO 3.3cc/kg/hr overnight.\\n\\nID - wbc 11,100 32P 0B 52L plat 264 Hct 40.4%\\nOn amp and gent.\\n\\nAssessment/plan: Preterm infant with nice response to surfactant.\\nWill wean vent support and hopefully be able to go to CPAP later today.\\nPN to be initiated today.\\nWill follow lytes - bili later today.\\nWill set up family meeting prior to mother's discharge to home.\\nHUS to be scheduled for Thursday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987166,\n \"text\": \"Social Work:\\n\\nParents of these twins have been known to me from mom's 6s antepartum admission. Please see note in sister's chart for complete social work note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987167,\n \"text\": \"NPN Days\\n\\n\\n#1 Pt cont on ampi and gent. no s/s of infection. BC\\npending. P- Will cont to monitor for sepsis.\\n#2 Pt received intubated 20/5 with a rate of 18. FiO2\\n21%. Pt weaned throughout the am and cbg drawn\\n7.32/56/29/30/0. Pt extubated @ 1400 to CPAP. Pt currently\\non CPAP 6. FiO2 21%. LS course bilat. IC SC retrac. no\\nspells so far this shift. sx for mod cloudy secr from ETT.\\nand sm clear from mouth. P- Will cont to monitor resp\\nstatus.\\n#3 FEN- TF=80cc/kg/d to be increased to 100cc/kg/d after\\nlabs this pm. Pt NPO. IV fluids D10W infuising through PIV.\\nabd benign voiding and stooling mec. d-stick 87. P- Will\\ndraw lytes and bili @ 1700 and cont to monitor FEN.\\n#4 G&D- Temp stable on servo warmer. alert and active with\\ncares. irritable at times. sucking on pacifier. HUS\\nscheduled for thurs. P- Will cont to monitor G&D.\\n#5 Parents- Parents visiting throughout the shift. helping\\nwith cares. loving and caring. updates given. asking approp\\nques. P- Will cont to encourage parental visits and calls.\\nSee flowhseet for further details.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987168,\n \"text\": \"Neonatology NP Exam Note\\nInfant eaxmined, care discussed with team.\\nPlease refer to Dr note for detailed evaluation and plan.\\n\\nPhyical exam:\\nInfant nested on open warmer, orally intubated. AFOF, Caput over occiput. Sutures overriding.\\nChest is clear, equal BS. Good air exchange.\\nRRR, nl S1, split S2. Pulses plus 2 and equal.\\nAbd: active BS, cord dry.\\nGU: immature female genitalia.\\nExt: MAE, WWP\\nNeuro: equal grasps, symmetric moro\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987169,\n \"text\": \"Respiratory Care\\nPt recieved on SIMV rate of 18, pressures of 20/5 with the fio2 21%. Pt weaned down on PIP from 20 to 18, pt also weaned down on ventilator rate from 18 to 14. Blood gas results obtained with good results. Pt extubated and place on nasal prong CPAP. Plan is to follow on CPAP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987170,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #2 remains on Prong CPAP 6 FiO2 23-25%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. RR 30-50's stable on Prong CPAP cont to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987238,\n \"text\": \"Clinical Nutrition\\nO:\\n~34 wk CGA BG on DOL 16.\\nWT: 1790 g (+35)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~20 g/kg/day.\\nHC: 30 cm (~10th to 25th %ile); last: 29.5 cm at birth\\nLN: 43 cm (~25th %ile); last: 42 cm at birth\\nLabs not due yet.\\nMeds include Fe\\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant takes ~ to full volume w/ po feeds. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\\nGI: Abdomen benign; one small spit\\n\\nA/Goals:\\nTolerating feeds without GI problems except occasional small spit. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. Average HC and LN gains over past 2 wks not meeting recommended ~0.5 to 1 cm/wk for HC gain or ~1 cm/wk for LN gain; expect improvement now that feeds have surpassed initial goal. Will continue to follow w/ team and participate in nutrition plans.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987239,\n \"text\": \"0700- NPN\\n\\n\\nRESP: In RA with RR 30's-60's. LS clear/=. No\\nretractions. No A/B spells or desats.\\n\\nFEN: TF=150cc/kg/d. PE26 with PM (45cc Q4hr) PO/PG. Pt\\nbottlefed x 2, taking 22-42cc at each feed. Small and\\nmedium spits. Minimal aspirates. Abdomen benign. Voiding,\\nsmall stool x 1. On Ferinsol.\\n\\nDEV: Temps stable in OAC. /active with cares. Sleeps\\nbetween cares, waking early for feeds. Sucks pacifier and\\nbrings hands to face for comfort. Fontanels soft/flat.\\nAGA.\\n\\nPARENTING: Both in to visit this shift, updated by\\nthis RN, asking appropriate questions.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987247,\n \"text\": \"NPNOte;\\n\\n\\n#2. Remains in R air, BBS clear, equal, mild subcostal\\nretractions present, no spells thus far this shift. A;\\nstable in R air. P; cont to monitor.\\n\\n#3. Tf=150cc/kg/day, PE26 with promod, po/pg fed, tolertaed,\\nBS+, no loops, voided, stooled. A; Feeds tolerated. P; cont\\ncurrent feeding plan.\\n\\n#4. , active with care, temp stable in a open crib,\\nswaddled with blanket, MAE. co-bedding with sibling,A; AGA\\nP; cont dev support.\\n\\n#5. visited, asking app questions. will be\\ndischarged home today after car seat screening.A; \\n P; cont update and teaching.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987248,\n \"text\": \"Social Work:\\nMet with . See note in sibling's chart.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987249,\n \"text\": \"NPN NOCS\\n\\n\\n2. Remians in RA. LS clear. O2 sats 91-100%. No drifts, no\\nspells. Stable.\\n\\n3. Wt up 25gms. TF at 150cc/kg of BM/PE26 with PM. Alt po/pg\\nfeeds. Gavaged over 50min. Small spits. Abd benign. Voiding,\\nno stool. Continue to work on po feed skills.\\n\\n4. Temp stable in open crib. and active with cares.\\nSwaddled. AGA.\\n\\n5. No contact from thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987250,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 19, CA 1/7 weeks.\\nIn RA - O2 sast >95%\\nRR 30-60s.\\nHR 130-150s BP 66/36 46\\n\\n\\nWt. 1880 up 25gm on 150cc/kg/d of PE or MM26 with Promod\\nFeedings well tolerated overall.\\nNormal urine and stool output.\\n\\nAssessment/plan:\\nVery nice progress overall.\\nWill continue with current management.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987182,\n \"text\": \"NPN 7p-7a\\n\\n6 Bili:\\n\\nResp: Infant remains in NC 02 100% 25-50cc flow. Ls clr/=.\\nMild ic/sc retractions. RR 50-60's. No spells or desats so\\nfar this shift. Cont to wean 02 as tol.\\n\\nFEn: Infant's wt tonoc 1.440kg (-5gms). Conts on tf 140cc/kg\\nEnteral feeds at 50cc/kg of pe 20. Increasing 10cc/kg at\\n0130&1330. IVf of pnd10w with IL via piv. Tol feeds well\\ngavaged over 20 mins. No spits minimal aspirates. Dstick 86.\\nAbd soft. Active bs. No stool thus far. Voiding with each\\ndiaper change. Cont to advance feeds as tol.\\n\\nDev: Temp stable in servo isolette. Nested in sheepskin with\\nboundries in place. Likes pacifier. Irritable at times.\\nLikes prone postion. Cont to support developmental\\nmilestones.\\n\\n: No contact from so far this shift.\\n\\nBili: Infant conts under double phototx. AM bili pending.\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Bili:; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987183,\n \"text\": \"Neonatology Attending Progress Note\\n\\nNow day of life 4.\\nOn 100% 25-50cc of O2 RR 50-80s\\nNo apnea and bradycardia.\\nHR 120-140, BP 69/38 51\\n\\nBili 8.9/0.3\\n\\nWt. 1440gm down 5gm on 140cc/kg/d - 90ml/kg/d of PN/IL - feedings up to 50cc/kg/d of MM or PE - gavage feedings well tolerated so far - occasional non-bilious aspirates noted.\\nDS 86\\nNormal urine and stool output.\\n\\nAssessment/plan:\\nVery nice progress continues.\\nWill continue with current management with gradual increase of feedings as tolerated.\\nMonitoring for apnea/bradycardia.\\nAwaiting further word on father's diagnosis of hepatitis.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987188,\n \"text\": \"Neonatology-NNP PRogress Note\\\\\\n\\nPE: in her isolette, in room air, (recently out of nc) bbs cl=, rrr s1s 2no murmur,abd soft, nontender, cord drying, V&S, nested, peripheral iv and gavage tube in\\n\\nUpdated at bedside\\n\\nSee attending note for plan\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987189,\n \"text\": \"NPN DAYS\\n\\n\\nRespiratory: Remains on NC 13cc Fio2 100%. Trialed in room\\nair x2 hours and failed r/t frequent drifts of sats. LS\\nclear and equal. IC/SC retractions. No spells. No caffeine.\\nWill continue to monitor.\\n\\nFluids: TF 150cc/kg/day. 80cc/kg/day PE20/BM20. 70cc/kg/day\\nPND10 via PIV in right leg. Increasing feeds by 10cc/kg/.\\nTolerating feeds. Belly benign. No spits. Urine output\\n3.6cc/kg/day. No stool. D/S 103. Will continue to increase\\nfeeds as tolerated.\\n\\nDevelopment: Temp stable in servo isolette. Awake and alert\\nwith cares. Sleeps well between cares. Likes her pacifier.\\nWill continue to support developmental needs.\\n\\n: in for 1pm cares, held baby. Asking\\nlots of questions. Will continue to provide teaching and\\nsupport.\\n\\nBili: Remains under single phototherapy. Will check bili\\ntonight.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987251,\n \"text\": \"Neonatology - NP Physical Exam\\nAwake and with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes, Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987252,\n \"text\": \"NPN 1500\\n\\n\\n#2 Resp: Infant remains in RA, no desats or brady spells. RR\\n40-70. Br. snds clear, = bilat.\\nA: Stable in RA w/o spells.\\nP: Cont to monitor for desats or bradys.\\n#3 F/N: Infant continues on 150cc/kg/d PE26/BM 26 w/ promod,\\n47cc q 4 hrs. Infant bottled well 25cc @ 0930 this AM. Abd\\nbenign, voiding well, no stool today. Tolerates gavage feed\\nw/o spits.\\nA: Tol. feeds, learning to po/breast feed.\\nP: Cont to monitor for s/s of feeding intolerance.\\n#4 Dev.: Infant maintaining temp well in an open crib. Awake\\nand w/ cares. Swaddled and positioned prone.\\nA: AGA\\nP: Cont dev. supports.\\n#5 : No contact thus far on shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987180,\n \"text\": \"Neonatology - NNP PRogress Note\\n\\n is active with good tone. AFOF. Head ultrasound today normal. She is pink, well perfused, no murmur auscultated. She remains in NCO2 25-75ccs/100%. Moderate retractions, breath sounds diminished on left side. CXR today clear.Total fluids @ 140cc/kg/day. PN/IL infusing via PIV. She is tolerating advancing feeds. Abd soft, active bowel sounds, no loops. Voding and stooling. Mod jaundice under single phototherapy. Bili today 11.5/0.2. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987181,\n \"text\": \"Rehab/OT\\n\\nMet at the bedside. Discussed the role of OT, infant stress signals, and ways to maximize infant comfort. Posted care plan at the bedside. Please refer to care plan for recommendations. OT to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987190,\n \"text\": \"NPN 7p-7a\\n\\n\\n#1 Remains in 13cc of 100% O2 via NC. BBS clear and =. Mild\\nretractions present. No bradys or desats. A: small O2 need\\npersists P;Follow\\n\\n#3 TF's presently at 95cc/k. IV leaking ~ 0045. NNP\\nRivers advance feeds 15cc/k and leave IV out. Receiving\\n24cc of PE20 Q 4hrs on a pump over 30 mins. No spits or\\naspirates. Abdominal exam unremarkable. Voiding. No stool\\npassed overnoc yet. A: tolerating feeds P: Advance feeds\\n15cc/k and follow weight\\n\\n#4 Isolette weaned x 1 for warm temp. Fiesty with cares.\\nNested on sheepskin with boundaries in place. Sleeps fairly\\nwell. A: AGA P: Support developmental needs\\n\\n#5 No contact.\\n\\n#6 Remains under single phototherapy. Am bili 6.1/.3-down\\nfrom 8.4/.3. Working up on feeds. No stool. A: bili\\ndecreasing P: f/u with team\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987191,\n \"text\": \"Atttending Note\\nDay of life 6 CGA 33 \\nnasal cannula 13-25 cc RR 50-60 mild retractions\\nlungs clear\\nno murmur 120-140 71/36 mean 55\\nbili 6.1/0.3 still on single phototherapy\\n1500 up 95 grams on 95 cc/kg/day of enteral adv 15 cc/kg/day\\nBM 20 PE 20\\nservocontrolled isolette\\n\\nimp-needs to wean from nasal cannula\\nas tolerated\\nwill discontinue photo and recheck rebound in am\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987192,\n \"text\": \"Nursing Progress Note\\n\\n\\n#2-O/A- Recieved infant on NCO2 100% 25cc. Infant remains\\non NCO2. No resp distress. No A's or B's. P- Cont to\\nassess for Resp needs.\\n#3-O/A- TF=110cc/kg/d of BM/PE20 via NGT. Abd exam benign.\\n Voiding, no stool so far this shift. Tol feeds. P- Cont\\nto assess for FEN needs.\\n#4-O/A- cont to be awake and active with cluster\\ncares q4hrs. Sleeps well between cares. Temp stable in\\nheated isolette. Sucks on pacifier. P- Cont to assess for\\nG&D needs.\\n#5-O/A- in to visit with updates given. Mom held\\n. interaction. P- Cont to enc parental calls\\nand visits.\\n#6-O/A- Photo d/c this am for bili= 6.1, 0.3. Plans to\\ncheck bili in am. P- Cont to assess for\\nHyperbilirubinemia.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987199,\n \"text\": \"progress note\\nAgree with note by Dr. .\\nDay of life 8 CGA 33 week\\ntransition from nasal cannula to room air last night\\nno spells\\nweight 1520 gram up 35\\non 150 cc/kg/day of PE/BM 20 cal/oz\\npo/pg\\n\\nImp-overall making good progress\\nwill increase to 24 cal/oz and\\ncontinue to encourage po feeds\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987200,\n \"text\": \"progress note\\nd8 corrected 33 wks\\nnc to RA last night - ok\\nno spells\\n\\n57/33 (38)\\n1520g (up 35)\\ntf 150 pe/ bm 20 gavage\\n\\n\\nexam:\\nafof\\nbs clr\\nno murmur\\nabd soft\\nwell perfused\\npink\\nslightly jaundice\\n\\na/p:\\nprematurity\\npremature feeding pattern\\ninc to 24 cal\\nfollow juandice - resolving\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987201,\n \"text\": \"NPN DAYS\\n\\n\\nRespiratory: Remains in room air with O2 sats 96-100%. LS\\nclear and equal. No desats or spells. Mild IC/SC\\nretractions. Continue to monitor closely.\\n\\nFluids: TF 150cc/kg/day PE22/BM22, gavaging feeds over\\n50mins. Belly benign. Spit x2. Voiding and stooling. Minimal\\naspirates. Will continue with current plan of care.\\n\\nDev: Temp stable in low air isolette while swaddled. Awake\\nand alert with cares. Kangaroo'd with mom for an hour and\\ntolerated well. Will conitnue to support developmental\\nneeds.\\n\\n: in to visit. Mom participated in cares and\\nkangaroo'd. Will continue to provide support and teaching.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987202,\n \"text\": \"NPN 1900-0700\\n\\n\\n1. Resp: Infant remains in RA, maintaining her O2 sats\\ngreater than 95%. Lung sounds clear/=. RR 30-60's. Mild\\nIC/SCR. Infant had one desat to 70 with spit. No bradys\\nnoted. P: Cont. to monitor resp. status.\\n\\n2. FEN: Weight is 1540 gms up 20 gms. TF remain at 150\\ncc/kg/day of BM/PE22. Tolerating feedings well; abd exam\\nbenign, min asp, AG stable, and one spit. Voiding qs and no\\nstool noted thus far. P: Cont. to support nutritional\\nneeds.\\n\\n3. G/D: Temps stable swaddled in air-controlled isolette.\\nAlert and active with cares. Settles well in between cares.\\nAppropriately brings hands to face and sucks on pacifier to\\ncomfort self. AFSF. AGA. P: Cont. to support\\ndevelopmental needs.\\n\\n4. ; No contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987203,\n \"text\": \"progress note\\nd9 corrected 33 wks\\nra 30-60's\\none desat to 70 with spit.\\n\\n1540g (up 20)\\ntf 150 pe22 - 3 spits - increased feeding time over 1 hr\\n\\nexam:\\nafof\\nno murmur\\nbs clr\\nabd soft\\nwell perfused\\n\\na/p:\\nprematurity\\npremature feeding pattern\\nfeeding over 1 hour 20 mins\\ninc 24 cals.\\nstart fe tommorrow (.15cc qd)\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987204,\n \"text\": \"progress note\\nAgree with Dr. \\n of life 9 CGA 33 \\nstable in room air RR 30-60\\none dat with feeds\\nweight 1540 gram up 20 on\\n150 cc/kg/day of BM/PE 22\\nvoiding and stooling\\n\\nImp-overall making progress\\nstill have a lot of spits\\nwill increase feeding time and\\nconsider decreasing total fluid\\nwhile at the same time increasing\\ncalories.\\n\\ntoday will increase to 24 cal/oz\\nand increase feeds to over 1 hour 20 min\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987211,\n \"text\": \"Nursing Progress Note\\n\\n\\n#2-O/A- Received infant in RA. Infant remains in RA. No\\nresp distress. No bradys. P- Cont to assess for Resp\\nneeds.\\n#3-O/A- TF=150cc/kg/d of BM/PE24 via NGT. Abd exam benign.\\n Voiding, trace stool so far this shift. Tol feeds gavaged\\nover 1hr20min. Started on FeSO4. P- Cont to assess for\\nFEN needs.\\n#4-O/A- cont to be awake and active with cluster\\ncares q4hrs. Sleeps well between cares. Transferred to\\nopen crib, temp stable. Sucks on pacifier. P- Cont to\\nassess for G&D needs.\\n#5-O/A- called, they plan to visit at 1700. P-\\nCont to enc parental calls and visits.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987212,\n \"text\": \"npn 1900-0700\\n\\n\\n#2 resp\\npt continues in r/a with sats >97%. lsc=. mild sc/ic\\nretractions. rr 40-50's. occational drift mid 80's-low\\n90's that qsr. no spells thus far this shift.\\n#3 fen\\ntf 150cc/kg of pe24/bm24 gavaged q4hours. wt. 1.590kg\\n(+25gms). abd benign. voiding and stooling qdiaper change\\ngreen yellow stools guiac neg. lg fissure noted 6pm,\\ndesitin applied with each diaper change. spitting with each\\nfeeding small to lg amts. gavage time increased to 1hour and\\n40 minutes due to spits. minimal aspirates.\\n#4 g&d\\npt in oac with stable temps. alert and active with cares.\\nmaew. fontanelles soft and flat. sucking on binki.\\n#5 parenting\\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987213,\n \"text\": \"pregress note\\nAgree with note by Dr. \\n of life 11 CGA 34 0/7 weeks\\nstable in room air RR 40-50\\nweight 1590 up 25 grams on 150 cc/kg/day\\nof BM/PE 24 cal/oz pg\\nvoiding and stooling\\non iron\\n\\nImp-overall doing well.\\nwill continue to encourage po feeds\\nWill advance to 26 cal/oz\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987214,\n \"text\": \"pregress note\\nd11 corrected 33 wks\\nRA 40-50's\\n\\n1590g (up 25)\\ntf 150 bm24/pe24\\nmod spits\\n\\nexam: NNP\\n\\na/p:\\nprematurity\\npremature feeding pattern\\ninc. to 26 cals\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987215,\n \"text\": \"Neonatology-NNP Physical Exam\\n\\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1987216,\n \"text\": \"NPNOte;\\n\\n\\n#2.Remains in R air, BBs clear, equal, mild subcostal\\nretarctions present, no spells, occassional sat drifts to\\nmid 80's noted, QSR. A; No spells P; cont to monitor.\\n\\n#3. On Tf=150cc/kg/day, MBM26/PE26, po/pg fed , tolerated.\\ncal increased today,BS+, no loops, voided, stooled.guaic\\nnegative, A; Feeds tolerated. P; cont current feeding plan.\\n\\n#4. alert,a ctive with care, temp stable open crib,\\nco-bedding with sibling.mae. A; AGA P; cont dev support.\\n\\n#5. visited, held the baby. A; ,\\ninvolved.P; cont dev support.\\n\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":249,"numItemsPerPage":100,"numTotalItems":24993,"offset":24900,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTgzOTIwNSwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTg0MjgwNSwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.cjImSAY3MYDXZ87VpUey_5it2J4Gm6PwRlFw-BKHQZP3z16BBa7Wj-xSX0z2IKJ0dIOAtwOS95i5Uju7GkADBQ","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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6,002 | 132,134 | Patient admitted SDA for above procedure, tolerated fairly well, tranferred to PACU in stable condition, extubated, CT to suction. PACU course significant for overnight monitoring for:low O2 Sats; close hemodynamic monitoring, aggressive pulmonary toilet, pain control w/ toradol, MSO4> transitioned to MSO4 PCA, atrovent/alb nebs, electrolyte monitoring and repleatment. Hospital Course: REspiratory- Tenuous resp status post-op requiring: high O2 supplementation (no intubation) bronchoscopy (clearance of obstructed r sided plugs- removed), 6/12,( thick secretions-removed),(lung expanded- minimal secretions), for scretion clearance; atelectasis RML; aggressive pulmonary toilet; CPT, broad antibiotic coverage(zosyn started ) requiring ICU admission x 5 days. Small air leak w/ small amount of sq air started POD#5, CT remains to suction. Pt resp status improved and patient transferred to floor. Floor course 6/15-21/06 significant for: POD#6- Pt desat 88% no NRB mask> changed to shovel mask and nc for humidification, nebs given q2h w/ improvement to O2 sat 90%, EKG w/o sig changes. CT leak resolved and trial of water seal failed w/: increased CT leak, pt c/o nausea, not feeling well, no change O2 sat. REplaced to Suction w/ improvemnt in sx. CXRY -revealed partial ptx, CT to suction. POD#7- POD#9-CT to waterseal and stable until overnight. POD#9- Pt episode of chest pressure at 1am w/ CT on water seal- CXRY> right apex ptx, CT placed to suction. EKG no sig changes, enzymes-WNL. Pt stable throughout, pain resolved w/in 5 min of placing CT to suction. CT to waterseal next day POD#10, CXRY stable but w/ small LLL pneumonia w/ vancomycin added to zosyn antibiotic regimen, CT d/c'd w/stable CXRY w/ small unchanged ptx. CXRY- POD#11- ()-unchanged right ptx, small hydropneumothorax- stable,unchaged LLLpneumoniasmall amount pulmonary edema- lasix 20 mg IVP w/ good u/o result ID- Afebrile throughout hosp course. Periodically cultered for resp atelectasis.See results for culture data. Broad antibiotic coverage(zosyn started ) for total right lower lobe atelectasis/collapse. Sputum - GNR-rare. - LLL pneumonia, Vanco started until discharge then d/c. PICC line placed - CXRY palcement confimation in results section. Zosyn will cont for 1 week post discharge. Activity Tolerance- Physical Therapy following patient throughout hospital course POD#1- discharge. Initial desats' w/ activity 80's on O2, at rest 4L-100%. SEe PT note. At time of discharge-activity tolerance minimal.O2 sats w/ activity 80's on 3L. Cardiac-Patient stable, NSR; POD#6- small burst of ^ rate to 150-160 resolved spontaneously-lopressor POD#1-present cont. POD#9- Pt episode of chest pressure at 1am w/ CT on water seal- detail as above. Pain- pain control w/ MSO4 PCA transtioned to po percocet POD#6 w/ good pain control. Discharged on same Heme- Post op Hct 29- resovling- and stable. Physical Therapy following patient throughout hospital course POD#1- discharge. | EASILY PALPABLE PULSES.RESP: BRONCHOSCOPY TODAY (SEE PREVIOUS NOTE). BLBS are expiratory wheezes. NPO TIL GAG REFELX POSITIVE. R CT to SX w/mod serosang output. 1x extra po lopressor admin for htn md w/min effect.SBP 110-130 after ?cleared mucus plug. Nebs admin q4hr. R CT to SX w/min serosang drainage.C/V: Nsr 80-90s. See carevue for abgs.C/V: nsr 80-90s. Low-grade temp.Neuro: Anxious.Initially A&Ox3. CXR TO BE DONE. Resp CarePt had repeat bedside bronch for mod amts thick secretions, weaned to NC, recieving nebs. rhoncherous allover, with some pleural rub. +PP.Gi/Gu: +BS. Pulm toilet admin as tol. Poor reserve, desat to 80s after act/nursing care. Briefly st low 100s. Min-adequate HUO.ID: Low grade temp. Switched to Hi- neb with slight improvement in oxygenation. A-line dampened & positional, sutured in a way that catheter kinks easily. RLL diminished, LUL cta w/occasional rhonci & LLL diminished. Received pt hypertensive (sbp 180-200), nsr 90s, sats 94% on coolneb 40% & nc 6L.Resp: Poor sats & pa02. SINUS TACHYCARDIA, SBP 120'S. Acute desat to 81%, sbp 190s, RR 30s-pt repositioned & instructed to C&DB-recovered to 96% and sbp 130s ?mucus plug. CAN GET SLIGHTLY ANXIOUS AT TIMES,IMPROVES WITH FAN,REPOSITIONING AND RSP TX.CV: PT. RESPIRATORY CARE NOTEPatient received from the PACU, acutely desaturated and placed on nebulizer with albuterol and atrovent. , RRT , RRT On po lopressor. On po lopressor. 1x ivp ativan for anxiety w/mod effect. Plan to place back on Hi- neb if tolerates. +PP. Mag repleated. PERRLA. Required fio2 increase & C&DB. Pulm toilet. Pul toilet & wean O2 as tol. Abs soft & NT. ), con't w/pulmonary toilet, deline in a.m. Nebs given as ordered, required NTS, paln to monitor resp status. Periods of desaturation continued through noc. DENTURES PLACED, MOUTHCARE GIVEN. Pt removed o2 mask & desaturated to 80s quickly. Resp CarePt had repeat bedside bronch for mod amts thick yellow. S/P flex bronch, cervical mediastinoscopy, & vats RUL wedge->complete RUL lobectomy & lymphadenectomy on . Decreasing right pneumothorax. Moderate-sized right apical pneumothorax, status post right upper lobectomy. The right chest tube has been removed. A moderate-sized right apical pneumothorax is present. FINDINGS: Since the previous examination, the right-sided chest tube has been partially withdrawn. The right chest tube position is unchanged, kinking in its upper portion. Small right pneumothorax is still present. A right-sided chest tube is present which is kinked towards the apex. The right-sided chest tube has been repositioned more superiorly within the right hemithorax. There is a right chest tube which demonstrates a focal bend near the apex. Post-surgical changes remain present in the right hemithorax. The right small apical pneumothorax is unchanged. Sinus tachycardia.Early precordial QRS transition - is nonspecificModest nonspecific ST-T wave changesSince previous tracing of , QRS voltage less prominent, ST-T waveabnormalities decreased and less suggestive of prior inferior myocardialinfarction There is associated partial right lung collapse. Unchanged small right pneumothorax. Deformity of the right humeral head with advanced right glenohumeral osteoarthritis is again noted. .resp: ls rhoncherous thru out although left side seemed clearer at beginning of shift. Left lower lobe patchy atelectasis is present. Additionally, subtle heterogeneous opacification overlying the right mid lung field likely represents atelectasis. Right pleural tube unchanged in position. INDICATION: Chest tube removal. Question air in right chest. The chest tube appears kinked towards the apex. FINDINGS: There is worsening of the right apical pneumothorax since the most recent study. The right pneumothorax has decreased in size, with associated improvement in right lung aeration. There is a new right PICC with tip at the junction of the superior vena cava and the right atrium. Worsening of the right lower lobe atelectasis. There is a small to moderate right pneumothorax, slightly increased compared to the previous study. The right lung aeration is stable with unchanged interstitial widespread markings. Unchanged bilateral subcutaneous emphysema. air in righ chest FINAL REPORT INDICATION: Status post right VATS with severe atelectasis and CT to waterseal. Slight improvement in right apical pneumothorax. The right lower lobe atelectasis has been markedly resolved. Persistent volume loss with elevation of the right hemidiaphragm and shift of the mediastinal structures to the right remained status post right upper lobectomy. INDICATION: Right upper lobectomy. UPRIGHT AP VIEW OF THE CHEST: The moderate-sized right apical pneumothorax has decreased in size, and likely a small residual pneumothorax is present. FINDINGS: Since the previous examination, the right-sided chest tube has been repositioned with tip now terminating along the lateral aspect of the right upper lobe. IMPRESSION: 1) Stable small right pneumothorax. 2) New mild pulmonary edema. Decreased right pneumothorax following repositioning of right-sided chest tube. Decreasing size of small right apical pneumothorax. FINDINGS: There has been interval improvement in the previously described areas of right-sided atelectasis. Single right-sided chest tube is again demonstrated, tip overlying the superior right hilum. IMPRESSION: Unchanged moderate right pneumothorax. The right chest tube postion is changed with less kinking now. There is worsening atelectasis in the remaining portion of the right lung, with only a small amount of residual aerated lung adjacent to the right hemidiaphragm. Lateral view shows persistent small right pleural effusion. Subcutaneous emphysema within the right lateral chest wall is stable. IMPRESSION: AP chest compared to and 14: Appreciable atelectasis and generalized edema persist in the postoperative right lung. IMPRESSION: PA and lateral chest compared to through 16 shows continued small right apical pneumothorax despite the right apical pleural tube and stable congestion in the right lung, though atelectasis at the base has improved. There has been slight decrease in size of the right apical pneumothorax. The right PICC tip is in the lower SVC. Worsening right lung atelectasis. IMPRESSION: 1) Moderate right pneumothorax is stable in size with a new hydrothorax component. Moderate right apical and anterior pneumothorax is unchanged in size, but a new hydrothorax component is now present. UPRIGHT AP VIEW OF THE CHEST: Right chest tube remains in place, and a small right pneumothorax is stable. | 43 | [
{
"category": "Nursing/other",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 1341233,
"text": "Neuro: pt oriented to person only at start of shift, oriented X 3 later in the day, medicated with morphine IVP for pain with good effect X2, OOB to chair X1, MAE's well but is weak, two person moderate assist OOB, currently sleeping\n\nCardiac: NSR no ectopy, BP stable, dipped slightly after brochosopy D/T verses\n\nResp: Resp distress at 0800, notified thoracic team, NT suctioned, CPT, lasix, bronch, @ PCXR's, suctioned out alot of mucous and a large blood clot, SPO2 much better, ABG better, pt looks comfortable, breathing not laborous, denies SOB, resp TX's per and flowsheet, lungs coarse throughout except RUL with no/diminished BS's, CT's to suction, no leak, draining serous fluid, quantity varies from 0 to 60 cc/hr, greater output after turning pt\n\nGI: + BS, no flatus, no BM, poor appetite\n\nGU: foley to gravity draing clear yellow urine, quantity borderline 20's to 30's, lasix with good results\n\nPlan: continue to pulmonary toilet and RX's, monitor vitals and labs and treat as indicated, encourage pt to cough and DB and use IS, keep HOB > 45, ? transfer to 2 tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 1341234,
"text": "Resp: pt became restless and aggitated, pulling O2 off, attempting to get OOB, SPO2 drifting down, CT with new air leak, Dr. notified, Resp TX given with good results, breathing more relaxed and SPO2 > 95%, air leak resolved\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 1341235,
"text": "Patient desaturated this AM treated with Albuterol.Bronchoscopic procedure done due to CXR result (R)lung white out.Done well post bronch,procedure may be repeated in AM.Now on Hi- 60% sat 95-100%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-13 00:00:00.000",
"description": "Report",
"row_id": 1341236,
"text": "Nursing 7p-7a\nNeuro: A&Ox3, initally confused about the events of the day. Became a&ox3. MAE. stand & pivot from chair to bed w/1 assist, tol fair. Slept most of shift. ivp morphine for c/o R flank pain (ct insertion site).\n\nResp: Remained on hi-, able to wean down to 60% briefly. Pt removed o2 mask & desaturated to 80s quickly. Required fio2 increase & C&DB. Weaning fio2 again, currently 80%. Nebs admin q4hr. Lungs coarse throughout except RUL. Poor tolerance for chest pt. Pulm toilet admin as tol. Desats to mid 80s after nursing care/any act (including swallowing)- requires about 15 min at rest for sats to improve. R CT to SX w/min serosang drainage.\n\nC/V: Nsr 80-90s. Briefly st low 100s. On po lopressor. No ectopy. SBP high 80s-130, 80s when asleep. A-line dampened & positional, sutured in a way that catheter kinks easily. +PP.\n\nGi/Gu: +BS. No BM/flatus. Na+ remains slightly low, but trending up. RISS for blood sugars. Min-adequate HUO.\nID: Low grade temp. WBC slightly elevated.\nSocial: Daughter called, updated by RN.\n\nPlan: CXR in am, re-eval need for repeat bronch. Pulm toilet. Increase diet/act as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 1341231,
"text": "Nursing 7p-7a\nAdmitted from PACU to CSRU @ 1900 for poor o2/ pulm toilet. S/P flex bronch, cervical mediastinoscopy, & vats RUL wedge->complete RUL lobectomy & lymphadenectomy on . Received pt hypertensive (sbp 180-200), nsr 90s, sats 94% on coolneb 40% & nc 6L.\n\nResp: Poor sats & pa02. Switched to hi- w/slight improvement in sats & pao2 increased to 73. Poor reserve, desat to 80s after act/nursing care. hi- increased gradually, as needed, to 95%. Changed to cont alb neb w/improvement in sats to 96%. MD aware. Acute desat to 81%, sbp 190s, RR 30s-pt repositioned & instructed to C&DB-recovered to 96% and sbp 130s ?mucus plug. RLL diminished, LUL cta w/occasional rhonci & LLL diminished. R CT to SX w/mod serosang output. No airleak or crepitus. See carevue for abgs.\n\nC/V: nsr 80-90s. No ectopy. Mag repleated. HTN sbp 180-210 initially. On po lopressor. 1x extra po lopressor admin for htn md w/min effect.SBP 110-130 after ?cleared mucus plug. +PP. Low-grade temp.\n\nNeuro: Anxious.Initially A&Ox3. Acute confusion (after iv morphine admin), pt unaware that she was at the hospital & had surgery. Needed frequent re-orientation to place/time. Currently Ox2 w/occasional need for reorientation to place. PERRLA. MAE. OOB to chair x2.5hr w/2 assist. 1x ivp ativan for anxiety w/mod effect. ivp toradol for pain.\n\nGi/Gu: reg diet, swallows thin liquids well. +BS x4. Abs soft & NT. Adequate HUO. RISS for blood sugars.\nSkin: See carvue for incisions.\nSocial: Daughter called, updated by RN.\n\nPlan: Monitor resp status. Pul toilet & wean O2 as tol. Increase act/diet as tol. Pain management. Reorientation/support given as needed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 1341232,
"text": "RESPIRATORY CARE NOTE\n\nPatient received from the PACU, acutely desaturated and placed on nebulizer with albuterol and atrovent. Switched to Hi- neb with slight improvement in oxygenation. BLBS are expiratory wheezes. Placed on continuous nebulizer and 6 lpm nasal cannula with good effect. Desaturates with any movement or speaking. Plan to place back on Hi- neb if tolerates.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1341246,
"text": "nursing note:\n\nneuro:a&ox3, mae's, oob to chair x 2, ambulate to w/pt x 1, appears more relaxed today not pulling off mask or tugging at clothes, given morphine 1 mg for pain mainly c/o right shoulder pain\n\n\nresp: weaned to 6l/nc sat>96%, rr wnl, bronched this morning minimal secretions removed, rhonchi throughout, @ times productive cough but mainly non-productive, given inhalers by respiratory, chest PT done, needs encouragement and reminder when using IS reaching volumes of 250 to 500cc when done properly\n\ncv: hr 90-100 nsr, sbp > 120's, aline very positional, palpable pulses, minimal drainage of ct, abg done @ 1800 results pnding along w/lytes\n\n\ngu/gi: hypobowel sounds, npo until 1600 late lunch/dinner given increased appetite today, boost given per orders, foley w/minimal UO 25-30cc/hr, abdomen soft & non-tender, no bm\n\nendo: ssri\n\nsocial: family in to visit\n\nplan/goal: transfer to 2 per thoracic awaiting bed transfer orders not done, increase activity & diet as tolerated (thoracic would like ambulte t.i.d.), con't w/pulmonary toilet, deline in a.m.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1341247,
"text": "Resp Care\nPt had repeat bedside bronch for mod amts thick secretions, weaned to NC, recieving nebs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 1341241,
"text": "nursing note (7a-7p):\n\nneuro: a&ox 2 to 3, patient desats w/increased anxiety & attempts to climb oob, no sedation meds to be given per Dr. ... Patient OOB x 1 to chair, ambulate x 1 w/PT, 2 person walk unsteady legs\n\nresp: on cool neb w/sat >96% when on quickly desats to 80's when removed, bronched this morning moderate secretions removed, rr 15- 20, lungs rhonchi & expiratory wheeze given nebs by respiratory,\n\ncv: hr 80 to 90's w/no ectopy, sbp >120, when ambulated CT put out 200cc of drainage, palpable pulse, pneumo boots\n\ngu/gi: increased diet to regular w/boost, foley removed d/t 1700 has not voided, bladder not distended receiving minimal fluids, +BS w/no BM\n\nendo: covered by ssri\n\nplan/goal: con't pulmonary toilet, increase diet and activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 1341242,
"text": "Resp Care\nPt had repeat bedside bronch for mod amts thick yellow. Nebs given as ordered, required NTS, paln to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 1341243,
"text": "addendum: air leak in ct, subcutaneous emphysema noted bilaterally, aware, stat cxr done @ 1830, ct placed back to suction, awaiting plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1341244,
"text": "csru update\ndegree of crepitus present on both anterior/posterior chest extending to the neck unchanged overnight, rpt cxr showed \"worse\" rll, even after ct back to suction. nt suctioned to copious bloody thick secretions, pt also able to expectorate some secretions after pain meds. tachypneic, complaining of \"horrible agonal pain\", temporarily relieved by morphine sc. breathing pattern now regular after 3rd dose of morphine, cough effort stronger. rhoncherous allover, with some pleural rub. abg initially hypoxemic, po2 to 50s, now wnl after pt more comfortable and pain controlled. hypertensive up to 200mmhg when agitated and in pain, sbp to 90s when asleep. NSR-ST, isolated pvc's. ao x3, can change position independently. slept well after pain controlled, sao2 maintained at 100% on 60% hiflow. kept npo, small ice chips given. foley reinserted, bolus 250cc LR for borderline uop. pressure areas intact, family visited, talked to dr \n\nplan: bronch today\n keep ct to suction, pulmonary toilet\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1341245,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains on 60% Hi- nebulizer and treated with q4 albuterol and atrovent nebulizers. Periods of desaturation continued through noc. Sxn x1 for copious amount thick bloody secretions. Plan to continue nebs, nts when needed, and hi- neb.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-13 00:00:00.000",
"description": "Report",
"row_id": 1341237,
"text": "PATIENT NPO FOR BRONCH, CXR REVEALED NEED FOR BRONCH D/R RLUNG WHITE OUT, LOTS OF THIVK BROWN/BLOODY SECRETIONS OBTAINED DURING BRONCHO, SPUTUM SENT FOR CULTURE. PATIENT TOLERATED PROCEDURE FAIRLY WELL, PLACED ON 100% DURING PROCEDURE. PER POST PROCEDURE PLACED IN CHAIR WITH 2MAN ASSIST WITH MODERATE ASSIST. INTO CHAIR ONCE SETTLED PLACED BACK ON 60%. DENTURES PLACED, MOUTHCARE GIVEN. NPO TIL GAG REFELX POSITIVE. CXR TO BE DONE. ALSO ANTIBIOTIC THERAPY TO BE STARTED D/T CXR PER . PATIENT RESTING COMFORTABLE IN CHAIR, FAN ON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-13 00:00:00.000",
"description": "Report",
"row_id": 1341238,
"text": "NEURO: PT. A&OX3, TRANSFERS FROM BED TO CHAIR EASILY WITH ASSIST X2, PT. CAN GET SLIGHTLY ANXIOUS AT TIMES,IMPROVES WITH FAN,REPOSITIONING AND RSP TX.\n\nCV: PT. SINUS TACHYCARDIA, SBP 120'S. NO ECTOPY NOTED. PT. HAS NOT RECEIVED LOPRESSOR DUE TO LACK OF GAG NP. EASILY PALPABLE PULSES.\n\nRESP: BRONCHOSCOPY TODAY (SEE PREVIOUS NOTE). PT. LUNG SOUNDS COARSE IN UPPER LOBES AND COARSE TO DIMINISHED IN LOWER. PT. EXPECTORATES LIGHT YELLOW TO BLOOD TINGED SPUTUM. PT. CONTINUES NEGATIVE GAG REFLEX 6 HRS AFTER BRONCHOSCOPY.NPO NP BECOMES TACHYPNIC WITH ANXIETY, TAKES OFF O2 MASK AND O2 SATS DECREASE. CT DRAINING SEROSANG DRAINAGE- MINIMAL AMT. IS WITH VOLUMES 250CC WITH ENCOURAGMENT\n\nGI/GU/ENDO: PT. ABD SOFT, PRESENT BOWEL SOUNDS, NONTENDER. PT. DRAINING CLEAR-SEDIMENT YELLOW URINE IN FOLEY. GOOD H/U/O. PT. ON RISS PER CSRU PROTOCOL.\n\nA/P: CONTINUE PULMONARY HYGIENE, CONTINUE TO MONITOR HEMODYNAMICS, ENCOURAGE DB/C AND IS. ADVANCE ACTIVITY AND DIET AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-13 00:00:00.000",
"description": "Report",
"row_id": 1341239,
"text": "Resp Care\nPt remains on hi- O2. Pt had bedside bronch, sx mod thick, bloody plugs. Nebs given q4, BS remain I/E wheezes. Paln to continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 1341240,
"text": "npn\nneuro: pt aox3 a few episodes of increased anxiety r/t to pt's breathing status, last epiosde at 315 am pt very anxious, difficult to calm her. pt became increasingly agitated making her resp status worse. ativan, morphine etc given as well as neb tx x2. pt finally settled down, rr wnl, resting comofrtable, pt does not tolerate turning\npain: c/o bakc pain for which pt received total of 5mg oxycodone x1 due to receiving tylenol at 1800. morphine given at 315 am with resp ditress with good effect\n\ncad hr 70 to 80's sr no ectopy noted, aline positional, drsg , 92/42 while asleep to 142/87, systolic into the 170-150's with anxiety. .\n\nresp: ls rhoncherous thru out although left side seemed clearer at beginning of shift. pt encouraged to db&c which she is clearing very little secretions. fio2 decreased to 45%, sats 92 to 99%. am abg 7.41/42/70. rr 20 to 30's.\n\ngi: bs+ no bm this shfit, taking po fluids and her pilss without difficulty.\n\ngu: uo varying 50 to 300cc/hr. pt is 2400 negative for los. am K+ 3.9\n\nid:afebrile, wbc 11.5 decreased from 14.8, continues on antibiotics.\n\nendo: bs 130 to 100's ssi given prn.\n\nsocial: no calls overnight, daughter visited last evening.\n\nplan: ? poss bronch today at bedside, cont to monitor vs. labs, resp status, provide emotional suppport to pt as needed.\n"
},
{
"category": "ECG",
"chartdate": "2148-05-20 00:00:00.000",
"description": "Report",
"row_id": 198806,
"text": "Sinus rhythm\nLateral ST-T changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 198807,
"text": "Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy with\nsecondary ST-T wave abnormalities. Compared to the previous tracing of \nthe voltage is slightly more prominent. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-12 00:00:00.000",
"description": "Report",
"row_id": 198808,
"text": "Sinus tachycardia.\nEarly precordial QRS transition - is nonspecific\nModest nonspecific ST-T wave changes\nSince previous tracing of , QRS voltage less prominent, ST-T wave\nabnormalities decreased and less suggestive of prior inferior myocardial\ninfarction\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916639,
"text": " 7:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? collapsed lobe\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, now with de-sat. Please do at 8pm\n\n REASON FOR THIS EXAMINATION:\n ? collapsed lobe\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient with previous right upper lobe\n lobectomy and desaturations.\n\n Portable AP chest radiograph compared to . The right small apical\n pneumothorax is unchanged. The right lung aeration is stable with unchanged\n interstitial widespread markings. The post-surgical changes in the right\n hemithorax are stable. Focal left lower lung opacity is unchanged and could\n represent developing pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 916771,
"text": " 3:35 PM\n CHEST (PA & LAT) Clip # \n Reason: assess lung expansion, for effusions\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS, now with chest tube removed\n REASON FOR THIS EXAMINATION:\n assess lung expansion, for effusions\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Previous study of at 1431.\n\n INDICATION: Chest tube removal. Pneumothorax.\n\n There is a small to moderate right pneumothorax, slightly increased compared\n to the previous study. There is associated worsening atelectasis in the right\n lung adjacent to the pneumothorax. There is otherwise no change from the\n recent radiograph of less than one hour earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915823,
"text": " 6:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? air in righ chest\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy and CT to water seal\n REASON FOR THIS EXAMINATION:\n ? air in righ chest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right VATS with severe atelectasis and CT to\n waterseal. Question air in right chest.\n\n COMPARISON: at 11:22 (seven hours prior).\n\n FINDINGS: Portable chest radiograph reviewed. There is massive subcutaneous\n air along both sides of the chest tracking into the neck and mediastinum.\n Small right pneumothorax is still present. Superior kink of the chest tube\n against the superior chest wall is unchanged in appearance. The lungs are\n clear. There are no pleural effusions. The heart and mediastinal contours are\n stable.\n\n IMPRESSION:\n 1. Extensive subcutaneous emphysema, new from a seven-hour comparison.\n 2. Unchanged small right pneumothorax. These findings were communicated to\n via at 7:20 .\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916561,
"text": " 12:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change on water seal-plaese obtain no later than 10\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS, now to waterseal with chest tube pulled back 6cm\n - placed to water seal\n REASON FOR THIS EXAMINATION:\n interval change on water seal-plaese obtain no later than 10am tx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post VATS with chest tube to water seal and pullback 6 cm.\n\n COMPARISON: Same date at 1:25 a.m.\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination, the right-sided chest tube has been\n partially withdrawn. The side-hole now terminates outside of the chest wall.\n There is interval increase in the right-sided pneumothorax and slight increase\n in subcutaneous gas within the right lateral chest wall. The heart size and\n mediastinal contours appear unchanged. Mild congestive heart failure is\n stable.\n\n IMPRESSION:\n\n 1. Increased right pneumothorax status post repositioning of chest tube and\n placement to water seal. In addition, the side-hole is outside the chest\n wall. Findings discussed with at the time of interpretation.\n\n 2. Stable mild CHF.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 916756,
"text": " 2:16 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please check placement of right med. cub. PICC line please\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, now with de-sat. Please do at\n 8pm\n REASON FOR THIS EXAMINATION:\n please check placement of right med. cub. PICC line please page IV nurse wet thanks #\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right upper lobectomy and PICC placement.\n\n COMPARISON: .\n\n CHEST: AP upright portable view. The right chest tube has been removed.\n There is a moderate right pneumothorax, increased in size compared to the\n previous study. There is associated partial right lung collapse. Left lower\n lobe opacity is unchanged. There is a new right PICC with tip at the junction\n of the superior vena cava and the right atrium. Deformity of the right\n humeral head with advanced right glenohumeral osteoarthritis is again noted.\n\n Increased pneumothorax was reported to Dr. at 3:05 p.m. on .\n PICC line position was subsequently reported to an intravenous therapy nurse.\n\n IMPRESSION:\n 1) Moderate right pneumothorax, increased since the previous study.\n 2) Satisfactory PICC position.\n 3) Unchanged left lower lobe opacity.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915851,
"text": " 12:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: c/o back pain-eval R PTX\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy and CT to water seal\n REASON FOR THIS EXAMINATION:\n c/o back pain-eval R PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after right upper lobe VATS\n lobectomy with severe atelectasis and subcutaneous emphysema.\n\n Portable AP chest radiograph compared to .\n\n Worsening of the right lung atelectasis with new consolidation and additional\n mediastinal shifting. The right chest tube position is unchanged, kinking in\n its upper portion. The large bilateral, more on the right subcutaneous\n emphysema is unchanged but the determination of a tiny residual pneumothorax\n is difficult in the presence of this emphysema. The heart size and the\n mediastinal widths are unchanged.\n\n IMPRESSION:\n 1. Unchanged bilateral subcutaneous emphysema.\n\n 2. Worsening of the right lower lobe atelectasis.\n\n 3. Small pneumothorax cannot be excluded in the presence of overlying\n subcutaneous emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915331,
"text": " 2:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumothorax\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy\n REASON FOR THIS EXAMINATION:\n Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right VATS and lobectomy.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Patient has undergone right upper lobectomy. A\n right-sided chest tube is present which is kinked towards the apex. A\n moderate-sized right apical pneumothorax is present. New sutures are seen\n along the superior aspect of the right lung. Large amount of subcutaneous\n emphysema is seen within the right lateral chest wall. Mild increased\n pulmonary vascularity reflects mild interstitial edema. Additionally, subtle\n heterogeneous opacification overlying the right mid lung field likely\n represents atelectasis. Left lower lobe patchy atelectasis is present. There\n are no effusions. The right humeral head appears abnormal in contour and may\n reflect prior fracture.\n\n IMPRESSION:\n 1. Moderate-sized right apical pneumothorax, status post right upper\n lobectomy. The chest tube appears kinked towards the apex.\n 2. Mild interstitial pulmonary edema.\n 3. Bibasilar atelectasis.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916605,
"text": " 3:40 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? chest tube placement\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, chest tube became dislodged and now\n is re-positioned. Please take at 2:30\n REASON FOR THIS EXAMINATION:\n ? chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right upper lobectomy, now status-post chest tube repositioning.\n\n COMPARISON: Four hours prior on the same day.\n\n CHEST: AP upright portable view. The right-sided chest tube has been\n repositioned more superiorly within the right hemithorax. The right\n pneumothorax has decreased in size, with associated improvement in right lung\n aeration. Post-surgical changes remain present in the right hemithorax. There\n is persistent mild congestive heart failure. A more focal opacity in the left\n lower lobe may represent developing pneumonia.\n\n IMPRESSION:\n\n 1. Decreasing right pneumothorax.\n 2. Possible developing left lower lobe pneumonia.\n 3. Unchanged mild congestive heart failure.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915481,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval atalectasis\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis on prior\n cxr Please do at 6am\n REASON FOR THIS EXAMINATION:\n eval atalectasis\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: AP chest, .\n\n HISTORY: 81-year-old woman with status post right VATS surgery.\n\n FINDINGS: There is worsening of the right apical pneumothorax since the most\n recent study. This appears similar in size to that from the study\n at 2:23 p.m. There is a right chest tube which demonstrates a focal bend near\n the apex. There is complete opacification of the remaining right lung with\n mediastinal shift and volume loss of the right side. The left lung is grossly\n clear. There is deformity to the right humeral head, likely post- traumatic in\n nature.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916460,
"text": " 7:43 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PTX, chest tube position\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, chest tube became dislodged and now\n is re-positioned.\n REASON FOR THIS EXAMINATION:\n PTX, chest tube position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:40 P.M., ON \n\n HISTORY: Status post VATS, right upper lobectomy.\n\n IMPRESSION: AP chest compared to 6:22 p.m. today and :\n\n Small right pneumothorax has decreased in volume since 6:22 p.m.\n Postoperative right lung remains congested. There is residual edema at the\n base of the hyperinflated left lung. Borderline cardiomegaly is stable.\n Right pleural tube unchanged in position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916274,
"text": " 10:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PTX. Please perform at 11pm, thanks.\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, chest tube repositioned and put to\n water seal.\n REASON FOR THIS EXAMINATION:\n PTX. Please perform at 11pm, thanks.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:55 \n\n HISTORY: Status post right upper lobectomy.\n\n IMPRESSION: AP chest compared to and 16:\n\n Atelectasis and congestion in the post-operative right lung have worsened\n again. Small right apical pneumothorax is larger. Subcutaneous emphysema\n persists in both sides of the chest. Moderate cardiomegaly has progressed.\n Left lung is clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915497,
"text": " 11:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: atelectasis\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy am\n REASON FOR THIS EXAMINATION:\n atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n HISTORY: Status post bronchoscopy\n\n FINDINGS: There is a moderate-sized right apical pneumothorax, which has\n slightly improved since the study from 3 hours earlier. There is a right\n apical chest tube which has an acute bend near the apex. There is\n consolidation within the right upper lobe, likely atelectasis. There is also\n mediastinal shift of the heart to the right side secondary to the volume loss.\n There is improved aeration at the right base since the earlier study. The\n left lung remains clear.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 916846,
"text": " 8:41 AM\n CHEST (PA & LAT) Clip # \n Reason: Change in size of PTX\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS, now with increased PTX after chest tube removal\n\n REASON FOR THIS EXAMINATION:\n Change in size of PTX\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Status post right upper lobectomy with pneumothorax.\n\n COMPARISON: at 7:16 p.m.\n\n CHEST: PA and lateral views. Moderate right apical and anterior pneumothorax\n is unchanged in size, but a new hydrothorax component is now present. New mild\n pulmonary edema is also noted. Mild cardiac enlargement is unchanged. Left\n lower lobe pneumonia and right perihilar postsurgical changes are also\n unchanged. Findings were discussed with Dr. at 11:15 a.m. on .\n\n IMPRESSION:\n 1) Moderate right pneumothorax is stable in size with a new hydrothorax\n component.\n 2) New mild pulmonary edema.\n 3) Unchanged left lower lobe pneumonia.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916452,
"text": " 5:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Tube placement, PTX\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, pulled chest tube half way out in\n agitation.\n REASON FOR THIS EXAMINATION:\n Tube placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:22 \n\n HISTORY: Status post VATS right upper lobectomy.\n\n IMPRESSION: AP chest compared to :\n\n Small right apical pneumothorax has increased in volume. A subsequent chest\n radiograph at 7:40 p.m. today dictated previously shows subsequent decrease in\n size of this pneumothorax.\n\n Vascular congestion persists in the right lung and there is residual edema at\n the base of the left. No appreciable right pleural effusion. The basal\n pleural tube is probably extrathoracic in the subcutaneous tissue. Heart size\n top normal, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916493,
"text": " 1:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Placement of chest tube\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, chest tube became dislodged and now\n is re-positioned.\n REASON FOR THIS EXAMINATION:\n Placement of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobectomy, repositioning of chest tube\n after dislodgement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination, the right-sided chest tube has been\n repositioned with tip now terminating along the lateral aspect of the right\n upper lobe. Small right apical pneumothorax is decreased in size in the\n interval. There is stable borderline cardiomegaly. Bilateral linear\n opacities within the right lung at the left base likely representing pulmonary\n edema, superimposed upon baseline emphysema, appear unchanged. Chain sutures\n are seen in the right upper lobe.\n\n IMPRESSION:\n\n 1. Decreased right pneumothorax following repositioning of right-sided chest\n tube.\n\n 2. Stable borderline cardiomegaly and probable pulmonary edema superimposed\n upon underlying emphysematous change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916790,
"text": " 7:03 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : assess lung expansion, please do at 7pm\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS RUL lobectomy, now with chest tube removed with\n post removal PTX slightly increased in size\n REASON FOR THIS EXAMINATION:\n assess lung expansion, please do at 7pm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right upper lobectomy with pneumothorax.\n\n COMPARISON: at 3:06 p.m.\n\n CHEST: AP upright portable view. The moderate right pneumothorax is\n unchanged. Left lower lobe opacity consistent with pneumonia and right\n perihilar postoperative changes are also again noted. The right PICC tip is\n in the lower SVC.\n\n IMPRESSION: Unchanged moderate right pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915582,
"text": " 11:41 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess lung expansion, for infiltrates\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy , s/p bronchoscopy AM\n REASON FOR THIS EXAMINATION:\n assess lung expansion, for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: Status post right VATS, right upper lobectomy, atelectasis, and\n status post bronchoscopy.\n\n COMPARISON: .\n\n FINDINGS: There has been interval improvement in the previously described\n areas of right-sided atelectasis. A right chest tube is in stable position.\n There has been no significant interval change in the right apical\n pneumothorax. There may be marginal improvement in the peripheral left base\n opacity. No other significant changes are identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916106,
"text": " 7:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for expansion\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis\n s/p bronchoscopy and CT to water seal, now w/desat to low 80's,\n distress\n REASON FOR THIS EXAMINATION:\n assess for expansion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:40 \n\n HISTORY: 81-year-old woman, right VATS, right upper lobectomy.\n\n IMPRESSION: AP chest compared to and 14:\n\n Appreciable atelectasis and generalized edema persist in the postoperative\n right lung. Particularly dense consolidation at the lung base, which\n developed between and 14 is either atelectasis or hemorrhage. Small\n right apical pneumothorax has increased and the right pleural tube which is\n sharply folded at the apex might not be fully functional. Subcutaneous\n emphysema on both sides of the chest running into the neck has improved.\n Moderately enlarged cardiac silhouette has increased. Left lung however is\n essentially clear. was paged to report these findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915566,
"text": " 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung expansion\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy am\n REASON FOR THIS EXAMINATION:\n assess lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Right upper lobectomy. Atelectasis.\n\n A right chest tube remains in place. There has been slight decrease in size\n of the right apical pneumothorax. There is worsening atelectasis in the\n remaining portion of the right lung, with only a small amount of residual\n aerated lung adjacent to the right hemidiaphragm. The left lung is\n overexpanded. There is a developing area of opacification in the periphery of\n the left lower lobe.\n\n IMPRESSION:\n 1. Worsening right lung atelectasis.\n 2. Slight improvement in right apical pneumothorax.\n 3. Worsening peripheral left lower lobe opacity, possibly due to pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916185,
"text": " 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung expansion, infiltrates, effusions\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS rulobectomy, now to waterseal\n REASON FOR THIS EXAMINATION:\n assess lung interval change, ptx on water seal b/w 10-11a,\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for interval changes in a patient with\n pneumothorax after right upper lobe lobectomy.\n\n Portable AP chest radiograph compared to done at 19:40 p.m.\n\n The right chest tube postion is changed with less kinking now. The right\n lower lobe atelectasis has been markedly resolved. The right lung\n interstitial markings are most probably due to re-expansion edema. The apical\n pneumothorax has been decreased. There is no significant change in\n subcutaneous emphysema.\n\n The left lung is unremarkable and there is no left pleural effusion.\n\n IMPRESSION: Better position of the right chest tube with almost complete\n resolution of atelectasis on the right and re-expansion edema of the pulmonary\n tissue.\n\n Decreased, tiny apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 916333,
"text": " 2:21 PM\n CHEST (PA & LAT) Clip # \n Reason: assess chest tube position, PTX\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman S/P VATS, now to waterseal with chest tube pulled back 6cm\n\n REASON FOR THIS EXAMINATION:\n assess chest tube position, PTX\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON .\n\n HISTORY: Status post VATS. Chest tube to waterseal.\n\n IMPRESSION: PA and lateral chest compared to through 16 shows\n continued small right apical pneumothorax despite the right apical pleural\n tube and stable congestion in the right lung, though atelectasis at the base\n has improved. Mild edema is also seen in the severely emphysematous left\n lung. Heart size top normal. Lateral view shows persistent small right\n pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915743,
"text": " 10:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, with severe atalectasis s/p\n bronchoscopy and CT to water seal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobectomy and VATS with severe\n atelectasis. Bronchoscopy on with chest tube to waterseal.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Right chest tube remains in place, and a small\n right pneumothorax is stable. Increasing heterogeneous opacity within the\n right upper lung may reflect increasing atelectasis, post-surgical change,\n and/or worsening pulmonary edema. Patchy opacity present within the left lung\n base may reflect atelectasis. Persistent volume loss with elevation of the\n right hemidiaphragm and shift of the mediastinal structures to the right\n remained status post right upper lobectomy. Increased pulmonary vascularity\n is consistent with increasing pulmonary vascular congestion. Osseous\n structures are unchanged.\n\n IMPRESSION:\n 1) Stable small right pneumothorax.\n\n 2) Worsening opacity in the right lung may reflect worsening atelectasis,\n post-surgical change, or asymmetric pulmonary edema.\n\n 3) Patchy opacity in the left lower lobe may be due to atelectasis, but\n pneumonia cannot be excluded.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915350,
"text": " 3:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p R VATS/RUL lobectomy, sudden decrease in O2 sat\n\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right VATS and upper lobectomy with sudden decreasing\n oxygen saturation.\n\n COMPARISON: , at 14:23.\n\n UPRIGHT AP VIEW OF THE CHEST: The moderate-sized right apical pneumothorax\n has decreased in size, and likely a small residual pneumothorax is present.\n Single right-sided chest tube is again demonstrated, tip overlying the\n superior right hilum. There is increasing volume loss within the right lung\n with shift of the mediastinal structures towards the right and tenting of the\n right hemidiaphragm. Additionally, increased opacification within the right\n mid lung field reflects increasing atelectasis and postoperative change.\n Subcutaneous emphysema within the right lateral chest wall is stable. The\n left lung is clear. No definite effusions are present.\n\n IMPRESSION:\n 1. Decreasing size of small right apical pneumothorax.\n 2. Increased opacification in right mid lung field and volume loss, findings\n likely representing worsening atelectasis, and possibly postoperative changes.\n\n DFDdp\n\n"
}
] |
13,407 | 136,790 | Pt calm whike dtr. Trivial mitral regurgitation is seen. D.H. tube repositioned in fluro, not post-pyloric. Nowe q 24hrs and Pt still receiving decadron. Moderate regional LV systolicdysfunction. Resp Care Note, Pt remains on current vent settings. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets. CV: Remains in nsr, rare pac's. Resp: Ls clear to coarse bilat throughout. Palpable DP/PT pulses bilaterally. 0cc residual from NGT.GU: Foley to gravity. Left upper extremity US done. STATUSD: NEURO STABLE..FOLLOWS SIMPLE COMMANDS..FIBRILE OTHER VSSA: NO VENT CHANGES..SUCTIONED FOR COPIOUS AMT THICK TAN/PURULENT SECREATIONS>>BRONKED FOR COPIOUS AMT OF SAME & SPEC SENT FOR CULTURE LASIX X1 WITH GOOD EFFECT..NA PHOS REPLETED..TOL TF'S WELL..1 LGE SOFT BROWN STOOL..C/O NECK PAIN RELIEVED WITH PERCOCETR: STABLEP: AWAITING PATH REPORT..CONTINUE WITH CARE AS ORDERED Pt c/o HA x2, ecieved Roxicet with pos effect. Resp CarePt remains intubated on CPAP. Lungs coarse throughout bilaterally, chest pt done as tolerated.GI: Abdomen soft, non-tender, BS+. Moderate secretions over the day. Mannitol being tapered. Tube feeds to be r/s. The mitral valve leaflets are mildlythickened. C/O neck discomfort which is relieved w/ roxicet and neck collar.Resp: Continues on CPAP. Resp CarePt remains intubated; Mode of ventilation changed from MMV to cpap/psv 8/5. The left ventricular cavity size is normal.There is moderate regional left ventricular systolic dysfunction. Social service consult requested.A: Neurological exam unchanged. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 62Weight (lb): 110BSA (m2): 1.48 m2BP (mm Hg): 142/53HR (bpm): 51Status: InpatientDate/Time: at 15:47Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of /2206.LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. +BS, abdomen soft, tolerating TFs restarting via NGT w/minimal residuals. C/O HA, recieved roxicet prn with pos effect. despite mannitol. +BS, abdomen softly distended. +PP, + lower ext edema. Tolerating Tfs, minimal residuals. Resp. Resp. Pt w/ sml loose bm. Respiratory CarePt. Condition UpdateAssessment:Please see carevue for details Neuro: Pt A&Ox3, follows all commands MAE although L sided weakness noted, but improved, sensation in extremities intact, PEERL. SC HEPARIN AND P BOOTS FOR DVT PROPHYLAXIS. side as per pt's baseline. Squeezing w/R. CarePt. ABGs acceptable. Palp dp/pt bilat. Dobhoff clamped. Moving R. side well, lifts/holds w/upper and lower extremities. LS coarse to clear bilat throughout. NIF and VC checked x2. c/o throat pain, medicated w/Roxicet w/some effect. data: adm. from ew @ 2400-intubated and sedated on low dose propofol.vss. CONTINUE TO MONITOR NEURO STATUS, RESP STATUS, COMFORT. CONDITION UPDATE:D/A: T MAX 98.9NEURO: LIGHTLY SEDATED ON PROPOFOL, FOLLOWS ALL COMMANDS, COMMUNICATES WELL WITH NODDING AND GESTURING. Low MV secondary to RR and periods of apnea, pt placed on MMV. Incision to head intact. VSS, afebrile. Other than rash, integ intact.Plan: continue with current plan of care per sicu team. Begun on PRN Lopressor. She has riss for bs coverage. Provide comfort, medicate pain prn. Pt continues on A/C 450/14/5/.40. moving rt side>lt. PT IN A DNR. Nursing note: Opening eyes to voice and spont. remains vented on cpap/ps 8 and 5 and 40%.Pt. BRONCH PRIOR TO EXTUBATION TO REMOVE SECREATIONS. Pt. Pt to go to flouro for dobhoff placement. DILANTIN LOADED. Dilantin loaded. + PPP, PBOOTS AND SC HEPARIN FOR DVT PROPHYLAXIS.RESP: LS COARSE, CLEAR AT TIMES WITH SUCTIONING. Mannitol cont. PULM HYGIENE. HEPARIN SC.PULM: VENTED. Resp Care Note, Pt weaned down to cpap/ips. ABG WITH ADAQUATE OXYGENATION. OOB as tolerated. Probalance TF infusing @ goal via OGT w/ minimal residuals. with SICU POC. CV: Remains in nsr, rare PAC's noted. PROPOFOL RESTARTED AFTER NIF MEASUREMENT. condition UpdatePlease see carevue for specifics.Pt arousable to voice. DNR/DNI. Palp dp/pt bilat. Focus Condition UpdateSee flowsheet for specific infoNeuro: Pt sedated on Propofol. PERRL. IF NOT EXTUBATED RESTART TUBE FEEDS.SEE CARE VUE FOR FULL SPECIFICS. +RADIAL/PT/DP X2. ABG wnl. Respiratory CarePt. GI: ABD soft, pos bs. Colace held this am. Pt w/ 3 sml loose bm's. .5mg IV ativan given w/ + effect. NGT in proper place. ABD: SD, +BSX4,S,NT. condition updated: pt sedated on propofol. pt remained on full vent support thoughout shift, secretions have decreased somewhat. CLS ON. BS bil. Respiratory to continue to wean vent support as tol. Pt intermittently appropriate and cooperative. Cont. Appears to be tol well. Condition UpdateAssessment:Please see carevue for details Neuro: Pt remains sedated on prop gtt. see flowsheet for abg results.gi: pt tolerating tube feeds and minimal residual present. Will cont to follow and adjust vent as tolerated. IV ABX. abd soft and positve bowel sounds.gu: urine output remains adequate.a: continue with neuro checks. NURSING VSS, AFEBRILE. Pt received last dose of IVIG this am.Plan: continue with current plan of care per NMED, SICU teams. Lightly sedated on Propofol gtt, follows commands. CPT done per pt. Abdomen soft, +BS, NPO. STATUSD: AWAKE FOLLOWS COMMANDS APPEARS ORIENTED..ABLE TO MOVE RT ARM OTHER EXTREM'S WEAK..HCT 22A: NO VENT CHANGES CONTINUES WITH LGE AMT THICK TAN/PURULENT SECREATIONS..TRANFUSED 1U PS FOLLOWED BY 10MGM LASIX..GOOD DIURESIS.. IVIG GIVEN TOL WELL..C/O THROAT PAIN RELIEVED BY PERCOCET Q4H..INCT LGE AMT LOOSE BROWN STOOL FIB PLACEDR: STABLEP: WILL CONTINUE WITH IVIG X5DAYS..WEAN VENT AS TOL..? extubate when IVIG complete. +pp, -edema. +pp, -edema. NPN7p-7a see carevue flowsheet for detailsD:Neuro unchanged, c/o slight headache mdicated with relief.CV:VSS, SR no ectopics.Resp:CDB, IS and CPT, O2 changed to 4l NP -tolerated. sb/p 120-137.neuro status unchanged-moving rt side more than lt. opening eyes to verbal stimuli-otherwise eyes closed. Resp CarePt remains intubated with # 7.0 ETT. EXTUBATE WHEN RISBI IMPROVED abs soft,nt,nd. Lung sounds clear, dim to bases. Nursing note: Neuro unchanged. Nursing note: Sedated lightly on Propofol gtt, able to follow commands on PPF gtt. stooling small am'ts loose brown.GU:Foley in place u/o not a problem. LCTA, minimal secretions.GI: Abdomen soft, non-tender, BS+, no BM this shift. Nods/squeezes understanding appropriately to ?s. Continue with SICU POC. See careview for details and specifics.Plan: wean as tolerated. nursing notePt remains neurologically intact with weak voice alothough improving with sound. Nodding appropriately to ?s. LS clear, coughing approp and into yankauer. hr 45-60 sb w/o ectopies. Roxicet given for H/A.CV: NSR with no ectopy noted this shift, SBP 110-140's, HR 60-70. | 71 | [
{
"category": "Echo",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 97902,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 110\nBSA (m2): 1.48 m2\nBP (mm Hg): 142/53\nHR (bpm): 51\nStatus: Inpatient\nDate/Time: at 15:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of /2206.\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Moderate regional LV systolic\ndysfunction. Depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic;\nlateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Ascites.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is moderate regional left ventricular systolic dysfunction. LV systolic\nfunction appears depressed. Resting regional wall motion abnormalities include\nmid to distal anteroseptal, anterior and apical akinesis/hypokinesis. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The estimated pulmonary artery systolic\npressure is normal. There is a small pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n/2206, left ventricular dysfunction is new.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2128-10-27 00:00:00.000",
"description": "Report",
"row_id": 266519,
"text": "Sinus rhythm\nAnt/septal ST-T changes are nonspecific, cannot exclude ischemia\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2128-10-16 00:00:00.000",
"description": "Report",
"row_id": 266520,
"text": "Sinus rhythm\nAnteroseptal ST segment elevation - consider anterior myocardial infarction\n\n"
},
{
"category": "ECG",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 266521,
"text": "Sinus bradycardia\nAnterolateral T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 266522,
"text": "Sinus bradycardia\nAnterolateral T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-12 00:00:00.000",
"description": "Report",
"row_id": 1436831,
"text": "Focus Condition Update\nSee flowsheet for specific information\n\nNeuro: Pt opens eyes to voice, follows commands, mae's, right side is stronger than left, nods appropriately to questions. Roxicet given for neck pain with good effect.\nCV: NSR with no ectopy noted this shift. Afebrile, SBP 110-130, HR 60's-70's. Cards consulted this afternoon for prior cardiac event. Will continue to monitor enzymes.\nResp: Pt continues on CPAP w/ Psupp 5/6/40%. Sux'd for moderate amount of thick yellow sputum. Lungs coarse throughout bilaterally, chest pt done as tolerated.\nGI: Abdomen soft, non-tender, BS+. Bisacodyl given, no BM this shift.\nTF at goal at 50cc/hr, minimal residuals.\nGU: Foley to gravity, UO WNL. 10 meq lasix given with effect.\nSocial: Friends and family in to visit most of day.\nPlan: Continue to monitor respiratory status.\n Pain control.\n Continue to tx MG\n Continue with SICU POC\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-13 00:00:00.000",
"description": "Report",
"row_id": 1436832,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. NIF done -10. RSBI done on 0 peep/5 ips 30.Temp 99. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-13 00:00:00.000",
"description": "Report",
"row_id": 1436833,
"text": "NURSING UPDATE\n VITAL SIGNS STABLE. NEURO EXAM ESSENTIALLY UNCHANGED. CARDIAC ENZYMES SENT X2, NEGATIVE SO FAR, AM LABS STILL PENDING AT THIS TIME. MEDICATED WITH PERCOCET ELIXIR X2 FOR C/O NECK PAIN WITH GOOD EFFECT.\nMONITORED CONTINUOUSLY OVERNOC.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-13 00:00:00.000",
"description": "Report",
"row_id": 1436834,
"text": "Resp Care\nPt remains intubated on CPAP. Pt bronched for copious amt of thick tan sputum, with large amt coming from the right lung. Sputum sample sent off for cultures. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-13 00:00:00.000",
"description": "Report",
"row_id": 1436835,
"text": "STATUS\nD: NEURO STABLE..FOLLOWS SIMPLE COMMANDS..FIBRILE OTHER VSS\nA: NO VENT CHANGES..SUCTIONED FOR COPIOUS AMT THICK TAN/PURULENT SECREATIONS>>BRONKED FOR COPIOUS AMT OF SAME & SPEC SENT FOR CULTURE LASIX X1 WITH GOOD EFFECT..NA PHOS REPLETED..TOL TF'S WELL..1 LGE SOFT BROWN STOOL..C/O NECK PAIN RELIEVED WITH PERCOCET\nR: STABLE\nP: AWAITING PATH REPORT..CONTINUE WITH CARE AS ORDERED\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-14 00:00:00.000",
"description": "Report",
"row_id": 1436836,
"text": "NURSING UPDATE\n DAUGHTER CALLED LAST NOC TO SAY THAT DR WOULD NO LONGER BE PT'S ATTENDING AFTER TODAY, AND DR TO START IVIG FOR TREATMENT OF MYASTHENIA ASAP.\n PT NEUROLOGICALLY UNCHANGED, THOUGH SLOW RESPIRATORY RATE RESULTED IN NEED FOR INCREASED VENT SUPPORT TO SIMV DURING NOC. DILANTIN LEVEL SUB-THERAPEUTIC THIS AM.\nPLAN: INTENSIFY TX OF MYASTHENIA. ADJUST DILANTIN DOSE TO ATTAIN THERAPEUTIC SERUM LEVELS. APPROACH PLAN FOR RX OF MALIGNANCY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-14 00:00:00.000",
"description": "Report",
"row_id": 1436837,
"text": "Resp Care\nRequired changing from psv to simv overnight due to apnea. Current minute volumes 4-6 liters. NIF this morning = 10 RSBI =40.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-14 00:00:00.000",
"description": "Report",
"row_id": 1436838,
"text": "Resp Care\nPt remains intubated on SIMV. No changes in Pt.'s status. Plan is to try and wean Pts settings. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-11 00:00:00.000",
"description": "Report",
"row_id": 1436829,
"text": "nursing Progress Note\nPlease see careview for details\n\nNeuro: unchanged, continues to sqeeze slightly with left hand.\n\nCV: stable\n\nPulm: see resp note, sx for very thick tan sputum. bs clear after sx.\n\ngi: tube feeds at goal of 50/hr, tol well no residuals. bowel sounds present, no bm, no flatus.\n\ngu: u/o tapering to <30 hr this am. will notify HO\n\nPain: pt c/o throat pain due to ETT, med with oxycodone 5 cc x 1 at 0500, pt resting comfortably now.\n\nwound: head dsg removed by neuro team, incision intact, clean and dry, leeft open to air.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-11 00:00:00.000",
"description": "Report",
"row_id": 1436830,
"text": "NPN: Review of Systems\nNeuro: Opens eyes to voice. PERRL. Communicates by nodding and hand gestures. Squeezes w/ both hands and able to lift right arm and leg. Bends left knee slightly. Dilantin to be held until next morning level. Mannitol being tapered. Nowe q 24hrs and Pt still receiving decadron. C/O neck discomfort which is relieved w/ roxicet and neck collar.\n\nResp: Continues on CPAP. Robotussin started today. Sxned thick yellow secretions. BS are CTA bilaterally. Strong cough.\n\nCV: SR. w/ rare PAC. MAP in the 60s. Tmax=100.3. Palpable DP/PT pulses bilaterally. Left upper extremity US done. Sodium phospate administered for PO4 level of 1.3 which is down from 1.8.\n\nGI: Probalance at goal rate of 50cc/hr. Abdomen is soft. Decreased bowel sounds. 0cc residual from NGT.\n\nGU: Foley to gravity. Urine clear yellow. Urine output >25cc/hr throughout the day.\n\nSkin: Head incision OTA. Clean and dry. No pressure wounds present.\n\nEndo: Fingerstick glucose this afternoon =225-> 20 units regualr insulin administered per sliding scale.\n\nSocial: Dtr. and son-in-law in by bedside today. Dtr. spoke w/ Dr. and Dr. regarding preliminary biopsy results. Pt and Dtr. both tearful. Pt calm whike dtr. sits w/ her. Social service consult requested.\n\nA: Neurological exam unchanged. Moderate secretions over the day. Hemodynamic and respiratory status stable. Adequate pain relief w/ roxicet and neck collar.\n\nP: Support Pt and family by continuing communication btwn family and care providers. Follow up w/ social service consult. Monitor as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-20 00:00:00.000",
"description": "Report",
"row_id": 1436861,
"text": "Condition Update:\nAssessment:\nPlease see carevue for details\n\n Neuro: No change in neruo status from previous exam. Pt alert, wiriting on clipboard to communicate, MAE with L sided weakness, PEERL. Pt c/o HA x2, ecieved Roxicet with pos effect.\n\n CV: Remains in nsr, rare pac's. Denies CP. No edema noted. Palp dp/pt bilat. VSS. Afebrile.\n\n Resp: Ls clear to coarse bilat throughout. Denies SOB. Placed on Cpap after Fluro today, tol well. Suctioned prn for small amounts of thick yellow secretions. Pt has been educated on trach placement and has yet to make a decision on whether or not pt will be reintubated after extubation. NIF 18. Will extubate tomorrow.\n\n GI: Abd soft, pos bs x4. D.H. tube repositioned in fluro, not post-pyloric. Tube feeds to be r/s.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n Social: Multiple meetings with family MD's and social work. Lots of teaching done with pt and family in regards to options revolving around extubation and advanced directives. As of now, pt will wait until tomorrow am to speak with Md and will make a decision at that point.\n\nPlan: Continue with teaching to pt and family, extubate tomorrow am, speak with MD in regards to fluid collection aspiration, r/s tubefeeds, continue with current plan of care, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-20 00:00:00.000",
"description": "Report",
"row_id": 1436862,
"text": "Resp Care\n\nPt remains intubated; Mode of ventilation changed from MMV to cpap/psv 8/5. MV has been in the 4-5L range. RR has varied from 8 to low teens. Spo2 100% abd bs are clear\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-21 00:00:00.000",
"description": "Report",
"row_id": 1436863,
"text": "Resp Care\nRemains intubated and ventilated with no remarkable changes overnight. RSBI this morning=23. NIF=18. Plan is for repeat NIF pre and post tensilon later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-21 00:00:00.000",
"description": "Report",
"row_id": 1436864,
"text": "Resp Care\n\nPt was weaned and extubated without incident; cuff leak present prior and no stridor note after\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-21 00:00:00.000",
"description": "Report",
"row_id": 1436865,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt A&Ox3, follows all commands MAE although L sided weakness noted, but improved, sensation in extremities intact, PEERL. C/O HA, recieved roxicet prn with pos effect.\n\n CV: Remains in nsr, no ectopy noted. Denies CP. VSS, afebrile. Palp dp/pt bilat. No edema noted.\n\n Resp: Pt extubated @ 1430. Tol well. Maintaining o2 sat >97% on 50% Cool neb. LS coarse to clear bilat throughout. resp nonlabored Denies SOB. C&DB with instruction, does not use IS well. Coughing and raising small amounts of thick yellow secretions.\n\n GI: ABD soft, non-tender, pos bs x4. Tubefeeds held for extubation will restart this evening, tol @ goal via D.H. tube. Small BM.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n Social: Family into visit multiple times, spoke with MD on multiple occations. Lots of teaching done with family and pt.\n\nPlan: Pt has decided to ok a trach should she need it in the future, monitor resp status closly, pulm toileting, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1436806,
"text": "data: adm. from ew @ 2400-intubated and sedated on low dose propofol.\nvss. hr 50's sb, sb/p130-140. urines o/p 20-40cc/hr c/y/u.\nneuro-slightly sedated on ppf gtt-when turned off for neuro exam pt opens to command. nodding head to ?'s. moving rt side>lt. lift and holds rt arm, bends rt leg. slight movement to lt arm/lt leg.\npupils 2mm react to light.\nsoft collar to neck on b/c of weak neck muscles-daughter will bring in\nneck brace that she uses @ home. mri of head done.\nmannitol 12.5gm given for osmo<315/na+,150.\nk+3.2- kcl 40meq down ngt to preserve periph iv's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1436807,
"text": "resp care\nPt intubated in ew and transported to ct and mri without incudent. Currently pt is on a/c 450x16 40% 5peep. Plan to hyperventilate per neuro. Suct for sml amt of thick white sput. Lots of oral secretions. Will cont to follow and adjust vent as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1436808,
"text": "Respiratory Care\nPt continues to be orally intubated/ventilated. BS: slightly coarse bilaterally. Suctioned for small amounts of thick white secretions. Pt continues on A/C 450/14/5/.40. Respiratory rate decreased from 16 this am with resultant abg: 7.44/33/195. Pt traveled for chest/abdomen/pelvis CTscan today w/o incident-results pending. Plan to continue current support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-19 00:00:00.000",
"description": "Report",
"row_id": 1436856,
"text": "Vent weaning\nNo neuro changes overnoc, Pt c/o headache x2 respectively relieived with oxycodone-acetamenaphine elixir 10ml. Sft neck collar on for pt comfort.\nCV:SB to SR 54-60/hr. CVP2-4, edematous hands and feet\nResp:vent changed to Cpap and PS5 by resp therapist, NIF-11 goal NIF -20. Small am't thick white secretions. Ceftriaxone for pseudomonas pneumonia.\nGI:Tolerating TF at goal 50ml/hr. No stool overnoc.\nGU:U/o 70-160 q 2 hrs.\nFamily called x1 update given.\nPlan:Continue plan of care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-19 00:00:00.000",
"description": "Report",
"row_id": 1436857,
"text": "resp care\npt remains intubated/vented initially in psv/cpap, however pt's rr low resulting in several drops in minute ventilation. placed on MMV mode, pt breathes only occasionally on this mode depending on how awake she is. sxned for yellow tinged sputum. nard.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-19 00:00:00.000",
"description": "Report",
"row_id": 1436858,
"text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\nNEURO: Intubated, ventilated on CPAP. Alert, oriented by writing communication, PERRL 3-4mm. Moves all extremities, left side weakness as baseline. No c/o headache this shift, no n/v, no seizure activity.\nDecadron as ordered for brain mass.\n\nRESP: ETT patent, ventilated on CPAP 0.40 w/ PS 8. Low MV secondary to RR and periods of apnea, pt placed on MMV. Retrialed on CPAP at 1700 and again resulted in hypoventilation, returned to - SICU Resident aware. Lungs clear to coarse, suctioned frequent for thick/yellow sputum in small amounts- oropharyngeal clear tenascious secretions frequent. On Ceftazidime for pneumonia.\n\nHEMODYNAMICS: NSR 56-72, no ectopy. SBP 130s-150s. Adequate u.o., daily fluid balance negative, overall still positive. NS maintenance IV at 40ml/hr while TF off.\n\nGI/METABOLIC: NPO. Dobhoff placement at bedside attempted by SICU team, placement not confirmed. Plan DObhoff placment via flouroscopy, pt has requested to be adequately sedated for this procedure secondary to moderate discomfort. Oral GT dc'd earlier in am by SICU team. Pt remains NPO, Mestonin administered intravenously pending GI access.\nGlucoses 146/131, no enteral feeding at this time.\n\nCOMFORT/PSYCHOSOCIAL: c/o moderate right nasal pain/throat pain after Dobhoff attempts, medicated with Oxycodone/Fentanyl with therapeutic effect. Pt frustratd with ventilatory dependence, grieiving husbands death and coping with new diagnosis of brain mass- emotional support provided to pt and daughter- pt expressing her feelings well in written communication and nonverbal behaviours. Family/MD conference held this am- plan to evaluate myasthenia respiratory component in am per Neurology team and assess any improvements to indicate extubation. Pt aware of this POC as well as Dobhoff placement and denies further questions. Dr at bedside today as well as Rabbi .\n\nPLAN: Monitor resp status, suction prn, turn and reposition q2-3hr to mobilize secretions. Monitor neurological signs. Provide comfort, medicate pain prn. Anticipate feeding tube placement under flouroscopy, check with SICU team for procedural sedation plan. Emotional support and education to pt and family onoging. Resume enteral feeding when GI access confirmed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-09 00:00:00.000",
"description": "Report",
"row_id": 1436823,
"text": "Nursing note:\n Waking through shift, PERRLA 2-3mm and brisk. Squeezing w/R. hand and nodding in attempts to communicate. Moving R. side well, lifts/holds w/upper and lower extremities. L. side weaker, minimal movement on bed to LUE , wiggling toes to LLE. Denies pain. Wearing soft collar for comfort. Incision to head intact. Low grade temps, 100. SB , Esmolol gtt d/c'd for HR in 50s. Begun on PRN Lopressor. SBP 90-120s. +PP, + lower ext edema. Lung sounds clear, dim to bases. IPS decreased to 10, tolerating well. ABGs acceptable. Suctioned for thick yellow secretions. +BS, abdomen soft, tolerating TFs restarting via NGT w/minimal residuals. Foley patent borderline amounts amber urine. Glucose stable, SSRI PRN. Skin intact. Daughter in visiting and updated by this RN and sicu teams.\n\nA/P: Stable neurologically s/p brain bx for large mass. Continue to monitor closely, f/u neurosurg for plan, wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-10 00:00:00.000",
"description": "Report",
"row_id": 1436824,
"text": "Resp. Care\nPt. remains vented on cpap/ps 8 and 5 and 40%.Pt. has been sx for large amts of thick yellow with scat rhonchi clearing with sx.NIFs were done when pt was not fully awake X 3 and they were 3-5-3 with a RSBI of 60. ABGs at 1700 were 7.40/33/100/21/-2\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-20 00:00:00.000",
"description": "Report",
"row_id": 1436859,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt alert. Mouths words and writes for communication. She follows commands consistently. She is able to MAE. LEft side weaker than the right. She has been afebrile. NSR-SB. CVP 3-5. Fentanyl given for c/o neck pain. Soft collar intact for pt's comfort,. Pt sxn'd several times for sml amts of thick, yellow secretions via ETT, and large amts of clear oral secretions. LS CTA, No vent changes made during the noc. Pt remains NPO. Dobhoff clamped. No used during the noc d/t incorrect positioning in pt's stomach. IVF D5 1/2 NS w/ 20meq KCL infusing @ 70cc/hr. Pt w/ sml loose bm. She has riss for bs coverage. Reddened rash continues on her feet. Other than rash, integ intact.\n\nPlan: continue with current plan of care per sicu team. Pt to have NIF / tensilon test done in the am. Pt to go to flouro for dobhoff placement. P.T/O.T OOB, Pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-20 00:00:00.000",
"description": "Report",
"row_id": 1436860,
"text": "Respiratory Care\nPt. intubated on ventilatory support. Tol MMV but experiences frequent episodes of bradypnea with drops in min. ventilation, NIF -14. Pt. awake and alert cooperates fully with mechanics and appears to put good effort into tests. RSB 10, but minute ventilation drops below 2 lpm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-10 00:00:00.000",
"description": "Report",
"row_id": 1436825,
"text": "Nursing progress note\nPlease see careview for details\n\nNeuro: pt nods appropriately, PERL, moves rt side well, can occasionally squeeze wit left hand, but barely, picks left leg up off bed, all to command. mannitol given x 2.\n\ncv: vss, afebrile, a line damped and unable to draw blood this am.\n\npulm: bs coarse this am, sx q 3-4 hrs for thick tan in copious amts. see rsp note for rsbi 60, and nif -3 to -5. Plan is to wean for extubation when pt is strong enough, large amt secretions may hamper this plan.\n\ngi: tube feeds at goal of 50/hr with min residuals, tol well, no stool.\n\ngu: u/o down to 20-30/hr. despite mannitol. wt up to 55.5 kg this am.\n\nhead dsg intact with sm amt old s/s drng.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-10 00:00:00.000",
"description": "Report",
"row_id": 1436826,
"text": "Resp. care note - Pt.remaines intubated and vented, no vent changes made at this time. NIF = - 7 cmH2o, VC = 700 cc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-10 00:00:00.000",
"description": "Report",
"row_id": 1436827,
"text": "Nursing note:\n Opening eyes to voice and spont. Stronger w/R. side as per pt's baseline. Moving LLE and LUE on bed, unchanged neurologically. PERRLA 3mm and brisk. c/o throat pain, medicated w/Roxicet w/some effect. Wearing soft collar for comfort. Lung sounds clear, dim to bases, no vent changes. Sats 100%. +BS, abdomen softly distended. Tolerating Tfs, minimal residuals. Foley patent adequate amount amber urine. Glucose elevated this am, tx'd w/SSRI w/effect. Skin intact.\nA/P: Stable neurologically, awaiting brain bx results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-11 00:00:00.000",
"description": "Report",
"row_id": 1436828,
"text": "resp care\nPt remained on psv8/peep5 and 40% with volumes of 400cc and rr 14-16. BS coarse. NIF and VC checked x2. AM results slightly better with nif -10 and vc-620cc. RSBI done this am=40. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-17 00:00:00.000",
"description": "Report",
"row_id": 1436851,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.9\n\nNEURO: LIGHTLY SEDATED ON PROPOFOL, FOLLOWS ALL COMMANDS, COMMUNICATES WELL WITH NODDING AND GESTURING. ALL STRENGTHS SEEM STRONGER, LEFT REMAINS MUCH WEAKER THAN RIGHT. PERL. MAE. DENIES PAIN TODAY. #4 OF 5 IVIG GIVEN TODAY.\n\nCV: HR 60'S-70'S NSR. NBP ~ 128/40, CVP ~ 8, + PPP BILAT, + PEDAL EDEMA. SC HEPARIN AND P BOOTS FOR DVT PROPHYLAXIS. FLUID BALANCE MN-1700 -685 CC'S.\n\nRESP: SECREATIONS HAVE LESSENED FROM YESTERDAY, BOTH ORAL AND VIA ETT. LATEST NIF -16. ON SIMV + PS, 40%, 10 X 400, 5 PEEP, 5 PS BREATHING AT A RATE OF ~ 14-16.\n\nGI: TUBE FEEDS AT GOAL, STOOLING. NO NAUSEA. NO RESIDUALS.\n\nGU: FOLEY-BSD WITH CLEAR URINE.\n\nSX: FAMILY VISITED.\n\nR: CONTINUES TO IMPROVE PER STRENGHTS AND NIFS.\n\nP: TO RECEIVE 5TH DOSE OF IVIG, GOAL NIF -20, EXTUBATE WHEN DEEMED APPROPRIATE. ? BRONCH PRIOR TO EXTUBATION TO REMOVE SECREATIONS. CONTINUE TO MONITOR NEURO STATUS, RESP STATUS, COMFORT. PT AND FAMILY SUPPORT. PT IN A DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-18 00:00:00.000",
"description": "Report",
"row_id": 1436852,
"text": "Respiratory Therapy\nPt remains orally intubated on SIMV. No changes overnight. Sx for sml amt thick tan. RSBI this AM 15 NIF, best of 2 -17. Pt pulled a -17 on second attempt. Plan: continue to monitor mechanics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-18 00:00:00.000",
"description": "Report",
"row_id": 1436853,
"text": "condition Update\nPlease see carevue for specifics.\n\nPt arousable to voice. She follows commands consistently. She is able to MAE. The left side upper/lower considerably weaker than the right. she has been afebrile. NSR. No ectopy noted. CVP 6-7. PPF gtt turned off this am. .5mg IV ativan given w/ + effect. Pt given 10ml roxicet for neck pain w/ + effect. Pt sxn'd several times for sml to moderate amts of thick, white secretions. LS coarse throughout. Pt remains on simv/ 40%/. Probalance TF infusing @ goal via OGT w/ minimal residuals. Pt w/ 3 sml loose bm's. Colace held this am. MS. was oob to the chair this afternoon w/ minimal assistance from P.T. She has a riss for bs coverage. Integ is intact. Reddened rash on her feet continues as noted. Pt received last dose of IVIG this am.\n\nPlan: continue with current plan of care per NMED, SICU teams. Attempt NIF approx 1600. Goal NIF -20. ? extubate if goal reached. DNR/DNI. IV ABX. OOB as tolerated. Pain mgmt. Pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-18 00:00:00.000",
"description": "Report",
"row_id": 1436854,
"text": "pt remained on full support through shift, sx'd for minimal secretions, NIF was -17 with extensive coaching. plan to reevalute in the AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-19 00:00:00.000",
"description": "Report",
"row_id": 1436855,
"text": "Respiratory Care\nPt. intubated on ventilatory support. Suctioned for fair amount thick yellow secretions. Mechanics performed this a.m. to best of pt. ability (appears to put good effort into maneuvers). NIF -11. RSBI 58\nVent support decreased to PSV initially but pt. C/O not getting enough air, PSV increased to to pt. satisfaction. Appears to be tol well. Respiratory to continue to wean vent support as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-08 00:00:00.000",
"description": "Report",
"row_id": 1436818,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains sedated on prop gtt. Pt able to follow commands through sedation. When sedation is off, pt follows all , although R>L, localizes pain, pupils equal and reactive but sluggish, opens eyes to voice. No seizure activity noted. Mannitol cont. Dilantin loaded. No evidence of pain.\n\n CV: Remains in nsr, rare PAC's noted. New L radial aline placed due to R aline draining serous fluid and inability to draw off line. Cuff 20-30 pts lower than aline, following mean of both. CVP 6-8. IVF NS @ 60cc/hr. Edema noted in BUE as well as tongue and lips. Palp dp/pt bilat.\n\n Resp: Remains on CMV with no changes during shift. ABG wnl. LS coarse and diminished at bases. Suctioned prn for small amounts of thick tan secretions.\n\n GI: ABD soft, pos bs. Tubefeeds held at MN for OR . NGT in proper place.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\nPlan: Continue with current plan of care, NPO for OR , pulm toileting, provide pt and family with emotional support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-08 00:00:00.000",
"description": "Report",
"row_id": 1436819,
"text": "resp care\nPt remained on a/c 450x14 40% 5peep with occ spont breaths. BS bil. Suct for sml amt of pale yellow sput. RSBI held due to impending or procedure. Will cont to follow and adjust vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-08 00:00:00.000",
"description": "Report",
"row_id": 1436820,
"text": "Focus Condition Update\nSee flowsheet for specific info\n\nNeuro: Pt sedated on Propofol. Follows commands, nods to simple questions. MAE, right side more than left. Denies pain, pupils equal 3mm and sluggish. No seziure activity noted. Denies pain.\n\nCV: NSR with no ectopy noted. SBP 90's -160's, A-line not correlating with cuff, which is about 20mm/hg lower. Mildly edematous throughout. Afebrile.\n\nResp: Remains vented on CMV, PEEP 5, 40%, no changes made today.. Sux'd for small amount of thick tan secretions. Lungs clear to coarse bilaterally, dim in bases.\n\nGI: BS+, abdomen soft. NPO. no BM.\n\nGU: Foley to gravity, UO WNL.\n\nPlan: To OR for brain Bx.\n Monitor for seziure activity.\n Family support.\n Cont. with SICU POC.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-09 00:00:00.000",
"description": "Report",
"row_id": 1436821,
"text": "Resp Care Note, Pt weaned down to cpap/ips. Suctioned mod amts thick yellow secretions.Temp 100.7.Propofol off. Not responding to command.To head Ct-Scan x 2. To OR for biopsy of cerebral mass. Having periods of apnea on SBT.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-09 00:00:00.000",
"description": "Report",
"row_id": 1436822,
"text": "Pt down for Head CT Scan and then directly to OR for brain Biopsy returned to unit around 2200, repeat head CT done at midnight. Pt receved Vercurium and Fentanyl in OR.\nNeuro: Propofol turned off around midnight but very slow to wake at present is moving only right side on bed with slight movement on left to painful stimuli she does not open eyes or follow commands. Pupils equal and reactive.\nResp: Vent changed to cpap with IPS this am ABG good RR 6-12 Pt suctioned for thick yellow secretions.\nC/V: vss Esmolol drip started to maintain HR<70. Running at 50mcg/kg/min BP stable. pt arrived from OR with metabolic acidosis which slowly improved with out treatment.\nGI: tube feeds restarted this am ProBalance at 10cc/hr.\nEndo: Blood sugars treated with sliding scale.\nGU: adequate urine outputs.\nPlan: Possible extubate when pt awakens. Monitor serum Osmolatlity and await biopsy reults, provide pt and family support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1436814,
"text": "condition update\nd: pt sedated on propofol. off propofol pupils are equal and reactve to light. spontaneous movement of right side. moves to command on left side on bed only. weakly able to squeeze left hand unable to lift off bed. left arm wiggles toes and slightly lifts off the bed. propofol titrated for for sedation and comfort. pt continues on mannitol q6 for edema.\ncardiac: nsr rate 50-64. sbp 140-150's depending on sedation. seen by cardiology for new ekg changes. see not for details.\nresp: pt suctioned for thick yellow sputum. breath sounds are clear to coarse and diminished in the bases. see flowsheet for abg results.\ngi: pt tolerating tube feeds and minimal residual present. abd soft and positve bowel sounds.\ngu: urine output remains adequate.\na: continue with neuro checks. continue with family support.\nr: no change in neuro status. continue to support family\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1436815,
"text": " Care\nPt remains intubated with #7.5 ETT. Pt currently on full vent support with no vent changes made this shift. BS coarse/diminshed bilaterally, suctioning for small amounts of thick yellow secretions. ABG shows good oxxygenation and ventilation. Morning RSBI attempted, no spont rr noted. See careview for specifics.\nPlan: Maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1436816,
"text": "BS fine crackles bibasilar; no MDI's given. Pt intermittently appropriate and cooperative. Suctioned for mod amount thick yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-16 00:00:00.000",
"description": "Report",
"row_id": 1436846,
"text": "CONDITION UPDATE:\nD/A: T MAX 99.\n\nNEURO: PT REQUESTING SEDATION THIS MORNING ON ROUNDS, WANTING TOO SLEEP THROUGH SOME OF THE TIME BEING INTUBATED. PROPOFOL STARTED, PT LIGHTLY SEDATED, RESTING WHEN NOT STIMULATED, AWAKE AND FOLLOWING COMMANDS WHEN STIMULATED. RIGHT UPPER ARM REMAINS STRONG, ABLE TO MOVE ALL EXTREMITIES. NIF -13, GOAL -20 FOR EXTUBATION. IVIG THIRD DOSE TODAY.\n\nCV: HR 60'S-70'S NSR WITH PAC'S -VS- SINUS ARRHYTHMIA? EKG DONE, SICU RESIDENT EVALUATED, NO CHANGE FROM PREVIOUS EKG. + PPP, PBOOTS AND SC HEPARIN FOR DVT PROPHYLAXIS.\n\nRESP: LS COARSE, CLEAR AT TIMES WITH SUCTIONING. VENT ON SIMV + PS, 40%, 10 X 400, 5 PEEP, 5 PS. LARGE AMOUNTS OF TENATIOUS SECRETIONS. LARGE AMOUNT OF ORAL SECRETIONS AS WELL.\n\nGI: TUBE FEEDS AT GOAL. STOOLING. NO RESIDUALS.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: MANY VISITORS.\n\nR: LOW GRADE TEMP, IMPROVING STRENGTHS, IVIG.\n\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT OF NEURO STATUS AND RESP STATUS. IVIG X 5 DAYS. TO EXTUBATE WHEN PT APPEARS STRONG ENOUGH, GOAL NIF -20. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-16 00:00:00.000",
"description": "Report",
"row_id": 1436847,
"text": "pt remained on full vent support thoughout shift, secretions have decreased somewhat. plan to continue with RSBI's and aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1436817,
"text": "NURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: SEDATED ON PPF. CONSISTENTLY FOLLOWS COMMANDS. PERRL. MAE WITH PURPOSEFUL MOVEMENT. LEFT SIDE WEAKER THAN RIGHT. +GAG/COUGH. C/O HA MMEDICATED 650NG TYLENOL WITH EFFECT. DILANTIN LOADED. MANNILTOL Q 8, DECADRON Q 12.\n\nCARDIAC: SB. VSS. SBP: 130-140'S/40'S. MEDICATED W/ HYDRALAZINE X1 WITH EFFECT. +RADIAL/PT/DP X2. HCT: STABLE. CLS ON. HEPARIN SC.\n\nPULM: VENTED. ABG WITH ADAQUATE OXYGENATION. LS+R+LUL COARSE, DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK SPUTUM.\n\nGI: TOLERATING TF VI OGT. ABD: SD, +BSX4,S,NT. NO BM.\n\nGU: FOLEY WITH QS URINE.\n\nSOCIAL: DAUGHTER VERY INVOLVED INCARE. MD'S MET TO DICUSS POC.\n\nPLAN: Q 1-2 HOUR NEURO CHECKS. MONITOR HEMODYNAMICS. PULM HYGIENE. OR ON . PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n\nENDO: FS QID CIVERAGE PER RISS.\n\nID: AFEBRILE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-17 00:00:00.000",
"description": "Report",
"row_id": 1436848,
"text": "NURSING\n VSS, AFEBRILE. CONITNUES ON VENT SETTINGS, 10 X 400, 5,5. NIF THIS AM -15. PRIOR TO NIF MEASUREMENT PROPOFOL OFF X 45 MINUTES, FULLY AWAKE, AND UPRIGHT IN BED. MD STATED POSSIBLE EXTUBATION TODAY. PROPOFOL RESTARTED AFTER NIF MEASUREMENT. TUBE FEEDS OFF AT 0500 IF EXTUBATION IS TO GO FOREWARD. COPIUS ORAL AND ENDOTRACHEAL SECRETIONS, SUCTIONED FREQUENTLY FOR TAN, FROTHY/THICK SPUTUM. COUGH EFFORT WEAK.\n MEDICATED FOR PAIN WITH ROXICET ELIXER WITH GOOD EFFECT. PROPOFOL CONTINUES AT 35 MCG'S FOR SEDATION.\n CONTINUE TO MONITER RESPIRATORY EFFORT, HEMODYNAMICS. IF NOT EXTUBATED RESTART TUBE FEEDS.SEE CARE VUE FOR FULL SPECIFICS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-17 00:00:00.000",
"description": "Report",
"row_id": 1436849,
"text": "Respiratory Therapy\nPt remains orally intubated on SIMV. sx for copious frothy tan secretions.Cough weak but productive. NIF -15 this AM sitting in high pos. Good effort tires easily. RSBI 23. Plan: continue W serial NIFS and assess readiness to ext.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-17 00:00:00.000",
"description": "Report",
"row_id": 1436850,
"text": "pt remained on full support through shift and was sx'd for a medium amount of secretions. NIF at end of shift was -16 with much coaching. plan includes probable extubation tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-14 00:00:00.000",
"description": "Report",
"row_id": 1436839,
"text": "STATUS\nD: FAMILY TOLD PT ABOUT PROGNOSIS..WILL CONTINUE WITH MED SUPPORT BUT PT NOW DNR/DNI PER FAMILY..CONTINUES TO FOLLOW COMMANDS MOVES ALL EXTREM'S LF WEAKER THAN RT & LEGS WEAKER THAN ARMS\nA: MULTILUMIN PLACED RT SUBCL WITHOUT INCIDENT..X-RAY SHOWED IN GOOD POSITION..LF SUBCL DC'D & TIP SENT FOR CULT..GOOD HUO'S..IVIG STARTED VS STABLE DURING INFUSION..NO VENT CHANGES..SUCTIONED FOR MOD AMT THICK TAN/PURULENT..GOOD SAT'S\nR: STABLE\nP: CONTINUE WITH MED TX..WILL ATTEMPT TO EXTUBATE WHEN STRONGER\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-15 00:00:00.000",
"description": "Report",
"row_id": 1436840,
"text": "Resp Care\nRemains intubated/ventilated on simv with no remarkable changes overnight. Few spontaneous breaths noted. NIF = 5 RSBI=52.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-15 00:00:00.000",
"description": "Report",
"row_id": 1436841,
"text": "cv: vss temp 100 max po. hr 67-74 nsr no ectopy.sbp 107-134/\n\ngi: tube feed probalance at 50 cc/hr via og tube. pos bowel sounds. small amounts of stool soft.\n\ngu: foley draining clear yellow urine. lasix 10 mg iv with good diuresis.\n\nneuro: pt alert. mouthing words and communicating via pen and paper and gestures. neck brace intact. pt c/o neck discomfort. medicated with percocet 10 ml q 4-6 hours with effect. pillow support and alighment of neck also helpful in relieving discomfort.\n\nintegumentary: incision r head dry and intact. staples intact. open to air. no drainage. feet pink and skin on feet very dry.\n\nresp: suctioned for thick tan ~Q2 hours.\n\nendo: Q 6 hour blood sugars covered with sliding scale.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-15 00:00:00.000",
"description": "Report",
"row_id": 1436842,
"text": "STATUS\nD: AWAKE FOLLOWS COMMANDS APPEARS ORIENTED..ABLE TO MOVE RT ARM OTHER EXTREM'S WEAK..HCT 22\nA: NO VENT CHANGES CONTINUES WITH LGE AMT THICK TAN/PURULENT SECREATIONS..TRANFUSED 1U PS FOLLOWED BY 10MGM LASIX..GOOD DIURESIS.. IVIG GIVEN TOL WELL..C/O THROAT PAIN RELIEVED BY PERCOCET Q4H..INCT LGE AMT LOOSE BROWN STOOL FIB PLACED\nR: STABLE\nP: WILL CONTINUE WITH IVIG X5DAYS..WEAN VENT AS TOL..? EXTUBATE WHEN RISBI IMPROVED\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-15 00:00:00.000",
"description": "Report",
"row_id": 1436843,
"text": "pt remained on full IMV support through shift, sx'd often for copious secretions. Plan to monitor requirement for support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-16 00:00:00.000",
"description": "Report",
"row_id": 1436844,
"text": "Nursing progress note:\nPt alert and oriented to self. Follows directions.MAE but very weak. Having continued neck pain. Med with oxycontin with good effect.\nCV: afebrile, HR 60-70's NSR with no ectopy. SBP 110-120's. Extremities warm with +PP. HCT 26.\nRESP: lungs coarse to dim at bases. No vent changes. Requiring occasional suctioning of thick tan secretions.\nGI: tol tube feed at goal. No stool tonight.\nGU: foley draining adequate amounts of clear yellow urine\nENDO: blood sugars Slightly elevated, covered per RISS.\nPLAN: Cont on IVIG for 5 days total. ? extubate when IVIG complete.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-16 00:00:00.000",
"description": "Report",
"row_id": 1436845,
"text": "Respiratory Therapy\nPt remains orally intubated on SIMV. NIF @ -13 good effort by pt. BS clr bilaterally Sx sml amt white secretions RSBI 20, NIF @ 0700 was -12, best of 2. also very good effort. please see carevue for specifics.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-22 00:00:00.000",
"description": "Report",
"row_id": 1436866,
"text": "Focus Condition Update\nSee flowsheet for specific info\n\nNeuro: A&O x3, MAE's with right side being stronger than left. Pt c/o left shoulder pain, Tylenol and heating pad given with effect. Roxicet given for H/A.\n\nCV: NSR with no ectopy noted this shift, SBP 110-140's, HR 60-70. Afebrile.\n\nResp: Sating 95-100% with humidified face tent at 50% O2. LCTA, minimal secretions.\n\nGI: Abdomen soft, non-tender, BS+, no BM this shift. Swallow eval done at bedside, then pt taken for video swallow eval. Pt able to swallow without difficulty, but is microaspirating. Pt to remain NPO, eval will be repeated Monday. TF at goal at 50cc/hr via Dobhoff in stomach.\n\nGU: Foley to gravity, UO WNL.\n\nEndo: Covered by RISS\n\nSocial: Dtr and friends in to visit.\n\nPlan: Pain control\n Monitor neuro status/ extremity strength.\n repeat swallow eval Monday.\n Continue with SICU POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-22 00:00:00.000",
"description": "Report",
"row_id": 1436867,
"text": "\n \n NEURO WNL A/O RELAXED GOOD PAIN CONTROL OCC H/A FRONTAL AREA AND CHRONIC LEFT NECK AREA SLEEPS WELL SHORT NAPS\n RESP CLEAR DIM AT BASES FM/.50 WITH HUMIDITY\n HEART S1S2 PULSES POS 3 THRU OUT NSR VSS\n ABD POS B/S STOOLING TOL T/F WELL\n PLEASE SEE CAREVIEW FOR DETAILS REGARDING PT CONDITION\n PLAN SUPPORT ROM T/P CPT SKIN CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-23 00:00:00.000",
"description": "Report",
"row_id": 1436868,
"text": "NPN\n7p-7a see carevue flowsheet for details\nD:Neuro unchanged, c/o slight headache mdicated with relief.\nCV:VSS, SR no ectopics.\nResp:CDB, IS and CPT, O2 changed to 4l NP -tolerated. Reinforced importance of resp activities, pt understands.\nGI:TF at goal of 50ml. stooling small am'ts loose brown.\nGU:Foley in place u/o not a problem.\n:Transfer to F5 when bed available.\nContinue vigorous CPT and IS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-23 00:00:00.000",
"description": "Report",
"row_id": 1436869,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt stable all day tolerating OOB well. Pt to say in ICU overnoc per family request reasses stepdown vs floor in am. cont with current plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-24 00:00:00.000",
"description": "Report",
"row_id": 1436870,
"text": "nursing note\nno neuro changes overnoc, cont to be oriented and approp with care. LS clear, coughing approp and into yankauer. CPT done per pt. request. abs soft,nt,nd. no BM overnoc. Clear yellow urine.\n\nplan:cont rehab care, await floor bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-25 00:00:00.000",
"description": "Report",
"row_id": 1436871,
"text": "nursing note\nPt remains neurologically intact with weak voice alothough improving with sound. Medicated with roxicet for r shoulder pain, hot pack. Questions answered regarding home care vs. rehab and case management aware to meet wiht patient and daughter.\n\nPLAN:rehab eval's, case mangement, repeat swallow study. OOB. await floor bed with tele.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1436809,
"text": "Nursing note:\n Sedated lightly on Propofol gtt, able to follow commands on PPF gtt. Moving all extremities, R. side stronger than L. Squeezing bilaterally with hands. Nodding appropriately to ?s. Denies pain. PERRLA 2mm and brisk. Wearing soft collar for comfort (pt. wears at home.) SR-SB in 50s, no ectopy. SBP 130-140s. +pp, -edema. Central line placed, CXR confirming placement. CT done of abd/pelvis/chest, results pending. Abdomen soft, +BS, NPO. OGT to sxn for minimal amount Baricat mixed with bilious material. Foley patent adequate amount amber urine. Glucose stable, SSRI PRN.\nA/P: Stable neurologically, continue to monitor closely. F/U w/neurosurg for plan re. brain mass/collection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1436810,
"text": "Resp Care\nPt remains intubated with # 7.0 ETT. Pt on full vent support and not breathing over the vent. No vent changes made this shift. BS coarse and diminished at bases. Suctioning for small amount of thick white secretions. ABG shows compensated respiratory alkalosis, with PaCO2 =33 and pH in normal range. RSBI attempted, no spontaneous respirations noted. See careview for details and specifics.\nPlan: wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1436811,
"text": "data: vss. hr 45-60 sb w/o ectopies. sb/p 120-137.\nneuro status unchanged-moving rt side more than lt. opening eyes to verbal stimuli-otherwise eyes closed. pupils = 2mm react to light.\nslightly sedated on propofol gtt w/ +effect.\ncontinues on mannitol q6hr w/ serum osmo's<315 and na+<150.\nurine output 30-60cc/hr c/y/u. cvp 1-4.\nno vent changes o/n. remains on cmv rate14/40% w/ acceptable abg's.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1436812,
"text": "Nursing note:\n Neuro unchanged. Lightly sedated on Propofol gtt, follows commands. R. side stonger than L. Moves L. side on bed. Lifts/holds w/R. side. Nods/squeezes understanding appropriately to ?s. Denies pain. Pupils 2mm and brisk bilaterally. Mannitol q6 hours, serum osmos and Na levels checked as well and within parameters. Afebrile. SB in 40s, team aware. SBP 140s. EKG/Echo and type and screen done for pre-op work-up. +pp, -edema. Lung sounds clear, dim to bases. No vent changes. PC02 increased to 36 from 30, ICU team aware, no new orders. +BS, abdomen soft, Tfs started @ 10cc/hr via OGT. Foley patent adequate amount amber urine. Glucose levels stable.\nDaughter in to visit and updated by this RN and neuro resident.\nA/P: Stable neurologically, continue to monitor closely. To have brain bx Friday night/Sat. am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1436813,
"text": "BS few fine crackles; no MDI's given. Rate increased to 16 due to PCO2 increasing from 29 - 36 which team wants normalized. They then decided to return rate to 14.\n"
}
] |
|
77,948 | 130,018 | HYPOTENSION: Ultimately Ms. hypotension was thought to be due to profound volume depletion in the setting of poor PO intake. Her baseline SBP was noted to be low in the 100's, according to out-patient records. On arrival she was admitted to the ICU. She was started on vancomycin and zosyn for presumed sepsis, though she remained afebrile and no infectious source was identified (CXR was unremarkable, abd exam benign, UA/UCx negative, no diarrhea, no skin lesions). MAPS's were maintained greater than 65 on norepinephrine upon admission. She was gradually weaned from pressors by and maintained SBP in the 90-100 range while awake (pressures dropped slightly to the 80's while sleeping). . Other causes of hypotension were ruled out. There was no evidence of bleeding. She has known hypothyroidism and is on levothyroxine, but TSH/free T4 were normal. She was not adrenally insufficient, as she passed a CortStim test. TTE did not show worsening valvular disease or focal wall motion abnormalities; although she had a slight troponin elevation on admission, CK-MB fractions were normal and there was no evidence of ischemia on EKG's. PE was considered unlikley given the patient's supratherapeutic INR on admission and good oxygenation. . She was transfered to the medical floor the first time on . She remained asymptomatic there but relatively hypotensive. On , she received a dose of zyprexa prior to an MRI, and her SBP was noted to be drop to the 60s. She also has found to have a UTI in the setting of this hypotension. She received 2L NS with improvement to the 80s, and was transferred back to the ICU, where levophed was again initiated. During her second ICU she was also aggressively diuresed as she had evidence of body volume overload and anasarca. With her known 4+ MR, it was felt that afterload reduction would improve her hemodynamics. She also received a transfusion of 1 unit of pRBCs to boost her intravascular oncotic pressure. She was slowly weaned down off pressors by . Of note, she had no evidence of hypoperfusion as evidenced by venous lactates of 1.1 despite a MAP in the 40s on one occasion. . She was transfered but to the medical floor on where her blood pressure remained stable on midodrine with occasional brief hypotensive episodes to the upper 70s. Even at these pressures mental status and urine output were maintained. Diuresis with bolus IV lasix was continued and then transfered to PO. However it was discontinued on because of increased autodiuresis and worsening tachycardia. With improved afib control with amio and dig her blood pressures improved to 120/80s. When a steady state if dig is reached, downtritration of midodrine showed be considered. . FAILURE TO THRIVE, PEG TUBE PLACEMENT: Ms. has been noted by family members, group home members and her out-pateint doctors to have had FTT over the several months with profound behavioral changes, including withdrawal and refusal to eat. Within the last year, she had been given a diagnosis of Alzheimer's Dementia (confirmed with neurologist Dr. in , MA). Per Dr. prior medical work-up for dementia and behavioral change had been negative, although it was difficult to obtain imaging studies as an out-patient due to the patient's inabilit to cooperate with the tests. Head CT was performed on in-house to complete a dementia work-up and showed no acute bleed or mass effect, but large 3rd & 4th ventricles. On admission, an NG tube was placed to deliver nutrition (albumin was noted to be 2.1), although the patient pulled out the NGT. Multiple conversations were had with the patient's HCP (her brother and sister-in-law about goals of care and the family's wishes. It was decided that she should have a PEG tube placed for feeding given her refusal to eat (throughout the admission she refused PO intake and medications, as well as mouth care). The surgical service placed a PEG tube on without complication. Medications were switched to PO and tube feedings were started on . After transfer to the floor Ms had an episode of hypoglyemia even with ongoing Tube feeds without residuals. Finger sticks were monitored, however no further hypoglyemia was noted. . ASPIRATION PNEUMONIA: During her second MICU stay she remained on TFs via her PEG tube. She did become nauseated and vomited x 1 on , with an associated desaturation and increased O2 requirement. It was felt c/w an aspiration event, and subsequent CXRs were c/w aspiration. She was begun on an empiric course of Vanc/Zosyn for a possible HAP x 10 day course ( - ). She was aggressively diuresed for concern of ARDS, but her O2 reuqirement was easily weaned back to baseline. Her paxil was d/c'ed out of concern for any contribution to an altered mental status. . ATRIAL FIBRILLATION: The patient was on sotalol and warfarin as an out-patient. INR was 11.3 on admission likely from poor nutritional status. She was given Vitamin K 5 mg and warfarin was held on admission with gradual improvement in INR. Sotalol was held while not taking PO medications; no other rate controlling agents were started given hypotension, and HR was generally in the 80-90 BPM range. By , her HR had started to climb to the 110-120's with occassional increases to the 130-140's (BP remained stable during these episodes). She was started on IV amiodarone for rhythm control on with good effect. After placement of the PEG tube, she was started on amiodarone 400 mg TID which was later deceased to 200 mg daily once a loading dose was finished. Warfarin was started on . On tachycardia worsening and unresponsive to metoprolol and fluids. Amio was increased to 400mg daily and Digoxin was loaded with 0.25mg x 4 IV. This load resulted in improved HR control with HR in 80-90s and a large increase IN BPs to 120s/80s. She is to continue on dig at .125mg daily. Please have her blood drawn on Tuesday, to measure her digoxin level. Fax this result to Dr. at (office phone ) and obtain recommendation from him regarding dosage changes of this medication. Dr. , her long-standing cardiologist, was aware of the plan to anticoagulate and discharge on PO amiodarone and Dig. He plans to electrically cardiovert in weeks after discharge. At the time of d/c INR had diped to 1.6 after decreasing the dose in the setting of a previously rising INR to 2.7. On coumadin was adjusted to previous home dose of 1 mg daily. INR is anticipated to rising quickly with this adjustment and subsequent increase in amiodarone dosage. INR should continue to be monitored closely. | Severe PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. FINAL REPORT REASON FOR EXAMINATION: Hypoxia. UPRIGHT AP VIEW OF THE CHEST: Mild cardiomegaly is redemonstrated. -- d/cd paxil as may be contributing to lethargy # ANEMIA: Hct stable, no evidence active bleeding. Mild (1+) AR.MITRAL VALVE: Myxomatous mitral valve leaflets. TECHNIQUE: Non-contrast head CT was obtained; the initial series was motion- degraded, and repeated. Hypotension: Still requiring some low dose pressors. Serial lactates have returned to limits. #) Dispo: ICU until above issues improved. Compared to the previous tracing of frequent ventricular ectopy has appeared. Probable slow atrial flutter or atrial tachycardia at rate of 185 withvariable dual level A-V block. Atrial flutter or tachycardia with 2:1 block. Atrial tachycardia or flutter with 2:1 block. EKG: Atrial fibrillation, normal axis, LVH with non-specific ST changes (T wave inversions in V2-V6 not seen on prior from ), question of ST depression in II, but not consistent--poor baseline. #) Dispo: ICU until above issues improved. -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on and remained afebrile; WBC normalized -- Manual BP to ensure correlates with automatic read -- cont D5 1/2NS for maintenance at 100 cc/hr -- wean levophed as tolerated #) Atrial fibrillation: Patient listed as on sotalol and coumadin as outpatient. -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on and remained afebrile; WBC normalized -- Manual BP to ensure correlates with automatic read -- cont D5 1/2NS for maintenance at 100 cc/hr -- wean levophed as tolerated #) Atrial fibrillation: Patient listed as on sotalol and coumadin as outpatient. -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on and remained afebrile; WBC normalized -- Manual BP to ensure correlates with automatic read -- cont D5 1/2NS for maintenance at 100 cc/hr #) Atrial fibrillation: Patient listed as on sotalol and coumadin as outpatient. #) Dispo: ICU until above issues improved (cannot be called out until off pressors) ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 11:46 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: #) Dispo: ICU until above issues improved. #) Dispo: ICU until above issues improved. Serial lactates have returned to limits. Serial lactates have returned to limits. #) PPx: SQ heparin until decision made re: heparin gtt & coumadin; PPI, bowel regimen if needed (would need to be PR given not taking PO . Coagulopathy (corrected) Assessment: Pt. -- Continue SQH for PPX for now #) Acute renal failure: resolved. #) Dispo: ICU until above issues improved. #) Dispo: ICU until above issues improved (cannot be called out until off pressors) ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 11:46 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: -Will attempt diuresis today in case RV distension is contributing to a diminished CO/HoTN. Microbiology: C diff: negative UCx: negative BCx: NGTD Assessment and Plan 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for pressor-dependent hypotension thought to be volume depletion; admitted now with hypotension. Microbiology: C diff: negative UCx: negative BCx: NGTD Assessment and Plan 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for pressor-dependent hypotension thought to be volume depletion; admitted now with hypotension. Levophed gtt weaned down and diuresis initiated. Levophed gtt weaned down and diuresis initiated. Levophed gtt weaned down and diuresis initiated. Peripheral edema: -If BP allows, will restart diuresis AF: Intermittently in AF -Continue amiodarone maintenance -Coumadin on hold for now as floor team had planned LP. Pt started on midodrine pngt. -Empiric Vanc/Zosyn for now. -Empiric Vanc/Zosyn for now. Pt w/ 1 episode of lg emesis followed by few small emesis. Also volume overloaded; pt with 4+ MR with intermittent RVR Hypotension (not Shock) Assessment: Pt remains on norpeip srip at .15 mcgs/kg/min Action: Attempted to wean drip Response: BP dropped to 77/48 Plan: Drip placed back to prior dose. Renal: Significant volume overload still -Goal net negative 1 liter with intermittent IV lasix AF: Remains on amiodarone, coumadin Somnolence: Paxil now d/c'd and reglan dose reduced. FWF at 30cc q6hr ICU - DNR/DNI - Requires ICU care - Prophy- PPI, warfarin. Course c/b aspiration event, with hypotension requiring vasopressors. TITLE: Chief Complaint: 24 Hour Events: - O2 requirement weaned down - remains on vanco/zosyn for presumptive HAP - remains on levophed - diuresed to goal on lasix gtt - had mild hematuria Allergies: Oxycodone Unknown; Ciprofloxacin Rash; Last dose of Antibiotics: Vancomycin - 07:41 AM Piperacillin - 06:00 AM Infusions: Norepinephrine - 0.15 mcg/Kg/min Other ICU medications: Metoprolol - 10:16 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:33 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.1C (98.7 Tcurrent: 36.3C (97.4 HR: 81 (79 - 180) bpm BP: 89/53(61) {67/37(48) - 129/112(116)} mmHg RR: 10 (10 - 19) insp/min SpO2: 100% Heart rhythm: AF (Atrial Fibrillation) Height: 62 Inch Total In: 2,493 mL 614 mL PO: TF: 656 mL 300 mL IVF: 1,227 mL 314 mL Blood products: Total out: 3,665 mL 850 mL Urine: 3,665 mL 850 mL NG: Stool: Drains: Balance: -1,172 mL -236 mL Respiratory support O2 Delivery Device: Aerosol-cool SpO2: 100% ABG: ///38/ Physical Examination General Appearance: Thin, NAD Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: unchanged 3/6 systolic murmur, irregularly irregular Respiratory / Chest:: poor air movement, + crackles bilateral way up Abdominal: Soft, Non-tender, Bowel sounds present Extremities: anasarca Labs / Radiology 391 K/uL 8.4 g/dL 93 mg/dL 0.9 mg/dL 38 mEq/L 3.9 mEq/L 13 mg/dL 92 mEq/L 133 mEq/L 24.5 % 8.1 K/uL [image002.jpg] 03:56 AM 03:16 AM 03:44 AM 02:25 AM 03:53 AM 04:53 AM WBC 9.8 7.9 8.0 9.1 8.6 8.1 Hct 26.3 24.6 25.6 27.0 25.3 24.5 Plt 367 324 338 371 380 391 Cr 0.6 0.7 0.6 0.7 0.9 0.9 TropT 0.05 Glucose 114 235 146 169 97 93 Other labs: PT / PTT / INR:19.9/31.0/1.9, CK / CKMB / Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %, Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL Imaging: none new Microbiology: BCx: NGTD C Diff: negative UCx: negative Assessment and Plan 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for pressor-dependent hypotension thought to be volume depletion; admitted now with hypotension, MICU course c/b aspiration event and increasing O2 requirement. -Continue midodrine -Follow up on cultures sent at time of transfer -Avoid zyprexa for now Peripheral edema: -Will diurese again today with lasix drip, goal negative 1 liter. -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on and remained afebrile; WBC normalized -- Manual BP to ensure correlates with automatic read -- will trial lasix 20mg IV for diuresis to help reduce preload given severe MR -- wean levophed as tolerated #) Atrial fibrillation: Patient on sotalol and coumadin as outpatient. Pt is now a DNR/DNI. ?check albumin levelstart tf. ?check albumin levelstart tf. ?check albumin levelstart tf. ?check albumin levelstart tf. + Mitral regurg. + Mitral regurg. + Mitral regurg. + Mitral regurg. Coagulopathy Assessment: Pt. Dvt prophylaxis with heparin sc. Dvt prophylaxis with heparin sc. Dvt prophylaxis with heparin sc. Dvt prophylaxis with heparin sc. Compazine and Reglan given. Start heparin gtt/coumadin for afib? | 231 | [
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652253,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:41 AM\n EKG - At 10:20 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:41 AM\n ng tube\n TTE done yesterday-->Severe MR = 60-64, Nml Biventricular\n function, no pericardial effusion\n Pressors tapered overnight but had to be increased this AM for HoTN.\n Patient self-d/c'd NGT.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:39 AM\n Vancomycin - 10:00 AM\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:54 AM\n Lorazepam (Ativan) - 10:17 AM\n Other medications:\n Thiamine, MVI, Trileptal, Folate, Levothyoxine, Pantoprazole, Valproate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 102 (82 - 111) bpm\n BP: 74/55(51) {71/43(49) - 115/92(97)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,948 mL\n 3,892 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 3,882 mL\n Blood products:\n Total out:\n 770 mL\n 670 mL\n Urine:\n 770 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 3,222 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.0 g/dL\n 324 K/uL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Microbiology: BCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present. Poor\n cardiac output from severe MR may be playing a role. No clear source\n of sepsis. Unclear if non-invasive BP's are accurate as she is alert\n and often times yelling with SBP's of 60's.\n -Will wean off pressors and follow lactates for signs of\n hypoperfusion. Her behavior prohibits A-line placement at this time.\n -D/C vancomycin. If UCx negative, will d/c zosyn.\n Hypernatremia: Hypovolemic. Improving\n -Continue with free water in D5 1/2NS drip. If continues to improve\n today, switch to Qdaily checks tomorrow\n Failure to Thrive: Needs GOC discussion. Patient not tolerating NGT\n placement and may not tolerate PEG placement. Will try to meet with\n family when able.\n -Continue vitamin support\n -Continue hydration\n Elevated cardiac Biomarkers: Appears stress related. No further\n intervention\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Will address this issue with family.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 656113,
"text": "Chief Complaint: Hypotension\n Aspiration pneumonia\n 24 Hour Events:\n -- got one unit RBC's\n -- consented for blood, not for ICU yet\n -- weaned off levophed in the afternoon\n -- remained on lasix drip\n History obtained from Patient\n Allergies:\n History obtained from PatientOxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:33 PM\n Piperacillin - 06:25 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 87 (80 - 98) bpm\n BP: 88/49(58) {70/34(45) - 100/59(63)} mmHg\n RR: 14 (9 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,647 mL\n 665 mL\n PO:\n TF:\n 1,335 mL\n 406 mL\n IVF:\n 1,802 mL\n 229 mL\n Blood products:\n 350 mL\n Total out:\n 5,000 mL\n 1,490 mL\n Urine:\n 5,000 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,353 mL\n -825 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n Anteriorly, Diminished: At bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG in place\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 511 K/uL\n 9.4 g/dL\n 66 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 93 mEq/L\n 133 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n 03:40 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n 6.3\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n 27.8\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n 511\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n 66\n Other labs: PT / PTT / INR:25.7/36.8/2.5, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR :\n IMPRESSION: Interval increase in right upper lobe opacification\n consistent\n with worsening aspiration or pneumonia. Persistent mild congestive\n heart\n failure and bilateral lower lobe air space consolidation\n Microbiology: No new data\n Assessment and Plan\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:20 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 656116,
"text": "Chief Complaint: Hypotension\n Aspiration pneumonia\n 24 Hour Events:\n -- got one unit RBC's\n -- consented for blood, not for ICU yet\n -- weaned off levophed in the afternoon\n -- remained on lasix drip\n History obtained from Patient\n Allergies:\n History obtained from PatientOxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:33 PM\n Piperacillin - 06:25 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 87 (80 - 98) bpm\n BP: 88/49(58) {70/34(45) - 100/59(63)} mmHg\n RR: 14 (9 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,647 mL\n 665 mL\n PO:\n TF:\n 1,335 mL\n 406 mL\n IVF:\n 1,802 mL\n 229 mL\n Blood products:\n 350 mL\n Total out:\n 5,000 mL\n 1,490 mL\n Urine:\n 5,000 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,353 mL\n -825 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n Anteriorly, Diminished: At bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG in place\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 511 K/uL\n 9.4 g/dL\n 66 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 93 mEq/L\n 133 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n 03:40 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n 6.3\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n 27.8\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n 511\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n 66\n Other labs: PT / PTT / INR:25.7/36.8/2.5, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR :\n IMPRESSION: Interval increase in right upper lobe opacification\n consistent\n with worsening aspiration or pneumonia. Persistent mild congestive\n heart\n failure and bilateral lower lobe air space consolidation\n Microbiology: No new data\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n -- CXR without significant improvement overall\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - blood cx from the aspiration event with NGTD, sputum was not produced\n by patient\n - weaning supplemental O2 , now on NC\n - continue diuresis to minimize pulm edema\n - TFs back on\n - standing reglan to avoid repeat N/V\n # Hypotension: not septic shock as does not even meet SIRS criteria.\n She did have a UTI but had been fully treated, with a negative\n surveillance urine culture from . No evidence of\n hypovolemic/hemorrhagic shock. Unclear how much autonomic instability\n is contributing to (chronic) hypotension. With severe MR on recent\n echo, poor forward flow is a likely contributor to hypoTN.\n -- not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n -- continue midodrine 10mg TID\n -- levophed has been off nearly 24 hrs\n -- lasix gtt changed to lasix boluses\n -- lytes\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily but may need to alternate 1mg/0.5mg dose\n -- trend INR\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- d/c\nd paxil as may be contributing to lethargy\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- transfused 1 unit to improve intravascular volume\n # Hyponatremia\n Resolved with diuresis\n -- lasix boluses, goal 1L neg\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:20 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652712,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained in AFib yesterday with occasional RVR.\n Antibiotics D/c'd yesterday.\n Remains on pressors, although requiring less.\n Still refusing po meds.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MVI, folate, Thiamin, Valproate, Levothyroxine IV, HSQ, RISS, Lamictal\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 111 (94 - 116) bpm\n BP: 98/63(69) {67/40(49) - 131/97(106)} mmHg\n RR: 14 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,308 mL\n 1,407 mL\n PO:\n TF:\n IVF:\n 4,308 mL\n 1,407 mL\n Blood products:\n Total out:\n 1,030 mL\n 855 mL\n Urine:\n 1,030 mL\n 705 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 3,278 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, More awake today\n Head, Ears, Nose, Throat: Normocephalic, MM dry\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Limited cooperation\n with exam\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Moans during\n exam\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 222 K/uL\n 116 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 114 mEq/L\n 142 mEq/L\n 28.6 %\n 8.3 K/uL\n [image002.jpg]\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n Plt\n 22\n Cr\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n Glucose\n 189\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present.\n Seems distributive shock. Poor cardiac output from severe MR may be\n playing a role although exam not consistent with this. Also though her\n RV function was normal she has mod pHTN so perhaps overresuscitated and\n RV distension. No clear source of sepsis. Unclear if non-invasive BP's\n are accurate as she is alert and often yelling with SBP's of 60's.\n stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Resolved\n -Continue with D5 1/2 NS maintenance fluids\n Failure to Thrive: Spoke with patient's sister-in-law at length\n yesterday. She and pt's brother will meet with us again today\n regarding ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR.\n -Will assess HR as we wean down levophed\n -If RVR is persistent problem, consider amio load.\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. need PICC with conscious sedation.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655002,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Diuresed yesterday/overnight. Levophed weaned,\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 0.5 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Levophed, bactrim, amiodarone, levothyroxine, Atrovent, Valproate,\n lansoprazole, paxil, warfarin, midodrine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98\n HR: 88 (84 - 96) bpm\n BP: 93/49(61) {77/41(51) - 104/64(72)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,237 mL\n 1,032 mL\n PO:\n TF:\n 1,147 mL\n 572 mL\n IVF:\n 689 mL\n 230 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,670 mL\n Urine:\n 3,160 mL\n 1,670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -923 mL\n -638 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///39/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Improved compared to\n yesterday)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 338 K/uL\n 146 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 94 mEq/L\n 134 mEq/L\n 25.6 %\n 8.0 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n WBC\n 9.8\n 7.9\n 8.0\n Hct\n 26.3\n 24.6\n 25.6\n Plt\n 367\n 324\n 338\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n Other labs: PT / PTT / INR:24.4/35.9/2.4, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.9 mg/dL\n Microbiology: BCx: NGTD\n UCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Continue midodrine\n -Follow up on cultures sent at time of transfer\n -Avoid zyprexa for now\n Peripheral edema:\n -Will diurese again today with lasix drip, goal negative 1 liter.\n Respiratory: CXR exam suggest mix of pulmonary edema +/- aspiration.\n No clinical signs of PNA at present.\n -Diuresis as above\n -Aspiration precautions\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -No plan for LP per neuro, so coumadin restarted.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:08 AM 64. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053911,
"text": " 6:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with ?altered mental status, risk of aspriation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status with possible risk for aspiration.\n\n COMPARISON: Chest radiograph, .\n\n UPRIGHT AP VIEW OF THE CHEST: Mild cardiomegaly is redemonstrated. The\n mediastinal and hilar contours are unchanged and within normal limits. The\n pulmonary vascularity is normal. The lungs are clear. There is no focal\n consolidation, pleural effusions or pneumothorax. Right upper quadrant\n abdominal surgical clips denote prior cholecystectomy.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-23 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1053947,
"text": ", Y. MED MICU-7 12:25 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for evidence of obstruction, constipation\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Down's syndrome, unable to communicate, presents with no\n PO intake, failure to thrive, acute renal failure, has hx of significant\n constipation\n REASON FOR THIS EXAMINATION:\n please assess for evidence of obstruction, constipation\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of obstruction or ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-23 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1053946,
"text": " 12:25 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for evidence of obstruction, constipation\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Down's syndrome, unable to communicate, presents with no\n PO intake, failure to thrive, acute renal failure, has hx of significant\n constipation\n REASON FOR THIS EXAMINATION:\n please assess for evidence of obstruction, constipation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf WED 9:41 PM\n PFI: No evidence of obstruction or ileus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Down syndrome, unable to communicate, presents with no p.o. intake,\n failure to thrive, acute renal failure, history of significant constipation.\n Assess for evidence of obstruction, constipation.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n COMPARISON: Compared to radiograph from .\n\n FINDINGS: There is no evidence of ileus, obstruction, or free air. There is\n normal bowel gas pattern. Clips are seen in the right upper abdominal\n quadrant likely from previous cholecystectomy. There is a single clip in the\n left lateral mid abdomen.\n\n IMPRESSION: No evidence of obstruction or ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1054157,
"text": " 5:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate NG tube placement\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with down syndrome, alzheimer's p/w failure to thrive\n REASON FOR THIS EXAMINATION:\n please evaluate NG tube placement\n ______________________________________________________________________________\n WET READ: GWp WED 8:48 PM\n OGT tip projects over gastric antrum GWlms\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Down syndrome, Alzheimer, check position of nasogastric\n tube.\n\n The tip of the nasogastric tube lies within the region of the pylorus in a\n satisfactory position. Atelectasis at the left base is present.\n\n IMPRESSION: Nasogastric tube satisfactory, atelectasis left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1055224,
"text": " 5:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Down's syndrome, likely alzheimer's dementia, altered\n mental status, not yet had imaging per outside neurologist\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl 7:42 PM\n Enlargement of the lateral, third and fourth ventricles, somewhat out of\n proportion to the degree of prominence of the cerebral sulci. Bifrontal\n subcortical hypodensities, without findings to suggest that this is an acute\n process.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: 52-year-old woman with Down's syndrome and likely Alzheimer\n dementia, with altered mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT was obtained; the initial series was motion-\n degraded, and repeated.\n\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, shift\n or shift of normally midline structures.\n\n The ventricles are markedly enlarged, somewhat out of portion to the degree of\n prominence of the cerebral sulci. Periventricular regions of hypodensity are\n compatible with chronic small vessel infarction. More prominent bifrontal\n subcortical hypodense regions may represent discrete larger vessel infarcts,\n but demonstrate no positive mass-effect, and do not appear acute. The\n posterior fossa is unremarkable, although its evaluation is limited by motion\n artifact.\n\n No suspicious osseous lesion is identified. Paranasal sinuses and mastoid air\n cells are well-aerated.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage or edema.\n 2. Marked, disproportionate enlargement of the 3rd, 4th and left more\n than right lateral ventricles, with no prior study available for comparison.\n\n COMMENT: While this may simply represent disproportionate central atrophy,\n perhaps related to the given history of Alzheimer dementia, underlying\n communicating hydrocephalus cannot be excluded based on this morphology, and\n the findings should be closely correlated clinically (ie. is there clinical\n evidence of NPH?).\n (Over)\n\n 5:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1055225,
"text": ", P. MED MICU-7 5:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Down's syndrome, likely alzheimer's dementia, altered\n mental status, not yet had imaging per outside neurologist\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT (REVISED)\n Enlargement of the lateral, third and fourth ventricles, somewhat out of\n proportion to the degree of prominence of the cerebral sulci. Bifrontal\n subcortical hypodensities, without findings to suggest that this is an acute\n process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057252,
"text": " 4:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval change\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc 7:25 PM\n No significant change compared to the prior study, still combination of\n pulmonary edema and multiple parenchymal opacities that might be consistent\n with aspiration. Slight improvement of the right upper lung opacity due to\n resolution of aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph was compared to obtained at\n 05:11.\n\n The patient continues to be in pulmonary edema in addition to bilateral\n opacities that might be consistent with aspiration. No focal air trapping is\n currently seen in the right lower lung with just some spared lung adjacent to\n the heart border. The right PICC line tip is in superior SVC. The\n cardiomegaly is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057253,
"text": ", P. MED MICU-7 4:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval change\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to the prior study, still combination of\n pulmonary edema and multiple parenchymal opacities that might be consistent\n with aspiration. Slight improvement of the right upper lung opacity due to\n resolution of aspiration.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Report",
"row_id": 95354,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion.\nWeight (lb): 108\nBP (mm Hg): 101/71\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 09:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA volume markedly increased (>32ml/m2).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe MVP. Eccentric\nMR jet. Severe (4+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrial volume is markedly increased (>32ml/m2). The interatrial\nseptum is aneurysmal. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are myxomatous. There is\nmoderate/severe mitral valve prolapse. An eccentric, posteriorly directed jet\nof severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is severe pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Severe prolapse of the anterior leaflet of the mitral valve with\nsevere, posteriorly directed mitral regurgitation, severe pulmonary\nhypertension and an inter-atrial septum that is bowed towards the right.\nBiventricular systolic function looks normal. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057929,
"text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Downs, end stage Alzheiemers, s/p aspiration event \n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc WED 3:02 PM\n PFI: Interval development of right upper lobe opacification consistent with\n worsening aspiration and/or pneumonia. Persistent bilateral lower lobe air\n space consolidation. Persistent mild congestive heart failure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 52-year-old female with Down's syndrome and end-\n stage Alzheimer's disease status post aspiration on . Please evaluate\n for interval change.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiographs from .\n\n FINDINGS: There is interval development of diffuse air space consolidation\n involving the right upper lobe that is consistent with worsening pneumonia\n and/or aspiration. There continues to be bilateral hazy opacities that are\n consistent with aspiration and/or pneumonia. There is engorgement of the\n pulmonary venous vasculature that is compatible with superimposed mild\n congestive heart failure. The cardiomediastinal silhouette is stable with\n moderate cardiomegaly. No pleural effusions or pneumothorax is seen. The\n visualized osseous structures are unremarkable. There is a right-sided PICC\n line with tip in stable position terminating within the mid SVC. Clips are\n noted within the right upper quadrant.\n\n IMPRESSION: Interval increase in right upper lobe opacification consistent\n with worsening aspiration or pneumonia. Persistent mild congestive heart\n failure and bilateral lower lobe air space consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1056442,
"text": ", P. MED MICU-7 8:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: Increased pulmonary congestion but also multiple parenchymal patchy\n infiltrates. Differential diagnoses include atypical edema but possible\n superimposed infectious processes due to aspiration. Further follow up\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057930,
"text": ", P. MED MICU-7 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Downs, end stage Alzheiemers, s/p aspiration event \n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Interval development of right upper lobe opacification consistent with\n worsening aspiration and/or pneumonia. Persistent bilateral lower lobe air\n space consolidation. Persistent mild congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057087,
"text": ", P. MED MICU-7 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PLease evaluate for interval change in infiltrates & effusio\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with AD, Down's syndrome. C/f possible aspiration event last\n night.\n REASON FOR THIS EXAMINATION:\n PLease evaluate for interval change in infiltrates & effusions.\n ______________________________________________________________________________\n PFI REPORT\n Right PICC ends in upper SVC. Severe cardiomegaly. Interstitial edema is\n unchanged. Bilateral multifocal alveolar opacity increased in right upper\n lobe and both bases could be aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1057088,
"text": " 4:09 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for obstruction, other acute pathology.\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman AD, Down's syndrome. Emesis overnight.\n REASON FOR THIS EXAMINATION:\n Please evaluate for obstruction, other acute pathology.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc 9:46 AM\n No ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE ABDOMEN\n\n INDICATION: 52-year-old woman with Down syndrome, emesis, evaluate for\n obstruction.\n\n COMPARISON: .\n\n FINDINGS: There is no ileus or obstruction. Amorphous air collections about\n the gastrostomy tube may represent residual post-operative air. The limited\n view of the lung bases is normal. There are no abnormal calcifications. The\n bones are normal.\n\n IMPRESSION: No acute intra-abdominal process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1054989,
"text": " 3:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,46cm and needs tip con\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with afib who needs picc for IV access.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,46cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 52-year-old female with atrial fibrillation who\n needs PICC for IV access. Please evaluate position of right-sided PICC line\n placement.\n\n EXAMINATION: Single portable semiupright chest radiograph.\n\n COMPARISON: Comparison to radiographs from and .\n\n FINDINGS: There is a right-sided PICC line that extends beyond approximately\n 15 cm through to the brachiocephalic vein. The pulmonary vasculature is\n prominent consistent with mild congestive heart failure. There are bibasilar\n atelectatic changes, and underlying pneumonia cannot be excluded. There is\n prominent left atrial enlargement. There is prominent interval development of\n left atrial enlargement as compared to prior chest radiographs. No\n pneumothorax is seen. The mediastinal contours are stable in appearance.\n There are clips noted within the right upper quadrant. There is a rounded\n ill-defined opacity projecting over the right upper quadrant of indeterminate\n significance. The visualized osseous structures are stable in appearance.\n\n IMPRESSION:\n 1. PICC line extending 15 cm beyond through to the brachiocephalic vein.\n\n 2. Interval left atrial enlargement. An echocardiogram can be performed for\n further evaluation as clinically indicated.\n\n 3. Mild congestive heart failure.\n\n 4. Bibasilar atelectatic changes, an underlying pneumonia cannot be excluded.\n\n ADDENDUM: These findings were discussed with at 5 p.m.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1056441,
"text": " 8:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 8:32 PM\n PFI: Increased pulmonary congestion but also multiple parenchymal patchy\n infiltrates. Differential diagnoses include atypical edema but possible\n superimposed infectious processes due to aspiration. Further follow up\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Hypotension, evaluate for infiltrates.\n\n _____: AP single view of the chest was obtained with patient in sitting\n semi-upright position and analysis is performed in direct comparison with a\n preceding similar chest examination of .\n\n FINDINGS: As before marked cardiomegaly including significant enlargement of\n the left atrium. Previously identified mal-placed right-sided PIC line is now\n in appropriate position pointing downwards and overlying the SVC at the level\n of the carina. No pneumothorax is seen. In comparison with the previous\n study of the pulmonary vasculature is now markedly more prominent\n and shows perivascular haze throughout. There are multiple patchy infiltrates\n bilaterally in the lungs. They could represent atypically distributed\n pulmonary edema patches in this disabled patient with presently marked\n hypotension. Possibility of superimposed infections or multiple aspiration\n infiltrates must however be considered as well.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1057089,
"text": ", P. MED MICU-7 4:09 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for obstruction, other acute pathology.\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman AD, Down's syndrome. Emesis overnight.\n REASON FOR THIS EXAMINATION:\n Please evaluate for obstruction, other acute pathology.\n ______________________________________________________________________________\n PFI REPORT\n No ileus or obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1057086,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PLease evaluate for interval change in infiltrates & effusio\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with AD, Down's syndrome. C/f possible aspiration event last\n night.\n REASON FOR THIS EXAMINATION:\n PLease evaluate for interval change in infiltrates & effusions.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 1:35 PM\n Right PICC ends in upper SVC. Severe cardiomegaly. Interstitial edema is\n unchanged. Bilateral multifocal alveolar opacity increased in right upper\n lobe and both bases could be aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 52-year-old woman with AD, Down syndrome, possible\n aspiration event last night. Evaluate for interval change.\n\n Since , a right PICC still ends in the upper SVC. Severe\n cardiomegaly and interstitial edema are unchanged. Small left pleural\n effusion is also stable.\n\n Multiple bilateral alveolar opacities increased in the right upper lobe and\n both bases, could be due to aspiration. Area of lucency adjacent to the right\n heart border is likely air trapping at the base, should be followed on further\n imaging.\n\n Clips are in the right upper quadrant and a gastrostomy tube is in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-05 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1056254,
"text": " 10:46 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: concern for communicating hydrocephalus\n Admitting Diagnosis: ACUTE RENAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with inceased ventricular size on CT\n REASON FOR THIS EXAMINATION:\n concern for communicating hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increased ventricular size on CT, evaluate for communicating\n hydrocephalus.\n\n COMPARISON: CT head, .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained.\n FINDINGS: Ventricles again appear markedly enlarged, with enlargement of the\n third, fourth, and left more than right lateral ventricles. This appearance\n is similar compared to prior CT. Multiple foci of increased T2 signal are\n seen in the periventricular white matter of both cerebral hemispheres.\n Additionally, scattered foci of increased T2 signal are seen within the\n frontal lobes bilaterally, as well as the occipital lobes bilaterally,\n suggesting prior infarcts. Small foci of blooming artifact consistent with\n prior blood products seen on GRE images. No abnormal restricted diffusion\n identified to suggest infarct.\n\n MRA demonstrates patent circle of and branches without evidence of\n aneurysm or stenosis. Left vertebral artery is not definitely visualized,\n possibly representing occlusion at the origin.\n\n IMPRESSION:\n 1. Markedly dilated ventricles again demonstrated, unchanged from prior CT.\n Findings could be consistent with communicating hydrocephalus and correlation\n for possible NPH is recommended.\n 2. Multiple old infarcts again identified, not significantly changed from\n prior CT.\n 3. Left vertebral artery not definitely visualized, possibly occluded at the\n origin versus hypoplastic artery, consider MRA neck for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-29 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1055130,
"text": " 10:16 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placed crosses midline, needs either a new PICC\n Admitting Diagnosis: ACUTE RENAL\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with Down's Syndrome, alzheimer dementia, failure to thrive\n REASON FOR THIS EXAMINATION:\n PICC placed crosses midline, needs either a new PICC or fluoroscopic\n guidance for re-positioning, thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Malposition of indwelling PICC line. A timeout was performed.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure. Dr. ,\n the attending radiologist, was present and supervised the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling right arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\n peel-away sheath was then placed over the guidewire. A new single-lumen PICC\n line measuring 40 cm in length was then placed through the peel-away sheath\n with its tip positioned in the SVC under fluoroscopic guidance. Position of\n the catheter was confirmed by a fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new\n single-lumen PICC with the tip positioned in the SVC. The line is ready to\n use.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-22 00:00:00.000",
"description": "Report",
"row_id": 253332,
"text": "Compared to the previous tracing no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-21 00:00:00.000",
"description": "Report",
"row_id": 253333,
"text": "Compared to the previous tracing ventricular rate is slower at a rate of 90.\nThe mechanism continues to be atrial tachycardia or very slow atrial flutter\nwith dual level A-V block. Non-specific repolarization abnormalities, most\nmarked laterally persist.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-21 00:00:00.000",
"description": "Report",
"row_id": 253334,
"text": "Probable slow atrial flutter or atrial tachycardia at rate of 185 with\nvariable dual level A-V block. Ventricular rate is approximately 131.\nCompared to the previous tracing of probably no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Report",
"row_id": 253335,
"text": "Atrial flutter versus atrial tachycardia with variable conduction. Diffuse\nnon-specific ST-T wave changes. Mild QTc interval prolongation. Compared to\nthe previous tracing of ventricular ectopy is absent, the ventricular\nresponse is faster and the Q-T interval appears more prolonged.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Report",
"row_id": 253336,
"text": "Atrial flutter with 2:1 A-V conduction and frequent ventricular ectopy\nin a trigeminal fashion. Compared to the previous tracing of \nfrequent ventricular ectopy has appeared. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Report",
"row_id": 253337,
"text": "Atrial flutter is likely with 3:1 conduction. Occasional ventricular premature\nbeats. Compared to the previous tracing of no definite change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Report",
"row_id": 253338,
"text": "Atrial tachycardia or flutter with 2:1 block. Since the previous tracing\nthe rate is slightly slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-22 00:00:00.000",
"description": "Report",
"row_id": 253339,
"text": "Atrial flutter or tachycardia with 2:1 block. Since the previous tracing\nthe heart rate has increased. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652325,
"text": "HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652379,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt with labile BP, systolic mid 90s.\n Action:\n BP supported by Levophed, unable to wean. This was briefly shut off per\n order by Dr. , with SBP down to 50s. Pt also given 1L fluid\n bolus LR for low u/o and BP.\n Response:\n Ongoing assessment and awaiting response.\n Plan:\n Wean Levophed, fluid boluses as needed for low u/o and BP.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is confused with dementia at baseline and has Downs Syndrome. Pt had\n been awake all night the previous day and yelling out and crying. Pt\n was more somulent overnight, but resting comfortably. Pt only yelling\n out and crying when turned and washed.\n Action:\n Pt had received Ativan x1 on previous shift.\n Response:\n Pt had good response to Ativan,\n Plan:\n Cont to monitor MS, provide comfort and emotional support. Ongoing\n communication with pt\ns brother to review goals of care.\n ------ Protected Section ------\n Of note, pt found to have new left sided facial swelling. Dr.\n notified, will cont to monitor.\n ------ Protected Section Addendum Entered By: , RN\n on: 04:44 AM ------\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 651968,
"text": "Chief Complaint: Hypernatremia, hypotension, acute renal failure,\n failure to thrive\n HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n Per report, her caregiver stated that her mental status appeared at\n baseline, which was not very communicative. A copy of her PCP visit\n note accompanies her paperwork and describes that she has lost about 35\n lbs, and possibly has been vomiting. Her INR was 7 recently and she\n received vitamin K for that.\n .\n Based on a speech and swallow evaluation note from in OMR, at\n that time staff in the group home were concerned about the patient's\n lack of PO intake. It was described at that time that the patient was\n refusing former favorite foods, and would eat about spoonfulls\n prior to spitting out solid foods at meals; there was also concern\n about choking on pills. It was also noted that the patient appeared to\n regurgitate food after meals (ongoing behavoir for 20 years). It was\n noted that she had lost about 15 pounds due to this behavoir. The\n evaluation by the speech and swallow team determined that her\n inadequate PO intake was possibly secondary to dementia and behavoiral\n changes, although further studies were recommended given inability to\n fully evaluate.\n .\n Also of note, patient was admitted in for failure to thrive\n and decreased PO intake. It was found that she was constipated, and she\n was tolerating a regular diet prior to discharge.\n .\n In the ED, initially it was difficult to measure the patient's blood\n pressure. Her heart rate was 90, respiratory rate of 14, with\n difficulty measuring oxygen saturation. First recorded blood pressure\n was 92/palp, with oxygen saturation of 100%. Patient was lethargic but\n responsive with moaning and crying out to verbal stimuli. She was given\n 2L of NS initially when her SBP dropped to 70's and 80's. She was\n guaiac negative, and a chest x-ray was unremarkable. Labs were notable\n for renal insufficiency, hypernatremia (166), hyperchloremia (124),\n lactate of 9.2, INR of 9.6 (then >11), and leukocytosis of 14.\n A femoral line was placed and patient was given 4L of IVF with\n improvement to systolics in 100's. However, then patient fell asleep\n and systolic dropped to 70's, so she received an additional 2 liters\n and levophed was started. She was given vancomycin and zosyn, and\n cultures were drawn. She was also given 5 mg of IV vitamin K for\n elevated INR. EKG was without concering changes. FAST was negative (no\n free fluid, bedside echo looked ok).\n .\n Upon arrival to the floor, patient was crying out. She would make eye\n contact occasionally and stated \"I love you\" once, otherwise was\n incomprehensible.\n History obtained from Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other medications:\n Home Medications:\n (per office visit note faxed over)\n - Coumadin 1 mg daily\n - Senna 8.6 mg daily\n - Sotalol 120 mg \n - Potassium Chloride 40 mEq daily\n - Lasix 40 mg daily\n - Ketaconazole as needed\n - Triamcinolone cream as needed\n - Prilosec 20 mg \n - Bacitracin ointment PRN\n - Amoxicillin prior to dental procedures\n - Levothyroxine 75 mcg\n - Lorazepam 1 mg prior to medical procedures\n - Depakote 1500 mg daily\n - Trileptal 300 mg \n Past medical history:\n Family history:\n Social History:\n - Down's syndrome\n - Alzheimers Dementia\n - Mitral valve regurgitation, followed by Dr. \n - Hypothyroidism\n - Status-post right mastectomy for breast cancer, last mammogram \n WNL\n - Atrial fibrillation\n - History of bacterial endocarditis in \n - Status-post appendectomy (laproscopic )\n - Esophageal reflux and H. Pylori infection ()\n - Status-post cholecystectomy\n - Status-post laparoscopic umbilical hernia repair\n - Status-post gangrenous cholecystitis, lap chole \n Unable to obtain.\n Patient lives in group home. She recently has stopped walking and has\n been in a wheelchair. No alcohol, drug, or tobacco use. She enjoys\n playing with beads (per office note).\n Review of systems:\n As noted in HPI.\n Flowsheet Data as of 03:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 100 (83 - 100) bpm\n BP: 79/56(61) {71/22(47) - 111/57(69)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,049 mL\n 1,973 mL\n PO:\n TF:\n IVF:\n 49 mL\n 1,973 mL\n Blood products:\n Total out:\n 760 mL\n 105 mL\n Urine:\n 60 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 1,868 mL\n Respiratory\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Temperature 95.7, HR 99, BP 111/57, RR 13, Oxygenation 100% on RA\n General: Thin, slightly catchetic female, moving around in bed when\n name is called, crying out and alternatively curling up\n HEENT: Very dry mucous membranes with fissuring of the lipds and\n tongue. PERRL, no scleral icterus or conjunctival pallor.\n Neck: Supple, no JVD\n Cardiac: RR, III/VI holosystolic murmur, no rubs or gallops\n Lungs: CTAB, although examination limited by effort, no apparent\n wheezes, raltes\n Abd: Soft, +BS, ND, cannot assess for tenderness, but no guarding\n Extr: Very dry, cracked skin over dorsum of hands, feet. Few small\n ecchymoses over right thigh, no discrete rashes or other lesions.\n Neuro: Awake, agitated, difficult to understand when makes attempts at\n speaking, CNs appear symmteric, moving all extremities equally\n Labs / Radiology\n 122 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 124 mEq/L\n 3.4 mEq/L\n 163 mEq/L\n 33.4 %\n [image002.jpg]\n \n 2:33 A12/30/ 11:24 PM\n \n 10:20 P12/30/ 11:30 PM\n \n 1:20 P12/31/ 01:10 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 33.4\n Cr\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, Lactic Acid:1.3 mmol/L, Ca++:6.2 mg/dL, Mg++:2.2\n mg/dL, PO4:4.3 mg/dL\n Microbiology Data:\n - Blood and urine cultures pending.\n .\n Imaging: CXR without acute process.\n KUB Pending.\n .\n EKG: Atrial fibrillation, normal axis, LVH with non-specific ST changes\n (T wave inversions in V2-V6 not seen on prior from ), question of\n ST depression in II, but not consistent--poor baseline. RBBB\n Assessment and Plan\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR.\n #) Hypotension: Differential includes hypovolemia secondary to very\n poor PO intake for a prolonged period, sepsis from underlying occult\n infection, cardiac shock or secondary to cardiac event in setting of\n elevated cardiac enzymes. No steroid use to make adrenal insufficiency\n more likely. Initially was tachycardiac, but not hypoxic to suggest PE\n with compromised cardiac output; additionally patient is already on\n coumadin making this less likely, especially with supratherapeutic\n levels. Attempted to measure pulsus, but was unable to do so secondary\n to patient repeatedly moving around.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis unremarkable), stool for c. diff should she have\n diarrhea\n - Transthoracic Echo in morning to assess for wall motion\n abnormalities, structure, function, effusion\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Levophed as needed should IVFs not improve BP\n - Trend lactate\n - Cortisol with AM labs\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Will need to investigate and discuss goals of care, as PEG tube may\n be necessary to meet caloric needs given that patient has had ongoing\n difficulties with PO intake since at least . Patient also has\n been recommended to get EGD to evaluate her dysphagia further, so\n consideration for completion of this on an inpatient basis should be\n made.\n - Supportive care with IVFs, electrolyte repletion\n - Working up infectious etiology\n - TSH, FT4\n - Speech and swallow evaluation\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabalized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n .\n #) Acute renal failure: Given elevated BUN, and history of virtually no\n PO intake for extended period, suspect pre-renal etiology. Baseline\n creatinine from was around 1.0. Improved to 2.4 after 6 L of\n IVFs.\n - Continue to trend creatinine, BUN\n - Urine electrolytes to be sent\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - VBG to check pH to ensure not acidotic (bicarbonate appears to be\n WNL, however)\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D5 or D51/2NS once no longer\n requiring IVF boluses to maintain BP.\n - Frequent (Q3-4 H) sodium checks\n .\n #) Hyperchloremia: Again suspected to be secondary to severe\n dehydration. No history of diarrhea or other GI symptoms to suggest\n etiology.\n - Using LR for volume resuscitation in lieu of NS.\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\n - Serial EKGs\n - Continue sotalol\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Re-check in AM\n - Checking VBG to ensure not acidotic.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption.\n - Holding coumadin, received 5 mg vitamin K in ED, following trend\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in atrial fibrillation, rate in 100's. Will hold\n at this time given risk of worsening hypotension.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (will concurrently\n evaluate for vegetation), KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out.\n .\n #) Hypothyroidism: Checking TSH/FT4. Continue home supplementation\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVFs, until speech and swallow evaluation. Nutrition\n consult appreciated.\n .\n #) PPx: Supratherapeutic INR, PPI.\n .\n #) Code: Full per ED discussion with patient's HCP's\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n Per ED discussion with family, she is full code.\n .\n #) Access: Right femoral central line placed in ED.\n .\n #) Dispo: ICU until above issues improved.\n ICU Care\n Nutrition: IVF, nutrition consult and speech and swallow consults\n placed\n Glycemic Control: N/A\n Lines:\n Multi Lumen - 11:46 PM\n 22 Gauge - 11:47 PM\n Prophylaxis:\n DVT: Supratherapeutic INR\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments: As noted above\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651960,
"text": "52 yo female with h/op downs syndrome, dementia and afib on coumadin\n who comes into the emergency room after visit with her pcp. lives\n in a group home and was brought to pcp failure to thrive poor to no\n po intake ? how long. She has had a 35lb weight loss and has had\n difficulty with her gait and per report has been wheelchair bound x\n several weeks. She has had swallowing studies and it remains unclear\n whether pt has difficulty swallowing or is having behavioral issue\n spitting out food, she is also know to regurgitate food which has been\n going on for awhile.. She comes into the ED from PCP she is hypotensive\n requiring 6liters NS she was put on Levophed, her electrolytes were\n grossly abnl with a cr 3.4\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651994,
"text": "52 yo female with h/o downs syndrome, dementia and afib on coumadin who\n comes into the emergency room after visit with her pcp. lives in a\n group home and was brought to pcp failure to thrive poor to no po\n intake ? how long. She has had a 35lb weight loss, and has had\n difficulty with her gait and per report has been wheelchair bound x\n several weeks. She has had swallowing studies and it remains unclear\n whether pt has difficulty swallowing or is having behavioral issue\n spitting out food, she is also know to regurgitate food which has been\n going on for awhile.. She comes into the ED from PCP she was\n hypotensive requiring 6liters NS she was put on Levophed, her\n electrolytes were grossly abnl with a Na 166 K+ 3.4 her urine was coke\n colored with a bun and cr 3.4\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n She is alert yelling out constantly not following commands, pupils\n equal and reactive, she moves all her extremities\n Action:\n She was given haldol .5mg IV x2, given morphine 1mg IV x1, lytes turned\n down, care channel on, pt reassured\n Response:\n She had no response to haldol continued to yell out and cry difficult\n to determine if she is having pain morphine enabled her to sleep for a\n while\n Plan:\n Try to reassure patient, provide quiet environment, speak to caregivers\n about baseline personality\n Electrolyte & fluid disorder, other\n Assessment:\n Na 165 now down to 163, K+ 3.4 continued hypotensive cl. 131to124,\n ionized ca 1.00\n Action:\n Given 2liters of LR and maintance d5lr at 125cc qhr , on levophed\n .3mcg/kg/min\n Response:\n Bp continues to be labile\n Plan:\n Continue to replete fluid as needed monitor electrolytes replete when\n necessary monitor lytles q 4 levophed titrated to bp\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine dark bun 69 cr 3.4 30cc q hr\n Action:\n Urine sent for lytes and c+s, given fluid boluses\n Response:\n Cr improving\n Plan:\n Continue to monitor closely, renal dose medication, fluid prn\n Atrial fibrillation (Afib)\n Assessment:\n On coumadin INR 11.3 when admitted now 5.4\n Action:\n ED was given vitamin K IV, coumadin on hold\n Response:\n INR down to 5.4, hct 33.2 no sign of bleeding\n Plan:\n Continue to monitor tx with vitamin K+ prn\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651996,
"text": "52 yo female with h/o downs syndrome, dementia and afib on coumadin who\n comes into the emergency room after visit with her pcp. lives in a\n group home and was brought to pcp failure to thrive poor to no po\n intake ? how long. She has had a 35lb weight loss, and has had\n difficulty with her gait and per report has been wheelchair bound x\n several weeks. She has had swallowing studies and it remains unclear\n whether pt has difficulty swallowing or is having behavioral issue\n spitting out food, she is also know to regurgitate food which has been\n going on for awhile.. She comes into the ED from PCP she was\n hypotensive requiring 6liters NS she was put on Levophed, her\n electrolytes were grossly abnl with a Na 166 K+ 3.4 her urine was coke\n colored with a bun and cr 3.4\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n She is alert yelling out constantly not following commands, pupils\n equal and reactive, she moves all her extremities\n Action:\n She was given haldol .5mg IV x2, given morphine 1mg IV x1, lights\n turned down, care channel on, pt reassured\n Response:\n She had no response to haldol continued to yell out and cry difficult\n to determine if she is having pain morphine enabled her to sleep for a\n while\n Plan:\n Try to reassure patient, provide quiet environment, speak to caregivers\n about baseline personality\n Electrolyte & fluid disorder, failure to thrive\n Assessment:\n Na 165 now down to 163, K+ 3.4 continued hypotensive cl. 131to124,\n ionized ca 1.00\n Action:\n Given 2liters of LR and maintance d5lr at 125cc qhr , on levophed\n .3mcg/kg/min\n Response:\n Bp continues to be labile\n Plan:\n Continue to replete fluid as needed monitor electrolytes replete when\n necessary monitor lytles q 4 levophed titrated to bp, pt needs\n nutrition consult, speech and swallow study,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine dark bun 69 cr 3.4 30cc q hr\n Action:\n Urine sent for lytes and c+s, given fluid boluses\n Response:\n Cr improving\n Plan:\n Continue to monitor closely, renal dose medication, fluid prn\n Atrial fibrillation (Afib)\n Assessment:\n On coumadin INR 11.3 when admitted now 5.4\n Action:\n ED was given vitamin K IV, coumadin on hold\n Response:\n INR down to 5.4, hct 33.2 no sign of bleeding\n Plan:\n Continue to monitor tx with vitamin K+ prn\n Heart disease, other\n Assessment:\n Troponins elevated .53/.31 h/o mitral regurg, afib\n Action:\n Serial cardiac enzymes\n Response:\n Trending down\n Plan:\n Cardiac echo, serial cardiac enzymes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651988,
"text": "52 yo female with h/o downs syndrome, dementia and afib on coumadin who\n comes into the emergency room after visit with her pcp. lives in a\n group home and was brought to pcp failure to thrive poor to no po\n intake ? how long. She has had a 35lb weight loss, and has had\n difficulty with her gait and per report has been wheelchair bound x\n several weeks. She has had swallowing studies and it remains unclear\n whether pt has difficulty swallowing or is having behavioral issue\n spitting out food, she is also know to regurgitate food which has been\n going on for awhile.. She comes into the ED from PCP she was\n hypotensive requiring 6liters NS she was put on Levophed, her\n electrolytes were grossly abnl with a Na 166 K+ 3.4 her urine was coke\n colored with a bun and cr 3.4\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n She is alert yelling out constantly not following commands, pupils\n equal and reactive, she moves all her extremities\n Action:\n She was given haldol .5mg IV x2, given morphine 1mg IV x1, lytes turned\n down, care channel on, pt reassured\n Response:\n She had no response to haldol continued to yell out and cry difficult\n to determine if she is having pain morphine enabled her to sleep for a\n while\n Plan:\n Try to reassure patient, provide quiet environment, speak to caregivers\n about baseline personality\n Afib\n Electrolyte & fluid disorder, other\n Assessment:\n Na 165 now down to 163, K+ 3.4 continued hypotensive\n Action:\n Given 2liters of LR and maintance d5lr at 125cc qhr , on levophed\n .3mcg/kg/min\n Response:\n Bp continues to be labile\n Plan:\n Continue to replete fluid as needed monitor electrolytes replete when\n necessary monitor lytles q 4 levophed titrated to bp\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652230,
"text": "24 Hour Events:\n - Transthoracic echocardiogram completed demonstrating severe mitral\n regurgitation, severe pulmonary hypertension, and bowed intra-artial\n septum to the right. Normal biventricular systolic function, no\n pericardial effusion.\n - NG tube placed, however patient pulled this out.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin 1000 mg IV Q48H (last dose 12/30)\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n - Pantoprazole (Protonix) - 10:54 AM\n - Valproate 500 mg IV Q8H\n - Oxcarbazepine 300 mg \n - Levothyroxine 75 mcg PO\n - Thiamine 100 mg IV daily\n - Folic Acid 1 mg IV daily\n - Multivitamin 10 mL IV Q24H\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n None\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 111 (82 - 111) bpm\n BP: 71/43(49) {71/43(49) - 115/92(97)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 6,948 mL\n 2,152 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 2,142 mL\n Blood products:\n Total out:\n 770 mL\n 380 mL\n Urine:\n 770 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 1,772 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 324 K/uL\n 11.0 g/dL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Microbiology Data:\n Blood culture NGTD x2\n Urine culture NGTD x1, no growth final\n Imaging Data:\n CXR final read pending\n Transthoracic Echocardiogram\n The left atrial volume is markedly increased (>32ml/m2). The\n interatrial septum is aneurysmal. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are myxomatous. There is moderate/severe mitral valve\n prolapse. An eccentric, posteriorly directed jet of severe (4+) mitral\n regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is severe pulmonary artery systolic hypertension.\n There is no pericardial effusion.\n IMPRESSION: Severe prolapse of the anterior leaflet of the mitral valve\n with severe, posteriorly directed mitral regurgitation, severe\n pulmonary hypertension and an inter-atrial septum that is bowed towards\n the right. Biventricular systolic function looks normal. There is no\n pericardial effusion.\n Assessment and Plan:\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR, with improving\n mental status and hypernatremia today.\n #) Hypotension: Etiology still remains not fully clear\npatient at that\n time has been aggressively fluid resuscitated and likely still has\n significant deficit, but would be hard to attribute hypotension solely\n to this source, especially given she was normotensive at outpatient\n visit. Cardiac echocardiogram with severe MR, but function was normal,\n without pericardial effusion. This leaves sepsis as a possibility,\n although source is unclear. steroid use to make adrenal\n insufficiency more likely. Initially was tachycardiac, but not hypoxic\n to suggest PE with compromised cardiac output; additionally patient is\n already on coumadin making this less likely, especially with\n supratherapeutic levels.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis not overwhelming ), stool for c. diff should she\n have diarrhea. LP is a consideration, but has not been febrile, MS\n appears to be at baseline, and would need to consciously sedate to\n complete given patient cannot cooperate with this.\n - Transthoracic echocardiogram as noted above.\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Levophed as needed should IVFs not improve BP\n - Lactate has returned to \n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Family , will be in today to begin to discuss goals of care,\n as PEG tube may be necessary to meet caloric needs given that patient\n has had ongoing difficulties with PO intake since at least .\n Patient also has been recommended to get EGD to evaluate her dysphagia\n further, so consideration for completion of this on an inpatient basis\n should be made. Concern is that patient will pull out PEG if placed\n - Supportive care with IVFs, electrolyte repletion (still has\n significant fluid deficit)\n - Working up infectious etiology\n - TSH, FT4 both WNL\n - Speech and swallow evaluation\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabalized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n .\n #) Acute renal failure: Given elevated BUN, and history of virtually no\n PO intake for extended period, suspect pre-renal etiology. Baseline\n creatinine from was around 1.0. Improved to 2.4 after 6 L of\n IVFs.\n - Continue to trend creatinine, BUN\n - Urine electrolytes to be sent\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - VBG to check pH to ensure not acidotic (bicarbonate appears to be\n WNL, however)\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D5 or D51/2NS once no longer\n requiring IVF boluses to maintain BP.\n - Frequent (Q3-4 H) sodium checks\n .\n #) Hyperchloremia: Again suspected to be secondary to severe\n dehydration. No history of diarrhea or other GI symptoms to suggest\n etiology.\n - Using LR for volume resuscitation in lieu of NS.\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\n - Serial EKGs\n - Continue sotalol\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Re-check in AM\n - Checking VBG to ensure not acidotic.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption.\n - Holding coumadin, received 5 mg vitamin K in ED, following trend\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in atrial fibrillation, rate in 100's. Will hold\n at this time given risk of worsening hypotension.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (will concurrently\n evaluate for vegetation), KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out.\n .\n #) Hypothyroidism: Checking TSH/FT4. Continue home supplementation\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVFs, until speech and swallow evaluation. Nutrition\n consult appreciated.\n .\n #) PPx: Supratherapeutic INR, PPI.\n .\n #) Code: Full per ED discussion with patient's HCP's\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n Per ED discussion with family, she is full code.\n .\n #) Access: Right femoral central line placed in ED.\n .\n #) Dispo: ICU until above issues improved.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652589,
"text": "Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient arouse to voice. Yelling while she is awake, I am unable to\n make out the words she is saying. At times she will yell out for\n\n Action:\n Provide a clam, quiet space. Keeping soft lights on. I have noted she\n will yell when the lights are off.\n Response:\n Sleeping ok during the night.\n Plan:\n Consider a neurobehavioral evaluation in the future. She has \n geriatrics MD in onset of AD r/t downs. Consider low\n dose ativan or haldol for agitation.\n Hypotension (not Shock)\n Assessment:\n While sleeping her b/p will drop to the 90\ns. When she is awake, her\n b/p 110\n Action:\n Levophed 0.1mcg/kg/min.\n Response:\n b/p 93/63 (70).\n Plan:\n Attempt to wean levophed. Titrate to SBP 90\n Atrial fibrillation (Afib)\n Assessment:\n AF w/ rear PVC noted hr 95 while sleeping, and 110 while awake.\n Action:\n Monitor.\n Response:\n Plan:\n Will start home dose sotalol. When she can take meds by mouth. Hold\n coumadin for now.\n Hypernatremia (high sodium)\n Assessment:\n NA 144. no seizure activity noted.\n Action:\n D51/2NS @ 100ml/hr continuous.\n Response:\n Plan:\n Am labs ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653105,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Brother/Sister-in-law returned last night but wished to get input from\n patient's cardiologist before making decisions regarding feeding tube.\n Briefly on levophed overnight.\n Some bradycardia this morning without BP compromise.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Valproate, HSQ, pantoprazole, levothyroxine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 96 (89 - 100) bpm\n BP: 108/61(74) {81/44(53) - 108/85(89)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,108 mL\n 2,422 mL\n PO:\n TF:\n IVF:\n 4,108 mL\n 2,422 mL\n Blood products:\n Total out:\n 740 mL\n 365 mL\n Urine:\n 490 mL\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,368 mL\n 2,057 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Agitated\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly, Diminished: at\n bases)\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 148 K/uL\n 113 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 25.3 %\n 6.2 K/uL\n [image002.jpg]\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n Hct\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n Plt\n 22\n 188\n 148\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.0\n mg/dL\n Imaging: No imaging today\n Microbiology: No recent micro\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Required some low dose pressors overnight but already off\n today. No clear source of sepsis. Unclear if non-invasive BP's are\n accurate as she is alert and often yelling with MAP's of 50's. \n stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Will refrain from pressors and check lactates if MAP's decrease.\n -Will attempt diuresis today in case RV distension is contributing to\n a diminished CO/HoTN.\n Hypernatremia: Hypovolemic. Resolved\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n -Will assess HR as we wean down levophed\n -Continue amio load. Check EKG for QTc.\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. Will try PICC with adjunctive ativan.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652364,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt with labile BP, systolic mid 90s.\n Action:\n BP supported by Levophed, unable to wean. This was briefly shut off per\n order by Dr. , with SBP down to 50s. Pt also given 1L fluid\n bolus LR for low u/o and BP.\n Response:\n Ongoing assessment and awaiting response.\n Plan:\n Wean Levophed, fluid boluses as needed for low u/o and BP.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is confused with dementia at baseline and has Downs Syndrome. Pt had\n been awake all night the previous day and yelling out and crying. Pt\n was more somulent overnight, but resting comfortably. Pt only yelling\n out and crying when turned and washed.\n Action:\n Pt had received Ativan x1 on previous shift.\n Response:\n Pt had good response to Ativan,\n Plan:\n Cont to monitor MS, provide comfort and emotional support. Ongoing\n communication with pt\ns brother to review goals of care.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653081,
"text": "Chief Complaint: FTT\n Hypotension\n 24 Hour Events:\n - family still undecided about feeding tube, want Dr. (her\n cardiologist) to weigh in \n - continues on amiodarone gtt--> calculated that she needs to load for\n 9.25 days from \n - weaned off levophed, but put backon overnight\n History obtained from Family / Friend\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 89 (89 - 100) bpm\n BP: 93/60(67) {81/44(53) - 106/85(91)} mmHg\n RR: 16 (0 - 26) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 4,108 mL\n 1,829 mL\n PO:\n TF:\n IVF:\n 4,108 mL\n 1,829 mL\n Blood products:\n Total out:\n 740 mL\n 295 mL\n Urine:\n 490 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,368 mL\n 1,534 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 8.9 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 25.3 %\n 6.2 K/uL\n [image002.jpg]\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n Hct\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n Plt\n 22\n 188\n 148\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.0\n mg/dL\n Imaging: No new\n Microbiology: Blood 12/30: NGTD\n Urine : NGTD\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC normalized\n -- Manual BP to ensure correlates with automatic read\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n -- wean levophed as tolerated\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest\n --loading amiodarone IV x 9 days since1/3/09; cannot give oral at this\n time.\n -- Ongoing discussion with family re: goals of care, and start hep gtt\n & coumadin for anticoagulation if plans for feeding tube; sotalol if\n ever able to give PO medications.\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, other metabolic\n abnormalities were corrected. Speech and swallow evaluation was\n completed (difficult to assess given patient\ns lack of cooperation).\n Had fam htg with brother, , and his wife; he is still deciding\n overall goals of care and whether to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube broad goals of care\n --will need PICC for accesss; need to remove fem line\n -- Working up infectious etiology as above- negative w/u to date\n --thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG will consider palliative care c/s for\n possible hospice placement; in addition, will do social work consult.\n -- Cont. folate, MV, thiamine supplementation via banana bag daily\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 or 0.5 mg IV given prolonged effect of the 1 mg dose\n on .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Resolved with\n hydration, Na normalized\n -- cont IVF maintenance fluids with D5-1/2NS\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR t.\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; improved with\n fluids. Baseline creatinine from was less than 1.0. UCx\n negative. Still poor urine output\n -- cont maintenance fluids.\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per discussion with patient's HCP\n #) Communication:\n Brother: is HCP ; work (? home)\n #) Access: Right femoral central line placed in ED Needs to be\n replaced. Spoke to family about PICC and they understant this would\n need to be placed with sedation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652801,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBP in mid 90\ns to 100.\n Action:\n Levophed titrated down slowly and stopped at 1500. stem test came\n back negative that was done yesterday. Checked BP manually and systolic\n was mid 90\ns correlating with noninvasive.\n Response:\n Current BP is 89/57 (61).\n Plan:\n Closely monitor BP. Goal mean 60.restart Levo if Mean BP down to low\n 50\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol. titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone? or low dose lopressor.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate15 mmol running for 6\n hrs. Pt also getting D5\n NS at 100cc/hr.\n Response:\n Plan:\n Closely monitor lytes.and replete if needed.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia seems more interactive than yesterday\n respod to her name. A\n Agitated screaming crying and laughing all day.\n Action:\n Cont to Reorient and provided calm and quiet environment.\n Response:\n Plan:\n Emotional support to family. Closely monitor mental status. Adivan if\n gets more agitated?\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653064,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received off Levophed ,SBP in mid 90\ns to 100. overnight dropped to\n 83 with Map55-56\n Action:\n Levophed restart. stem test came back negative that was done \n Response:\n BP is up to high80-low 90, MAP>60, pt received fluids bolus for low\n u/o with some response\n Plan:\n Closely monitor BP. Goal mean 60-65, wean lephofed.\n Atrial fibrillation (Afib)\n Assessment:\n Pt cont to be in SR/1^st degree Av block with HR 90\ns, rare PVC\n Action:\n Cont Amiodorone gtt 0.5 mcg/kg/min\n Response:\n Hr staying at 90\ns. in the morning pt had episode of HR down to 44 with\n stable BP for few seconds.\n Plan:\n Closely monitor her BP/HR.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia , awake but unale to assess orientation\n Agitated screaming crying and laughing in the beginning of shift.\n Action:\n Cont to Reorient and provided calm and quiet environment.given Ativan\n 0.5mg IV\n Response:\n Good response to Ativan, pt calm down, sleeping, but arousable to pain\n and stimil.\n Plan:\n Emotional support to family. Cont monitor mental status. , reorient\n pt.\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.cont D5%\n NS 100cc/hr\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available. PICC placement today.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652741,
"text": "Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60 .\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVc\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol.titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help ,try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.2 this afternoon\n Action:\n Pt had been given 40 of kcl earlier this afteroon\n Response:\n Still low k\n Plan:\n Will need repeat kcl this evening\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt agitiated calling crying all morning\n Action:\n Pt given zyperxa this am with no effect, to hr later ot given iv\n ativen with good effect\n Response:\n Pt sleeping when brother came more rousable this afternoon but would\n not repeat ativen because brother will return this evening and would\n like to see if he can get her to eat or drink\n Plan:\n need to reverse with fliumazenil this evening\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652742,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60 .\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVc\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol.titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help ,try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.2 this afternoon\n Action:\n Pt had been given 40 of kcl earlier this afteroon\n Response:\n Still low k\n Plan:\n Will need repeat kcl this evening\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt agitiated calling crying all morning\n Action:\n Pt given zyperxa this am with no effect, to hr later ot given iv\n ativen with good effect\n Response:\n Pt sleeping when brother came more rousable this afternoon but would\n not repeat ativen because brother will return this evening and would\n like to see if he can get her to eat or drink\n Plan:\n need to reverse with fliumazenil this evening\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652791,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBP in mid 90\ns to 100.\n Action:\n Levophed titrated down slowly and stopped at 1500. stem test\n came back negative done yesterday.\n Response:\n BP in\n Plan:\n Closely monitor BP. Goal mean 60.restart Levo if Mean BP down to low\n 50\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol. titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate15 mmol running for 6\n hrs. Pt also getting D5\n NS at 100cc/hr.\n Response:\n Plan:\n Closely monitor lytes.and replete if needed.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia seems more interactive than yesterday\n respod to her name. A\n Agitated screaming crying and laughing all day.\n Action:\n Cont to Reorient and provided calm and quiet environment.\n Response:\n Plan:\n Emotional support to family. Closely monitor mental status. Adivan if\n gets more agitated?\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652134,
"text": "52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient at times says words after you say them to her like hi. She\n does not obey commands. Tries to pull ekg leads off iv tubing off. She\n moves all ext. pearl. With care yells out in uncomprehensible sounds.\n Action:\n Safety devices applied to arms. Order for safety devices obtained for\n today. Bed alarm on.\n Response:\n Patient remains safe in bed.\n Plan:\n Safety devices to arms. Bed alarm on.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 2.4 this am. Uo around 30cc/hr. Down to 20cc/hr for 1 hour. Dr\n made aware.\n Action:\n Labs q 6 hours. 1l lr bolus ordered and given. Iv d51/2 at 100cc/hr\n cont.\n Response:\n Creat trending down. Uo up to 30-35cc/hr.\n Plan:\n Creat and lytes q 6 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n Na this am 161. K4.1.\n Action:\n Lytes checked q 4 hours. Cont on iv fluids d51/2ns at 150cc/hr.\n Response:\n Na trending down. Latest 158. K stable.\n Plan:\n Cont q 6 hour lytes. Next due at 2100\n Atrial fibrillation (Afib)\n Assessment:\n Appeared to be in afib on monitor.\n Action:\n Ekg obtained given to dr .\n Response:\n Has p\ns in some leads. 1^st degree avb.\n Plan:\n Cont to monitor rhytmn.\n Heart disease, other\n Assessment:\n Continues to require levophed. Hr in the high 90\ns to low 100\n Action:\n Tte done at bedside. Titrating levophed as needed.\n Response:\n Results of tte pending. Levo wened from .30mcgs/kg/min to\n .19mcgs/kg/min. Presently on .21mcgs/kg/min.\n Plan:\n Wean levo as able.\n Social- no calls from family today. People from resources for human\n development in with paperwork signed by paitient\ns guardian saying that\n they could receive information. Plan of care given to them. ? need for\n feeding tube depending on what the patient\ns guadians goal of care are\n for the patient . Director of Development for human resources \n name and # placed on card on front of chart.\n Awaiting resident\ns spaking to son to see if ngt or dobof tube will be\n placed.\n ------ Protected Section ------\n Social- Dr did talk to patient\ns brother. will be in tomorrow\n to discuss goals of care. For now ngt was placed that needs to be\n confirmed by xray prior to use. This we can use for meds as she has not\n received her antiseizure meds.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:11 ------\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652584,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt receivd on Levo at .18 mics/kg/hr,SBP in mid 90\ns to 105 .\n Action:\n Unable towean Levophed 2/2low BP. UOP ~ 30cc/hr.\n Response:\n Cont Levophed at same rate.\n Plan:\n Wean Levophed as tolerated, Closly Monitor UOP and BP . Fluid bolus\n for low UOP and BP ?\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h dementia and Down syndrome,been awake all the time Pt\n constantly yelling ,crying and laughing, follow ing simple commands.\n Action:\n Re oriented, provided calm and quiet environment.DR a discussion\n about PEG tube and PICC lnt as along term plan with her Sister in law\n (HCP) .\n Response:\n Plan:\n Cont to monitor MS closely, provide comfort and emotional support.\n Follow up with Broither and sister in law about their opinion.\n Hypernatremia (high sodium)\n Assessment:\n Na this morning was 147.\n Action:\n Initiated D5\n NS at 100cc/hr,sent evening lytes.\n Response:\n Na this afternoon down to 144.\n Plan:\n Closely monitor lytes and treat accordingly. Cont D5\n NS for now.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652929,
"text": "Chief Complaint: dehydration\n ftt\n hypernatremia\n 24 Hour Events:\n - fam didn't come in for discussion\n - manually checked BP; matched automatic \n - weaned off levophed; SBP remained in 100's, MAPs > 60-65 --. went\n down when she was sleeping\n - tachy to 110-120's, occ 130's; as night went on even higher; started\n on IV amio\n - gave ativan 0.5 mg IV x 1 at 7:30 pm\n Patient unable to provide history: Encephalopathy\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:40 PM\n Lorazepam (Ativan) - 07:40 PM\n Other medications:\n See \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.6\n HR: 93 (92 - 127) bpm\n BP: 95/67(73) {79/37(51) - 109/76(82)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,961 mL\n 1,105 mL\n PO:\n TF:\n IVF:\n 3,961 mL\n 1,105 mL\n Blood products:\n Total out:\n 1,465 mL\n 500 mL\n Urine:\n 1,315 mL\n 250 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 2,496 mL\n 607 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, Thin, edematous\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdomen: soft, pt cries out but can be distracted\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, not oriented, yelling out periodically\n Labs / Radiology\n 188 K/uL\n 9.8 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 139 mEq/L\n 28.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n Plt\n 22\n 188\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.0\n mg/dL\n Microbiology: Blood 12/30 x 2 - ngtd\n Urine - ng (final)\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC normalized\n -- Manual BP to ensure correlates with automatic read\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n -- wean levophed as tolerated\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest\n --loading amiodarone IV; cannot give oral at this time.\n -- Ongoing discussion with family re: goals of care, and start hep gtt\n & coumadin for anticoagulation if plans for feeding tube; sotalol if\n ever able to give PO medications.\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, other metabolic\n abnormalities could corrected. Speech and swallow evaluation was\n completed (difficult to assess given patient\ns lack of cooperation).\n Had fam htg with brother, , and his wife; he is still deciding\n overall goals of care and whether to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube and PICC line, broad goals of\n care\n -- Working up infectious etiology as above- negative w/u to date\n --thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG (and thus PICC), will consider\n palliative care c/s for possible hospice placement; in addition, will\n do social work consult.\n -- Cont. folate, MV, thiamine supplementation via banana bag daily\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 or 0.5 mg IV given prolonged effect of the 1 mg dose\n on .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Resolved with\n hydration, Na normalized\n -- cont IVF maintenance fluids with D5-1/2NS\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR t.\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; improved with\n fluids. Baseline creatinine from was less than 1.0. UCx\n negative.\n -- cont maintenance fluids.\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per discussion with patient's HCP\n #) Communication:\n Brother: is HCP ; work (? home)\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will discuss further with family; will need conscious\n sedation for the procedure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652521,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt receivd on Levo at .18 mics/kg/hr,SBP in mid 90\ns to 105 .\n Action:\n Unable towean Levophed 2/2low BP. UOP ~ 30cc/hr.\n Response:\n Cont Levophed at same rate.\n Plan:\n Wean Levophed as tolerated, Closly Monitor UOP and BP . Fluid bolus\n for low UOP and BP ?\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h dementia and Down syndrome,been awake all the time Pt\n constantly yelling an washed.\n Action:\n Pt had received Ativan x1 on previous shift.\n Response:\n Pt had good response to Ativan,\n Plan:\n Cont to monitor MS, provide comfort and emotional support. Ongoing\n communication with pt\ns brother to review goals of care.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652875,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received off Levophed ,SBP in mid 90\ns to 100. obernight dropped to\n 70\ns with Map50.\n Action:\n Levophed restart. stem test came back negative that was done \n Response:\n BP is up to high80-low 90, MAP>60\n Plan:\n Closely monitor BP. Goal mean 60-65, wean lephofed.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR-120 up to 135-160, at this point Lephofed was off\n and pt received Ativan with good effect\n Action:\n Start Amiodorone gtt\n Response:\n Hr down to high 90\n Plan:\n Closely monitor her BP/HR.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia , awake but unale to assess orientation\n Agitated screaming crying and laughing in the beginning of shift.\n Action:\n Cont to Reorient and provided calm and quiet environment.given Ativan\n 0.5mg IV\n Response:\n Good response to Ativan, pt calm down, sleeping, but arousable to pain\n and stimil.\n Plan:\n Emotional support to family. Cont monitor mental status. , reorient\n pt.\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652986,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Off pressors most of the day, went back on for some mild hypotension\n overnight.\n Started on amio for AF with RVR.\n Still refusing PO meds\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:40 PM\n Lorazepam (Ativan) - 07:40 PM\n Other medications:\n Levothyroxine IV, folate, MVI, thiamine, Trileptal, valproate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.3\nC (95.6\n HR: 95 (92 - 127) bpm\n BP: 93/73(77) {79/37(51) - 108/73(91)} mmHg\n RR: 17 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,961 mL\n 1,483 mL\n PO:\n TF:\n IVF:\n 3,961 mL\n 1,483 mL\n Blood products:\n Total out:\n 1,465 mL\n 548 mL\n Urine:\n 1,315 mL\n 298 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 2,496 mL\n 935 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: Agitated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace edema\n Musculoskeletal: R femoral line.\n Skin: erythema on hands and feet\n Neurologic: Responds to verbal and tactile stimuli with screaming\n Labs / Radiology\n 9.8 g/dL\n 188 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 139 mEq/L\n 28.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n Plt\n 22\n 188\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.0\n mg/dL\n Microbiology: BCx: NGTD\n UCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Required some low dose pressors overnight but can\n hopefully come off today. No clear source of sepsis. Unclear if\n non-invasive BP's are accurate as she is alert and often yelling with\n SBP's of 60's. stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Resolved\n -Continue with D5 1/2 NS maintenance fluids\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n -Will assess HR as we wean down levophed\n -Continue amio load\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. need PICC with conscious sedation.\n ICU Care\n Nutrition: as able plus IVF\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: family meeting today for goals\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653168,
"text": "HX of Down's Syndrome, dementia, & AF on coumadin,P/W failure to\n thrive, hypernatremia & electrolyte depletion . Members of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Events:. Levophed weaned & d/c\nd,diuresed. Bedside PICC placed but not\n in correct position. Will need to be repositioned or replaced in IR\n . (Do not use)\n Hypotension (not Shock)\n Assessment:\n Levophed d/c\nd. NBP noted to be 60\ns-70\ns, Pt\ns cardiologist ,Dr. \n states SBP approx 90\n Action:\n Ascultated BP with low NBP was 94/70\n Response:\n No intervention as pt was not hypotensive\n Plan:\n If BP, MAP\ns low, ascultate or Doppler BP for confirmation\n Atrial fibrillation (Afib)\n Assessment:\n HR 90\ns to low 100\ns AF. With occas to frequent VEA. Cont on amioderone\n gtt\n Action:\n K , phos repleted. Lasix given after repletion\n Response:\n Increas in VEA after lasix administration\n Plan:\n Cont IV amioderone until PEG placement . Repeat afternoon leyes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Frequently crying, screaming.\n Action:\n Attempted to orient, reassure pt. Ativan 1mg IVP for bedside PICC line\n placement\n Response:\n Unable to calm pt by talking, orienting her. Pt calm, sleeping after\n ativan\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. Positive fld balance >28 liters for LOS\n Action:\n Lasix 20 mg IVP\n Response:\n Excellent response\n Plan:\n Repeat & replete afternoon lytes\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 652120,
"text": "Chief Complaint: Shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:40 AM\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:59 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Down's Syndrome\n Mitral Regurg. - no echo in our system\n Breast Ca - DCIS in , s/p masectomy\n GERD\n gangrenous cholecystitis - s/p cholecystectomy\n As per resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: as per resident note\n Review of systems: Unable to obtain from pt\n Flowsheet Data as of 09:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 102 (83 - 102) bpm\n BP: 93/71(69) {59/22(37) - 111/71(75)} mmHg\n RR: 15 (9 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 6,049 mL\n 3,443 mL\n PO:\n TF:\n IVF:\n 49 mL\n 3,443 mL\n Blood products:\n Total out:\n 760 mL\n 290 mL\n Urine:\n 60 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 3,153 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Anxious, Crying out\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) (both\n lung and heart exams difficult due to pt\ns shouting)\n Respiratory / Chest: (Breath Sounds: Bronchial: bibasilar)\n Abdominal: Soft, Non-tender\n Skin: No rahses\n Neurologic: Movement: Purposeful\n Labs / Radiology\n 33.4 %\n 170 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 128 mEq/L\n 4.1 mEq/L\n 161 mEq/L\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n Hct\n 33.4\n Cr\n 2.4\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n 170\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.3 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 52 year old woman with down's syndrome who presents with hypernatremia\n as well as shock and lactic acidosis of unclear etiology. Lactate\n rapidly trending down in the setting of moderate fluid resuscitation.\n Certainly a component of hypovolemia but doubt that this alone is\n adequate explanation. Dirty UA so most likely scenario would be\n hypovolemia in the setting of decreased po intake and then sepsis from\n urinary source. Seizure is also a possibility but history seems\n inconsistent. Cardiac arrhythmia also on the differential but no\n evidence on tele or EKG here. Suspect troponin is demand rather than\n primary cardiac event but will check TTE today. PE unlikely in the\n setting of supertherapeutic INR. Other explanations such as mesenteric\n ischemia seem inconsistent with rapid resolution. For now, will\n continue fluid resuscitation , vanc/zosyn and correct metabolic\n abnormalities. Given multiple recent hospital admits and persistent\n failure to thrive, I am concerned for long term prognosis and will try\n to meet with family today to discuss her recent history and clarify\n goals of care. Further plans as per resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Multi Lumen - 11:46 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652121,
"text": "52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient at times says words after you say them to her like hi. She\n does not obey commands. Tries to pull ekg leads off iv tubing off. She\n moves all ext. pearl. With care yells out in uncomprehensible sounds.\n Action:\n Safety devices applied to arms. Order for safety devices obtained for\n today. Bed alarm on.\n Response:\n Patient remains safe in bed.\n Plan:\n Safety devices to arms. Bed alarm on.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 2.4 this am. Uo around 30cc/hr. Down to 20cc/hr for 1 hour. Dr\n made aware.\n Action:\n Labs q 6 hours. 1l lr bolus ordered and given. Iv d51/2 at 100cc/hr\n cont.\n Response:\n Creat trending down. Uo up to 30-35cc/hr.\n Plan:\n Creat and lytes q 6 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n Na this am 161. K4.1.\n Action:\n Lytes checked q 4 hours. Cont on iv fluids d51/2ns at 150cc/hr.\n Response:\n Na trending down. Latest 158. K stable.\n Plan:\n Cont q 6 hour lytes. Next due at 2100\n Atrial fibrillation (Afib)\n Assessment:\n Appeared to be in afib on monitor.\n Action:\n Ekg obtained given to dr .\n Response:\n Has p\ns in some leads. 1^st degree avb.\n Plan:\n Cont to monitor rhytmn.\n Heart disease, other\n Assessment:\n Continues to require levophed. Hr in the high 90\ns to low 100\n Action:\n Tte done at bedside. Titrating levophed as needed.\n Response:\n Results of tte pending. Levo wened from .30mcgs/kg/min to\n .19mcgs/kg/min. Presently on .21mcgs/kg/min.\n Plan:\n Wean levo as able.\n Social- no calls from family today. People from resources for human\n development in with paperwork signed by paitient\ns guardian saying that\n they could receive information. Plan of care given to them. ? need for\n feeding tube depending on what the patient\ns guadians goal of care are\n for the patient . Director of Development for human resources \n name and # placed on card on front of chart.\n Awaiting resident\ns spaking to son to see if ngt or dobof tube will be\n placed.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652190,
"text": "Electrolyte & fluid disorder, other\n Assessment:\n Hypotensive on Levophed gtt. Labs consistent with hypovolemia.\n Action:\n Rc\nd IVF bolus shortly prior to this shift. Levophed gtt weaned down\n aggressively.\n Response:\n Urine output improved. Electrolytes, renal function consistent with\n rehydration. Pt self d/c\nd NGT shortly after tube feeds commenced.\n Plan:\n Wean Levophed gtt off. Secure plan for long term nutrition and med\n access.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652295,
"text": "24 Hour Events:\n - Transthoracic echocardiogram completed demonstrating severe mitral\n regurgitation, severe pulmonary hypertension, and bowed intra-artial\n septum to the right. Normal biventricular systolic function, no\n pericardial effusion.\n - NG tube placed, however patient pulled this out.\n This morning patient more interactive, appears to understand questions\n asked and answers a few appropriately, then begins to cry and swing\n arms around. Denies pain.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin 1000 mg IV Q48H (last dose 12/30)\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n - Pantoprazole (Protonix) - 10:54 AM\n - Valproate 500 mg IV Q8H\n - Oxcarbazepine 300 mg \n - Levothyroxine 75 mcg PO\n - Thiamine 100 mg IV daily\n - Folic Acid 1 mg IV daily\n - Multivitamin 10 mL IV Q24H\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n None\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 111 (82 - 111) bpm\n BP: 71/43(49) {71/43(49) - 115/92(97)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 6,948 mL\n 2,152 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 2,142 mL\n Blood products:\n Total out:\n 770 mL\n 380 mL\n Urine:\n 770 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 1,772 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General: Awake, moaning, crying out but not comprehensible, appears\n more comfortable than yesterday\n HEENT: Mucous membranes remain very dry, no scleral icterus, PERRL\n Neck: Supple\n Lungs: Decreased BS at bases, but otherwise appear clear, examination\n limited by effort, no wheezes or rales\n Cardiac: Holosystolic murmur III-IV/VI present throughout precordium,\n no gallops, rubs\n Abd: Soft, NT, ND, +BS\n Extr: Warm, dry rough skin, no lesions\n Vasc: Fem line c/d/I, no erythema\n Neuro: Able to answer some questions when asked, but attention span\n very short, moving all extremities equally\n Psych: Yelling out and moaning, taking all clothes off and pulling off\n monitoring leads\n Labs / Radiology\n 324 K/uL\n 11.0 g/dL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Microbiology Data:\n Blood culture NGTD x2\n Urine culture NGTD x1, first culture contaminated\n Imaging Data:\n CXR final read pending\n Transthoracic Echocardiogram\n The left atrial volume is markedly increased (>32ml/m2). The\n interatrial septum is aneurysmal. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are myxomatous. There is moderate/severe mitral valve\n prolapse. An eccentric, posteriorly directed jet of severe (4+) mitral\n regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is severe pulmonary artery systolic hypertension.\n There is no pericardial effusion.\n IMPRESSION: Severe prolapse of the anterior leaflet of the mitral valve\n with severe, posteriorly directed mitral regurgitation, severe\n pulmonary hypertension and an inter-atrial septum that is bowed towards\n the right. Biventricular systolic function looks normal. There is no\n pericardial effusion.\n Assessment and Plan:\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR, with improving\n mental status and hypernatremia today.\n #) Hypotension: Etiology still remains not fully clear\npatient at that\n time has been aggressively fluid resuscitated and likely still has\n significant deficit, but would be hard to attribute hypotension solely\n to this source, especially given she was normotensive at outpatient\n visit. Cardiac echocardiogram with severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause. This\n leaves sepsis as a possibility, although source would unclear\nU/A from\n ED was fairly unremarkable, repeat one in ICU with many white (but also\n many red) cells; initial culture contaminated, second pending. No\n steroid use to make adrenal insufficiency more likely. Initially was\n tachycardiac, but not hypoxic to suggest PE with compromised cardiac\n output; additionally patient is already on coumadin making this less\n likely, especially with supratherapeutic levels.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis not overwhelming ), stool for c. diff should she\n have diarrhea. LP is a consideration, but has not been febrile, MS\n appears to be at baseline, and would need to consciously sedate to\n complete given patient cannot cooperate with this. Will stop vancomycin\n currently (no indwelling line or other reason to think she has MRSA\n skin or blood stream infection). Will continue zosyn until repeat\n urine/blood cultures are no growth for another 24 hrs (during last\n admission had UTI that was felt to be contributing to failure to\n thrive).\n - Transthoracic echocardiogram as noted above.\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Continue levophed as needed should IVFs not improve BP, will try to\n wean\n - Lactate has returned to \n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Family , will be in today to begin to discuss goals of care,\n as PEG tube may be necessary to meet caloric needs given that patient\n has had ongoing difficulties with PO intake since at least .\n Patient also has been recommended to get EGD to evaluate her dysphagia\n further, so consideration for completion of this on an inpatient basis\n should be made. Concern is that patient will pull out PEG if placed.\n - Supportive care with IVFs, electrolyte repletion (still has\n significant fluid deficit)\n - Working up infectious etiology\n - TSH, FT4 both WNL\n - Speech and swallow evaluation completed (difficult to assess given\n patient\ns lack of cooperation)\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult appreciated\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation was unremarkable\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n - Given question of acutely worsening dementia, checking vitamin B12,\n no known risk factors (not sexually active) for syphilis, TSH WNL,\n working on correcting other metabolic abnormalities that could be\n contributing to dementia\n .\n #) Acute renal failure: Much improved today, creatinine down to 1.7.\n Given elevated BUN, and history of virtually no PO intake for extended\n period, suspect pre-renal etiology. Baseline creatinine from was\n around 1.0.\n - Continue to trend creatinine, BUN\n - Urine electrolytes as noted\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D51/2NS once no longer requiring\n IVF boluses to maintain BP.\n - Space out sodium checks to given improvement to 150\n .\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities as noted\n above.\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Given still unclear etiology of , wean off pressors, and as\n long as mental status is at baseline, will tolerate lower BP and\n re-check lactate after off pressors to see if rising.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2.\n - Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n - Will discuss with family goals of care, and start hep gtt for\n anticoagulation if desired; sotalol once able to give PO medications.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (no vegetations),\n KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out. Giving IV valproate while\n here in ICU\n .\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt, PPI, bowel\n regimen if needed (would need to be PR given not taking PO\n .\n #) Code: Full per ED discussion with patient's HCP, will further\n discuss during meetingn today\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will need to discuss further with family and further\n line/PICC per that discussion.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition: As discussed above, pending discussion with family/HCP\n Glycemic Control: Elevated glucose this AM, will start insulin SS\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652700,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 102 (94 - 116) bpm\n BP: 87/46(57) {83/40(49) - 131/97(106)} mmHg\n RR: 9 (9 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,308 mL\n 1,069 mL\n PO:\n TF:\n IVF:\n 4,308 mL\n 1,069 mL\n Blood products:\n Total out:\n 1,030 mL\n 770 mL\n Urine:\n 1,030 mL\n 620 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 3,278 mL\n 299 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), V/VI SEM, heard throughout with\n radiation to back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), unable to cooperate with\n lung exam due to MS/MR\n Abdominal: Soft, Bowel sounds present, Tender: ? more tender than\n yesterday; pt moaning on exam but unable to answer yes/no to pain;\n unclear whether specific response to abd or just exam in general\n Extremities: Right: 2+, Left: 2+, hands 2+ b/l; same as yesterday\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 222 K/uL\n 10.0 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 114 mEq/L\n 142 mEq/L\n 28.6 %\n 8.3 K/uL\n [image002.jpg]\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n Plt\n 22\n Cr\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n Glucose\n 189\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated and remains\n levophed-dependent. Cardiac echocardiogram showed severe MR, but\n function was normal, without pericardial effusion; severe MR could be\n contributing to hypotension, but again seems less likely that this is\n sole cause. There is no evidence of sepsis/infection with improving\n WBC, afebrile state, nothing localizing and no positive Cx data; LP\n deferred for now given MS appears to be at (recent) baseline. Adrenal\n insufficiency as primary cause of hypotension is less likely w/o risk\n factors; had a random cortisol level that was 20.4, though has not had\n CortStim test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2) will d/c Zosyn\n -- IVF boluses PRN for hypotension; will defer weaning from levophed\n today given SBP in the 90\ns this morning\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, working on\n correcting other metabolic abnormalities that could be contributing to\n dementia. Speech and swallow evaluation was completed (difficult to\n assess given patient\ns lack of cooperation). Had fam htg with brother,\n , on ; he is still deciding overall goals of care and whether\n to provide a PEG for feeding.\n -- will have another family meeting today to discuss options of PEG\n and PICC line, broad goals of care\n -- Sips given MS feeds and maintenance IVF\n -- Working up infectious etiology as above; thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- Cont. folate, MV, thiamine supplementation\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 mg IV given prolonged effect of the 1 mg dose on\n .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Improving\n while on IVF supplementation.\n -- cont IVF maintenance fluids with D5-1/2NS\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2. INR 1.4 on\n .\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy.\n #) Acute renal failure: resolved. Likely prerenal; improved to 1.1\n from 3.4 on admission. Baseline creatinine from was around\n 1.0. UCx negative.\n -- cont maintenance fluids.\n #) Elevated lactate: resolved.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n -- Will discuss with family goals of care, and start hep gtt & coumadin\n for anticoagulation if desired; sotalol once able to give PO\n medications.\n #) Leukocytosis: resolving; 14.1 on admission; 10.1 on \n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;\n PPI, bowel regimen if needed (would need to be PR given not taking\n PO\n .\n #) Code: Full per ED discussion with patient's HCP\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will discuss further with family on ; will need\n conscious sedation for the procedure.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652739,
"text": "Hypotension (not Shock)\n Assessment:\n While sleeping her b/p will drop to the 90\ns. When she is awake, her\n b/p 110\n Action:\n Levophed 0.1mcg/kg/min.\n Response:\n b/p 93/63 (70).\n Plan:\n Attempt to wean levophed. Titrate to SBP 90\n Atrial fibrillation (Afib)\n Assessment:\n AF w/ rear PVC noted hr 95 while sleeping, and 110 while awake.\n Action:\n Monitor.\n Response:\n Plan:\n Will start home dose sotalol. When she can take meds by mouth. Hold\n coumadin for now.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653153,
"text": "HX of Down's Syndrome, dementia, & AF on coumadin,P/W failure to\n thrive, hypernatremia & electrolyte depletion . Members of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Events: bedside PIC placed. Levophed weaned & d/c\n Hypotension (not Shock)\n Assessment:\n Levophed d/c\nd. NBP noted to be 60\ns-70\ns, Pt\ns cardiologist ,Dr. \n states SBP approx 90\n Action:\n Ascultated BP with low NBP was 94/70\n Response:\n No intervention as pt was not hypotensive\n Plan:\n If BP, MAP\ns low, ascultate or Doppler BP for confirmation\n Atrial fibrillation (Afib)\n Assessment:\n HR 90\ns to low 100\ns AF. With occas to frequent VEA. Cont on amioderone\n gtt\n Action:\n K , phos repleted. Lasix given after repletion\n Response:\n Increas in VEA after lasix administration\n Plan:\n Cont IV amioderone until PEG placement . Repeat afternoon leyes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Frequently crying, screaming.\n Action:\n Attempted to orient, reassure pt. Ativan 1mg IVP for bedside PICC line\n placement\n Response:\n Unable to calm pt by talking, orienting her. Pt calm, sleeping after\n ativan\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. Positive fld balance >28 liters for LOS\n Action:\n Lasix 20 mg IVP\n Response:\n Excellent response\n Plan:\n Repeat & replete afternoon lytes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652781,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated. stem test came back\n negative done yesterday.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol. titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate15 mmol running for 6\n hrs. Pt also\n Response:\n Plan:\n Closely monitor lytes\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia seems more interactive than yesterday\n respod to her name. A\n Agitated screaming crying and laughing all day.\n Action:\n Cont to Reorient and provided calm and quiet environment.\n Response:\n Plan:\n Emotional support to family. Closely monitor mental status. Adivan if\n gets more agitated?\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652909,
"text": "Chief Complaint: dehydration\n ftt\n hypernatremia\n 24 Hour Events:\n - fam didn't come in for discussion\n - manually checked BP; matched automatic \n - weaned off levophed; SBP remained in 100's, MAPs > 60-65 --. went\n down when she was sleeping\n - tachy to 110-120's, occ 130's; as night went on even higher; started\n on IV amio\n - gave ativan 0.5 mg IV x 1 at 7:30 pm\n Patient unable to provide history: Encephalopathy\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:40 PM\n Lorazepam (Ativan) - 07:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.6\n HR: 93 (92 - 127) bpm\n BP: 95/67(73) {79/37(51) - 109/76(82)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,961 mL\n 1,105 mL\n PO:\n TF:\n IVF:\n 3,961 mL\n 1,105 mL\n Blood products:\n Total out:\n 1,465 mL\n 500 mL\n Urine:\n 1,315 mL\n 250 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 2,496 mL\n 607 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, Thin, edematous\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, not oriented, yelling out periodically\n Labs / Radiology\n 188 K/uL\n 9.8 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 139 mEq/L\n 28.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n Plt\n 22\n 188\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.0\n mg/dL\n Microbiology: Blood 12/30 x 2 - ngtd\n Urine - ng (final)\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC normalized\n -- Manual BP to ensure correlates with automatic read\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest\n --loaded amiodarone IV, need to discuss how to give it given her lack\n of PO intake\n -- Will discuss with family goals of care, and start hep gtt & coumadin\n for anticoagulation if desired; sotalol once able to give PO\n medications.\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, working on\n correcting other metabolic abnormalities that could be contributing to\n dementia. Speech and swallow evaluation was completed (difficult to\n assess given patient\ns lack of cooperation). Had fam htg with brother,\n , on ; he is still deciding overall goals of care and whether\n to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube and PICC line, broad goals of\n care\n -- Working up infectious etiology as above; thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG (and thus PICC), will consider\n palliative care c/s for possible hospice placement; in addition, will\n do social work consult.\n -- Cont. folate, MV, thiamine supplementation\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 mg IV given prolonged effect of the 1 mg dose on\n .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Improving\n while on IVF supplementation. Sig improved; Na normalized\n -- cont IVF maintenance fluids with D5-1/2NS\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2. .\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; improved with\n fluids. Baseline creatinine from was less than 1.0. UCx\n negative.\n -- cont maintenance fluids.\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per ED discussion with patient's HCP\n #) Communication:\n Brother: is HCP ; work (? home)\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will discuss further with family; will need conscious\n sedation for the procedure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652919,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Off pressors most of the day, went back on for some mild hypotension\n overnight.\n Started on amio for AF with RVR.\n Still refusing PO meds\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:40 PM\n Lorazepam (Ativan) - 07:40 PM\n Other medications:\n Levothyroxine IV, folate, MVI, thiamine, Trileptal, valproate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.3\nC (95.6\n HR: 95 (92 - 127) bpm\n BP: 93/73(77) {79/37(51) - 108/73(91)} mmHg\n RR: 17 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,961 mL\n 1,483 mL\n PO:\n TF:\n IVF:\n 3,961 mL\n 1,483 mL\n Blood products:\n Total out:\n 1,465 mL\n 548 mL\n Urine:\n 1,315 mL\n 298 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 2,496 mL\n 935 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: Agitated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: R femoral line.\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 188 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.0 mEq/L\n 7 mg/dL\n 110 mEq/L\n 139 mEq/L\n 28.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n Plt\n 22\n 188\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:2.1 mg/dL, PO4:2.0\n mg/dL\n Microbiology: BCx: NGTD\n UCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Required some low dose pressors overnight but can\n hopefully come off today. No clear source of sepsis. Unclear if\n non-invasive BP's are accurate as she is alert and often yelling with\n SBP's of 60's. stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Resolved\n -Continue with D5 1/2 NS maintenance fluids\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n -Will assess HR as we wean down levophed\n -Continue amio load\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. need PICC with conscious sedation.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653002,
"text": "Atrial fibrillation (Afib)\n Assessment:\n NSR. Rate85-95. rare pac.\n Action:\n Amiodarone gtt @ 0.5mg/hr\n Response:\n Remained in NSR\n Plan:\n Continue gtt until 7gram load met OR po access obtained.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Intermittent laughs,cries, and shouting out for brother .\n Appropriate behavior for baseline mental status.\n Action:\n 1:1 contact q 10mins. Providing comfortable quiet surroundings.\n Reassurance given to pt prn.\n Response:\n pt acceptable to care, non aggressive.continues with intermittent\n shouts/laughs/cries.\n Plan:\n Maintain safety measures. Reorient pt prn.\n Hypotension (not Shock)\n Assessment:\n Baseline hypotension. MAP goal >60. Levopohed gtt.\n Action:\n Levophed gt weaned off. MAP <53 x 1 hr. Gtt re-started and weaned again\n later in shift\n Response:\n Levophed gt off. Bp stable MAP> 60.\n Plan:\n Continue with IVF to support Bp.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652512,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not )\n Assessment:\n Pt with labile BP, systolic mid 90s.\n Action:\n BP supported by Levophed, unable to wean. This was briefly shut off per\n order by Dr. , with SBP down to 50s. Pt also given 1L fluid\n bolus LR for low u/o and BP.\n Response:\n Ongoing assessment and awaiting response.\n Plan:\n Wean Levophed, fluid boluses as needed for low u/o and BP.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is confused with dementia at baseline and has Downs Syndrome. Pt had\n been awake all night the previous day and yelling out and crying. Pt\n was more somulent overnight, but resting comfortably. Pt only yelling\n out and crying when turned and washed.\n Action:\n Pt had received Ativan x1 on previous shift.\n Response:\n Pt had good response to Ativan,\n Plan:\n Cont to monitor MS, provide comfort and emotional support. Ongoing\n communication with pt\ns brother to review goals of care.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652517,
"text": "Chief Complaint: admitted with FTT, dehydration, hypotension\n 24 Hour Events:\n n failed wean from levophed yest afternoon; SBP dropped to 50\n while off within 15 minutes.\n n Received ativan 1 mg IV yesterday morning, which caused\n somnolence throughout the day\n n Had conversation with brother, , about possibility of PEG\n tube and overall prognosis; brother still undecided about goals of\n care, feeding tubes, etc.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: not able to obtain from patient given lack of verbal\n communication\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 112 (80 - 121) bpm\n BP: 115/84(90) {74/40(51) - 115/84(90)} mmHg\n RR: 23 (0 - 29) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,553 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,553 mL\n Blood products:\n Total out:\n 1,210 mL\n 340 mL\n Urine:\n 1,210 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Lungs: unable to cooperate with exam due to baseline MR/MS\n : V/VI SEM throughout w/ radiation to the back\n Abd: +BS; soft, NTND\n Extremities: + edema in hands and legs; symmetric; WWP\n Skin: fine\n\n blanching macular rash on back/legs/hands (not abd);\n scabbed erosion on right hip/trochanter, no evidence of surrounding\n erythema, fluctuance or drainage; no other evidence of skin breakdown\n Neuro: awake, follows simple commands slowly (e.g., open eyes); moaning\n frequently; cannot answer questions to assess orientation; moving all\n limbs spontaneously; CN II - XII grossly in tact\n Labs / Radiology\n 303 K/uL\n 11.1 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Assessment and Plan\n Assessment and Plan:\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no Po\n intake.\n #) Hypotension: Etiology still remains not fully clear\npatient at that\n time has been aggressively fluid resuscitated and likely still has\n significant deficit, but would be hard to attribute hypotension solely\n to this source, especially given she was normotensive at outpatient\n visit. Cardiac echocardiogram with severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause. This\n leaves sepsis as a possibility, although source would unclear\nU/A from\n ED was fairly unremarkable, repeat one in ICU with many white (but also\n many red) cells; initial culture contaminated, second pending. No\n steroid use to make adrenal insufficiency more likely. Initially was\n tachycardiac, but not hypoxic to suggest PE with compromised cardiac\n output; additionally patient is already on coumadin making this less\n likely, especially with supratherapeutic levels.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis not overwhelming ), stool for c. diff should she\n have diarrhea. LP is a consideration, but has not been febrile, MS\n appears to be at baseline, and would need to consciously sedate to\n complete given patient cannot cooperate with this. Will stop vancomycin\n currently (no indwelling line or other reason to think she has MRSA\n skin or blood stream infection). Will continue zosyn until repeat\n urine/blood cultures are no growth for another 24 hrs (during last\n admission had UTI that was felt to be contributing to failure to\n thrive).\n - Transthoracic echocardiogram as noted above.\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Continue levophed as needed should IVFs not improve BP, will try to\n wean\n - Lactate has returned to \n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Family , will be in today to begin to discuss goals of care,\n as PEG tube may be necessary to meet caloric needs given that patient\n has had ongoing difficulties with PO intake since at least .\n Patient also has been recommended to get EGD to evaluate her dysphagia\n further, so consideration for completion of this on an inpatient basis\n should be made. Concern is that patient will pull out PEG if placed.\n - Supportive care with IVFs, electrolyte repletion (still has\n significant fluid deficit)\n - Working up infectious etiology\n - TSH, FT4 both WNL\n - Speech and swallow evaluation completed (difficult to assess given\n patient\ns lack of cooperation)\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult appreciated\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation was unremarkable\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n - Given question of acutely worsening dementia, checking vitamin B12,\n no known risk factors (not sexually active) for syphilis, TSH WNL,\n working on correcting other metabolic abnormalities that could be\n contributing to dementia\n .\n #) Acute renal failure: Much improved today, creatinine down to 1.7.\n Given elevated BUN, and history of virtually no PO intake for extended\n period, suspect pre-renal etiology. Baseline creatinine from was\n around 1.0.\n - Continue to trend creatinine, BUN\n - Urine electrolytes as noted\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D51/2NS once no longer requiring\n IVF boluses to maintain BP.\n - Space out sodium checks to given improvement to 150\n .\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities as noted\n above.\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Given still unclear etiology of , wean off pressors, and as\n long as mental status is at baseline, will tolerate lower BP and\n re-check lactate after off pressors to see if rising.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2.\n - Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n - Will discuss with family goals of care, and start hep gtt for\n anticoagulation if desired; sotalol once able to give PO medications.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (no vegetations),\n KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out. Giving IV valproate while\n here in ICU\n .\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt, PPI, bowel\n regimen if needed (would need to be PR given not taking PO\n .\n #) Code: Full per ED discussion with patient's HCP, will further\n discuss during meetingn today\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will need to discuss further with family and further\n line/PICC per that discussion.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652772,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated. stem test came back\n negative done yesterday.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVc\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol.titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate15 mmol running for 6\n hrs. Pt also\n Response:\n Plan:\n Closely monitor lytes\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia seems more interactive than yesterday\n respod to her name. A\n Agitated screaming crying and laughing all day.\n Action:\n Cont to Reorient and provided calm and quiet environment.\n Response:\n Plan:\n Emotional support to family. Closely monitor mental status . Adivan if\n gets more agitated?\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653142,
"text": "HX of Down's Syndrome, dementia, & AF on coumadin,P/W failure to\n thrive, hypernatremia & electrolyte depletion . Members of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Events bedside PIC placed. Levophed weaned & d/c\n Hypotension (not Shock)\n Assessment:\n Levophed d/c\nd. NBP noted to be 60\ns-70\ns, Pt\ns cardiologist ,Dr. \n states SBP approx 90\n Action:\n Ascultated BP with low NBP was 94/70\n Response:\n No intervention as pt was not hypotensive\n Plan:\n If BP, MAP\ns low, asc or Doppler BP.\n Atrial fibrillation (Afib)\n Assessment:\n HR 90\ns to low 100\ns AF. With occas to frequent VEA. Cont on amioderone\n gtt\n Action:\n K , phos repleted. Lasix given after repletion\n Response:\n Increas in VEA after lasix administration\n Plan:\n Cont IV amioderone until PEG placement . Repeat afternoon leyes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Frequently crying, screaming.\n Action:\n Attempted to orient, reassure pt. Ativan 1mg IVP for bedside PICC line\n placement\n Response:\n Unable to calm pt by talking, orienting her. Pt calm, sleeping after\n ativan\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. Positive fld balance >23 liters for LOS\n Action:\n Lasix 20 mg IVP\n Response:\n Excellent response\n Plan:\n Repeat & replete afternoon lytes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652095,
"text": "52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient at times says words after you say them to her like hi. She\n does not obey commands. Tries to pull ekg leads off iv tubing off. She\n moves all ext. pearl. With care yells out in uncomprehensible sounds.\n Action:\n Safety devices applied to arms. Order for safety devices obtained for\n today. Bed alarm on.\n Response:\n Patient remains safe in bed.\n Plan:\n Safety devices to arms. Bed alarm on.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 2.4 this am. Uo around 30cc/hr. Down to 20cc/hr for 1 hour. Dr\n made aware.\n Action:\n Labs q 6 hours. 1l lr bolus ordered and given. Iv d51/2 at 100cc/hr\n cont.\n Response:\n Creat trending down. Uo up to 30-35cc/hr.\n Plan:\n Creat and lytes q 6 hours.\n Electrolyte & fluid disorder, other\n Assessment:\n Na this am 161. K4.1.\n Action:\n Lytes checked q 4 hours. Cont on iv fluids d51/2ns at 100cc/hr.\n Response:\n Na trending down. K stable.\n Plan:\n Cont q 6 hour lytes.\n Atrial fibrillation (Afib)\n Assessment:\n Appeared to be in afib on monitor.\n Action:\n Ekg obtained given to dr .\n Response:\n Has p\ns in some leads. 1^st degree avb.\n Plan:\n Cont to monitor rhytmn.\n"
},
{
"category": "Nutrition",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 652096,
"text": "Subjective\n Pt incomprehensible\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 49.4 kg\n 20.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9\n 70\n 70\n Diagnosis: Acute Renal Failure, FTT\n PMH : mental retardation, mitral regurgitation, bacterium endocarditis,\n hypothyriodism, appy, cholesystectomy\n Pertinent medications: 1LNS bolus, 20mEq KCl, CaGluc 2g, 1L LR bolus,\n Thiamine 100mg, folic acid 1mg, MVI, lansoprazole, protonix, 1L D5 \n NS continous\n Labs:\n Value\n Date\n Glucose\n 160 mg/dL\n 09:05 AM\n Glucose Finger Stick\n 162\n 12:00 PM\n BUN\n 67 mg/dL\n 09:05 AM\n Creatinine\n 2.3 mg/dL\n 09:05 AM\n Sodium\n 159 mEq/L\n 09:05 AM\n Potassium\n 4.0 mEq/L\n 09:05 AM\n Chloride\n 128 mEq/L\n 09:05 AM\n TCO2\n 27 mEq/L\n 09:05 AM\n PO2 (venous)\n 43 mm Hg\n 01:10 AM\n PCO2 (venous)\n 52 mm Hg\n 01:10 AM\n pH (venous)\n 7.33 units\n 01:10 AM\n pH (urine)\n 5.0 units\n 01:43 AM\n CO2 (Calc) venous\n 29 mEq/L\n 01:10 AM\n Albumin\n 2.1 g/dL\n 11:24 PM\n Calcium non-ionized\n 8.0 mg/dL\n 09:05 AM\n Phosphorus\n 3.9 mg/dL\n 09:05 AM\n Ionized Calcium\n 1.00 mmol/L\n 01:10 AM\n Magnesium\n 2.2 mg/dL\n 09:05 AM\n ALT\n 20 IU/L\n 11:24 PM\n Alkaline Phosphate\n 58 IU/L\n 11:24 PM\n AST\n 41 IU/L\n 11:24 PM\n Amylase\n 15 IU/L\n 11:24 PM\n Total Bilirubin\n 0.7 mg/dL\n 11:24 PM\n Hematocrit\n 33.4 %\n 11:30 PM\n Current diet order / nutrition support: Thin liquids/Pureed solids\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: Low po intake\n Estimated Nutritional Needs (based on admit wt)\n Calories: 1470-1715 (BEE x or / 30-35 cal/kg)\n Protein: 59-59 (1-1.4 g/kg)\n Fluid: Per Team\n Specifics:\n 51 yo female admitted to ICU with ARF, FTT, and dehydration. Recent h/o\n of poor po intake associated with 35lbs weight loss in past 2-3 months\n per PCP notes resulting in severe malnutrition. SLP cleared pt for\n thin liquid sips and regular consistency solids . SLP\n re-evaluated this AM and recommend pureed solids and thin liquids if pt\n accepting to po\ns. Currently, refusing any po\ns. Noted calorie count\n c/s, which is not indicated at this point given refusing po\ns. Noted\n plan for family meeting today to discuss plan of care\ns vs. TF. Pt\n is at risk for re-feeding syndrome when nutrition resumed. Noted\n hypernatremia, D5 and LR boluses given\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If plan of care includes nutrition support:\n a. Rec place feeding tube\n long term feeding access (ie PEG) may\n be needed\n b. Suggest start TF: Fibersource @ 15mL/hr advance 10ml q6h to\n goal of 55 mL/hr 1584kcals/70g protein\n 2) Check residuals q6h, hold if >150mL\n 3) Water flushes prn\n 4) Encourage po\ns; if pt eating will send Ensure plus tid\n 5) Chem 10 daily, closely monitor lytes *esp Mag, Phos, K* and\n replete prn\n 6) Will follow poc\n 15:10\n"
},
{
"category": "Nutrition",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 652097,
"text": "Subjective\n Pt incomprehensible\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 49.4 kg\n 20.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9\n 70\n 70\n Diagnosis: Acute Renal Failure, FTT\n PMH : mental retardation, mitral regurgitation, bacterium endocarditis,\n hypothyriodism, appy, cholesystectomy\n Pertinent medications: 1LNS bolus, 20mEq KCl, CaGluc 2g, 1L LR bolus,\n Thiamine 100mg, folic acid 1mg, MVI, lansoprazole, protonix, 1L D5 \n NS continous\n Labs:\n Value\n Date\n Glucose\n 160 mg/dL\n 09:05 AM\n Glucose Finger Stick\n 162\n 12:00 PM\n BUN\n 67 mg/dL\n 09:05 AM\n Creatinine\n 2.3 mg/dL\n 09:05 AM\n Sodium\n 159 mEq/L\n 09:05 AM\n Potassium\n 4.0 mEq/L\n 09:05 AM\n Chloride\n 128 mEq/L\n 09:05 AM\n TCO2\n 27 mEq/L\n 09:05 AM\n PO2 (venous)\n 43 mm Hg\n 01:10 AM\n PCO2 (venous)\n 52 mm Hg\n 01:10 AM\n pH (venous)\n 7.33 units\n 01:10 AM\n pH (urine)\n 5.0 units\n 01:43 AM\n CO2 (Calc) venous\n 29 mEq/L\n 01:10 AM\n Albumin\n 2.1 g/dL\n 11:24 PM\n Calcium non-ionized\n 8.0 mg/dL\n 09:05 AM\n Phosphorus\n 3.9 mg/dL\n 09:05 AM\n Ionized Calcium\n 1.00 mmol/L\n 01:10 AM\n Magnesium\n 2.2 mg/dL\n 09:05 AM\n ALT\n 20 IU/L\n 11:24 PM\n Alkaline Phosphate\n 58 IU/L\n 11:24 PM\n AST\n 41 IU/L\n 11:24 PM\n Amylase\n 15 IU/L\n 11:24 PM\n Total Bilirubin\n 0.7 mg/dL\n 11:24 PM\n Hematocrit\n 33.4 %\n 11:30 PM\n Current diet order / nutrition support: Thin liquids/Pureed solids\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: Low po intake\n Estimated Nutritional Needs (based on admit wt)\n Calories: 1470-1715 (BEE x or / 30-35 cal/kg)\n Protein: 59-59 (1-1.4 g/kg)\n Fluid: Per Team\n Specifics:\n 51 yo female admitted to ICU with ARF, FTT, and dehydration. Recent h/o\n of poor po intake associated with 35lbs weight loss in past 2-3 months\n per PCP notes resulting in severe malnutrition. SLP cleared pt for\n thin liquid sips and regular consistency solids . SLP\n re-evaluated this AM and recommend pureed solids and thin liquids if pt\n accepting to po\ns. Currently, refusing any po\ns. Noted calorie count\n c/s, which is not indicated at this point given refusing po\ns. Noted\n plan for family meeting today to discuss plan of care\ns vs. TF. Pt\n is at risk for re-feeding syndrome when nutrition resumed. Noted\n hypernatremia, D5 and LR boluses given\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If plan of care includes nutrition support:\n a. Rec place feeding tube\n long term feeding access (ie PEG) may\n be needed\n b. Suggest start TF: Fibersource @ 15mL/hr advance 10ml q6h to\n goal of 55 mL/hr 1584kcals/70g protein\n 2) Check residuals q6h, hold if >150mL\n 3) Water flushes prn\n 4) Encourage po\ns; if pt eating will send Ensure plus tid\n 5) Chem 10 daily, closely monitor lytes *esp Mag, Phos, K* and\n replete prn\n 6) Will follow poc\n 15:10\n ------ Protected Section ------\n Clarification: current diet order = sips\n Agree w/ above note and plan.\n Page if ?s *\n ------ Protected Section Addendum Entered By: , RD,\n on: 03:14 PM ------\n PM\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653391,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC line placed but crossed the midline so being readjused this AM.\n Remained off pressors overnight. Diuresed a little yesterday.\n Still refusing po's.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:35 PM\n Other medications:\n Trileptal, Valproate, Levothyroxine, HSQ, protonix, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.7\nC (96.2\n HR: 92 (87 - 98) bpm\n BP: 90/55(63) {61/40(48) - 136/78(90)} mmHg\n RR: 18 (9 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,992 mL\n 455 mL\n PO:\n TF:\n IVF:\n 3,992 mL\n 455 mL\n Blood products:\n Total out:\n 3,140 mL\n 190 mL\n Urine:\n 3,140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 852 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, Moaning\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: Bases B/L.)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 157 K/uL\n 67 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 112 mEq/L\n 138 mEq/L\n 26.4 %\n 4.7 K/uL\n [image002.jpg]\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n Hct\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n Plt\n 22\n 188\n 148\n 157\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:6.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors overnight. Urine output improved\n compared to yesterday\n -Continue to monitor\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC. Most immediate question is regarding placement of\n feeding tube or not.\n -Continue hydration\n -Will try to obtain records from her neurologist: Dr. \n () to determine what evaluation she has had thus far.\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today if BP tolerates.\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n QT=432ms\n -Continue amio load.\n MS\n Down\ns syndrome with presumed Alzheimer\ns dementia\n - Attempting to obtain neuron records as above\n Hypothyroid: Now on IV replacement.\n Access: Once PICC repositioned, pull femoral line.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652343,
"text": "HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive on levophed this morning Bp in the 60\ns systolic\n levophed ^ up to .27 mcgs/ kg min now able to drop to .19 mcg/kg min\n Action:\n Titrate to map > 60\n Response:\n Now 90-100 systolic\n Plan:\n Would maintain on levo at present dose\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.2 this afternoon\n Action:\n Pt had been given 40 of kcl earlier this afteroon\n Response:\n Still low k\n Plan:\n Will need repeat kcl this evening\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt agitiated calling crying all morning\n Action:\n Pt given zyperxa this am with no effect, to hr later ot given iv\n ativen with good effect\n Response:\n Pt sleeping when brother came more rousable this afternoon but would\n not repeat ativen because brother will return this evening and would\n like to see if he can get her to eat or drink\n Plan:\n need to reverse with fliumazenil this evening\n Hyperglycemia\n Assessment:\n Pt started on sliding scale\n Action:\n Needing coverage for bs 209-221\n Response:\n n/a\n Plan:\n Follow blood sugars\n We had a family meeting this afternoon with brothers and informed him\n about patients condition, he is aware that he status has been failing\n in the, past month would like to try him self to see if he can get her\n to eat, He has been informed that her mental status will most likely\n continue to slide and at present it thinking over how he would like to\n progress\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652511,
"text": "Chief Complaint: admitted with FTT, dehydration, hypotension\n 24 Hour Events:\n n failed wean from levophed yest afternoon; SBP dropped to 50\n while off within 15 minutes.\n n Received ativan 1 mg IV yesterday morning, which caused\n somnolence throughout the day\n n Had conversation with brother, , about possibility of PEG\n tube and overall prognosis; brother still undecided about goals of\n care, feeding tubes, etc.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: not able to obtain from patient given lack of verbal\n communication\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 112 (80 - 121) bpm\n BP: 115/84(90) {74/40(51) - 115/84(90)} mmHg\n RR: 23 (0 - 29) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,553 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,553 mL\n Blood products:\n Total out:\n 1,210 mL\n 340 mL\n Urine:\n 1,210 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Lungs: unable to cooperate with exam due to baseline MR/MS\n : V/VI SEM throughout w/ radiation to the back\n Abd: +BS; soft, NTND\n Extremities: + edema in hands and legs; symmetric; WWP\n Skin: fine\n\n blanching macular rash on back/legs/hands (not abd);\n scabbed\n Labs / Radiology\n 303 K/uL\n 11.1 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Assessment and Plan\n Assessment and Plan:\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR, with improving\n mental status and hypernatremia today.\n #) Hypotension: Etiology still remains not fully clear\npatient at that\n time has been aggressively fluid resuscitated and likely still has\n significant deficit, but would be hard to attribute hypotension solely\n to this source, especially given she was normotensive at outpatient\n visit. Cardiac echocardiogram with severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause. This\n leaves sepsis as a possibility, although source would unclear\nU/A from\n ED was fairly unremarkable, repeat one in ICU with many white (but also\n many red) cells; initial culture contaminated, second pending. No\n steroid use to make adrenal insufficiency more likely. Initially was\n tachycardiac, but not hypoxic to suggest PE with compromised cardiac\n output; additionally patient is already on coumadin making this less\n likely, especially with supratherapeutic levels.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis not overwhelming ), stool for c. diff should she\n have diarrhea. LP is a consideration, but has not been febrile, MS\n appears to be at baseline, and would need to consciously sedate to\n complete given patient cannot cooperate with this. Will stop vancomycin\n currently (no indwelling line or other reason to think she has MRSA\n skin or blood stream infection). Will continue zosyn until repeat\n urine/blood cultures are no growth for another 24 hrs (during last\n admission had UTI that was felt to be contributing to failure to\n thrive).\n - Transthoracic echocardiogram as noted above.\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Continue levophed as needed should IVFs not improve BP, will try to\n wean\n - Lactate has returned to \n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Family , will be in today to begin to discuss goals of care,\n as PEG tube may be necessary to meet caloric needs given that patient\n has had ongoing difficulties with PO intake since at least .\n Patient also has been recommended to get EGD to evaluate her dysphagia\n further, so consideration for completion of this on an inpatient basis\n should be made. Concern is that patient will pull out PEG if placed.\n - Supportive care with IVFs, electrolyte repletion (still has\n significant fluid deficit)\n - Working up infectious etiology\n - TSH, FT4 both WNL\n - Speech and swallow evaluation completed (difficult to assess given\n patient\ns lack of cooperation)\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult appreciated\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation was unremarkable\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n - Given question of acutely worsening dementia, checking vitamin B12,\n no known risk factors (not sexually active) for syphilis, TSH WNL,\n working on correcting other metabolic abnormalities that could be\n contributing to dementia\n .\n #) Acute renal failure: Much improved today, creatinine down to 1.7.\n Given elevated BUN, and history of virtually no PO intake for extended\n period, suspect pre-renal etiology. Baseline creatinine from was\n around 1.0.\n - Continue to trend creatinine, BUN\n - Urine electrolytes as noted\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D51/2NS once no longer requiring\n IVF boluses to maintain BP.\n - Space out sodium checks to given improvement to 150\n .\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities as noted\n above.\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Given still unclear etiology of , wean off pressors, and as\n long as mental status is at baseline, will tolerate lower BP and\n re-check lactate after off pressors to see if rising.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2.\n - Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n - Will discuss with family goals of care, and start hep gtt for\n anticoagulation if desired; sotalol once able to give PO medications.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (no vegetations),\n KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out. Giving IV valproate while\n here in ICU\n .\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt, PPI, bowel\n regimen if needed (would need to be PR given not taking PO\n .\n #) Code: Full per ED discussion with patient's HCP, will further\n discuss during meetingn today\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will need to discuss further with family and further\n line/PICC per that discussion.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652768,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated. stem test came back\n negative done yesterday.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVc\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol.titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate running for 6 hrs. Pt\n also\n Response:\n Plan:\n Closely monitor lytes\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome,dementia seems more interactive than yesterday\n respod to her name.A\n gitiated screaming crying and laughing all day.\n Action:\n Cont to Reorient and given calm and quiet environment.\n Response:\n Plan:\n Emotional support to family.Closely mo nitor mental status\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652094,
"text": "52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient at times says words after you say them to her like hi. She\n does not obey commands. Tries to pull ekg leads off iv tubing off. She\n moves all ext. pearl. With care yells out in uncomprehensible sounds.\n Action:\n Safety devices applied to arms. Order for safety devices obtained for\n today. Bed alarm on.\n Response:\n Patient remains safe in bed.\n Plan:\n Safety devices to arms. Bed alarm on.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 653368,
"text": "Subjective\n pt crying/yelling out\n Objective\n Pertinent medications: Lasix, Heparin, MVI, Pantoprazole, Amiodare gtt;\n KCl 20mEq repleted, Ca gm repleted\n Labs:\n Value\n Date\n Glucose\n 67 mg/dL\n 04:05 AM\n Glucose Finger Stick\n 82\n 01:00 PM\n BUN\n 4 mg/dL\n 04:05 AM\n Creatinine\n 0.7 mg/dL\n 04:05 AM\n Sodium\n 138 mEq/L\n 04:05 AM\n Potassium\n 3.8 mEq/L\n 04:05 AM\n Chloride\n 112 mEq/L\n 04:05 AM\n TCO2\n 24 mEq/L\n 04:05 AM\n PO2 (venous)\n 45 mm Hg\n 03:18 PM\n PCO2 (venous)\n 54 mm Hg\n 03:18 PM\n pH (venous)\n 7.32 units\n 03:42 PM\n pH (urine)\n 5.0 units\n 01:43 AM\n CO2 (Calc) venous\n 27 mEq/L\n 03:18 PM\n Albumin\n 1.7 g/dL\n 03:37 AM\n Calcium non-ionized\n 6.9 mg/dL\n 04:05 AM\n Phosphorus\n 2.7 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:42 PM\n Magnesium\n 2.5 mg/dL\n 04:05 AM\n ALT\n 21 IU/L\n 03:15 AM\n Alkaline Phosphate\n 54 IU/L\n 03:15 AM\n AST\n 37 IU/L\n 03:15 AM\n Amylase\n 15 IU/L\n 11:24 PM\n Total Bilirubin\n 0.5 mg/dL\n 03:15 AM\n WBC\n 4.7 K/uL\n 04:05 AM\n Hgb\n 9.2 g/dL\n 04:05 AM\n Hematocrit\n 26.4 %\n 04:05 AM\n Current diet order / nutrition support: DIET: sips\n TF: off (Replete w/ Fiber @ 40ml/hr)\n GI: firm/distended, (+) bs; (+) liquid stool\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, wt loss, refusing po's\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n Pt admitted w/ FTT, dehydration d/t refusing po\ns, wt loss. NGT placed\n for nutrition support, however pt self d/c\nd. Pt continues to refuse\n po\ns (approved by SLP for regular solids/thin liquids). Noted family\n discussing PEG placement for LT nutrition support. Surgery consulted.\n Noted multiple lytes \n Medical Nutrition Therapy Plan - Recommend the Following\n Will await family decision re: POC\n 1. If plan for PEG; recommend TF: Fibersource HN @ 15ml/hr,\n advance as tolerated to goal of 55ml/hr (1584calories and 70g protein)\n 2. If no plans for PEG; recommend po diet if pt accepts\n Continue lyte repletions prn\n Will follow up w/ further recommendations pending POC. Page if ?s\n *\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653546,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n pt. ready for transfer out of ICU as pt. has stabilized. Pt. to\n go for PEG placement today in OR and then should go to the floor when\n bed available. Currently, pt. on amiodorone gtt at 0.5mg/min to change\n to PO Amiodorone 400mg TID post PEG placement. Also, pt. to start\n Coumadin and Paxil when she has PEG. Nutrition consult ordered as well\n as PT to facilitate discharge to NH. Of note, pt. has had\n intermittment hypotension when she is asleep. BP rises upon\n stimulation. Also of note, pt.\ns cardiologist, Dr. would like to\n cardiovert pt. in weeks after therapeutic INR achieved.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. currently in NSR with frequent PVCs. Pt. with history of Afib.\n Action:\n Pt. currently requiring IV amiodorone gtt at 0.5mg/min.\n Response:\n Pt. in NSR w/ frequent PVCs.\n Plan:\n PEG placement this afternoon and should start 400mg TID in AM.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt. continue to call out frequently when awake and does respond to\n emotional support and familiar voices.\n Action:\n Pt. environment secure and safe.\n Response:\n Pt. continues to call out and cry for brother .\n :\n To start antidepressant and is currently on Depakote IV to be changed\n to PO with PEG.\n Coagulopathy (corrected)\n Assessment:\n Pt. with normalized INR now that pt. is hydrated and renal failure has\n resolved.\n Action:\n To restart coumadin when PEG placed with plan of mechanical\n cardioversion when INR appropriately therapeutic in 4-6weeks.\n Response:\n Plan:\n Decubitus ulcer (Not Present At Admission)\n Assessment:\n Pt. with intact Allevyn dsg on right side near hip and coccyx intact\n and not changed.\n Action:\n Visible skin impairments assessed and cleaned/ dried.\n Response:\n No improvement in skin impairments given gross edema throughout and\n poor nutritional status.\n Plan:\n PEG, start TF, increase albumin w/ protein which will increase\n likelihood of wound healing\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652225,
"text": "24 Hour Events:\n - Transthoracic echocardiogram completed demonstrating severe mitral\n regurgitation, severe pulmonary hypertension, and bowed intra-artial\n septum to the right. Normal biventricular systolic function, no\n pericardial effusion.\n - NG tube placed, however patient pulled this out.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin 1000 mg IV Q48H (last dose 12/30)\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n - Pantoprazole (Protonix) - 10:54 AM\n - Valproate 500 mg IV Q8H\n - Oxcarbazepine 300 mg \n - Levothyroxine 75 mcg PO\n - Thiamine 100 mg IV daily\n - Folic Acid 1 mg IV daily\n - Multivitamin 10 mL IV Q24H\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n None\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 111 (82 - 111) bpm\n BP: 71/43(49) {71/43(49) - 115/92(97)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 6,948 mL\n 2,152 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 2,142 mL\n Blood products:\n Total out:\n 770 mL\n 380 mL\n Urine:\n 770 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 1,772 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 324 K/uL\n 11.0 g/dL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652226,
"text": "24 Hour Events:\n - Transthoracic echocardiogram completed demonstrating severe mitral\n regurgitation, severe pulmonary hypertension, and bowed intra-artial\n septum to the right. Normal biventricular systolic function, no\n pericardial effusion.\n - NG tube placed, however patient pulled this out.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Vancomycin 1000 mg IV Q48H (last dose 12/30)\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n - Pantoprazole (Protonix) - 10:54 AM\n - Valproate 500 mg IV Q8H\n - Oxcarbazepine 300 mg \n - Levothyroxine 75 mcg PO\n - Thiamine 100 mg IV daily\n - Folic Acid 1 mg IV daily\n - Multivitamin 10 mL IV Q24H\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n None\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 111 (82 - 111) bpm\n BP: 71/43(49) {71/43(49) - 115/92(97)} mmHg\n RR: 12 (11 - 27) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 6,948 mL\n 2,152 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 2,142 mL\n Blood products:\n Total out:\n 770 mL\n 380 mL\n Urine:\n 770 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 1,772 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 324 K/uL\n 11.0 g/dL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Microbiology Data:\n Blood culture NGTD x2\n Urine culture NGTD x1, no growth final\n Imaging Data:\n CXR final read pending\n Transthoracic Echocardiogram\n The left atrial volume is markedly increased (>32ml/m2). The\n interatrial septum is aneurysmal. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are myxomatous. There is moderate/severe mitral valve\n prolapse. An eccentric, posteriorly directed jet of severe (4+) mitral\n regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is severe pulmonary artery systolic hypertension.\n There is no pericardial effusion.\n IMPRESSION: Severe prolapse of the anterior leaflet of the mitral valve\n with severe, posteriorly directed mitral regurgitation, severe\n pulmonary hypertension and an inter-atrial septum that is bowed towards\n the right. Biventricular systolic function looks normal. There is no\n pericardial effusion.\n Assessment and Plan:\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR.\n #) Hypotension: Differential includes hypovolemia secondary to very\n poor PO intake for a prolonged period, sepsis from underlying occult\n infection, cardiac shock or secondary to cardiac event in setting of\n elevated cardiac enzymes. No steroid use to make adrenal insufficiency\n more likely. Initially was tachycardiac, but not hypoxic to suggest PE\n with compromised cardiac output; additionally patient is already on\n coumadin making this less likely, especially with supratherapeutic\n levels. Attempted to measure pulsus, but was unable to do so secondary\n to patient repeatedly moving around.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis unremarkable), stool for c. diff should she have\n diarrhea\n - Transthoracic Echo in morning to assess for wall motion\n abnormalities, structure, function, effusion\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Levophed as needed should IVFs not improve BP\n - Trend lactate\n - Cortisol with AM labs\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Will need to investigate and discuss goals of care, as PEG tube may\n be necessary to meet caloric needs given that patient has had ongoing\n difficulties with PO intake since at least . Patient also has\n been recommended to get EGD to evaluate her dysphagia further, so\n consideration for completion of this on an inpatient basis should be\n made.\n - Supportive care with IVFs, electrolyte repletion\n - Working up infectious etiology\n - TSH, FT4\n - Speech and swallow evaluation\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabalized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n .\n #) Acute renal failure: Given elevated BUN, and history of virtually no\n PO intake for extended period, suspect pre-renal etiology. Baseline\n creatinine from was around 1.0. Improved to 2.4 after 6 L of\n IVFs.\n - Continue to trend creatinine, BUN\n - Urine electrolytes to be sent\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - VBG to check pH to ensure not acidotic (bicarbonate appears to be\n WNL, however)\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D5 or D51/2NS once no longer\n requiring IVF boluses to maintain BP.\n - Frequent (Q3-4 H) sodium checks\n .\n #) Hyperchloremia: Again suspected to be secondary to severe\n dehydration. No history of diarrhea or other GI symptoms to suggest\n etiology.\n - Using LR for volume resuscitation in lieu of NS.\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\n - Serial EKGs\n - Continue sotalol\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Re-check in AM\n - Checking VBG to ensure not acidotic.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption.\n - Holding coumadin, received 5 mg vitamin K in ED, following trend\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in atrial fibrillation, rate in 100's. Will hold\n at this time given risk of worsening hypotension.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (will concurrently\n evaluate for vegetation), KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out.\n .\n #) Hypothyroidism: Checking TSH/FT4. Continue home supplementation\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVFs, until speech and swallow evaluation. Nutrition\n consult appreciated.\n .\n #) PPx: Supratherapeutic INR, PPI.\n .\n #) Code: Full per ED discussion with patient's HCP's\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n Per ED discussion with family, she is full code.\n .\n #) Access: Right femoral central line placed in ED.\n .\n #) Dispo: ICU until above issues improved.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653593,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Team discussed patient's case with her outpatient neurologist. She\n confirmed that she had been diagnsosed with alzheimer's about one year\n ago and that she felt that her symptoms had been progressing over the\n past few months.\n Head CT done yesterday: Bifrontal hypdensities and ventricular\n enlargement.\n Family requested PEG tube placement yesterday, surgery consulted.\n Remained off pressors for the last 36 hours.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Pantoprazole (Protonix) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 07:47 AM\n Other medications:\n Valproate, levotyroxine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.1\nC (95.1\n HR: 87 (87 - 135) bpm\n BP: 82/55(62) {69/34(48) - 115/62(189)} mmHg\n RR: 15 (11 - 53) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,467 mL\n 936 mL\n PO:\n TF:\n IVF:\n 1,467 mL\n 936 mL\n Blood products:\n Total out:\n 2,065 mL\n 1,460 mL\n Urine:\n 2,065 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -598 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: Agitated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 163 K/uL\n 90 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 3 mg/dL\n 109 mEq/L\n 139 mEq/L\n 27.4 %\n 5.1 K/uL\n [image002.jpg]\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n Plt\n 48\n 157\n 163\n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 7\n 116\n 126\n 113\n 67\n 143\n 90\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors for 36 hours. Urine output\n improved compared to yesterday\n -Continue to monitor\n Failure to Thrive: Likely dementia. Family requesting G tube.\n -Surgery consulted, she is an add-on today\n -Follow up official read of head CT.\n -Consider anti-depressant trial.\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today if BP tolerates after G tube placed.\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n QT=432ms\n -Continue amio load, will transition to PGT once tube is in and can\n be used\n -Start coumadin via G tube. Goal INR \n MS\n Down\ns syndrome with presumed Alzheimer\ns dementia\n Hypothyroid: Now on IV replacement, will change to PGT once able.\n Access: PICC in place, femoral line now out.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652567,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Met with patient's brother yesterday to discuss some . Informed him\n that patient's FTT is likely due to dementia and that she probably will\n not be able to feed herself. He felt strongly that she would not want\n a PEG tube but he wanted to try to help feel her himself.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n folate, MVI, Thiamine, Trileptal, Levothyroxine, protonix, RISS,\n Valproate\n Flowsheet Data as of 09:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 112 (80 - 121) bpm\n BP: 115/73(82) {74/40(51) - 115/84(90)} mmHg\n RR: 14 (0 - 29) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,848 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,848 mL\n Blood products:\n Total out:\n 1,210 mL\n 375 mL\n Urine:\n 1,210 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,473 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Moaning, not interactive\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular Irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing, R\n femoral line in place\n Skin: faint erythematous rash on back\n Neurologic: Responds to: Verbal stimuli, Movement: moves spontaneously,\n Tone: Not assessed\n Labs / Radiology\n 11.1 g/dL\n 303 K/uL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Microbiology: UCx: No Growth\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present.\n Seems distributive shock. Poor cardiac output from severe MR may be\n playing a role although exam not consistent with this. Also though her\n RV function was normal she has mod pHTN so perhaps overresuscitated and\n RV distension. No clear source of sepsis. Unclear if non-invasive BP's\n are accurate as she is alert and often yelling with SBP's of 60's.\n -Her behavior prohibits A-line placement at this time.\n -As urine culture is negative, will d/c Zosyn\n -Check stim\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Improving\n -Continue with free water in D5 1/2NS drip.\n Failure to Thrive: Will continue to discuss overall with patient's\n brother. If no plans for PEG tube, transitioning to comfort care may\n be appropriate\n -Continue vitamin support\n -Continue hydration\n Elevated cardiac Biomarkers: Appears stress related. No further\n intervention\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. If overall plan is for continued aggressive care, will\n heparinize\n Hypothyroid: Will switch to IV levothyroxine if goals of care conclude\n continued aggressive treatment rather than symptom- guided\n treatment.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n Family meetings with pt\ns brother and his wife to determine appropriate\n direction of care.\n"
},
{
"category": "Nutrition",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 653527,
"text": "Objective\n Labs:\n Value\n Date\n Glucose\n 90 mg/dL\n 02:27 AM\n Glucose Finger Stick\n 90\n 06:00 AM\n BUN\n 3 mg/dL\n 02:27 AM\n Creatinine\n 0.7 mg/dL\n 02:27 AM\n Sodium\n 139 mEq/L\n 02:27 AM\n Potassium\n 3.7 mEq/L\n 02:27 AM\n Chloride\n 109 mEq/L\n 02:27 AM\n TCO2\n 28 mEq/L\n 02:27 AM\n PO2 (venous)\n 45 mm Hg\n 03:18 PM\n PCO2 (venous)\n 54 mm Hg\n 03:18 PM\n pH (venous)\n 7.32 units\n 03:42 PM\n pH (urine)\n 5.0 units\n 02:27 AM\n CO2 (Calc) venous\n 27 mEq/L\n 03:18 PM\n Albumin\n 1.7 g/dL\n 03:37 AM\n Calcium non-ionized\n 7.4 mg/dL\n 02:27 AM\n Phosphorus\n 2.6 mg/dL\n 02:27 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:42 PM\n Magnesium\n 1.9 mg/dL\n 02:27 AM\n ALT\n 21 IU/L\n 03:15 AM\n Alkaline Phosphate\n 54 IU/L\n 03:15 AM\n AST\n 37 IU/L\n 03:15 AM\n Amylase\n 15 IU/L\n 11:24 PM\n Total Bilirubin\n 0.5 mg/dL\n 03:15 AM\n WBC\n 5.1 K/uL\n 02:27 AM\n Hgb\n 9.7 g/dL\n 02:27 AM\n Hematocrit\n 27.4 %\n 02:27 AM\n Current diet order / nutrition support: sips\n Assessment of Nutritional Status\n Estimation of current intake: inadequate\n Specifics:\n Family would like to purse PEG\n pt is add on in OR today. Consulted\n for TF recommendations. Please see full note in Metavision . Pt is\n at high refeeding risk d/t prolonged poor po\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. 24 hours after PEG placed, rec begin TF: Fibersource HN @\n 15ml/hr, advance slowly as tolerated and if electrolytes are stable to\n goal of 55ml/hr = 1584calories and 84g protein\n 2. Check residuals, hold TF if >/= 150ml\n 3. Monitor lytes closely\n esp. Mg, Phos, K\n replete prn\n 4. Will follow\n page if ?s *\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653530,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n pt. ready for transfer out of ICU as pt. has stabilized. Pt. to\n go for PEG placement today in OR and then should go to the floor when\n bed available. Currently, pt. on amiodorone gtt at 0.5mg/min to change\n to PO Amiodorone 400mg TID post PEG placement. Also, pt. to start\n Coumadin and Paxil when she has PEG. Nutrition consult ordered as well\n as PT to facilitate discharge to NH. Of note, pt. has had\n intermittment hypotension when she is asleep. BP rises upon\n stimulation. Also of note, pt.\ns cardiologist, Dr. would like to\n cardiovert pt. in weeks after therapeutic INR achieved.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. currently in NSR with frequent PVCs. Pt. with history of Afib.\n Action:\n Pt. currently requiring IV amiodorone gtt at 0.5mg/min.\n Response:\n Pt. in NSR w/ frequent PVCs.\n Plan:\n PEG placement this afternoon and should start 400mg TID in AM.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt. continue to call out frequently when awake and does not respond to\n emotional support.\n Action:\n Pt. environment secure and safe.\n Response:\n Pt. continues to call out and cry for brother .\n :\n To start antidepressant and is currently on Depakote IV to be changed\n to PO with PEG.\n Coagulopathy\n Assessment:\n Pt. with normalized INR now that pt. is hydrated and renal failure has\n resolved.\n Action:\n To restart coumadin when PEG placed with plan of mechanical\n cardioversion when INR appropriately therapeutic.\n Response:\n Plan:\n Decubitus ulcer (Not Present At Admission)\n Assessment:\n Pt. with intact Allevyn dsg on right side near hip and coccyx\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652334,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:41 AM\n EKG - At 10:20 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:41 AM\n ng tube\n TTE done yesterday-->Severe MR = 60-64, Nml Biventricular\n function, no pericardial effusion\n Pressors tapered overnight but had to be increased this AM for HoTN.\n Patient self-d/c'd NGT.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:39 AM\n Vancomycin - 10:00 AM\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:54 AM\n Lorazepam (Ativan) - 10:17 AM\n Other medications:\n Thiamine, MVI, Trileptal, Folate, Levothyoxine, Pantoprazole, Valproate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.4\nC (95.8\n HR: 102 (82 - 111) bpm\n BP: 74/55(51) {71/43(49) - 115/92(97)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,948 mL\n 3,892 mL\n PO:\n TF:\n 10 mL\n IVF:\n 6,948 mL\n 3,882 mL\n Blood products:\n Total out:\n 770 mL\n 670 mL\n Urine:\n 770 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,178 mL\n 3,222 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: ), no wheeze\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: warm, eyrthematous hands and feet\n Neurologic: crying, batting away examiners purposefully\n Labs / Radiology\n 11.0 g/dL\n 324 K/uL\n 212 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 120 mEq/L\n 151 mEq/L\n 32.9 %\n 13.7 K/uL\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n WBC\n 12.0\n 13.7\n Hct\n 33.4\n 0\n 36\n 33.0\n 32.9\n Plt\n 352\n 324\n Cr\n 2.4\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n TropT\n 0.31\n 0.29\n Glucose\n 93\n 122\n 170\n 160\n 189\n 192\n 212\n Other labs: PT / PTT / INR:16.0/30.1/1.4, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:1.8 mg/dL\n Microbiology: BCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present. Poor\n cardiac output from severe MR may be playing a role.\n Also though her RV function was normal she has mod pHTN so perhaps\n overresuscitated and RV distension.\n No clear source of sepsis. Unclear if non-invasive BP's are accurate\n as she is alert and often times yelling with SBP's of 60's.\n -Will wean off pressors and follow lactates for signs of\n hypoperfusion. Her behavior prohibits A-line placement at this time.\n -D/C vancomycin. If UCx negative, will d/c zosyn.\n Hypernatremia: Hypovolemic. Improving\n -Continue with free water in D5 1/2NS drip. If continues to improve\n today, switch to Qdaily checks tomorrow\n Failure to Thrive: Needs GOC discussion. Patient not tolerating NGT\n placement and may not tolerate PEG placement. Will try to meet with\n family when able.\n -Continue vitamin support\n -Continue hydration\n Elevated cardiac Biomarkers: Appears stress related. No further\n intervention\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Will address this issue with family.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out.\n ICU Care\n Nutrition: IVF for now, need to discuss nitrition with brother\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653127,
"text": "Chief Complaint: FTT\n Hypotension\n 24 Hour Events:\n - family still undecided about feeding tube, want Dr. (her\n cardiologist) to weigh in \n - continues on amiodarone gtt--> calculated that she needs to load for\n 9.25 days from \n - weaned off levophed, but put backon overnight\n History obtained from Family / Friend\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 89 (89 - 100) bpm\n BP: 93/60(67) {81/44(53) - 106/85(91)} mmHg\n RR: 16 (0 - 26) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 4,108 mL\n 1,829 mL\n PO:\n TF:\n IVF:\n 4,108 mL\n 1,829 mL\n Blood products:\n Total out:\n 740 mL\n 295 mL\n Urine:\n 490 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,368 mL\n 1,534 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 8.9 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 25.3 %\n 6.2 K/uL\n [image002.jpg]\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n Hct\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n Plt\n 22\n 188\n 148\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.0\n mg/dL\n Imaging: No new\n Microbiology: Blood 12/30: NGTD\n Urine : NGTD\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains intermittently pressor-dependent and\n with no PO intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC normalized\n -- Manual BP to ensure correlates with automatic read\n -- will trial lasix 20mg IV for diuresis to help reduce preload given\n severe MR\n -- wean levophed as tolerated\n #) Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Currently in afib , on , had HR 110- 120\ns, occ 130\ns even while\n at rest\n --loading amiodarone IV x 9 days since1/3/09; cannot give oral at this\n time.\n -- Ongoing discussion with family re: goals of care, and start hep gtt\n & coumadin for anticoagulation if plans for feeding tube; sotalol if\n ever able to give PO medications.\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, other metabolic\n abnormalities were corrected. Speech and swallow evaluation was\n completed (difficult to assess given patient\ns lack of cooperation).\n Had fam htg with brother, , and his wife; he is still deciding\n overall goals of care and whether to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube broad goals of care\n --will need PICC for accesss; need to remove fem line\n -- Working up infectious etiology as above- negative w/u to date\n --thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG will consider palliative care c/s for\n possible hospice placement; in addition, will do social work consult.\n -- Cont MV\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 or 0.5 mg IV given prolonged effect of the 1 mg dose\n on .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Resolved with\n hydration, Na normalized.\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR.\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; resolved with\n fluids. UCx negative. Still poor urine output\n -- trial of lasix to improve urine output\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU; check level\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per discussion with patient's HCP\n #) Communication:\n Brother: is HCP ; work (? home)\n #) Access: Right femoral central line placed in ED Needs to be\n replaced. Spoke to family about PICC and they understant this would\n need to be placed with sedation. Will replace today with IV sedation\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 652078,
"text": "Chief Complaint: Shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:40 AM\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:59 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Down's Syndrome\n Mitral Regurg. - no echo in our system\n Breast Ca - DCIS in , s/p masectomy\n GERD\n gangrnous cholecystitis - s/p cholecystectomy\n As per resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: as per resident note\n Review of systems:\n Flowsheet Data as of 09:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 102 (83 - 102) bpm\n BP: 93/71(69) {59/22(37) - 111/71(75)} mmHg\n RR: 15 (9 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 6,049 mL\n 3,443 mL\n PO:\n TF:\n IVF:\n 49 mL\n 3,443 mL\n Blood products:\n Total out:\n 760 mL\n 290 mL\n Urine:\n 60 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 3,153 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Anxious, Crying out\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Bronchial: bibasilar)\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 33.4 %\n 170 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 128 mEq/L\n 4.1 mEq/L\n 161 mEq/L\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n Hct\n 33.4\n Cr\n 2.4\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n 170\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.3 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 52 year old woman with down's syndrome who presents with hypernatremia\n as well as shock and lactic acidosis of unclear etiology. Lactate\n rapidly trending down in the setting of moderate fluid resuscitation.\n Certainly a component of hypovolemia but doubt that this alone is\n adequate explanantion. Dirty UA so most likely scenario would be\n hypovolemia in the setting of decreased\n po intake and then sepsis from urinary source. Seizure is also a\n possibility but history seems inconsistent. Cardiac arrythmia also on\n the differential but no\n evidence on tele or EKG here. Suspect troponin is demand rather than\n primary cardiac event but will check TTE today. PE unlikely in the\n setting of supertherapeutic INR. Other explanations such as mesenteric\n ischemia seem inconsistent with rapid resolution. For now, will\n continue fluid resuscitation , vanc/zosyn and correct metabolic\n abnormalities. Given multiple recent hospital admits and persistent\n failure to thrive, concerned for long term prognosis and will meet with\n family today. Further plans as per resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Multi Lumen - 11:46 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652766,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received on Levophed at .07 mics/kg/hr,SBp in mid 90\ns to 100.\n Action:\n Levophed titrated down to .03 as tolerated. stem test came back\n negative done yesterday.\n Response:\n BP in\n Plan:\n Attempt to wean levophed. Titrate to mean 60.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVc\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol.titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone?\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 this morning and phosphorus 1,8 and Na 142\n Action:\n Given 40 mEq potassium and potassium phosphate running for 6 hrs. Pt\n also\n Response:\n Plan:\n Closely monitor lytes\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome,dementia agitiated screaming crying and laughing\n all day.\n Action:\n Cont to Reorient and given calm and quiet environment.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653645,
"text": " pt. ready for transfer out of ICU as pt. has stabilized. Pt. to\n go for PEG placement today in OR and then should go to the floor when\n bed available. Currently, pt. on amiodorone gtt at 0.5mg/min to change\n to PO Amiodorone 400mg TID post PEG placement. Also, pt. to start\n Coumadin and Paxil when she has PEG. Nutrition consult ordered as well\n as PT to facilitate discharge to NH. Of note, pt. has had\n intermittment hypotension when she is asleep. BP rises upon\n stimulation. Also of note, pt.\ns cardiologist, Dr. would like to\n cardiovert pt. in weeks after therapeutic INR achieved.\n Atrial fibrillation (Afib)\n Assessment:\n Pt started on po amiodarone last eve\n Action:\n Amiodarone gtt dc\n Response:\n Pt remained in a-fib this entire shift, w/ occasional PVC\n Plan:\n Next po dose via PEG at 08:00\n Heart disease, other\n Assessment:\n Hx hrt valve dz\n Action:\n Pt received Lasix to assist diursis and lessen work on heart\n Response:\n Pt had good diuretic effect (seee nusrses\n Plan:\n Pt ordered for daily lasix\n Problem - Description In Comments\n Assessment:\n Pt s/p placement PEG yest early eve\n Action:\n PEG tube used for meds only, according to surgey team;\n Site c/d/i\n Response:\n Used for meds, tube feeds to wait until later .\n Plan:\n Pt called out to floor care; is felt pt needs private room due to pti\n patients calling out\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652331,
"text": "HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n Hypotension (not Shock)\n Assessment:\n Pt hypotensive on levophed this morning Bp in the 60\ns systolic\n levophed ^ up to .27 mcgs/ kg min now able to drop to .19 mcg/kg min\n Action:\n Titrate to map > 60\n Response:\n Now 90-100 systolic\n Plan:\n Would maintain on levo at present dose\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.2 this afternoon\n Action:\n Pt had been given 40 of kcl earlier this afteroon\n Response:\n Still low k\n Plan:\n Will need repeat kcl this evening\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt agitiated calling crying all morning\n Action:\n Pt given zyperxa this am with no effect, to hr later ot given iv\n ativen with good effect\n Response:\n Pt sleeping when brother came more rousable this afternoon but would\n not repeat ativen because brother will return this evening and would\n like to see if he can get her to eat or drink\n Plan:\n need to reverse with fliumazenil this evening\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 652049,
"text": "Chief Complaint: Shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 year old woman with Down's syndrome, afib on coumadin, lives at a\n group home. Referred to the ED from PCP's office yesterday for\n dehydration, altered mental status and failure to thrive. Reports 35lb\n weight loss over the last 2-3 months, declining po intake over the same\n time course. In ED hypotensive (92/palp) for which she got 2L\n NS.Subsequent BP's in the 70's and started on levophed. Labs notable\n for lactate of 9, hypernatremia to 160's. Given vanc/zosyn, FAST exam\n wnl and admitted to MICU.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:40 AM\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:59 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Down's Syndrome\n Mitral Regurg. - no echo in our system\n Breast Ca - DCIS in , s/p masectomy\n GERD\n gangrnous cholecystitis - s/p cholecystectomy\n As per resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: as per resident note\n Review of systems:\n Flowsheet Data as of 09:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.8\n Tcurrent: 35.4\nC (95.8\n HR: 102 (83 - 102) bpm\n BP: 93/71(69) {59/22(37) - 111/71(75)} mmHg\n RR: 15 (9 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 6,049 mL\n 3,443 mL\n PO:\n TF:\n IVF:\n 49 mL\n 3,443 mL\n Blood products:\n Total out:\n 760 mL\n 290 mL\n Urine:\n 60 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 3,153 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Anxious, Crying out\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Bronchial: bibasilar)\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 33.4 %\n 170 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 128 mEq/L\n 4.1 mEq/L\n 161 mEq/L\n [image002.jpg]\n 11:24 PM\n 11:30 PM\n 01:10 AM\n 04:58 AM\n Hct\n 33.4\n Cr\n 2.4\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n 170\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Lactic Acid:1.3 mmol/L, Albumin:2.1 g/dL,\n LDH:365 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 52 year old woman with down's syndrome who presents with hypernatremia\n as well as shock and lactic acidosis of unclear etiology. Lactate\n rapidly trending down in the setting of moderate fluid resuscitation.\n Certainly a component of hypovolemia but doubt that this alone is\n adequate explanantion. Dirty UA so most likely scenario would be\n hypovolemia in the setting of decreased\n po intake and then sepsis from urinary source. Seizure is also a\n possibility but history seems inconsistent. Cardiac arrythmia also on\n the differential but no\n evidence on tele or EKG here. Suspect troponin is demand rather than\n primary cardiac event but will check TTE today. PE unlikely in the\n setting of supertherapeutic INR. Other explanations such as mesenteric\n ischemia seem inconsistent with rapid resolution. For now, will\n continue fluid resuscitation , vanc/zosyn and correct metabolic\n abnormalities. Given multiple recent hospital admits and persistent\n failure to thrive, concerned for long term prognosis and will meet with\n family today. Further plans as per resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Multi Lumen - 11:46 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 652074,
"text": "Chief Complaint: Hypernatremia, hypotension, acute renal failure,\n failure to thrive\n HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n Per report, her caregiver stated that her mental status appeared at\n baseline, which was not very communicative. A copy of her PCP visit\n note accompanies her paperwork and describes that she has lost about 35\n lbs, and possibly has been vomiting. Her INR was 7 recently and she\n received vitamin K for that.\n .\n Based on a speech and swallow evaluation note from in OMR, at\n that time staff in the group home were concerned about the patient's\n lack of PO intake. It was described at that time that the patient was\n refusing former favorite foods, and would eat about spoonfulls\n prior to spitting out solid foods at meals; there was also concern\n about choking on pills. It was also noted that the patient appeared to\n regurgitate food after meals (ongoing behavoir for 20 years). It was\n noted that she had lost about 15 pounds due to this behavoir. The\n evaluation by the speech and swallow team determined that her\n inadequate PO intake was possibly secondary to dementia and behavoiral\n changes, although further studies were recommended given inability to\n fully evaluate.\n .\n Also of note, patient was admitted in for failure to thrive\n and decreased PO intake. It was found that she was constipated, and she\n was tolerating a regular diet prior to discharge.\n .\n In the ED, initially it was difficult to measure the patient's blood\n pressure. Her heart rate was 90, respiratory rate of 14, with\n difficulty measuring oxygen saturation. First recorded blood pressure\n was 92/palp, with oxygen saturation of 100%. Patient was lethargic but\n responsive with moaning and crying out to verbal stimuli. She was given\n 2L of NS initially when her SBP dropped to 70's and 80's. She was\n guaiac negative, and a chest x-ray was unremarkable. Labs were notable\n for renal insufficiency, hypernatremia (166), hyperchloremia (124),\n lactate of 9.2, INR of 9.6 (then >11), and leukocytosis of 14.\n A femoral line was placed and patient was given 4L of IVF with\n improvement to systolics in 100's. However, then patient fell asleep\n and systolic dropped to 70's, so she received an additional 2 liters\n and levophed was started. She was given vancomycin and zosyn, and\n cultures were drawn. She was also given 5 mg of IV vitamin K for\n elevated INR. EKG was without concering changes. FAST was negative (no\n free fluid, bedside echo looked ok).\n .\n Upon arrival to the floor, patient was crying out. She would make eye\n contact occasionally and stated \"I love you\" once, otherwise was\n incomprehensible.\n History obtained from Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other medications:\n Home Medications:\n (per office visit note faxed over)\n - Coumadin 1 mg daily\n - Senna 8.6 mg daily\n - Sotalol 120 mg \n - Potassium Chloride 40 mEq daily\n - Lasix 40 mg daily\n - Ketaconazole as needed\n - Triamcinolone cream as needed\n - Prilosec 20 mg \n - Bacitracin ointment PRN\n - Amoxicillin prior to dental procedures\n - Levothyroxine 75 mcg\n - Lorazepam 1 mg prior to medical procedures\n - Depakote 1500 mg daily\n - Trileptal 300 mg \n Past medical history:\n Family history:\n Social History:\n - Down's syndrome\n - Alzheimers Dementia\n - Mitral valve regurgitation, followed by Dr. \n - Hypothyroidism\n - Status-post right mastectomy for breast cancer, last mammogram \n WNL\n - Atrial fibrillation\n - History of bacterial endocarditis in \n - Status-post appendectomy (laproscopic )\n - Esophageal reflux and H. Pylori infection ()\n - Status-post cholecystectomy\n - Status-post laparoscopic umbilical hernia repair\n - Status-post gangrenous cholecystitis, lap chole \n Unable to obtain.\n Patient lives in group home. She recently has stopped walking and has\n been in a wheelchair. No alcohol, drug, or tobacco use. She enjoys\n playing with beads (per office note).\n Review of systems:\n As noted in HPI.\n Flowsheet Data as of 03:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 100 (83 - 100) bpm\n BP: 79/56(61) {71/22(47) - 111/57(69)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,049 mL\n 1,973 mL\n PO:\n TF:\n IVF:\n 49 mL\n 1,973 mL\n Blood products:\n Total out:\n 760 mL\n 105 mL\n Urine:\n 60 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 1,868 mL\n Respiratory\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Temperature 95.7, HR 99, BP 111/57, RR 13, Oxygenation 100% on RA\n General: Thin, slightly catchetic female, moving around in bed when\n name is called, crying out and alternatively curling up\n HEENT: Very dry mucous membranes with fissuring of the lipds and\n tongue. PERRL, no scleral icterus or conjunctival pallor.\n Neck: Supple, no JVD\n Cardiac: RR, III/VI holosystolic murmur, no rubs or gallops\n Lungs: CTAB, although examination limited by effort, no apparent\n wheezes, raltes\n Abd: Soft, +BS, ND, cannot assess for tenderness, but no guarding\n Extr: Very dry, cracked skin over dorsum of hands, feet. Few small\n ecchymoses over right thigh, no discrete rashes or other lesions.\n Neuro: Awake, agitated, difficult to understand when makes attempts at\n speaking, CNs appear symmteric, moving all extremities equally\n Labs / Radiology\n 122 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 124 mEq/L\n 3.4 mEq/L\n 163 mEq/L\n 33.4 %\n [image002.jpg]\n \n 2:33 A12/30/ 11:24 PM\n \n 10:20 P12/30/ 11:30 PM\n \n 1:20 P12/31/ 01:10 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 33.4\n Cr\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, Lactic Acid:1.3 mmol/L, Ca++:6.2 mg/dL, Mg++:2.2\n mg/dL, PO4:4.3 mg/dL\n Microbiology Data:\n - Blood and urine cultures pending.\n .\n Imaging: CXR without acute process.\n KUB Pending.\n .\n EKG: Atrial fibrillation, normal axis, LVH with non-specific ST changes\n (T wave inversions in V2-V6 not seen on prior from ), question of\n ST depression in II, but not consistent--poor baseline. RBBB\n Assessment and Plan\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR.\n #) Hypotension: Differential includes hypovolemia secondary to very\n poor PO intake for a prolonged period, sepsis from underlying occult\n infection, cardiac shock or secondary to cardiac event in setting of\n elevated cardiac enzymes. No steroid use to make adrenal insufficiency\n more likely. Initially was tachycardiac, but not hypoxic to suggest PE\n with compromised cardiac output; additionally patient is already on\n coumadin making this less likely, especially with supratherapeutic\n levels. Attempted to measure pulsus, but was unable to do so secondary\n to patient repeatedly moving around.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis unremarkable), stool for c. diff should she have\n diarrhea\n - Transthoracic Echo in morning to assess for wall motion\n abnormalities, structure, function, effusion\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Levophed as needed should IVFs not improve BP\n - Trend lactate\n - Cortisol with AM labs\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Will need to investigate and discuss goals of care, as PEG tube may\n be necessary to meet caloric needs given that patient has had ongoing\n difficulties with PO intake since at least . Patient also has\n been recommended to get EGD to evaluate her dysphagia further, so\n consideration for completion of this on an inpatient basis should be\n made.\n - Supportive care with IVFs, electrolyte repletion\n - Working up infectious etiology\n - TSH, FT4\n - Speech and swallow evaluation\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabalized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n .\n #) Acute renal failure: Given elevated BUN, and history of virtually no\n PO intake for extended period, suspect pre-renal etiology. Baseline\n creatinine from was around 1.0. Improved to 2.4 after 6 L of\n IVFs.\n - Continue to trend creatinine, BUN\n - Urine electrolytes to be sent\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - VBG to check pH to ensure not acidotic (bicarbonate appears to be\n WNL, however)\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D5 or D51/2NS once no longer\n requiring IVF boluses to maintain BP.\n - Frequent (Q3-4 H) sodium checks\n .\n #) Hyperchloremia: Again suspected to be secondary to severe\n dehydration. No history of diarrhea or other GI symptoms to suggest\n etiology.\n - Using LR for volume resuscitation in lieu of NS.\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\n - Serial EKGs\n - Continue sotalol\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Re-check in AM\n - Checking VBG to ensure not acidotic.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption.\n - Holding coumadin, received 5 mg vitamin K in ED, following trend\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in atrial fibrillation, rate in 100's. Will hold\n at this time given risk of worsening hypotension.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (will concurrently\n evaluate for vegetation), KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out.\n .\n #) Hypothyroidism: Checking TSH/FT4. Continue home supplementation\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVFs, until speech and swallow evaluation. Nutrition\n consult appreciated.\n .\n #) PPx: Supratherapeutic INR, PPI.\n .\n #) Code: Full per ED discussion with patient's HCP's\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n Per ED discussion with family, she is full code.\n .\n #) Access: Right femoral central line placed in ED.\n .\n #) Dispo: ICU until above issues improved.\n ICU Care\n Nutrition: IVF, nutrition consult and speech and swallow consults\n placed\n Glycemic Control: N/A\n Lines:\n Multi Lumen - 11:46 PM\n 22 Gauge - 11:47 PM\n Prophylaxis:\n DVT: Supratherapeutic INR\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments: As noted above\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n Post-call addendum.\n Patient given several additional boluses of LR overnight to maintain\n MAP >60. She continued to cry out and moan throughout night. Sodium\n improved from 166 to 161 overnight at steady goal rate. Chloride also\n improved after transitioning to LR. TSH, cultures pending, will\n continue empiric antibiotic coverage.\n Elevated lactate that resolved so quickly supports either low level\n ischemia secondary to hypotension, seizure, or arrhythmia, but no\n evidence on history to support seizure (group home staff did not give\n history of his) or arrhythmias on telemetry.\n Today will get transthoracic echocardiogram to further evaluate\n structure, function, any focal wall motion abnormalities, or\n pericardial effusion. Prior cardiac event is possibility, but no major\n changes on EKG (although baseline difficult to compare), will obtain\n repeat EKG today. Renal function improving with fluid resuscitation.\n Will follow up electrolytes closely throughout the day.\n Major goal today will be to assess goals of care with family and\n caregivers to determine how aggressively to target nutrition\n supplementation (Dobhoff versus PEG). Appreciate multidisciplinary team\n assistance (social work, nutrition).\n ------ Protected Section Addendum Entered By: , MD\n on: 12:14 ------\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652537,
"text": "Chief Complaint: admitted with FTT, dehydration, hypotension\n 24 Hour Events:\n n failed wean from levophed yest afternoon; SBP dropped to 50\n while off within 15 minutes.\n n Received ativan 1 mg IV yesterday morning, which caused\n somnolence throughout the day\n n Had conversation with brother, , about possibility of PEG\n and overall prognosis; brother still undecided about goals of\n care, feeding tubes, etc.\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: not able to obtain from patient given lack of verbal\n communication\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 112 (80 - 121) bpm\n BP: 115/84(90) {74/40(51) - 115/84(90)} mmHg\n RR: 23 (0 - 29) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,553 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,553 mL\n Blood products:\n Total out:\n 1,210 mL\n 340 mL\n Urine:\n 1,210 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Lungs: unable to cooperate with exam due to baseline MR/MS\n : V/VI SEM throughout w/ radiation to the back\n Abd: +BS; soft, NTND\n Extremities: + edema in hands and legs; symmetric; WWP\n Skin: fine\n\n blanching macular rash on back/legs/hands (not abd);\n scabbed erosion on right hip/trochanter, no evidence of surrounding\n erythema, fluctuance or drainage; no other evidence of skin breakdown\n Neuro: awake, follows simple commands slowly (e.g., open eyes); moaning\n frequently; cannot answer questions to assess orientation; moving all\n limbs spontaneously; CN II - XII grossly in tact\n Labs / Radiology\n 303 K/uL\n 11.1 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n No new micro or radiology data.\n Assessment and Plan:\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated and remains\n levophed-dependent. Cardiac echocardiogram showed severe MR, but\n function was normal, without pericardial effusion; severe MR could be\n contributing to hypotension, but again seems less likely that this is\n sole cause. There is no evidence of sepsis/infection with improving\n WBC, afebrile state, nothing localizing and no positive Cx data; LP\n deferred for now given MS appears to be at (recent) baseline. Adrenal\n insufficiency as primary cause of hypotension is less likely w/o risk\n factors; had a random cortisol level that was 20.4, though has not had\n CortStim test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2) will d/c Zosyn\n -- IVF boluses PRN for hypotension; will defer weaning from levophed\n today given SBP in the 90\ns this morning\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, working on\n correcting other metabolic abnormalities that could be contributing to\n dementia. Speech and swallow evaluation was completed (difficult to\n assess given patient\ns lack of cooperation). Had fam htg with brother,\n , on ; he is still deciding overall goals of care and whether\n to provide a PEG for feeding.\n -- will have another family meeting today to discuss options of PEG\n and PICC line, broad goals of care\n -- Sips given MS feeds and maintenance IVF\n -- Working up infectious etiology as above; thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- Cont. folate, MV, thiamine supplementation\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 mg IV given prolonged effect of the 1 mg dose on\n .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Improving\n while on IVF supplementation.\n -- cont IVF maintenance fluids with D5-1/2NS\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2. INR 1.4 on\n .\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy.\n #) Acute renal failure: resolved. Likely prerenal; improved to 1.1\n from 3.4 on admission. Baseline creatinine from was around\n 1.0. UCx negative.\n -- cont maintenance fluids.\n #) Elevated lactate: resolved.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n -- Will discuss with family goals of care, and start hep gtt & coumadin\n for anticoagulation if desired; sotalol once able to give PO\n medications.\n #) Leukocytosis: resolving; 14.1 on admission; 10.1 on \n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;\n PPI, bowel regimen if needed (would need to be PR given not taking\n PO\n .\n #) Code: Full per ED discussion with patient's HCP\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will discuss further with family on ; will need\n conscious sedation for the procedure.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition:\n Glycemic Control: SSI\n Lines: right femoral line; would like to place PICC pending family\n agreement (see above)\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: protonix 40 mg IV QD\n VAP: NA\n Comments:\n Communication: Comments: see above\n Code status: Full code\n Disposition: to in ICU while on pressors\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652545,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt receivd on Levo at .18 mics/kg/hr,SBP in mid 90\ns to 105 .\n Action:\n Unable towean Levophed 2/2low BP. UOP ~ 30cc/hr.\n Response:\n Cont Levophed at same rate.\n Plan:\n Wean Levophed as tolerated, Closly Monitor UOP and BP . Fluid bolus\n for low UOP and BP ?\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h dementia and Down syndrome,been awake all the time Pt\n constantly yelling ,crying and laughing, follow ing simple commands.\n Action:\n Re oriented, provided calm and quiet environment.DR a discussion\n about PEG tube and PICC lnt as along term plan with her Sister in law\n (HCP) .\n Response:\n Plan:\n Cont to monitor MS closely, provide comfort and emotional support.\n Follow up with Broither and sister in law about their opinion.\n Hypernatremia (high sodium)\n Assessment:\n Na this morning was 147.\n Action:\n Initiated D5\n NS at 100cc/hr,sent evening lytes.\n Response:\n Na this afternoon down to 144.\n Plan:\n Closely monitor lytes and treat accordingly. Cont D5\n NS for now.\n"
},
{
"category": "General",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Generic Note",
"row_id": 653739,
"text": "TITLE:\n"
},
{
"category": "General",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Generic Note",
"row_id": 653740,
"text": "Nursing Progress\n"
},
{
"category": "General",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Generic Note",
"row_id": 653741,
"text": "Nursing Progress\n Atrial fibrillation (Afib)\n Assessment:\n Pt. currently in NSR with frequent PVCs. Pt. with history of Afib.\n Action:\n Pt. currently requiring IV amiodorone gtt at 0.5mg/min.\n Response:\n Pt. in NSR w/ frequent PVCs.\n Plan:\n PEG placement and should started 400mg TID.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt. continue to call out frequently when awake and does not respond to\n emotional support.\n Action:\n Pt. environment secure and safe.\n Response:\n Pt. continues to call out and cry for brother .\n :\n To start antidepressant and is currently on Depakote IV to be changed\n to PO with PEG.\n Coagulopathy\n Assessment:\n Pt. with normalized INR now that pt. is hydrated and renal failure has\n resolved.\n Action:\n To restart coumadin when PEG placed with plan of mechanical\n cardioversion when INR appropriately therapeutic.\n Response:\n Plan:\n Coumadin ordered for today\n Decubitus ulcer (Not Present At Admission)\n Assessment:\n Pt. with intact Allevyn dsg on right side near hip and coccyx\n Action:\n Dressing intact\n Response:\n Plan:\n Turn q2\n Change allevyen prn when soiled or q72\n Pt with fs 58 at 12pm, med with Dextrose 50 25gm iv.\n Bed available on , report called and pt transported with tele in\n place.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652829,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained in AFib yesterday with occasional RVR.\n Antibiotics D/c'd yesterday.\n Remains on pressors, although requiring less.\n Still refusing po meds.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MVI, folate, Thiamin, Valproate, Levothyroxine IV, HSQ, RISS, Lamictal\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 111 (94 - 116) bpm\n BP: 98/63(69) {67/40(49) - 131/97(106)} mmHg\n RR: 14 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,308 mL\n 1,407 mL\n PO:\n TF:\n IVF:\n 4,308 mL\n 1,407 mL\n Blood products:\n Total out:\n 1,030 mL\n 855 mL\n Urine:\n 1,030 mL\n 705 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 3,278 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, More awake today\n Head, Ears, Nose, Throat: Normocephalic, MM dry\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Limited cooperation\n with exam\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Moans during\n exam\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.0 g/dL\n 222 K/uL\n 116 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 114 mEq/L\n 142 mEq/L\n 28.6 %\n 8.3 K/uL\n [image002.jpg]\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n Plt\n 22\n Cr\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n Glucose\n 189\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present.\n Seems distributive shock. Poor cardiac output from severe MR may be\n playing a role although exam not consistent with this. Also though her\n RV function was normal she has mod pHTN so perhaps overresuscitated and\n RV distension. No clear source of sepsis. Unclear if non-invasive BP's\n are accurate as she is alert and often yelling with SBP's of 60's.\n stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Resolved\n -Continue with D5 1/2 NS maintenance fluids\n Failure to Thrive: Spoke with patient's sister-in-law at length\n yesterday. She and pt's brother will meet with us again today\n regarding ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR.\n -Will assess HR as we wean down levophed\n -If RVR is persistent problem, consider amio load.\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. need PICC with conscious sedation.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652831,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received off Levophed ,SBP in mid 90\ns to 100. obernight dropped to\n 70\ns with Map50.\n Action:\n Levophed titrated down slowly and stopped at 1500. stem test came\n back negative that was done yesterday. Checked BP manually and systolic\n was mid 90\ns correlating with noninvasive.\n Response:\n Current BP is 89/57 (61).\n Plan:\n Closely monitor BP. Goal mean 60.restart Levo if Mean BP down to low\n 50\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR ranges from 105-120 upto 135 while screaming.\n Action:\n Held home sotalol. titrated Levo slowly up to .03\n Response:\n Plan:\n Closely monitor her BP.WEAN Levo first if it doesn\nt help, try\n Amiodarone? or low dose lopressor.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia seems more interactive than yesterday\n respod to her name. A\n Agitated screaming crying and laughing all day.\n Action:\n Cont to Reorient and provided calm and quiet environment.\n Response:\n Plan:\n Emotional support to family. Closely monitor mental status. Adivan if\n gets more agitated?\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652835,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received off Levophed ,SBP in mid 90\ns to 100. obernight dropped to\n 70\ns with Map50.\n Action:\n Levophed restart. stem test came back negative that was done \n Response:\n BP is up to high80-low 90, MAP>60\n Plan:\n Closely monitor BP. Goal mean 60-65, wean lephofed.\n Atrial fibrillation (Afib)\n Assessment:\n AF with rare PVC\ns HR-120 up to 135-160, at this point Lephofed was off\n and pt received Ativan with good effect\n Action:\n Start Amiodorone gtt\n Response:\n Hr down to high 90\n Plan:\n Closely monitor her BP/HR.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia , awake but unale to assess orientation\n Agitated screaming crying and laughing in the beginning of shift.\n Action:\n Cont to Reorient and provided calm and quiet environment.given Ativan\n 0.5mg IV\n Response:\n Good response to Ativan, pt calm down, sleeping, but arousable to pain\n and stimil.\n Plan:\n Emotional support to family. Cont monitor mental status. , reorient\n pt.\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 652021,
"text": "Chief Complaint: Hypernatremia, hypotension, acute renal failure,\n failure to thrive\n HPI:\n Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n .\n Per report, her caregiver stated that her mental status appeared at\n baseline, which was not very communicative. A copy of her PCP visit\n note accompanies her paperwork and describes that she has lost about 35\n lbs, and possibly has been vomiting. Her INR was 7 recently and she\n received vitamin K for that.\n .\n Based on a speech and swallow evaluation note from in OMR, at\n that time staff in the group home were concerned about the patient's\n lack of PO intake. It was described at that time that the patient was\n refusing former favorite foods, and would eat about spoonfulls\n prior to spitting out solid foods at meals; there was also concern\n about choking on pills. It was also noted that the patient appeared to\n regurgitate food after meals (ongoing behavoir for 20 years). It was\n noted that she had lost about 15 pounds due to this behavoir. The\n evaluation by the speech and swallow team determined that her\n inadequate PO intake was possibly secondary to dementia and behavoiral\n changes, although further studies were recommended given inability to\n fully evaluate.\n .\n Also of note, patient was admitted in for failure to thrive\n and decreased PO intake. It was found that she was constipated, and she\n was tolerating a regular diet prior to discharge.\n .\n In the ED, initially it was difficult to measure the patient's blood\n pressure. Her heart rate was 90, respiratory rate of 14, with\n difficulty measuring oxygen saturation. First recorded blood pressure\n was 92/palp, with oxygen saturation of 100%. Patient was lethargic but\n responsive with moaning and crying out to verbal stimuli. She was given\n 2L of NS initially when her SBP dropped to 70's and 80's. She was\n guaiac negative, and a chest x-ray was unremarkable. Labs were notable\n for renal insufficiency, hypernatremia (166), hyperchloremia (124),\n lactate of 9.2, INR of 9.6 (then >11), and leukocytosis of 14.\n A femoral line was placed and patient was given 4L of IVF with\n improvement to systolics in 100's. However, then patient fell asleep\n and systolic dropped to 70's, so she received an additional 2 liters\n and levophed was started. She was given vancomycin and zosyn, and\n cultures were drawn. She was also given 5 mg of IV vitamin K for\n elevated INR. EKG was without concering changes. FAST was negative (no\n free fluid, bedside echo looked ok).\n .\n Upon arrival to the floor, patient was crying out. She would make eye\n contact occasionally and stated \"I love you\" once, otherwise was\n incomprehensible.\n History obtained from Medical records\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other medications:\n Home Medications:\n (per office visit note faxed over)\n - Coumadin 1 mg daily\n - Senna 8.6 mg daily\n - Sotalol 120 mg \n - Potassium Chloride 40 mEq daily\n - Lasix 40 mg daily\n - Ketaconazole as needed\n - Triamcinolone cream as needed\n - Prilosec 20 mg \n - Bacitracin ointment PRN\n - Amoxicillin prior to dental procedures\n - Levothyroxine 75 mcg\n - Lorazepam 1 mg prior to medical procedures\n - Depakote 1500 mg daily\n - Trileptal 300 mg \n Past medical history:\n Family history:\n Social History:\n - Down's syndrome\n - Alzheimers Dementia\n - Mitral valve regurgitation, followed by Dr. \n - Hypothyroidism\n - Status-post right mastectomy for breast cancer, last mammogram \n WNL\n - Atrial fibrillation\n - History of bacterial endocarditis in \n - Status-post appendectomy (laproscopic )\n - Esophageal reflux and H. Pylori infection ()\n - Status-post cholecystectomy\n - Status-post laparoscopic umbilical hernia repair\n - Status-post gangrenous cholecystitis, lap chole \n Unable to obtain.\n Patient lives in group home. She recently has stopped walking and has\n been in a wheelchair. No alcohol, drug, or tobacco use. She enjoys\n playing with beads (per office note).\n Review of systems:\n As noted in HPI.\n Flowsheet Data as of 03:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 100 (83 - 100) bpm\n BP: 79/56(61) {71/22(47) - 111/57(69)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,049 mL\n 1,973 mL\n PO:\n TF:\n IVF:\n 49 mL\n 1,973 mL\n Blood products:\n Total out:\n 760 mL\n 105 mL\n Urine:\n 60 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,289 mL\n 1,868 mL\n Respiratory\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Temperature 95.7, HR 99, BP 111/57, RR 13, Oxygenation 100% on RA\n General: Thin, slightly catchetic female, moving around in bed when\n name is called, crying out and alternatively curling up\n HEENT: Very dry mucous membranes with fissuring of the lipds and\n tongue. PERRL, no scleral icterus or conjunctival pallor.\n Neck: Supple, no JVD\n Cardiac: RR, III/VI holosystolic murmur, no rubs or gallops\n Lungs: CTAB, although examination limited by effort, no apparent\n wheezes, raltes\n Abd: Soft, +BS, ND, cannot assess for tenderness, but no guarding\n Extr: Very dry, cracked skin over dorsum of hands, feet. Few small\n ecchymoses over right thigh, no discrete rashes or other lesions.\n Neuro: Awake, agitated, difficult to understand when makes attempts at\n speaking, CNs appear symmteric, moving all extremities equally\n Labs / Radiology\n 122 mg/dL\n 2.4 mg/dL\n 69 mg/dL\n 25 mEq/L\n 124 mEq/L\n 3.4 mEq/L\n 163 mEq/L\n 33.4 %\n [image002.jpg]\n \n 2:33 A12/30/ 11:24 PM\n \n 10:20 P12/30/ 11:30 PM\n \n 1:20 P12/31/ 01:10 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 33.4\n Cr\n 2.4\n TropT\n 0.31\n Glucose\n 93\n 122\n Other labs: PT / PTT / INR:48.0/43.4/5.4, CK / CKMB /\n Troponin-T:334/9/0.31, Lactic Acid:1.3 mmol/L, Ca++:6.2 mg/dL, Mg++:2.2\n mg/dL, PO4:4.3 mg/dL\n Microbiology Data:\n - Blood and urine cultures pending.\n .\n Imaging: CXR without acute process.\n KUB Pending.\n .\n EKG: Atrial fibrillation, normal axis, LVH with non-specific ST changes\n (T wave inversions in V2-V6 not seen on prior from ), question of\n ST depression in II, but not consistent--poor baseline. RBBB\n Assessment and Plan\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR.\n #) Hypotension: Differential includes hypovolemia secondary to very\n poor PO intake for a prolonged period, sepsis from underlying occult\n infection, cardiac shock or secondary to cardiac event in setting of\n elevated cardiac enzymes. No steroid use to make adrenal insufficiency\n more likely. Initially was tachycardiac, but not hypoxic to suggest PE\n with compromised cardiac output; additionally patient is already on\n coumadin making this less likely, especially with supratherapeutic\n levels. Attempted to measure pulsus, but was unable to do so secondary\n to patient repeatedly moving around.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis unremarkable), stool for c. diff should she have\n diarrhea\n - Transthoracic Echo in morning to assess for wall motion\n abnormalities, structure, function, effusion\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Levophed as needed should IVFs not improve BP\n - Trend lactate\n - Cortisol with AM labs\n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Will need to investigate and discuss goals of care, as PEG tube may\n be necessary to meet caloric needs given that patient has had ongoing\n difficulties with PO intake since at least . Patient also has\n been recommended to get EGD to evaluate her dysphagia further, so\n consideration for completion of this on an inpatient basis should be\n made.\n - Supportive care with IVFs, electrolyte repletion\n - Working up infectious etiology\n - TSH, FT4\n - Speech and swallow evaluation\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabalized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n .\n #) Acute renal failure: Given elevated BUN, and history of virtually no\n PO intake for extended period, suspect pre-renal etiology. Baseline\n creatinine from was around 1.0. Improved to 2.4 after 6 L of\n IVFs.\n - Continue to trend creatinine, BUN\n - Urine electrolytes to be sent\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - VBG to check pH to ensure not acidotic (bicarbonate appears to be\n WNL, however)\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D5 or D51/2NS once no longer\n requiring IVF boluses to maintain BP.\n - Frequent (Q3-4 H) sodium checks\n .\n #) Hyperchloremia: Again suspected to be secondary to severe\n dehydration. No history of diarrhea or other GI symptoms to suggest\n etiology.\n - Using LR for volume resuscitation in lieu of NS.\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\n - Serial EKGs\n - Continue sotalol\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Re-check in AM\n - Checking VBG to ensure not acidotic.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption.\n - Holding coumadin, received 5 mg vitamin K in ED, following trend\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in atrial fibrillation, rate in 100's. Will hold\n at this time given risk of worsening hypotension.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (will concurrently\n evaluate for vegetation), KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out.\n .\n #) Hypothyroidism: Checking TSH/FT4. Continue home supplementation\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVFs, until speech and swallow evaluation. Nutrition\n consult appreciated.\n .\n #) PPx: Supratherapeutic INR, PPI.\n .\n #) Code: Full per ED discussion with patient's HCP's\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n Per ED discussion with family, she is full code.\n .\n #) Access: Right femoral central line placed in ED.\n .\n #) Dispo: ICU until above issues improved.\n ICU Care\n Nutrition: IVF, nutrition consult and speech and swallow consults\n placed\n Glycemic Control: N/A\n Lines:\n Multi Lumen - 11:46 PM\n 22 Gauge - 11:47 PM\n Prophylaxis:\n DVT: Supratherapeutic INR\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments: As noted above\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652022,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n She is alert yelling out constantly not following commands, pupils\n equal and reactive, she moves all her extremities\n Action:\n She was given haldol .5mg IV x2, given morphine 1mg IV x1, lights\n turned down, care channel on, pt reassured\n Response:\n She had no response to haldol continued to yell out and cry difficult\n to determine if she is having pain morphine enabled her to sleep for a\n while\n Plan:\n Try to reassure patient, provide quiet environment, speak to caregivers\n about baseline personality\n Electrolyte & fluid disorder, failure to thrive\n Assessment:\n Na 165 now down to 163, K+ 3.4 continued hypotensive cl. 131to124,\n ionized ca 1.00\n Action:\n Given 2liters of LR and maintance d5lr at 125cc qhr , on levophed\n .3mcg/kg/min\n Response:\n Bp continues to be labile\n Plan:\n Continue to replete fluid as needed monitor electrolytes replete when\n necessary monitor lytles q 4 levophed titrated to bp, pt needs\n nutrition consult, speech and swallow study, IVf changed to D51/2NS at\n 125cc qhr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine dark bun 69 cr 3.4 30cc q hr\n Action:\n Urine sent for lytes and c+s, given fluid boluses\n Response:\n Cr improving\n Plan:\n Continue to monitor closely, renal dose medication, fluid prn\n Atrial fibrillation (Afib)\n Assessment:\n On coumadin INR 11.3 when admitted now 5.4\n Action:\n ED was given vitamin K IV, coumadin on hold\n Response:\n INR down to 5.4, hct 33.2 no sign of bleeding\n Plan:\n Continue to monitor tx with vitamin K+ prn\n Heart disease, other\n Assessment:\n Troponins elevated .53/.31 h/o mitral regurg, afib\n Action:\n Serial cardiac enzymes\n Response:\n Trending down\n Plan:\n Cardiac echo, serial cardiac enzymes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652024,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n She is alert yelling out constantly not following commands, pupils\n equal and reactive, she moves all her extremities\n Action:\n She was given haldol .5mg IV x2, given morphine 1mg IV x1, lights\n turned down, care channel on, pt reassured\n Response:\n She had no response to haldol continued to yell out and cry difficult\n to determine if she is having pain morphine enabled her to sleep for a\n while\n Plan:\n Try to reassure patient, provide quiet environment, speak to caregivers\n about baseline personality\n Electrolyte & fluid disorder, failure to thrive\n Assessment:\n Na 165 now down to 163, K+ 3.4 continued hypotensive cl. 131to124,\n ionized ca 1.00\n Action:\n Given 2liters of LR and maintance d5lr at 125cc qhr , on levophed\n .3mcg/kg/min\n Response:\n Bp continues to be labile\n Plan:\n Continue to replete fluid as needed monitor electrolytes replete when\n necessary monitor lytles q 4 levophed titrated to bp, pt needs\n nutrition consult, speech and swallow study, IVf changed to D51/2NS at\n 125cc qhr\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine dark bun 69 cr 3.4 30cc q hr\n Action:\n Urine sent for lytes and c+s, given fluid boluses\n Response:\n Cr improving\n Plan:\n Continue to monitor closely, renal dose medication, fluid prn\n Atrial fibrillation (Afib)\n Assessment:\n On coumadin INR 11.3 when admitted now 5.4\n Action:\n ED was given vitamin K IV, coumadin on hold\n Response:\n INR down to 5.4, hct 33.2 no sign of bleeding\n Plan:\n Continue to monitor tx with vitamin K+ prn\n Heart disease, other\n Assessment:\n Troponins elevated .53/.31 h/o mitral regurg, afib\n Action:\n Serial cardiac enzymes\n Response:\n Trending down\n Plan:\n Cardiac echo, serial cardiac enzymes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652591,
"text": "Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Patient arouse to voice. Yelling while she is awake, I am unable to\n make out the words she is saying. At times she will yell out for\n\n Action:\n Provide a clam, quiet space. Keeping soft lights on. I have noted she\n will yell when the lights are off.\n Response:\n Sleeping ok during the night.\n Plan:\n Consider a neurobehavioral evaluation in the future. She has \n geriatrics MD in onset of AD r/t downs. Consider low\n dose ativan or haldol for agitation.\n Hypotension (not Shock)\n Assessment:\n While sleeping her b/p will drop to the 90\ns. When she is awake, her\n b/p 110\n Action:\n Levophed 0.1mcg/kg/min.\n Response:\n b/p 93/63 (70).\n Plan:\n Attempt to wean levophed. Titrate to SBP 90\n Atrial fibrillation (Afib)\n Assessment:\n AF w/ rear PVC noted hr 95 while sleeping, and 110 while awake.\n Action:\n Monitor.\n Response:\n Plan:\n Will start home dose sotalol. When she can take meds by mouth. Hold\n coumadin for now.\n Hypernatremia (high sodium)\n Assessment:\n NA 144. no seizure activity noted.\n Action:\n D51/2NS @ 100ml/hr continuous.\n Response:\n Plan:\n Am labs ordered.\n FTT:\n Assessment:\n Admit with FTT. No oral intake at this time. Secondary to question of\n aspiration. She has had a poor intake for months which has remained an\n on going issue. Question if this is because of her Alzheimer\n dementia.\n Action:\n Speech and swallow was done. They were unable to complete it \n difficulty to ass given lack of cooperation.\n Response:\n Family meeting w/ her brother , and sister-in-law for a picc-\n line a peg placement.\n Plan:\n Re-address the family for a peg/ access issues.\n 01:25\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652445,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 112 (80 - 121) bpm\n BP: 115/84(90) {74/40(51) - 115/84(90)} mmHg\n RR: 23 (0 - 29) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,553 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,553 mL\n Blood products:\n Total out:\n 1,210 mL\n 340 mL\n Urine:\n 1,210 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 303 K/uL\n 11.1 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Assessment and Plan\n HYPERGLYCEMIA\n HYPOTENSION (NOT SHOCK)\n HEART DISEASE, OTHER\n ATRIAL FIBRILLATION (AFIB)\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n HYPOCALCEMIA (LOW CALCIUM)\n HYPERNATREMIA (HIGH SODIUM)\n ELECTROLYTE & FLUID DISORDER, OTHER\n COAGULOPATHY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652448,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 112 (80 - 121) bpm\n BP: 115/84(90) {74/40(51) - 115/84(90)} mmHg\n RR: 23 (0 - 29) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,553 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,553 mL\n Blood products:\n Total out:\n 1,210 mL\n 340 mL\n Urine:\n 1,210 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 303 K/uL\n 11.1 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Assessment and Plan\n Assessment and Plan:\n Patient is a 52 year old female with past medical history of Down's\n syndrome, dementia, atrial fibrillation and hypothyroidism who presents\n with failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR, with improving\n mental status and hypernatremia today.\n #) Hypotension: Etiology still remains not fully clear\npatient at that\n time has been aggressively fluid resuscitated and likely still has\n significant deficit, but would be hard to attribute hypotension solely\n to this source, especially given she was normotensive at outpatient\n visit. Cardiac echocardiogram with severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause. This\n leaves sepsis as a possibility, although source would unclear\nU/A from\n ED was fairly unremarkable, repeat one in ICU with many white (but also\n many red) cells; initial culture contaminated, second pending. No\n steroid use to make adrenal insufficiency more likely. Initially was\n tachycardiac, but not hypoxic to suggest PE with compromised cardiac\n output; additionally patient is already on coumadin making this less\n likely, especially with supratherapeutic levels.\n - Cultures pending, patient given vancomycin and zosyn in ED, but no\n real clear source of infection at present (CXR unremarkable, abd exam\n benign, urine analysis not overwhelming ), stool for c. diff should she\n have diarrhea. LP is a consideration, but has not been febrile, MS\n appears to be at baseline, and would need to consciously sedate to\n complete given patient cannot cooperate with this. Will stop vancomycin\n currently (no indwelling line or other reason to think she has MRSA\n skin or blood stream infection). Will continue zosyn until repeat\n urine/blood cultures are no growth for another 24 hrs (during last\n admission had UTI that was felt to be contributing to failure to\n thrive).\n - Transthoracic echocardiogram as noted above.\n - IVF boluses and IVF maintanence to make up for severe dehydration\n - Continue levophed as needed should IVFs not improve BP, will try to\n wean\n - Lactate has returned to \n .\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavoiral component in setting of possibly\n worsening Alzheimer's dementia.\n - Family , will be in today to begin to discuss goals of care,\n as PEG tube may be necessary to meet caloric needs given that patient\n has had ongoing difficulties with PO intake since at least .\n Patient also has been recommended to get EGD to evaluate her dysphagia\n further, so consideration for completion of this on an inpatient basis\n should be made. Concern is that patient will pull out PEG if placed.\n - Supportive care with IVFs, electrolyte repletion (still has\n significant fluid deficit)\n - Working up infectious etiology\n - TSH, FT4 both WNL\n - Speech and swallow evaluation completed (difficult to assess given\n patient\ns lack of cooperation)\n - Nutrition consult as patient is at high risk for re-feeding syndrome\n (will need to do calorie count versus Dobhoff for tube feeds versus\n consideration of PEG)\n - Social work consult appreciated\n - PT consult once out of ICU\n - Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations\n - KUB to evaluate for obstruction, constipation was unremarkable\n - Folate, MV, thiamine supplementation\n - Low dose haldol if needed for help with agitation\n - Given question of acutely worsening dementia, checking vitamin B12,\n no known risk factors (not sexually active) for syphilis, TSH WNL,\n working on correcting other metabolic abnormalities that could be\n contributing to dementia\n .\n #) Acute renal failure: Much improved today, creatinine down to 1.7.\n Given elevated BUN, and history of virtually no PO intake for extended\n period, suspect pre-renal etiology. Baseline creatinine from was\n around 1.0.\n - Continue to trend creatinine, BUN\n - Urine electrolytes as noted\n - Urine analysis/urine culture\n - Consider renal ultrasound to evaluate for obstruction or\n hydronephrosis should creatinine not continue to improve\n - Will hold any nephrotoxic medications\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Water deficit\n is over 8 L, however currently needs fluid boluses to increase\n intravascular volume.\n - Fluid resuscitation with D5LR, then D51/2NS once no longer requiring\n IVF boluses to maintain BP.\n - Space out sodium checks to given improvement to 150\n .\n #) Elevated troponin: Patient unable to give history if she has had\n chest pain or other symptoms. Slow decline in functional status does\n not support ACS, however could have had event at some point in past. On\n admission CK elevated to 235, with troponin of 0.53, but MB index WNL.\n In setting of renal insufficiency, these are difficult to interpret.\n Her EKG has a poor baseline, and furthermore ST segments difficult to\n interpret in percoridal leads given LVH.\n - Cycle cardiac enzymes\nimproved.\n - Continue sotalol once able to take PO\n - Once INR improves and not clearly bleeding, initiate aspirin therapy\n - Transthoracic echo to evaluate for focal wall abnormalities as noted\n above.\n .\n #) Elevated lactate: Suspect this was secondary to hypotension (patient\n was not hypotensive in office visit, but unclear what BP has been over\n last few weeks) with hypoperfusion. Abdominal examination is benign and\n not supportive of mesenteric ischemia (no apparent tenderness or\n guarding on examination). Serial lactates have returned to \n limits.\n - Given still unclear etiology of , wean off pressors, and as\n long as mental status is at baseline, will tolerate lower BP and\n re-check lactate after off pressors to see if rising.\n .\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2.\n - Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently appears to be in sinus, rate in 100's.\n - Will discuss with family goals of care, and start hep gtt for\n anticoagulation if desired; sotalol once able to give PO medications.\n .\n #) Leukocytosis: Could be secondary to occult infection. Work-up as\n noted above, including cultures, transthoracic echo (no vegetations),\n KUB to look for abdominal pathology.\n .\n #) Seizure disorder: Continue home medications, unable to check level\n of Depakote here and trileptal is send out. Giving IV valproate while\n here in ICU\n .\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n .\n #) GERD: Continuing PPI.\n .\n #) FEN: Sips, IVF. Nutrition consult appreciated.\n .\n #) PPx: SQ heparin until decision made re: heparin gtt, PPI, bowel\n regimen if needed (would need to be PR given not taking PO\n .\n #) Code: Full per ED discussion with patient's HCP, will further\n discuss during meetingn today\n .\n #) Communication:\n Brother:\n is HCP ; work (? home)\n .\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will need to discuss further with family and further\n line/PICC per that discussion.\n .\n #) Dispo: ICU until above issues improved (cannot be called out until\n off pressors)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652466,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Met with patient's brother yesterday to discuss some . Informed him\n that patient's FTT is likely due to dementia and that she will probably\n will not be able to feed herself. He felt strongly that she would not\n want a PEG tube but he wanted to try to help feel her himself.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n folate, MVI, Thiamine, Trileptal, Levothyroxine, protonix, RISS,\n Valproate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.5\nC (97.7\n HR: 112 (80 - 121) bpm\n BP: 115/73(82) {74/40(51) - 115/84(90)} mmHg\n RR: 14 (0 - 29) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 7,148 mL\n 1,848 mL\n PO:\n TF:\n 10 mL\n IVF:\n 7,138 mL\n 1,848 mL\n Blood products:\n Total out:\n 1,210 mL\n 375 mL\n Urine:\n 1,210 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,938 mL\n 1,473 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Moaning, baseline MS\n , Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular Irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing, R\n femoral line in place\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.1 g/dL\n 303 K/uL\n 91 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 117 mEq/L\n 147 mEq/L\n 32.2 %\n 10.1 K/uL\n [image002.jpg]\n 04:58 AM\n 09:05 AM\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n WBC\n 12.0\n 13.7\n 10.1\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n Plt\n \n Cr\n 2.4\n 2.3\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n TropT\n 0.29\n Glucose\n 170\n 160\n 189\n 192\n 1\n Other labs: PT / PTT / INR:14.5/31.0/1.3, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.4\n mg/dL\n Microbiology: UCx: No Growth\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Still requiring some low dose pressors. Unclear if\n source is all from dehydration or if a second process is present. Poor\n cardiac output from severe MR may be playing a role although exam not\n consistent with this. Also though her RV function was normal she has\n mod pHTN so perhaps overresuscitated and RV distension. No clear source\n of sepsis. Unclear if non-invasive BP's are accurate as she is alert\n and often times yelling with SBP's of 60's.\n -Her behavior prohibits A-line placement at this time.\n -As urine culture is negative, will d/c Zosyn\n -Check stim\n -Wean pressors as able\n Hypernatremia: Hypovolemic. Improving\n -Continue with free water in D5 1/2NS drip.\n Failure to Thrive: Will continue to discuss overall with patient's\n brother. If no plans for PEG tube, transitioning to comfort care may\n be appropriate\n -Continue vitamin support\n -Continue hydration\n Elevated cardiac Biomarkers: Appears stress related. No further\n intervention\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. If overall plan is for continued aggressive care, will\n heparinize\n Hypothyroid: Will switch to IV levothyroxine if goals of care will be\n aggressive.\n Access: Currently has femoral line. Given her behavior, placing an\n IJ vs SC line would be challenging and there is concern that she may\n pull it out.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652823,
"text": "Chief Complaint: admitted with FTT, hypotension\n 24 Hour Events:\n -- passed CortStim test yesterday\n -- was taken off all antibiotics, remained afebrile\n -- had meeting with sister-in-law about goals of care, PICC line/PEG\n waiting to hear from brother regarding a decision (they are still\n undecided about how to proceed)\n -- has been slightly tachycardic overnight with HR 110-120\ns, occ\n 130\ns; BP stable during higher rates\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 07:30 AM\n Infusions:\n Norepinephrine - 0.07 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history: NA\n Review of systems is unchanged from admission except as noted below\n Review of systems: unable to obtain due to MR/MS\n Flowsheet Data as of 08:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.8\nC (96.4\n HR: 102 (94 - 116) bpm\n BP: 87/46(57) {83/40(49) - 131/97(106)} mmHg\n RR: 9 (9 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,308 mL\n 1,069 mL\n PO:\n TF:\n IVF:\n 4,308 mL\n 1,069 mL\n Blood products:\n Total out:\n 1,030 mL\n 770 mL\n Urine:\n 1,030 mL\n 620 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n 3,278 mL\n 299 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), V/VI SEM, heard throughout with\n radiation to back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), unable to cooperate with\n lung exam due to MS/MR\n Abdominal: Soft, Bowel sounds present, Tender: ? more tender than\n yesterday; pt moaning on exam but unable to answer yes/no to pain;\n unclear whether specific response to abd or just exam in general\n Extremities: Right: 2+, Left: 2+, hands 2+ b/l; same as yesterday\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 222 K/uL\n 10.0 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 114 mEq/L\n 142 mEq/L\n 28.6 %\n 8.3 K/uL\n [image002.jpg]\n 03:03 PM\n 03:18 PM\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n Hct\n 0\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n Plt\n 22\n Cr\n 2.1\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n Glucose\n 189\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:20/41, Alk Phos / T Bili:58/0.7,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:2.1 g/dL, LDH:365 IU/L, Ca++:7.3 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains pressor-dependent and with no PO\n intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated and remains\n levophed-dependent. Cardiac echocardiogram showed severe MR, but\n function was normal, without pericardial effusion; severe MR could be\n contributing to hypotension, but again seems less likely that this is\n sole cause. There is no evidence of sepsis/infection with improving\n WBC, afebrile state, nothing localizing and no positive Cx data; LP\n deferred for now given MS appears to be at (recent) baseline. Adrenal\n insufficiency as primary cause of hypotension is less likely w/o risk\n factors; had a random cortisol level that was 20.4, though has not had\n CortStim test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC continues to improve.\n -- will check manual BP to ensure correlating with automatic read\n -- cont D5 1/2NS for maintenance at 100 cc/hr\n #) Atrial fibrillation: Patient listed as on sotalol and coumadin as\n outpatient. Currently in afib with HR 110- 120\ns, occ 130\ns even while\n at rest\n -- Will discuss with family goals of care, and start hep gtt & coumadin\n for anticoagulation if desired; sotalol once able to give PO\n medications.\n -- will consider adding amio or dig if HR more persistently in the\n 130\ns or becomes HD unstable\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, working on\n correcting other metabolic abnormalities that could be contributing to\n dementia. Speech and swallow evaluation was completed (difficult to\n assess given patient\ns lack of cooperation). Had fam htg with brother,\n , on ; he is still deciding overall goals of care and whether\n to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube and PICC line, broad goals of\n care\n -- Working up infectious etiology as above; thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG (and thus PICC), will consider\n palliative care c/s for possible hospice placement; in addition, will\n do social work consult.\n -- Cont. folate, MV, thiamine supplementation\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 mg IV given prolonged effect of the 1 mg dose on\n .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Improving\n while on IVF supplementation. Sig improved; Na 142 on \n -- cont IVF maintenance fluids with D5-1/2NS unless Na falls below 140;\n would then switch to NS.\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR to <2. INR 1.4 on\n .\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; improved to 1.1\n from 3.4 on admission. Baseline creatinine from was around\n 1.0. UCx negative.\n -- cont maintenance fluids.\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per ED discussion with patient's HCP\n #) Communication:\n Brother: is HCP ; work (? home)\n #) Access: Right femoral central line placed in ED. Would ideally like\n to change this out, but would need to consciously sedate patient to\n place subclavian or IJ or PICC; not able to get additional peripheral\n IV\ns. Also great concern that patient would pull these out, even with\n restraints as she has repeatedly pulled off leads for telemetry\n monitoring. Will discuss further with family on ; will need\n conscious sedation for the procedure.\n ICU Care\n Nutrition: see above\n Glycemic Control: no prior DM dx; has has glucose in low to mid-100\n will d/c SSI\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: IV PPI\n VAP: NA\n Communication: Comments: waiting to hear back form family about GOC\n Code status: Full code\n Disposition: to remain in ICU until stable and off pressors; otherwise,\n stable to be called out from the ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653025,
"text": "Patient is a 52 year old female with history of Down's Syndrome,\n dementia, and atrial fibrillation on coumadin, who presents to the\n emergency room after a visit with her physician. of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Hypotension (not Shock)\n Assessment:\n Pt received off Levophed ,SBP in mid 90\ns to 100. overnight dropped to\n 83 with Map55-56\n Action:\n Levophed restart. stem test came back negative that was done \n Response:\n BP is up to high80-low 90, MAP>60, pt received fluids bolus for low\n u/o\n Plan:\n Closely monitor BP. Goal mean 60-65, wean lephofed.\n Atrial fibrillation (Afib)\n Assessment:\n Pt cont to be inSr/1^st degree Av block with HR 90\ns, rare PVC\n Action:\n Cont Amiodorone gtt 0.5 mcg/kg/min\n Response:\n Hr staying at 90\n Plan:\n Closely monitor her BP/HR.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/h down syndrome, dementia , awake but unale to assess orientation\n Agitated screaming crying and laughing in the beginning of shift.\n Action:\n Cont to Reorient and provided calm and quiet environment.given Ativan\n 0.5mg IV\n Response:\n Good response to Ativan, pt calm down, sleeping, but arousable to pain\n and stimil.\n Plan:\n Emotional support to family. Cont monitor mental status. , reorient\n pt.\n FTT:\n Assessment:\n Admitted with FTT from group home. NPO at this time (Pulled out NGT 2\n times) .Speech and swallow failed lack of co-operation\n Action:\n Drs with Sister in law regarding PEG tube and PICC line\n placement.\n Response:\n Cont hydration and cont Multivitamin.cont D5%\n NS 100cc/hr\n Plan:\n Re-address the family for a peg/ access issues. Try feeding pt when\n her brother available.PICC placement \n"
},
{
"category": "Physician ",
"chartdate": "2140-11-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653181,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Brother/Sister-in-law returned last night but wished to get input from\n patient's cardiologist before making decisions regarding feeding tube.\n Briefly on levophed overnight.\n Some bradycardia this morning without BP compromise.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Valproate, HSQ, pantoprazole, levothyroxine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 96 (89 - 100) bpm\n BP: 108/61(74) {81/44(53) - 108/85(89)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,108 mL\n 2,422 mL\n PO:\n TF:\n IVF:\n 4,108 mL\n 2,422 mL\n Blood products:\n Total out:\n 740 mL\n 365 mL\n :\n 490 mL\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,368 mL\n 2,057 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Agitated\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly, Diminished: at\n bases)\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 148 K/uL\n 113 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 110 mEq/L\n 136 mEq/L\n 25.3 %\n 6.2 K/uL\n [image002.jpg]\n 03:42 PM\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n Hct\n 36\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n Plt\n 22\n 188\n 148\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.8 g/dL, LDH:365 IU/L, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.0\n mg/dL\n Imaging: No imaging today\n Microbiology: No recent micro\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Required some low dose pressors overnight but already off\n today. No clear source of sepsis. Unclear if non-invasive BP's are\n accurate as she is alert and often yelling with MAP's of 50's. \n stim normal.\n -Her behavior prohibits A-line placement at this time.\n -Will attempt to refrain from pressors and check lactates if MAP's\n decrease. MS output are challenging to use on this patient\n as surrogate measures of perfusion.\n -Will attempt diuresis today in case RV distension is contributing to\n a diminished CO/HoTN.\n Hypernatremia: Hypovolemic. Resolved\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC.\n -Continue vitamin support\n -Continue hydration\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n -Will assess HR as we wean down levophed\n -Continue amio load. Check EKG for QTc.\n Hypothyroid: Now on IV replacement.\n Access: Currently has femoral line. Given her behavior, placing an IJ\n vs SC line would be challenging and there is concern that she may pull\n it out. Will try PICC with adjunctive ativan.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655927,
"text": "ADDENDIUM: pt is >2L neg for this shift. Lasix gtt decreased to 2mg hr.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656190,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension.\n DNR/DNI\n Pneumonia, aspiration aspiration: pneumonia after vomiting TF\n Assessment:\n RR 10-22 reg nonlabored Lungs clear occassional rhonchi dim bases.\n Received pt on 02 3l/min removed by pt left off R/A sats 90-94%\n drifts to 88% w/ spont recovery to 90\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting. HOB maintained >30.\n Response:\n No N/V to Goal TF. Pt afebrile, labile poor pleth but sats 90-95 on\n r/a. CXR without significant improvement overall.\n Plan:\n Continue abx, aspiration precautions\n continue vanco/zosyn for HAP x 10 day course: ( - )\n weaning supplemental O2 , now on NC\n continue diuresis to minimize pulm edema\n TFs back on\n standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >24 hrs, Received on lasix gtt off @\n 0730. BP remains labile NBP 75-95.40-51 MAPS>50 despite hypotension\n NVS remain unchanged. Responsive to verbal stimulation (Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.)\n Action:\n Lasix IV gtt d/c @ 0730 received Lasix `10mg IV @ 12n. Cont on\n midodrine tid,\n Response:\n BP labile Maintaining systolics 80\ns, MAP\ns >45, + diuresis.\n Plan:\n Continue midodrine, maintain MAP\ns >45\n not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n continue midodrine 10mg TID\n lasix boluses\n . Monitor electrolytes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Awake alert , Pupils 3mm equal\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily but may need to alternate 1mg/0.5mg dose\n -- trend INR\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- d/c\nd paxil as may be contributing to lethargy\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656195,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension.\n DNR/DNI\n Pneumonia, aspiration aspiration: pneumonia after vomiting TF\n Assessment:\n RR 10-22 reg nonlabored Lungs clear occassional rhonchi dim bases.\n Received pt on 02 3l/min removed by pt left off R/A sats 90-94%\n drifts to 88% w/ spont recovery to 90\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting. HOB maintained >30.\n Response:\n No N/V to Goal TF. Pt afebrile, labile poor pleth but sats 90-95 on\n r/a. CXR without significant improvement overall.\n Plan:\n Continue abx, aspiration precautions\n continue vanco/zosyn for HAP x 10 day course: ( - )\n weaning supplemental O2 , now on NC\n continue diuresis to minimize pulm edema\n TFs back on\n standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >24 hrs, Received on lasix gtt off @\n 0730. BP remains labile NBP 75-95.40-51 MAPS>50 despite hypotension\n NVS remain unchanged. Responsive to verbal stimulation (Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.)\n Action:\n Lasix IV gtt d/c @ 0730 received Lasix `10mg IV @ 12n. Cont on\n midodrine tid,\n Response:\n BP labile Maintaining systolics 80\ns, MAP\ns >45, + diuresis.\n Plan:\n Continue midodrine, maintain MAP\ns >45\n not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n continue midodrine 10mg TID\n lasix boluses\n . Monitor electrolytes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Awake alert , Pupils 3mm equal communicated by short sentances ansers\n yes no. imconsistently follows commands. Will cry out with turnings and\n care. OOB minimal weight bearing.\n Action:\n Depakote dose decreased due to somulence. OOB to Chair w/ PT back\n to bved\n Response:\n Awake most of day\n Plan:\n Daily PT OOB chair.\n Eval for rehab.\n AFIB\n Assessment:\n NSR w freq PAC\n Action:\n Received amiodarone per routine. Coumadin 1mg . INR 2.5 therapeudic\n range.\n Response:\n Plan:\n continue coumadin; therapeutic INR now that dose has been increased to\n 1 mg daily but may need to alternate 1mg/0.5mg dose\n trend INR\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 656196,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension.\n DNR/DNI\n Pneumonia, aspiration aspiration: pneumonia after vomiting TF\n Assessment:\n RR 10-22 reg nonlabored Lungs clear occassional rhonchi dim bases.\n Received pt on 02 3l/min removed by pt left off R/A sats 90-94%\n drifts to 88% w/ spont recovery to 90\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting. HOB maintained >30.\n Response:\n No N/V to Goal TF. Pt afebrile, labile poor pleth but sats 90-95 on\n r/a. CXR without significant improvement overall.\n Plan:\n Continue abx, aspiration precautions\n continue vanco/zosyn for HAP x 10 day course: ( - )\n weaning supplemental O2 , now on NC\n continue diuresis to minimize pulm edema\n TFs back on\n standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >24 hrs, Received on lasix gtt off @\n 0730. BP remains labile NBP 75-95.40-51 MAPS>50 despite hypotension\n NVS remain unchanged. Responsive to verbal stimulation (Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.)\n Action:\n Lasix IV gtt d/c @ 0730 received Lasix `10mg IV @ 12n. Cont on\n midodrine tid,\n Response:\n BP labile Maintaining systolics 80\ns, MAP\ns >45, + diuresis.\n Plan:\n Continue midodrine, maintain MAP\ns >45\n not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n continue midodrine 10mg TID\n lasix boluses\n . Monitor electrolytes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Awake alert , Pupils 3mm equal communicated by short sentances ansers\n yes no. imconsistently follows commands. Will cry out with turnings and\n care. OOB minimal weight bearing.\n Action:\n Depakote dose decreased due to somulence. OOB to Chair w/ PT back\n to bved\n Response:\n Awake most of day\n Plan:\n Daily PT OOB chair.\n Eval for rehab.\n AFIB\n Assessment:\n NSR w freq PAC\n Action:\n Received amiodarone per routine. Coumadin 1mg . INR 2.5 therapeudic\n range.\n Response:\n Plan:\n continue coumadin; therapeutic INR now that dose has been increased to\n 1 mg daily but may need to alternate 1mg/0.5mg dose\n trend INR\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656197,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension.\n DNR/DNI\n Pneumonia, aspiration aspiration: pneumonia after vomiting TF\n Assessment:\n RR 10-22 reg nonlabored Lungs clear occassional rhonchi dim bases.\n Received pt on 02 3l/min removed by pt left off R/A sats 90-94%\n drifts to 88% w/ spont recovery to 90\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting. HOB maintained >30.\n Response:\n No N/V to Goal TF. Pt afebrile, labile poor pleth but sats 90-95 on\n r/a. CXR without significant improvement overall.\n Plan:\n Continue abx, aspiration precautions\n continue vanco/zosyn for HAP x 10 day course: ( - )\n weaning supplemental O2 , now on NC\n continue diuresis to minimize pulm edema\n TFs back on\n standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >24 hrs, Received on lasix gtt off @\n 0730. BP remains labile NBP 75-95.40-51 MAPS>50 despite hypotension\n NVS remain unchanged. Responsive to verbal stimulation (Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.)\n Action:\n Lasix IV gtt d/c @ 0730 received Lasix `10mg IV @ 12n. Cont on\n midodrine tid,\n Response:\n BP labile Maintaining systolics 80\ns, MAP\ns >45, + diuresis.\n Plan:\n Continue midodrine, maintain MAP\ns >45\n not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n continue midodrine 10mg TID\n lasix boluses\n . Monitor electrolytes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Awake alert , Pupils 3mm equal communicated by short sentances ansers\n yes no. imconsistently follows commands. Will cry out with turnings and\n care. OOB minimal weight bearing.\n Action:\n Depakote dose decreased due to somulence. OOB to Chair w/ PT back\n to bved\n Response:\n Awake most of day\n Plan:\n Daily PT OOB chair.\n Eval for rehab.\n AFIB\n Assessment:\n NSR w freq PAC\n Action:\n Received amiodarone per routine. Coumadin 1mg . INR 2.5 therapeudic\n range.\n Response:\n Plan:\n continue coumadin; therapeutic INR now that dose has been increased to\n 1 mg daily but may need to alternate 1mg/0.5mg dose\n trend INR\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 656198,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension.\n DNR/DNI\n Pneumonia, aspiration aspiration: pneumonia after vomiting TF\n Assessment:\n RR 10-22 reg nonlabored Lungs clear occassional rhonchi dim bases.\n Received pt on 02 3l/min removed by pt left off R/A sats 90-94%\n drifts to 88% w/ spont recovery to 90\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting. HOB maintained >30.\n Response:\n No N/V to Goal TF. Pt afebrile, labile poor pleth but sats 90-95 on\n r/a. CXR without significant improvement overall.\n Plan:\n Continue abx, aspiration precautions\n continue vanco/zosyn for HAP x 10 day course: ( - )\n weaning supplemental O2 , now on NC\n continue diuresis to minimize pulm edema\n TFs back on\n standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >24 hrs, Received on lasix gtt off @\n 0730. BP remains labile NBP 75-95.40-51 MAPS>50 despite hypotension\n NVS remain unchanged. Responsive to verbal stimulation (Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.)\n Action:\n Lasix IV gtt d/c @ 0730 received Lasix `10mg IV @ 12n. Cont on\n midodrine tid,\n Response:\n BP labile Maintaining systolics 80\ns, MAP\ns >45, + diuresis.\n Plan:\n Continue midodrine, maintain MAP\ns >45\n not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n continue midodrine 10mg TID\n lasix boluses\n . Monitor electrolytes.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Awake alert , Pupils 3mm equal communicated by short sentances ansers\n yes no. imconsistently follows commands. Will cry out with turnings and\n care. OOB minimal weight bearing.\n Action:\n Depakote dose decreased due to somulence. OOB to Chair w/ PT back\n to bved\n Response:\n Awake most of day\n Plan:\n Daily PT OOB chair.\n Eval for rehab.\n AFIB\n Assessment:\n NSR w freq PAC\n Action:\n Received amiodarone per routine. Coumadin 1mg . INR 2.5 therapeudic\n range.\n Response:\n Plan:\n continue coumadin; therapeutic INR now that dose has been increased to\n 1 mg daily but may need to alternate 1mg/0.5mg dose\n trend INR\n ------ Protected Section ------\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE RENAL\n Code status:\n DNR / DNI\n Height:\n 62 Inch\n Admission weight:\n 65.8 kg\n Daily weight:\n Allergies/Reactions:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias\n Additional history: Downs syndrome, mitral regurgitation, h/o\n bacterial endocarditis in , h/o afib electrical cardioversion in\n past, hypothyroidism, bunions/foot pain, h/o right breast cancer,\n seizure disorder\n Surgery / Procedure and date: s/p right mastectomy for breast cancer,\n s/p laparoscopic appendectomy , s/p laparoscopuic umbilical hernia\n repair, s/p gangrenous cholecystitis, lap chole \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:84\n D:48\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 10 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 91% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,467 mL\n 24h total out:\n 2,430 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 03:40 AM\n Potassium:\n 4.1 mEq/L\n 03:40 AM\n Chloride:\n 93 mEq/L\n 03:40 AM\n CO2:\n 37 mEq/L\n 03:40 AM\n BUN:\n 13 mg/dL\n 03:40 AM\n Creatinine:\n 0.8 mg/dL\n 03:40 AM\n Glucose:\n 66 mg/dL\n 03:40 AM\n Hematocrit:\n 27.8 %\n 03:40 AM\n Finger Stick Glucose:\n 112\n 06:00 AM\n Valuables / Signature\n Patient valuables: N/A\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: N/A\n Transferred from: MICU7\n Transferred to: \n Date & time of Transfer: 1730\n ------ Protected Section Addendum Entered By: , RN\n on: 16:54 ------\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656023,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt not following commands. Not answering questions. Does yell out with\n nursing care and turning. Pt is non verbal except for yelling out.\n Action:\n Yesterday pt sister in law did come in and state that pt recognized\n her. Pt. OOB to chair using this AM.\n Response:\n Pt has been awake throughout most of the shift. Became restless while\n in chair, placed back in bed. PT by this PM to work with patient\n edge\n of bed to dangle and ROM. Not consistently following commands, no\n verbalizations, will resist when prompted to move during nursing care.\n Plan:\n Cont to get pt up in the chair during the day. PT daily.\n Hypotension (not Shock)\n Assessment:\n Pt B/P has been 70-80 range systolic. Received on levophed\n 0.04mic/kg/min. pt is also on lasix gtt at 2 mg hr.\n Action:\n Was 2L negative at midnight. Levo gtt shut off, team ok with MAP > 45.\n Response:\n Continues to be 1500-1700 cc negative. Transfused 1 unit PRBC this PM\n for volume.\n plan\n Cont to diurese per orders, MAP > 45.\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 656024,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: PNA /\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 52 yo f c Downs\n Syndrome and Alzheimers Disease admitted from PCPs office to ED\n with FTT, initially pt found to be hypotensive, dehydrated, and\n hypernatremic, and had a UTI. Pt was admitted to MICU and started on\n levophed for SBPs in 70's, while in ICU pt was having runs of afib with\n RVR, also with altered mental status and head CT showed enlarged\n ventricles c/w hydrocephalus which neuro is following. Pt underwent peg\n placement , weaned levophed and was transferred to the floor. Pt\n returned to ICU after receiving Zyprexa and becoming hypotensive,\n pt vomited and developed likely aspiration PNA. Pt has remain in\n MICU requiring Levophed which at this time they feel maybe related to\n severe 4+ MR.\n Past Medical / Surgical History: Down's Syndrome, dementia,\n non-verbal, CAD, 4+ MR, diastolic dysfunction, anemia, hypothyroidism,\n Afib, h/o bacterial endocarditis, s/p R mastectomy for breast cancer ,\n s/p appendectomy , GERD, s/p cholecystectomy, s/p gangrenous\n cholecystitis, lap chole , s/p laparoscopic umbilical hernia\n repair\n Medications: morphine, valpronic acid, levophed, warfarin,\n piperacillin, amiodarone, lasix\n Radiology: Chest AP portable : No significant change compared to\n the prior study, still combination of pulmonary edema and multiple\n parenchymal opacities that might be consistent with aspiration. Slight\n improvement of the right upper lung opacity due to resolution of\n aspiration; MR head w/o contrast : Markedly dilated ventricles\n again demonstrated, unchanged from prior CT. Findings could be\n consistent with communicating hydrocephalus and correlation for\n possible NPH is recommended. Multiple old infarcts again identified,\n not significantly changed from prior CT. Left vertebral artery not\n definitely visualized, possibly occluded at the origin versus\n hypoplastic artery\n Labs:\n 26.2\n 8.7\n 604\n 7.1\n [image002.jpg]\n Other labs:\n Activity Orders: out of bed to chair\n Social / Occupational History: lives in group home\n Living Environment: live in group home\n Prior Functional Status / Activity Level: Per daughter was ambulatory\n up until 2 weeks PTA, otherwise used w/c\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt is non-verbal.\n Awake throughout evaluation, visual tracks, followed < 10% of simple\n one step commands after max encouragement,\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 84\n 78/34\n 99% 3L\n Rest\n /\n Sit\n 88\n 66/50\n 90% 3L\n Activity\n /\n Stand\n /\n Recovery\n 84\n 74/48\n 98%3L\n Total distance walked:\n Minutes:\n Pulmonary Status: Diminished LS t/o, shallow breathing\n pattern\n Integumentary / Vascular: foley, PIV, B LE edema, B foot errythema R >\n L\n Sensory Integrity: Pt responds to nail bed pressure x 4 with grimacing\n and vocalizing in pain\n Pain / Limiting Symptoms: No signs of discomfort with ROM, pt appeared\n uncomfortable sitting at EOB trying to lie down\n Posture:\n Range of Motion\n Muscle Performance\n B UE and LE grossly WFL\n Ankle DF to approx neutral B\n Pt moving all extremities in bed, moving B UE against gravity at EOB\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Pt was total A to transition from supine to sitting\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required Max A to maintain balance at EOB for approx 5\n mins. Pt pushing into extension, in what appeared to be an attempt to\n lay back down.\n Education / Communication: Pt status discussed with RN\n Intervention:\n Other: Rec gauze rolls in pts hands to prevent skin breakdown as pt\n prefers to keep her fists clenched\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Posture, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n 7.\n Range of Motion, Impaired\n Clinical impression / Prognosis: 52 yo f with Downs Syndrome admitted\n with FTT, hypernatremia, and hypotension. Pt has been in the ICU\n for majority of admission and requiring levophed, hospital course also\n significant for treatment of UTI and aspiration. Pts above impairments\n are c/w deconditioning, and CV pump dysfunction. Per group home and pts\n family in the weeks PTA she was ambulatory, therefore at this time she\n is well below baseline. Feel if pts hemodynamics improves she may\n tolerate increased activity and would benefit from rehab upon d/c, to\n optimize function.\n Goals\n Time frame:\n 1.\n Follow > 50% of 1 step commands\n 2.\n Max A for bed mobility\n 3.\n Maintain sitting at EOB > 15 mins c Min A\n 4.\n SBP > 80 with upright activity\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Bed mobility, EOB balance, strength training\n Frequency / Duration: \n Cont pt edu and d/c planning\n Nursing should continue to patient OOB as tolerated\n NO MS\n agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 656011,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: PNA /\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 52 yo f c Downs\n Syndrome and Alzheimers Disease admitted from PCPs office to ED\n with FTT, initally pt found to be hypotensive, dehydrated, and\n hypernatremic, and had a UTI. Pt was admitted to MICU and started on\n levophed for SBPs in 70's, while in ICU pt was having runs of afib with\n RVR, also with altered mental status and head CT showed enlarged\n ventricles c/w hydrocephalus which neuro is following. Pt underwent peg\n placement , weaned levophed and was transfered to the floor. Pt\n returned to ICU after recieving zyprexa and becoming hypotensive,\n pt vomited and developed likely aspiration PNA. Pt has remain in\n MICU requiring Levophed which at this time they feel maybe related to\n severe 4+ MR.\n Past Medical / Surgical History: Down's Syndrome, dementia,\n non-verbal, CAD, 4+ MR, diastolic dysfunction, anemia, hypothyroidism,\n Afib, h/o bacterial endocarditis, s/p R mastectomy for breast cancer ,\n s/p appendectomy , GERD, s/p cholecystectomy, s/p gangrenous\n cholecystitis, lap chole , s/p laparoscopic umbilical hernia\n repair\n Medications: morphine, valpronic acid, levophed, warfarin,\n piperacillin, amiodarone, lasix\n Radiology: Chest AP portable : No significant change compared to\n the prior study, still combination of pulmonary edema and multiple\n parenchymal opacities that might be consistent with aspiration. Slight\n improvement of the right upper lung opacity due to resolution of\n aspiration; MR head w/o contrast : Markedly dilated ventricles\n again demonstrated, unchanged from prior CT. Findings could be\n consistent with communicating hydrocephalus and correlation for\n possible NPH is recommended. Multiple old infarcts again identified,\n not significantly changed from prior CT. Left vertebral artery not\n definitely visualized, possibly occluded at the origin versus\n hypoplastic artery\n Labs:\n 26.2\n 8.7\n 604\n 7.1\n [image002.jpg]\n Other labs:\n Activity Orders: out of bed to chair\n Social / Occupational History: lives in group home\n Living Environment: live in group home\n Prior Functional Status / Activity Level: Per daughter was ambulatory\n up until 2 weeks PTA, otherwise used w/c\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt is non-verbal.\n Awake throughout evaluation, followed simple one step commands after\n max encouragement,\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status:\n Integumentary / Vascular:\n Sensory Integrity:\n Pain / Limiting Symptoms:\n Posture:\n Range of Motion\n Muscle Performance\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Posture, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n 7.\n Range of Motion, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 656012,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: PNA /\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 52 yo f c Downs\n Syndrome and Alzheimers Disease admitted from PCPs office to ED\n with FTT, initally pt found to be hypotensive, dehydrated, and\n hypernatremic, and had a UTI. Pt was admitted to MICU and started on\n levophed for SBPs in 70's, while in ICU pt was having runs of afib with\n RVR, also with altered mental status and head CT showed enlarged\n ventricles c/w hydrocephalus which neuro is following. Pt underwent peg\n placement , weaned levophed and was transfered to the floor. Pt\n returned to ICU after recieving zyprexa and becoming hypotensive,\n pt vomited and developed likely aspiration PNA. Pt has remain in\n MICU requiring Levophed which at this time they feel maybe related to\n severe 4+ MR.\n Past Medical / Surgical History: Down's Syndrome, dementia,\n non-verbal, CAD, 4+ MR, diastolic dysfunction, anemia, hypothyroidism,\n Afib, h/o bacterial endocarditis, s/p R mastectomy for breast cancer ,\n s/p appendectomy , GERD, s/p cholecystectomy, s/p gangrenous\n cholecystitis, lap chole , s/p laparoscopic umbilical hernia\n repair\n Medications: morphine, valpronic acid, levophed, warfarin,\n piperacillin, amiodarone, lasix\n Radiology: Chest AP portable : No significant change compared to\n the prior study, still combination of pulmonary edema and multiple\n parenchymal opacities that might be consistent with aspiration. Slight\n improvement of the right upper lung opacity due to resolution of\n aspiration; MR head w/o contrast : Markedly dilated ventricles\n again demonstrated, unchanged from prior CT. Findings could be\n consistent with communicating hydrocephalus and correlation for\n possible NPH is recommended. Multiple old infarcts again identified,\n not significantly changed from prior CT. Left vertebral artery not\n definitely visualized, possibly occluded at the origin versus\n hypoplastic artery\n Labs:\n 26.2\n 8.7\n 604\n 7.1\n [image002.jpg]\n Other labs:\n Activity Orders: out of bed to chair\n Social / Occupational History: lives in group home\n Living Environment: live in group home\n Prior Functional Status / Activity Level: Per daughter was ambulatory\n up until 2 weeks PTA, otherwise used w/c\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt is non-verbal.\n Awake throughout evaluation, followed approx 10% of simple one step\n commands after max encouragement,\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 84\n 78/34\n 99% 3L\n Rest\n /\n Sit\n 88\n 66/50\n 90% 3L\n Activity\n /\n Stand\n /\n Recovery\n 84\n 74/48\n 98%3L\n Total distance walked:\n Minutes:\n Pulmonary Status: Diminshed LS t/o, shallow breathing\n pattern\n Integumentary / Vascular:\n Sensory Integrity:\n Pain / Limiting Symptoms:\n Posture:\n Range of Motion\n Muscle Performance\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Posture, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n 7.\n Range of Motion, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656186,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension\n Pneumonia, aspiration\n Assessment:\n Pt with aspiration pneumonia after vomiting TF\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting\n Response:\n Pt afebrile, poor pleth but sats 97-100% on 3l NC\n Plan:\n Continue abx, aspiration precautions\n CXR without significant improvement overall\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - blood cx from the aspiration event with NGTD, sputum was not produced\n by patient\n - weaning supplemental O2 , now on NC\n - continue diuresis to minimize pulm edema\n - TFs back on\n - standing reglan to avoid repeat N/V\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >12 hrs, lasix gtt on Hypotension:\n not septic shock as does not even meet SIRS criteria. She did have a\n UTI but had been fully treated, with a negative surveillance urine\n culture from . No evidence of hypovolemic/hemorrhagic shock.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. With severe MR on recent echo, poor forward flow is a\n likely contributor to hypoTN.\n Action:\n On midodrine tid, Levophed remains off, tolerating lasix gtt\n Response:\n Maintaining systolics 80\ns, MAP\ns >45, -1.3L at midnight\n Plan:\n Continue midodrine, maintain MAP\ns >45\n -- not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n -- continue midodrine 10mg TID\n -- levophed has been off nearly 24 hrs\n -- lasix gtt changed to lasix boluses\n -- lytes\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily but may need to alternate 1mg/0.5mg dose\n -- trend INR\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- d/c\nd paxil as may be contributing to lethargy\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656182,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension\n Pneumonia, aspiration\n Assessment:\n Pt with aspiration pneumonia after vomiting TF\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting\n Response:\n Pt afebrile, poor pleth but sats 97-100% on 3l NC\n Plan:\n Continue abx, aspiration precautions\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >12 hrs, lasix gtt on\n Action:\n On midodrine tid, Levophed remains off, tolerating lasix gtt\n Response:\n Maintaining systolics 80\ns, MAP\ns >45, -1.3L at midnight\n Plan:\n Continue midodrine, maintain MAP\ns >45\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656063,
"text": "52 year old female with bipolar disorder, new onset dementia, Down\n syndrome, readmitted to MICU on /12 from floor with hypotension\n Pneumonia, aspiration\n Assessment:\n Pt with aspiration pneumonia after vomiting TF\n Action:\n Continues on Vanco and Zosyn, reglan for persistent nausea and\n vomiting\n Response:\n Pt afebrile, poor pleth but sats 97-100% on 3l NC\n Plan:\n Continue abx, aspiration precautions\n Hypotension (not Shock)\n Assessment:\n Pt remains off Levophed gtt for >12 hrs, lasix gtt on\n Action:\n On midodrine tid, Levophed remains off, tolerating lasix gtt\n Response:\n Maintaining systolics 80\ns, MAP\ns >45, -1.3L at midnight\n Plan:\n Continue midodrine, maintain MAP\ns >45\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 656172,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Weaned of pressors yesterday morning and remained off all day.\n Diuresed effectively yesterday.\n History obtained from Medical records\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n lansoprazole, valproate, levothyroxine, amidarone, midodrine, colace,\n folate, coumadin, senna\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 85 (80 - 98) bpm\n BP: 81/41(51) {70/34(45) - 100/59(63)} mmHg\n RR: 10 (9 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,647 mL\n 1,214 mL\n PO:\n TF:\n 1,335 mL\n 600 mL\n IVF:\n 1,802 mL\n 464 mL\n Blood products:\n 350 mL\n Total out:\n 5,000 mL\n 1,730 mL\n Urine:\n 5,000 mL\n 1,730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,353 mL\n -516 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bibasilar), Poor insp\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 511 K/uL\n 66 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 93 mEq/L\n 133 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n 03:40 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n 6.3\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n 27.8\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n 511\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n 66\n Other labs: PT / PTT / INR:25.7/36.8/2.5, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Imaging: No new imaging\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload.\n Hypotension: Remains off pressors and is tolerating diuresis.\n -Continue midodrine, MAP goal remain >50\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now on nasal\n cannula. CXR with persistent B/L opacities\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidence biliary\n process.\n -Continue to monitor for residuals on reduced dose reglan.\n Renal: Significant volume overload still\n -Goal net negative 1 liter with intermittent IV lasix\n AF: Remains on amiodarone, coumadin\n Somnolence: Paxil now d/c'd and reglan dose reduced.\n -Decrease valproate dosing as she appears to be much more somnolent\n after this.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:20 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 656173,
"text": "Chief Complaint: Hypotension\n Aspiration pneumonia\n 24 Hour Events:\n -- got one unit RBC's\n -- consented for blood, not for ICU yet\n -- weaned off levophed in the afternoon\n -- remained on lasix drip\n History obtained from Patient\n Allergies:\n History obtained from PatientOxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:33 PM\n Piperacillin - 06:25 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 87 (80 - 98) bpm\n BP: 88/49(58) {70/34(45) - 100/59(63)} mmHg\n RR: 14 (9 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,647 mL\n 665 mL\n PO:\n TF:\n 1,335 mL\n 406 mL\n IVF:\n 1,802 mL\n 229 mL\n Blood products:\n 350 mL\n Total out:\n 5,000 mL\n 1,490 mL\n Urine:\n 5,000 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,353 mL\n -825 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n Anteriorly, Diminished: At bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG in place\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 511 K/uL\n 9.4 g/dL\n 66 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 93 mEq/L\n 133 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n 03:40 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n 6.3\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n 27.8\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n 511\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n 66\n Other labs: PT / PTT / INR:25.7/36.8/2.5, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR :\n IMPRESSION: Interval increase in right upper lobe opacification\n consistent\n with worsening aspiration or pneumonia. Persistent mild congestive\n heart\n failure and bilateral lower lobe air space consolidation\n Microbiology: No new data\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n -- CXR without significant improvement overall\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - blood cx from the aspiration event with NGTD, sputum was not produced\n by patient\n - weaning supplemental O2 , now on NC\n - continue diuresis to minimize pulm edema\n - TFs back on\n - standing reglan to avoid repeat N/V\n # Hypotension: not septic shock as does not even meet SIRS criteria.\n She did have a UTI but had been fully treated, with a negative\n surveillance urine culture from . No evidence of\n hypovolemic/hemorrhagic shock. Unclear how much autonomic instability\n is contributing to (chronic) hypotension. With severe MR on recent\n echo, poor forward flow is a likely contributor to hypoTN.\n -- not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n -- continue midodrine 10mg TID\n -- levophed has been off nearly 24 hrs\n -- lasix gtt changed to lasix boluses\n -- lytes\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily but may need to alternate 1mg/0.5mg dose\n -- trend INR\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- d/c\nd paxil as may be contributing to lethargy\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- transfused 1 unit to improve intravascular volume\n # Hyponatremia\n Resolved with diuresis\n -- lasix boluses, goal 1L neg\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:20 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 656176,
"text": "Subjective:\n Patient was essentially non-verbal, said \"no\" two times during\n treatment.\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: off pressors since last night; Called out of\n ICU\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n To right\n\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n Stand p\n\n\n\n\n\n T\n Sit to Stand:\n\n\n\n\n T\n Ambulation:\n n/a\n\n\n\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 84\n 75/55\n 12\n 97% RA\n Activity\n Sit\n 85\n 82/57\n 11\n Recovery\n Sit\n 85\n 79/42\n 10\n 90% RA\n Total distance walked: n/a\n Minutes:\n Mobility Clarification:\n Rolling to right: required assist to flex L knee and initiate roll, but\n pt did assist by pulling through L UE\n Sup to sit: required max A, pt unable to initiate movement\n Stand pivot: pt unable to take weight through B LE, B knees buckled,\n required max A to dependent transfer\n Balance: Seated: maintained EOB with B UE support x 5 min, able to turn\n head and body without LOB\n Standing: unable to maintain without max A x 1\n Education / Communication: Educated patient as to benefits of OOB.\n Communicated with RN.\n Other: n/a\n Assessment: Patient shows improved participation and improved\n hemodynamic response to activity (although still has hypotension).\n Patient remains far below baseline and is not safe for return to group\n home, unless 24 hour care and lift transfers can be provided.\n Anticipated Discharge: Rehab\n Plan: Continue to follow for transfer training, balance training,\n functional activities.\n RN recommendations: OOB to chair via lift\n Face Time: 12:40\n 12:55\n"
},
{
"category": "Nutrition",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 656146,
"text": "Subjective\n calm, sleeping\n Objective\n Pertinent medications: NS @ 10ml/hr, Abx, Lansoprazole, Colace, Folic\n Acid, Coumadin, Senna, MVI, Reglan\n Labs:\n Value\n Date\n Glucose\n 66 mg/dL\n 03:40 AM\n Glucose Finger Stick\n 112\n 06:00 AM\n BUN\n 13 mg/dL\n 03:40 AM\n Creatinine\n 0.8 mg/dL\n 03:40 AM\n Sodium\n 133 mEq/L\n 03:40 AM\n Potassium\n 4.1 mEq/L\n 03:40 AM\n Chloride\n 93 mEq/L\n 03:40 AM\n TCO2\n 37 mEq/L\n 03:40 AM\n Albumin\n 1.9 g/dL\n 04:09 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:40 AM\n Phosphorus\n 2.8 mg/dL\n 03:40 AM\n Magnesium\n 2.3 mg/dL\n 03:40 AM\n ALT\n 11 IU/L\n 04:09 AM\n Alkaline Phosphate\n 81 IU/L\n 04:09 AM\n AST\n 30 IU/L\n 04:09 AM\n Amylase\n 26 IU/L\n 04:09 AM\n Total Bilirubin\n 0.4 mg/dL\n 04:09 AM\n WBC\n 6.3 K/uL\n 03:40 AM\n Hgb\n 9.4 g/dL\n 03:40 AM\n Hematocrit\n 27.8 %\n 03:40 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Fibersource HN @ 55ml/hr\n GI: soft/distended, (+)bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropiate:\n Multivitamin / Mineral supplement:\n Check chemistry 10 panel\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 656147,
"text": "Subjective\n calm, sleeping\n Objective\n Pertinent medications: NS @ 10ml/hr, Abx, Lansoprazole, Colace, Folic\n Acid, Coumadin, Senna, MVI, Reglan\n Labs:\n Value\n Date\n Glucose\n 66 mg/dL\n 03:40 AM\n Glucose Finger Stick\n 112\n 06:00 AM\n BUN\n 13 mg/dL\n 03:40 AM\n Creatinine\n 0.8 mg/dL\n 03:40 AM\n Sodium\n 133 mEq/L\n 03:40 AM\n Potassium\n 4.1 mEq/L\n 03:40 AM\n Chloride\n 93 mEq/L\n 03:40 AM\n TCO2\n 37 mEq/L\n 03:40 AM\n Albumin\n 1.9 g/dL\n 04:09 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:40 AM\n Phosphorus\n 2.8 mg/dL\n 03:40 AM\n Magnesium\n 2.3 mg/dL\n 03:40 AM\n ALT\n 11 IU/L\n 04:09 AM\n Alkaline Phosphate\n 81 IU/L\n 04:09 AM\n AST\n 30 IU/L\n 04:09 AM\n Amylase\n 26 IU/L\n 04:09 AM\n Total Bilirubin\n 0.4 mg/dL\n 04:09 AM\n WBC\n 6.3 K/uL\n 03:40 AM\n Hgb\n 9.4 g/dL\n 03:40 AM\n Hematocrit\n 27.8 %\n 03:40 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Fibersource HN @ 55ml/hr\n GI: soft/distended, (+)bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt w/ HoTN, MICU course c/b aspiration event. Currently, pressors\n off. Lasix gtt changed to boluses . TF continues at goal via PEG.\n Pt tolerating w/o further episodes of vomiting (last emesis ).\n Noted last bm \n Senna/Colace being given.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue TF at goal\n Check residuals, hold TF if >/= 150ml; monitor for N/V\n Multivitamin / Mineral supplement: via TF, can d/c outside MVI\n Check chemistry 10 panel\n Will continue to follow\n page if ?s *\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655843,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is very alert today with less periods of sleep. OOB in chair with\n lift for 3 hrs. Tolerated well. Pt\ns sister in law in to visit.\n Pt appeared to smile and recognize her but remained non-verbal except\n for yes/no. Per sister in law, pt is conversant like a\n5 yr old\n. Ms\n does not follow any commands. She withdraws to noxious stimuli.\n She has not yelled out today at all. Family is aware that pt will not\n return to group home in the condition which she presently is.\n Action:\n OOB in chair with lift.\n Response:\n Appeared to enjoy this. Very alert the whole time in chair.\n Plan:\n Con\nt to get OOB. PT to come and assess tomorrow and work with patient.\n Hypotension (not Shock)\n Assessment:\n Remains on Levo with attempts to wean .01mcg/kg/min every 2hrs. MAP\n >50. UO decreased to 30cc hr and Lasix drip to be restarted at 1715.\n Pt is still receiving 10 mg Midodrine ppeg. HR remains in\n afib/aflutter with rate controlled in the 80\ns. No VEA observed. K+\n repleted with 40 meq po kcl. K+ 4.6 now.\n Action:\n Attempting to wean Levo.\n Response:\n Remains on .04mcg/kg/min with MAP 61. Very slow process in which lasix\n drip will not help with attempt to wean Levo.\n Plan:\n Con\nt to diurese. Attempt to wean Levo. Offer support. Turn q2 hrs.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655901,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt not following commands. Not answering questions. Does yell out with\n nursing care and turning. Pt is non verbal except for yelling out.\n Action:\n Yesterday pt sister in law did come in and state that pt recognized\n her. Pt also got oob to the chair during the previous shift.\n Response:\n Pt has been awake throughout most of the shift.\n Plan:\n Cont to get pt up in the chair during the day. PT is scheduled to come\n and assess pt today and work with her.\n Hypotension (not Shock)\n Assessment:\n Pt B/P has been 70-80 range systolic. Remains on levophed\n 0.04mic/kg/min. pt is also on lasix gtt at mg hr.\n Action:\n Started lasix gtt as team had wanted to have pt a liter neg by midnight\n which did not happen.\n Response:\n u/o currently -\n plan\n Cont to diurese and wean levophed as pt tol.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655896,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 654763,
"text": "Chief Complaint:\n 24 Hour Events:\n - CXR fluid overloaded\n - got 20mg IV lasix at 2:30pm\n - neuro: no need for LP--> restarted coumadin\n - weaned levophed but not off yet\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Furosemide (Lasix) - 02:45 PM\n Coumadin (Warfarin) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 115 (87 - 116) bpm\n BP: 90/46(57) {73/34(45) - 102/63(80)} mmHg\n RR: 20 (10 - 22) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,593 mL\n 659 mL\n PO:\n TF:\n 595 mL\n 327 mL\n IVF:\n 1,798 mL\n 202 mL\n Blood products:\n Total out:\n 2,340 mL\n 200 mL\n Urine:\n 2,340 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 253 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 324 K/uL\n 8.0 g/dL\n 235 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 24.6 %\n 7.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n WBC\n 9.8\n 7.9\n Hct\n 26.3\n 24.6\n Plt\n 367\n 324\n Cr\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n Other labs: PT / PTT / INR:25.3/35.7/2.5\n Ca++:6.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR:\n Increased pulmonary congestion but also multiple parenchymal patchy\n infiltrates. Differential diagnoses include atypical edema but possible\n superimposed infectious processes due to aspiration. Further follow up\n recommended.\n HEAD MRI:\n . Markedly dilated ventricles again demonstrated, unchanged from prior\n CT.\n Findings could be consistent with communicating hydrocephalus and\n correlation\n for possible NPH is recommended.\n 2. Multiple old infarcts again identified, not significantly changed\n from\n prior CT.\n 3. Left vertebral artery not definitely visualized, possibly occluded\n at the\n origin versus hypoplastic artery, consider MRA neck for further\n evaluation.\n Microbiology: C diff: negative\n UCx: negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days.\n Of note, baseline BP runs 90-100's; 80's when sleeping.\n -- hold home dose lasix 40 mg QD\n -- will give IVF boluses & wean levophed tolerating MAPS\ns > 50 (not\n septic; lactic acid 1.4 yest)\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro.\n -- f/u urine cultures today\n -- cont Bactrim through per floor team plans\n (#) SOMNOLENCE: in setting of zyprexa for MRI; INR 2.9, though\n non-focal neuro exam and no evidence of herniation, etc. No evidence\n of resp distress, no risk factors for hypercarbia. Improving this\n morning\n -- f/u MRI read\n -- will check ABG, though unlikely vent/oxy contributing currently\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Floor team\n plans to LP once INR nromalizes.\n -- f/u MRI read (still pending)\n -- cont to hold coumadin for possible LP\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: supratx on coumadin; on amio\n -- cont amio; well rhtyhm/rate controlled\n -- cont to hold coumadin for possible LP\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutriion (vitammin def)\n and suppressed BM from chronic disease.\n -- should be on folic acid, MVI\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n .\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: must contact HCP brother for ICU consent\n (#) CODE: FULL\n (#) DISPO: possible transfer to floor this afternoon stabilizes & off\n pressors\n ICU Care\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:46 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 654765,
"text": "Chief Complaint:\n 24 Hour Events:\n - CXR fluid overloaded\n - got 20mg IV lasix at 2:30pm\n - neuro: no need for LP--> restarted coumadin\n - weaned levophed but not off yet\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Furosemide (Lasix) - 02:45 PM\n Coumadin (Warfarin) - 04:00 PM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 115 (87 - 116) bpm\n BP: 90/46(57) {73/34(45) - 102/63(80)} mmHg\n RR: 20 (10 - 22) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,593 mL\n 659 mL\n PO:\n TF:\n 595 mL\n 327 mL\n IVF:\n 1,798 mL\n 202 mL\n Blood products:\n Total out:\n 2,340 mL\n 200 mL\n Urine:\n 2,340 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 253 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///34/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), harsh V/VI SEM heard throughout\n with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Rhonchorous: ), not cooperative with lung exam\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG Tube\n Extremities: 2+ edema throughout LE/UE\n Skin: Warm, fine reticular rash on trunk, arms\n Neurologic: arousable, moaning; able to follow simple command of\n opening eyes/squeezing hands; moving all limbs, CN II\n XII in tact\n Labs / Radiology\n 324 K/uL\n 8.0 g/dL\n 235 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 24.6 %\n 7.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n WBC\n 9.8\n 7.9\n Hct\n 26.3\n 24.6\n Plt\n 367\n 324\n Cr\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n Other labs: PT / PTT / INR:25.3/35.7/2.5\n Ca++:6.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR:\n Increased pulmonary congestion but also multiple parenchymal patchy\n infiltrates. Differential diagnoses include atypical edema but possible\n superimposed infectious processes due to aspiration. Further follow up\n recommended.\n HEAD MRI:\n . Markedly dilated ventricles again demonstrated, unchanged from prior\n CT.\n Findings could be consistent with communicating hydrocephalus and\n correlation\n for possible NPH is recommended.\n 2. Multiple old infarcts again identified, not significantly changed\n from\n prior CT.\n 3. Left vertebral artery not definitely visualized, possibly occluded\n at the\n origin versus hypoplastic artery, consider MRA neck for further\n evaluation.\n Microbiology: C diff: negative\n UCx: negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- hold home dose lasix 40 mg QD; lasix PRN for volume overload\n -- will give IVF boluses & wean levophed tolerating MAPS\ns > 50 (not\n septic; lactic acid 1.4 yest)\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro.\n -- f/u urine cultures today\n -- cont Bactrim through per floor team plans\n (#) SOMNOLENCE: in setting of zyprexa for MRI; INR 2.9, though\n non-focal neuro exam and no evidence of herniation, etc. No evidence\n of resp distress, no risk factors for hypercarbia. Improving this\n morning\n -- f/u MRI read\n -- will check ABG, though unlikely vent/oxy contributing currently\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Floor team\n plans to LP once INR nromalizes.\n -- f/u MRI read (still pending)\n -- cont to hold coumadin for possible LP\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: supratx on coumadin; on amio\n -- cont amio; well rhtyhm/rate controlled\n -- restarted coumadin 0.5 mg last light\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutriion (vitammin def)\n and suppressed BM from chronic disease.\n -- should be on folic acid, MVI\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: must contact HCP brother for ICU consent\n (#) CODE: FULL\n (#) DISPO: possible transfer to floor this afternoon stabilizes & off\n pressors\n ICU Care\n ACCESS: PICC\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 654805,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Diuresed yesterday\n Levophed still on, but amount has been decreased\n Some AF with RVR this AM, rate improved with IV metoprolol\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Coumadin (Warfarin) - 04:00 PM\n Metoprolol - 08:10 AM\n Other medications:\n Bactrim, amiodarone, synthroid, valproic acid, lansoprazole, paxil,\n coumadin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 84 (84 - 116) bpm\n BP: 104/64(72) {73/34(45) - 104/64(80)} mmHg\n RR: 18 (10 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,593 mL\n 1,049 mL\n PO:\n TF:\n 595 mL\n 496 mL\n IVF:\n 1,798 mL\n 313 mL\n Blood products:\n Total out:\n 2,340 mL\n 360 mL\n Urine:\n 2,340 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 253 mL\n 689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : anteriorly, Diminished:\n At baseline)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 324 K/uL\n 235 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 24.6 %\n 7.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n WBC\n 9.8\n 7.9\n Hct\n 26.3\n 24.6\n Plt\n 367\n 324\n Cr\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n Other labs: PT / PTT / INR:25.3/35.7/2.5, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.6 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.6 mg/dL\n Imaging: CXR (): B/L patchy opacities\n Brain MRI: Old infarcts, dilated ventricles\n Microbiology: C diff Neg\n UCx: Neg\n BCx: Neg\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. However, cannot rule out new/evolving infectious\n process. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Will add midodrine today\n -Follow up on cultures sent yesterday\n -Avoid zyprexa for now\n Peripheral edema:\n -Will diurese with lasix drip.\n Respiratory: CXR exam suggest mix of pulmonary edema +/- aspiration.\n No clinical signs of PNA at present.\n -Diuresis as above\n -Aspiration precautions\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -No plan for LP per neuro, so coumadin restarted.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 07:43 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 654806,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Diuresed yesterday\n Levophed still on, but amount has been decreased\n Some AF with RVR this AM, rate improved with IV metoprolol\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Coumadin (Warfarin) - 04:00 PM\n Metoprolol - 08:10 AM\n Other medications:\n Bactrim, amiodarone, synthroid, valproic acid, lansoprazole, paxil,\n coumadin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 84 (84 - 116) bpm\n BP: 104/64(72) {73/34(45) - 104/64(80)} mmHg\n RR: 18 (10 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,593 mL\n 1,049 mL\n PO:\n TF:\n 595 mL\n 496 mL\n IVF:\n 1,798 mL\n 313 mL\n Blood products:\n Total out:\n 2,340 mL\n 360 mL\n Urine:\n 2,340 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 253 mL\n 689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : anteriorly, Diminished:\n At baseline)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 324 K/uL\n 235 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 24.6 %\n 7.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n WBC\n 9.8\n 7.9\n Hct\n 26.3\n 24.6\n Plt\n 367\n 324\n Cr\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n Other labs: PT / PTT / INR:25.3/35.7/2.5, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.6 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.6 mg/dL\n Imaging: CXR (): B/L patchy opacities\n Brain MRI: Old infarcts, dilated ventricles\n Microbiology: C diff Neg\n UCx: Neg\n BCx: Neg\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. However, cannot rule out new/evolving infectious\n process. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Will add midodrine today\n -Follow up on cultures sent yesterday\n -Avoid zyprexa for now\n Peripheral edema:\n -Will diurese with lasix drip.\n Respiratory: CXR exam suggest mix of pulmonary edema +/- aspiration.\n No clinical signs of PNA at present.\n -Diuresis as above\n -Aspiration precautions\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -No plan for LP per neuro, so coumadin restarted.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 07:43 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 654822,
"text": "Chief Complaint:\n 24 Hour Events:\n - CXR fluid overloaded\n - got 20mg IV lasix at 2:30pm\n - neuro: no need for LP--> restarted coumadin\n - weaned levophed but not off yet\n - this morning on pre-rounds, had Afib with RVR 140-150 w/o decrease in\n BP\n gave metoprolol 5 mg IV x 1 with improvement in HR to 80-90\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Furosemide (Lasix) - 02:45 PM\n Coumadin (Warfarin) - 04:00 PM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 115 (87 - 116) bpm\n BP: 90/46(57) {73/34(45) - 102/63(80)} mmHg\n RR: 20 (10 - 22) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,593 mL\n 659 mL\n PO:\n TF:\n 595 mL\n 327 mL\n IVF:\n 1,798 mL\n 202 mL\n Blood products:\n Total out:\n 2,340 mL\n 200 mL\n Urine:\n 2,340 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 253 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///34/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), harsh V/VI SEM heard throughout\n with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Rhonchorous: ), not cooperative with lung exam\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG Tube\n Extremities: 2+ edema throughout LE/UE\n Skin: Warm, fine reticular rash on trunk, arms\n Neurologic: arousable, moaning; able to follow simple command of\n opening eyes/squeezing hands; moving all limbs, CN II\n XII in tact\n Labs / Radiology\n 324 K/uL\n 8.0 g/dL\n 235 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 24.6 %\n 7.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n WBC\n 9.8\n 7.9\n Hct\n 26.3\n 24.6\n Plt\n 367\n 324\n Cr\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n Other labs: PT / PTT / INR:25.3/35.7/2.5\n Ca++:6.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR:\n Increased pulmonary congestion but also multiple parenchymal patchy\n infiltrates. Differential diagnoses include atypical edema but possible\n superimposed infectious processes due to aspiration. Further follow up\n recommended.\n HEAD MRI:\n . Markedly dilated ventricles again demonstrated, unchanged from prior\n CT.\n Findings could be consistent with communicating hydrocephalus and\n correlation\n for possible NPH is recommended.\n 2. Multiple old infarcts again identified, not significantly changed\n from\n prior CT.\n 3. Left vertebral artery not definitely visualized, possibly occluded\n at the\n origin versus hypoplastic artery, consider MRA neck for further\n evaluation.\n Microbiology: C diff: negative\n UCx: negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- holding home dose lasix 40 mg QD; will place on lasix drip for goal\n negative1-1.5 L negative while on levophed (evidence of pulm edema on\n CXR)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4 yest; RF\n stable)\n -- starting midodrine 5 mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team-- NGTD\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- cont Bactrim through per floor team plans\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Neuro planning\n to defer the LP.\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin 0.5 mg last light\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutrition (vitammin\n def) and suppressed BM from chronic disease. Folate, B12 not low.\n -- cont to follow\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) SOMNOLENCE: improved; likely Zyprexa\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: signed on admission on \n (#) CODE: FULL\n (#) DISPO: possible transfer to floor tomorrow afternoon if stabilizes\n & off pressors\n ICU Care\n ACCESS: PICC\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 654596,
"text": "Chief Complaint:\n 24 Hour Events:\n transferred to floor overnight\n -- on low dose levophed; IVF boluses overnight throughout night\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.5\n HR: 90 (74 - 100) bpm\n BP: 90/54(61) {63/38(43) - 110/76(80)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,286 mL\n 1,761 mL\n PO:\n TF:\n 188 mL\n IVF:\n 1,226 mL\n 1,503 mL\n Blood products:\n Total out:\n 180 mL\n 205 mL\n Urine:\n 180 mL\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,106 mL\n 1,556 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 367 K/uL\n 8.7 g/dL\n 114 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 03:56 AM\n WBC\n 9.8\n Hct\n 26.3\n Plt\n 367\n Cr\n 0.6\n TropT\n 0.05\n Glucose\n 114\n Other labs: PT / PTT / INR:23.7/36.5/2.3, CK / CKMB /\n Troponin-T:39//0.05, Ca++:6.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days.\n Of note, baseline BP runs 90-100's; 80's when sleeping.\n -- hold home dose lasix 40 mg QD\n -- will give IVF boluses & wean levophed tolerating MAPS\ns > 50 (not\n septic; lactic acid 1.4 yest)\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro.\n -- f/u urine cultures today\n -- cont Bactrim through per floor team plans\n (#) SOMNOLENCE: in setting of zyprexa for MRI; INR 2.9, though\n non-focal neuro exam and no evidence of herniation, etc. No evidence\n of resp distress, no risk factors for hypercarbia. Improving this\n morning\n -- f/u MRI read\n -- will check ABG, though unlikely vent/oxy contributing currently\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Floor team\n plans to LP once INR nromalizes.\n -- f/u MRI read (still pending)\n -- cont to hold coumadin for possible LP\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: supratx on coumadin; on amio\n -- cont amio; well rhtyhm/rate controlled\n -- cont to hold coumadin for possible LP\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutriion (vitammin def)\n and suppressed BM from chronic disease.\n -- should be on folic acid, MVI\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n .\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: must contact HCP brother for ICU consent\n (#) CODE: FULL\n (#) DISPO: possible transfer to floor this afternoon stabilizes & off\n pressors\n ICU Care\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2140-12-05 00:00:00.000",
"description": "Overnight Intensivist",
"row_id": 654475,
"text": "TITLE: Overnight \n Pt seen and examined; please see resident H and P (Dr. for\n details. Briefly, this a 52 yo woman with Down\ns syndrome who is\n well-known to the MICU service. She returns from the floor after\n becoming hypotensive earlier today after receiving Zyprexa for a CT\n scan. She is currently normotensive, albeit on an intermediate dose of\n Levophed. She has no evidence of an infectious source at his time and\n her unexplained hypotension was extensively worked up during her prior\n MICU stay. Tilt table testing may be a consideration at some point in\n the future. Will plan on weaning levophed overnight.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 654566,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Transferred to the ICU overnight for hypotension on the wards.\n Originally admitted with hypotension and dehydration and spent several\n days in the MICU earlier in her stay. She had received a G tube,\n weaned off pressors and ultimately was transferred to the floor. While\n on the wards, she was undergoing a work-up for dementia and received\n zyprexa in preparation for an MRI. A few hours after this dose, she was\n noted to be hypotensive and was transferred to the ICU. She was\n started on levophed. She has been treated with ciprofloxacin and then\n bactrim for a pan-sensitive UTI. (Apparently developed a rash with\n ciprofloxacin).\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Bactrim, amiodarone, levothyroxine, Atovent, Valproic acid,\n lansoprazole, paxil\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.5\n HR: 90 (74 - 100) bpm\n BP: 101/57(66) {63/38(43) - 110/76(80)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,286 mL\n 1,497 mL\n PO:\n TF:\n 107 mL\n IVF:\n 1,226 mL\n 1,390 mL\n Blood products:\n Total out:\n 180 mL\n 130 mL\n Urine:\n 180 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,106 mL\n 1,367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Sleeping\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Shallow respirations\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, Rash: truncal morbilliform rash, No(t) Jaundice\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 367 K/uL\n 114 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 03:56 AM\n WBC\n 9.8\n Hct\n 26.3\n Plt\n 367\n Cr\n 0.6\n TropT\n 0.05\n Glucose\n 114\n Other labs: PT / PTT / INR:23.7/36.5/2.3, CK / CKMB /\n Troponin-T:39//0.05, Lactic Acid:1.4, Ca++:6.8 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.5 mg/dL\n Imaging: Brain MRI: Pending\n Microbiology: UCx: Pan-sensitive E coli\n BCx: NGTD\n UCx: Pending\n C diff: neg\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. Autonomic instability may also be a contributor.\n -Follow up on cultures sent yesterday\n -Check CXR\n -Avoid zyprexa for now\n -Wean pressors today, she has clearly tolerated MAPs in the 50's in\n the past.\n Peripheral edema:\n -If BP allows, will restart diuresis\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -Coumadin on hold for now as floor team had planned LP.\n Dementia:\n -F/u Brain MRI\n -No plans for LP at this point, will defer until normotensive.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:30 AM 15 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655046,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n PT has been sleeping for most of shift except when stimulated for care.\n She does not move spontaneously, nor does she follow commands. Opens\n eyes to name. Pt is not interactive with staff. She appears to be more\n somnolent than yesterday. NO phone calls or visitors as of this time.\n Action:\n Redirected and reoriented frequently. Made pt aware of any intervention\n that includes being stimulated prior to doing.\n Response:\n Pt still calls out and yells. Her only intelligible word is\n Plan:\n Family meeting to discuss plan of care and directives of care.\n Hypotension (not Shock)\n Assessment:\n Weaning levo to maintain MAP >50. Lasix gtt off. Pt remains with uo\n >50cc hr. MAP has been greater than 50 all shift.\n Action:\n Weaning levo , presently on .02mcg/kg/min\n Response:\n MAP remains >50.\n Plan:\n Maintain MAP >50. Plan for family meeting to discuss plan of care and\n directives of care.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655827,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained on low dose pressors overnight\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 05:53 AM\n Vancomycin - 08:29 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Amiodarone, Synthroid, Valproate, lansoprazole, paxil, colace,\n midodrine, senna, MVI, folate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 95 (83 - 95) bpm\n BP: 91/60(67) {66/37(44) - 103/65(71)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,488 mL\n 1,435 mL\n PO:\n TF:\n 959 mL\n 619 mL\n IVF:\n 1,259 mL\n 507 mL\n Blood products:\n Total out:\n 4,015 mL\n 925 mL\n Urine:\n 3,985 mL\n 925 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,527 mL\n 510 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Asleep, mildly arousable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Poor inspiratory effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 460 K/uL\n 97 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 96 mEq/L\n 135 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n Plt\n 367\n 324\n 338\n 371\n 60\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n Other labs: PT / PTT / INR:23.1/34.9/2.2, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Imaging: No new imaging\n Microbiology: BCx: NGTD\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload. Pt MAPs slightly improving with diuresis.\n Hypotension: Pressor requirement continuing to wean. Remains on\n midodrine.\n -Wean pressors to off if able today\n -Continue midodrine\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now off\n oxygen.\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidnece biliary\n process.\n -Continue anti-emetics\n -Restart TF and check for residuals\n Renal: Significant volume overload still\n -Continue diuresis with goal of negative -500cc to 1L. She may\n benefit from low dose neo/levophed to aid GFR and diuresis\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 12:00 PM 55 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654539,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n Pt received with SBP in 80\ns. Maps 50\ns. UOP 10-30/hr. Tmax 99.5\n (rectal). + pp. Generalized pitting edema +6. Crackles in LUL which\n have subsided. Satting 93-100 % 2LNC. Bun 8, Creat 0.6.\n Action:\n 1L fluid bolus on arrival to MICU. Levophed gtt initiated for Map goal\n > 60. Currently @ 0.28mcg/kg/min.\n Response:\n UOP poor. (MD aware, no interventions at present time) SBP > 85, Maps\n ranging 50\ns-80\ns. LS Clear at this time, dim at bases.\n Plan:\n Titrate Levophed gtt as tolerated for MAP goal >60. Monitor labs and\n UOP.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654545,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n Pt received with SBP in 80\ns. Maps 50\ns. UOP 10-30/hr. Tmax 99.5\n (rectal). + pp. Generalized pitting edema +6. Crackles in LUL which\n have subsided. Satting 93-100 % 2LNC. Bun 8, Creat 0.6.\n Action:\n Total 2L fluid bolus since arrival to MICU. Levophed gtt initiated for\n Map goal > 60. Currently @ 0.28mcg/kg/min.\n Response:\n UOP poor. (MD aware, no interventions at present time) SBP > 85, Maps\n ranging 50\ns-80\ns. LS Clear at this time, dim at bases.\n Plan:\n Titrate Levophed gtt as tolerated for MAP goal >60. Monitor labs and\n UOP.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654662,
"text": "Hypotension (not Shock)\n Assessment:\n AF with PVC and occ SR on tele. HR 80-110. SBP range 83-105 with MAP\n 55-68. Rec\nd on Levophed gtt this AM at 0.24 mcg/kg/min. NS fluid bolus\n running on receipt of pt. LS clear throughout, occasional crackles. CXR\n this AM showed fluid overload per MDs. Noted desaturation on monitor\n around 1800.\n Action:\n Team aware of pt\ns hypotension. Levophed gtt weaned down and diuresis\n initiated. Received lasix 20 mg IV x 1 this afternoon. Pt turned and\n repositioned after desat noted and new oxisensor placed, O2 increased\n to 3L via NC. Coumadin restarted this afternoon at 0.5 mg for\n anticoagulation.\n Response:\n Negative 1.6L since lasix dose. Has maintained SBP 80-100 with MAP\n 50s-60s which is acceptable per Dr. . O2 sat currently \n > 98%. Continues with UO > 100 cc/hr.\n Plan:\n Wean pressors as pt tolerates. Monitor cardiopulmonary status. Provide\n emotional support. Monitor lytes/labs per order.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654735,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n AF with PVC noted. HR 80-110. Tachycardic to 170\ns upon any stimulation\n (baseline) SBP range 79-105 with MAP 45-70. Rec\nd on Levophed gtt this\n AM at 0.10 mcg/kg/min. LS clear throughout, dim at time. CXR \n showed fluid overload per MDs. O2 sat 94-100%\n Action:\n Team aware of pt\ns hypotension. Levophed gtt weaned down and diuresis\n initiated. Received lasix 20 mg IV x 1 in afternoon. Levophed\n titrated to 0.14mcg/kg/min for MAP goal >50.\n Response:\n + 500cc since midnight. Has maintained SBP 80-100 with MAP 50s-60s\n which is acceptable per MICU team. Continues with UO 0-150/hr.\n Plan:\n Wean pressors as tolerated. Monitor cardiopulmonary status. Monitor\n lytes/labs .\n Note: Pt is weeping fluid volume. Monitor PICC dsg for saturation.\n Along with groin area/thigh.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654857,
"text": "Hypotension (not Shock)\n Assessment:\n Pt remains hypotensive with MAP >50. This is order from team to have\n MAP >50. Levo titrated up and down, presently at .12mcg/kg/min with MAP\n 55. Pt started on midodrine pngt. Lasix gtt started with goal of -500\n if pt\ns bp can tolerate. UO >200 cc hr since starting drip at 1300. SBP\n 82-104/50\ns with MAP 55-72. Two family members have phoned.\n Action:\n Weaning levo to MAP >50.\n Response:\n MAP >50 all shift. UO had been low but responded better when Levo was\n increased. Now on lasix gtt with no significant change in MAP as Levo\n is weaned down.\n Plan:\n Con\nt to monitor. Con\nt to diurese. If pt can get off of levo, plan to\n tx to floor tomorrow. Family meeting should be held to discuss plan of\n care and directives of care.\n Pt sleeping most of shift. Agitated with any care given. Remains on\n Kinair bed and turned every 2 hrs. Allyvn dressing on R hip intact.\n Buttocks without breakdown. Feet have ?fungus or dermatitis . R picc\n line site oozing small amts of serous drainage.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655195,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Bilious emesis overnight and shortly after that developed increasing\n oxygen requirements.\n Has remained on pressors\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:30 PM\n Other medications:\n Bactrim, amiodarone, levothyroxine, atovent, valproate, lansoprazole,\n paxil, colace, midodrine, coumadin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.6\nC (96\n HR: 88 (82 - 150) bpm\n BP: 83/48(55) {71/25(38) - 117/64(71)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,378 mL\n 446 mL\n PO:\n TF:\n 1,341 mL\n IVF:\n 547 mL\n 306 mL\n Blood products:\n Total out:\n 3,570 mL\n 385 mL\n Urine:\n 2,970 mL\n 385 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -1,192 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 92%\n ABG: ///38/\n Physical Examination\n General Appearance: No acute distress, Somnolent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : B/L, Diminished: at\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 371 K/uL\n 169 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.6 mEq/L\n 13 mg/dL\n 91 mEq/L\n 130 mEq/L\n 27.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n Plt\n 367\n 324\n 338\n 371\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n Other labs: PT / PTT / INR:18.6/31.5/1.7, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: PICC in place. Bilateral infiltrates\n Microbiology: C diff neg x 2\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Persistent\n pressor requirement may be related SIRS in setting of likely repeated\n aspirations. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Continue midodrine\n -Follow up on cultures sent at time of transfer\n -Avoid zyprexa for now\n Respiratory: Worsening oxygen requirement overnight after vomiting.\n Very likely aspirated. Unclear if just pneumonitis vs PNA.\n -Empiric Vanc/Zosyn for now. Obtain sputum culture if able. If\n process resolves quickly consider stopping abx.\n -Aspiration precautions\n Peripheral edema:\n -Will hold on futher diuresis today until her overall trajectory is\n clearer in setting of recent aspiration.\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -Increase coumadin tonight.\n UTI:\n -Bactrim stops after today.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655211,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n AF with PVC noted. HR 80-110. Tachycardic to 170\ns upon any stimulation\n (baseline) SBP range 79-105 with MAP 45-70. Rec\nd on Levophed gtt this\n AM at 0.10 mcg/kg/min. LS clear throughout, dim at time. CXR \n showed fluid overload per MDs. O2 sat 94-100%\n Action:\n Team aware of pt\ns hypotension. Levophed gtt weaned down and diuresis\n initiated. Received lasix 20 mg IV x 1 in afternoon. Levophed\n titrated to 0.14mcg/kg/min for MAP goal >50.\n Response:\n + 500cc since midnight. Has maintained SBP 80-100 with MAP 50s-60s\n which is acceptable per MICU team. Continues with UO 0-150/hr.\n Plan:\n Wean pressors as tolerated. Monitor cardiopulmonary status. Monitor\n lytes/labs .\n Note: Pt is weeping fluid volume. Monitor PICC dsg for saturation.\n Along with groin area/thigh.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655812,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained on low dose pressors overnight\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 05:53 AM\n Vancomycin - 08:29 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Amiodarone, Synthroid, Valproate, lansoprazole, paxil, colace,\n midodrine, senna, MVI, folate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 95 (83 - 95) bpm\n BP: 91/60(67) {66/37(44) - 103/65(71)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,488 mL\n 1,435 mL\n PO:\n TF:\n 959 mL\n 619 mL\n IVF:\n 1,259 mL\n 507 mL\n Blood products:\n Total out:\n 4,015 mL\n 925 mL\n Urine:\n 3,985 mL\n 925 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,527 mL\n 510 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Asleep, mildly arousable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Poor inspiratory effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 460 K/uL\n 97 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 96 mEq/L\n 135 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n Plt\n 367\n 324\n 338\n 371\n 60\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n Other labs: PT / PTT / INR:23.1/34.9/2.2, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Imaging: No new imaging\n Microbiology: BCx: NGTD\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload. Pt MAPs slightly improving with diuresis.\n Hypotension: Pressor requirement continuing to wean. Remains on\n midodrine.\n -Wean pressors to off if able today\n -Continue midodrine\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now off\n oxygen.\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidnece biliary\n process.\n -Continue anti-emetics\n -Restart TF and check for residuals\n Renal: Significant volume overload still\n -Continue diuresis with goal of negative -500cc to 1L.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 12:00 PM 55 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 654654,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Transferred to the ICU overnight for hypotension on the wards.\n Originally admitted with hypotension and dehydration and spent several\n days in the MICU earlier in her stay. She had received a G tube,\n weaned off pressors and ultimately was transferred to the floor. While\n on the wards, she was undergoing a work-up for dementia and received\n zyprexa in preparation for an MRI. A few hours after this dose, she was\n noted to be hypotensive and was transferred to the ICU. She was\n started on levophed. She has been treated with ciprofloxacin and then\n bactrim for a pan-sensitive UTI. (Apparently developed a rash with\n ciprofloxacin).\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Bactrim, amiodarone, levothyroxine, Atovent, Valproic acid,\n lansoprazole, paxil\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.5\n HR: 90 (74 - 100) bpm\n BP: 101/57(66) {63/38(43) - 110/76(80)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,286 mL\n 1,497 mL\n PO:\n TF:\n 107 mL\n IVF:\n 1,226 mL\n 1,390 mL\n Blood products:\n Total out:\n 180 mL\n 130 mL\n Urine:\n 180 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,106 mL\n 1,367 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Sleeping\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Shallow respirations\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, Rash: truncal morbilliform rash, No(t) Jaundice\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 367 K/uL\n 114 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 8 mg/dL\n 104 mEq/L\n 137 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 03:56 AM\n WBC\n 9.8\n Hct\n 26.3\n Plt\n 367\n Cr\n 0.6\n TropT\n 0.05\n Glucose\n 114\n Other labs: PT / PTT / INR:23.7/36.5/2.3, CK / CKMB /\n Troponin-T:39//0.05, Lactic Acid:1.4, Ca++:6.8 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.5 mg/dL\n Imaging: Brain MRI: Pending\n Microbiology: UCx: Pan-sensitive E coli\n BCx: NGTD\n UCx: Pending\n C diff: neg\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. However, cannot rule out new/evolving infectious\n process. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past\n -Follow up on cultures sent yesterday\n -Check CXR\n -Avoid zyprexa for now\n Peripheral edema:\n -If BP allows, will restart diuresis\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -Coumadin on hold for now as floor team had planned LP.\n Dementia:\n -F/u Brain MRI\n -No plans for LP at this point, will defer until normotensive.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:30 AM 15 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Patient is critically ill.\n Total time spent: 50 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654657,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654917,
"text": "Hypotension (not Shock)\n Assessment:\n Borderline hypotension but with map > 50. no change in dose of levo\n still at .12mcg/kg/min. Remains on lasix gtt as well to keep balance\n negative by 500. Almost negative 1 liter at midnight. HO aware.\n Action:\n levo and lasix gtts. No changes\n Response:\n map>.50 uop>100cc/hr o2 sats mid 90\ns on 4lnp\n Plan:\n Wean levophed if tolerated. Continue to dieurese. Replete lytes as\n needed. Turn q2h to prevent skin breakdown.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654921,
"text": "52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU on for hypotension after receiving zyprexa.\n Hypotension (not Shock)\n Assessment:\n Borderline hypotension but with map > 50. no change in dose of levo\n still at .12mcg/kg/min. Remains on lasix gtt as well to keep balance\n negative by 500. Almost negative 1 liter at midnight. HO aware.\n Action:\n levo and lasix gtts. No changes\n Response:\n map>.50 uop>100cc/hr o2 sats mid to high 90\ns on 3lnp\n Plan:\n Wean levophed if tolerated. Continue to diereses. Replete lytes as\n needed. Turn q2h to prevent skin breakdown.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654922,
"text": "52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU on for hypotension after receiving zyprexa. Pt. is a\n full code\n Hypotension (not Shock)\n Assessment:\n Borderline hypotension but with map > 50. no change in dose of levo\n still at .12mcg/kg/min. Remains on lasix gtt as well to keep balance\n negative by 500. Almost negative 1 liter at midnight. HO aware.\n Action:\n levo and lasix gtts. No changes\n Response:\n map>.50 uop>100cc/hr o2 sats mid to high 90\ns on 3lnp\n Plan:\n Wean levophed if tolerated. Continue to diereses. Replete lytes as\n needed. Turn q2h to prevent skin breakdown.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655201,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Bilious emesis overnight and shortly after that developed increasing\n oxygen requirements.\n Has remained on pressors\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:30 PM\n Other medications:\n Bactrim, amiodarone, levothyroxine, atovent, valproate, lansoprazole,\n paxil, colace, midodrine, coumadin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.6\nC (96\n HR: 88 (82 - 150) bpm\n BP: 83/48(55) {71/25(38) - 117/64(71)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,378 mL\n 446 mL\n PO:\n TF:\n 1,341 mL\n IVF:\n 547 mL\n 306 mL\n Blood products:\n Total out:\n 3,570 mL\n 385 mL\n Urine:\n 2,970 mL\n 385 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -1,192 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 92%\n ABG: ///38/\n Physical Examination\n General Appearance: No acute distress, Somnolent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : B/L, Diminished: at\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.0 g/dL\n 371 K/uL\n 169 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.6 mEq/L\n 13 mg/dL\n 91 mEq/L\n 130 mEq/L\n 27.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n Plt\n 367\n 324\n 338\n 371\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n Other labs: PT / PTT / INR:18.6/31.5/1.7, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR: PICC in place. Bilateral infiltrates\n Microbiology: C diff neg x 2\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Persistent\n pressor requirement may be related SIRS in setting of likely repeated\n aspirations. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Continue midodrine\n -Follow up on cultures sent at time of transfer\n -Avoid zyprexa for now\n Respiratory: Worsening oxygen requirement overnight after vomiting.\n Very likely aspirated. Unclear if just pneumonitis vs PNA.\n -Empiric Vanc/Zosyn for now. Obtain sputum culture if able. If\n process resolves quickly consider stopping abx.\n -Aspiration precautions\n Peripheral edema:\n -Will hold on futher diuresis today until her overall trajectory is\n clearer in setting of recent aspiration.\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -Increase coumadin tonight.\n UTI:\n -Bactrim stops after today.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 655203,
"text": "Objective\n Pertinent medications: Norepi gtt, NS @ 10ml/hr, Lansoprazole, Colace\n Labs:\n Value\n Date\n Glucose\n 169 mg/dL\n 02:25 AM\n Glucose Finger Stick\n 90\n 10:00 PM\n BUN\n 13 mg/dL\n 02:25 AM\n Creatinine\n 0.7 mg/dL\n 02:25 AM\n Sodium\n 130 mEq/L\n 02:25 AM\n Potassium\n 4.6 mEq/L\n 02:25 AM\n Chloride\n 91 mEq/L\n 02:25 AM\n TCO2\n 38 mEq/L\n 02:25 AM\n Albumin\n 1.7 g/dL\n 03:56 AM\n Calcium non-ionized\n 7.0 mg/dL\n 02:25 AM\n Phosphorus\n 3.3 mg/dL\n 02:25 AM\n Magnesium\n 2.3 mg/dL\n 02:25 AM\n WBC\n 9.1 K/uL\n 02:25 AM\n Hgb\n 9.0 g/dL\n 02:25 AM\n Hematocrit\n 27.0 %\n 02:25 AM\n Current diet order / nutrition support: DIET: NPO\n TF: OFF (Fibersource HN @ 55ml/hr)\n GI: soft/distended, hypoactive bs, (+)flatus; loose bm x2 overnight\n Assessment of Nutritional Status\n Estimation of current intake: Inadequate d/t NPO\n Specifics:\n Pt remains hypotensive. TF was running at goal until held for emesis\n yesterday. Pt w/ 1 episode of lg emesis followed by few small emesis.\n After emesis, O2 requirement increased. TF stopped and remains off\n ?resume later today. RN, ?aspiration when pt vomited. Abd CT (-)\n for ileus/obstruction. CXR done, results pending. Also, RN, plan\n for family meeting ?tonight.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Consider re-trial TF\n Monitor residuals, hold TF if >/= 150ml\n Monitor for emesis\n Keep HOB >30degrees\n Rec Reglan\n Multivitamin / Mineral supplement: via TF\n Check chemistry 10 panel daily\n BS mgmt\n Will continue to follow\n page if ?s *\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655206,
"text": "Chief Complaint: hypotension\n 24 Hour Events:\n -- around 8:45 pm, had an episode of bilious emesis; gave\n compazine/reglan PRN --> ended up having multiple episodes of bilious,\n non-bloody emesis overnight\n -- also lots of stool output; sent for C diff thought stools well\n formed\n -- was off lasix in late afternoon; tried to d/c levophed, but MAPs\n dropped to 30's when off. Started back on low rate of levophed.\n Didn't start back on lasix given emesis and stool output.\n -- had slight increase in O2 requirement from 2L to 4L after emesis; ?\n aspiration; improved throughout the night back to baseline\n -- hyponatremic with am labs on ; reduced free water flushes from\n 50 ml to 30 ml Q6 hours.\n Patient unable to provide history: Encephalopathy\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.5\nC (95.9\n HR: 82 (82 - 150) bpm\n BP: 84/49(58) {71/25(38) - 117/64(70)} mmHg\n RR: 16 (7 - 21) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,378 mL\n 250 mL\n PO:\n TF:\n 1,341 mL\n IVF:\n 547 mL\n 190 mL\n Blood products:\n Total out:\n 3,570 mL\n 310 mL\n Urine:\n 2,970 mL\n 310 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -1,192 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///38/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : , Crackles : bilateral, way\n up)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 371 K/uL\n 9.0 g/dL\n 169 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.6 mEq/L\n 13 mg/dL\n 91 mEq/L\n 130 mEq/L\n 27.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n Plt\n 367\n 324\n 338\n 371\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n Other labs: PT / PTT / INR:18.6/31.5/1.7, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.3 mg/dL\n Microbiology: Stool Neg for Cdiff and \n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n # Hypoxia\n likely due to aspiration event overnight. Could be due to\n pulm edema but less likely she has been diuresed some and this was an\n acute change. Aspiration pneumonitis vs pneumonia.\n - start vanco/zosyn for HAP\n - sputum and blood cx\n - wean O2 as tolerated\n # Nausea/Vomiting: unclear etiology, no residuals from tube feeds.\n - held lasix gtt over night\n - anti-emetics prn\n - hold tube feeds but attempt to re-start later today\n # HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR 80's,\n RR teens, WBC 5.8, afebrile); does have UTI but has been treated for\n days now & little evidence of systemic infection. Hct stable today &\n over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Apprears volume overloaded on exam.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- lasix gtt (held now due to N/V and hyponatremia)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4)\n -- midodrine 10mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u cultures - no new data\n # UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- stop Bactrim as has completed > 7 day course\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP. No new recs from neurology\n -- on. Paxil for possible depression as cause for decreased PO intake &\n FTT; decrease dose to 10mg as may be contributing to her lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin; INRsubtherapeutic, increase to 1 mg daily\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # FEN: on tube feeds via PEG; w/o complication. Hyponatremic -\n hold lasix gtt\n -- cont TF; nutrition following\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n # PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n # CONSENT: signed on admission on \n # CODE: FULL\n # DISPO: transfer to floor if stabilizes & off pressors\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Fam mtg planned\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655617,
"text": "52yo with Downs and Alzheimer's disease admitted with\n hypotension due to dehydration / FTT. Re-admitted on for\n hypotension thought medications. Course c/b aspiration event, with\n hypotension requiring vasopressors. Also volume overloaded; pt with 4+\n MR with intermittent RVR\n Hypotension (not Shock)\n Assessment:\n Pt remains on norpeip srip at .15 mcgs/kg/min\n Action:\n Attempted to wean drip\n Response:\n BP dropped to 65/48\n Plan:\n Titrate levophed as per BP.\n Pneumonia, aspiration/ failer\n Assessment:\n Pt remains on 40% cool neb, they still feel pt needs to be diuresed\n Action:\n Took o2 off sats dropped to 86% , lasix drip running to .5 mg hr\n Response:\n Pt greater then 1500 out so far this shift\n Plan:\n Follow lytes.\n Nausea / vomiting\n Assessment:\n Pt vomited around 300ml @ 0515 and SVT to 200\n Action:\n Tube feed held and received compazine 10mg IVP for vomiting. Received\n metoprolol 5mg IVP which immediately broke the SVT.\n Response:\n she is still gagging and vomiting small amounts, HR maintaining in\n 80\n Plan:\n Aspiration precaution, Keep her NPO until further orders.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655792,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin - 05:53 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 87 (83 - 96) bpm\n BP: 87/49(57) {66/37(44) - 103/65(71)} mmHg\n RR: 12 (8 - 19) insp/min\n SpO2: 95%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,488 mL\n 660 mL\n PO:\n TF:\n 959 mL\n 421 mL\n IVF:\n 1,259 mL\n 239 mL\n Blood products:\n Total out:\n 4,015 mL\n 585 mL\n Urine:\n 3,985 mL\n 585 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,527 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: 3/6 SEM radiating to axilla\n Respiratory / Chest: poor air movement, doesn\nt take deep breaths\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Labs / Radiology\n 460 K/uL\n 8.0 g/dL\n 97 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 96 mEq/L\n 135 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n Plt\n 367\n 324\n 338\n 371\n 60\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n Other labs: PT / PTT / INR:23.1/34.9/2.2, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n MICRO:\n Blood 1/16: NGTD\n IMAGING:\n None new\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - follow up blood cx, sputum was not produced by patient\n - weaning supplemental O2 , now on NC\n - continue diuresis to minimize pulm edema\n - TFs restarted at low rate\n - consider changing reglan to standing to avoid rpeat N/V\n # Hypotension: unlikely septic shock as does not even meet SIRS\n criteria (HR 80's, RR teens, WBC 5.8, afebrile). She did have a UTI but\n has been treated for days now, with a negative surveillance urine\n culture from . No evidence of gross blood loss to suggest\n hypovolemic/hemorrhagic shock. Actually appears volume overloaded on\n exam. Unclear how much autonomic instability is contributing to\n (chronic) hypotension. With severe MR on recent echo, poor forward flow\n is a likely contributor to hypoTN. Of note, her baseline BP runs\n 90-100's; 80's when sleeping.\n -- not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n -- continue midodrine 10mg TID\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL), now at 0.08\n -- lasix as needed for goal -1 -2 L today\n -- consider afterload reduction with low dose captopril, may have\n paradoxical improvement in BP\n # s/p E. coli UTI - grew from UCx ; earlier cultures were\n negative. Floor team started cipro on with intention to treat\n for seven days. Rash was noted; floor team changed to bactrim. Repeat\n UCx from negative.\n -- now s/p Bactrim 7 day course\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- continue paxil for possible depression as cause for decreased PO\n intake & FTT; decreased dose to 10mg as may be contributing to her\n lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n Resolving with diuresis\n -- lasix gtt with goal negative liter today\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition: TFs\n Fibersource HN (Full) - 12:00 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: sQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655261,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Events: Pt did have large amts of emesis last night () which has\n led to Asp. PNA. Family meeting held this afternoon. Pt is now a\n DNR/DNI. PICC line has been pulled back ~ 5cm. Radiology, MICU team and\n IV therapy in agreement of position and that we can cont. to use it. If\n any further dislodgement occurs, please stop IVF and call resident. Do\n not advance per IV therapy.\n While turning pt/or stimulating pt, HR increases to 170\ns but settles\n out one repositioned. Team is also in agreement with renal for ~18cc/hr\n of urine.\n Hypotension (not Shock)\n Assessment:\n Afib. . HR 80-110. Tachycardic to 170\ns upon any stimulation (baseline)\n SBP range 79-105 with MAP 45-75. Rec\nd on Levophed gtt this AM at 0.15\n mcg/kg/min. LS dim throughout.. CXR showing asp. pna. O2 sat down\n to 88% this afternoon.\n Action:\n Team aware of pt\ns hypotension issues. Levophed gtt remains at\n 0.15mcg/kg/min. Pt received Lasix 20 mg IV x 1 this afternoon. MAP goal\n >50.\n Response:\n Pt has maintained SBP 80-100 with MAP 50s-70\ns which is acceptable per\n MICU team. Continues with UO 0-30/hr. + diuresis 400-500cc/hr with\n Lasix.\n Plan:\n Wean pressors as tolerated. Monitor cardiopulmonary status. Monitor\n lytes/labs .\n Note: Pt is weeping fluid volume. Monitor PICC dsg for saturation.\n Along with groin area/thigh.\n Pneumonia, aspiration\n Assessment:\n Received pt on 2L NC. Lung sounds dim throughout. O2 requirement has\n increased significantly throughout the day. O2 sat 85-100%. Increased\n lethargy noted as well. CXR obtained post emesis showing aspiration pna\n vs. pneumonitis.\n Action:\n TF withheld this afternoon for probable intubation (prior to code\n status discussion) IV antibiotics started. Lasix 20mg IV x 1. Paxil\n dose decreased to 10mg daily. Keep MAP > 50. 100% NRB placed. TF\n restarted at 10cc/hr.\n Response:\n Pt currently satting 98-100%. TF currently @ 10cc with no residuals.\n Remains on Levo gtt as noted above.\n Plan:\n Run pt even if possible. Cont to monitor resp status and O2\n consumption. Cont. IV abx. DNR/DNI. Emotional support as needed.\n Advance TF is warranted.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655365,
"text": "52yo with Downs Syndrome, Alzheimer's Dementia and 4+ MR \nmal Afib with RVR returned to ICU after hypotensive episode,\n thought secondary to medications. Now complicated by aspiration event,\n with hypoxemia. Requiring vasopressors to maintain MAPs.\n Pneumonia, aspiration/ failer\n Assessment:\n Pt on 100% nrb , lung course bilaterally in bases sats 98%, pt has\n some failer by chest xray\n Action:\n Fio2 wean to 50% cool areasol with sats of 97% rr 16-20, lasix drip\n restarted at 3mg hr and ^ to 5 mg hr\n Response:\n Pt was able to tolerate wean of fio2, u/o 120 hr\n Plan:\n Maintain aspiration precautions, wean fio2 as tolerated, and continue\n with iv antibiotics. Goal of lasix drip is to have pt neg one liter\n today, hours goal to make pt 100cc/ negative an hour\n Hypotension (not Shock)\n Assessment:\n Pt remains on a norepi drip at .15 mcg/kg/min\n Action:\n Attempted to wean drip\n Response:\n Bp dropped into the 80\ns sbp\n Plan:\n Drip turned back to prior rate\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt well call out when turn or when care is given, will say no but\n that\ns about all the verbal conversation I get with patient\n Action:\n Attempt to reorient\n Response:\n No effective\n Plan:\n Continue to provide safe environment, orient to place and time\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655978,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n OOB to a chair yesterday and this AM.\n Diuresis continued. Has remained on pressors to date.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:11 AM\n Vancomycin - 08:22 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:21 AM\n Other medications:\n amiodarone, levothyroxine, valporate, paxil, colace, midodrine, senna,\n folate, coumadin, reglan, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 80 (80 - 96) bpm\n BP: 84/44(53) {73/39(49) - 91/61(65)} mmHg\n RR: 9 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 3,006 mL\n 1,375 mL\n PO:\n TF:\n 1,333 mL\n 637 mL\n IVF:\n 1,193 mL\n 628 mL\n Blood products:\n Total out:\n 3,235 mL\n 3,160 mL\n Urine:\n 3,235 mL\n 3,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -229 mL\n -1,785 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///40/\n Physical Examination\n General Appearance: No acute distress, Sitting in chair\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic), Irreg Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Bibasilar), Poor insp\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 604 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 40 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 96 mEq/L\n 139 mEq/L\n 26.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n Other labs: PT / PTT / INR:23.8/34.1/2.3, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: PICC line in place. Retrocardiac opacity. More diffuse\n R-sided opacity.\n Microbiology: BCx (): NGTD\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload.\n Hypotension: Pressor requirement persists. Remains on midodrine.\n -Continue midodrine\n -Will try to wean pressors and use PRBC transfusion to bolster\n oncotic pressure.\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now on\n nasal cannula. CXR with persistent B/L opacities\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidnece biliary\n process.\n -Reduce Reglan to as she is a little more somnolent today.\n -Continue TF and check for residuals\n Renal: Significant volume overload still\n -Goal net negative 1-2 liters today using lasix drip.\n AF: Remains on amiodarone, coumadin\n Somnolence: Wean reglan as above. D/C paxil.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655359,
"text": "Chief Complaint:\n -\n HPI:\n 52yo with Downs Syndrome, Alzheimer's Dementia and 4+ MR \nmal Afib with RVR retruned to ICU after hypotensive episode, no\n evidence of infectious. Then with aspiration event, with hypoxemia.\n 24 Hour Events:\n - No major o/n events\n - FiO2 weaned to 50% shovel mask\n - continues on Norepinephrine (0.15 mcg/kg/min) to maintain MAPs>50\n - episode of Afib RVR responded to metop.\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 10:05 PM\n Vancomycin - 07:41 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Metoprolol - 10:16 AM\n Other medications:\n Folate\n MVI\n Warfarin 1mg\n Midodrine 10mg po tid\n PPI\n Valproic acid 400mg q8hr\n Syntrhoid\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:04 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 83 (81 - 180) bpm\n BP: 85/37(48) {85/37(48) - 129/112(116)} mmHg\n RR: 17 (8 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 1,517 mL\n 1,303 mL\n PO:\n TF:\n 129 mL\n 253 mL\n IVF:\n 1,067 mL\n 690 mL\n Blood products:\n Total out:\n 1,935 mL\n 700 mL\n Urine:\n 1,935 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 603 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask , Aerosol-cool\n FiO2: 50% shovel mask\n SpO2: 100%\n ABG: ///37/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n on sides at bases.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 380 K/uL\n 97 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 5.0 mEq/L\n 14 mg/dL\n 91 mEq/L\n 131 mEq/L\n 25.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n Plt\n 367\n 324\n 338\n 371\n 380\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n Other labs: PT / PTT / INR:19.3/30.4/1.8, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR = pulm edema. RLL and LLL opacities. LVH and LAE.\n Microbiology: Blood Cx = neg\n Assessment and Plan\n 52yo with Down's and Alzheimer's now hypotensive, with aspiration\n pneumonia.\n 1. Hypotensive, unclear whether potential sepsis vs cardiogenic\n shock given 4+ MR.\n a) volue overloaded --> will diurese TBB -1L\n b) Consider afterload reduction if not responding to lasix\n c) Wean pressors for MAPs >50\n d) continue Abx (Vanc and Zosyn)\n e) On Midodrine 10mg tid\n f) Afib- On amiodarone and warfarin . Supp with beta blokcers for\n RVR\n 2. Pulm-\n a) Wean FiO2\n 3. GI- continues on tube feeds\n 4. Renal -\n a) Diuresis\n b) pm lytes\n 5. ID- continues on Vanc and Zosyn (started )\n 6. Heme- no issues; on warfarin (INR=1.7), will increase warafrin.\n 7. Endo- will follow dexis\n 8. ICU- DNR/DNI\n Access- PICC\n PPI, warfarin\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:27 AM 20 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655363,
"text": "Chief Complaint:\n -\n HPI:\n 52yo with Downs Syndrome, Alzheimer's Dementia and 4+ MR \nmal Afib with RVR returned to ICU after hypotensive episode,\n thought secondary to medications. Now complicated by aspiration event,\n with hypoxemia. Requiring vasopressors to maintain MAPs.\n 24 Hour Events:\n - No major o/n events\n - FiO2 weaned to 50% shovel mask\n - continues on Norepinephrine (0.15 mcg/kg/min) to maintain MAPs>50\n - episode of Afib RVR responded to metop.\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 10:05 PM\n Vancomycin - 07:41 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Metoprolol - 10:16 AM\n Other medications:\n Folate\n MVI\n Warfarin 1mg\n Midodrine 10mg po tid\n PPI\n Valproic acid 400mg q8hr\n Syntrhoid\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:04 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 83 (81 - 180) bpm\n BP: 85/37(48) {85/37(48) - 129/112(116)} mmHg\n RR: 17 (8 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 1,517 mL\n 1,303 mL\n PO:\n TF:\n 129 mL\n 253 mL\n IVF:\n 1,067 mL\n 690 mL\n Blood products:\n Total out:\n 1,935 mL\n 700 mL\n Urine:\n 1,935 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 603 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask , Aerosol-cool\n FiO2: 50% shovel mask\n SpO2: 100%\n ABG: ///37/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic at\n apex)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n on sides at bases.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Muscle wasting\n Skin: warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 380 K/uL\n 97 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 5.0 mEq/L\n 14 mg/dL\n 91 mEq/L\n 131 mEq/L\n 25.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n Plt\n 367\n 324\n 338\n 371\n 380\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n Other labs: PT / PTT / INR:19.3/30.4/1.8, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR = pulm edema. RLL and LLL opacities. LVH and LAE.\n Microbiology: Blood Cx = neg\n Assessment and Plan\n 52yo with Down's and Alzheimer's now hypotensive, with aspiration\n pneumonia.\n 1. Hypotensive, unclear whether related to sepsis physiology vs\n cardiogenic shock (given Hx 4+ MR and volume repletion)..\n a) volue overloaded --> will diurese TBB -1L\n b) Consider afterload reduction if not responding to lasix\n c) Wean pressors for MAPs >50\n d) continue Abx (Vanc and Zosyn); attempt sputum cultures\n e) On Midodrine 10mg tid\n f) Afib- On amiodarone and warfarin . Supp with beta blokcers for\n RVR\n 2. Pulm-\n a) Wean FiO2\n 3. GI- continues on tube feeds\n 4. Renal -\n a) Diuresis\n b) pm lytes\n 5. ID- continues on Vanc and Zosyn (started ); will need 8 day\n course.\n 6. Heme- no issues; on warfarin (INR=1.7), will increase warafrin.\n 7. Endo- will follow dexis\n 8. ICU- DNR/DNI\n Access- PICC\n PPI, warfarin\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:27 AM 20 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: on warfarin\n Stress ulcer: will start PPI\n VAP: head of bed at 45 degrees.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655544,
"text": ":\n 52yo with Downs and Alzheimer's disease admitted with\n hypotension due to dehydration / FTT. Re-admitted on for\n hypotension thought medications. Course c/b aspiration event, with\n hypotension requiring vasopressors. Also volume overloaded; pt with 4+\n MR with intermittent RVR\n Hypotension (not Shock)\n Assessment:\n Pt remains on norpeip srip at .15 mcgs/kg/min\n Action:\n Attempted to wean drip\n Response:\n BP dropped to 77/48\n Plan:\n Drip placed back to prior dose.\n Pneumonia, aspiration/ failer\n Assessment:\n Pt remains on 40% cool neb, they still feel pt needs to be diuresed\n Action:\n Took o2 off sats dropped to 86% , lasix drip restarted was but to 5 mg\n hr now down to .5 mg hr\n Response:\n Pt greater then 1500 out so far this shift\n Plan:\n Plan to keep lasix drip going even thought she has already made herself\n neg a liter so far, pt continues on Iv antibiotics , will have lytes\n checked this afternoon.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655948,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n 24h:\n - diuresed, weaned levophed down to 0.04\n - was OOB to chair\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:25 PM\n Piperacillin - 06:11 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 88 (85 - 96) bpm\n BP: 83/47(55) {73/39(49) - 91/61(67)} mmHg\n RR: 13 (9 - 20) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 3,006 mL\n 748 mL\n PO:\n TF:\n 1,333 mL\n 424 mL\n IVF:\n 1,193 mL\n 324 mL\n Blood products:\n Total out:\n 3,235 mL\n 2,860 mL\n Urine:\n 3,235 mL\n 2,860 mL\n NG:\n Stool:\n Drains:\n Balance:\n -229 mL\n -2,112 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///40/\n Physical Examination\n General Appearance: No acute distress, Thin, attentive and moaning\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: 3/6 SEM radiating to axilla\n Respiratory / Chest: poor air movement, doesn\nt take deep breaths\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Labs / Radiology\n 604 K/uL\n 8.7 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 40 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 96 mEq/L\n 139 mEq/L\n 26.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n Other labs: PT / PTT / INR:23.8/34.1/2.3, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: (my read)\n worsened airspace disease ont he right, with improvement on the left\n Microbiology: BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n -- CXR this AM without significant improvement overall\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - blood cx from the aspiration event with NGTD, sputum was not produced\n by patient\n - weaning supplemental O2 , now on NC\n - continue diuresis to minimize pulm edema (already 2 liters negative\n today)\n - TFs restarted at low rate\n - standing reglan to avoid repeat N/V\n # Hypotension: not septic shock as does not even meet SIRS criteria.\n She did have a UTI but has been treated for days now, with a negative\n surveillance urine culture from . No evidence of\n hypovolemic/hemorrhagic shock. Unclear how much autonomic instability\n is contributing to (chronic) hypotension. With severe MR on recent\n echo, poor forward flow is a likely contributor to hypoTN.\n -- not hypoperfusing given lactate of 1.1 while MAPs were in high 40\n -- continue midodrine 10mg TID\n -- weaning levophed to MAP\ns > 50, now at 0.04 from 0.08 24 hours ago\n goal off today\n -- lasix as needed for goal -1 L today\n -- lytes\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily\n -- trend INR\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- continue paxil\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n Resolved with diuresis\n -- lasix gtt with goal negative 1 liter today\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655985,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n OOB to a chair yesterday and this AM.\n Diuresis continued. Has remained on pressors to date.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:11 AM\n Vancomycin - 08:22 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:21 AM\n Other medications:\n amiodarone, levothyroxine, valporate, paxil, colace, midodrine, senna,\n folate, coumadin, reglan, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 80 (80 - 96) bpm\n BP: 84/44(53) {73/39(49) - 91/61(65)} mmHg\n RR: 9 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 3,006 mL\n 1,375 mL\n PO:\n TF:\n 1,333 mL\n 637 mL\n IVF:\n 1,193 mL\n 628 mL\n Blood products:\n Total out:\n 3,235 mL\n 3,160 mL\n Urine:\n 3,235 mL\n 3,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -229 mL\n -1,785 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///40/\n Physical Examination\n General Appearance: No acute distress, Sitting in chair\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic), Irreg Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Bibasilar), Poor insp\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 604 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 40 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 96 mEq/L\n 139 mEq/L\n 26.2 %\n 7.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n Other labs: PT / PTT / INR:23.8/34.1/2.3, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: PICC line in place. Retrocardiac opacity. More diffuse\n R-sided opacity.\n Microbiology: BCx (): NGTD\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload.\n Hypotension: Pressor requirement persists. Remains on midodrine.\n -Continue midodrine\n -Will try to wean pressors and use PRBC transfusion to bolster\n oncotic pressure.\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now on\n nasal cannula. CXR with persistent B/L opacities\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidnece biliary\n process.\n -Reduce Reglan to as she is a little more somnolent today.\n -Continue TF and check for residuals\n Renal: Significant volume overload still\n -Goal net negative 1-2 liters today using lasix drip.\n AF: Remains on amiodarone, coumadin\n Somnolence: Wean reglan as above. D/C paxil.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:49 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 656143,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Weaned of pressors yesterday morning and remained off all day.\n Diuresed effectively yesterday.\n History obtained from Medical records\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n lansoprazole, valproate, levothyroxine, amidarone, midodrine, colace,\n folate, coumadin, senna\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 85 (80 - 98) bpm\n BP: 81/41(51) {70/34(45) - 100/59(63)} mmHg\n RR: 10 (9 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,647 mL\n 1,214 mL\n PO:\n TF:\n 1,335 mL\n 600 mL\n IVF:\n 1,802 mL\n 464 mL\n Blood products:\n 350 mL\n Total out:\n 5,000 mL\n 1,730 mL\n Urine:\n 5,000 mL\n 1,730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,353 mL\n -516 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bibasilar), Poor insp\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 511 K/uL\n 66 mg/dL\n 0.8 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 93 mEq/L\n 133 mEq/L\n 27.8 %\n 6.3 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n 04:30 AM\n 03:49 AM\n 03:40 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n 7.8\n 7.1\n 6.3\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n 24.1\n 26.2\n 27.8\n Plt\n 367\n 324\n 338\n 371\n 60\n 604\n 511\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n 97\n 82\n 66\n Other labs: PT / PTT / INR:25.7/36.8/2.5, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Imaging: No new imaging\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload.\n Hypotension: Remains off pressors and is tolerating diuresis.\n -Continue midodrine, MAP goal remain >50\n Aspiration: Pneumonia vs pneumonitis. Rapidly improved. Now on nasal\n cannula. CXR with persistent B/L opacities\n -Will complete empiric course of abx for 8 days.\n GI: With nausea/vomiting --> no residuals. No evidnece biliary\n process.\n -Continue to monitor for residuals on reduced dose reglan.\n Renal: Significant volume overload still\n -Goal net negative 1 liter with intermittent IV lasix\n AF: Remains on amiodarone, coumadin\n Somnolence: Paxil now d/c'd and reglan dose reduced.\n -Decrease valproate dosing as she appears to be much more somnolent\n after this.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:20 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656047,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt not following commands. Not answering questions. Does yell out with\n nursing care and turning. Pt is non verbal except for yelling out.\n Action:\n Yesterday pt sister in law did come in and state that pt recognized\n her. Pt. OOB to chair using this AM.\n Response:\n Pt has been awake throughout most of the shift. Became restless while\n in chair, placed back in bed. PT by this PM to work with patient\n edge\n of bed to dangle and ROM. Not consistently following commands, no\n verbalizations, will resist when prompted to move during nursing care.\n According to other MICU staff, pt. much more alert and restless today\n than previous days. ? of need for restraints as patient may invertently\n pull out lines.\n Plan:\n Cont to get pt up in the chair during the day. PT daily.\n Hypotension (not Shock)\n Assessment:\n Pt B/P has been 70-80 range systolic. Received on levophed\n 0.04mic/kg/min. pt is also on lasix gtt at 2 mg hr.\n Action:\n Was 2L negative at midnight. Levo gtt shut off, team ok with MAP > 45.\n Response:\n Continues to be 1500-1700 cc negative. Transfused 1 unit PRBC this PM\n for volume.\n plan\n Cont to diurese per orders, MAP > 45.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655018,
"text": "Chief Complaint:\n 24 Hour Events:\n - started on midodrine\n - on lasix gtt with very good diuresis (currently at a rate of 0.5\n mg/hour)\n - levophed not off yet (weaned from levo 0.12\n 0.08); MAPs mostly in\n the 60\ns overnight\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:10 AM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.1\nC (97\n HR: 91 (84 - 96) bpm\n BP: 89/41(53) {77/41(51) - 104/64(72)} mmHg\n RR: 10 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,237 mL\n 814 mL\n PO:\n TF:\n 1,147 mL\n 454 mL\n IVF:\n 689 mL\n 190 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,470 mL\n Urine:\n 3,160 mL\n 1,470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -923 mL\n -656 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///39/\n Physical Examination\n Labs / Radiology\n 338 K/uL\n 8.8 g/dL\n 146 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 94 mEq/L\n 134 mEq/L\n 25.6 %\n 8.0 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n WBC\n 9.8\n 7.9\n 8.0\n Hct\n 26.3\n 24.6\n 25.6\n Plt\n 367\n 324\n 338\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n Other labs: PT / PTT / INR:24.4/35.9/2.4, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.9 mg/dL\n Imaging: No new imaging\n Microbiology: UCx; negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- holding home dose lasix 40 mg QD; will place on lasix drip for goal\n negative1-1.5 L negative while on levophed (evidence of pulm edema on\n CXR)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4 yest; RF\n stable)\n -- starting midodrine 5 mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team-- NGTD\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- cont Bactrim through per floor team plans\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Neuro planning\n to defer the LP.\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin 0.5 mg last light\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutrition (vitammin\n def) and suppressed BM from chronic disease. Folate, B12 not low.\n -- cont to follow\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) SOMNOLENCE: improved; likely Zyprexa\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: signed on admission on \n (#) CODE: FULL\n (#) DISPO: possible transfer to floor tomorrow afternoon if stabilizes\n & off pressors\n ICU Care\n ACCESS: PICC\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655019,
"text": "Chief Complaint:\n 24 Hour Events:\n - started on midodrine\n - on lasix gtt with very good diuresis (currently at a rate of 0.5\n mg/hour)\n - levophed not off yet (weaned from levo 0.12\n 0.08); MAPs mostly in\n the 60\ns overnight\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:10 AM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.1\nC (97\n HR: 91 (84 - 96) bpm\n BP: 89/41(53) {77/41(51) - 104/64(72)} mmHg\n RR: 10 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,237 mL\n 814 mL\n PO:\n TF:\n 1,147 mL\n 454 mL\n IVF:\n 689 mL\n 190 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,470 mL\n Urine:\n 3,160 mL\n 1,470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -923 mL\n -656 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///39/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), harsh V/VI SEM heard throughout\n with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Rhonchorous: ), not cooperative with lung exam\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG Tube\n Extremities: 2+ edema throughout LE/UE\n Skin: Warm, fine reticular rash on trunk, arms\n Neurologic: arousable, moaning less than yesterday, seems more alert;\n able to follow simple command of opening eyes/squeezing hands; moving\n all limbs, CN II\n XII in tact\n Labs / Radiology\n 338 K/uL\n 8.8 g/dL\n 146 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 94 mEq/L\n 134 mEq/L\n 25.6 %\n 8.0 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n WBC\n 9.8\n 7.9\n 8.0\n Hct\n 26.3\n 24.6\n 25.6\n Plt\n 367\n 324\n 338\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n Other labs: PT / PTT / INR:24.4/35.9/2.4, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.9 mg/dL\n Imaging: No new imaging\n Microbiology: UCx; negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- holding home dose lasix 40 mg QD; will place on lasix drip for goal\n negative1-1.5 L negative while on levophed (evidence of pulm edema on\n CXR)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4 yest; RF\n stable)\n -- will increase midodrine ffrom 5 mg to 10 mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures from earlier today drawn by floor team-- NGTD\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- cont Bactrim through per floor team plans\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Neuro planning\n to defer the LP. No new recs from neurology\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n (#) AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin 0.5 mg QHS; INR 2.4 today\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutrition (vitammin\n def) and suppressed BM from chronic disease. Folate, B12 not low.\n -- cont to follow\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: signed on admission on \n (#) CODE: FULL\n (#) DISPO: possible transfer to floor tomorrow afternoon if stabilizes\n & off pressors\n ICU Care\n ACCESS: PICC\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655534,
"text": "Chief Complaint:\n HPI:\n 52yo with Downs and Alzheimer's disease admitted with\n hypotension due to dehydration / FTT. Re-admitted on for\n hypotension thought medications. Course c/b aspiration event, with\n hypotension requiring vasopressors. Also volume overloaded; pt with 4+\n MR with intermittent RVR.\n 24 Hour Events:\n - FiO2 weaned to 40%\n - Pt diuresed ~1L yesterday.\n - Suctioning q4hr for small amt\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 09:07 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:16 AM\n Other medications:\n Amiodarone 200mg daily\n Synthroid 88mcg\n Atrovent Neb\n Valproic acid 400mg po q8hr\n Midordrine 10mg tid\n Lasix gtt (now off)\n Paroxetine 10mg daily\n Warfarin 1mg\n MVI\n folate\n Lansoprazole\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.5\nC (95.9\n HR: 86 (79 - 180) bpm\n BP: 77/41(48) {67/37(48) - 129/112(116)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,493 mL\n 1,000 mL\n PO:\n TF:\n 656 mL\n 413 mL\n IVF:\n 1,227 mL\n 587 mL\n Blood products:\n Total out:\n 3,665 mL\n 1,150 mL\n Urine:\n 3,665 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,172 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n FiO2: 40% shovel mask\n SpO2: 92%\n ABG: ///38/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), \n systolic murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases bilat)\n Abdominal: Soft, Non-tender\n Extremities: Right: 3+, Left: 3+\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 391 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.5 %\n 8.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n Other labs: PT / PTT / INR:19.9/31.0/1.9, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: No new CXR\n Microbiology: Blood 1/16= NGTD\n No sputum\n Assessment and Plan\n 52yo with hypotension aspiration pneumonia and volume overload.\n 1. Pulm-\n a) Diuresing goal TBB -1-2 L with levophed per day\n b) continue Vanc /Zosyn for 8 days course; no culture data to guide\n therapy unfortunately\n c) BiPAP/ NiPPV with sleep for likely OSA\n 2. CV\n a) Hypotension\n - unclear source --> sepsis vs. volume overloaded (MR). r/o for\n adrenal insufficiency. Unlikely PE given supratherapeutic INR.\n - Continues on low dose levophed and midodrine\n - Consider stopping pressors and following clinical parameters\n for hypotension (cap refill, urine output, lactates)\n - benefit from low dose digoxin ( po/iv) for added\n inotropic support\n b) -\n - On amiodarone for rate control\n - Warfarin for anticoag\n 3. GI- continue tube feeds via G-tube\n 4. Renal-\n a) duirese TBB -1l\n b) Hyponatremia improving with diuresis\n 5. Endo-\n a) Hypothyroid, on syntroid\n b) On ISS\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 04:21 AM 55 mL/hour\n Comments: Senna/Colace\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :\n Total time spent: 35 min minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655607,
"text": "52yo with Downs and Alzheimer's disease admitted with\n hypotension due to dehydration / FTT. Re-admitted on for\n hypotension thought medications. Course c/b aspiration event, with\n hypotension requiring vasopressors. Also volume overloaded; pt with 4+\n MR with intermittent RVR\n Hypotension (not Shock)\n Assessment:\n Pt remains on norpeip srip at .15 mcgs/kg/min\n Action:\n Attempted to wean drip\n Response:\n BP dropped to 65/48\n Plan:\n Titrate levophed as per BP.\n Pneumonia, aspiration/ failer\n Assessment:\n Pt remains on 40% cool neb, they still feel pt needs to be diuresed\n Action:\n Took o2 off sats dropped to 86% , lasix drip running to .5 mg hr\n Response:\n Pt greater then 1500 out so far this shift\n Plan:\n Follow lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655702,
"text": "Hypotension (not Shock)\n Assessment:\n Pt. remains levo dependent\n see flowsheet for BP.\n Action:\n Levo gtt weaned to .08mcg/kg/min. Cont\ns on midodrine.\n Response:\n BP 70\ns/40\ns while asleep on present levo dose. Team accepting MAP>50\n at this time. MAP in high 40\ns x 2 checked this afternoon\n HO aware,\n lactate checked and was normal.\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655705,
"text": "Hypotension (not Shock)\n Assessment:\n Pt. remains levo dependent\n see flowsheet for BP. Received pt. with\n lasix gtt off with adeq. UO.\n Action:\n Levo gtt weaned to .08mcg/kg/min. Cont\ns on midodrine.\n Response:\n BP 70\ns/40\ns while asleep on present levo dose. Team accepting MAP>50\n at this time. MAP in high 40\ns x 2 checks (q 30 mins) this afternoon\n HO aware, lactate checked and was normal. Pt. remains arousable,\n (yet sleepy this afternoon) warm, and dry with these pressures. Her\n UO, however, has decreased.\n Plan:\n Titrate levophed to maintain MAP>50. (Goal to d/c levo). Lasix gtt\n available to keep pt. 1-2 liters negative today. Get OOB this eve.\n Pneumonia, aspiration\n Assessment:\n LS diminished at bases with crackles bibasilar. No distress noted.\n Action:\n Pt. weaned to NC. Coughing and deep breathing encourgaged.\n Response:\n Sats stable. Pt. rarely follows commands to c/d/b.\n Plan:\n Pulmonary hygiene as able. Wean O2 as appropriate.\n Nausea / vomiting\n Assessment:\n Pt. with soft, benign abdomen , but vomited small amounts bile this\n a.m. Pt. had small BM this a.m.\n Action:\n TF held until noontime. Pt. premedicated with compazine prior to a.m.\n meds, also given reglan. LFT\ns checked.\n Response:\n No residuals noted. No further episodes of vomiting. LFT\n unremarkable.\n Plan:\n Cont. to monitor. Team to consider KUB if pt. vomits again. Monitor\n for TF residuals and hold feeds if >100cc.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655335,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - started vanco/zosyn for HAP after presumed aspiration event\n - cultured (sputum/blood)\n - escalating O2 requirement (on NRB by 4pm)\n - repeat CXR, essentially unchanged\n - gave 20mg IV lasix b/c of breathing and concern for vol overload\n - Family mtg - DNR/DNI\n - restarted TFs, no residuals\n This AM, pt more lethargic than usual self, but no obvious respiratory\n distress.\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 10:05 PM\n Vancomycin - 07:41 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.3\nC (95.6\n HR: 85 (81 - 137) bpm\n BP: 92/54(63) {83/42(51) - 105/64(78)} mmHg\n RR: 15 (8 - 17) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 1,517 mL\n 807 mL\n PO:\n TF:\n 129 mL\n 160 mL\n IVF:\n 1,067 mL\n 426 mL\n Blood products:\n Total out:\n 1,935 mL\n 480 mL\n Urine:\n 1,935 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///37/\n Physical Examination\n General Appearance: Thin, NAD\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: unchanged 3/6 systolic murmur, irregularly irregular\n Respiratory / Chest:: poor air movement, + crackles bilateral way\n up\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: anasarca\n Labs / Radiology\n 380 K/uL\n 8.7 g/dL\n 97 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 5.0 mEq/L\n 14 mg/dL\n 91 mEq/L\n 131 mEq/L\n 25.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n Plt\n 367\n 324\n 338\n 371\n 380\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n Other labs: PT / PTT / INR:19.3/30.4/1.8, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR (PM)\n No significant change compared to the prior study, still combination of\n pulmonary edema and multiple parenchymal opacities that might be\n consistent with aspiration. Slight improvement of the right upper lung\n opacity due to resolution of aspiration.\n CXR (AM)\n Right PICC ends in upper SVC. Severe cardiomegaly. Interstitial edema\n is\n unchanged. Bilateral multifocal alveolar opacity increased in right\n upper\n lobe and both bases could be aspiration.\n Microbiology: BCx: PND\n sputum not obtained\n Stoool CDiff negative\n CDiff negative\n UCx: negative\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event and\n increasing O2 requirement.\n # Hypoxemia\n likely due to aspiration event, PNA vs pneumonitis.\n Concern for development of ARDS. Could also be due to pulm edema.\n - continue vanco/zosyn for HAP\n - follow up blood cx, try to get sputum if possible\n - supplemental O2 as needed\n - continue diuresis to minimize pulm edema\n # HYPOTENSION: unlikely sepsis as does not meet SIRS criteria (HR 80's,\n RR teens, WBC 5.8, afebrile); did have UTI but has been treated for\n days now & little evidence of systemic infection. Hct stable & over\n prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Apprears volume overloaded on exam.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- continue lasix gtt\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL)\n -- midodrine 10mg TID\n -- f/u cultures - no new data\n -- consider additional afterload reduction with ACE-I?\n # s/p UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted; floor team changed to bactrim. Repeat UCx from\n negative.\n -- now s/p Bactrim 7 day course\n # Nausea/Vomiting: unclear etiology, no residuals from tube feeds.\n - back on TFs with no residuals\n - antiemetics prn\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP. No new recs from neurology\n -- on. Paxil for possible depression as cause for decreased PO intake &\n FTT; decreased dose to 10mg as may be contributing to her lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; INR still subtherapeutic, increased to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n appear hypervolemic on exam, and with pulmonary edema,\n merits diuresis\n n lasix gtt with goal negative 1 liter today\n # FEN: on tube feeds via PEG; w/o complication. Hyponatremic -\n hold lasix gtt\n -- cont TF; nutrition following\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:27 AM 20 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655494,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - O2 requirement weaned down\n - remains on vanco/zosyn for presumptive HAP\n - remains on levophed\n - diuresed to goal on lasix gtt\n - had mild hematuria\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:41 AM\n Piperacillin - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.4\n HR: 81 (79 - 180) bpm\n BP: 89/53(61) {67/37(48) - 129/112(116)} mmHg\n RR: 10 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,493 mL\n 614 mL\n PO:\n TF:\n 656 mL\n 300 mL\n IVF:\n 1,227 mL\n 314 mL\n Blood products:\n Total out:\n 3,665 mL\n 850 mL\n Urine:\n 3,665 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,172 mL\n -236 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///38/\n Physical Examination\n General Appearance: Thin, NAD\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: unchanged 3/6 systolic murmur, irregularly irregular\n Respiratory / Chest:: poor air movement, + crackles bilateral way\n up\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: anasarca\n Labs / Radiology\n 391 K/uL\n 8.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.5 %\n 8.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n Other labs: PT / PTT / INR:19.9/31.0/1.9, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: none new\n Microbiology: BCx: NGTD\n C Diff: negative\n UCx: negative\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event and\n increasing O2 requirement.\n # Hypoxemia\n likely due to aspiration event, PNA vs pneumonitis.\n Concern for development of ARDS. Could also be due to pulm edema.\n - continue vanco/zosyn for HAP\n - follow up blood cx, try to get sputum if possible\n - supplemental O2 as needed\n - continue diuresis to minimize pulm edema\n # HYPOTENSION: unlikely sepsis as does not meet SIRS criteria (HR 80's,\n RR teens, WBC 5.8, afebrile); did have UTI but has been treated for\n days now & little evidence of systemic infection. Hct stable & over\n prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Apprears volume overloaded on exam.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- continue lasix gtt\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL)\n -- midodrine 10mg TID\n -- f/u cultures - no new data\n -- consider additional afterload reduction with ACE-I?\n # s/p UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted; floor team changed to bactrim. Repeat UCx from\n negative.\n -- now s/p Bactrim 7 day course\n # Nausea/Vomiting: unclear etiology, no residuals from tube feeds.\n - back on TFs with no residuals\n - antiemetics prn\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP. No new recs from neurology\n -- on. Paxil for possible depression as cause for decreased PO intake &\n FTT; decreased dose to 10mg as may be contributing to her lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; INR still subtherapeutic, increased to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n appear hypervolemic on exam, and with pulmonary edema,\n merits diuresis\n n lasix gtt with goal negative 1 liter today\n # FEN: on tube feeds via PEG; w/o complication. Hyponatremic -\n hold lasix gtt\n -- cont TF; nutrition following\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 04:21 AM 40 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655497,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - O2 requirement weaned down\n - remains on vanco/zosyn for presumptive HAP\n - remains on levophed\n - diuresed to goal on lasix gtt\n - had mild hematuria\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:41 AM\n Piperacillin - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.4\n HR: 81 (79 - 180) bpm\n BP: 89/53(61) {67/37(48) - 129/112(116)} mmHg\n RR: 10 (10 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,493 mL\n 614 mL\n PO:\n TF:\n 656 mL\n 300 mL\n IVF:\n 1,227 mL\n 314 mL\n Blood products:\n Total out:\n 3,665 mL\n 850 mL\n Urine:\n 3,665 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,172 mL\n -236 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///38/\n Physical Examination\n General Appearance: Thin, NAD\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: unchanged 3/6 systolic murmur, irregularly irregular\n Respiratory / Chest:: poor air movement, + crackles bilateral way\n up\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: anasarca\n Labs / Radiology\n 391 K/uL\n 8.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.5 %\n 8.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n Other labs: PT / PTT / INR:19.9/31.0/1.9, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: none new\n Microbiology: BCx: NGTD\n C Diff: negative\n UCx: negative\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event and\n increasing O2 requirement.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n - continue vanco/zosyn for HAP x 7 day course\n - follow up blood cx, sputum unlikely to yield positive data at this\n point\n - wean supplemental O2\n - continue diuresis to minimize pulm edema\n - TFs resumed, unclear why she had the episodes of N/V\n # Hypotension: unlikely septic shock as does not even meet SIRS\n criteria (HR 80's, RR teens, WBC 5.8, afebrile). She did have a UTI but\n has been treated for days now, with a negative surveillance urine\n culture from . No evidence of gross blood loss to suggest\n hypovolemic/hemorrhagic shock. Actually appears volume overloaded on\n exam. Unclear how much autonomic instability is contributing to\n (chronic) hypotension. With severe MR on recent echo, poor forward flow\n is a likely contributor to hypoTN. Of note, her baseline BP runs\n 90-100's; 80's when sleeping.\n -- midodrine 10mg TID\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL)\n -- continue lasix gtt for hypervolemia and afterload reduction, goal -1\n -2 L today\n -- would add additional afterload reduction with low dose captopril\n today, may have paradoxical improvement in BP\n # s/p E. coli UTI - grew from UCx ; earlier cultures were\n negative. Floor team started cipro on with intention to treat\n for seven days. Rash was noted; floor team changed to bactrim. Repeat\n UCx from negative.\n -- now s/p Bactrim 7 day course\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- continue paxil for possible depression as cause for decreased PO\n intake & FTT; decreased dose to 10mg as may be contributing to her\n lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; trending towards therapeutic INR now that dose\n has been increased to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n improving with diuresis\n -- lasix gtt with goal negative liter today\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 04:21 AM 40 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655691,
"text": "Chief Complaint:\n FTT\n AMS\n Aspiration\n Hypotension\n 24 Hour Events:\n -- diuresed 1.5 L yesterday\n -- ~4:30 am developed NBNB emesis; HR went up to the 190's; gave\n compazine & metoprolol 5 mg IV x 1 with improvement in HR to the 110's\n -- held TF after emesis (there was no residual on the feeds prior to\n emesis)\n -- didn't make much progress on weaning levophed (remains at 0.15)\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 PM\n Piperacillin - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 89 (44 - 172) bpm\n BP: 96/56(64) {77/41(48) - 108/73(80)} mmHg\n RR: 12 (11 - 28) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 3,161 mL\n 737 mL\n PO:\n TF:\n 1,456 mL\n 419 mL\n IVF:\n 1,495 mL\n 318 mL\n Blood products:\n Total out:\n 4,740 mL\n 1,570 mL\n Urine:\n 4,740 mL\n 1,570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,579 mL\n -832 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 88%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 476 K/uL\n 8.0 g/dL\n 80 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 93 mEq/L\n 135 mEq/L\n 23.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n 476\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n Other labs: PT / PTT / INR:20.8/33.0/2.0, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.9 g/dL, Ca++:7.6 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR :\n The patient continues to be in pulmonary edema in addition to bilateral\n opacities that might be consistent with aspiration. No focal air\n trapping is\n currently seen in the right lower lung with just some spared lung\n adjacent to\n the heart border. The right PICC line tip is in superior SVC. The\n cardiomegaly is unchanged.\n Microbiology: Blood 1/16: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event and\n increasing O2 requirement.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n - continue vanco/zosyn for HAP x 10 day course: ( - )\n - follow up blood cx, sputum was not produced by patient\n - wean supplemental O2\n - continue diuresis to minimize pulm edema\n - TFs\n on hold due to emesis, restart at low rate\n # Hypotension: unlikely septic shock as does not even meet SIRS\n criteria (HR 80's, RR teens, WBC 5.8, afebrile). She did have a UTI but\n has been treated for days now, with a negative surveillance urine\n culture from . No evidence of gross blood loss to suggest\n hypovolemic/hemorrhagic shock. Actually appears volume overloaded on\n exam. Unclear how much autonomic instability is contributing to\n (chronic) hypotension. With severe MR on recent echo, poor forward flow\n is a likely contributor to hypoTN. Of note, her baseline BP runs\n 90-100's; 80's when sleeping.\n -- midodrine 10mg TID\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL)\n -- continue lasix gtt for hypervolemia and afterload reduction, goal -1\n -2 L today\n -- consider afterload reduction with low dose captopril, may have\n paradoxical improvement in BP\n # s/p E. coli UTI - grew from UCx ; earlier cultures were\n negative. Floor team started cipro on with intention to treat\n for seven days. Rash was noted; floor team changed to bactrim. Repeat\n UCx from negative.\n -- now s/p Bactrim 7 day course\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- continue paxil for possible depression as cause for decreased PO\n intake & FTT; decreased dose to 10mg as may be contributing to her\n lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n improving with diuresis\n -- lasix gtt with goal negative liter today\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655152,
"text": "Chief Complaint: hypotension\n 24 Hour Events:\n -- around 8:45 pm, had an episode of bilious emesis; gave\n compazine/reglan PRN --> ended up having multiple episodes of bilious,\n non-bloody emesis overnight\n -- also lots of stool output; sent for C diff thought stools well\n formed\n -- was off lasix in late afternoon; tried to d/c levophed, but MAPs\n dropped to 30's when off. Started back on low rate of levophed.\n Didn't start back on lasix given emesis and stool output.\n -- had slight increase in O2 requirement from 2L to 4L after emesis; ?\n aspiration; improved throughout the night back to baseline\n -- hyponatremic with am labs on ; reduced free water flushes from\n 50 ml to 30 ml Q6 hours.\n Patient unable to provide history: Encephalopathy\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.5\nC (95.9\n HR: 82 (82 - 150) bpm\n BP: 84/49(58) {71/25(38) - 117/64(70)} mmHg\n RR: 16 (7 - 21) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,378 mL\n 250 mL\n PO:\n TF:\n 1,341 mL\n IVF:\n 547 mL\n 190 mL\n Blood products:\n Total out:\n 3,570 mL\n 310 mL\n Urine:\n 2,970 mL\n 310 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -1,192 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///38/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : , Crackles : bilateral, way\n up)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 371 K/uL\n 9.0 g/dL\n 169 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.6 mEq/L\n 13 mg/dL\n 91 mEq/L\n 130 mEq/L\n 27.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n Plt\n 367\n 324\n 338\n 371\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n Other labs: PT / PTT / INR:18.6/31.5/1.7, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:7.0 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.3 mg/dL\n Microbiology: Stool Neg for Cdiff and \n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n # Nausea/Vomiting: unclear etiology, no residuals from tube feeds.\n - held lasix gtt over night\n - anti-emetics prn\n - hold tube feeds but attempt to re-start later today\n # HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR 80's,\n RR teens, WBC 5.8, afebrile); does have UTI but has been treated for\n days now & little evidence of systemic infection. Hct stable today &\n over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Apprears volume overloaded on exam.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- lasix gtt (held now due to N/V and hyponatremia)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4)\n -- midodrine 10mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u cultures - no new data\n # UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- cont Bactrim through per floor team plans\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP. No new recs from neurology\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin; INRsubtherapeutic, increase to 1 mg daily\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # FEN: on tube feeds via PEG; w/o complication. Hyponatremic -\n hold lasix gtt\n -- cont TF; nutrition following\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n # PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n # CONSENT: signed on admission on \n # CODE: FULL\n # DISPO: transfer to floor if stabilizes & off pressors\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655515,
"text": "Chief Complaint:\n HPI:\n 52yo with Downs and Alzheimer's disease admitted with\n hypotension due to dehydration / FTT. Re-admitted on for\n hypotension thought medications. Course c/b aspiration event, with\n hypotension requiring vasopressors. Also volume overloaded; pt with 4+\n MR with intermittent RVR.\n 24 Hour Events:\n - FiO2 weaned to 40%\n - Pt diuresed ~1L yesterday.\n - Suctioning q4hr for small amt\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 09:07 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:16 AM\n Other medications:\n Amiodarone 200mg daily\n Synthroid 88mcg\n Atrovent Neb\n Valproic acid 400mg po q8hr\n Midordrine 10mg tid\n Lasix gtt (now off)\n Paroxetine 10mg daily\n Warfarin 1mg\n MVI\n folate\n Lansoprazole\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.5\nC (95.9\n HR: 86 (79 - 180) bpm\n BP: 77/41(48) {67/37(48) - 129/112(116)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 2,493 mL\n 1,000 mL\n PO:\n TF:\n 656 mL\n 413 mL\n IVF:\n 1,227 mL\n 587 mL\n Blood products:\n Total out:\n 3,665 mL\n 1,150 mL\n Urine:\n 3,665 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,172 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n FiO2: 40% shovel mask\n SpO2: 92%\n ABG: ///38/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), \n systolic murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases bilat)\n Abdominal: Soft, Non-tender\n Extremities: Right: 3+, Left: 3+\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 391 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.5 %\n 8.1 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n Other labs: PT / PTT / INR:19.9/31.0/1.9, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: No new CXR\n Microbiology: Blood 1/16= NGTD\n No sputum\n Assessment and Plan\n 52yo with hypotension aspiration pneumonia and volume overload.\n 1. Pulm-\n a) Diuresing goal TBB -1 L\n b) continue Vanc /Zosyn for 8 days course; no culture data to guide\n therapy unfortunately\n 2. CV\n a) Hypotension\n - unclear source --> sepsis vs. volume overloaded (MR). r/o for\n adrenal sepsis. Unlikely PE given supratherapeutic INR.\n - Continues on low dose levophed and midodrine\n - Consider stopping pressors and following clinical parameters\n for hypotension (cap refill, urine output, lactates)\n b) -\n - On amiodarone for rate control\n - Warfarin for anticoag\n 3. GI- continue tube feeds via G-tube\n 4. Renal-\n a) duirese TBB -1l\n b) Hyponatremia improving with diuresis\n 5. Endo-\n a) Hypothyroid, on syntroid\n b) On ISS\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 04:21 AM 55 mL/hour\n Comments: Senna/Colace\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :\n Total time spent: 30 min minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655693,
"text": "Chief Complaint:\n HPI:\n 52yo with Downs syndrome and Alzheimer's dementia, admit with FTT;\n re-admitted to ICU for hypotension. course c/b aspiration event;\n currently on Vanc and zosyn. also volume overloaded; has 4+ MR \nlic dysfunction.\n 24 Hour Events:\n - Diuresed 1.5L yesterday\n - Emesis this am; no prior residuals\n - Remains on Levophed 0.15mcg/kg/min ; MAPs~60\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 08:15 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Amiodarone 200\n Synthroid 88\n Atrovent\n VPA 400mg q8h\n Lansoprazole\n Paroxetine 10mg\n Lasix gtt (now on hold)\n Midodrine 10 tid\n Senna/Colace\n Warfarin 1.5mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 89 (44 - 172) bpm\n BP: 92/59(68) {88/50(56) - 108/73(80)} mmHg\n RR: 16 (11 - 28) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 3,161 mL\n 1,110 mL\n PO:\n TF:\n 1,456 mL\n 419 mL\n IVF:\n 1,495 mL\n 611 mL\n Blood products:\n Total out:\n 4,740 mL\n 2,180 mL\n Urine:\n 4,740 mL\n 2,150 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,579 mL\n -1,070 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n FiO2: Shovel mask at 50%\n SpO2: 97%\n ABG: ///37/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n anteriorly, diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 476 K/uL\n 80 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 93 mEq/L\n 135 mEq/L\n 23.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n 476\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n Other labs: PT / PTT / INR:20.8/33.0/2.0, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Imaging: No new imaging\n Microbiology: No new microbiology data\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload. Pt MAPs slightly improving with diuresis.\n CV\n - Hypotension, likely moreso cardiac in etiology, as opposed to\n septic physiology.\n + TBB goal -1 to-2 L today\n + Unsure if cuff pressures accurate. Will turn off vasopressors\n and follow clinical parameters and lactate. If concern of hypotension\n will insert A-line with goal of being able to titrate of pressors.\n - Afib on amiodarone and warfarin\n ID\n - Increase Vancomycin to 1g q12h\n - Continue Abx (Vanc / Zosyn) for 10 days (unclear culture given\n difficulty obtaining sputum)\n Pulm\n - Hypoxemic likely edema and pna; wean FiO2 to keep SpO2>92%\n GI\n - With nausea/vomiting --> no residuals. No evidnece biliary process.\n - ? due to volume overload and right heart failure\n - Will restart tube feeds\n - Check KUB if this recurs\n Renal\n - Continue diuresis\n - Recheck pm lytes\n - Hypernatremia- improved. FWF at 30cc q6hr\n ICU\n - DNR/DNI\n - Requires ICU care\n - Prophy- PPI, warfarin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 35 min, patient remains critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 654493,
"text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Insp Wheeze\n Comments:\n Plan\n Next 24-48 hours: Continue with ordered neb\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654490,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-12-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 654625,
"text": "Subjective\n pt calm\n Objective\n Pertinent medications: Norepi gtt, NS @ 10ml/hr, Lasix, Lansoprazole\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 03:56 AM\n Glucose Finger Stick\n 137\n 12:00 PM\n BUN\n 8 mg/dL\n 03:56 AM\n Creatinine\n 0.6 mg/dL\n 03:56 AM\n Sodium\n 137 mEq/L\n 03:56 AM\n Potassium\n 4.3 mEq/L\n 03:56 AM\n Chloride\n 104 mEq/L\n 03:56 AM\n TCO2\n 30 mEq/L\n 03:56 AM\n Albumin\n 1.7 g/dL\n 03:56 AM\n Calcium non-ionized\n 6.8 mg/dL\n 03:56 AM\n Phosphorus\n 2.5 mg/dL\n 03:56 AM\n Magnesium\n 2.3 mg/dL\n 03:56 AM\n WBC\n 9.8 K/uL\n 03:56 AM\n Hgb\n 8.7 g/dL\n 03:56 AM\n Hematocrit\n 26.3 %\n 03:56 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Fibersource @ 55ml/hr (goal)\n GI: soft/distended, hypoactive bs; (+) sm bm \n Assessment of Nutritional Status\n Specifics:\n Pt s/p PEG placement prolonged poor po\ns. Transferred to MICU\n d/t HoTN. Pt w/ high residuals while TF running at goal over the\n weekend (300ml, 185-215ml) thus TF held. TF resumed at 15ml/hr.\n Currently, TF running at 25ml/hr, pt tolerating w/ minimal residuals\n (10ml) per d/w RN. Noted C-diff (-) x1 (). s/p brain MRI\n report\n pending. Noted low phos.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations:\n 1. continue to advance TF as tolerated to goal of 55ml/hr (1584\n calories and 70g protein)\n 2. Monitor residuals, hold TF if >/= 200ml\n Check chemistry 10 panel daily\n Rec replete phos\n Will continue to follow\n page if ?s *\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654687,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 654688,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Hypotension (not Shock)\n Assessment:\n AF with PVC and occ SR on tele. HR 80-110. SBP range 83-105 with MAP\n 55-68. Rec\nd on Levophed gtt this AM at 0.24 mcg/kg/min. NS fluid bolus\n running on receipt of pt. LS clear throughout, occasional crackles. CXR\n this AM showed fluid overload per MDs. Noted desaturation on monitor\n around 1800.\n Action:\n Team aware of pt\ns hypotension. Levophed gtt weaned down and diuresis\n initiated. Received lasix 20 mg IV x 1 this afternoon. Pt turned and\n repositioned after desat noted and new oxisensor placed, O2 increased\n to 3L via NC. Coumadin restarted this afternoon at 0.5 mg for\n anticoagulation.\n Response:\n Negative 1.6L since lasix dose. Has maintained SBP 80-100 with MAP\n 50s-60s which is acceptable per Dr. . O2 sat currently \n > 98%. Continues with UO > 100 cc/hr.\n Plan:\n Wean pressors as pt tolerates. Monitor cardiopulmonary status. Provide\n emotional support. Monitor lytes/labs per order.\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653706,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n pt. ready for transfer out of ICU as pt. has stabilized. Pt. to\n go for PEG placement today in OR and then should go to the floor when\n bed available. Currently, pt. on amiodorone gtt at 0.5mg/min to change\n to PO Amiodorone 400mg TID post PEG placement. Also, pt. to start\n Coumadin and Paxil when she has PEG. Nutrition consult ordered as well\n as PT to facilitate discharge to NH. Of note, pt. has had\n intermittment hypotension when she is asleep. BP rises upon\n stimulation. Also of note, pt.\ns cardiologist, Dr. would like to\n cardiovert pt. in weeks after therapeutic INR achieved.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. currently in NSR with frequent PVCs. Pt. with history of Afib.\n Action:\n Pt. currently requiring IV amiodorone gtt at 0.5mg/min.\n Response:\n Pt. in NSR w/ frequent PVCs.\n Plan:\n PEG placement this afternoon and should start 400mg TID in AM.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt. continue to call out frequently when awake and does not respond to\n emotional support.\n Action:\n Pt. environment secure and safe.\n Response:\n Pt. continues to call out and cry for brother .\n :\n To start antidepressant and is currently on Depakote IV to be changed\n to PO with PEG.\n Coagulopathy\n Assessment:\n Pt. with normalized INR now that pt. is hydrated and renal failure has\n resolved.\n Action:\n To restart coumadin when PEG placed with plan of mechanical\n cardioversion when INR appropriately therapeutic.\n Response:\n Plan:\n Decubitus ulcer (Not Present At Admission)\n Assessment:\n Pt. with intact Allevyn dsg on right side near hip and coccyx\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n ACUTE RENAL\n Code status:\n Full code\n Height:\n Admission weight:\n 49.4 kg\n Daily weight:\n Allergies/Reactions:\n Oxycodone\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: Downs syndrome, mitral regurgitation, h/o\n bacterial endocarditis in , h/o afib electrical cardioversion in\n past, hypothyroidism, bunions/foot pain, h/o right breast cancer,\n seizure disorder\n Surgery / Procedure and date: s/p right mastectomy for breast cancer,\n s/p laparoscopic appendectomy , s/p laparoscopuic umbilical hernia\n repair, s/p gangrenous cholecystitis, lap chole \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:89\n D:45\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 198 mL\n 24h total out:\n 430 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:06 AM\n Potassium:\n 3.9 mEq/L\n 02:06 AM\n Chloride:\n 108 mEq/L\n 02:06 AM\n CO2:\n 27 mEq/L\n 02:06 AM\n BUN:\n 2 mg/dL\n 02:06 AM\n Creatinine:\n 0.7 mg/dL\n 02:06 AM\n Glucose:\n 61 mg/dL\n 02:06 AM\n Hematocrit:\n 28.5 %\n 02:06 AM\n Finger Stick Glucose:\n 99\n 06:00 AM\n Valuables / Signature\n Patient valuables: IN BAG WITH PATIENT\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: 210\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655397,
"text": "Chief Complaint:\n -\n HPI:\n 52yo with Downs Syndrome, Alzheimer's Dementia and 4+ MR \nmal Afib with RVR returned to ICU after hypotensive episode,\n thought secondary to medications. Now complicated by aspiration event,\n with hypoxemia. Requiring vasopressors to maintain MAPs.\n 24 Hour Events:\n - No major o/n events\n - FiO2 weaned to 50% shovel mask\n - continues on Norepinephrine (0.15 mcg/kg/min) to maintain MAPs>50\n - episode of Afib RVR responded to metop.\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 10:05 PM\n Vancomycin - 07:41 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Metoprolol - 10:16 AM\n Other medications:\n Folate\n MVI\n Warfarin 1mg\n Midodrine 10mg po tid\n PPI\n Valproic acid 400mg q8hr\n Syntrhoid\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:04 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 83 (81 - 180) bpm\n BP: 85/37(48) {85/37(48) - 129/112(116)} mmHg\n RR: 17 (8 - 19) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 1,517 mL\n 1,303 mL\n PO:\n TF:\n 129 mL\n 253 mL\n IVF:\n 1,067 mL\n 690 mL\n Blood products:\n Total out:\n 1,935 mL\n 700 mL\n Urine:\n 1,935 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 603 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask , Aerosol-cool\n FiO2: 50% shovel mask\n SpO2: 100%\n ABG: ///37/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic at\n apex)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n on sides at bases.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Muscle wasting\n Skin: warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 380 K/uL\n 97 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 5.0 mEq/L\n 14 mg/dL\n 91 mEq/L\n 131 mEq/L\n 25.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n Plt\n 367\n 324\n 338\n 371\n 380\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n Other labs: PT / PTT / INR:19.3/30.4/1.8, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR = pulm edema. RLL and LLL opacities. LVH and LAE.\n Microbiology: Blood Cx = neg\n Assessment and Plan\n 52yo with Down's and Alzheimer's now hypotensive, with aspiration\n pneumonia.\n 1. Hypotensive, unclear whether related to sepsis physiology vs\n cardiogenic shock (given Hx 4+ MR and volume repletion)..\n a) volue overloaded --> will diurese TBB -1L\n b) Consider afterload reduction if not responding to lasix\n c) Wean pressors for MAPs >50\n d) continue Abx (Vanc and Zosyn); attempt sputum cultures\n e) On Midodrine 10mg tid\n f) Afib- On amiodarone and warfarin . Supp with beta blokcers for\n RVR\n 2. Pulm-\n a) Wean FiO2\n 3. GI- continues on tube feeds\n 4. Renal -\n a) Diuresis\n b) pm lytes\n 5. ID- continues on Vanc and Zosyn (started ); will need 8 day\n course.\n 6. Heme- no issues; on warfarin (INR=1.7), will increase warafrin.\n 7. Endo- will follow dexis\n 8. ICU- DNR/DNI\n Access- PICC\n PPI, warfarin\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:27 AM 20 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: on warfarin\n Stress ulcer: will start PPI\n VAP: head of bed at 45 degrees.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 35 minutes, patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655469,
"text": "Pneumonia, aspiration/ failer\n Assessment:\n lung course bilaterally in bases sats 98%,\n Action:\n Fio2 cont on 50% cool areasol with sats of 97%.\n Response:\n Pt looks very comfortable w/ mask sating >94% bet sometimes unable to\n get good plegth.\n Plan:\n Maintain aspiration precautions, wean fio2 as tolerated, and continue\n with iv antibiotics.\n Hypotension (not Shock)\n Assessment:\n Pt remains on a norepi drip at .15 mcg/kg/min\n Action:\n Not attempted to wean epi because SBP was 69-95 w/ map of 55-60.\n Response:\n Pending.\n Plan:\n Wean epi if BP remains stable.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt well call out when turn or when care is given, will say no but\n that\ns about all the verbal conversation I get with patient\n Action:\n Attempt to reorient\n Response:\n No effective\n Plan:\n Continue to provide safe environment, orient to place and time\n"
},
{
"category": "Case Management ",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Discharge Planning Note",
"row_id": 653688,
"text": "TITLE: Discharge Planning\n Conference Call \n spoke with staff from the patient\ns group home and from Resources\n for Human Development (RHD ,) the agency that manages the group\n home via conference call at . On the call were the\n following people: , Director of RHD , ,\n Program Coordinator and , Manager of the group home.\n reports that she and her staff have a meeting scheduled today\n with the Department of Mental Retardation (DMR) and the patient\n co-guardians\n her brother and his wife. The meeting was\n scheduled prior to the patient being admitted to the hospital. At that\n meeting, expects to talk about the patient\ns recent functional\n decline, her current hospitalization and what the patient may need in\n the way of additional services/rehab prior to returning to the group\n home setting. indicated that she would also ask that someone\n from DMR contact this to set up a case conference here at to\n discuss more fully what the patient\ns post-acute needs will be. DMR\n will then be able to assist in facilitating discharge planning.\n - Awaiting f/u call from RHD/DMR regarding results of meeting.\n VM left this morning requesting update. It is not yet clear whether\n patient will be able to return to the group home with the G-tube.\n Anticipate arranging case conference in the next few days.\n Please call with any questions/concerns at 2-7925/.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653698,
"text": "Chief Complaint: Admitted with hypotension, FTT\n 24 Hour Events:\n OR SENT - At 03:00 PM\n to OR for PEG placement, returned for PEG placement in ICU at bedside\n d/t incorrect equipment being sterilized and correct equip not\n available.\n PEG INSERTION - At 06:01 PM\n PEG done by general surgery and this RN at bedside, pt. given moderate\n sedation (1mg of Versed and 50mcg of Fentanyl) during the case. Pt.\n tolerated well.\n - sedated with fentanyl/versed for procedure\n - lethargic 1-2 hours afterwards - BP 80s/30s\n - BPs came up to baseline 90s/40s\n - was in pain, gave morphine IV - BP held\n - changed meds to PO\n - started on warfarin/paxil\n - called out but no bed available yet\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 03:55 PM\n Midazolam (Versed) - 06:05 PM\n Furosemide (Lasix) - 08:34 PM\n Fentanyl - 08:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 96 (85 - 107) bpm\n BP: 84/48(57) {69/30(44) - 125/66(127)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,499 mL\n 72 mL\n PO:\n TF:\n IVF:\n 1,499 mL\n 72 mL\n Blood products:\n Total out:\n 2,590 mL\n 320 mL\n Urine:\n 2,590 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,091 mL\n -248 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), V/VI\n SEM with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Absent : )\n Abdominal: Soft, Bowel sounds present, No(t) Tender:\n Extremities: Right: 2+, Left: 2+, + UEE b/l\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 186 K/uL\n 10.3 g/dL\n 61 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.5 %\n 12.1 K/uL\n [image002.jpg]\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n 02:06 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n 12.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n 28.5\n Plt\n 48\n 157\n 163\n 186\n Cr\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n 143\n 90\n 61\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.6\n mg/dL\n Imaging: No new imaging overnight\n Microbiology: UCx (pre-op): NGTD\n Assessment and Plan\nPatient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving post-IVF, though remains intermittently hypotensive during\n sleep. Had PEG placed w/o complication.\n #) FTT: Had PEG placed w/o complication. Tube feeds started on\n per nutrition recs; at high risk for refeeding syndrome.\n -- monitor lytes closely; check chemistry-10 at 4 pm\n -- neurologist recommended trial of antidepressant as may have\n depression (in addition to dementia) been have been contributing to\n refusal to eat. Started on Paxil on .\n -- morphine PRN for pain control related to PEG (BP tolerated small\n doses morphine overnight)\n #) Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Earlier in week remained in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest. Was loaded with amio IV with conversion to\n SR and HR < 100. Changed to amio PO after placement of PEG on .\n Had an episode of RPR to 130-150\ns w/o change in BP this morning (prior\n to am PO amio dose); tolerated metoprolol 5 mg IV w/o dropping BP with\n improvement of HR.\n -- cont amio 400 mg TID PO\n -- coumadin 1 mg PO QHS started on ; not bridging with heparin.\n -- Dr. plans to electrically cardiovert in weeks once\n anticoagulated\n #) Hypotension: resolved; on home lasix; very edematous; SBP\ns now\n stably 100-110\ns; gentle diuresis started overnight.\n -- restarting home dose lasix 40 mg QD with careful monitoring of BP\n #) ? Seizure disorder, Meds for Mood Stabilization: clarified with\n neurologist that depakote is for mood stabilization. She is not also\n on trileptal.\n -- cont home dose depakote\n #) Hypothyroidism:\n -- cont home dose synthroid 75 mcg QD\n #) GERD:\n -- cont lansoprazole\n #) FEN: see above\n #) Code: Full per discussion with patient's HCP\n #) Communication: Brother: is HCP ; work\n (? home)\n ICU Care\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed\n Code status: Full code\n Disposition:Transfer to floor ; awiating placement at ; PT consult\n pending\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653702,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653703,
"text": "Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving post-IVF, though remains intermittently hypotensive during\n sleep. Had PEG placed w/o complication.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653704,
"text": "Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving post-IVF, though remains intermittently hypotensive during\n sleep. Had PEG placed w/o complication.\n Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Earlier in week remained in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest. Was loaded with amio IV with conversion to\n SR and HR < 100. Changed to amio PO after placement of PEG on .\n Had an episode of RPR to 130-150\ns w/o change in BP this morning (prior\n to am PO amio dose); tolerated metoprolol 5 mg IV w/o dropping BP with\n improvement of HR.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653705,
"text": "Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving post-IVF, though remains intermittently hypotensive during\n sleep. Had PEG placed w/o complication.\n Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Earlier in week remained in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest. Was loaded with amio IV with conversion to\n SR and HR < 100. Changed to amio PO after placement of PEG on .\n Had an episode of RPR to 130-150\ns w/o change in BP this morning (prior\n to am PO amio dose); tolerated metoprolol 5 mg IV w/o dropping BP with\n improvement of HR.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section------\n Note already written.\n ------ Protected Section Error Entered By: , RN\n on: 10:42 ------\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653408,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake.\n Hypotension (not Shock)\n Assessment:\n BP remains labile SBP 75-110 MAPS >55, Manual BP checked during\n hypotensive episode findings >NBP. Pt LOC unchanged cont to cry out,\n not able to follow commands yet tracks surroundings and calls out for\n Brother\n\n. Remains Fluid overloaded>27Liters LOS. Pressors\n off>24hrs. afebrile T-max 96.6.\n Action:\n Ascultated BP change from NBP cuff. Received Lasix 20mg w/+diuresis.\n Response:\n Gentle diuresis w/lasix and responding hypotension. Goal MAPS>58\n Plan:\n Goal BP>90 MAPS>58\n Monitor manual cuff BP for correlation.\n Diures goal neg 1liter\n Atrial fibrillation (Afib)\n Assessment:\n HR 80s-90s in AF/NSR. With freq PVC occas . Cont on amioderone gtt,\n Hypokalemia, hypomagnesium, hypocalcemia\n Action:\n Cont Amiodarone Electrolyte repletion K+ Mag, Ca+., Head CT\n Response:\n Less ventriucular ectopyw/ electrolyte repletion.\n Plan:\n Cont IV amioderone\n F/U labs\n Repletion electrolytes.\n f/u results of head CT\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. ^u/o s/p lasix , Anascara + FB >27 liters for LOS\n Action:\n Lasix @ 12n transient hypotension. Electrolyte repletion.\n Response:\n + response to lasix, BP labile.\n Plan:\n Goal FB (\n)1liter\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS 61-150, hypoglycemia 61\n Action:\n Received\n amp D50 for BS 61\n Response:\n FSBS labile\n Plan:\n Q2-4hrs FSBS\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655658,
"text": "Chief Complaint:\n HPI:\n 52yo with Downs syndrome and Alzheimer's dementia, admit with FTT;\n re-admitted to ICU for hypotension. course c/b aspiration event;\n currently on Vanc and zosyn. also volume overloaded; has 4+ MR \nlic dysfunction.\n 24 Hour Events:\n - Diuresed 1.5L yesterday\n - Emesis this am; no prior residuals\n - Remains on Levophed 0.15mcg/kg/min ; MAPs~60\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 08:15 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Amiodarone 200\n Synthroid 88\n Atrovent\n VPA 400mg q8h\n Lansoprazole\n Paroxetine 10mg\n Lasix gtt (now on hold)\n Midodrine 10 tid\n Senna/Colace\n Warfarin 1.5mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 89 (44 - 172) bpm\n BP: 92/59(68) {88/50(56) - 108/73(80)} mmHg\n RR: 16 (11 - 28) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 3,161 mL\n 1,110 mL\n PO:\n TF:\n 1,456 mL\n 419 mL\n IVF:\n 1,495 mL\n 611 mL\n Blood products:\n Total out:\n 4,740 mL\n 2,180 mL\n Urine:\n 4,740 mL\n 2,150 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,579 mL\n -1,070 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n FiO2: Shovel mask at 50%\n SpO2: 97%\n ABG: ///37/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n anteriorly, diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 476 K/uL\n 80 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 93 mEq/L\n 135 mEq/L\n 23.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n 476\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n Other labs: PT / PTT / INR:20.8/33.0/2.0, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:, Alk Phos / T Bili:81/0.4, Amylase\n / Lipase:26/35, Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %,\n Mono:9.0 %, Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.9 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Imaging: No new imaging\n Microbiology: No new microbiology data\n Assessment and Plan\n 52yo hypotension in setting of aspiration pneumonia and volume\n overload. Pt MAPs slightly improving with diuresis.\n CV\n - Hypotension, likely moreso cardiac in etiology, as opposed to\n septic physiology.\n + TBB goal -1 to-2 L today\n + Unsure if cuff pressures accurate. Will turn off vasopressors\n and follow clinical parameters and lactate. If concern of hypotension\n will insert A-line with goal of being able to titrate of pressors.\n - Afib on amiodarone and warfarin\n ID\n - Increase Vancomycin to 1g q12h\n - Continue Abx (Vanc / Zosyn) for 10 days (unclear culture given\n difficulty obtaining sputum)\n Pulm\n - Hypoxemic likely edema and pna; wean FiO2 to keep SpO2>92%\n GI\n - With nausea/vomiting --> no residuals. No evidnece biliary process.\n - ? due to volume overload and right heart failure\n - Will restart tube feeds\n - Check KUB if this recurs\n Renal\n - Continue diuresis\n - Recheck pm lytes\n - Hypernatremia- improved. FWF at 30cc q6hr\n ICU\n - DNR/DNI\n - Requires ICU care\n - Prophy- PPI, warfarin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nutrition",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 655665,
"text": "Subjective\n calm\n Objective\n Pertinent medications: Norepi gtt, Abx, Lansoprazole, Colace, Senna,\n MVI, Folic Acid, Reglan\n Labs:\n Value\n Date\n Glucose\n 80 mg/dL\n 04:09 AM\n Glucose Finger Stick\n 129\n 06:00 PM\n BUN\n 12 mg/dL\n 04:09 AM\n Creatinine\n 0.9 mg/dL\n 04:09 AM\n Sodium\n 135 mEq/L\n 04:09 AM\n Potassium\n 4.0 mEq/L\n 04:09 AM\n Chloride\n 93 mEq/L\n 04:09 AM\n TCO2\n 37 mEq/L\n 04:09 AM\n Albumin\n 1.9 g/dL\n 04:09 AM\n Calcium non-ionized\n 7.6 mg/dL\n 04:09 AM\n Phosphorus\n 2.7 mg/dL\n 04:09 AM\n Magnesium\n 2.1 mg/dL\n 04:09 AM\n ALT\n 11 IU/L\n 04:09 AM\n Alkaline Phosphate\n 81 IU/L\n 04:09 AM\n AST\n 30 IU/L\n 04:09 AM\n Amylase\n 26 IU/L\n 04:09 AM\n Total Bilirubin\n 0.4 mg/dL\n 04:09 AM\n WBC\n 10.9 K/uL\n 04:09 AM\n Hgb\n 8.0 g/dL\n 04:09 AM\n Hematocrit\n 23.3 %\n 04:09 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Fibersource HN @ 55ml/hr = goal\n GI: soft/distended, hypoactive bs, (+) soft bm\n Assessment of Nutritional Status\n Specifics:\n Pt continues w/ HoTN. s/p family meeting\n pt changed to DNR/DNI. TF\n resumed over weekend (held d/t emesis). TF was up to goal until\n pt vomited overnight. Previously, pt w/ tolerating TF w/o residuals.\n Currently, TF just resumed at 30ml/hr per d/w RN\n plan to monitor\n residuals, N/V closely. Agree w/ plan.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: continue to advance TF\n to goal of 55ml/hr (1584calories and 70g protein)\n Check residuals, hold TF if >/= 150ml\n Monitor N/V\n Multivitamin / Mineral supplement: via TF; d/c outside MVI\n Check chemistry 10 panel\n replete lytes prn\n Will continue to follow\n page if ?s *\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653404,
"text": "Chief Complaint:\n 24 Hour Events:\n - PICC placed, but crosses midline, so scheduled for IR-guided\n fluoroscopic adjustment today\n - remained off levophed but pressures as low as 70s\n asymptomatic; not\n placed on pressors overnight\n - urine output marginal overnight\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Lorazepam (Ativan) - 02:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.6\nC (96\n HR: 88 (87 - 98) bpm\n BP: 79/45(52) {61/40(48) - 136/78(90)} mmHg\n RR: 13 (9 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,991 mL\n 162 mL\n PO:\n TF:\n IVF:\n 3,991 mL\n 162 mL\n Blood products:\n Total out:\n 3,140 mL\n 90 mL\n Urine:\n 3,140 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 72 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 157 K/uL\n 9.2 g/dL\n 67 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 112 mEq/L\n 138 mEq/L\n 26.4 %\n 4.7 K/uL\n [image002.jpg]\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n Hct\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n Plt\n 22\n 188\n 148\n 157\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:6.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains intermittently hypotensive during\n sleep and with no PO intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission. Given\n negative cx data (UCx, BCx x 2); discontinued Zosyn on and\n remained afebrile; WBC normalized. Manual BP checked to ensure\n correlates with automatic read.\n -- will trial lasix 20mg IV for diuresis to help reduce preload given\n severe MR; keep MAP\ns > 65\n #) Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Earlier in week remained in afib , on , had HR 110- 120\ns, occ\n 130\ns even while at rest. Was loaded with amio IV with conversion to\n SR and HR < 100.\n --calculated amio dosing to go through (9 days since );\n cannot give oral at this time, but will convert to PO if she gets PEG\n tube\n -- per family who want to be aggressive with full care at this point,\n will consider restarting heparin with bridge to coumadin after PEG tube\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, other metabolic\n abnormalities were corrected. Speech and swallow evaluation was\n completed (difficult to assess given patient\ns lack of cooperation).\n Family has decided to go ahead with PEG.\n -- will call surgery RE PEG placement\n -- will discuss long-term placement options with CM\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 or 0.5 mg IV given prolonged effect of the 1 mg dose\n on .\n -- will clarify recent medical hx with neurologist and PCP\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR.\n -- per family who want to be aggressive with full care at this point,\n will consider restarting heparin with bridge to coumadin after PEG tube\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; resolved with\n fluids. UCx negative. Still poor urine output.\n -- trial of lasix 20 mg IV to improve urine output\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU; check level\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF. Family would like\n PEG tube placed; awaiting surgery input.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per discussion with patient's HCP\n #) Communication: Brother: is HCP ; work\n (? home)\n #) Access: PICC line was placed yesterday; needs to be adjusted today\n b/c crossed mid-line.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: IV PPI\n VAP: NA\n Code status: Full code\n Disposition: to remain in ICU while monitoring HD stability off\n pressors; likely d/c to floor or LTC facility after PEG tube placement.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655641,
"text": "Chief Complaint:\n FTT\n AMS\n Aspiration\n Hypotension\n 24 Hour Events:\n -- diuresed 1.5 L yesterday\n -- ~4:30 am developed NBNB emesis; HR went up to the 190's; gave\n compazine & metoprolol 5 mg IV x 1 with improvement in HR to the 110's\n -- held TF after emesis (there was no residual on the feeds prior to\n emesis)\n -- didn't make much progress on weaning levophed (remains at 0.15)\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:37 PM\n Piperacillin - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 89 (44 - 172) bpm\n BP: 96/56(64) {77/41(48) - 108/73(80)} mmHg\n RR: 12 (11 - 28) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 62 Inch\n Total In:\n 3,161 mL\n 737 mL\n PO:\n TF:\n 1,456 mL\n 419 mL\n IVF:\n 1,495 mL\n 318 mL\n Blood products:\n Total out:\n 4,740 mL\n 1,570 mL\n Urine:\n 4,740 mL\n 1,570 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,579 mL\n -832 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 88%\n ABG: ///37/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 476 K/uL\n 8.0 g/dL\n 80 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 93 mEq/L\n 135 mEq/L\n 23.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n 02:25 AM\n 03:53 AM\n 04:53 AM\n 04:09 AM\n WBC\n 9.8\n 7.9\n 8.0\n 9.1\n 8.6\n 8.1\n 10.9\n Hct\n 26.3\n 24.6\n 25.6\n 27.0\n 25.3\n 24.5\n 23.3\n Plt\n 367\n 324\n 338\n 371\n 380\n 391\n 476\n Cr\n 0.6\n 0.7\n 0.6\n 0.7\n 0.9\n 0.9\n 0.9\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n 169\n 97\n 93\n 80\n Other labs: PT / PTT / INR:20.8/33.0/2.0, CK / CKMB /\n Troponin-T:39//0.05, ALT / AST:10/32, Alk Phos / T Bili:75/0.3,\n Differential-Neuts:57.0 %, Band:3.0 %, Lymph:25.0 %, Mono:9.0 %,\n Eos:2.0 %, Lactic Acid:2.0 mmol/L, Albumin:1.9 g/dL, Ca++:7.6 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR :\n The patient continues to be in pulmonary edema in addition to bilateral\n opacities that might be consistent with aspiration. No focal air\n trapping is\n currently seen in the right lower lung with just some spared lung\n adjacent to\n the heart border. The right PICC line tip is in superior SVC. The\n cardiomegaly is unchanged.\n Microbiology: Blood 1/16: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension, MICU course c/b aspiration event and\n increasing O2 requirement.\n # Aspiration PNA\n occurred in setting of extensive vomiting on\n Thursday . Concern for development of ARDS vs cardiogenic pulmonary\n edema\n - continue vanco/zosyn for HAP x 7 day course: ( - )\n - follow up blood cx, sputum was not produced by patient\n - wean supplemental O2\n - continue diuresis to minimize pulm edema\n - TFs on hold, recurrent N/V\n # Hypotension: unlikely septic shock as does not even meet SIRS\n criteria (HR 80's, RR teens, WBC 5.8, afebrile). She did have a UTI but\n has been treated for days now, with a negative surveillance urine\n culture from . No evidence of gross blood loss to suggest\n hypovolemic/hemorrhagic shock. Actually appears volume overloaded on\n exam. Unclear how much autonomic instability is contributing to\n (chronic) hypotension. With severe MR on recent echo, poor forward flow\n is a likely contributor to hypoTN. Of note, her baseline BP runs\n 90-100's; 80's when sleeping.\n -- midodrine 10mg TID\n -- levophed for MAP\ns > 50 (not septic; lactic acid WNL)\n -- continue lasix gtt for hypervolemia and afterload reduction, goal -1\n -2 L today\n -- consider afterload reduction with low dose captopril, may have\n paradoxical improvement in BP\n # s/p E. coli UTI - grew from UCx ; earlier cultures were\n negative. Floor team started cipro on with intention to treat\n for seven days. Rash was noted; floor team changed to bactrim. Repeat\n UCx from negative.\n -- now s/p Bactrim 7 day course\n # DEMENTIA, FTT: Was evaluated by neuro for poss communication\n hydrocephalus or other cause to dementia. Neuro planning to defer the\n LP.\n -- continue paxil for possible depression as cause for decreased PO\n intake & FTT; decreased dose to 10mg as may be contributing to her\n lethargy\n # AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- continue coumadin; therapeutic INR now that dose has been increased\n to 1 mg daily\n -- trend INR\n # ANEMIA: Hct stable, no evidence active bleeding. Chronic problem,\n likely from malnutrition (vitammin def) and suppressed BM from chronic\n disease. Folate, B12 not low.\n -- cont to follow\n # Hyponatremia\n improving with diuresis\n -- lasix gtt with goal negative liter today\n # HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655734,
"text": "Hypotension (not Shock)\n Assessment:\n Pt. remains levo dependent\n see flowsheet for BP. Received pt. with\n lasix gtt off with adeq. UO.\n Action:\n Levo gtt increased from .04mcg/kg to .08mcg/kg for MAPs < 50 for\n several cycles. Cont\ns on midodrine. Pt had been given 20mg IV lasix\n by previous RN earlier in shift.\n Response:\n BP 70\ns-80s on present levo dose. Team accepting MAP>50 at this time.\n Pt remains wide awake and vocal, warm and dry with these BPs. Pt\n diuresed well with Lasix.\n Plan:\n Titrate levophed to maintain MAP>50. (Goal to d/c levo). Lasix gtt\n still ordered if pt not responsive to prn boluses.\n Pneumonia, aspiration\n Assessment:\n LS diminished at bases with crackles bibasilar. No distress noted.\n Action:\n Pt. weaned to RA, as she would continuously remove nasal canula.\n Coughing and deep breathing encourgaged.\n Response:\n Sats mid 90s, when picking up good pleth. Pt. does not follow\n commands to c/d/b.\n Plan:\n Pulmonary hygiene as able. Cont to monitor sats, chest PT as pt\n tolerates.\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653677,
"text": "Chief Complaint: Admitted with hypotension, FTT\n 24 Hour Events:\n OR SENT - At 03:00 PM\n to OR for PEG placement, returned for PEG placement in ICU at bedside\n d/t incorrect equipment being sterilized and correct equip not\n available.\n PEG INSERTION - At 06:01 PM\n PEG done by general surgery and this RN at bedside, pt. given moderate\n sedation (1mg of Versed and 50mcg of Fentanyl) during the case. Pt.\n tolerated well.\n - sedated with fentanyl/versed for procedure\n - lethargic 1-2 hours afterwards - BP 80s/30s\n - BPs came up to baseline 90s/40s\n - was in pain, gave morphine IV - BP held\n - changed meds to PO\n - started on warfarin/paxil\n - called out but no bed available yet\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 03:55 PM\n Midazolam (Versed) - 06:05 PM\n Furosemide (Lasix) - 08:34 PM\n Fentanyl - 08:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 96 (85 - 107) bpm\n BP: 84/48(57) {69/30(44) - 125/66(127)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,499 mL\n 72 mL\n PO:\n TF:\n IVF:\n 1,499 mL\n 72 mL\n Blood products:\n Total out:\n 2,590 mL\n 320 mL\n Urine:\n 2,590 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,091 mL\n -248 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), V/VI\n SEM with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Absent : )\n Abdominal: Soft, Bowel sounds present, No(t) Tender:\n Extremities: Right: 2+, Left: 2+, + UEE b/l\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 186 K/uL\n 10.3 g/dL\n 61 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.5 %\n 12.1 K/uL\n [image002.jpg]\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n 02:06 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n 12.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n 28.5\n Plt\n 48\n 157\n 163\n 186\n Cr\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n 143\n 90\n 61\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.6\n mg/dL\n Imaging: No new imaging overnight\n Microbiology: UCx (pre-op): NGTD\n Assessment and Plan\nPatient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains intermittently hypotensive during\n sleep and with no PO intake\n #) FTT: medical w/u negative; has had as out-patient as well, which was\n negative. Confirmed time course and diagnosis of dementia with pt\n neurologist. Family wants to proceed with PEG. No evidence of bleed\n on prelim Head CT read. ? relevance of enlarged ventricles on imaging\n -- surgery plans to take to OR today (coags, UA done; recent CXR in\n computer)\n -- f/u final read of\n -- Neurologist recommended trial of antidepressant (e.g., Paxil or\n Remeron) once taking PO\n CT\n #) Hypotension: remains off pressors; SBP dips to 80\ns while sleeping,\n but no evidence of end organ damage.\n #) Atrial fibrillation: Patient on sotalol and coumadin as\n outpatient. Earlier in week remained in afib , on , had HR 110-\n 120\ns, occ 130\ns even while at rest. Was loaded with amio IV with\n conversion to SR and HR < 100.\n -- cont IV amio; will convert to amio 400 mg TID PO once PEG can be\n used\n -- will discuss with surgery when heparin ggt can be started; will use\n as bridge to coumadin\n -- Dr. plans to electrically cardiovert in weeks once\n anticoagulated\n #) ? Seizure disorder, Meds for Mood Stabilization: clarified with\n neurologist that depakote is for mood stabilization. She is not also\n on trileptal.\n -- canceled trileptal order (though wasn\nt taking b/c was a PO med)\n -- Giving IV valproate while here in ICU; will convert back to home\n dose depakote once taking meds through PEG\n #) Hypothyroidism:\n -- cont levothyroxine 37.5 mg IV QD; convert back to PO home dose once\n taking meds by PEG\n #) GERD:\n -- Continuing PPI IV as unable to take PO\ns; will convert when taking\n meds through PEG\n #) FEN:\n -- nutrition consult for feed recs once using PEG\n -- was on IVF overnight for maintenance\n #) Code: Full per discussion with patient's HCP\n #) Communication: Brother: is HCP ; work\n (? home)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 654473,
"text": "Chief Complaint: transferred from floor to MICU for hypotension\n HPI:\n Briefly, Ms. is a 52 yoF with Down's Syndrome & Alzheimer's\n Disease who is being transfered for hypotension. She was initially\n admitted to the MICU on with FTT & hypotension requiring\n pressors; there was no clear cause to the hypotension besides volume\n depletion (infection w/u was negative; normal cortisol levels; thyroid\n studies normal). She recieved a PEG tube this admission. Head CT\n showed enlarged ventricles, and neurology is currently consulting for a\n dementia work-up. She is also currently being treated for a UTI with\n Bactrim. Coumadin for AFib is being held for an INR of 2.9.\n .\n Today, Ms. received zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n routine vitals check this afternoon, prompting transfer to the ICU.\n Prior to the transfer, she received two liters of NS bolus with\n improvement in BP from 60/palp to 80's systolic. She has been\n afebrile.\n History obtained from Medical records\n Patient unable to provide history: MR\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Coumadin (currently held for supratherapeutic INR)\n Levothyroxine 88 mcg\n Amiodarone 200 mg PO QD\n Valproic acid 400 mg Q8 hours\n Ipratropium nebs PRN\n Morphine, acetaminophen PRN for pain\n Nystatin S&S\n Miconazole powder\n Paroxetine 20 mg QD\n Lansoprazole 30 mg QD\n Lasix 40 mg QD\n Bactrim DS (was changed from cipro to Bactrim when she developed\n rash on )\n Past medical history:\n Family history:\n Social History:\n - Down's syndrome\n - Alzheimers Dementia\n - Mitral valve regurgitation, followed by Dr. \n - Hypothyroidism\n - Status-post right mastectomy for breast cancer, last mammogram \n WNL\n - Atrial fibrillation\n - History of bacterial endocarditis in \n - Status-post appendectomy (laproscopic )\n - Esophageal reflux and H. Pylori infection ()\n - Status-post cholecystectomy\n - Status-post laparoscopic umbilical hernia repair\n - Status-post gangrenous cholecystitis, lap chole \n Occupation: none\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives in home\n Review of systems:\n Flowsheet Data as of 10:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 82 (74 - 85) bpm\n BP: 95/76(80) {63/38(43) - 95/76(80)} mmHg\n RR: 14 (14 - 17) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,095 mL\n PO:\n TF:\n IVF:\n 1,095 mL\n Blood products:\n Total out:\n 0 mL\n 120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,975 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (Murmur: Systolic), harsh V/VI SEM heard throughout\n with radiation to the back\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Rhonchorous: ), not cooperative with lung exam\n Abdominal: Soft, Non-tender, Bowel sounds present, PEG Tube\n Extremities: 2+ edema throughout LE/UE\n Skin: Warm, fine reticular rash on trunk, arms\n Neurologic: Responds to: Not assessed, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 240\n 0.6\n 8\n 34\n 100\n 3.7\n 138\n 24.4\n 5.8\n [image002.jpg]\n Other labs: PT / PTT / INR:28.6/46.2/2.9, Ca++:6.9, Mg++:1.9, PO4:2.4\n Imaging: MRI pending\n Microbiology: BCx, UCx: pending\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n .\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR 80's,\n RR teens, WBC 5.8, afebrile); does have UTI but has been treated for\n four days now & little evidence of systemic infection. Hct stable today\n & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days.\n Of note, baseline BP runs 90-100's; 80's when sleeping.\n -- hold home dose lasix 40 mg QD\n -- will give IVF boluses for MAPS > 60-65; may need to start levophed.\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team\n -- will defer broadening coverage with abx given little evidence of\n -- will check diff on CBC to look for bands and eos\n -- will place A-line for hemodynamic monitoring if she goes onto\n pressors\n .\n (#) SOMNOLENCE: in setting of zyprexa for MRI; INR supratherpeutic to\n 2.9, though non-focal neuro exam and no evidence of herniation, etc.\n No evidence of resp distress, no risk factors for hypercarbia.\n -- f/u MRI read\n -- will check ABG, though unlikely vent/oxy contributing currently\n .\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro.\n -- f/u urine cultures today\n -- cont Bactrim through per floor team plans\n .\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Floor team\n plans to LP once INR nromalizes.\n -- f/u MRI read\n -- cont to hold coumadin for possible LP\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n .\n (#) AFIB: supratx on coumadin; on amio\n -- cont amio; well rhtyhm/rate controlled\n -- cont to hold coumadin for possible LP\n .\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutriion (vitammin def)\n and suppressed BM from chronic disease.\n -- should be on folic acid, MVI\n .\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n .\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n .\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools)\n .\n (#) CONSENT: must contact HCP brother for ICU consent\n .\n (#) CODE: FULL\n .\n (#) DISPO: to remain in ICU overnight; possible transfer to floor in am\n if stabilizes & off pressors\n ICU Care\n Nutrition:\n Comments: Fibersource TF\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653767,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PEG INSERTION - At 06:01 PM\n PEG done by general surgery and this RN at bedside, pt. given moderate\n sedation (1mg of Versed and 50mcg of Fentanyl) during the case. Pt.\n tolerated well.\n History obtained from Medical records\n Patient unable to provide history: dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:55 PM\n Midazolam (Versed) - 06:05 PM\n Furosemide (Lasix) - 08:34 PM\n Fentanyl - 08:44 PM\n Metoprolol - 09:05 AM\n Other medications:\n Paxil, warfarin, lasix, lansoprazole, amiondarone, Valproate,\n levothyroxine.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 93 (85 - 151) bpm\n BP: 87/51(59) {70/30(44) - 109/77(127)} mmHg\n RR: 12 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,499 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,499 mL\n 116 mL\n Blood products:\n Total out:\n 2,590 mL\n 470 mL\n Urine:\n 2,590 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,091 mL\n -264 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.3 g/dL\n 186 K/uL\n 61 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.5 %\n 12.1 K/uL\n [image002.jpg]\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n 02:06 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n 12.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n 28.5\n Plt\n 48\n 157\n 163\n 186\n Cr\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n 143\n 90\n 61\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.2 mg/dL, Mg++:2.1 mg/dL, PO4:3.0\n mg/dL\n Imaging: No new imaging\n Microbiology: No new micro\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors for 48+ hours. Urine output\n improved compared to yesterday\n -Continue to monitor\n Failure to Thrive: Likely dementia. G tube in place.\n -Start tube feeds today\n -PM labs to monitor for refeeding syndrome\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio this AM. QT=432ms\n -Continue amio load via NGT today\n -Coumadin via G tube. Goal INR \n MS\n Down\ns syndrome with presumed Alzheimer\ns dementia\n -Trial of SSRI in case depression contributing\n Hypothyroid: Now on IV replacement, will change to PGT\n Access: PICC in place\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653260,
"text": "Chief Complaint:\n 24 Hour Events:\n - PICC placed, but crosses midline, so scheduled for IR-guided\n fluoroscopic adjustment today\n - remained off levophed but pressures as low as 70s - asymptomatic. I\n refused to put her on pressors.\n - urine output marginal overnight\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Lorazepam (Ativan) - 02:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.6\nC (96\n HR: 88 (87 - 98) bpm\n BP: 79/45(52) {61/40(48) - 136/78(90)} mmHg\n RR: 13 (9 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,991 mL\n 162 mL\n PO:\n TF:\n IVF:\n 3,991 mL\n 162 mL\n Blood products:\n Total out:\n 3,140 mL\n 90 mL\n Urine:\n 3,140 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 72 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 157 K/uL\n 9.2 g/dL\n 67 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 112 mEq/L\n 138 mEq/L\n 26.4 %\n 4.7 K/uL\n [image002.jpg]\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n Hct\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n Plt\n 22\n 188\n 148\n 157\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:6.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains intermittently pressor-dependent and\n with no PO intake.\n #) Hypotension: Etiology still remains unclear. Pt profoundly volume\n depleted on admission, though has been recuscitated. Was off pressors\n during day, but had mild hypotensio o/n and levophed put back on.\n Cardiac echocardiogram showed severe MR, but function was normal,\n without pericardial effusion; severe MR could be contributing to\n hypotension, but again seems less likely that this is sole cause.\n There is no evidence of sepsis/infection with improving WBC, afebrile\n state, nothing localizing and no positive Cx data; LP deferred for now\n given MS appears to be at (recent) baseline. Had negative CortStim\n test. Thyroid studies were normal earlier this admission.\n -- given negative cx data (UCx, BCx x 2); discontinued Zosyn on \n and remained afebrile; WBC normalized\n -- Manual BP to ensure correlates with automatic read\n -- will trial lasix 20mg IV for diuresis to help reduce preload given\n severe MR\n -- wean levophed as tolerated\n #) Atrial fibrillation: Patient on sotalol and coumadin as outpatient.\n Currently in afib , on , had HR 110- 120\ns, occ 130\ns even while\n at rest\n --loading amiodarone IV x 9 days since1/3/09; cannot give oral at this\n time.\n -- Ongoing discussion with family re: goals of care, and start hep gtt\n & coumadin for anticoagulation if plans for feeding tube; sotalol if\n ever able to give PO medications.\n #) Failure to thrive/poor PO intake: Per OMR notes and office visit\n note detailing concerns of her care-givers, this has been an ongoing\n issue for months that appears to have acutely worsened. There appears\n to be at least some behavioral component in setting of possibly\n worsening Alzheimer's dementia. Given family\ns report of sharp\n decline 3-4 months ago, would also consider vascular dementia as\n contributing to (seemingly) abrupt decline. Given question of acutely\n worsening dementia, checked vitamin B12 (was high); no known risk\n factors (not sexually active) for syphilis, TSH WNL, other metabolic\n abnormalities were corrected. Speech and swallow evaluation was\n completed (difficult to assess given patient\ns lack of cooperation).\n Had fam htg with brother, , and his wife; he is still deciding\n overall goals of care and whether to provide a PEG tube for feeding.\n -- awaiting family decision on PEG tube broad goals of care\n --will need PICC for accesss; need to remove fem line\n -- Working up infectious etiology as above- negative w/u to date\n --thyroid studies normal\n -- Consider psychiatry/neurobehavoiral evaluation once further\n stabilized or as outpatient for further recommendations; might benefit\n from seeing Dr. in geriatrics who specializes in early\n onset AD r/t Down\n -- if family decides against PEG will consider palliative care c/s for\n possible hospice placement; in addition, will do social work consult.\n -- Cont MV\n -- Low dose haldol or ativan if needed for help with agitation; would\n give ativan 0.25 or 0.5 mg IV given prolonged effect of the 1 mg dose\n on .\n #) Hypernatremia: Suspect hypovolemic given history, exam, also not\n helped by patient continuing to take home dose of lasix. Resolved with\n hydration, Na normalized.\n #) Elevated INR: INR in ED was , suspect again secondary to poor\n nutritional status and lack of vitamin K consumption. Patient received\n 5 mg IV vitamin K in ED, with normalization of INR.\n -- Will discuss with family goals of care, will need to start heparin\n gtt if wish to continue aggressive treatment.\n -- Continue SQH for PPX for now\n #) Acute renal failure: resolved. Likely prerenal; resolved with\n fluids. UCx negative. Still poor urine output\n -- trial of lasix to improve urine output\n #) Leukocytosis: resolved\n #) Seizure disorder: unable to take home meds depakote and trileptal\n b/c PO.\n -- Giving IV valproate while here in ICU; check level\n -- unable to take PO trileptal\n #) Hypothyroidism: TSH/FT4 within normal limits. Continue home\n supplementation, but changing dose to IV ( of PO dose).\n -- cont levothyroxine 37.5 mg IV QD\n #) GERD: Continuing PPI IV as unable to take PO\n #) FEN: Sips as nursing feels comfortable, IVF.\n #) PPx: SQ heparin until decision made re: heparin gtt & coumadin;IV\n PPI\n #) Code: Full per discussion with patient's HCP\n #) Communication: Brother: is HCP ; work\n (? home)\n #) Access: Right femoral central line placed in ED Needs to be\n replaced. Spoke to family about PICC and they understant this would\n need to be placed with sedation. Will replace today with IV sedation\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653358,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake.\n Hypotension (not Shock)\n Assessment:\n BP remains labile SBP 75-110 MAPS >55, Manual BP checked during\n hypotensive episode findings >NBP. Pt LOC unchanged cont to cry out,\n not able to follow commands yet tracks surroundings and calls out for\n Brother\n\n. Remains Fluid overloaded>27Liters LOS. Pressors\n off>24hrs. afebrile T-max 96.6.\n Action:\n Ascultated BP change from NBP cuff. Received Lasix 20mg w/+diuresis.\n Response:\n Gentle diuresis w/lasix and responding hypotension. Goal MAPS>58\n Plan:\n Goal BP>90 MAPS>58\n Monitor manual cuff BP for correlation.\n Diures goal neg 1liter\n Atrial fibrillation (Afib)\n Assessment:\n HR 80s-90s in AF/NSR. With freq PVC occas . Cont on amioderone gtt,\n Hypokalemia, hypomagnesium, hypocalcemia\n Action:\n Cont Amiodarone Electrolyte repletion K+ Mag, Ca+., Head CT\n Response:\n Less ventriucular ectopyw/ electrolyte repletion.\n Plan:\n Cont IV amioderone\n F/U labs\n Repletion electrolytes.\n f/u results of head CT\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. ^u/o s/p lasix , Anascara + FB >27 liters for LOS\n Action:\n Lasix @ 12n transient hypotension. Electrolyte repletion.\n Response:\n + response to lasix, BP labile.\n Plan:\n Goal FB (\n)1liter\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS 61-150, hypoglycemia 61\n Action:\n Received\n amp D50 for BS 61\n Response:\n FSBS labile\n Plan:\n Q2-4hrs FSBS\n"
},
{
"category": "Respiratory ",
"chartdate": "2140-12-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 654716,
"text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653492,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Team discussed patient's case with her outpatient neurologist. She\n confirmed that she had been diagnsosed with alzheimer's about one year\n ago and that she felt that her symptoms had been progressing over the\n past few months.\n Head CT done yesterday: Bifrontal hypdensities and ventricular\n enlargement.\n Family requested PEG tube placement yesterday, surgery consulted.\n Remained off pressors for the last 36 hours.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Pantoprazole (Protonix) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 07:47 AM\n Other medications:\n Valproate, levotyroxine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.1\nC (95.1\n HR: 87 (87 - 135) bpm\n BP: 82/55(62) {69/34(48) - 115/62(189)} mmHg\n RR: 15 (11 - 53) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,467 mL\n 936 mL\n PO:\n TF:\n IVF:\n 1,467 mL\n 936 mL\n Blood products:\n Total out:\n 2,065 mL\n 1,460 mL\n Urine:\n 2,065 mL\n 1,460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -598 mL\n -524 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: Agitated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 163 K/uL\n 90 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 3 mg/dL\n 109 mEq/L\n 139 mEq/L\n 27.4 %\n 5.1 K/uL\n [image002.jpg]\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n Plt\n 48\n 157\n 163\n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 7\n 116\n 126\n 113\n 67\n 143\n 90\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors for 36 hours. Urine output\n improved compared to yesterday\n -Continue to monitor\n Failure to Thrive: Likely dementia. Family requesting G tube.\n -Surgery consulted, she is an add-on today\n -Follow up official read of head CT.\n -Consider anti-depressant trial.\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today if BP tolerates after G tube placed.\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n QT=432ms\n -Continue amio load, will transition to PGT once tube is in and can\n be used\n -Start coumadin via G tube. Goal INR \n MS\n Down\ns syndrome with presumed Alzheimer\ns dementia\n Hypothyroid: Now on IV replacement, will change to PGT once able.\n Access: PICC in place, femoral line now out.\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653333,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC line placed but crossed the midline so being readjused this AM.\n Remained off pressors overnight. Diuresed a little yesterday.\n Still refusing po's.\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:35 PM\n Other medications:\n Trileptal, Valproate, Levothyroxine, HSQ, protonix, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.7\nC (96.2\n HR: 92 (87 - 98) bpm\n BP: 90/55(63) {61/40(48) - 136/78(90)} mmHg\n RR: 18 (9 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,992 mL\n 455 mL\n PO:\n TF:\n IVF:\n 3,992 mL\n 455 mL\n Blood products:\n Total out:\n 3,140 mL\n 190 mL\n Urine:\n 3,140 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 852 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, Moaning\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: Bases B/L.)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 157 K/uL\n 67 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 4 mg/dL\n 112 mEq/L\n 138 mEq/L\n 26.4 %\n 4.7 K/uL\n [image002.jpg]\n 08:36 PM\n 03:53 AM\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n WBC\n 12.0\n 13.7\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n Hct\n 33.0\n 32.9\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n Plt\n 22\n 188\n 148\n 157\n Cr\n 2.0\n 1.7\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n Glucose\n 192\n 212\n 802\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n Other labs: PT / PTT / INR:13.9/30.2/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:6.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors overnight. Urine output improved\n compared to yesterday\n -Continue to monitor\n Failure to Thrive: Spoke with patient's sister-in-law at length\n . She and pt's brother will meet with us again today regarding\n ultimate GOC.\n -Continue hydration\n -Will try to obtain records from her neurologist: Dr. \n () to determine what evaluation she has had thus far.\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today if BP tolerates.\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio overnight with improved rates.\n QT=432ms\n -Continue amio load.\n Hypothyroid: Now on IV replacement.\n Access: Once PICC repositioned, pull femoral line.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:46 PM\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 654984,
"text": "Chief Complaint:\n 24 Hour Events:\n - started on midodrine\n - on lasix gtt with very good diuresis\n - levophed not off yet\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:10 AM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.1\nC (97\n HR: 91 (84 - 96) bpm\n BP: 89/41(53) {77/41(51) - 104/64(72)} mmHg\n RR: 10 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,237 mL\n 814 mL\n PO:\n TF:\n 1,147 mL\n 454 mL\n IVF:\n 689 mL\n 190 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,470 mL\n Urine:\n 3,160 mL\n 1,470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -923 mL\n -656 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///39/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 338 K/uL\n 8.8 g/dL\n 146 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 94 mEq/L\n 134 mEq/L\n 25.6 %\n 8.0 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n WBC\n 9.8\n 7.9\n 8.0\n Hct\n 26.3\n 24.6\n 25.6\n Plt\n 367\n 324\n 338\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n Other labs: PT / PTT / INR:24.4/35.9/2.4, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.9 mg/dL\n Imaging: No new imaging\n Microbiology: UCx; negative\n BCx: NGTD\n Assessment and Plan\n 52 yoF with Down's Syndrome & AD, MICU stay earlier in course for\n pressor-dependent hypotension thought to be volume depletion;\n admitted now with hypotension.\n (#) HYPOTENSION: unlike sepsis as does not meet SIRS criteria (HR\n 80's, RR teens, WBC 5.8, afebrile); does have UTI but has been treated\n for four days now & little evidence of systemic infection. Hct stable\n today & over prior days; no evidence of gross blood loss causing\n hypotension/hemorrhagic shock. Has been on home lasix dose 40 mg PO QD\n for volume overload; may be volume depleted, though BUN/CR stable.\n Unclear how much autonomic instability is contributing to (chronic)\n hypotension. Evidence of drug rxn to cipro per floor team (rash);\n unlikely vasodilation from allergic rxn. With severe MR on recent\n echos; was stable earlier in admission, and no evidence for worsening\n valvular disease in last few days. Of note, baseline BP runs 90-100's;\n 80's when sleeping.\n -- holding home dose lasix 40 mg QD; will place on lasix drip for goal\n negative1-1.5 L negative while on levophed (evidence of pulm edema on\n CXR)\n -- levophed for MAP\ns > 50 (not septic; lactic acid 1.4 yest; RF\n stable)\n -- starting midodrine 5 mg TID\n -- unlikely to get tilt table test while in-house\n -- f/u blood cultures, urine cultures from earlier today drawn by floor\n team-- NGTD\n -- will defer broadening coverage with abx given little evidence of\n infection\n (#) UTI: E. coli UTI from UCx ; earlier cultures were negative.\n Floor team started cipro on with intention to treat for seven\n days. Rash was noted today; floor team changed to cipro. Repeat UCx\n from negative.\n -- cont Bactrim through per floor team plans\n (#) DEMENTIA, FTT: currently being evaluated by neuro for poss\n communication hydrocephalus or other cause to dementia. Neuro planning\n to defer the LP.\n -- cont. Paxil for possible depression as cause for decreased PO intake\n & FTT\n -- f/u neuro recs\n (#) AFIB: on amio, on coumadin\n -- cont amio; metoprolol PRN for RPR\n -- restarted coumadin 0.5 mg last light\n (#) ANEMIA: repeat Hct 24 today; hypotensive, but no evidnece that this\n is blood loss. Chronic problem, likely from malnutrition (vitammin\n def) and suppressed BM from chronic disease. Folate, B12 not low.\n -- cont to follow\n (#) NUTRITION: on tube feeds via PEG; w/o complication.\n -- cont TF; nutrition following\n (#) HYPOTHYROIDISM:\n -- cont levothyroxine 88 mcg QD\n (#) SOMNOLENCE: improved; likely Zyprexa\n (#) PPX:\n -- systemmic anticoagulation w/ coumadin for AFIB (supratx, being held)\n -- lansoprazole\n -- no need for bowel regimen (having loose stools; C diff neg)\n (#) CONSENT: signed on admission on \n (#) CODE: FULL\n (#) DISPO: possible transfer to floor tomorrow afternoon if stabilizes\n & off pressors\n ICU Care\n ACCESS: PICC\n Nutrition: Fibersource TF\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2140-12-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655003,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Diuresed yesterday/overnight. Levophed weaned,\n History obtained from Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Oxycodone\n Unknown;\n Ciprofloxacin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 0.5 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Levophed, bactrim, amiodarone, levothyroxine, Atrovent, Valproate,\n lansoprazole, paxil, warfarin, midodrine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98\n HR: 88 (84 - 96) bpm\n BP: 93/49(61) {77/41(51) - 104/64(72)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 62 Inch\n Total In:\n 2,237 mL\n 1,032 mL\n PO:\n TF:\n 1,147 mL\n 572 mL\n IVF:\n 689 mL\n 230 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,670 mL\n Urine:\n 3,160 mL\n 1,670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -923 mL\n -638 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///39/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Improved compared to\n yesterday)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 338 K/uL\n 146 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.3 mEq/L\n 10 mg/dL\n 94 mEq/L\n 134 mEq/L\n 25.6 %\n 8.0 K/uL\n [image002.jpg]\n 03:56 AM\n 03:16 AM\n 03:44 AM\n WBC\n 9.8\n 7.9\n 8.0\n Hct\n 26.3\n 24.6\n 25.6\n Plt\n 367\n 324\n 338\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n 0.05\n Glucose\n 114\n 235\n 146\n Other labs: PT / PTT / INR:24.4/35.9/2.4, CK / CKMB /\n Troponin-T:39//0.05, Albumin:1.7 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.9 mg/dL\n Microbiology: BCx: NGTD\n UCx: NGTD\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's Dementia transferred back\n to the ICU for hypotension after receiving zyprexa.\n Hypotension: No clear evidence of infection at this point. Seems most\n consistent with med effect in the setting of someone with borderline BP\n to begin with. Autonomic instability may also be a contributor.\n -Cont require pressors\n wean as tolerated keeping in mind has had\n persistently low baseline maps in past. MAP goal is <50.\n -Continue midodrine\n -Follow up on cultures sent at time of transfer\n -Avoid zyprexa for now\n Peripheral edema:\n -Will diurese again today with lasix drip, goal negative 1 liter.\n Respiratory: CXR exam suggest mix of pulmonary edema +/- aspiration.\n No clinical signs of PNA at present.\n -Diuresis as above\n -Aspiration precautions\n AF: Intermittently in AF\n -Continue amiodarone maintenance\n -No plan for LP per neuro, so coumadin restarted.\n UTI:\n -Bactrim until .\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:08 AM 64. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653352,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653356,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake.\n Hypotension (not Shock)\n Assessment:\n BP remains labile SBP 75-110 MAPS >55, Manual BP checked during\n hypotensive episode findings >NBP. Pt LOC unchanged cont to cry out,\n not able to follow commands yet tracks surroundings and calls out for\n Brother\n\n. Remains Fluid overloaded>27Liters LOS. Pressors\n off>24hrs. afebrile T-max 96.6.\n Action:\n Ascultated BP change from NBP cuff. Received Lasix 20mg w/+diuresis.\n Response:\n Gentle diuresis w/lasix and responding hypotension. Goal MAPS>58\n Plan:\n Goal BP>90 MAPS>58\n Monitor manual cuff BP for correlation.\n Diures goal neg 1liter\n Atrial fibrillation (Afib)\n Assessment:\n HR 80s-90s in AF/NSR. With freq PVC occas . Cont on amioderone gtt,\n Hypokalemia, hypomagnesium, hypocalcemia\n Action:\n Cont Amiodarone Electrolyte repletion K+ Mag, Ca+., Head CT\n Response:\n Less ventriucular ectopyw/ electrolyte repletion.\n Plan:\n Cont IV amioderone\n F/U labs\n Repletion electrolytes.\n f/u results of head CT\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. ^u/o s/p lasix , Anascara + FB >27 liters for LOS\n Action:\n Lasix @ 12n transient hypotension. Electrolyte repletion.\n Response:\n + response to lasix, BP labile.\n Plan:\n Goal FB (\n)1liter\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653357,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake.\n Hypotension (not Shock)\n Assessment:\n BP remains labile SBP 75-110 MAPS >55, Manual BP checked during\n hypotensive episode findings >NBP. Pt LOC unchanged cont to cry out,\n not able to follow commands yet tracks surroundings and calls out for\n Brother\n\n. Remains Fluid overloaded>27Liters LOS. Pressors\n off>24hrs. afebrile T-max 96.6.\n Action:\n Ascultated BP change from NBP cuff. Received Lasix 20mg w/+diuresis.\n Response:\n Gentle diuresis w/lasix and responding hypotension. Goal MAPS>58\n Plan:\n Goal BP>90 MAPS>58\n Monitor manual cuff BP for correlation.\n Diures goal neg 1liter\n Atrial fibrillation (Afib)\n Assessment:\n HR 80s-90s in AF/NSR. With freq PVC occas . Cont on amioderone gtt,\n Hypokalemia, hypomagnesium, hypocalcemia\n Action:\n Cont Amiodarone Electrolyte repletion K+ Mag, Ca+., Head CT\n Response:\n Less ventriucular ectopyw/ electrolyte repletion.\n Plan:\n Cont IV amioderone\n F/U labs\n Repletion electrolytes.\n f/u results of head CT\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. ^u/o s/p lasix , Anascara + FB >27 liters for LOS\n Action:\n Lasix @ 12n transient hypotension. Electrolyte repletion.\n Response:\n + response to lasix, BP labile.\n Plan:\n Goal FB (\n)1liter\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653422,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653424,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake. +\n Mitral regurg.\n Cardiac\nhypotension --Atrial fibrillation (Afib)\n Assessment:\n Received patient in NSR\nAFIB rate 70s-90s, occasional pvcs.\n SBP >90s-100s when aroused moaning but dropped intermittently to 70s\n with sleeping. Map marginal 50s-60\n Bodily very edematous, skin w/d. +dopplerable pulses.\n Action:\n Con\nt amiodarone gtt infusing at 0.5mg/min. replete\n k/calcium\n Started maintenance IVF infusing 125ml/hr for NPO for peg\n placement in the morning and low FS. Give\n Lasix dose 10mg x1 per micu\n residence .\n Keep all extremities elevated. Dvt prophylaxis with heparin\n sc.\n Resent UA for pre-peg placement as ordered.\n Response:\n Skin remain w/d. +csm. Sufficient diuresis with Lasix.\n Plan:\n Con\nt monitor. Change to po amiodarone when peg placed?\n Start heparin gtt/coumadin for afib?\n ?check albumin level\nstart tf.\n Neuro --Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Received patient moaning, making incomprehensible sounds, yelling out.\n Calling\n\n few time. Eye kept closed. Perrl, open eye to\n turning/stimulus only. Maex4 to nail bed pressure and spontaneous. Not\n following any command. Difficult to complete neuro assessment. (not\n new per Micu residence). No seizure noted\n Action:\n Con\nt reorient, provide support, maintain safety\n Response:\n Patient slept most of night\n Plan:\n Follow up with head Ct report. Neuro consult? Check valproate level??\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653425,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake. +\n Mitral regurg.\n Cardiac\nhypotension --Atrial fibrillation (Afib)\n Assessment:\n Received patient in NSR\nAFIB rate 70s-90s, occasional pvcs.\n SBP >90s-100s when aroused moaning but dropped intermittently to 70s\n with sleeping. Map marginal 50s-60\n Bodily very edematous, skin w/d. +dopplerable pulses.\n Action:\n Con\nt amiodarone gtt infusing at 0.5mg/min. replete\n k/calcium\n Started maintenance IVF infusing 125ml/hr for NPO for peg\n placement in the morning and low FS. Give\n Lasix dose 10mg x1 per micu\n residence .\n Keep all extremities elevated. Dvt prophylaxis with heparin\n sc.\n Resent UA for pre-peg placement as ordered.\n Added 2lnc for sat marginal 92%\n Response:\n Skin remain w/d. +csm. Sufficient diuresis with Lasix. Sat\n improved to >97% on 2lnc\n Plan:\n Con\nt monitor. Change to po amiodarone when peg placed?\n Start heparin gtt/coumadin for afib?\n ?check albumin level\nstart tf.\n Neuro --Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Received patient moaning, making incomprehensible sounds, yelling out.\n Calling\n\n few time. Eye kept closed. Perrl, open eye to\n turning/stimulus only. Maex4 to nail bed pressure and spontaneous. Not\n following any command. Difficult to complete neuro assessment. (not\n new per Micu residence). No seizure noted\n Action:\n Con\nt reorient, provide support, maintain safety\n Response:\n Patient slept most of night\n Plan:\n Follow up with head Ct report. Neuro consult? Check valproate level??\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 653712,
"text": "52 yo female with hx significant for downs syndrome, dementia, and\n afib on coumadin, who comes into the emergency room after visit with\n her pcp. lives in a group home and was brought to pcp failure\n to thrive poor to no po intake ? how long. She has had a 35lb weight\n loss ? over how long, and has had difficulty with her gait and per\n report has been wheelchair bound x several weeks. She has had\n swallowing studies and it remains unclear whether pt has difficulty\n swallowing or is having behavioral issues spitting out food, she is\n also known to regurgitate food which has been going on for awhile.. She\n comes into the ED hypotensive requiring 6liters NS she was put on\n Levophed, her electrolytes were grossly abnl with a Na 166 K+ 3.4 her\n urine was coke colored with a bun 69 and cr 3.4, troponin elevated. Her\n HCP is her brother \n pt. ready for transfer out of ICU as pt. has stabilized. Pt. to\n go for PEG placement today in OR and then should go to the floor when\n bed available. Currently, pt. on amiodorone gtt at 0.5mg/min to change\n to PO Amiodorone 400mg TID post PEG placement. Also, pt. to start\n Coumadin and Paxil when she has PEG. Nutrition consult ordered as well\n as PT to facilitate discharge to NH. Of note, pt. has had\n intermittment hypotension when she is asleep. BP rises upon\n stimulation. Also of note, pt.\ns cardiologist, Dr. would like to\n cardiovert pt. in weeks after therapeutic INR achieved.\n Atrial fibrillation (Afib)\n Assessment:\n Pt. currently in NSR with frequent PVCs. Pt. with history of Afib.\n Action:\n Pt. currently requiring IV amiodorone gtt at 0.5mg/min.\n Response:\n Pt. in NSR w/ frequent PVCs.\n Plan:\n PEG placement and should started 400mg TID.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt. continue to call out frequently when awake and does not respond to\n emotional support.\n Action:\n Pt. environment secure and safe.\n Response:\n Pt. continues to call out and cry for brother .\n :\n To start antidepressant and is currently on Depakote IV to be changed\n to PO with PEG.\n Coagulopathy\n Assessment:\n Pt. with normalized INR now that pt. is hydrated and renal failure has\n resolved.\n Action:\n To restart coumadin when PEG placed with plan of mechanical\n cardioversion when INR appropriately therapeutic.\n Response:\n Plan:\n Coumadin ordered for today\n Decubitus ulcer (Not Present At Admission)\n Assessment:\n Pt. with intact Allevyn dsg on right side near hip and coccyx\n Action:\n Dressing intact\n Response:\n Plan:\n Turn q2\n Change allevyen prn when soiled or q72\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n ACUTE RENAL\n Code status:\n Full code\n Height:\n Admission weight:\n 49.4 kg\n Daily weight:\n Allergies/Reactions:\n Oxycodone\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: Downs syndrome, mitral regurgitation, h/o\n bacterial endocarditis in , h/o afib electrical cardioversion in\n past, hypothyroidism, bunions/foot pain, h/o right breast cancer,\n seizure disorder\n Surgery / Procedure and date: s/p right mastectomy for breast cancer,\n s/p laparoscopic appendectomy , s/p laparoscopuic umbilical hernia\n repair, s/p gangrenous cholecystitis, lap chole \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:89\n D:45\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 198 mL\n 24h total out:\n 430 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:06 AM\n Potassium:\n 3.9 mEq/L\n 02:06 AM\n Chloride:\n 108 mEq/L\n 02:06 AM\n CO2:\n 27 mEq/L\n 02:06 AM\n BUN:\n 2 mg/dL\n 02:06 AM\n Creatinine:\n 0.7 mg/dL\n 02:06 AM\n Glucose:\n 61 mg/dL\n 02:06 AM\n Hematocrit:\n 28.5 %\n 02:06 AM\n Finger Stick Glucose:\n 99\n 06:00 AM\n Valuables / Signature\n Patient valuables: IN BAG WITH PATIENT\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: 210\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2140-12-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 653715,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PEG INSERTION - At 06:01 PM\n PEG done by general surgery and this RN at bedside, pt. given moderate\n sedation (1mg of Versed and 50mcg of Fentanyl) during the case. Pt.\n tolerated well.\n History obtained from Medical records\n Patient unable to provide history: dementia\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:55 PM\n Midazolam (Versed) - 06:05 PM\n Furosemide (Lasix) - 08:34 PM\n Fentanyl - 08:44 PM\n Metoprolol - 09:05 AM\n Other medications:\n Paxil, warfarin, lasix, lansoprazole, amiondarone, Valproate,\n levothyroxine.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 93 (85 - 151) bpm\n BP: 87/51(59) {70/30(44) - 109/77(127)} mmHg\n RR: 12 (9 - 25) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,499 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,499 mL\n 116 mL\n Blood products:\n Total out:\n 2,590 mL\n 470 mL\n Urine:\n 2,590 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,091 mL\n -264 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, Irreg\n Irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, G\n tube in place\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.3 g/dL\n 186 K/uL\n 61 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 2 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.5 %\n 12.1 K/uL\n [image002.jpg]\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n 02:06 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n 12.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n 28.5\n Plt\n 48\n 157\n 163\n 186\n Cr\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 171\n 91\n 137\n 116\n 126\n 113\n 67\n 143\n 90\n 61\n Other labs: PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.2 mg/dL, Mg++:2.1 mg/dL, PO4:3.0\n mg/dL\n Imaging: No new imaging\n Microbiology: No new micro\n Assessment and Plan\n 52 yo F with Down's Syndrome and Alzheimer's p/w profound dehydration.\n Hypotension: Remained off pressors for 48+ hours. Urine output\n improved compared to yesterday\n -Continue to monitor\n Failure to Thrive: Likely dementia. G tube in place.\n -Start tube feeds today\n -PM labs to monitor for refeeding syndrome\n Volume status: Still grossly total volume overloaded\n -Diurese with goal -1L today\n AFib: Currently off of sotalol and coumadin as she is not taking\n PO's. Having some RVR requiring amio this AM. QT=432ms\n -Continue amio load via NGT today\n -Coumadin via G tube. Goal INR \n MS\n Down\ns syndrome with presumed Alzheimer\ns dementia\n -Trial of SSRI in case depression contributing\n Hypothyroid: Now on IV replacement, will change to PGT\n Access: PICC in place\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655129,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655136,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who was\n initially admitted to the MICU on with FTT & hypotension\n requiring pressors, There was no clear cause to the hypotension besides\n volume depletion. PEG tube was place during admission. Head CT showed\n enlarged ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Pt readmitted to MICU on , pt received Zyprexa 5 mg for sedation\n and underwent head MRI per neuro recs. She was noted to be somnolent\n and hypotensive in the afternoon. Prior to the transfer, she received\n two liters of NS bolus with improvement in BP from 60/palp to 80's\n systolic.\n Hypotension (not Shock)\n Assessment:\n Pt BP 71/36-95/53 with MAPs 45-62, HR 80s-90s A.fib. Pt received on\n levophen 0.02mcg/kg/min and titrated up, currently on 0.15mcg/kg/min.\n Pt continues to be afebrile.WBC 9.1 up from 8.0\n Action:\n Pt\ns levophed increased to maintain MAPs >60. Pt also given 5mg IV\n lopressor for HR 160s with no drop in BP after lopressor.\n Response:\n Most recent BP 83/52, MAP 60. UOP 30-50cc/hr.\n Plan:\n Continue to titrated levophed for MAP >60.\n Nausea / vomiting\n Assessment:\n Pt had episode of 1 large emesis of tube feeds with a few subsequent\n small emesis that were bilious in appearance. After vomiting pt\ns o2\n requirement increased.\n Action:\n Pt positioned to prevent aspiration if she vomits again. O2 increased\n to 4L NC but was able to titrate back down to 2L NC after few hours.\n Breath sounds auscultated. Compazine and Reglan given. AM CXR and\n abdomen obtained. Tude feeds turned off.\n Response:\n No significant change in breath sounds. Pt now satting 94-97% on 2L\n NC. Tube feeds remain off. Pt with no more vomiting since last reglan\n dose. Pt did also have 2 loose brown BMs.\n Plan:\n Continue to monitor for vomiting, keep positioned to prevent\n aspiration. NPO for now. Reglan and compazine PRN. Monitor resp\n status. F/U with x-ray results.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653239,
"text": "HX of Down's Syndrome, dementia, & AF on coumadin,P/W failure to\n thrive, hypernatremia & electrolyte depletion . Members of her group\n home brought her to the physician office as they were concerned about\n her safety in the group home due to lack of oral intake, difficulty\n walking (per report was newly in a wheelchair for last two week). The\n ED physicians spoke with her brother, who is also her HCP, who per\n report told them that she had had very poor PO intake for \"a while\" at\n the group home, and the family had been discussing moving her to a\n facility with a higher-level of care.\n Events:. Bedside PICC placed yesterday but not in correct position.\n Will need to be repositioned or replaced in IR . (Do not use)\n Hypotension (not Shock)\n Assessment:\n Levophed d/c\nd. NBP noted to be 70\ns overnight while pt sleeping. Pt\n cardiologist ,Dr. states SBP approx 90\n Action:\n Ascultated BP with Doppler which correlated with NBP cuff. Discussed\n findings with Dr. .\n Response:\n No intervention, MICU team accepting SBP as low as 70.\n Plan:\n Cont to monitor, BPs have picked up since pt more awake. Now with SBP\n 80s-90s.\n Atrial fibrillation (Afib)\n Assessment:\n HR 80s-90s in AF/NSR. With occas PVCs. Cont on amioderone gtt\n Action:\n Pt given 2g Mag, lasix held overnight.\n Response:\n Less PVCs noted after Mg repletion.\n Plan:\n Cont IV amioderone until PEG placement . F/U with am labs.\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt very sedate most of shift. Over last few hours, becoming more awake\n but only crying out and yelling.\n Action:\n Attempted to orient, reassure pt and provide emotional support.\n Response:\n Unable to calm pt by talking, orienting her as she does not understand\n Plan:\n Cont to provide support as we are doing.\n Electrolyte & fluid disorder, other\n Assessment:\n UO 5-20 cc hr. Positive fld balance >28 liters for LOS\n Action:\n Lasix held this shift in setting of hypotension.\n Response:\n Pt had excellent response to Lasix given yesterday.\n Plan:\n Will cont to monitor, if BP improves when pt more awake, will try to\n diurese further.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653453,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake. +\n Mitral regurg.\n Cardiac\nhypotension --Atrial fibrillation (Afib)\n Assessment:\n Received patient in NSR\nAFIB rate 70s-90s, occasional pvcs\n rare\n missed beats\n SBP >90s-100s when aroused moaning but dropped intermittently to 70s\n with sleeping. Map marginal 50s-60\n Bodily very edematous, skin w/d. +dopplerable pulses.\n Action:\n Con\nt amiodarone gtt infusing at 0.5mg/min. replete\n k/calcium/magnesium\n Started maintenance IVF infusing 125ml/hr x1L for NPO for\n peg placement in the morning and low FS. Give\n Lasix dose 10mg x1 per\n micu residence .\n Keep all extremities elevated. Dvt prophylaxis with heparin\n sc.\n Resent UA for pre-peg placement as ordered.\n Added 2lnc for sat marginal 92%\n Response:\n Skin remains w/d. +csm. Sufficient diuresis with Lasix. Sat\n improved to >97% on 2lnc\n Plan:\n Con\nt monitor. Change to po amiodarone when peg placed?\n Start heparin gtt/coumadin for afib?\n ?check albumin level\nstart tf.\n Neuro --Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Received patient moaning, making incomprehensible sounds, yelling out.\n Calling\n\n few time. Eye kept closed. Perrl, open eye to\n turning/stimulus only. Maex4 to nail bed pressure and spontaneous. Not\n following any command. Difficult to complete neuro assessment. (not\n new per Micu residence). No seizure noted\n Action:\n Con\nt reorient, provide support, maintain safety\n Response:\n Patient slept most of night. More awake in am\n open eye spontaneous and\n follow some simple commands.\n Plan:\n Follow up with head Ct report. Neuro consult? Check valproate level??\n"
},
{
"category": "Physician ",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653457,
"text": "Chief Complaint: admitted for FTT, hypotension\n 24 Hour Events:\n -- PICC line repositioned by IR guiadance w/o complication\n -- family aggreed to PEG; surgery consulted and plan to do at some\n point on (she's as add-on and not yet scheduled)\n -- spoke with neurologist in (Dr. ); said AD dx\n was given within last year; has had behavioral changes (including\n ongoing regurgitation/emesis) for multiple years now, though. Medical\n workup negative, though never had brain imaging (wanted to have MRI but\n didn't cooperate). Also said her depakote/trileptal was not for\n seizure d/o, but for mood stabilization; she's only meant to be on\n depakote. She has also been wondeirng whether the patient has been\n depressed and might benefit from trial of an antidepressant.\n -- had head CT complete out-patient dementia w/u; pre-lim read said no\n bleed or mass effect; ? old insult to frontal lobes b/l (\"bifrontal\n subcortical hypodensities\"); large ventricles\n -- touched base with SW, , to start working on\n placement\n -- also spoke with Dr. ; agrees w/ sending out on PO amio; plans to\n electrically cardiovert after 4-6 weeks of anticoagulation\n Patient unable to provide history: MS/MR\n Allergies:\n Oxycodone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 87 (87 - 135) bpm\n BP: 74/45(52) {74/34(48) - 104/62(189)} mmHg\n RR: 12 (12 - 53) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,467 mL\n 700 mL\n PO:\n TF:\n IVF:\n 1,467 mL\n 700 mL\n Blood products:\n Total out:\n 2,065 mL\n 830 mL\n Urine:\n 2,065 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -598 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, moaning frequently\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), with\n radiation ot the back\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: 2+, Left: 2+, 2+ UE b/l\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, unable to follow simple commands due to baseline MS\n / Radiology\n 163 K/uL\n 9.7 g/dL\n 90 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 3 mg/dL\n 109 mEq/L\n 139 mEq/L\n 27.4 %\n 5.1 K/uL\n [image002.jpg]\n 04:07 PM\n 06:25 PM\n 03:49 AM\n 02:45 PM\n 03:15 AM\n 03:28 AM\n 03:37 AM\n 04:05 AM\n 04:35 PM\n 02:27 AM\n WBC\n 10.1\n 8.3\n 7.0\n 6.2\n 4.7\n 5.1\n Hct\n 32.2\n 28.6\n 28.0\n 25.3\n 26.4\n 27.4\n Plt\n 48\n 157\n 163\n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n 0.9\n 0.7\n 0.7\n 0.7\n 0.7\n Glucose\n 7\n 116\n 126\n 113\n 67\n 143\n 90\n Other : PT / PTT / INR:13.5/30.6/1.2, CK / CKMB /\n Troponin-T:310/10/0.29, ALT / AST:21/37, Alk Phos / T Bili:54/0.5,\n Amylase / Lipase:15/28, Differential-Neuts:79.0 %, Band:1.0 %,\n Lymph:13.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L,\n Albumin:1.7 g/dL, LDH:365 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.6\n mg/dL\n Fluid analysis / Other : UA:\n negative LE, nitrtites,\n 4 WBC\n 21 RBC\n Few bacteria\n 0 epis\n pH 5.5, SG 1.005\n Imaging: HEAD CT, Pre-lim report:\n Enlargement of the lateral, third and fourth ventricles, somewhat out\n of\n proportion to the degree of prominence of the cerebral sulci. Bifrontal\n subcortical hypodensities, without findings to suggest that this is an\n acute\n process.\n Microbiology: UA/UCx sent this am for pre-op, per surgery recs\n Assessment and Plan\n Patient is a 52 year old female with Down's syndrome, Alzhemier\n dementia, atrial fibrillation and hypothyroidism who presented with\n failure to thrive, decreased PO intake, elevated lactate,\n hypernatremia, hypotension, and supratherapeutic INR. Overall has been\n improving with IVF, though remains intermittently hypotensive during\n sleep and with no PO intake\n #) FTT: medical w/u negative; has had as out-patient as well, which was\n negative. Confirmed time course and diagnosis of dementia with pt\n neurologist. Family wants to proceed with PEG. No evidence of bleed\n on prelim Head CT read. ? relevance of enlarged ventricles on imaging\n -- surgery plans to take to OR today (coags, UA done; recent CXR in\n computer)\n -- f/u final read of\n -- Neurologist recommended trial of antidepressant (e.g., Paxil or\n Remeron) once taking PO\n CT\n #) Hypotension: remains off pressors; SBP dips to 80\ns while sleeping,\n but no evidence of end organ damage.\n #) Atrial fibrillation: Patient on sotalol and coumadin as\n outpatient. Earlier in week remained in afib , on , had HR 110-\n 120\ns, occ 130\ns even while at rest. Was loaded with amio IV with\n conversion to SR and HR < 100.\n -- cont IV amio; will convert to amio 400 mg TID PO once PEG can be\n used\n -- will discuss with surgery when heparin ggt can be started; will use\n as bridge to coumadin\n -- Dr. plans to electrically cardiovert in weeks once\n anticoagulated\n #) ? Seizure disorder, Meds for Mood Stabilization: clarified with\n neurologist that depakote is for mood stabilization. She is not also\n on trileptal.\n -- canceled trileptal order (though wasn\nt taking b/c was a PO med)\n -- Giving IV valproate while here in ICU; will convert back to home\n dose depakote once taking meds through PEG\n #) Hypothyroidism:\n -- cont levothyroxine 37.5 mg IV QD; convert back to PO home dose once\n taking meds by PEG\n #) GERD:\n -- Continuing PPI IV as unable to take PO\ns; will convert when taking\n meds through PEG\n #) FEN:\n -- nutrition consult for feed recs once using PEG\n -- was on IVF overnight for maintenance\n #) Code: Full per discussion with patient's HCP\n #) Communication: Brother: is HCP ; work\n (? home)\n ICU Care\n Lines:\n PICC Line - 10:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU until PEG surgery ; transfer to floor after\n that until using EPG ; will discuss need for IV heparin bridge vs.\n Lovenox upon discharge.\n CM contact to begin work on placement options.\n"
},
{
"category": "Nursing",
"chartdate": "2140-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653465,
"text": "Pt 52 yo F with Down's syndrome, Alzhemier\ns dementia, atrial\n fibrillation and hypothyroidism who presented with failure to thrive,\n decreased PO intake, elevated lactate, hypernatremia, hypotension, and\n supratherapeutic INR. Overall has been improving with IVF, though\n remains intermittently pressor-dependent and with no PO intake. +\n Mitral regurg.\n Cardiac\nhypotension --Atrial fibrillation (Afib)\n Assessment:\n Received patient in NSR\nAFIB rate 70s-90s, occasional pvcs\n rare\n missed beats\n SBP >90s-100s when aroused moaning but dropped intermittently to 70s\n with sleeping. Map marginal 50s-60\n Bodily very edematous, skin w/d. +dopplerable pulses.\n Action:\n Con\nt amiodarone gtt infusing at 0.5mg/min. replete\n k/calcium/magnesium\n Started maintenance IVF infusing 125ml/hr x1L for NPO for\n peg placement in the morning and low FS. Give\n Lasix dose 10mg x1 per\n micu residence .\n Keep all extremities elevated. Dvt prophylaxis with heparin\n sc.\n Resent UA for pre-peg placement as ordered.\n Added 2lnc for sat marginal 92%\n Response:\n Skin remains w/d. +csm. Sufficient diuresis with Lasix. Sat\n improved to >97% on 2lnc\n Plan:\n Con\nt monitor. Change to po amiodarone when peg placed?\n Start heparin gtt/coumadin for afib?\n ?check albumin level\nstart tf.\n Neuro --Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Received patient moaning, making incomprehensible sounds, yelling out.\n Calling\n\n few time. Eye kept closed. Perrl, open eye to\n turning/stimulus only. Maex4 to nail bed pressure and spontaneous. Not\n following any command. Difficult to complete neuro assessment. (not\n new per Micu residence). No seizure noted\n Action:\n Con\nt reorient, provide support, maintain safety\n Response:\n Patient slept most of night. More awake in am\n open eye spontaneous and\n follow some simple commands.\n Plan:\n Follow up with head Ct report. Neuro consult? Check valproate level??\n"
},
{
"category": "Nursing",
"chartdate": "2140-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655306,
"text": "Pt is 52 year old w/ Down's Syndrome & Alzheimer's Disease who is being\n transferred back to MICU for hypotension. She was initially admitted\n to the MICU on with FTT & hypotension requiring pressors, There\n was no clear cause to the hypotension besides volume depletion. PEG\n tube was place on during admission. Head CT showed enlarged\n ventricles, and neurology is currently consulting for dementia\n work-up. She is also currently being treated for a UTI with Bactrim.\n Coumadin for AFib is being held for an INR of 2.9. Prior to transfer to\n MICU on pt received Zyprexa 5 mg for sedation and underwent head\n MRI per neuro recs. She was noted to be somnolent and hypotensive on\n this afternoon. Prior to the transfer, she received two liters of NS\n bolus with improvement in BP from 60/palp to 80's systolic. She has\n been afebrile.\n Events: Pt did have large amts of emesis last night () which\n has led to Asp. PNA. Family meeting held this afternoon. Pt is now a\n DNR/DNI. PICC line has been pulled back ~ 5cm. Radiology, MICU team and\n IV therapy in agreement of position and that we can cont. to use it. If\n any further dislodgement occurs, please stop IVF and call resident. Do\n not advance per IV therapy.\n While turning pt/or stimulating pt, HR increases to 170\ns but settles\n out one repositioned. Team is also in agreement with renal for ~18cc/hr\n of urine.\n Hypotension (not Shock)\n Assessment:\n Afib. . HR 80-110. Tachycardic to 170\ns upon any stimulation (baseline)\n SBP range 79-105 with MAP 45-75. Rec\nd on Levophed gtt this AM at 0.15\n mcg/kg/min. LS dim throughout.. CXR showing asp. pna. O2 sat down\n to 88% this afternoon.\n Action:\n Team aware of pt\ns hypotension issues. Levophed gtt remains at\n 0.15mcg/kg/min\n Response:\n Pt has maintained SBP 80-100 with MAP 50s-70\ns which is acceptable per\n MICU team. Continues with UO 50-80ml/hr.\n Plan:\n Wean pressors as tolerated. Monitor cardiopulmonary status. Monitor\n lytes/labs .\n Note: Pt is weeping fluid volume. Monitor PICC dsg for saturation.\n Pneumonia, aspiration\n Assessment:\n Received pt on 2L NC. Lung sounds dim throughout. Oxygen cont on NRB\n overnight. O2 sat 85-100%. Increased lethargy noted as well\n Action:\n TF increased to 20ml/hr.\n Response:\n Pt currently satting 98-100%. TF currently @ 10cc with no residuals.\n Remains on Levo gtt as noted above.\n Plan:\n Run pt even if possible. Cont to monitor resp status and O2\n consumption. Cont. IV abx. DNR/DNI. Emotional support as needed.\n"
}
] |
94,234 | 162,751 | 87 yo F h/o dementia, GI bleed in , popliteal artery embolus in , atrial fibrillation on warfarin, who presents with several days of maroon colored stool. . ACTIVE ISSUES: #. GI Bleed: She presented with hematochezia in the setting of elevated INR to 6.6. It was felt initially that she likely had an upper GI bleed due to elevated BUN and history of gastritis in the past. She was placed on a PPI twice daily and her INR was reversed with vitamin K and FFP. She was given 1 uPRBC and her hematocrit remained stable. She was seen by the GI consult service who did not feel that she needed to undergo endoscopy. She was advanced to full solids which she tolerted well. . #. Elevated INR: She was given 10 mg IV vitamin K and two units of FFP on admission. Her coumadin was held. Her INR trended down to 1.1 and after the bleeding had stopped she was restarted on warfarin 2 mg daily with planned frequent monitoring at rehabilitation. . #. ECG Changes: She had ECG changes which were consistent with digoxin effect. Her digoxin level was normal. She ruled out for MI. . #. UTI: She had a positive UA and was started on ceftriaxone for treatment of UTI. Her culture came back as klebsiella and she was switched to cipro for a planned course of 7 days (last day PM). . #Acute kidney injury: During admission her creatinine increased from 1 to 1.3. This was felt to be prerenal and she was given 1 L of NS. Her urine was sent for electrolytes. This will need to be followed up in rehab. . CHRONIC ISSUES: #. Atrial Fibrillation: Has had multiple complications including popliteal artery embolus requiring embolectomy and TIAs/CVAs. Her warfarin was held on admission. Her beta blocker was also initially held but restarted on HD1. He warfarin was restarted on the day prior to discharge. . #. Dementia: Due to Alzheimers and vascular etiolgy. She was frequently reoriented during this admission. . #. Hypertension: She was hypertensive on admission and treated with her home ACE-I and an oral dose of hydralazine with good effect. Later her home beta blocker was restarted and her BP remained well controlled. . #. Hyperlipidemia: Continued on simvastatin . #. Diabetes: Diet controlled at home, she was continued on humalog ISS in house . TRANSITIONAL ISSUES: #INR monitoring: She was restarted on warfarin 2 mg daily. She will need frequent INR checks at rehabilitation. #Elevated creatinine. Please check creatinine tomorrow and friday to ensure decreasing creatinine. HCP: is lawyer who makes all medical decisions. is son and primary caretaker. | Compared to the previous tracing of atrial fibrillationhas resolved.TRACING #1 Clinical correlation issuggested. COMPARISONS: CT head . Assess for acute process. WET READ VERSION #1 FINAL REPORT INDICATION: Altered mental status, GI bleed. Sinus rhythm. Coronal and sagittal reformations were prepared. IMPRESSION: No acute intracranial process. Ventricular and sulcal prominence reflects age-appropriate atrophic changes. Imaged paranasal sinuses and mastoid air cells are well aerated. Same as tracing #1.TRACING #2 TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. There is no shift of normally midline structures. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Inferolateral ST-T wave changes may be due to left ventricularhypertrophy but cannot rule out myocardial ischemia. bleed No contraindications for IV contrast WET READ: SHSf FRI 6:50 PM No acute intracranial process. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarction. There is no fracture. 5:33 PM CT HEAD W/O CONTRAST Clip # Reason: ? | 3 | [
{
"category": "Radiology",
"chartdate": "2143-08-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1205520,
"text": " 5:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with altered mental status in setting of GI bleed\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHSf FRI 6:50 PM\n No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, GI bleed. Assess for acute process.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISONS: CT head .\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarction. Periventricular and subcortical white\n matter hypodensities are compatible with chronic small vessel ischemic\n disease. Ventricular and sulcal prominence reflects age-appropriate atrophic\n changes. There is no shift of normally midline structures. There is no\n fracture. Imaged paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-08-10 00:00:00.000",
"description": "Report",
"row_id": 203655,
"text": "Same as tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2143-08-09 00:00:00.000",
"description": "Report",
"row_id": 203656,
"text": "Sinus rhythm. Inferolateral ST-T wave changes may be due to left ventricular\nhypertrophy but cannot rule out myocardial ischemia. Clinical correlation is\nsuggested. Compared to the previous tracing of atrial fibrillation\nhas resolved.\nTRACING #1\n\n"
}
] |
4,163 | 137,425 | Respiratory - Infant was intubated with maximum ventilator settings with IMV of 20, PIP of 24, positive end-expiratory pressure 25. The infant received a total of four doses of Survanta and was extubated to CPAP on day of life #5. Infant changed to nasal cannula by day of life #6 and is currently on nasal cannula 25 cc of flow on 100% FIO2 with respiratory rates in the 30s to 60s. Caffeine citrate was started on day of life #6 for apnea of prematurity. Cardiovascular - The infant has remained hemodynamically stable this hospitalization. No murmur. Fluid, electrolytes and nutrition - The infant was initially started on intravenous fluids of D10/W at 80 cc/kg/day and advanced to 150 cc/kg/day by day of life #6. Enteral feedings of premature Enfamil 20 cal/oz were started on day of life #2 and advanced to 150 cc/kg/day by day of life #6, infant was advanced to 22 cal of Premature Enfamil by day of life #7. The infant has tolerated feeding advancement without difficulty. Most recent weight is 1650 gm. Most recent electrolytes were on day of life #4, sodium 142, potassium 4.1, chloride 108, pCO2 21. Gastrointestinal - Infant received single phototherapy for a total of three days, maximum bilirubin was 8 with a direct of 0.3. The most recent bilirubin on day of life #7 which was a rebound was 7.1 with a direct of 0.3. Hematology - Most recent complete blood count from day of life #4 showed a white blood cell count of 7.4, hematocrit 43.7, platelets 212, 34 polys, 0 bands, 46 lymphocytes. Hematocrit on day of delivery was 51.7. Infectious disease - Infant received a total of 48 hours of Ampicillin and gentamicin. Blood cultures remained negative to date. Neurology - The infant has not received initial head ultrasound and was scheduled for head ultrasound on day of life #9. Sensory - Audiology, hearing screening is recommended prior to discharge. Ophthalmology, the patient is due for first examination at three weeks of age. Psychosocial - social work involved with family. The contact social worker can be reached at . | Bili level due in am.Light's d/c'd yest. BS with coarse rhonchi, clear after sxn. Follow-up CBG: 7.30/53/43/27/0. Returned this am w/ cramping, progressive labor despite MgSO4.Proceeded to delivery by repeat Cesarean section. +intubated. min BS. Serologies: O+, ab neg, hep neg, RPR NR, RI, chl neg, GBS unk. Occ spells. Baseline IC/SC retractions. Lungs ounds clear and eqaul with mildretractions. +facial CPAP. Symmetric.CBC 15.8 (diff pending)/51.7/237Bld cx pendingCBG 7.25/54Impression:1. PIV D/C. D sticks WNL. Murmer noted this am. Advance cals to PE22. Noincreased wob noted. Oncaffeine. MILD RTXN'S. Bili 7.2/0.3/6.9. IC/SC retractions present. Current wgt 1650g (BW1770g) Tolerating gavage feeds well of Pe 22 cals q 4 hrs, with occasional spits. A: toleratingfeeds well. NPN3-11PM1. Sx lg from NP tube. DSTIX 76.#3 MOM X1 FOR UPDATE.#4 TEMPS ARE STABLE SWADDLED IN AIR ISO. Abd slightly full andsoft with good bs and no loops. D-stick 103 at 0430.Continue per plan, monitor spits. RR 50's-60's with mild IC/SCR. r/o sepsis - risks prematurity, GBS unk.Plan:1. Aspetic technique. temp stable in heated isolette. GU nl phallus for age. Respiratory CareBaby rec on 15/5, R 14. A: doing well on NPCPAP, havingsome apnea. A: AGA. P: Continue to moniter. P:Continue to moniter for milestones.#5 O: Rebound bili level drawn this mroning was 6.6/.3/6.3.Skin slightly jaundiced. RR 30-40's with clear BS and minimal secretions. Resp care noteBaby remains on NP CPAP +6 21-25% fio2. FEN - NPO, maintenance IVF.4. a/ resolving p/ cont to monitor level. BBS clear. IVF2. Now in low flow O2 per NC. P:Continue to monitor, check another gas this am.#2 FEN O: Tf remain at 120cc/k/day. CV - Monitor for hypotension, PDA. Ext pink and well perfused.Studies:CXR - ETT ok. NICU NPN ADDENDUMcap gas this am 7.30/53. Continue to support g/d.BILI: Second rebound bili sent at 0430. Newborn Med AttendingWeaned off of CPAP yest. Bp 66/44m51. < 32 , need HUS screening. Abdomenbenign. Afofs. Wt=1650 up 10, on 150 cc/kg PE20.A/P: Infant with resolving RDS. IVF ofd10pn, infusing through piv well, along with IL, at90cc/k/day. Min aspirates. Continute PN at D10. A: Tolfeeds. Stable temp in isolette. Lytes today wnl. Kanagroo'dX30mins. TF at 120 cc/k/d. TF at 120 cc/k/d. O: Temp stable in servo mode isolette. Ls crs, clears with Sxn. A: AGA P:Cont. Hct today 43.7. benign, min.aspirates. Dstix 74. NPN1.Remaisn in NPcpap with peep of 6, rr 40-60's, bscl=, wellaerated, sux x2 for mod. P: Cont to monitorbili. TF to be held stable since incresaed during noc. Abdoemn benign. Check bili in am. CBG obtained. Bili under single photo 7.2. Mild-moderate retractions noted with xyphosternum present. O: Under single phototherapy. Brady x1this shift. Fio2 requirement .21-.30. P: Cont. pHOTO DC'D AT 110O WITH PLANS FOR REBOUND IN AMTOMORROW.rEM SL JAUNDICED. NPN 0700-19001. TF120cc/kg. Abd soft withpos bs tol all fdgs well. CBG: 7.25/57/47/26/-3. Infant sxn for mod amts subsequently. O: Pt with TF 120cc/kg. TF at 140 cc/k/d . P: Continue to monitor.#2 FEN O: Tf remain at 100cc/k/day. Pt self extubated today at 1200 and another Endotracheal tube was placed at 8.0cm. Feeds at 10 cc/k/d. feeds at 90 cc/k/d. On single phototherapy, NBpending. A:Stable at present.P: Cont. BBs coarse->clear. NICU NPN ADDENDUMMorning labs(lytes) 143/4.3/106/20/21. Will wean as tolerated. on vent settings of19/5x16. Resp care note 7p-7aPt remains on vent settings 19/5 x 16 fio2 25-35%. Will advance to 140 cc/k/d. Tolerating advance of 20 cc/k/d advancement. Cont with intercostal/subcostalretractions. Respiratory TherapyContinues on NP CPAP of 6, 0.26-0.30. Mildly tachypneic. 90cc/kg PN D10+IL infusing wellvia PIV. Lg yellowsecretions via ETT. Neonatology - Progress NOteInfant is active with good tone. Document A/B's.2. tosupport developmentally. Bili 8.0/0.3/7.7. Weight 1640g, down125g.Tolerating gavage feeds of pe20 well, at 10cc/k/day. Abdomen soft,round, bs are active, no stool to time this shift. PCont to assess g&d needs.#5O/A-rECEIVED ON SINGLE PHOTO WITH BILI MASKS REMOVED WITHCARES. O: Received pt orally intubated on IMV settings of 19/5X16. NeonatologyRemains on SIMV. NeonatologyRemains on SIMV. NeonatologyPhototherapy to be dced and bili follwoed. P: Adv as ordered and assesstolerance. ordered a N/G tube to be placed (1.1ccaspirate 1x.) Wean vent as tol. A:Resp status. A: Tol wean vent settings. Moderate substernal, subcostal, and intercostal retractions noted. DEV: moved into an isolette. DSTIXSTABLE 66,120. MAE.A: AGA P: Cont to support g+d. and a glycerin sup to be given, resultspending. RR 40-60.Contsw/mild SC/IC retractions. On amp/gent. Labs noted and PN adjusted accordingly. Mod subcostal/intercostal retractions. Last CBG 7.38/48. PTSTARTED ON AMP AND GENT, GIVEN AS PER ORDERS. P:Cont to follow resp status. A/P: Contto monitor temp. Temps stable on servocontrol. TF 80 d10. Will keep NPO but start PN. Settles well andsleeps betw cares. See attending admit noted for hx and further details. Cont to cluster care. D-sticks stable.Abomen full soft with +BS. Tol d10. Cont towean settings as tol.3. Xyphosternum present. A:AGAP:Support. Resp care note 7p-7aPt remains on vent settings 21/5 x 20 fio2 28-36%. Sx sm-mod clear secretions. 1yellow spit. +bs. NeonatologyDoing well. NPO with PN. P: Cont to monitor resp status. Lsclear and diminished, yet increased aeration from beginningof shift. FINDINGS: ETT is in place with its tip at the thoracic inlet. Keep TF at 80 cc/k/day. DS 94-131. A:Vested and caring P:Support andeducateD/G: Nested under warmer. Cap gas on those settings 7.26/57. Weaned pt to 21/5 X20. Will advance to 100 cc/k/d. Continue to follow.Completing 48 h r/o. Sux q4hr for thinwhite secretions in sm amts. Vent parameters as per flowsheet. PN started on DOL 1 via PIV. Will continure for 48 hour sepsis rule out.Neuro: Fotenells soft and flat with sutures mobile and separated slightly. NPN RESP: remains intubated on IMV.current settings are19/5 x16. Asking appropquestions. LScoarse-> cl after sux, occas diminished. P:Monitor and wean astolerated.FEN: total fluids at 80cc/kg/day of PNd10. FEN: is on TF 100cc/k/d PIV D10PN at 90cc/k/infusingwell and 10cc/k/d enteral feeds PE20. O: Temp stable nested on open warmer. Respiratory Care NOteBaby 2 continues vented on a rate of 16 19/5 and 28-32%. | 53 | [
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734935,
"text": "NPN Days 7a-3p\n\n\n#1 O: Infants remains on NPCPAP of 6 cms of pressure. FIO2\nneeds mostly 21-24%. Lungs ounds clear and eqaul with mild\nretractions. Sxn for small amt yellow secretions. Resp\nrates 30-40s. Infant having contniued periods of apnea,\nespecially after crying and did bradys x this shift -\ncaffeine has been ordered. A: doing well on NPCPAP, having\nsome apnea. P: Continue to moniter resp status closely.\nPlan to give loading dose of caffeine when it arrives from\npharmacy.\n#2 O: TF increased to 150cc/k/day. Feeds of Pe 20 cals\ncurrently at 130cc/k/day. Tolerating gavage feeds well,\nwith no aspirates and no spits. Abd remains softly round,\n+bs, no loops, Ag stable. Voiding adeq amts. A: tolerating\nfeeds well. P: Continue to moniter. Advance feeds to full\nvolume later today.\n#3 O: Infant's were in to visit this afternoon.\nThey particpated in cares and mother held both babies.\nAsking appr. questions. Bedside family meeting was\ncancelded d/t unit acuity and we made a tentative reschedule\ndate with for sometime tomorrow afternoon. A:\ninvolved andinvested . P: Contniue to support.\nTentative family meeting scheduled for bedside tomorrow\nafternoon.\n#4 O: Infant and active with cares, irritable at times\nbut does settle with sucking on his pacifier. Ant fotn soft\nand flat. temp stable in heated isolette. A: AGA. P:\nContinue to moniter for milestones.\n#5 O: Rebound bili level drawn this mroning was 6.6/.3/6.3.\nSkin slightly jaundiced. A: resolving hyperbilirubinemia.\nP: Recheck bili tomorrow morning.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734936,
"text": "NPN3-11PM\n\n\n\n1. Received infant on cpap 6cm. Fio2 21-27% with sats 95%\nand greater. Infant changed to nc at 2030hrs at 100cc flow\nand fio2 of 50-55%. Sats remain mid to high 90's. No\nincreased wob noted. RR 50-60's. No spells thus far in\nshift. Conts on caffeine. Loading dose given this evening.\na/ stable with nc p/ cont to monitor for any increased wob,\nincreased spells.\n\n2. Tf increased to 150cc/k/d of pe20. Abd slightly full and\nsoft with good bs and no loops. Voiding and stooling qs\namts. Abd girth 23.5cm. No spits and minimal asp. a/ tol\nfeedings and gaining weight. p/ cont to monitor abd exam,\nmonitor for any feeding intolerance.\n\n3. Mom called for update tonight. Aware of infant's change\nto nc and is pleased of that. Mom reported to this RN that\nshe will be in around 1100-1130 tomorrow. a/ involved and\ninformed p/ cont to support and encourage questions.\n\n4. Infant in air mode isolette with stable temps. Resting\nquietly between cares. and slightly irritable during\ncares settling quietly after. Afofs. Maew, tone appopriate\nfor ga. a/ aga p/ cont to support dev needs of infant.\n\n5. Color pink with good perfusion. Bili level due in am.\nLight's d/c'd yest. a/ resolving p/ cont to monitor level.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734931,
"text": "#1 PT CONT ON CPAP 6 RA -25%. SX FOR LARGE WHITE VIA TUBE,\nLARGE CLEAR VIA MOUTH. MILD RTXN'S. NO SPONT BRADY'S OR\nDESATS.\n#2 TF 150CC/KG. PIV D/C. FEEDS OF PE20 AT 130CC/KG, TO\nADVANCE TO FULL FEEDS TODAY AT 1230PM. WEIGHT REMAINS\nUNCHANGED. VOIDING, NO STOOL AT THIS TIME. DSTIX 76.\n#3 MOM X1 FOR UPDATE.\n#4 TEMPS ARE STABLE SWADDLED IN AIR ISO. IRRITABLE WITH\nCARES, DIFFICULT TO SETTLE.\n#5 REBOUND BILI SENT, PENDING.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734932,
"text": "Resp care note\nBaby remains on NP CPAP +6 21-25% fio2. RR 30-50's. BBS clear. Sx lg from NP tube. Tube patent and secure in good position. Will follow, wean off cpap as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734933,
"text": "NICU Attending Note\n\nDOL # 6 s/p 30 6/7 weeks with pulmonary immaturity, advancing to full volume feeds, resolving hyperbili.\n\nPlease see .\n\nCVR/RESP: s/p surf x 4, now on CPAP at 6 21-30% FiO2, last CBG: 7.33/54. + two epsiodes of A/B, not on stimulant. Will continue CPAP, start caffeine, otherwise continue current managment.\n\nFEN: Weight today 1640, no chnange from yesterday, on TF of 140 cc/kg/d, of which 130 cc/kg/d is PE 20, tolerated well. D sticks WNL. Will increase TF to 150 cc/kg/d, all given enterally.\n\nBILI: Rebound bili 6.6/0.3, up from 5.4/0.3 yesterday for which phototx stopped. Will leave phototx off, check another rebound bili tomorrow am.\n\nNEURO: first head U/S schedculed for re: IVH.\n\nDISPO: TO go to when stable off of CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-14 00:00:00.000",
"description": "Report",
"row_id": 1734934,
"text": "Respiratory Care\n boy #2 continues on CPAP 6, 21-25% O2. RR 30-40's with clear BS and minimal secretions. Loaded with caffiene today, plan to trial off CPAP either tonight or tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-15 00:00:00.000",
"description": "Report",
"row_id": 1734937,
"text": "NICU NPN 2300-0700\n\n\nRESP: Infant remains in NC O2, 100cc, 35-50% this shift. RR\n30-60's. LS clear and equal. IC/SC retractions present. TB\nsuctioned x1 for lg amt of yellow secretions. No spells. On\ncaffeine. Continue to monitor resp status, wean O2 as\ntolerated.\n\nFEN: Weight 1650 grams, up 10g. TF=150cc/k/d, PE20, 44cc q 4\nhours over 1 hour. Large spit x1, no aspirates. Abdomen\nbenign. Girth 23cm. Voiding, stooling. D-stick 103 at 0430.\nContinue per plan, monitor spits.\n\n: No contact this shift. Continue to support and\nupdate.\n\nDEV: Infant is swaddled in an air mode isolette, stable\ntemps this shift. , active. Sleeping well b/w cares.\nBrings hands to face. Continue to support g/d.\n\nBILI: Second rebound bili sent at 0430. Results pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-15 00:00:00.000",
"description": "Report",
"row_id": 1734938,
"text": "Newborn Med Attending\n\nWeaned off of CPAP yest. Occ spells. Now in low flow O2 per NC. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1650 up 10, on 150 cc/kg PE20.\nA/P: Infant with resolving RDS. Monitor for spells. Advance cals to PE22.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-15 00:00:00.000",
"description": "Report",
"row_id": 1734939,
"text": "Nursing Transfer Note:\nA: BAby boy is ready for transport to . Infant remains on O2 nasal cannula, in 100% and needing mostly 12.5-25cc of flow. Lung sounds remains clear and equal with mild retractions. HR regular with no murmur heard. To receive first maintenance dose of caffeine to today, no As or Bs this shift. Current wgt 1650g (BW1770g) Tolerating gavage feeds well of Pe 22 cals q 4 hrs, with occasional spits. Abd soft, +bs, no loops. Voiding adeq amts, mec stools. Maintaining temp in heated isolette. Irritable at times, does settle with containment and sucking on his pacifier. Biliruin levels this morning were 7.1/.3/6.8 (phototherapy was d/c'd on ). Infant's mother was in to visit this afternoon - she is aware of plan for trnasport of her infant and signed consent for transport. A/P: 7 day old, former 30 wkr, in nasal cannula and rec. gavage feeds, ready for transport to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734915,
"text": "5 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 5 Hyperbilirubinemia; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734916,
"text": "Respiratory care note;\nPt remains on CV settings currently= 15/5, RR= 14. Fio2= 30-33%. Suctioning large amounts of thick, white sputum quite frequently. Another CBG is needed to check setting changes. decided to decrease settings based on cbg: 7.29, 38, 57, 19, -7.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-08 00:00:00.000",
"description": "Report",
"row_id": 1734889,
"text": "Neonatology-NNP Progress Note\nProcedure: Intubation\nIndication: RDS\n\nInfant on warmer with oximetry & cardiac monitoring in place, in midline position, using #0 laryngoscope blade,m 3.0 ett passed through vocal cord, taped at 8 cm mark at lip, Tolerated procedure well, CXR in progress to confirm placement\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-08 00:00:00.000",
"description": "Report",
"row_id": 1734890,
"text": "Neonatology Attending Admit Note\n\nInfant is a 31 week, 1770 gm male newborn, twin B, who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 35 y.o. G2P1 mother. Serologies: O+, ab neg, hep neg, RPR NR, RI, chl neg, GBS unk. Maternal history of fibroids, s/p myomectomy x 2. Prior Cesarean section with previous pregnancy and delivery (38 week male, doing well).\n\nThis pregnancy notable for:\n1. IVF\n2. PTL, admission at 29 weeks, received betamethasone at that time.\n3. Returned this am w/ cramping, progressive labor despite MgSO4.\n\nProceeded to delivery by repeat Cesarean section. Clear fluid, no maternal fever.\n\nTwin B emerged crying, active, Dried, suctioned, stimulated, given BBO2. Responded well, but early signs of respiratory distress. +facial CPAP. Apgars 7,8. Shown to parents and transported to the NICU.\n\nNICU course: Intubated soon after arrival to NICU. Blood work drawn, IVF started, abx begun.\n\nExam:\nAFSF. +intubated. Lungs coarse, rtxns, poor to fair air entry. CV RRR, no murmur, 2+FP. Abd soft. min BS. GU nl phallus for age. Testes high but palpable. Ext pink and well perfused.\n\nStudies:\nCXR - ETT ok. Complete opacification of lung fields w/ air bronchograms. Symmetric.\nCBC 15.8 (diff pending)/51.7/237\nBld cx pending\nCBG 7.25/54\n\nImpression:\n1. AGA, preterm male.\n2. Respiratory distress syndrome.\n3. r/o sepsis - risks prematurity, GBS unk.\n\nPlan:\n1. Resp - vent support/surfactant as needed. Monitor gases closely.\n2. CV - Monitor for hypotension, PDA. Consider arterial access for monitoring of blood gases given moderate to severe RDS.\n3. FEN - NPO, maintenance IVF.\n4. ID - Amp and gent pending lab results and clinical course.\n5. < 32 , need HUS screening.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-08 00:00:00.000",
"description": "Report",
"row_id": 1734891,
"text": "Procedure Note: Peripheral arterial cannulation\nIndication: elevated FiO2 requirement on vent necessitating frequent blood gas monitoring\n\n#22 g Jelco catheter percutaneously inserted in right radial artery. Draws and flushes easily, appropriate wave form via transducer. Aspetic technique. Infant tolerated procedure well, minimal blood loss. No complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734892,
"text": "1 RESP\n2 FEN\n3 PARENTS\n4 DEV\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; added\n Start date: \n 2 FEN; added\n Start date: \n 3 PARENTS; added\n Start date: \n 4 DEV; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734917,
"text": "NICU NPN 1900-0700\n\n\n#1 RESP O: remains orally intubated, on current vent\nsettings of 15/5x16. Breath rate increased for an ABG of\n7.27/56/27/-1, PO2 85. Lungs are coarse, suctioned q3hr, for\nthick yellow-white secretions from ETT. Resp rate 40-60's,\no2 sats 93-98%, with drifts to the high 80's, mainly with\ncares. Baseline IC/SC retractions. No murmur, hr 130-160's.\nA: Breath rate increased, Desat x1 to 60's, after weight. P:\nContinue to monitor, check another gas this am.\n\n#2 FEN O: Tf remain at 120cc/k/day. Weight 1555g, down 90g.\nTolerating advancing feeds of pe20 well, now at 50cc/k/day.\nIVF of d10pn, and il, are infusing through new piv well,\nstooling, u/o 3.4cc/k/hr. Abdomen is soft, ag stable, no\nspits. A: Tolerating feeds. P: Continue to advance feeds as\ntolerated.\n\n#3 Parenting O: Mom in to visit, asking appropriate\nquestions. A: Involved, loving parents. P: Continue to keep\nparents informed.\n\n#4 DEV O: Temps are stable, nested on sheepskin, in servo\nisolette. Baby is and active with cares, sleeps well\nin between cares. Fontanells are soft and flat. A: aga P:\nContntinue to support development.\n\n#5 Bili O: Baby remains under single photo, wearing eye\nshields. Bili 7.2/0.3/6.9.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734918,
"text": "NICU NPN ADDENDUM\ncap gas this am 7.30/53. Soft murmur heard this am. aware. Fio2 also slightly increased. Bp 66/44m51. Peripheral pulses normal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734919,
"text": "Respiratory Care\nBaby rec on 15/5, R 14. BS with coarse rhonchi, clear after sxn. Sxn for mod-lg amts thick white- yellow secretions. ETT retaped without incident. RR 50's-60's with mild IC/SCR. ABG: 7.27/56/85/27/1; rate increased to 16. Follow-up CBG: 7.30/53/43/27/0. No spells noted. Murmer noted this am. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734920,
"text": "Neonatology\nRemains on SIMV. No evidence of PDA.\n\nWt 1770 down 70. TF at 120 cc/k/d. Will advance to 140 cc/k/d. feeds at 50 cc/k/d. Abdoemn benign. No difficulty with advancemnets\n\nBili in 7 range\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734909,
"text": "NICU NPN 1900-0700\n\n\n#1 RESP O: Baby remains intubated,. on vent settings of\n19/5x16. O2 sats are 95-100%, with occasional drifts with\ncares to the high 80's. Lungs coarse, clear after\nsuctioning. Resp rate 40-50's, baseline ic/sc retractions.\nNo bradys to time this shift. Fio2 25-35% durint the night.\nA: stable on current vent settings. P: Continue to monitor.\n\n#2 FEN O: Tf remain at 100cc/k/day. Weight 1640g, down125g.\nTolerating gavage feeds of pe20 well, at 10cc/k/day. IVF of\nd10pn, infusing through piv well, along with IL, at\n90cc/k/day. Dstick 69, no spits, no asp. Abdomen soft,\nround, bs are active, no stool to time this shift. A: Tol.\nfeeds. Urine output for the shift is 5.3cc/k/hr. P: Continue\nto monitor.\n\n#3 Parenting O: No contact thus far this shift.\n\n#4 DEV O: Temps are stable, nested on sheepskin, in servo\nisolette. Baby is and active with cares, sleeps well\nin between cares, fontanells are soft and flat. A: aga P:\nContinue to support development.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734910,
"text": "Resp care note 7p-7a\nPt remains on vent settings 19/5 x 16 fio2 25-35%. RR 40-50's. No spells. BBs coarse->clear. Sx mod white secretions. OET patent/secure in good position. AM gas pending. Will wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734911,
"text": "NICU NPN ADDENDUM\nMorning labs(lytes) 143/4.3/106/20/21. Bili 8.0/0.3/7.7. Tf increased to 120cc/k/day, and baby started on single phototherapy. He has a large meconium stool after glycerine supp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734912,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds course, good aeration throughout. Nl S1S2, no audible murmur. pink, jaundiced and well perfused. Abd benign, no HSM. active bowel sounds. infant active and with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734913,
"text": "Neonatology\nRemains on SIMV. Low fio2. Generally comfortable appearing. Mildly tachypneic. CBG shows CO2 in mid 50s. No evidence of PDA.\n\nWt 1640 down 125. TF at 120 cc/k/d. Feeds at 10 cc/k/d. Abdomen benign. TF to be held stable since incresaed during noc. Lytes in good range.\n\nBili in 8 rang. To be followed.\n\nCompleted 48 h r/o with abx.\n\nCBC to be repeated with diff for initial count that showed relative granulocytopenia.\n\nHUS for later this week.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-11 00:00:00.000",
"description": "Report",
"row_id": 1734914,
"text": "NPN 0700-1900\n\n\n1. O: Received pt orally intubated on IMV settings of 19/5\nX16. CBG obtained. (see lab for results) Settings decreased\nto 17/5 X16. FiO2 23-30%. Ls crs, clears with Sxn. Lg yellow\nsecretions via ETT. Cont with intercostal/subcostal\nretractions. No A's&B's. A: Cont to require ventilation to\nmaintain adequate aeration. P: Cont to monitor resp status.\n\n2. O: Pt with TF 120cc/kg. 90cc/kg PN D10+IL infusing well\nvia PIV. 30cc/kg enteral feeds of PE 20. Min aspirates. No\nspits. AG21-22 cm. Voiding. No stool. Dstix 74. A: Tol\nfeeds. P: Cont to monitor wt, abd, and tol of feeds. Cont to\nincrease feeds 20cc/kg as tol.\n\n3. O: Mom in mult time. Min assist with care. Kanagroo'd\nX30mins. Asking appropriate questions. A/P: Cont to educate\nand support family. FTM tomorrow.\n\n4. O: Temp stable in servo mode isolette. and active\nwith care. A/P: Cont to monitor temp. Cont to cluster care.\n\n5. O: Under single phototherapy. Eye shields on. Voiding. TF\n120cc/kg. Ruddy. A: Hyperbilirubinemia. P: Cont to monitor\nbili. Check bili in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734925,
"text": "NPN\n\n\n1.Remaisn in NPcpap with peep of 6, rr 40-60's, bscl=, well\naerated, sux x2 for mod. yellow -white secretions. Brady x1\nthis shift. CBG at 0430 7.25/57, no changes made. Self\nextubated at 1900 on . Fio2 requirement .21-.30. A:\nStable at present.P: Cont. to follow. Document A/B's.\n2. TF@ 140/kg/d, PIV of PND10w at 50/kg/d, DS 106, enteral\nfeeds presently at 90/kg/d of PE 20, abd. benign, min.\naspirates. Voiding and stooling. On single phototherapy, NB\npending. A: Tolerating advancement of feeds. P: Cont. to\nadvance 20/kg/ as tolerated.\n3. Parents called this shift. Plan on visiting tomorrow,\nplan on family mtg on sat. at 1300.\n4. Stable temp on sservo probe in isloette. ,\nirritable at times, sucking on pacifier. A: AGA P:Cont. to\nsupport developmentally.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734926,
"text": "Neonatology\nTolerating CPAP after self extubation so far this morning. Spells not problem at this point\n\nWT 1640 up 85. TF at 140 cc/k/d . feeds at 90 cc/k/d. Tolerating advance of 20 cc/k/d advancement. Lytes in good range yesterday. Comfortable appearing. Abdomen benign\n\nHUS for next week.\n\nParents interested in transfer to when both babies ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734927,
"text": "Neonatology\nPhototherapy to be dced and bili follwoed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734928,
"text": "Nrsg Progress Note-0700-1500\n\n\nReport received at 0700 with infant on npcpap 6.\n#1o/a-rEM ON NPCPAP 6 WITH F102 21-28% WITH RR 30-50'S WITH\nBBS CLEAR AND EQUAL. Gd aeration with sx'ing for large thick\n-white secretions . Maintiaining 02 sats >94%. No desats or\nbradys. P_Cont to assess tolerance to cpap.\n#2O/A-Tf 140 cc's/kg with pn d10w decreased to 30 ccs'/kg at\n1230 pm fdg. Fdgs of Pe 20 pg via 5 fr fdg tube advanced at\n1230pm to 110 cc's/kg(32 cc's q 4 hours). aBD SOFT WITH NO\nSPITS OR ASPS.Piv replaced in lt saphenous vein due to\nprevios piv leaking in left hand. A-Fen status stable.P-\nP-Cont to assess tolerance of fdg advancement.\n#3O/A-MOM HERE AT 11:15 AM WITH HER mOM WITH VISITING AT\nBEDSIDE. COMPLETE UPDATE GIVEN TO MOM.A- REMAIN\nINVOLVED WITH CARES. P_CONT TO ENC CALLS AND VISITS.\n#4O/A-Rem in heated isol on servo with minimal stressors.\nPrefers pacifier to soothe with cares. Moving all exteem\nequally. P_Cont to assess g&d needs.\n#5O/A-rECEIVED ON SINGLE PHOTO WITH BILI MASKS REMOVED WITH\nCARES. pHOTO DC'D AT 110O WITH PLANS FOR REBOUND IN AM\nTOMORROW.rEM SL JAUNDICED. P-CONT TO ASSESS BILI NEEDS.\npLANS FOR REPORT AT 1500\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734929,
"text": " Physical Exam\n\npink, mottles infant comfortable on CPAP,AFOF, saggital suture overriding, breath sounds clear/equal with minimal retracting, no murmur, abd soft, non distended, bowel sounds present, no rashes, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734930,
"text": "Respiratory Therapy\nContinues on NP CPAP of 6, 0.26-0.30. RR 20-40. No spells. Trial off next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734921,
"text": "Nrsg Progress Note-0700-1500\n\n\nReceived report from night RN at 0700.\n#1O/A-Received on simv 15/5 rate of 16. F102 of 25-35%. At\n12:35 pm self extubated with infant bagged and masked with\ndesat to 44 with 02 sat increased by 13:35 pm TO\n96-2100%.Dr. notified ay 12:35 pm and present at\nbedside with 3.0 ett reinserted orally at 8cm upper lip mark\nby Dr. . Chest x ray confirmed placement. Maintaied 02\nsats to 94-100% throughout the shift.Parents aware of self\nextubation. Color pink with baseline mild intercostal\nretractions. P-Cont to assess resp needs.\n#2O/A-Rem with tf of 140 cc's/kg with adv to 150 cc's/kg of\npn d10w with il at 80 ccs's/kg. Fdgs of pe 20 cal via 5 fr\npg tube adv to 70 cc's/kg (20 cc's q 4 hrs). Abd soft with\npos bs tol all fdgs well. New pg tube reinserted in lt nares\nafter extubation.P-Cont to assess fen needs.\n#3O/A-Mom here at bedside as well as dad with update and\nreassurance surrounding self extubation.Family meeting\nplanned for Saturday at 1PM. MOM WILL VISIT DAILY AROUND THE\n12 NOON FDGS.Parenting coping with hospitalization of\npremature twin boys.\n#4O/A-Moving all extrem equally with preferance of pacifier\nfor soothing. P-Cont to assess g&d needs.\n#5O/A-Rem and active with cares tol well q 4 hours.\nRem on single phototherapy with masks placed and removed\nwith cares. Plans for bili in am .P-Cont to assess\nbili needs.\nPlans for report at 1500.\n#\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734922,
"text": "Respiratory care note:\nPt remains on CV: settings: 15/5, RR= 16. Total RR= 50-60. Fio2 ranges from 28-35%. Pt self extubated today at 1200 and another Endotracheal tube was placed at 8.0cm. Moderate, white sputum sucitoned frequently from tube.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-12 00:00:00.000",
"description": "Report",
"row_id": 1734923,
"text": "Neonatology - Progress NOte\n\nInfant is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He self extubated to CPAP of 6 this afternoon. FIO2 ~ 25-30%. Breath sounds course. Total fluids @ 140cc/kg/day. He is tolerating enteral feeds @ 50cc/kg/day. Abd soft, active bowel sounds, no loops. Voiding and stooling. Lytes today wnl. Bili under single photo 7.2. Hct today 43.7. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-13 00:00:00.000",
"description": "Report",
"row_id": 1734924,
"text": "Respiratory Care\nBaby self-extubated @ 1900 and was placed on NPCPAP 6. 02 req was 36-50% until NPT sxn for lg thick yellow secretions. Infant sxn for mod amts subsequently. 02 req since had been 25-30%. CBG: 7.25/57/47/26/-3. One A & B noted, no desat. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734905,
"text": "Neonatology - Student Progress Note\nInfant alert and active on open warmer on day of life 2. Tolerates exam without compromise. Physical exam and plan as follows:\n\nRespiratory: Infant intubated with current settings at 18/5 x18, FiO2 28-38%. Lung sounds coarse and equal bilaterally with full areation throughout all lobes. Mild-moderate retractions noted with xyphosternum present. Will decrease rate by 2 and follow up with CBG. Plan to wean conventional ventilation as tolerated.\n\nCV: Heart rate regular with no audible murmur. Precordium quiet. Blood pressure stable. Femoral and brachial pulses palpable and equal bilaterally. Palmar and calf pulses not present. Capillary refill <3 seconds with skin pink and warm. Will continue to monitor for signs and symptoms of PDA.\n\nGI/FEN: Abdomen full, round, and soft. Bowel sounds present x4 quadrants. Cord dry. Bilious aspirate reported during the night, with none this AM. D10 PN infusing via PIV at total fluids of 80 cc/kg/day. Weight down 5 grams to 1765 today. Will begin trophic feeds at 10 cc/kg and advance total fluids to 100 cc/kg/day. Continute PN at D10. Will evaluate electrolytes (with bilirubin) in the AM.\n\nID: Admission cultures negative to date. Will D/C IV antibiotics after 48 hour doses.\n\nHEENT: Mucous membranes pink. No drainage noted OU. Neck supple without masses.\n\nIntegumentary: PIV infiltrating in right foot. Foot, ankle, and calf firm with edema. Will monitor site for signs of breakdown.\n\nNeuro: Fontanells soft and flat with sutures mobile and slightly overriding. Infant moves all extremeties with tone appripriate for gestational age. Moro, grasp, and suck reflexes present. HUS at one week.\n\nSocial: Family meeting scheduled for Thursday. Mother still an inpatient: planned discharge on Thursday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734906,
"text": "Reviewed above note and agree with exam and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734907,
"text": "Respiratory Care NOte\nBaby 2 continues vented on a rate of 16 19/5 and 28-32%. CBG on those settings was 7.26-57. No vent changes made, plan to repeat gas this pm. BS slightly coarse with distant aeration.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734908,
"text": "NPN\n\n\n RESP: remains intubated on IMV.current settings are\n19/5 x16. Cap gas on those settings 7.26/57. RR 40-60.Conts\nw/mild SC/IC retractions. Sats >94%. No desats or spells. LS\ncoarse-> cl after sux, occas diminished. Sux q4hr for thin\nwhite secretions in sm amts. A: Tol wean vent settings. P:\nCont to follow resp status.\n\n FEN: is on TF 100cc/k/d PIV D10PN at 90cc/k/infusing\nwell and 10cc/k/d enteral feeds PE20. DS 94-131. Abd soft,\nmin asp, no loops, +BS, voiding 2.7cc/k/hr, no stool today.\nA: Tol trophic feeds. P: Adv as ordered and assess\ntolerance.\n\n PARENTS: Mom up for 1300 and 1700 cares. Updates on\ninfant's progress and plan given at the bedside. She has not\nheld yet. wait until tomorrow if she is too tired\ntonight. She kangarooed his sibling at 1600. Asking approp\nquestions. A: Involved parent P: Cont teaching and support.\n\n DEV: moved into an isolette. Temps stable on servo\ncontrol. Alert and irritable w/cares. Settles well and\nsleeps betw cares. Sucks on pacifier briefly. AFOF. MAE.\nA: AGA P: Cont to support g+d.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734893,
"text": "#1 PT INTUBATED AND SURFED X3. CURRENT VENT SETTINGS 25/5\nR=25. FI02 30-40%. LS COARSE WITH POOR AERATION. MOD\nIC/SC/SS RTXN'S.\n#2 TF 80CC/KG D10W INFUSING WELL VIA RIGHT FOOT PIV. DSTIX\nSTABLE 66,120. VOIDING WELL, NO STOOL THIS SHIFT. ABD SOFT,\nROUND, ACTIVE.\n#3 MOM AND DAD TO VISIT PT, PARENTS UPDATED AT BEDSIDE BY\nNNP BUCK. MOM CALLED IN A.M. FOR UPDATE.\n#5 PT STABLE ON OPEN WARMER. IRRITABLE WITH CARES. PT\nSTARTED ON AMP AND GENT, GIVEN AS PER ORDERS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734894,
"text": "Respiratory Care\nBaby admitted to NICU and placed on vent at end of previous shift. See attending admit noted for hx and further details. Vent parameters as per flowsheet. BS distant. Rec 3 doses of Survanta through the noc. Tol well but unable to wean vent parameters. Support increased due to clinical status- significant retractions and CBG 7.25/54. See flowsheet for blood gases also. Will cont to follow closely, adjust vent parameters as indicated, assess need for 4th dose Survanta.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734895,
"text": "Neonatology Attending Note\nDay 1\n\nIMV 25/5 x 20, 30%. Last CBG 7.38/48. Received third surf dose this am. HR 120-140s. Mean BP 50s. Good pulses and perfusion. Wt 1770,. TF 80 d10. NPO. d/s 114. On amp/gent. Under radiant warmer.\n\nWill need fourth and final dose of surfactant. Wean vent as tol. Keep TF at 80 cc/k/day. Will keep NPO but start PN. Con't a/g. Check lytes, bili in 24 h. HUS at 1 week, unless clinical course changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734896,
"text": "Nursing Progress Note 0700-1900\n\n\n2. O: Pt receiving 80cc/kg of D10 infusing well via PIV. To\nstart PN D10 at 1800. Abd full, soft. +bs. No loops. 1\nyellow spit. Voiding. No stool. Dstix 114. Obtain Lytes and\nBili at 1800. A: No stool. Tol d10. P: Cont to monitor wt,\nI&O's, and abd, and labs.\n\n3. O: No contact from family thus far this shift.\n\n4. O: Temp stable nested on open warmer. Active with care.\nRests well inbetween. Fontanelles soft and flat. A/P: Cont\nto monitor temp. Cont to cluster care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734897,
"text": "Neonatology - NNP Student Progress Report\nInfant sleeping soundly on open warmer on day of life 1. Tolerates exam without compromise, transitioning to light sleep. Physical exam and plan as follows:\n\nRespiratory: Infant intubated with current setting 24/5 x20 FiO2 22% after 4 doses of survanta (last dose at 1300). Last gas (before 4th dose of survanta) pH 7.34, CO2 42. Moderate substernal, subcostal, and intercostal retractions noted. Xyphosternum present. Lung sounds clear and equal bilarterally with fair aeration throughout. Will continue to monitor blodd gases and wean conventional ventilation as tolerated.\n\nCV: Heart rate regular with no audible murmur. Blood pressure stable with no inotropic support. Skin warm and pink with capillary refill <3 seconds. Mucous membranes pink. Femoral and brachial pulses palpable and equal bilaterally. No palmar or calf pulses present. Will monitor for widening pulse pressures, murmur, and other signs indicitive of PDA.\n\nFEN: Infant NPO with D10W infusing via PIV at 80 cc/kg/day. Will start perentral nutrition today, keeping total fluids at 80 cc/kg/day. 24 hour electrolytes due this evening: will re-evaluate total fluid needs pending results. Abdomen round and soft with bowel sounds present x4 quadrants.\n\nID: Infant recieving IV antibiotics, Ampicillin and Gentamicin, pending admission blood cultures. Will continure for 48 hour sepsis rule out.\n\nNeuro: Fotenells soft and flat with sutures mobile and separated slightly. Infant moves all extremeties with tone appropriate for gestational age. Moro, suck, and grasp reflexes present. Will monitor for any changes in status. Head ultrasound in one week.\n\nSocial: Will update family as needed. Plan family meeting as soon as possible.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734898,
"text": "Review and agree with above note and intervention.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734899,
"text": "Review and agree with above note and interventions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-09 00:00:00.000",
"description": "Report",
"row_id": 1734900,
"text": "Addendum\n\n\n1. O: Received pt orally intubated on IMV settings of 25/5\nX20. Mod subcostal/intercostal retractions. Surf #4 given.\nCBG obtained. Weaned pt to 21/5 X20. Fio2 22-35% ABG\nobtained. No further changes made. (See lab for results.) Ls\nclear and diminished, yet increased aeration from beginning\nof shift. RR 30-70's. A: Cont to require ventilation for\nadequate aeration. P: Cont to monitor resp status. Cont to\nwean settings as tol.\n\n3. O: Mom and Dad in at 1500. Asking appropriate questions.\nRn discussed care times, visiting, and updated. A/P: Cont to\neducate and support family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734901,
"text": "Resp care note 7p-7a\nPt remains on vent settings 21/5 x 20 fio2 28-36%. RR 50-70. BBS essentially clear. Sx sm-mod clear secretions. No new gases thus far, will wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734902,
"text": "nursing progress note\n\n\nResp: Received on vent settings of 21/5 rate of 20,\nweaned at 0445 to vent settings of 19/5 rate 18 fio2 22-36%.\nSaturations 94-98%> Lungs coarse to clear after suctioning.\nRR 50-70. Subcoastal/intercoastal retractions noted.\nSuctioned for sm-mod white sputum. Orally baby suctioned for\nsm yellow/green sputum x2 (no further bilious sputum noted\nafter n.g placed). A:Resp status. P:Monitor and wean as\ntolerated.\n\nFEN: total fluids at 80cc/kg/day of PNd10. D-sticks stable.\nAbomen full soft with +BS. had been oozing bilious\naspirate. ordered a N/G tube to be placed (1.1cc\naspirate 1x.) and a glycerin sup to be given, results\npending. Voiding 2.8cc/kg/hr x12 hrs.Weight 1.765 -5grams\nsince b/w. A:G.I status P:Monitor\n\nParents: Mom in and also called to inquire on son's status.\nAble to explain in greater detail baby's systems and\npotential plan. Mom would like to have a family set up for\nThursday if possible, she will be d/c from hospital and\nhusband will be avaliable. A:Vested and caring P:Support and\neducate\n\nD/G: Nested under warmer. Boundaries and sheepskin in place.\nAlert and active with cares. Easily setting. A:AGA\nP:Support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734903,
"text": "Neonatology\nDoing well. No evidence of PDA. Weaning slowly from vent. Abgs in good range.\n\nWt 1765 down 5. NPO with PN. Having sl bilios aspirates with normal abd exam. Will advance to 100 cc/k/d. Lytes in good range.\nWill begin trophic feeds this am and monitor tolerance.\n\n\nBili in 5 range. Continue to follow.\n\nCompleting 48 h r/o.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-10 00:00:00.000",
"description": "Report",
"row_id": 1734904,
"text": "Clinical Nutrition\nO:\n31 wk gestational age BB, AGA, now on DOL 2.\nBirth wt: 1770 g (~75th to 90th %ile); current wt: 1765 g (down ~0.3 % from birth wt.)\nHC: 30 cm @ birth (~75th %ile)\nLN: 43.25 cm @ birth (~75th %ile)\nLabs noted.\nNutrition: TF @ 100 cc/kg/d. PN started on DOL 1 via PIV. Plan to start trophic feeds today @ 10 cc/kg/d PE/BM 20. Projected intake for next 24 hrs. from PN ~50 kcal/kg/d, ~2.6 g pro/kg/d, and ~1.1 g fat/kg/d. From EN: ~7 kcal/kg/d, ~0.2 g pro/kg/d, and ~0.3 g fat/kg/d. Glucose infusion rate from PN ~6.3 mg/kg/min.\nGI: repogle draining ~1 cc bilious material, no BM yet.\n\nA/Goals:\nTolerating PN without dextrose control issues. Plan to start trophic feeds today; cautious advancement in next few days if tolerated. Labs noted and PN adjusted accordingly. Initial goal for feedings is ~150 cc/kg/d of BM/PE 24, providing ~120 kcal/kg/d and ~3.3 to 3.6 g pro/kg/d; further advances in feedings as per tolerance and growth. Iron appropriate to be started at that time as well. Growth goals after initial diuresis are ~15 to 20 g/kg/d in wt gain, ~1 cm/wk in LN gain, and ~0.5 to 1.0 cm/wk in HC gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-12 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 750618,
"text": " 2:29 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: s/p reintubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n s/p reintubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, , 2:52 P.M.:\n\n CLINICAL DATA: S/P reintubation.\n\n Comparison is made to prior study from .\n\n FINDINGS:\n ETT is in place with its tip at the thoracic inlet. NGT extends to the\n proximal stomach. The cardiac silhouette remains unchanged. There are hazy\n parenchymal opacities throughout both lungs which are consistent with\n respiratory distress syndrome and have slightly improved as compared to the\n earlier film. No evidence of pneumothorax or pleural effusion.\n\n Evaluation of the abdomen shows air within a mildly distended stomach. There\n is also air throughout the abdomen within nondilated loops of bowel without\n evidence of bowel obstruction. No evidence of pneumatosis, portal venous gas\n or free intraperitoneal air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-08 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 750357,
"text": " 8:07 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: assess lung expansion & ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 31 week twin\n REASON FOR THIS EXAMINATION:\n assess lung expansion & ett placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST @ 20:00 HOURS:\n\n HISTORY: 31 week twin gestation.\n\n Supine view of the chest obtained portably demonstrates an ETT terminating\n just below the thoracic inlet with the neck neutral. Diffuse hazy granular\n alveolar opacity is present throughout both lungs causing obscuration of the\n heart and hemidiaphragm margins in keeping with RDS. No evidence of\n pneumothorax. Visualized osseous structures are unremarkable.\n\n"
}
] |
28,760 | 168,303 | The patient was admitted to the neurologic ICU for further observation and management. Given the extent of the hemorrhage and the patient's clinical state (only with Gag relex and some extremity posturing to noxious), the neurologic team relayed the patient's extremely poor prognosis to the family. The patient was screened for organ donation, and only deemed a candidate to donate his corneas, which would be done post-mortem. The family decided to make the patient comfort measures only; he was thus extubated on the evening of admission. The patient died comfortably in the evening. | ABP 100's-130's systolic. Effacement of basal cisterns, with uncal, downward tentorial, and early tonsillar herniation. Respiratory Care NotePt admitted for IPH. pt given mannitol EEP and vit K. pt transfered to . The tip of the newly inserted ET tube lies some 3.7 cm proximal to the carina, and the side-hole and tip of the endogastric tube lie in the gastric fundus, directed cephalad. Q-T interval prolongation.Intraventricular conduction delay. pt was registed with NEOB. FINAL REPORT (Cont) the midbrain. G-tube to gravity, sm amt bilious drainage. +pp's.RESP: Lungs coarse/with occ. hypo bs. 11:05 AM CHEST (PORTABLE AP) Clip # Reason: tube placement? HTN, afib- on coumadinCt showed large right IPH with shift. abd soft.GU- recieved mannitol at OSH. EMS called. 11:03 AM CT HEAD W/O CONTRAST Clip # Reason: ich? The QTc interval islonger. Increased subfalcine herniation, with uncal, downward transtentorial and early tonsillar herniation. lung sounds clear.GI- OGT to sx. Pt received from ER intubated and mechanically ventilated. Increased size of intraparenchymal hemorrhage centered at the right basal ganglia, with extension into the right thalamus, and possible involvement of (Over) 11:03 AM CT HEAD W/O CONTRAST Clip # Reason: ich? C/DB and chest PT Q2-3 hrs.GI: Abd firm and less distended, BS hypo. Consider left ventricular hypertrophy oranteroseptal myocardial infarction. triple flexion in lower ext. cont nursing admit note.neuro- pt unresponsive. currently on .3mcg/kg/min.resp- vented AC rate 16 not breathing over vent settings. There is increase in shift of normally midline structures with a subfalcine herniation of approximately 1.7 cm. New #18 PIV placed.ID: T-max 101.3. tx floor tommorrrow Hemorrhage involves the right basal ganglia, extends into the right thalamus, and possible midbrain involvement. Since the previoustracing of atrial fibrillation is new and ventricular premature beatsare no longer present. ST-T wave abnormalities. posturing to deep nialbed pressure. Magnesium/calcium, and K+ repleted this am.SKIN: Midline abd staples intact-WNl. These findings are most consistent with hypertension in the setting of anticoagulation. There is obliteration of the suprasellar and ambient cisterns consistent with uncal and downward transtentorial herniation. There are atherosclerotic changes involving the thoracic aorta. Atrial fibrillation with slow ventricular response. NPN 0700-1900PLEASE SEE CAREVUE FOR SPECIFIC DATA.EVENTS: Pt traveled without incident to CT for CT of torso and to r/o abscess.NEURO: A/Ox3, no neuro deficits. osmo 327. tube placement. brisk U/O . Plan to remain intubated and mechanically ventilated at this time. IMPRESSION: 1. IMPRESSION: 1. Findings communicated to Drs. Cipro and fluconazole d/c-Caspofungan started (recieved 1 dose this afternoon and to start full dose tommorrow am). st. Replete with fiber continues through J tube-goal (which pt is now at) increased to 75cc/hr. wheezes in R lobes=>alb inhaler Q4-6 hrs with good effect. There is also early left tonsillar herniation. Enlargement of the contralateral lateral ventricle is seen, suggesting an increase in trapping and obstruction of the ventricular system. ET and NG tubes in satisfactory position. The heart size and pulmonary vessels are likely within normal limits with no evident pleural effusion (in this position). RR 18-26. Clinical correlation is suggested. REASON FOR THIS EXAMINATION: tube placement? DSD to G and J tube sites clean/intact. now tubed, no exam but bilat upgoing babinskis REASON FOR THIS EXAMINATION: ich? Afternoon lytes pending. pt not currently brain dead. intubated taken to hospital.Hx. FINDINGS: Since the prior study from approximately 3-1/2 hours ago, there is further increase in size of a right intraparenchymal hemorrhage centered at the right basal ganglia with now further extension into the right thalamus and possibly also involving the mid brain at the level of the superior cerebellar peduncle. 4pm dose heldendo- s/s coverage.social- organ bank notified. Noted are gas-filled bowel loops in the left central upper abdomen. 2L NC-O2 sats 94-100%. CT here showed worsening bleed. PLEASE DISREGARD ABOVE NOTE ON PT-WRONG PT. TECHNIQUE: Contiguous axial images of the head were obtained without the administration of IV contrast. 1 c-diff spec sent.GU: Foley draining adequate amts of clear yellow urine Q/hr. pt extubated at 1830. No contraindications for IV contrast WET READ: JXKc WED 12:34 PM Compared with Hospital Scan (3.5 hours earlier), larger intraparenchymal hemorrage with significantly increased subfalcine herniation, enlarging intraventricular hemorrhage with trapping of lateral ventricle. Hemorrhage is also seen within the subarachnoid space, which is new since prior study. 3. mushroom cath then placed early this evening-patenet thus far. Pt constantly stooling throughout day-leaking through diaper and rectal bag. Pt using IS with RN encouragement-up to 300. Using yankeur to clear sm amts thick white secretions. Allowing for the numerous tubes and monitoring electrodes overlying the upper thorax, other than left basilar subsegmental atelectasis, the lungs are clear. Marked increase in intraventricular hemorrhage with increased trapping and obstruction of the ventricular system. | 8 | [
{
"category": "Radiology",
"chartdate": "2167-01-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 994473,
"text": " 11:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with ich from outside hospital with report of shift. now tubed,\n no exam but bilat upgoing babinskis\n REASON FOR THIS EXAMINATION:\n ich?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc WED 12:34 PM\n Compared with Hospital Scan (3.5 hours earlier), larger\n intraparenchymal hemorrage with significantly increased subfalcine herniation,\n enlarging intraventricular hemorrhage with trapping of lateral ventricle.\n Hemorrhage involves the right basal ganglia, extends into the right thalamus,\n and possible midbrain involvement. Effacement of basal cisterns, with uncal,\n downward tentorial, and early tonsillar herniation.\n\n Discussed with Dr. and Dr. at 12:30 p.m.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old male with intracranial hemorrhage from outside hospital,\n with reported shift.\n\n COMPARISON: Comparison is made to outside hospital study from \n Hospital. The study was from approximately 3-1/2 hours prior to this study.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without the\n administration of IV contrast.\n\n FINDINGS: Since the prior study from approximately 3-1/2 hours ago, there is\n further increase in size of a right intraparenchymal hemorrhage centered at\n the right basal ganglia with now further extension into the right thalamus and\n possibly also involving the mid brain at the level of the superior cerebellar\n peduncle. There is increase in shift of normally midline structures with a\n subfalcine herniation of approximately 1.7 cm. Additionally, there is\n increased intraventricular extension with hemorrhage seen in the lateral,\n third, and fourth ventricles. Enlargement of the contralateral lateral\n ventricle is seen, suggesting an increase in trapping and obstruction of the\n ventricular system. Hemorrhage is also seen within the subarachnoid space,\n which is new since prior study.\n\n There is obliteration of the suprasellar and ambient cisterns consistent with\n uncal and downward transtentorial herniation. There is also early\n left tonsillar herniation.\n\n These findings are most consistent with hypertension in the setting of\n anticoagulation.\n\n IMPRESSION:\n 1. Increased size of intraparenchymal hemorrhage centered at the right basal\n ganglia, with extension into the right thalamus, and possible involvement of\n (Over)\n\n 11:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the midbrain.\n 2. Increased subfalcine herniation, with uncal, downward transtentorial\n and early tonsillar herniation.\n 3. Marked increase in intraventricular hemorrhage with increased trapping and\n obstruction of the ventricular system.\n\n Findings communicated to Drs. and at 12:30 p.m. by telephone.\n Findings also entered into the ED dashboard at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994475,
"text": " 11:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with ich and intubation with 8-0 tube 27@lip.\n REASON FOR THIS EXAMINATION:\n tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF CHEST :\n\n HISTORY: 69-year-old man with intracranial hemorrhage, status post\n intubation, with 8-0 tube, 27.0 cm from lip; ? tube placement.\n\n FINDINGS: Limited single bedside AP examination labeled \"semi-erect\" and no\n comparisons. The tip of the newly inserted ET tube lies some 3.7 cm proximal\n to the carina, and the side-hole and tip of the endogastric tube lie in the\n gastric fundus, directed cephalad. Allowing for the numerous tubes and\n monitoring electrodes overlying the upper thorax, other than left basilar\n subsegmental atelectasis, the lungs are clear. The heart size and pulmonary\n vessels are likely within normal limits with no evident pleural effusion (in\n this position). There are atherosclerotic changes involving the thoracic\n aorta. Noted are gas-filled bowel loops in the left central upper abdomen.\n\n IMPRESSION:\n 1. ET and NG tubes in satisfactory position.\n 2. Left basilar atelectasis, with no other acute process.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 1636652,
"text": "NPN 0700-1900\nPLEASE SEE CAREVUE FOR SPECIFIC DATA.\n\nEVENTS: Pt traveled without incident to CT for CT of torso and to r/o abscess.\n\nNEURO: A/Ox3, no neuro deficits. Medicated with 50mcg Fentanyl x 3 throughout day with good pain control. Pt in good spirits as PT into work with pt and was OOB to chair for 3 hrs today.\n\nCV: HR 80's NSR with frequent PVCs/PACs. ABP 100's-130's systolic. +pp's.\n\nRESP: Lungs coarse/with occ. wheezes in R lobes=>alb inhaler Q4-6 hrs with good effect. Pt using IS with RN encouragement-up to 300. Using yankeur to clear sm amts thick white secretions. 2L NC-O2 sats 94-100%. RR 18-26. C/DB and chest PT Q2-3 hrs.\n\nGI: Abd firm and less distended, BS hypo. Pt constantly stooling throughout day-leaking through diaper and rectal bag. mushroom cath then placed early this evening-patenet thus far. st. Replete with fiber continues through J tube-goal (which pt is now at) increased to 75cc/hr. G-tube to gravity, sm amt bilious drainage. 1 c-diff spec sent.\n\nGU: Foley draining adequate amts of clear yellow urine Q/hr. Afternoon lytes pending. Magnesium/calcium, and K+ repleted this am.\n\nSKIN: Midline abd staples intact-WNl. DSD to G and J tube sites clean/intact. Barrier cream applied to peri area-slightly reddened due to frequent loose stools throughout day. New #18 PIV placed.\n\nID: T-max 101.3. Cipro and fluconazole d/c-Caspofungan started (recieved 1 dose this afternoon and to start full dose tommorrow am). Cxs pending.\n\nENDO: 2 units Regular insulin given per RISS.\n\nSOCIAL:Multiple family memebers into visit throughout day-updated by MD.\n\nPOC: replete lytes PRN\n monitor mushroom catheter\n pulmonary h ygiene\n update/support family\n ? tx floor tommorrrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 1636653,
"text": "PLEASE DISREGARD ABOVE NOTE ON PT-WRONG PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 1636654,
"text": "Respiratory Care Note\nPt admitted for IPH. Pt received from ER intubated and mechanically ventilated. Pt transported while in ER to CT Scan without incident. BS are essentially clear and equal. PEEP increased to 5. FiO2 weaned to 60% according to sats which are 100%. Plan to remain intubated and mechanically ventilated at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 1636655,
"text": "admit.\n69 yr man who woke this am at home with left side flacid and slurred speech. EMS called. pt unresponsive upon arrival. intubated taken to hospital.\nHx. HTN, afib- on coumadinCt showed large right IPH with shift. pt given mannitol EEP and vit K. pt transfered to . CT here showed worsening bleed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 1636656,
"text": "cont nursing admit note.\n\nneuro- pt unresponsive. no on sedation. pupils 6mm non-reactive. posturing to deep nialbed pressure. triple flexion in lower ext. + cough when sx, no gag no corneals.\n\nCV- bradycardic, a-fib rate 30-50. no nipride to keep b/p SBP<185. currently on .3mcg/kg/min.\n\nresp- vented AC rate 16 not breathing over vent settings. lung sounds clear.\n\nGI- OGT to sx. hypo bs. abd soft.\n\nGU- recieved mannitol at OSH. brisk U/O . osmo 327. 4pm dose held\n\nendo- s/s coverage.\n\nsocial- organ bank notified. pt was registed with NEOB. pt not a DCD canidate due to age and morbidities. pt not currently brain dead. not a donor canidate. pt was screen for tissue and can donate corneas. family agrees to donate. NEOB to be called after withdrawl.\n\nfamily meeting held with neuro med attending and resident, nursing, clergy, and social work. family wishes to withdraw care. pt extubated at 1830.\n"
},
{
"category": "ECG",
"chartdate": "2167-01-14 00:00:00.000",
"description": "Report",
"row_id": 146922,
"text": "Atrial fibrillation with slow ventricular response. Q-T interval prolongation.\nIntraventricular conduction delay. Consider left ventricular hypertrophy or\nanteroseptal myocardial infarction. ST-T wave abnormalities. Since the previous\ntracing of atrial fibrillation is new and ventricular premature beats\nare no longer present. The QRS voltage has increased. The QTc interval is\nlonger. Clinical correlation is suggested.\n\n"
}
] |
51,793 | 111,708 | The patient was admitted to the ACS surgery service on and had a exlap, washout, R colectomy, CCY. The patient tolerated the procedure well. | FINDINGS: Orogastric tube is seen to course below level of diaphragm; however, beyond that is off the radiographic view. Prominent enhancing right lower quadrant lymph nodes are noted. The orogastric tube is seen coursing below the level of diaphragm with the distal end within the stomach and adequately positioned. CT PELVIS: There is an approximately 7-cm long segment of the cecum and proximal ascending colon which demonstrates mass-like, irregular, enhancing, circumferential wall thickening, most consistent with malignancy. There is marked atrophy of the pancreas. The spleen, adrenal glands, stomach, small bowel, gallbladder, and kidneys are within normal limits. REASON FOR THIS EXAMINATION: verify position of NG tube placed intraop FINAL REPORT CHEST RADIOGRAPH INDICATION: COPD, hypertension, status post ex lap, now with nasogastric tube, for the evaluation of NG tube. REASON FOR THIS EXAMINATION: Appy, gb path, peritonitis No contraindications for IV contrast WET READ: JKSd MON 6:44 PM Area of circumferential wall thickening of the proximal ascending colon, concerning for malignancy. TECHNIQUE: MDCT-acquired images were obtained from lung bases to the pubic symphysis after administration of 130 cc of Optiray intravenous contrast. FINDINGS: Bilateral lung volumes are low. FINDINGS: CT ABDOMEN: The lung bases are clear. COMPARISON: Right upper quadrant ultrasound, . The rectum, uterus, bladder are within normal limits. Bilateral lower lung opacities, likely atelectasis/consolidation have improved since . Comparisons were made with prior chest radiographs through and . There is mild grade 1 retrolisthesis of L5 on S1. Directly abutting this area is a large abscess containing foci of gas which extends through the right anterior abdominal wall and into the subcutaneous tissues, which measures 11.8 cm (TRV) x 11.3 cm (CC) x 9.2 cm (AP). Abutting the abnormal colon is a large abscess extending through the right lower anterior abdominal wall measuring 11.8 (trv) x 11.3 (CC) x 9.2 cm (AP), presumably caused by perforation of the colon. No osseous lesions (Over) 5:46 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Appy, gb path, peritonitis Contrast: OPTIRAY Amt: FINAL REPORT (Cont) concerning for metastatic disease are present. IMPRESSION: Findings highly concerning for colonic malignancy in the cecum and proximal ascending colon with associated perforation causing a large abscess which extends through the right lower quadrant anterior abdominal wall and into the subcutaneous tissues. 5:13 AM CHEST (PORTABLE AP) Clip # Reason: please eval for effusions, consolidation Admitting Diagnosis: ABDOMINAL ABCESS MEDICAL CONDITION: 68 year old woman s/p ex lap, abscess drainage, open chole and R colectomy, ileocolostomy with h/o COPD REASON FOR THIS EXAMINATION: please eval for effusions, consolidation FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Semi-erect portable radiograph of chest. A prominent posterior disc bulge is noted at L4-5 causing spinal canal narrowing at this level. Heart size, mediastinal and hilar contours are stable. Comparison was made with prior chest radiograph on . 7:19 AM CHEST (PORTABLE AP) Clip # Reason: verify position of NG tube placed intraop Admitting Diagnosis: ABDOMINAL ABCESS MEDICAL CONDITION: 68 year old woman with COPD, HTN, HLD, s/p ex lap now w/ NG tube. TECHNIQUE: Semi-erect portable radiograph of chest. Assess for appendicitis, gallbladder pathology or peritonitis. Compared to the previous tracingof there is now diffuse low voltage. Small retroperitoneal lymph nodes do not meet CT criteria for pathologic enlargement. Due to rotation, the assessment of the cardiomediastinal silhouette was limited. Coronal and sagittal reformatted images were also displayed. Sinus rhythm. Followup and clinical correlationare suggested. The heart size is normal. Both lungs are remarkable for increased bibasilar lung opacities, which are likely due to lung atelectasis. Upper lungs are clear. Diffuse low voltage. 5:46 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Appy, gb path, peritonitis Contrast: OPTIRAY Amt: MEDICAL CONDITION: 68 year old woman with a hx of cholecystits, copd, dm2, hypothyroid who is scheduled for lap chole in two weeks now p/f diarrhea, rlq pain. | 4 | [
{
"category": "Radiology",
"chartdate": "2138-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214051,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for effusions, consolidation\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p ex lap, abscess drainage, open chole and R colectomy,\n ileocolostomy with h/o COPD\n REASON FOR THIS EXAMINATION:\n please eval for effusions, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Semi-erect portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through and\n .\n\n FINDINGS: Orogastric tube is seen to course below level of diaphragm;\n however, beyond that is off the radiographic view. Bilateral lower lung\n opacities, likely atelectasis/consolidation have improved since . Upper lungs are clear. Heart size, mediastinal and hilar contours are\n stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1213885,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: verify position of NG tube placed intraop\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with COPD, HTN, HLD, s/p ex lap now w/ NG tube.\n REASON FOR THIS EXAMINATION:\n verify position of NG tube placed intraop\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: COPD, hypertension, status post ex lap, now with nasogastric\n tube, for the evaluation of NG tube.\n\n TECHNIQUE: Semi-erect portable radiograph of chest. Comparison was made with\n prior chest radiograph on .\n\n FINDINGS: Bilateral lung volumes are low. Both lungs are remarkable for\n increased bibasilar lung opacities, which are likely due to lung atelectasis.\n Due to rotation, the assessment of the cardiomediastinal silhouette was\n limited. The orogastric tube is seen coursing below the level of diaphragm\n with the distal end within the stomach and adequately positioned.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-11-10 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1213836,
"text": " 5:46 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Appy, gb path, peritonitis\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with a hx of cholecystits, copd, dm2, hypothyroid who is\n scheduled for lap chole in two weeks now p/f diarrhea, rlq pain.\n REASON FOR THIS EXAMINATION:\n Appy, gb path, peritonitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd MON 6:44 PM\n Area of circumferential wall thickening of the proximal ascending colon,\n concerning for malignancy. Abutting the abnormal colon is a large abscess\n extending through the right lower anterior abdominal wall measuring 11.8 (trv)\n x 11.3 (CC) x 9.2 cm (AP), presumably caused by perforation of the colon.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old woman with history of cholecystitis, COPD, diabetes,\n and hyperthyroidism, who was scheduled for laparoscopic cholecystectomy in two\n weeks, who now presents with diarrhea and right lower quadrant pain. Assess\n for appendicitis, gallbladder pathology or peritonitis.\n\n COMPARISON: Right upper quadrant ultrasound, .\n\n TECHNIQUE: MDCT-acquired images were obtained from lung bases to the pubic\n symphysis after administration of 130 cc of Optiray intravenous contrast.\n Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS:\n CT ABDOMEN: The lung bases are clear. The heart size is normal. The spleen,\n adrenal glands, stomach, small bowel, gallbladder, and kidneys are within\n normal limits. There is marked atrophy of the pancreas. Small\n retroperitoneal lymph nodes do not meet CT criteria for pathologic\n enlargement. There is no free air or free fluid.\n\n CT PELVIS: There is an approximately 7-cm long segment of the cecum and\n proximal ascending colon which demonstrates mass-like, irregular, enhancing,\n circumferential wall thickening, most consistent with malignancy. Prominent\n enhancing right lower quadrant lymph nodes are noted. Directly abutting this\n area is a large abscess containing foci of gas which extends through the right\n anterior abdominal wall and into the subcutaneous tissues, which measures 11.8\n cm (TRV) x 11.3 cm (CC) x 9.2 cm (AP).\n\n There is no free fluid. The rectum, uterus, bladder are within normal limits.\n There is no inguinal or pelvic lymphadenopathy.\n\n BONE WINDOWS: No concerning osseous lesions are identified. There is mild\n grade 1 retrolisthesis of L5 on S1. A prominent posterior disc bulge is noted\n at L4-5 causing spinal canal narrowing at this level. No osseous lesions\n (Over)\n\n 5:46 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Appy, gb path, peritonitis\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n concerning for metastatic disease are present.\n\n IMPRESSION: Findings highly concerning for colonic malignancy in the cecum\n and proximal ascending colon with associated perforation causing a large\n abscess which extends through the right lower quadrant anterior abdominal wall\n and into the subcutaneous tissues.\n\n Findings were discussed with Dr. at 6:10 p.m. on in person.\n\n"
},
{
"category": "ECG",
"chartdate": "2138-11-11 00:00:00.000",
"description": "Report",
"row_id": 250705,
"text": "Sinus rhythm. Diffuse low voltage. Compared to the previous tracing\nof there is now diffuse low voltage. Followup and clinical correlation\nare suggested.\n\n"
}
] |
29,035 | 170,826 | The patient is a 62 y/o F hx NASH cirrhosis now s/p TIPS, with total body overload, acute on chronic kidney disease with worsening creatinine, and acute hypoxia requiring intubation During her stay on the liver service, the patient's diuretic regimen was adjusted but her ascites was felt to be refractory and on the patient underwent TIPS, which was complicated by a small injury to the left portal vein. Despite this however, the patient's hemoglobin remained stable. Over the next 2 days, it was noted that the patient's creatinine had increased and that her urine output had decreased. The patient was found to be hypoxic to 70% on RA and was also febrile to 101.3F with a new leukocytosis. Given her respiratory distress and hypoxia, she was transferred to the MICU for further management. . In the MICU, subsequent radiographs (CXR and CT ) showed moderate pulmonary edema and multifocal pneumonia with lobar collapse. She was eventually intubated on for her progressive hypoxia and serial radiographs showed massive pulmonary edema with superimposed multifocal pnuemonia. She was started on vanc/zosyn/cipro. Bronchoscopy was performed and was unrevealing. She completed an 8 day course of vanc/zosyn/cipro but remained febrile throughout until day of d/c on , and by report remained afebrile thereafter, leading to a working diagnosis of drug fever in the context of a resolving PNA. Her renal failure contiuned to worsen, presumably from ATN, and CVVH was started through a femoral line, mostly to take off volume. She contiuned to require mechanical ventilation until , when she was successfully extubated. CXR from s/p extubation showed marked improvement in pulmonary volume overload and pleural effusions. Was easily weaned down to 2L NC with sats in the high 90's. Despite resolution of her hypoxia, her renal function did not improve and she required HD on . And was sent to the floor. ► CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy. Recently s/p UGIB and banding of grade II varices. She also developed dysphagia after EGD and variceal banding, which has resolved. Continue ursodiol, allopurinol, rifaximin. Nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion and abd distention irritation of abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS procedure complicated by slight injury to L portal vein. Repeat US abd showed lack of flow in right and left portal vein. Abdomen tympanic but with no ascites on imaging or bedside. Recent abdominal CT shows no evidence of obstruction. Abd pain has been resolved in recent days. GI against proflaxtic anticoagulation of L portal vein thrombosis given high risk bleed. trend LFTs lack of portal vein flow does not elimate pt as canidate for liver , liver will discuss possibity of future as team. Pt also recently was abusing benzos. Ordered Hep panel, PPD as part of workup. Pt will need liver eventually, currently due to her renal fuction it is unclear whether she will need a renal concurrently (see below). | Right internal jugular catheter terminates in the lower SVC. Mild [1+] TR.Moderate PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. LIMITED RIGHT UPPER QUADRANT ULTRASOUND: Comparison is made to and , ultrasound examinations and TIPS exam dated . The right lateral hemithorax is excluded. Portal vein is noted to be slightly ectatic at the main bifurcation, with some regions of aliasing noted, not significantly changed from prior exam. REASON FOR THIS EXAMINATION: Any interval change PFI REPORT Tubes and catheters in unchanged position. FINDINGS: There has been interval insertion of an endotracheal and nasogastric tube. Bilateral pleural effusions, more prominent on the right, associated with alveolar opacity, possibly due to atelectasis or multifocal pneumonia are unchanged. REASON FOR THIS EXAMINATION: Any interval change PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 7:47 PM Tubes and catheters in unchanged position. Stable right adrenal myelolipoma. Stable right adrenal myelolipoma. Stable right adrenal myelolipoma. There is a stable right adrenal myelolipoma. Moderate-to-large right pleural effusion, as previously seen on ultrasound from . FINDINGS: CHEST: There is a stable moderate-to-large right pleural effusion, as seen on prior ultrasound from . The possibility of a pneumonic infiltrate at the right base cannot be entirely excluded, though much of the appearance could relate to atelectasis and alveolar edema. There are atherosclerotic calcifications of the aorta. Haziness of the left hemithorax is consistent with a left pleural effusion as well. A right internal jugular line ends at the superior cavoatrial junction. Right IJ line tip in the distal SVC. There is moderate cardiomegaly, with prominence of the main pulmonary artery. FINDINGS: In comparison with earlier study of this date, the tip of the left IJ catheter extends to the upper portion of the SVC. Possible right lower lobe consolidation on physical exam. Multiple mesenteric and retroperitoneal lymph nodes are noted, which are not pathologically enlarged by size criteria. Levophed gtt & PEEP both successfully weaned down today.RESP: Pt received on AC-28-40-380-12 with nl sats and pt typically breathing @ set rate of 28. ABG with decreased pH---renal and MICU team aware and dialysate solution to be changed. Right radial aline with good waveform, right IJ TLC site C/D/I, CVP= , Left IJ HD line site C/D/I---line kinks easily.Resp: Lungs with bilat upper lobe rhonchi and diminished at bilat bases, freq. levofed gtt titrated to keep map>60 currently at 0.04mcg/kg/min. Good cough reflex noted, essentially non-prod cough.GU: CVVHDF therapy remains ongoing with revised hourly I/O goal of net even. Resp Care: Pt continues intubated #8 oett secured @ 22 @ lip and on ventilatory support with psv, worsening oxygenation overnoc necessitating increased peep/fio2; bs coarse, sxn loose clear secretions, rx with mdi albuterol/atrovent, rsbi 80, will cont support as tol. ACCESS: RIJ TLC.Resp) LS CTA to upper lobes and diminished at the bases. Venodyne boots/SQ Heparin dosing in place for DVT prophylaxis. Pt freq re-oriented to person/place/time/care rationale to assist with nl cognition.GU: in place and meeting negative hourly goal of minus 200ml. Pt rec'd Vancomycin in am after trough 15.3, and cont on Zosyn and Ceftriaxone. Pt has been inc to DB&C, and present with a dry non-prod cough. CT abd/chest with oral contrast done, results pndg.GI: Abd very distended/soft with +BS. LENI's done yesterday neg.GI: Abd cont very distended with + BS. Needs nutrition c/s.Endo) Lantus with humalog SS.GU) Pt has CKD and is in ARF. plan for PICC line once afebrile for 24 hrs.Resp) LS CTA to upper lobes with diminished bases. drains mod to large amt golden loose stool.ENDO: sliding scale and fixed dose. IV ANTIBX, VANCO BY LEVEL. IVABs:cipro, zosyn and vanco, which is renally dosed q day. Subsequently the pt was started on an IV Levophed gtt which is currently infusing @ 0.055mcg/kg/min to maintain MAP's above 60. Continue on po lactulose and patient had owel movements. Pt rec'd 1 dose flagyl, levofloxacin. Briefly hypotensive directly after intubation responded to small fluid bolus. Presently treating as ARDS protocol and requiring initiation of CRRT.Neuro: Fent/versed gtt changed to bolus; no boluses given; briefly opening eyes with mod amt verbal stimuli; MAE with minimal mvm't noted to LUE--?r/t rotator cuff injury/sprain. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. - HBG now 9.4, stable, consider transfusion if clinical situation worsen or hgb below 7.0 DIABETES MELLITUS (DM), TYPE II BG consistantly elevated -discontinue Glargine + HISS. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. Recently s/p UGIB and banding of grade II varices - continue ursodiol, allopurinol, rifaximin, - nadolol no longer necessary with successful TIPS Abdominal discomfort: Likely related to pleural effusion irritation of abodomen. - HBG now 9.4, stable, consider transfusion if clinical situation worsen or hgb below 7.0 DIABETES MELLITUS (DM), TYPE II BG consistantly elevated -discontinue Glargine + HISS. | 110 | [
{
"category": "Echo",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 73341,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Pulmonary embolus.\nHeight: (in) 66\nWeight (lb): 242\nBSA (m2): 2.17 m2\nBP (mm Hg): 106/41\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 10:04\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild functional MS due to MAC. Mild to moderate (+) MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and global systolic function (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets are\nmoderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2).\nThe mitral valve leaflets are mildly thickened. There is mild functional\nmitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification.\nMild to moderate (+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no definite\nchange. No echo evidence of a large pulmonary embolism.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-28 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1023444,
"text": " 8:35 AM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: Please eval portal and hepatic flow pre TIPS procedure.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESLD NASH, ascites and edema difficult to control\n d/t ARF and also with h/o variceal bleed.\n REASON FOR THIS EXAMINATION:\n Please eval portal and hepatic flow pre TIPS procedure.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe MON 10:03 AM\n Normal hepatic vascularity with unchanged splenomegaly and coarsened/echogenic\n liver.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage liver disease, pre-TIPS secondary to NASH.\n\n Comparison is made to ultrasound and CT.\n\n LIMITED ABDOMINAL ULTRASOUND\n\n No focal intrahepatic mass lesions identified with stable coarsened and\n slightly echogenic liver parenchyma. The patient is status post\n cholecystectomy. No intrahepatic ductal dilatation is identified.\n\n The main, left and right anterior/posterior branches demonstrate appropriate\n directional flow and flow velocity. Appropriate venous waveforms are noted\n within the main, left and right hepatic veins in addition to a normal low\n resistance arterial indices within the left, right and main hepatic arteries.\n Portal vein is noted to be slightly ectatic at the main bifurcation, with some\n regions of aliasing noted, not significantly changed from prior exam.\n Splenomegaly persists at approximately 21 cm on today's exam. Venous\n velocities are noted within the SMV and the distal splenic vein, previously\n noted proximal eccentric splenic vein thrombosis is not appreciated on current\n study. No significant ascites is present.\n\n IMPRESSION:\n 1. Patent vasculature with appropriate flow velocities. Unchanged slight\n ectasia of the main portal vein near its bifurcation.\n\n 2. Stable coarsened/echogenic liver likely related to underlying hepatic\n fibrosis/cirrhosis. Unchanged splenomegaly. No ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-28 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1023445,
"text": ", P. MED FA10 8:35 AM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: Please eval portal and hepatic flow pre TIPS procedure.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESLD NASH, ascites and edema difficult to control\n d/t ARF and also with h/o variceal bleed.\n REASON FOR THIS EXAMINATION:\n Please eval portal and hepatic flow pre TIPS procedure.\n ______________________________________________________________________________\n PFI REPORT\n Normal hepatic vascularity with unchanged splenomegaly and coarsened/echogenic\n liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-30 00:00:00.000",
"description": "INSERT HEPATIC HUNT TIPS",
"row_id": 1023960,
"text": " 5:07 PM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: VISAPAQUE Amt: 260\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with rfractory ascites, renal failure, on transplant list\n REASON FOR THIS EXAMINATION:\n TIPS\n ______________________________________________________________________________\n FINAL REPORT\n Clinical Information: 62 year old female with end stage liver disease and\n refractory ascites. Request is made for TIPS placement.\n\n Operators: , MD, , MD, , MD, and\n , MD. Dr. , the attending radiologist was present and\n supervised the entire procedure.\n\n Procedures:\n 1. Portal venogram\n 2. Pressure measurement\n 3. TIPS placement\n\n Medications: General anesthesia and lidocaine for local anesthesia.\n Procedure and Findings: After the risks and benefits of the procedure as well\n as conscious sedation were explained, informed consent was obtained. The\n patient was brought to the angiography suite and placed supine on the imaging\n table. General anesthesia was given. The neck was prepped and draped in the\n usual sterile fashion.\n\n With ultrasound guidance, access was obtained into the right internal jugular\n vein with the micropuncture needle. An 018 wire was placed through the needle.\n The needle was removed and the micropuncture sheath was placed over the wire.\n The 3 French sheath and wire were removed and an 035 wire was placed\n through the 5 French sheath into the IVC. The 5 French sheath was removed and\n replaced with a long 10 French sheath.\n\n A C2 catheter was placed over the wire was used to select the right hepatic\n vein. The wire was removed and replaced with an Amplatz wire. The C2\n catheter was removed and replaced with an occlusion catheter. The balloon at\n the tip was inflated and CO2 angiography was performed allowing anatomic\n evaluation of the portal veins. The occlusion catheter was removed.\n A curved metallic sheath was placed over the wire into the hepatic vein. The\n wire was removed and replaced with a sheathed needle. The needle was\n redirected by torquing the sheath and advanced through the hepatic parenchyma.\n Approximately 5 passes were made till access was obtained into the portal\n system via the right portal vein. A stiff Glidewire was placed through the\n tract into the main portal vein. During attempts to access the main portal\n vein from the right portal vein, the Glidewire was passed into the left portal\n (Over)\n\n 5:07 PM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: VISAPAQUE Amt: 260\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vein. Contrast injection demonstrated a small amount of extravasation from a\n branch of the left portal vein.\n\n The metallic sheath was removed and a multi-sidehole straight flush catheter\n was placed over the wire into the main portal vein. A portal venogram was\n performed which demonstrated the anatomy of the portal system. No collateral\n vessels were seen. Pressures were obtained and are as follows:\n\n Pre-TIPS main portal vein: 37 mmHg\n Pre-TIPS right atrium: 22 mmHg\n Pre-TIPS gradient: 15 mmHg\n\n An Amplatz wire was placed through the catheter and the catheter was removed.\n A 10 mm French high pressure balloon was placed over the wire and the\n parenchymal tract was dilated. The balloon was removed and a 10 mm x 8 cm\n Viatorr TIPS stent was placed into the newly created tract. A 10 French\n balloon was placed over the wire and the stent was expanded with the balloon.\n Repeat venography was performned which demonstrated diversion of portal flow\n through the TIPS stent into the IVC. Repeat pressures were obtained as\n follows:\n\n Pre-TIPS main portal vein: 34 mmHg\n Pre-TIPS right atrium: 26 mmHg\n Pre-TIPS gradient: 8 mmHg\n\n The wire, catheter, and sheath were removed and pressure was applied at the\n access site until adequate hemostasis was obtained. A sterile dressing was\n applied.\n\n Complication: Small amount of extravasation from a branch of the left portal\n vein consistent with small perforation.\n\n Impression:\n 1. Portal venogram\n 2. Decrease in portosystemic pressure gradient from 15 mmHg to 8 mmHg.\n 3. 10mm x 8 cm Viatorr TIPS stent placed.\n\n Plan: Follow-up with ultrasound for TIPS stent in 1 week and then every 3\n months.\n\n\n (Over)\n\n 5:07 PM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: VISAPAQUE Amt: 260\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-25 00:00:00.000",
"description": "L WRIST(3 + VIEWS) LEFT",
"row_id": 1023107,
"text": " 2:09 PM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: Pls assess for scaphoid/distal radius fx.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with wrist px & limited mobility x 1 week\n REASON FOR THIS EXAMINATION:\n Pls assess for scaphoid/distal radius fx.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain with limited mobility after fall, to evaluate for fracture.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again, there is some periosteal reaction along the ulnar cortex of the fifth\n metacarpal. This could represent a subacute non-displaced fracture, though\n there is no evidence of a fracture line on the views presented.\n\n The remainder of the examination is within normal limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-01 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1024251,
"text": " 9:31 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: CRT DROP S/P TIPS PROCEDURE - EVAL FOR HEMATOMA/LEAKING BLOOD\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ETOH cirrhosis s/p TIPS on with nicked vein during\n procedure now with RUQ pain, puritis, and hct drop\n REASON FOR THIS EXAMINATION:\n Please eval for hematoma/leaking blood\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe FRI 11:39 AM\n No perihepatic fluid collections identified. Findings worrisome for\n thrombosis of left portal vein. If further confirmation is needed, can\n consider non-gadolinium-enhanced MRI due to patient's elevated creatinine.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post TIPS on , complicated by small perforation of left\n portal vein during the procedure with increasing right upper quadrant pain and\n mild hematocrit drop of points.\n\n LIMITED RIGHT UPPER QUADRANT ULTRASOUND:\n\n Comparison is made to and , ultrasound examinations and\n TIPS exam dated .\n\n Liver parenchyma is again slightly heterogenous with no focal lesions. No\n surrounding perihepatic fluid collections are identified. A small to\n moderate-sized right pleural effusion is noted. Doppler interrogation of the\n portal venous systems demonstrated appropriate hepatopetal flow within the\n main portal vein and appropriate reversal of flow within the right anterior\n portal vein. However, no flow can be identified within the left portal venous\n system on color and Doppler imaging in addition to focused examination with a\n high-frequency transducer. The TIPS was identified, however, flow could not\n be detected due to its covered lining. Splenomegaly is unchanged at 22 cm. No\n free fluid was noted within the lower quadrants.\n\n IMPRESSION:\n\n 1. No perihepatic fluid collections identified.\n\n 2. Findings worrisome for left portal vein thrombosis, alternatively very\n slow flow through the left portal system which is not able to be interrogated\n by Doppler examination is also in the differential. Given the patient's high\n creatinine, if further confirmation is needed (if it will alter clinical\n care), a non-gadolinium-enhanced MRI can be considered.\n\n 3. Dedicated TIPS ultrasound is again recommended seven days post-procedure\n for full (new baseline) Doppler evaluation including interrogation of TIPS\n stent.\n\n Findings were discussed with covering physician for Dr. .\n (Over)\n\n 9:31 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: CRT DROP S/P TIPS PROCEDURE - EVAL FOR HEMATOMA/LEAKING BLOOD\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-01 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1024252,
"text": ", H. MED FA10 9:31 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: CRT DROP S/P TIPS PROCEDURE - EVAL FOR HEMATOMA/LEAKING BLOOD\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ETOH cirrhosis s/p TIPS on with nicked vein during\n procedure now with RUQ pain, puritis, and hct drop\n REASON FOR THIS EXAMINATION:\n Please eval for hematoma/leaking blood\n ______________________________________________________________________________\n PFI REPORT\n No perihepatic fluid collections identified. Findings worrisome for\n thrombosis of left portal vein. If further confirmation is needed, can\n consider non-gadolinium-enhanced MRI due to patient's elevated creatinine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024997,
"text": ", MED MICU 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal failure, s/p TIPS\n with hypoxia and increasing oxygen requirement.\n REASON FOR THIS EXAMINATION:\n Any interval change\n ______________________________________________________________________________\n PFI REPORT\n Severe pulmonary edema continues to worsen though mediastinal vascular\n engorgement has decreased suggesting decrease in central venous pressure or\n volume. No pneumothorax. Lines and tubes in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025529,
"text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, now intubated.\n REASON FOR THIS EXAMINATION:\n Any interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the chest demonstrates no change in the support\n lines when compared to . The heart and lungs remain similar in\n appearance. No pneumothorax. Trachea is midline.\n\n IMPRESSION:\n\n No interval change. Pneumonia is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1025393,
"text": " 8:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Evaluate for patentcy of portal vein. Please use dopplers.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and renal failure.\n REASON FOR THIS EXAMINATION:\n Evaluate for patentcy of portal vein. Please use dopplers.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 5:30 PM\n Patent TIPS shunt.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and renal failure and recent TIPS placement; evaluate\n TIPS patency.\n\n COMPARISON: None.\n\n FINDINGS: No liver masses are identified and there is no biliary dilatation\n seen. A trace of ascites is identified and there is a large right pleural\n effusion.\n\n Doppler examination, color Doppler and pulse wave Doppler images were\n obtained. The TIPS shunt is patent with wall-to-wall flow and velocities\n range from 70-90 cm/sec. The main portal vein is patent with hepatopetal flow\n and a velocity of flow is about 35 cm/sec. No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this may be\n due to technical factors. Appropriate flow is seen in the hepatic veins and\n IVC.\n\n IMPRESSION: Patent TIPS with wall-to-wall flow. Large right pleural effusion\n and trace of ascites.\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1025394,
"text": ", MED MICU 8:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Evaluate for patentcy of portal vein. Please use dopplers.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and renal failure.\n REASON FOR THIS EXAMINATION:\n Evaluate for patentcy of portal vein. Please use dopplers.\n ______________________________________________________________________________\n PFI REPORT\n Patent TIPS shunt.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025630,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, intubated.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the chest is submitted. The right lateral\n hemithorax is excluded. Support lines are unchanged. There is persistent\n opacity projecting over both lungs and probable persistent bilateral pleural\n effusions. Bibasilar atelectasis is again noted. No pneumothorax is seen.\n When allowing for differences in positioning, the cardiomediastinal contours\n are similar as well.\n\n IMPRESSION:\n\n Limited study. No interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025474,
"text": " 4:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, intubated.\n REASON FOR THIS EXAMINATION:\n Any interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 7:47 PM\n Tubes and catheters in unchanged position. No change since yesterday.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n COMMENTS: 63-year-old woman with multifocal pneumonia and probable PE,\n intubated. Any interval change?\n\n Tubes and catheters are in unchanged position. The tip of the NG tube is not\n included in this study.\n\n There is no significant change since yesterday.\n\n Bilateral pleural effusions, more prominent on the right, associated with\n alveolar opacity, possibly due to atelectasis or multifocal pneumonia are\n unchanged. The cardiomegaly and vascular congestion are also unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1023376,
"text": " 3:55 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for e/o hydrothorax/effusions.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESLD now with increased O2 requirement. No cough, no\n fevers. Has h/o hydrothorax.\n REASON FOR THIS EXAMINATION:\n Please eval for e/o hydrothorax/effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased oxygen requirement without cough or fever.\n\n FINDINGS: In comparison with the study of , there is no interval change.\n The cardiac silhouette is at the upper limits of normal in size. No evidence\n of acute pneumonia, vascular congestion or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024996,
"text": " 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal failure, s/p TIPS\n with hypoxia and increasing oxygen requirement.\n REASON FOR THIS EXAMINATION:\n Any interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 2:43 PM\n Severe pulmonary edema continues to worsen though mediastinal vascular\n engorgement has decreased suggesting decrease in central venous pressure or\n volume. No pneumothorax. Lines and tubes in standard placements.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:17 A.M., \n\n HISTORY: Cirrhosis, acute and chronic renal failure. Worsening hypoxia.\n\n IMPRESSION: AP chest compared to though 29:\n\n Pulmonary edema worsening progressively since is now quite severe\n accompanied by at least moderate right pleural effusion. Cardiac size is\n partially obscured, probably large but not grossly changed. Interval decrease\n in azygous distention suggests a relative decrease in right-sided pressures.\n No pneumothorax. ET tube in standard placement. Nasogastric tube passes into\n the stomach and out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025475,
"text": ", MED MICU 4:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, intubated.\n REASON FOR THIS EXAMINATION:\n Any interval change\n ______________________________________________________________________________\n PFI REPORT\n Tubes and catheters in unchanged position. No change since yesterday.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026330,
"text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and ESRD.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:25 AM\n PFI: Status post extubation. Markedly improved pulmonary vascular congestion\n and right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old with NASH cirrhosis and end-stage renal disease.\n Evaluate for interval change.\n\n COMPARISON: One day prior.\n\n SINGLE SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPH: The ET tube has been removed.\n Right internal jugular catheter terminates in the lower SVC. Pulmonary\n vascular congestion has decreased, and the right pleural effusion appears\n markedly improved, although this may be due to different positioning of the\n patient. The left lung remains clear with no sizeable effusion. No\n pneumothorax.\n\n IMPRESSION: Status post extubation. Markedly improved pulmonary vascular\n congestion and right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024917,
"text": " 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: VERIFY TUBE PLACEMENT AND OG TUBE PLACEMENT\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal failure, s/p\n TIPS with hypoxia, possible RLL consolidation on physical exam, now intubated.\n REASON FOR THIS EXAMINATION:\n Verify tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy TUE 10:32 PM\n PFI: The ET tube is 5 cm from the carina. The NG tube is in the stomach.\n There is no significant change in severe pulmonary edema. There is likely an\n effusion on the right. Pneumonia can certainly not be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with NASH cirrhosis and acute-on-chronic renal\n failure. Now hypoxic and requiring intubation. Evaluate ET tube placement.\n\n COMPARISON: Comparison is made to film from at 3:15 in the\n morning as well as film from .\n\n FINDINGS: There has been interval insertion of an endotracheal and\n nasogastric tube. The ET tube terminates approximately 5 cm from the carina.\n A nasogastric tube passes into the stomach. There has been no significant\n interval change in marked pulmonary edema. A moderate dependent pleural\n effusion is likely present on the right as well. There is cardiomegaly. An\n underlying pneumonia cannot be excluded.\n\n IMPRESSION:\n 1. Interval insertion of endotracheal tube and NG tube, in adequate position.\n 2. No significant change in marked pulmonary edema and right-sided pleural\n effusion. Underlying pneumonia cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024918,
"text": ", MED MICU 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: VERIFY TUBE PLACEMENT AND OG TUBE PLACEMENT\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal failure, s/p\n TIPS with hypoxia, possible RLL consolidation on physical exam, now intubated.\n REASON FOR THIS EXAMINATION:\n Verify tube placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: The ET tube is 5 cm from the carina. The NG tube is in the stomach.\n There is no significant change in severe pulmonary edema. There is likely an\n effusion on the right. Pneumonia can certainly not be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1025138,
"text": " 5:29 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Verify IJ placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with multifocal pneumonia and pleural effusions intubated for\n hypoxia with new right IJ.\n REASON FOR THIS EXAMINATION:\n Verify IJ placement\n ______________________________________________________________________________\n WET READ: 12:31 AM\n Right IJ line tip projects over expected course of atro-caval junction. No\n pneumothorax. Slight interval improvement of pulm. edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess line placement.\n\n New right IJ line tip is in the distal SVC. There is no evidence for\n pneumonia. Compared to prior study performed the same day earlier in the\n morning, there has been mild interval improvement on still severe pulmonary\n edema. Large bilateral pleural effusions are greater on the right side.\n Cardiomediastinal contours are unchanged. ET tube tip is 2.5 cm above the\n carina. NG tube tip is out of view below the diaphragm.\n\n IMPRESSION: No pneumothorax. Right IJ line tip in the distal SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1025849,
"text": ", MED MICU 2:12 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Compare R lung parencyma to previous CT scan - ? pleural eff\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, renal failure on CVVH, and respiratory\n failure now intubated with leukocytosis and ? R sided pleural effusion.\n Ultrasound shows no evidence of R pleural effusion.\n REASON FOR THIS EXAMINATION:\n Compare R lung parencyma to previous CT scan - ? pleural effusion vs.\n consolidated lung\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure;renal failure;renal failure\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable moderate-to-large right pleural effusion, not significantly changed\n compared to ultrasound from .\n\n 2. Dense lower lobe consolidation representing pneumonia versus dense\n atelectasis.\n\n 3. Stable findings of cirrhosis with TIPS in place.\n\n 4. Stable right adrenal myelolipoma.\n\n 5. Stable fat-containing umbilical hernia, containing internal stranding\n which is not significantly changed in appearance.\n\n 6. Stable cystic left adnexal lesion, measuring up to 5.9 cm in size.\n Further evaluation with dedicated ultrasound or MR should be performed if not\n already performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1024468,
"text": " 4:13 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o lower extremity DVT\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal insufficiency,\n s/p TIPS on with acute hypoxia, fever and leukocytosis.\n REASON FOR THIS EXAMINATION:\n r/o lower extremity DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): WWM SAT 5:00 PM\n No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND AT 16:10 HOURS\n\n HISTORY: Acute hypoxia, fever, and leukocytosis in a patient with history of\n NASH cirrhosis and renal insufficiency.\n\n COMPARISON: .\n\n FINDINGS: -scale, color Doppler, and Doppler waveform evaluation was\n performed on the deep veins of both lower extremities. Normal\n compressibility, wall-to-wall color flow, and waveforms were obtained\n throughout. No intraluminal thrombus identified.\n\n IMPRESSION: No DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1024469,
"text": ", H. MED MICU 4:13 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o lower extremity DVT\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal insufficiency,\n s/p TIPS on with acute hypoxia, fever and leukocytosis.\n REASON FOR THIS EXAMINATION:\n r/o lower extremity DVT\n ______________________________________________________________________________\n PFI REPORT\n No DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1025848,
"text": " 2:12 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Compare R lung parencyma to previous CT scan - ? pleural eff\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, renal failure on CVVH, and respiratory\n failure now intubated with leukocytosis and ? R sided pleural effusion.\n Ultrasound shows no evidence of R pleural effusion.\n REASON FOR THIS EXAMINATION:\n Compare R lung parencyma to previous CT scan - ? pleural effusion vs.\n consolidated lung\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure;renal failure;renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BMzb MON 8:29 PM\n 1. Stable moderate-to-large right pleural effusion, not significantly changed\n compared to ultrasound from .\n\n 2. Dense lower lobe consolidation representing pneumonia versus dense\n atelectasis.\n\n 3. Stable findings of cirrhosis with TIPS in place.\n\n 4. Stable right adrenal myelolipoma.\n\n 5. Stable fat-containing umbilical hernia, containing internal stranding\n which is not significantly changed in appearance.\n\n 6. Stable cystic left adnexal lesion, measuring up to 5.9 cm in size.\n Further evaluation with dedicated ultrasound or MR should be performed if not\n already performed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, renal failure, respiratory failure, leukocytosis,\n question right pleural effusion.\n\n TECHNIQUE: Helical CT through the chest, abdomen and pelvis was performed.\n Intravenous contrast was not administered. Oral contrast was also not\n administered. Direct visual comparison is made to multiple prior studies,\n including , as well as more recent studies from , and an\n ultrasound from .\n\n FINDINGS:\n\n CHEST: There is a stable moderate-to-large right pleural effusion, as seen on\n prior ultrasound from . There is consolidative airspace disease of the\n left base, representing pneumonia versus dense atelectasis. Linear airspace\n disease is also seen within the left upper lobe. The patient is intubated. A\n nasoduodenal tube is in place. There are atherosclerotic calcifications of\n the aorta. Calcification is also noted involving the coronary arteries.\n (Over)\n\n 2:12 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Compare R lung parencyma to previous CT scan - ? pleural eff\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are degenerative changes of the spine.\n\n ABDOMEN: The liver is mildly nodular in appearance, consistent with patient's\n history of cirrhosis. A TIPS is in place. Patency cannot be evaluated due to\n lack of IV contrast. The gallbladder is surgically absent. There is a stable\n right adrenal myelolipoma. The spleen is enlarged. There is a stable fat\n containing midline umbilical hernia, which also contains stranding, not\n significantly changed compared to prior studies, including a . There\n are extensive atherosclerotic calcifications of the abdominal aorta. There\n are degenerative changes of the spine. The solid and hollow abdominal organs\n are otherwise within normal limits, allowing for non-contrast technique.\n Multiple mesenteric and retroperitoneal lymph nodes are noted, which are not\n pathologically enlarged by size criteria.\n\n PELVIS: There is a stable cystic left adnexal lesion, measuring 4.8 x 4.1 x\n 5.9 cm in size, not significantly changed compared to prior cross-sectional\n studies. Both the Foley catheter and rectal tube are in place. The remaining\n pelvic viscera are otherwise within normal limits. The osseous structures are\n intact.\n\n IMPRESSION:\n\n 1. Moderate-to-large right pleural effusion, as previously seen on ultrasound\n from .\n\n 2. Consolidative left lower lobe airspace disease, representing pneumonia\n versus dense atelectasis.\n\n 3. Linear left upper lobe airspace opacity representing atelectasis versus\n early pneumonia.\n\n 4. Stable findings of cirrhosis with TIPS in place. Patency cannot be\n evaluated due to lack of intravenous contrast material.\n\n 5. Stable right adrenal myelolipoma.\n\n Stable cystic left adnexal lesion, measuring up to 5.9 cm in size.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026798,
"text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change or new infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESLD, recent hypoxic respiratory failure in setting of\n multifocal PNA and pulmonary edema, now newly febrile\n REASON FOR THIS EXAMINATION:\n eval for interval change or new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxic respiratory failure, now febrile.\n\n FINDINGS: In comparison with study of , obliquity of the patient makes it\n somewhat difficult to compare the mediastinal structures. Probable\n atelectatic changes at the left base. Apparent increased opacification at the\n right cardiophrenic angle may merely reflect the pulmonary vessels partially\n obscured by the overlying mediastinum. If there is serious clinical concern\n for developing pneumonia, a repeat study without patient rotation would be\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025915,
"text": " 3:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with volume overload, resp failure, intubated\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Volume overload and respiratory failure, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there has been improvement in\n the pulmonary vascular status, some of which may reflect the semiupright\n position. The extensive layering pleural effusions are less prominent. It is\n unclear whether much of this may merely reflect the semiupright position.\n Lateral decubitus views would be necessary to appropriately evaluate the\n amount of residual pleural fluid.\n\n Atelectatic changes are again seen at the bases and the monitoring leads\n remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-18 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1027023,
"text": " 8:53 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Placement of HD tunnel catheter\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yo w/ NASH cirrhosis and recent TIPS with ESRD\n REASON FOR THIS EXAMINATION:\n Placement of HD tunnel catheter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd MON 11:51 AM\n Right-sided tunneled dialysis catheter placed and okay to use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 62-year-old female with underlying NASH cirrhosis with\n end-stage renal disease who presents for hemodialysis catheter placement.\n\n OPERATORS: , M.D. and , M.D., attending\n physician, was present for the entire procedure. Dr. has reviewed\n this study.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 100 mcg of fentanyl and 2 mg of Versed throughout the total intra-service time\n of 50 minutes during which the patient's hemodynamic parameters were\n continuously monitored. 1% lidocaine was used for local anesthesia.\n\n PROCEDURE: After review of the risks and benefits of the procedure as well as\n conscious sedation, informed consent was obtained. The patient was brought to\n the angiography suite by supine on the imaging table. The right neck was\n prepped and draped in the usual sterile fashion. Access was obtained into the\n right internal jugular vein using ultrasound guidance and micropuncture\n needle. Hard copy ultrasound images were obtained befreo and after venous\n access documenting vessel patency. An 018 wire was passed through the\n micropuncture needle. A small was made on the skin over the needle. The\n needle was removed and replaced with the micropuncture sheath. The inner 3\n French sheath and wire were removed and replaced with a short wire which\n was used to obtain measurements.\n\n Next, a tunnel was made from the anterior superior chest wall to the access\n site through which the dialysis catheter was pulled. A peel-away sheath was\n placed over the wire using flouroscopic guidance. The dilator was removed and\n the dialysis catheter was placed through the peel-away sheath as the sheath\n was peeled away. The final tip position is in the right atrium. The access\n site was sutured with 4-0 Vicryl. The catheter was sutured to the skin with 0\n silk. Both ports were flushed and aspirated. A sterile dressing was applied.\n There were no immediate complications.\n\n IMPRESSION: Uncomplicated placement of 23-cm 15.5 French Angiodynamics\n hemodialysis catheter via the right internal jugular vein with tip in the\n (Over)\n\n 8:53 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Placement of HD tunnel catheter\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right atrium.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-18 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1027024,
"text": ", MED FA10 8:53 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Placement of HD tunnel catheter\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yo w/ NASH cirrhosis and recent TIPS with ESRD\n REASON FOR THIS EXAMINATION:\n Placement of HD tunnel catheter\n ______________________________________________________________________________\n PFI REPORT\n Right-sided tunneled dialysis catheter placed and okay to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024504,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA vs. pulm edema\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, acute on chronic renal failure, s/p TIPS\n with hypoxia, possible RLL consolidation on physical exam\n REASON FOR THIS EXAMINATION:\n ? PNA vs. pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NASH cirrhosis, chronic renal failure, hypoxia. Possible right\n lower lobe consolidation on physical exam.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n There is moderate cardiomegaly, with prominence of the main pulmonary artery.\n There is upper zone redistribution and diffuse interstitial and alveolar\n opacity, consistent with pulmonary edema. There is a small-to-moderate right\n effusion with underlying collapse and/or consolidation. There is some\n increased retrocardiac density, consistent with left lower lobe collapse\n and/or consolidation. No left effusion is identified.\n\n Compared with , CHF findings have progressed. The possibility of a\n pneumonic infiltrate at the right base cannot be entirely excluded, though\n much of the appearance could relate to atelectasis and alveolar edema.\n\n Incidental note is made of widening of the left AC joint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026562,
"text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and ESRD, recently extubated\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:34 A.M. \n\n HISTORY: Cirrhosis and end-stage renal disease. Recently extubated.\n\n IMPRESSION: AP chest compared to through 7.\n\n Previous pleural effusions and pulmonary edema have cleared, however.\n Mediastinal vascular engorgement suggests persistent volume overload. Heart\n size is normal. Lungs are clear. A right internal jugular line ends at the\n superior cavoatrial junction. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-16 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1026824,
"text": " 2:05 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please perform U/S guided diagnostic paracentesis, eval flui\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and recent TIPS now with fever\n REASON FOR THIS EXAMINATION:\n please perform U/S guided diagnostic paracentesis, eval fluid for cell count w/\n diff, culture, protein, albumin, LDH\n ______________________________________________________________________________\n WET READ: PXDb SAT 3:30 PM\n no ascites noted on four quadrant evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with NASH cirrhosis and recent TIPS, now with\n fever. Evaluate for ascites. If ascites, perform ultrasound-guided\n diagnostic paracentesis. Discussed with Dr. .\n\n COMPARISON: .\n\n FINDINGS: Limited four quadrant evaluation demonstrates no ascites. Large\n amount of shadowing from fat and abdominal gas is noted. Splenomegaly is\n noted.\n\n IMPRESSION: No ascites noted on four quadrant evaluation. This was discussed\n with Dr. . Splenomegaly is noted.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025193,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, intubated with\n increasing oxygen requirement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:44 AM\n ___interval change. Lines and tubes remain in adequate position. There are\n bilateral pleural effusions, right greater than left with associated\n atelectasis. ___.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing oxygen requirement in the setting of suspected multifocal\n pneumonia and probable PE.\n\n COMPARISON: Portable chest radiograph from .\n\n FINDINGS: Overall, there is no significant interval change. There are\n bilateral dependent effusions, right greater than left. Associated\n atelectasis is present, but an underlying pneumonia cannot be excluded. The\n cardiac silhouette remains enlarged, with vascular engorgement and pulmonary\n edema suggesting volume overload.\n\n The endotracheal tube remains in adequate position, as does the right IJ line\n and NG tube.\n\n IMPRESSION: Little significant interval change in bilateral pleural effusions\n with associated atelectasis. Underlying pneumonia cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025194,
"text": ", MED MICU 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ? Multifocal pneumonia and probable PE, intubated with\n increasing oxygen requirement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n ___interval change. Lines and tubes remain in adequate position. There are\n bilateral pleural effusions, right greater than left with associated\n atelectasis. ___.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026115,
"text": " 2:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evalute for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESRD on CVVHD.\n REASON FOR THIS EXAMINATION:\n Evalute for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 11:35 AM\n No appreciable interval change compared to the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Change in a patient with end-stage renal disease on\n continuous -venous dialysis.\n\n Portable AP chest radiograph was compared to prior study obtained on .\n\n The ET tube tip is about 2.7 cm above the carina , neck in flexion. The NG\n tube tip is in the stomach. The right internal jugular line tip is at the\n cavoatrial junction. Note is made that the ET tube cuff is most likely\n overinflated. The cardiomediastinal silhouette is unchanged. There is also no\n change in bibasal opacities consistent with atelectasis. Small right pleural\n effusion is present, grossly unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026116,
"text": ", MED MICU 2:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evalute for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ESRD on CVVHD.\n REASON FOR THIS EXAMINATION:\n Evalute for interval change\n ______________________________________________________________________________\n PFI REPORT\n No appreciable interval change compared to the prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026331,
"text": ", MED MICU 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and ESRD.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Status post extubation. Markedly improved pulmonary vascular congestion\n and right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1025341,
"text": " 9:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Line placement in L IJ--? placement, PTX.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with ARF, needs CVVHD\n REASON FOR THIS EXAMINATION:\n Line placement in L IJ--? placement, PTX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left IJ placement.\n\n FINDINGS: In comparison with earlier study of this date, the tip of the left\n IJ catheter extends to the upper portion of the SVC. No evidence of\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024795,
"text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and hypoxia.\n\n FINDINGS: In comparison with the study of , there is worsening congestive\n failure and right pleural effusion. Haziness of the left hemithorax is\n consistent with a left pleural effusion as well. Bibasilar atelectatic\n changes and the possibility of superimposed pneumonia can certainly not be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025741,
"text": " 3:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis and on CVVHD.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NASH cirrhosis to evaluate for change.\n\n FINDINGS: In comparison with study of , there again is evidence of\n bilateral pleural effusions, much more prominent on the right, with bibasilar\n atelectatic change. No evidence of pneumothorax. Monitoring leads remain in\n place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1024464,
"text": " 3:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for pneumonia vs pulmonary edema\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, Acute on chronic renal insufficiency,\n s/p TIPS, with hypoxia, fever and leukocytosis.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia vs pulmonary edema\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old with NASH cirrhosis, recent TIPS placement and acute\n on chronic renal insufficiency, presenting with hypoxia, fever and\n leukocytosis, evaluate for pneumonia or pulmonary edema.\n\n COMPARISONS: CT abdomen and pelvis of and chest x-ray performed on\n .\n\n TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis without IV\n contrast due to poor renal status with coronal and sagittal reformatted\n images.\n\n CT CHEST WITHOUT IV CONTRAST: There is a moderate-to-large right pleural\n effusion with associated atelectasis/consolidation. On the left, there is\n developing basilar consolidation, and in the upper lobe and lingula, there are\n more patchy centrilobular ground-glass opacities suspicious for an infectious\n etiology. Small mediastinal lymph nodes present throughout, none greater than\n a centimeter in short axis. Without IV contrast, we cannot assess for\n pulmonary embolism. There is coronary artery and dense mitral annulus\n calcification. There is a prominent left perihilar peribronchovascular\n thickening, difficult to fully distinguish from vessels on non-contrast study.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Evaluation of the abdominal viscera is\n severely limited without IV and very little oral contrast. The liver is\n nodular consistent with the history given of cirrhosis. TIPS stent is in\n place. Hepatic arterial, venous, and portal venous vasculature patency cannot\n be assessed on this non-contrast study. The spleen is markedly enlarged.\n There is a large fat-containing right adrenal lesion consistent with a\n myelolipoma which appears stable from prior studies. The kidneys are\n unremarkable. There is scattered celiac axis, mesenteric, and retroperitoneal\n lymphadenopathy, not significantly changed. There is no significant ascites.\n No bowel obstruction. No free fluid in the abdomen.\n\n CT PELVIS WITHOUT IV CONTRAST: Large fat-containing umbilical hernia is\n present. There is a large cystic mass in the left adnexa measuring up to 5.5\n cm which appears stable from the prior study and is not well evaluated on CT.\n No free fluid in the pelvis. Foley catheter is in place.\n\n BONE WINDOWS: There are mild degenerative changes of the thoracic spine. No\n (Over)\n\n 3:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Please evaluate for pneumonia vs pulmonary edema\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n acute fractures are seen.\n\n IMPRESSION:\n\n 1) Left lower lobe consolidation and patchy centrilobular ground-glass\n opacities in the left upper lobe and lingula, worrisome for multifocal\n pneumonia.\n\n 2) Moderate right-sided pleural effusion with associated atelectasis/\n consolidation.\n\n 3) No acute CT findings to explain the patient's acute abdominal pain and\n worsening distention. No ascites.\n\n 4) Cirrhotic liver with TIPS stent in place. The hepatic vasculature patency\n is not be assessed on this non-contrast study.\n\n 5) Stable large fat-containing right adrenal lesion, likely a myelolipoma.\n\n 6) 5.4-cm left adnexal cystic mass, appears essentially stable from prior CT\n studies but would be better followed by ultrasound.\n\n 7) Fat-containing umbilical hernia.\n\n Findings discussed by the ordering clinician, Dr. .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1639037,
"text": "7pm to 7am:\n\nNeuro) Pt intubated with fentanyl and versed gtt for sedation with good effect after it was increased at 8pm. Pt will now open eyes to voice and follows simple commands. No contact from family on this shift. Full Code.\n\nID) Low grade temp (99.2->99.0). Pt remains on vanco, cipro and zosyn.\n\nEndo) Pt on lantus and humalog SS.\n\nCV) Pt has been in SB (48-55) with occ PACs. SBP stable at 120-140's with MAP law at 58-66. MD aware. Hydralazine IV started to reduce preload. Am labs pending. Hct dropped this am again from 32 to 27. PLT 77 and inr 2.1 .\n\nResp) Intubated in AC mode as noted with ABGs as noted in care vue. Pt has been deep sx'd for sml amounts of rusty colored secretions. Oral care done q4hrs. Continue to wean vent as tol by pt. '\n\nGI) Abd dist firm and with hypoactive BS. Flexiseal in place for liq brown stool in sml-mod amounts. Stool sample sent for C-diff. Pt has had high residuals throughout the night, and unable to give po meds. MD aware. OGT placed to LIS, and draining mod amounts of yellow bilious drainage.\n\nGU) U/O via foley catheter from 35-60 cc/hr. Albumin given with little effect on U/O. ? increase dosage today. Pt was also diuresed yesterday and ? more lasix today. Pt is now (+)850 cc for LOS.\n\nSkin) see care vue for details.\n\nPlan : * PICC line once afebrile for 24 hrs.\n * ? need for MRI for PV evaluation.\n * F/U hct levels 2/2 drop today.\n * Wean vent settings as tolerated.\n * F/U cultures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1639038,
"text": "Respiratory\nPt received on cmv 500X16, 10 peep and 70% 02. settings were changed to 380x 22, 15 peep for lung injury precautions. Abgs were fair with poor oxygenation. peep then increased to 18. Pt bs coarse and pt was suctioned for rusty colored secretions. plan to continue with current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1639039,
"text": "Micu Nursing Progress Notes\nEvents: Peep increased to max due to low PaO2, central line placed.\n\nNeuro: Pt on fentanyl at 50 mcg/hr and versed at 2mg/hr. She is comfortable, responding to verbal commands, attempting to assist with care.\n\nResp: Vent settings A/C 500 x 16, peep 10, FiO2 70%, O2 sata 93%. She was placed on ARDS protocol not because she has ARDS but because her pressures were increasing. So she was changed to A/C 380 x 22, Peep increased to 15, then to 18. ABG 7.38/51/65. FiO2 was increased to 100% during central line insertion, she had to lye flat. Her O2 sats dropped to 89% while flat. When she was upright again she was dropped back to 79% with O2 sats 94-95%. She has been suctioned x2 for small to mod amount of rusty colored sputum. Specimen sent for C%S.\n\nCardiac: B/P 128-138/40's, HR 50's, SR/SB. Hydralazine was increased to 10mg Q8h and the midodrine was D/C'ed, as well as the octreotide and albumin.\n\nGI: Pt had another 50cc out from her OGT. She was given her 8am meds on her empty stomach. When checked at 1400 she had 10cc in her stomach. She continues to have liquid brown stool via flexiseal which is working well. No orders for tube feeding yet until gastric emptying is improved.\n\nEndo: Blood sugar wasd 144 this am and she was given 1/2 dose of her glargine. At 12n she was 84 then 87 at 1600 and 97 at 1800. Hopefully she will be able to tolerate tube feedings soon.\n\nGU: Foley draining clear amber urine. U/O has been decreasing most of the day, from 45cc/hr to 5-10cc/hr. She started on lasix 160 mg at 1900.\n\nLines: A central line was placed in her right IJ without difficulty. She also has an Aline and 2 perpherials.\n\nSocial: Daughter in after noon. She spoke to the liver transplant surgeon who spoke frankly about her condition. She became very upset and called her brothers in. They will be talking to Dr. before they leave.\n\nPlan: MRI cancelled due to her inability to lie flat, continue to monitor renal status and I&O, attempt to wean vent if possible with the start of lasix, emotionally support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Report",
"row_id": 1639061,
"text": "Resp Care: Pt continues intubated #8 oett secured @ 22 @ lip and on ventilatory support with psv, worsening oxygenation overnoc necessitating increased peep/fio2; bs coarse, sxn loose clear secretions, rx with mdi albuterol/atrovent, rsbi 80, will cont support as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1639059,
"text": "no weaning this shift, pt transported to CT for image of abdomen, sx'd for moderate amount of secretions. plan is to locate source of infection before weaning from vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Report",
"row_id": 1639060,
"text": "shift update:\n\nneuro: lethargic but easily arrousable. mae. follows commands. nodding appropriately to questions. medicated w/fentanyl q2-3hrs prn pain. ^rr & appeared restless medicated w/versed w/good effect. unable to turn d/t difficulty w/dialysis cath team aware.\n\ncv/skin: nsr w/hr 70-90's. no vea. levofed gtt titrated to keep map>60 currently at 0.04mcg/kg/min. +pp bilat. peri area red excoriated nystatin cream applied.\n\nresp: lungs clear->coarse & dim in bases. abg's initially good on cpap 40% 5/10 at 0400 pao2 66 & sat as low as 92% fio2 increased to 50% & peep increased to 8. sat currently 100% suctioned for thin clear secreations.\n\ngi/gu: og patent +placement. tf infusing at goal. -residual. abd firm & distended. +bs. foley patent w/scant amt amber cloudy urine.\n\nrenal: cont goal -150cc/hr. unable to attain goal throughout night d/t difficulty w/access cath. access line very positional & sensitive to an movement or cough. line flushed w/o difficulty. filter changed d/t failure alarm re access line. team aware of need for new line to facillitate effective . to address in am rounds.\n\nendo: bs>200 team aware insulin gtt starting dose increased by team & following ss for adjustments. currently at 17u/hr.\n\nid: afebrile. bc x1 sent off dialysis cath. wbc 18. vanco dose given per team at 2100.\n\nsocial: many family members into visit last evening.\n\nplan: pain management & sedation for comfort. titrate levo to keep map>60. goal -150cc/hr. ?new line for more effective hd & more mobility. insulin gtt per protocol titirate prn. ?adding small lantus dose to better control bs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1639048,
"text": "1900-0700 npn\nEVents: cont on CVVHD supported by Levophed with increase ability to remove fluids. Peep now at 14cm and rr 28.\n\nNEURO: lethargic on min. sedation, fentanyl for pain. perl, able to move upper arms to command, wiggle toes. follows commands inconsistantly\n\nCV: Tmax 100.2, bair hugger off most of eve with temp maintained. sinus brady. levophed steady dose at .06 for maps low 60's. urine output improved with maps over 60. wbc 14, hct improved at 29 platlets rising now at 90's.\n\nRESP: 40% SATS high 90's, increase secretions ETT thick yellow with plugs, improved cough effort, coarse to clear after suction.\n\nGU/GI: foley amber clear, most hours producing some urine. abd obese and firm. bt present. mushroom cath in for return golden stool. cont. lactulose.\n\nENDO: tf at goal 10 cc hr. tol with residuals 10cc. bs required coverage from sliding scale.\n\nID: cdiff neg. universal precautions. vanco dosing done late due to ID not approving. last level 13. will redose with ID consent.\n\nACCESS: RIJ intact wnl, artline wnl,dialysis access wnl.\n\nCVVHD: no filter change this shift, able to meet goal of 200 cc hr removal on average\n\nPAIN: light sedation, 50 mcq fentanyl givenIV with good response for 2-4 hrs.\n\nSKIN: some improvement of perianal rash. cont. barrier cream and miconazole powder.\n\nSOCIAL: family attentive at bedside. updated on status.\n\nPLAN: cont. cvvhd with goal 200cc removal/hr. cont. to wean vent/peep as able, follow labs and replete as need, meticulous skin care, pulm. toilet, revisit ID to approve vanco dosing, support pt and family emotionally.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1639049,
"text": "Resp Care\nPt remains on vent. Intubated with #8 et @ 22, patent and secure. Suctioned for mod amt of blood-tinged secretions. Weaned peep and increased rr based on abgs. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1639050,
"text": "Nursing Progress Note.\n\nEVENTS: circuit has remained patent throughout shift with pt meeting hourly goal of negative 200ml/hr. Levophed gtt & PEEP both successfully weaned down today.\n\nRESP: Pt received on AC-28-40-380-12 with nl sats and pt typically breathing @ set rate of 28. Serial ABG's today reveal adequate oxygenation & borderline ventilation, PEEP subsequently dropped to 10. Small amounts of thin off-white sec per ETT today. Good powerful cough noted, mostly non-prod though. LS have varied from coarse rhonchi to fairly clear, poorly appreciated lower lobes 2nd body habitus.\n\nCV: Pt received on 0.06mcg/kg/min IV Levophed gtt to /maintain MAP values above 60. Fortunately the pts has tol reduced gtt rates with maintained MAPs today, currently infusing @ 0.03mcg/kg/min -- will cont to titrate according to pts needs. 99.4 Oral tmax today. Will check next random Vanco level @ 23:00 per HO request. CVP values dropping below 10 today with pt negative an additional 3.5 liters today and 4.5 liters for LOS. Venodyne boots in place for DVT prophylaxis.\n\nMS: More alert and interactive today with less c/o pain and anxiety. However, pt cont to require approx 50mcg IVP Fentanyl Q 4 hrs and approx 1mg IVP Verced Q 4 hrs. Pt has consistantly followed commands today, MAE, nods head appropriately to simple yes/no questions. Pt freq re-oriented to person/place/time/care rationale to assist with nl cognition.\n\nGU: in place and meeting negative hourly goal of minus 200ml. Unfortunately the pt developed high negative access pressures alarms that could not be clear with air being introduced into the line -- therefore the circuit was d/c'ed @ 17:15. Of note, the pts urine output has increased today likely in context to improve BP values on IV Levophed gtt. IV Calcium & IV Potassium gtts titrated according to serail labs/ repletion guidelines.\n\nDERM: Excoriated/erythematic perineal folds cleansed with foam/dried with antifungal powder applied topically.\n\nGI: Nutren Renal tube feeds ramped up to 20ml/hr via OGT with low residuals noted. 425ml Liquid brown stool output via mushroom cath.\n\nSOC: Pt cont to receive multiple family visitors around the clock -- all kept up to date with POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions remain in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1639051,
"text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. Oxygenation cont to improve allowing for peep decrease from 14-12-10 this shift. Pt alert, breathing above vent. BS occas coarse but otherwise clear. Sxn for minimal secretions. cont current settings consider change to PSV soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1639052,
"text": "MICU Nursing Note 1900-0700\nEvents: Continues on and tolerating 200ml/hr off, access pressures with freq. neg. values requiring freq. line manipulation and less freq. position changes for patient, Circuit replaced d/t high access pressures and introduction of air into circuit. ABG with decreased pH---renal and MICU team aware and dialysate solution to be changed. Failed attempt at d/c'ing iv Levophed gtt, still requiring minimal dosing to maintain MAP's >60.\n\nNeuro: Easily arouseable, follows commands, c/o anxiety and pain when asked, requiring IV Versed 1-2mg bolus doses Q2-3 hours and requiring 50 mcgs IV Fentanyl bolus doses Q3-4hours. Moving all extremities, pt moves upper extremities toward face but does not attempt to pull at any lines--currently unrestrained, PEARL, does well with calm approach.\n\nCardiac: HR=60's SR with occas. PAC noted, BP= 100-130's/40's with MAP's >60 on Levophed at 0.03mcgs. Attempt to d/c Levophed with BP 90/40's and MAP's=55. Right radial aline with good waveform, right IJ TLC site C/D/I, CVP= , Left IJ HD line site C/D/I---line kinks easily.\n\nResp: Lungs with bilat upper lobe rhonchi and diminished at bilat bases, freq. bronchospasm on vent, ETtube suctioned for small amts thin white Q2hr, oral suction for same, No vent changes overnight, Current settings include AC 380-40%-28 with Peep=10. MV=10, not overbreathing vent, Sats= 98-100%, ABG= 7.30-39-115. MICU team and renal aware of recent ABG\n\nGI: Abd soft with + bowel sounds all quads, Mushroom cath draining large amts liquid golden brown stool >500ml for shift, OGtube placement checked by ausculatation and pt tol. FS Nutren Renal at 20 ml/hr.\n\nGU: scant urine output---30ml/shift, Continues on and tolerating removal of 200ml/hr. Currently neg. 5 L in last 24 hrs and neg 6 L for LOS---renal aware. Calcium and KCL replaced as per sliding scale, Citrate infusing as ordered. Renal aware of pH = 7.30 and to change dialysate solution.\n\nSkin: perianal area remains reddened---antifungal cream applied, no other sig. changes\n\nID: Low grade temp, Tmax= 100.7, off bair hugger all noc, WBC down to 12.7, Lactate up to 2.7, remains on cipro, zosyn, and vanco\n\nEndo: fingersticks remains elevated 200-300. Pt on Lantus and sliding scale humulog.\n\nSocial: Family in to visit all evening and updated on pt's condition and plan of care\n\nPlan: Change dialysate solution as ordered, recheck ABG soon after,\nAddress with renal what end goal is for , If pt continues on would benefit from new access site as current access is kinking freq., monitor sugars---? if needs insulin gtt, replace lytes as ordered, continue light sedation prn, support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1639053,
"text": "Respiratory Care:\n\nPt remains intubated & ventilated on full A/C setting support; pls see flowsheet for details. No changes made to vent settings throughout shift. ABG this a.m. shows a metabolic acidosis; pt remains on at this time. Plan to continue ventilatory support & wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1639054,
"text": "Respiratory Care\nPatient remains on mechanical ventilation with all settings documented in Carevue. Requiring sedation at one point with increased spontaneous efforts.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1639055,
"text": "Nursing Progress Note.\n\nEVENTS: Per Renal service, pts CVVHDF hourly I/O goal is net even and will d/c therapy when circuit is d/c'ed. Unable to wean off IV Levophed gtt today. No fever spike today.\n\nRESP: Pt received on AC-28-40-380-10 with nl sats, RR @ set rate and adequate serial ABG's obtained overnight. PEEP dropped to 8 this AM, repeat ABG indicate adequate oxygenation (7.37-37-98 @ 15:00). Minimal thin off-white sec per ETT today. LS have varied from coarse rhonchi to clear today. Good cough reflex noted, essentially non-prod cough.\n\nGU: CVVHDF therapy remains ongoing with revised hourly I/O goal of net even. Pt cont to have freq access low pressure issues (triggered by coughing & LIJ catheter position issues)(LIJ dsg change did not ameiliorate this issue). The pt is currently net negative 1.5 liters today and is net output 7.5 liters for LOS. Pt nodded yes when asked whether she was thirsty. Oliguric today likely 2nd vol depletion of CVVHDF therapy. Both Calcium & Potassium gtt's titrated according to their respective sliding scales, both infuse into the return port. IV Citrate gtt cont to infuse via access port as ordered.\n\nCV: Pt received/maintained on IV Levophed gtt, currently infusing @ 0.035mcg/kg/min via RIJ TLC to maintain MAP's > 60. NSR today, no VEA. 99.1 Oral tmax today off bare hugger. Elevated FS cov with Insulin SS & fixed dosing, ? increasing cov to normoglycemia. Venodyne boots/SQ Heparin dosing in place for DVT prophylaxis. CVP values in single digits with 8 to 10 of PEEP on board.\n\nMS: Pt opens eyes to verbal stimuli, MAE to commands and able to nod head appropriately to simple yes/no questions. IVP Midazolam & IVP\nFentanyl provided PRN throughout shift for c/o anxiety & pain respectively with good pt comfort noted. Please see med sheet for time/dosing of meds. Pt re-oriented to person/place/time/care rationale to assist with nl cognition.\n\nGI: Pt cont to tol FS Nutren Renal tube feeds @ 20ml/hr via OGT with low residuals today. Abd is obese with + BS appreciated. Mushroom cath cont to work well with approx 300ml liquid greenish-brown stool output.\n\nSOC: Supportive family vigil maintained by family all shift. All family members kept up to date with /pt status. The pt remains a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions remain in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1639056,
"text": "MICU Nursing Note 1900-0700\nEvents: Pt vent changed to CPAP+PS and tolerated overnight, increased agitation with Q1-2hr bolus dosing of both fentanyl and versed---changed to IV gtt versed and IV gtt fentanyl overnight and lightly sedated, continued with negative pressure line access issues all night and filter clotted during am CXR--- d/c'd as per renal attending recommedation and to be reassessed this am, Levophed weaned to off at 5am with MAP's >60 at present.\n\nNeuro: Restless and mild agitation, c/o anxiety and pain when asked, opens eyes and tracks, follows all commands, requiring freq Q1-2 hour bolus dosing of both versed and fentanyl so IV gtt versed started at 1mg/hr and infused overnight, IV Fentanyl gtt started at 25 mcgs/hr and infused overnight. Both versed and fentanyl gtts placed on hold as per MICU team in hopes of extubation today---pt now requiring bolus doses of both meds. PEARL, moving all extremities.\n\nCardiac: HR= 70-80's SR with no ectopy noted, Right radial Aline with good waveform and BP= 110-130's/40-50's with MAP's >60, IV Levophed titrated between 0.03-0.06 mcgs/kg/min overnight and finally able to wean to off at 0500. Right IJ TLC site C/D/I and one port clotted, CVP= , Left IJ HD cath site C/D/I and ports flushed and instilled with 1.5ml of Heparin following treatment.\n\nResp: Lungs clear bilat upper lobes and diminished at bilat bases, ETtube suctioned for scant amts thin white sputum and oral suction for same. Strong nonproductive cough and occasional bronchospasm, started on inhalers, Tolerated vent change to CPAP+PS at 40% with PS= 10 and Peep initially at 8 and weaned to 5. Good ABG=7.38-39-104. RSBI= 80 this am. Sats= 98-100%, TV= 400-600 with MV= \n\nGI: Abd obese and soft, + bowel sounds all quads, OGtube placement checked by auscultation, Tolerating FS Nutren Renal at 20mg/hr, tube feedings placed on hold at 0500 in hopes of extubation today. Mushroom cath continues to drain golden brown liquid stool.\n\nGU: all night with goal of running pt even. Pt even since MN, clotted with am CXR procedure and D/C'd at 0400. Pt currently neg. 7.9 L for LOS, creatinine down to 2.5, still with scant amts of yellow urine 60ml for shift. Possible restart of today.\n\nSkin: perianal area remains reddended but slightly improved from previous, continues with antifungal cream and powder, no other skin breakdown noted.\n\nID: Afebrile, WBC = 17, Lactate = 2.2, continues on IV Cipro, Zosyn, and Vanco.\n\nEndo: Fingersticks remain elevated. Lantus dosing and sliding scale dosing increased.\n\nSocial: Family in to visit during evening and were updated on pt's condition and plan of care. Very supportive\n\nPlan: Possible restart of today---await plan, Restart Levphed for MAP's<60, prn dosing of Fentanyl and versed in hopes of extubation, Wean vent as tolerated and possible extubation today, Support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1639057,
"text": "Respiratory Care:\n\nPt continues ventilatory support via OETT on PSV settings settings as charted; Peep weaned from 8cm to 5cm this shift. RSBI = 84 this a.m. Pt placed on prn inhalers d/t mild bronchospasm; given with good relief. Plan for possible extubations this a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1639058,
"text": "7am to 7pm:\n\nEvents: Pt's temp spiked again and pan cultured and sent to CT of chest and torso (w/o contrast) to look for inflamatory process (results pending). CXR this am worse regarding pulm edema and decision made to place back on for another few days, for goal to extubate tomorrow if CXR improves.\n\nROS:\n\nNeuro) Intubated (OETT) and no sedation required. Pt very lethargic and will open eyes to name () and follows simple commands. Pt able to communicate via squeezing hand for yes and no. Pt cooperative with care, and restraints remains off. Full Code. Family at bedside.\n\nID) Tmax 101.2->100.7. Pan cultured and given Tylenol po,- awaiting effect. Vanco held this am TR 18. Goal to hold if TR >15. Zosyn changed to Q6hrs since back on .\n\nCV) SR (70-80's) w/o ectopy noted. SBP stable, but started back on levophed gtt after started on in order to maintain MAP>60. A-line with good wave form. ACCESS: RIJ TLC.\n\nResp) LS CTA to upper lobes and diminished at the bases. No changes made to the vent and pt continues to have good ABGs. Current vent setting at CPAP+PS: 40%/. Pt has been deep sx'd for sml amounts of thick white secretions with occ tan clots. Pt also continues to be bronchospastic.\n\nGI) Abd very dist and semi-firm and non-tender to palp. TF restarted and running w/o residuals noted. ? stop in am again for ? extubation...needs F/U. Pt has sml amounts of liq brown stool via rectal tube. Pt has been R/O for C-diff.\n\nEndo) FSBS has been running high and pt placed on insulin gtt with great effect. FSBS now 116-120's.\n\nGU/) No U/O noted until 3pm. U/O cloudy and with amber color. Pt is currently (-) 7 liters for LOS. restarted at 4pm and being run(-)150 cc/hr per renal team w/o complications. labs q 6hrs at 04-10-16-22 with labs Q12hrs at 04 and 16. Rescue line in place and due for a rescue flush at 20:00 if not indicated before.\n\nSkin) Reddness to perirectal area as noted in care vue slight improved. Pt placed on a kinair bed to improve skin status immobility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1639042,
"text": "Nursing Note (0700-190hrs)\nPt is an 83 yr old hx NASHcirrhosis; recent TIPS complicated by portal vein thrombosis/tear with CKD; Dx with PNA/pleural effusions vs PE from portal vein thrombosis. Presently treating as ARDS protocol and requiring initiation of CRRT.\n\nNeuro: Fent/versed gtt changed to bolus; no boluses given; briefly opening eyes with mod amt verbal stimuli; MAE with minimal mvm't noted to LUE--?r/t rotator cuff injury/sprain. +gag/cough, impaired. Plastics/hand consulted in past. restraints off, close observation.\n\nCV: HR 50's, SB with stable Bp in 100/50's. CVP 11-14--CXR shows pulm edema, no response to lasix/diuril.Echo with evidence of large amt mitral calcificaiton. Aline/right TLCL, unremarkable. Perineum with yeast like rash, nystatin powder freq applied.\nResp: LS clear, dim to bases.RR increased, FI02 decreased per ABG. anticipate <Fio2. Sm amt secretions. Abd US on hold per MICU team--originally ordered by liver to f/u portal vein status.\n\nGi: TF started 10cc/hr, tol; question of absorption-may need TPN. Lactulose decreased d/t liquid stool; flexiseal patent 500cc. 3rd c-diff spec sent, pnd--remains on contact pnd cx\n\ngu: No response as stated to additional diuretics. renal/liver following. Inadequate u/o, rising Bun/Cr.\n\nSocial: Mutliple family members. Daughter at bedside thru shift, tearful; speaking with staff re; prognosis. Full code.\n\nPlan; PLACE HD LINE THIS PM; INITIATE CRRT. CONT TO WEAN FIO2 AS TOL; TREAT AS ARDS. BOLUS SEDATION. IV ANTIBX. IV ANTIBX, VANCO BY LEVEL. FFP PRIOR TO LINE PLACEMENT--ELEVATED INR. DO NOT ADVANCE TF AT THIS TIME. Emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1639043,
"text": "Resp Care\nPt remains itnaubted on a/c pao2 slightly improved this shift fio2 subsequently decreased to 50% sats remain >96%. BLBs diminished suctioned for scant secretions. plan to continue to monitor resp status and slowly wean fio2 as toelrated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1639044,
"text": "1900-0700 npn\nEVENTS: Febrile at 101.0 oral. Pan culture done. Dialysis line placed in left IJ, verified by xray and clear at 2200. Initiated CVVHD at approx 2300 with filter change at 0330 for clotting at pods.\n\nNEURO: awakens to voice, nods head yes/no, perl at 2 cm. fent/versed for pain/sedation prn. mae reluctantly secondary to pain.\n\nCV: Tmax 101.0, sinus brady, maps at 55-60. tol cvvhd fairly well. min. urine out. bair hugger on through night for temp. maintainence. pp intact. cvp 10-15. lactate 1.6, sliding scale for calcium and potassium in place.\n\nRESP: decreased to 50%, TV 340, rr 24 breathing at 24, peep18 with acceptable abg. lungs clear bil, dimished at bases bil. suction for min. thin whte with drk brwn flecks. min oral secretions.\n\nGU/GI: foley with yellow urine min amt. , tf off for procedure, bilious drainage with min residual with some pill fragments. flexiseal found in bed, replaced with mushroom cath. drains mod to large amt golden loose stool.\n\nENDO: sliding scale and fixed dose. fsbs wnl. tube feeding remains at 10 cc hr for now.\n\nPAIN: bolus with 50-100 mcq fentanyl with poor control intially, then pt. appeared comfortable except grimace with arm movements.\n\nID: contact for possible cdiff. vanco dosing prescribed daily, cipro and pipercillin. pan culture done.\n\nACCESS: art line, cvp line with good trace. triple lumen right iJ, dialysis cath in left IJ.\n\nCVVHD: filter without citrate or heparin due to platlets in 60's. filter changed at 0330 for clotting. site condition good.\n\nSKIN: intact except perianal area, excoriated, red raised rash. nystatin oint and powder in use. mushroom cath for stool mangement.\n\nSOCIAL: Family at bedside for prayer with pt. Chaplain visit with sacrement of sick given.\n\nPLAN: cont. cvvhd, without citrate, sliding scale for K+ and Calcium repletions, labs q 6 hrs. wean fio2 as tol. medicate with fent/versed for comfort. abd US needed today. treat fevers, bair hugger to maintain normalized temp. support pt/family emotionally/spiritually. skin care in peri area cont.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1639045,
"text": "Respiratory therapy\npt remains orally intubated on ful ventilatory support. FiO2 increased to 100% for CVVHD line placement. Tol well, decreased to .5. Sx sml secretions. BS clear bilaterally, diminished bases. Plan wean ventilatory support as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1639046,
"text": "Resp. Care Note\nPt remains intubated and vented on AC settings as charted on resp flowsheet. Improving oxygenation allowing for decreased FiO2 to 40% and peep decrease to 16. BS with decreased aeration to bases. Stable on current vent settings, cont. to slowly wean peep as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1639047,
"text": "Nursing Progress Note.\n\nEVENTS: Pt started on IV Levophed gtt this afternoon for MAP values in the low 50's. circuit clotted off and changed @ 11:00. Abd US of this AM showed a patent portal vein. Pt tol PEEP reduction to 16.\n\nCV: Pt with MAP's in the low 50's this AM while on protocol. Pt initailly kept net even on and placed in supine position with no change in BP values. Subsequently the pt was started on an IV Levophed gtt which is currently infusing @ 0.055mcg/kg/min to maintain MAP's above 60. CVP values today in low teens. Normal sinus brady- cardia all shift. Random Vanco value @ 14:00, awaiting ID approval to re-dose @ this time. IV 2.25gm Zosyn dosing changed from Q 12 to Q 8 hrs today. 99.8 Oral tmax today with BareHugger in place/set @ 32. NBP values ten points lower than ABP in both systolic and diastolic values.\n\nRESP: Pt received on AC-24-40-380-18 with nl sats, not overbreathing set rate and no issues of SOB/dyspnea. Serail ABG's today c/w adequate oxygenation, PEEP dropped to 16 with adequate f/u ABG's. Small amounts of thick tan to brown sec per ETT today. LS are coarse to clear, weak cough reflex noted. No RSBI today 2nd PEEP >10. ARDS protocol in place. Afternoon CXR obtained, results pending.\n\nGU: Pt circuit filter clotted off @ approx 10:15, system back up and running by 11:45 with revised rates per renal service. Pt now receiving IV Citrate via access line with IV Calcium infusing in replacement line. Both KCL & Calcium repleted on an ongoing basis per protocol. Stated output per hour remains 100ml which she is now tol with IV Levophed gtt in place. Approx 125ml urine output via foley cath today.\n\nMS: PRN Fentanyl & Midazolam dosing in place today with good pt comfort @ this time. Pt follows simple commands and nods head appro- priately to simple yes/no questions. Pt kept up to date with POC/pt status to assist with nl cognition. No restraints required @ this time.\n\nGI: Pt received/maintained on Nutren Renal trophic feeds @ 10ml/hr via OGT with low residuals noted. PO Lactulose dosing remains ongoing with 400ml of liquid brown stool output via mushroom catheter today. Abd is obese with hypoactive BS @ times today.\n\nDERM: Perineum remains red/excoriated, barrier/Nystatin cream topical applied with area left open to air.\n\nSOC: Continuous family vigil maintained by multiple family members today including power of attorney son . family kept up to date with POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions now in place s/p 3 neg c.diff stool specimens.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1639040,
"text": "7pm to 7am:\n\nPt has had an uneventful night. Family meeting done last night regarding pt's status and POC. Family at bedside and emotional support given.\n\nROS:\n\nNeuro) Pt intubated with fentanyl and versed gtt for sedation with good effect. Pt will open eyes to voice and follows simple commands eg squeezes hand. Family at bedside and updated. Family very emotional regarding pt's status and emotional support given. Pt is Full .\n\nID) Tmax 99.8 -> 99.0 (O). No changes made to IV ABXs for Pna. IVABs:cipro, zosyn and vanco, which is renally dosed q day. #2 sample for C-diff sent and #3 due . #1 sample negative. Follow up pan cultures.\n\nCV) SB (50-56) with no ectopy noted. SBP stable at 100-130's with MAP > 50. Pt noted to have some trace edema to exts. Am labs pending as of 5am. CVP low at 4->6, MD aware and no interventions to be done per Dr .\n\nResp) Pt's vent settings are in ARDS mode in order to optimal resp status. Fio2 weaned to 60% with good ABGs. Continue to wean as tolerated. Current vent settings are AC: 60/300x22/18. CXR done this am and results pending. Pt has been deep sx'd for sml amounts of thick rusty colored secretions.\n\nGI) Abd remains very dist and firm to palp. HypOactive BS x 4. Pt continues to have mod amounts of liq brown stool via flexiseal and was inc x 2 this shift. OGT residuals have been minimal today and ? start TF or TPN today. Needs nutrition c/s.\n\nEndo) Lantus with humalog SS.\n\nGU) Pt has CKD and is in ARF. Pt found to have low U/O via foley catheter. Pt being diuresed TID with lasix, with no effect on U/O. Needs re-evaluation. Pt is currently (+)700 cc for LOS. Renal team following pt. Creatine and BUN pending this am.\n\nSkin) Pt noted at 8pm to have a severe red rash to peri-rectal area and started on nystatin cream and powder with good effect. Redness has improved over the coarse of the shift.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1639041,
"text": "Respiratory Therapy\nPt presents orally intubated on full ventilatory support. BS clr bilaterally with diminished bases. Sx for sml amounts thick rusty secretions. Pt placed on ARDSnet protocol earlier yesterday with good effect. P/F ratio improved from 92 to 171, FiO2 weaned to .6 for ABG of 7.36/50/103/29. CXR appears slightly improved. Awaiting official read. Please see carevue for specifics. Maintain ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1639030,
"text": "Nurwsing Progress note 0700-1900\nPt with N/V and increasing SOB today, general malaise. MRI deferred, and PICC deferred until pt afebrile.\n\nReview of systems:\n\nNeuro: Pt sleeping most of day, freq C/O nausea and vomited X 1. She rec'd total Zofran 4mg X 3 IV, and refused all but 15ml Lactulose D/T nausea. She denied pain except for back pain related to lying in bed. Pain relieved by Tylenol 325mg X 1.\n\nResp: O2 sat 89-94% on VM @ 10 liters/min, dropping to 80's when humidified FT attempted. Sat drops rapidly to low 80's on RA. Lung snds clear in upper lobes, diminished in bases. Cough productive of small amt sputum in am that pt swallowed, otherwise non-productive.\n\nCV: HR 59-65SR with occas freq PAC's. EKG done. BP 120/38-136/49. Pt transfused 1u PRBC's for am Hct 24.8, down 4 points from yesterday. Post Hct pndg. AM Na 125, pt now on fluid restriction 750ml po/day. LENI's done yesterday neg.\n\nGI: Abd cont very distended with + BS. Pt with nausea per above, no food intake today and minimal po liqs. Pt unable to keep lactulose down. No BM today.\n\nGU: Pt with avg 15ml/hr clear yellow urine out via foley cath. AM BUN/creat 75/4.4. Per renal attending, pt not a candidate for dialysis yet.\n\nEndo: Pt essentially NPO D/T N/V. AM glargine held with FSG 102, however FSG @ 1800 163. Insulin fixed dose now rewritten for pt to receive fixed dose insulin when NPO.\n\nID: Tmax 99.1 ax. Pt rec'd Vancomycin in am after trough 15.3, and cont on Zosyn and Ceftriaxone. Chest CT from yesterday suggestive for multifocal PNA. Unable to otain Sputum spec for cx.\n\nSocial: son and brother called for updates, pt refused speaking to them D/T malaise.\n\nPlan: Cont antibiotic tx and C&DB for PNA. Monitor Na, cont with fluid restriction. Cont emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1639031,
"text": "MICU NPN 1900-0700\n\nEvents: C/o SOB, bronchospasm and desats to low 80's on 12L face mask. Blood gas 7.40/47/58, albuterol and atrovent nebs given with good effect. Sats improved to 92-94% with 0.95% high flow. MRI abd on hold d/t unable to lie flat,\n\nNeuro: Alert, oriented x2, following commands and cooperative with care. MAE but very weak. Denies pain, unable to take 45 ml lactulose, d/t nausea and able to take only 30ml.\n\nResp: Continued on VM @ 10L and towards morning patient became bronchospastic, exp wheeze, ^^SOB and desats to low 80's. Blood gas 7.40/47/58/30, improvement with nebs and O2 high flow 0.95%. Bilateral lung sounds clear and diminished bases, unproductive dry cough, sputum smple need to be collected.\n\nCv: NSR to SB with rare PAc's,SBP 110-130, HCt stable. Na 129, fluid restriction to 750ml/day. started on iv albumin.\n\nGi/Gu: C/o nausea at the begining of shift and no zofran this shift, ? more distended abdomen, BS present, on po lactulose and BM x1 loose.\nUo improved 20-40ml and one time 200ml/hr. BUN/Cr 84/4.3.\n\nEndo: Half dose of fixed dose given d/t poor oral intake.\nAccess: PiV x2, awaitting PICC line when her temp improved to normal\n\nID: Low grade temp, continue on antibiotics\nSkin: Intact\nSocial: Call from her Son last night.\n\nPlan: continue monitor resp status/? fluid overload\n Continue antibiotics for PNA\n Monitor Uo/lytes/\n Fluid restriction 750ml/day\n PICC line placement when temp become normal\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1639028,
"text": "Nursing Admit/Progress note 1030-1900\nPt initially admitted to 10 with C/O weight gain assoc with LE edema. TIPS was done C/B L portal vein perforation. Now admitted from 10 with resp distress, O2 sat 74% on RA with RR to 28. Pt also with temp to 101.8, creat 1.9->3.8. Pt on transplant list, DNR reversed to full code. Long PMH, see admission form. Allergies: Erythromycin, indomethacin, actonal, reglan.\n\nreview of systems:\n\nNeuro: Pt X , unable to spell own last name. Pt cooperative, affect not depressed @ this time. Pt reports RUQ chronic pain , not requiring pain med. MAE with L arm somewhat withered from old injury, splint for L wrist in belongings.\n\nResp: pt on FM @ 10liters/min, O2 sat 97%. RR 15-22 and regular.Pt put on NC @ 5liters/min with O2 sat low 90's, dropping to 80's when pt sleeping. Pt has been dx'd with OSA, but does not wear FM while sleeping. Lung snds clear in upper airways, diminished in bases. Occas exp wheeze audible.\n\nCV: HR 60-65SR without VEA. BP 113/36-125/36. Pt missed number of am meds before transfer to MICU. LENI's done, results pndg. CT abd/chest with oral contrast done, results pndg.\n\nGI: Abd very distended/soft with +BS. Bedside US done by attending MD neg for tap-able fluid collection. Pt taking po meds and contrast without difficulty swallowing. Pt rec'ing lactulose for ? worsening encephalopathy. BM X 2 of mod amts soft, golden stool.\n\nGU: 10 reported pt had not voided in several hrs. Foley cath inserted on arrival, with 140ml clear yellow urine resulting. Specs sent for U/A and cxs. Urine output since 5-25ml/hr. MS aware.\n\nID: Temp 99.6po. Pt rec'd 1 dose flagyl, levofloxacin. Then those antibiotics changed to zosyn and ciprofloxacin. Pt also rec'd Vancomycin X 1.\n\nAccess: Pt with 1 periph #20 IV in RL arm, flushing well.\n\nSocial: Multiple family members @ bedside, supportive of pt. , , is proxy.\n\nPlan: Cont to monitor resp status. ? BIPAP mask tonight. ? po intake this pm. Cont to monitor urine output and lytes, creat. MRI tomorrow. Cont emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1639029,
"text": "MICU NPN 1900-0700\n\nAllergy: e-mycin,indomethacin,actonel,reglan\nAccess; PIV x2\nCode: Full, active on liver transplant list\n\nEvents: Low UO 0-10mls/hr, albumin 12.5gm x6(50ml) given, continue on po lactulose, BM /shift.\n\nNeuro: Alert, oriented x2-3( unable to say the year), following commands and MAE, and very cooperative care. Continue on po lactulose and patient had owel movements. Noted to have jerky movements on wrist with extension and h/o lt wrist injury in the past. C/o pain on rt UQ, and good effect with po tylenol. No seizure activity noted and continue on keppra/lamotrigine and gabapentin.\n\nCV: SB to NSR without ectopy, Sbp 110-120/ continue on po nadolol and midodrine. Ct chest/abd/pelvis results pending, and LENIS- no DVT. MRI in AM. Albumin 12.5 gm x6 for low UO, New PIV by IV nurse but in AM needs a CVL or a PICC line.\n\nResp: Continue on O2 5L via nasal canula and O2 sats 90-94%, MD BIPAP at night if O2 sats <90. Bilateral lung sounds clear and crackles and diminished bases. Patient has a dry unproductive cough.\n\nGi/Gu: Regular heart healthy diabetic diet, abd obese, ? ascitis, no fluid for tapping, BS present and continue on po lactulose loose golden color stool. Uo 0-10ml/hr, ^^ bun/creat, no fluid bolus or lasix. continiue on albumin 12.5gm x6 for low UO.\n\nEndo: insulin SS and fixed dose (half dose) given for poor po intake.\n\nId: A febrile, continue on po cipro, flagyl and zosyn, vanco X1 given level to be checked in AM.\nSkin: Intact.\n\nPlan: MRI in AM, F/U CT abdomen/Pelvis\n continue to monitor UO, and BUn/creat\n Continue po lactulose\n Need iv access? CVL or PICC\n Monitor resp status? O2 sats>90, ? fluid overload\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1639032,
"text": "RESPIRATORY CARE NOTE\n\nPatient placed on Hi-Flow nebulizer d/t desaturation into 80's. BLBS are crackles and diminished at the bases. Albuterol and atrovent nebulizer given with little effect. This patient has known OSA but stated that she \"does not wear the machine at home\" and has not worn it \"for years.\" She is not interested in wearing it here. MD aware of this situation and has spoken to the patient and myself. Upon observing the patient, she did not appear to be having periods of apnea during the night. If situation changes, we will re-assess.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1639033,
"text": "Micu Nursing Progress Notes\nEvents: Pt having increasing O2 requirements, given lasix x2, continues to vomit.\n\nNeuro: Pt awake and oriented x2, (having trouble with time) MAE and tries to help with ADL but continues to be weak. She denies pain but continues to be nauseous, vomiting up all her 8am meds- in whole pills at 12:30. She tries to take the lactulose but could only take 30cc.\n\nResp: She had a high flow face mask at 95% this am but her O2 sats dropped to 88% at rest. 5l NC added under the face with sats increasing to 91-93%. With movement she desaturated as low as 82% then improved with rest. She was given lasix 40mg at 1300 but had only 175cc out. She was given lasix 80mg with initial response of 240cc but she is also subjectively less SOB and the NC was weaned to 3l with no change in O2 sats. She is coughing but non productively.\n\nCardiac: B/P 130-140/40's, HR 58-65. K+ 5.0, Na 131, She is on a free water restriction and fluid restriction of 750cc.\n\nGI: This am she said that the nausea was better and drank a cup of tea and slice of toast. She was able to take all of her 8am pills with the tea. However when she drank the lactulose at 12n and also requested some zofran, she was given 4mg. However w/i 1/2h she vomited the pills given at 8am some that were whole. Her abd is soft and slightly tender. (+) bowel sounds and she had a large loose stool. A rectal bag was applied due to her getting lactulose tid.\n\nEndo: She was given usual dose, 32units, of her glargine this am due to her nausea and inability to eat. Her BS was 144 at 10am and she received 8 units of humalog. At 1600 her BS was 124 so no insulin was given because she does not want to eat.\n\nGU: Foley draining clear yellow urine with U/O dropping during the am from 130cc/hr to 10cc/hr.\n\nID: temp from 97.4-99.6. She continues on pipercillin and cipro.\n\nSocial: Her son called in to inquire about her condition but no visitors in today.\n\nPlan: Monitor resp status closely, with the potential of intubation, monitor I&O for continued output, zofran PRN, PICC line on hold until resp status more stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-05 00:00:00.000",
"description": "Report",
"row_id": 1639034,
"text": "7pm to 7am:\n\nNeuro) Pt is now oriented x 3, but does not remember what brought her into the hospital in the first place. Pt has been able to sleep most of the night.\n\nID) Low grade temp with tmax of 100.1 ->>99.8 . No changes made to ABx for pna.\n\nEndo) Pt on lantus and on humalog SS.\n\nCV) Pt in SR with rare PACs. SBP stable at 120-140's with MAP >60. No edema noted. Am labs pending as of 5am. Pt on fluid restriction low Na level (750cc/day). ? plan for PICC line once afebrile for 24 hrs.\n\nResp) LS CTA to upper lobes with diminished bases. RR 22-26. O2sat 91-97% on 95%high flow mask. Pt has been inc to DB&C, and present with a dry non-prod cough. In need of sputum sample once cough productive. Pt noted to desat to 86% once in supine (flat) position for more than 5min, but will recover quickly.\n\nGI) Abd VERY dist and firm with hypOactive BS. Pt has had 2 episodes of liq brown stool. Muschrrom catheter was placed instead of rectal bag leakage and red skin,- but this also noted to leak. Flexi seal placed this am and awaiting effect. Pt c/o nausea and given zofran with some effect. (Pt is allergic to reglen). Pt was able to take her pills one at a time with 15 min in between each one.\n\nGU) Pt was diuresed throughout the day and is now (+) 1 liter for LOS. U/O 60-200 cc/hr. ? need for more diuresing today. F/U renal function.\n\nSkin) see crae vue for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-05 00:00:00.000",
"description": "Report",
"row_id": 1639035,
"text": "Resp CAre\nPt intubated this afternoon with 8.0 22 @lip for worsening hypoxia and resp status. Pt placed on a/c with 10 of peep sats marginal on 80% plan to wean fio2 slowly as tolerated. BLBS diminished and slightly course, suctioned for small amt thick blood tinged secretions. PLan to continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-05 00:00:00.000",
"description": "Report",
"row_id": 1639036,
"text": "Nursing Progress Note 0700-1900\n\nEvents: Increasingly Hypoxic despite being on 100% high flow. Pt with increased WOB ultimately intubated at 1430 for respiratory distress. Arterial line placed.\n\nNeuro: Through day increasingly lethargic, although A&Ox3. MAE. Post intubation Lightly sedated on Versed 1 mg & Fentanyl at 25 mcg. Opens eyes to name, withdrawing from painful stimuli.\n\nResp: Pt with complaints of increasing SOB through day. Sats 88-90 despite high flow, nebs and lasix. RR 20-24. Desated to low 80's with talking, any stimulation. Decision made to intubated pt at 1430 for increasing respiratory distress. Currently on AC 500/x16/+10/80% with sats 93-96 % overbreathing vent by 2 bpm. Repeat ABG on these settings pending. See carevue for ABG data.\n\nCardiac: Tele SB-SR 50-60's with occ PAC's. Briefly hypotensive directly after intubation responded to small fluid bolus. Arterial line placed for ABG's and BP monitoring. Currently hemodynamically stable. Trace edema\n\nGI: This am pt with nausea & retching. Given compazine with good effect. Tolerating pills at at time with spaces inbetween without nausea. Abdomen firm distend, + BS in 4 quadrents. Flexiseal draining adequate amounts of liquid brown stool. OGT placed position confirmed by X-ray. remains NPO at this time\n\nRenal: Foley draining adequate amounts of yellow urine with sediment. 80 IV lasix given this am for diuresis without effect even for day, 1.5 liters positive for LOS team aware.\n\nID: Temp spike to 101 axillary, given 650 mg tylenol with + effect, Pan cultured. WBC trending down, lactate 1.5. Continues on Zoysn & Cipro am vanco trough 15, given addtional dose of vanco today\n\nSkin: Skin intact, no current issues\n\nHeme: Repeat HCT this afternoon 32.4 up from 27.9.\n\nSocial: Son in to visit this afternoon after told about need for probably intubation. Updated by team & RN. Pt remains Full code\n\nFEN: Continues on lantus & Humalog SS. Given half doses of each D/T NPO status.\n\nPlan:\n\n1. ? MRI tonight to further evaluate portal vein\n2. Follow temp curve, culture data, ? Bronch in AM to further evaluate pulmonary status\n3. Routine ICU monitoring and care\n4. Emotional support to pt and family\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024420,
"text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for PNA, lung infiltrate, or other acute process\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with NASH cirrhosis, s/p TIPS on with possible portal\n vein thrombus, now with fever of 101.8 and desatted to 78% on RA.\n REASON FOR THIS EXAMINATION:\n Please eval for PNA, lung infiltrate, or other acute process.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and desaturations.\n\n Portable AP chest radiograph was compared to .\n\n The heart size is moderately enlarged, unchanged since the prior study. The\n mediastinal contours are stable except for slight widening of the azygos vein\n compared to the prior study suggesting volume overload. In addition, there is\n new bilateral perihilar interstitial opacity that most likely represents\n pulmonary edema. In addition, right infrahilar consolidation with air\n bronchogram is seen, which is worrisome for a separate issue such as\n pneumonia. No appreciable pleural effusion is demonstrated. There is no\n pneumothorax.\n\n IMPRESSION: New pulmonary edema, interstitial, moderate in degree.\n\n Right lower lobe infrahilar consolidation containing air bronchogram highly\n suspicious for pneumonia.\n\n Small right pleural effusion, new since the prior study.\n\n\n Findingds discussed with clinical team by Dr .\n\n"
},
{
"category": "ECG",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 166941,
"text": "Sinus rhythm. Without diagonstic abnormality. Compared to the previous\ntracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 166942,
"text": "Sinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific and\ntracing is probably within normal limits\nSince previous tracing of , Q-T interval appears shorter but may be no\nsignificant change\n\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332657,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Patient received on p/s with satisfactory abgs\n Action:\n Fluid removal to a total of 1.5l via crrt to aid extubation\n Response:\n Satisfactory abgs on 5/0 therefore extubated at 15.30hrs, initial sats\n @ 85%, ? accuracy but abgs shows po2 @ 77, presently on face tent @ 70%\n Plan:\n Encourage cough/deep breath, IS, chest PT, check abg, if pt experiences\n resp difficulty consider non-invasive as first line therapy\n Hyperglycemia\n Assessment:\n Labile blood sugars,ranging 120-180\n Action:\n Titrating insulin drip to maintain < 150, blood sugars decreasing now\n that feed has been d/c\n Response:\n Insulin presently @ 4u/hr, b/s < 130\n Plan:\n Continue to monitor hourly, ? stop infussion\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile at present but patient has recently stopped crrt,\n Action:\n Monitor, inform team of any spike, blood cxs pending, of all abs at\n present\n Response:\n Continue to monitor\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient received on crrt\n Action:\n Patient removed 1.5l fluid\n Response:\n Stopped @ 15.00hrs, as adequate fluid removal as per renal\n Plan:\n If pt gets into resp distress pt will possibly go back onto CRRT,\n patient may well commence HD tomorrow/fri\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332450,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Stable respiratory function with improved oxygenation\n Action:\n Bronched, minimal secretions, cx sent\n Fio2 reduced to 40% and peep reduced to 5\n Stopped abs at this point\n Negative fluid balance at this point despite CRRT on hold due to access\n issues\n Response:\n Improved abg this pm, sats @ 100%\n Plan:\n Observe abgs /sats overnight..attempt more fluid removal with crrt\n overnight, risbi in am in prep for extubation\n Hyperglycemia\n Assessment:\n Labile blood sugars, on insulin drip, blood sugars 150-200, on /of tube\n feeding for procedures therefore b/s labile\n Action:\n Insulin drip titrated to maintain <150, drip changed q2-3hrly\n Response:\n Presently < 150\n Plan:\n Maintain tube feed to maintain consistency with blood sugars\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Febrile to 101.4\n Action:\n Fungal cx to be drawn, sputum cxs via bronch taken, abs d/c, tylnol\n held at present time for procedure\n Response:\n Continue to have low grade fevers ? origin, numerous cxs pending\n Plan:\n Monitor fever curve, Tylenol when able, f/u bcs\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains oluguric with rising creat, CRRT held for access issues\n Action:\n Multiple attempts to re-commence crrt through original line, TPA\n placed, re-postioned,now team are re-sighting in left groin..ffp in\n prep for new line, old line for left ij removed and tip sent for cx\n Response:\n Fluid balance essentially euvolumic\n Plan:\n New line placed, commence CRRT tonight, aim neg 2l for 24hrs, follow\n electrolytes treat PRN\n"
},
{
"category": "General",
"chartdate": "2152-09-13 00:00:00.000",
"description": "ICU Event Note",
"row_id": 332585,
"text": "Clinician: Attending\n Critical Care\n Gas exchange good. She is now on PSV 5/5 and RSBI 87. Minute\n ventilation is close to 10 so would be inclined to be slow to extubate.\n I am inclined to continue to remove fluid as long as we do not have to\n go up on levophed. BAL yesterday showed no cellls and no organisms so\n pulmonary infection unlikely. Suspect effusions and pulm infiltrates\n are primarily due to cirrhosis and CHF.\n Total time spent: 45 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333025,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.1, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation yesterday, Insulin gtt\n turned down from to 5mg/hr.\n -restart Glargine + HISS.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n -If tolerate HD tomorrow will transfer to floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332854,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Patient received on face tent @ 50%\n Action:\n Weaned to n/c 3l, fluid restriction to 750cc/hr\n Response:\n Sats maintained > 95%\n Plan:\n Continue to monitor, TB test to be placed\n Anxiety\n Assessment:\n Patient verbalized she feels anxiety [ known at baseline]\n Action:\n Patient ordered lorazapam q6, verbally reassured by team, visited by\n family and priest\n Response:\n Comfortable at present\n Plan:\n Continue to monitor anxiety ? increase dose\n Hyperglycemia\n Assessment:\n Received on iv dose of insulin @ 5u/hr to maintain B/S < 150, hrly\n fingersticks\n Action:\n Given long acting insulin @ 1300hrs [ for b/d dose], and s/s q6\n Response:\n b/s maintained < 150\n Plan:\n Continue to monitor closely\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n No action\n Response:\n To continue to monitor\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient producing no urine, rising creat\n Action:\n Renal team have reviewd, for 750cc fluid restriction\n Response:\n Maintaining fluid balance\n Plan:\n For HD tomorrow on the unit in view of previous low b/ps on CRRT,\n possible tunnel line placement monday\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332855,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Patient received on face tent @ 50%\n Action:\n Weaned to n/c 3l, fluid restriction to 750cc/hr\n Response:\n Sats maintained > 95%\n Plan:\n Continue to monitor, TB test to be placed\n Anxiety\n Assessment:\n Patient verbalized she feels anxiety [ known at baseline]\n Action:\n Patient ordered lorazapam q6, verbally reassured by team, visited by\n family and priest\n Response:\n Comfortable at present\n Plan:\n Continue to monitor anxiety ? increase dose\n Hyperglycemia\n Assessment:\n Received on iv dose of insulin @ 5u/hr to maintain B/S < 150, hrly\n fingersticks\n Action:\n Given long acting insulin @ 1300hrs [ for b/d dose], and s/s q6\n Response:\n b/s maintained < 150\n Plan:\n Continue to monitor closely\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n No action\n Response:\n To continue to monitor\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient producing no urine, rising creat\n Action:\n Renal team have reviewd, for 750cc fluid restriction\n Response:\n Maintaining fluid balance\n Plan:\n For HD tomorrow on the unit in view of previous low b/ps on CRRT,\n possible tunnel line placement monday\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332857,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Patient received on face tent @ 50%\n Action:\n Weaned to n/c 3l, fluid restriction to 750cc/hr\n Response:\n Sats maintained > 95%\n Plan:\n Continue to monitor, TB test to be placed\n Anxiety\n Assessment:\n Patient verbalized she feels anxiety [ known at baseline]\n Action:\n Patient ordered lorazapam q6, verbally reassured by team, visited by\n family and priest\n Response:\n Comfortable at present\n Plan:\n Continue to monitor anxiety ? increase dose\n Hyperglycemia\n Assessment:\n Received on iv dose of insulin @ 5u/hr to maintain B/S < 150, hrly\n fingersticks\n Action:\n Given long acting insulin @ 1300hrs [ for b/d dose], and s/s q6\n Response:\n b/s maintained < 150\n Plan:\n Continue to monitor closely\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n No action\n Response:\n To continue to monitor\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient producing no urine, rising creat\n Action:\n Renal team have reviewd, for 750cc fluid restriction\n Response:\n Maintaining fluid balance\n Plan:\n For HD tomorrow on the unit in view of previous low b/ps on CRRT,\n possible tunnel line placement monday\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332834,
"text": "Chief Complaint: Pt reports improved breathing. Denies abd or chest\n pain. Reports feeling anxious.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:42 PM\n One of CVL ports clotted, put TPA through\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Fentanyl - 10:45 AM\n Midazolam (Versed) - 12:44 PM\n Hydralazine - 04:47 PM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.6\n HR: 83 (83 - 94) bpm\n BP: 126/42(64) {110/37(58) - 151/66(76)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 5,015 mL\n 152 mL\n PO:\n 120 mL\n TF:\n 335 mL\n IVF:\n 4,420 mL\n 32 mL\n Blood products:\n Total out:\n 6,628 mL\n 0 mL\n Urine:\n 15 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -1,613 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 453 (453 - 702) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.38/42/85./22/0\n Ve: 12.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly anxioius\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 9.1 g/dL\n 109 mg/dL\n 4.1 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 99 mEq/L\n 137 mEq/L\n 26.7 %\n 17.7 K/uL\n [image002.jpg]\n Micro:\n fungal cult pending\n LIJ cult pending\n BAL, GS 1+ polys, prelim cults negative\n and blood pending\n urine\n : sputum rejected\n CXR: \nbibasilar opacities atelectasis, small R pleural effusion\n : unread, decreased R opacity and effusion.\n 08:41 AM\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n WBC\n 17.7\n Hct\n 26.7\n Plt\n 116\n Cr\n 3.0\n 2.6\n 4.1\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 169\n 134\n 109\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:19/25, Alk Phos / T\n Bili:104/1.8, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:181 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.1, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation yesterday, Insulin gtt\n turned down from to 5mg/hr.\n -restart Glargine + HISS.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n -If tolerate HD tomorrow will transfer to floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Comments: TF stoped since OG pulled. Starting soft DM, renal, cardiac\n diet\n Glycemic Control: Glargine and ISS\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU, for transfer to floor tomorrow if tolerates HD without\n hypotension\n ------ Protected Section ------\n Additional Liver recs: sent Hep panel and ordered PPD for liver\n transplant work up\n Epogen ordered as per renal\n ------ Protected Section Addendum Entered By: , MD\n on: 15:42 ------\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332907,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Comfortable on 3L NC, Sats high 90s, RR teens. Lungs CTA.\n Action:\n NC O2 3L overnight.\n Response:\n Plan:\n Monitor resp status. Wean O2 as tolerated. TB test on left arm pending.\n Hyperglycemia\n Assessment:\n FSBS q 6 hrs low 200s. Ate ~ of dinner.\n Action:\n Glargine 60 @ 12AM. SS insulin.\n Response:\n Plan:\n Monitor FSBS on glargine and SS insulin regime. Diabetic diet.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 15cc->0cc last night. 2200cc neg LOS.\n Action:\n 750cc fluid restriction per renal.\n Response:\n Doing well off of CRRT.\n Plan:\n HD today. Plan to d/cl fem HD line if tolerates HD. Plan for tunneled\n HD line on Monday. 750cc fluid restriction QD per renal.RR\n Anemia, other\n Assessment:\n No S/S bleeding. AM Hct 24.5 (26.7)\n Action:\n T&S sent.\n Response:\n Baseline chronic anemia.\n Plan:\n ? transfuse PRBC in HD today. Epogen ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332996,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.1, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation yesterday, Insulin gtt\n turned down from to 5mg/hr.\n -restart Glargine + HISS.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n -If tolerate HD tomorrow will transfer to floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333105,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF. Pt was adm to MICU s/p TIPS procedure, which was\n complicated by a slight injury to portal vein. Pt was adm with Sob and\n was intubated for rep distress pna, pulm edema and effusions\n (unable to tap). Pt was also in ARF and in LF, but too unstable to go\n for a transplant surgery. Pt was placed on CRRT for aggressive fluid\n removal with good effect. Pt was extubated and CRRT stopped .\n Since Wednesday creatine has been increasing, and today pt had first\n run of HD w/o complications (? HD dependent at this time). Nephrology\n is planning to DC HD line to Lt fem today; for plan for tunneled\n catheter Monday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n Impaired Skin Integrity\n Assessment:\n Pt has a very red coccyx and very red perirectal area.\n Action:\n Nystatin powder, aloe vesta and nystatin cream applied.\n Response:\n Skin status is slowly improving.\n Plan:\n Continue to turn pt q2hrs while in bed.\n Acute Pain\n Assessment:\n Pt noted to have pain to Lt wrist with minimal movements and with pal\n of wrist.\n Action:\n Pt given pain medications as needed with good effect. Pt is also\n awaiting OT c/s for splint placement.\n Response:\n Pt respond well to pain medications.\n Plan:\n Continue to eval comfort level.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333106,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF. Pt was adm to MICU s/p TIPS procedure, which was\n complicated by a slight injury to portal vein. Pt was adm with Sob and\n was intubated for rep distress pna, pulm edema and effusions\n (unable to tap). Pt was also in ARF and in LF, but too unstable to go\n for a transplant surgery. Pt was placed on CRRT for aggressive fluid\n removal with good effect. Pt was extubated and CRRT stopped .\n Since Wednesday creatine has been increasing, and today pt had first\n run of HD w/o complications (? HD dependent at this time). Nephrology\n is planning to DC HD line to Lt fem today; for plan for tunneled\n catheter Monday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n Impaired Skin Integrity\n Assessment:\n Pt has a very red coccyx and very red perirectal area.\n Action:\n Nystatin powder, aloe vesta and nystatin cream applied.\n Response:\n Skin status is slowly improving.\n Plan:\n Continue to turn pt q2hrs while in bed.\n Acute Pain\n Assessment:\n Pt noted to have pain to Lt wrist with minimal movements and with pal\n of wrist.\n Action:\n Pt given pain medications as needed with good effect. Pt is also\n awaiting OT c/s for splint placement.\n Response:\n Pt respond well to pain medications.\n Plan:\n Continue to eval comfort level.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333107,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF. Pt was adm to MICU s/p TIPS procedure, which was\n complicated by a slight injury to portal vein. Pt was adm with Sob and\n was intubated for rep distress pna, pulm edema and effusions\n (unable to tap). Pt was also in ARF and in LF, but too unstable to go\n for a transplant surgery. Pt was placed on CRRT for aggressive fluid\n removal with good effect. Pt was extubated and CRRT stopped .\n Since Wednesday creatine has been increasing, and today pt had first\n run of HD w/o complications (? HD dependent at this time). Nephrology\n is planning to DC HD line to Lt fem today; for plan for tunneled\n catheter Monday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n Impaired Skin Integrity\n Assessment:\n Pt has a very red coccyx and very red perirectal area.\n Action:\n Nystatin powder, aloe vesta and nystatin cream applied.\n Response:\n Skin status is slowly improving.\n Plan:\n Continue to turn pt q2hrs while in bed.\n Acute Pain\n Assessment:\n Pt noted to have pain to Lt wrist with minimal movements and with pal\n of wrist.\n Action:\n Pt given pain medications as needed with good effect. Pt is also\n awaiting OT c/s for splint placement.\n Response:\n Pt respond well to pain medications.\n Plan:\n Continue to eval comfort level.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 103 kg\n Daily weight:\n 96 kg\n Allergies/Reactions:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin, GI Bleed, Liver Failure, Renal Failure,\n Seizures\n CV-PMH: Hypertension\n Additional history: NASH/Cirrhosis stage IV on transplant list,\n Thrombocytopenia, GERD, Retinal hemorrhage/DM retinopathy, nephropathy,\n OSA, restless leg syndrome, DJD neck, ASD with murmur, Hyperdynamic\n LVH, Intermittent CP, Dermoid cyst, R adrenal mass, s/p\n Choly/appendectomy, Tubal ligation, L oophrectomy, Depression with hx\n of cutting/burning self, OD, ECT\n Surgery / Procedure and date: S/P TIPS\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.5\n Arterial BP:\n S:101\n D:37\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 3% %\n 24h total in:\n 520 mL\n 24h total out:\n 53 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 03:22 AM\n Potassium:\n 3.6 mEq/L\n 03:22 AM\n Chloride:\n 98 mEq/L\n 03:22 AM\n CO2:\n 21 mEq/L\n 03:22 AM\n BUN:\n 58 mg/dL\n 03:22 AM\n Creatinine:\n 5.4 mg/dL\n 03:22 AM\n Glucose:\n 178 mg/dL\n 03:22 AM\n Hematocrit:\n 24.5 %\n 03:22 AM\n Finger Stick Glucose:\n 173\n 06:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU -6\n Transferred to: 1014\n Date & time of Transfer: \n"
},
{
"category": "Respiratory ",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 332439,
"text": "TITLE:\n 24 Hour Events:\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n Assessment And Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal:\n Renal:\n Hematology:\n Infectious Disease:\n Endocrine:\n Fluids:\n Electrolytes:\n Nutrition:\n General:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason: intubated for worsening resp distress\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: BAL sent today from bronch... please keep ETT cuff full,\n sputum cultures have shown oral secretions.\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1630)\n Comments: BAL sent, otherwise airways clean\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333101,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly sedated today after\n receiving oxycodone.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n -CXR greatly improved PVC and effusion over last 2 days.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n -f/u hep panel and PPD (placed ) for beginning of transplant work\n up.\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 8.4, stable, type and screen sent this am for possible\n transfusion of pRBC with HD\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation\n -restarted Glargine + HISS and sugars well controlled.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n - For HD today, possibly get unit prbc.\n - Will keep in Central line until after HD completed in case\n hypotension develops. Should d/c IJ once leave floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Comments: TF stoped since OG pulled. Starting soft DM, renal, cardiac\n diet\n Glycemic Control: Glargine and ISS\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU, for transfer to floor today\n ------ Protected Section ------\n Left wrist pain: continue prn oxycodone\n Consult OT for splint placement on left wrist\n ------ Protected Section Addendum Entered By: , MD\n on: 11:16 ------\n Critical Care\n Present for key portions of history and physical exam. Agree with Dr.\n \ns assessment and plan as above. She has improved dramatically\n over the last several days without clear explanation. Although she has\n significant mitral regurgitation there has not been a dramatic change\n in her cardiac function to explain why she developed pulmonary edema.\n Temporally the connection to her TIPS raises the possibility that she\n had hemodynamic changes post procedure that may have contributed to\n cardiac decomp. Nevertheless, she is now breathing comfortably with\n clear chest and her R pleural effusion has even resolved.\n Time Spent: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333097,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF. Pt was adm to MICU s/p TIPS procedure, which was\n complicated by a slight injury to portal vein. Pt was adm with Sob and\n was intubated for rep distress pna, pulm edema and effusions\n (unable to tap). Pt was also in ARF and in LF, but too unstable to go\n for a transplant surgery. Pt was placed on CRRT for aggressive fluid\n removal with good effect. Pt was extubated and CRRT stopped .\n Since Wednesday creatine has been increasing, and today pt had first\n run of HD w/o complications (? HD dependent at this time). Nephrology\n is planning to DC HD line to Lt fem today; for plan for tunneled\n catheter Monday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333098,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF. Pt was adm to MICU s/p TIPS procedure, which was\n complicated by a slight injury to portal vein. Pt was adm with Sob and\n was intubated for rep distress pna, pulm edema and effusions\n (unable to tap). Pt was also in ARF and in LF, but too unstable to go\n for a transplant surgery. Pt was placed on CRRT for aggressive fluid\n removal with good effect. Pt was extubated and CRRT stopped .\n Since Wednesday creatine has been increasing, and today pt had first\n run of HD w/o complications (? HD dependent at this time). Nephrology\n is planning to DC HD line to Lt fem today; for plan for tunneled\n catheter Monday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332607,
"text": "Chief Complaint: Intubated, complains of back pain. Denies chest pain.\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 PM\n ARTERIAL LINE - START 01:24 PM\n DIALYSIS CATHETER - START 01:25 PM. Left fem line\n inserted, pulled Left IJ for continued difficulty with CVVHD\n MULTI LUMEN - START 01:25 PM\n DIALYSIS CATHETER - STOP 04:21 PM\n BRONCHOSCOPY - At 04:29 PM - fluid not suggestive on\n infection.\n DIALYSIS CATHETER - START 08:07 PM\n FEVER - 101.4\nF - 06:00 PM\n - stoped antibiotics, however still febrile, sent fungal cx\n -liver recs - still could be transplant canidate if recover from other\n comorbidities.\n History obtained from Patient, Family / Medical records\n Allergies:\n History obtained from Patient, Family / Medical\n in Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 10.2 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:06 AM\n Heparin Sodium (Prophylaxis) - 08:06 AM\n Fentanyl - 10:45 AM\n Midazolam (Versed) - 12:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Gastrointestinal: No(t) Abdominal pain, Diarrhea\n Pain: Mild\n Pain location: back\n Flowsheet Data as of 02:46 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.1\nC (98.8\n HR: 88 (81 - 94) bpm\n BP: 134/46(68) {107/33(52) - 160/66(86)} mmHg\n RR: 19 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 8 (4 - 14)mmHg\n Total In:\n 3,314 mL\n 4,737 mL\n PO:\n TF:\n 431 mL\n 335 mL\n IVF:\n 777 mL\n 4,143 mL\n Blood products:\n 599 mL\n Total out:\n 4,683 mL\n 5,973 mL\n Urine:\n 195 mL\n NG:\n Stool:\n 900 mL\n 150 mL\n Drains:\n Balance:\n -1,369 mL\n -1,236 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 702 (396 - 702) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 87\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.41/36/96./22/0\n Ve: 15.3 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (Murmur: Systolic), RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Non-tender, Bowel sounds present, Distended, No(t) Tender: ,\n Obese, reducible umbilical hernia\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice, echymosis on Right\n abd\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 120 K/uL\n 9.4 g/dL\n 169 mg/dL\n 3.0 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 25 mg/dL\n 99 mEq/L\n 137 mEq/L\n 27.3 %\n 16.8 K/uL\n [image002.jpg]\n 09:32 AM\n 03:41 PM\n 03:55 PM\n 06:20 PM\n 08:55 PM\n 09:00 PM\n 02:53 AM\n 03:03 AM\n 08:41 AM\n 08:53 AM\n WBC\n 15.4\n 17.5\n 16.8\n Hct\n 27.2\n 26.8\n 27.3\n Plt\n 109\n 114\n 120\n Cr\n 3.4\n 3.9\n 4.2\n 3.4\n 3.0\n TCO2\n 25\n 24\n 26\n 24\n 24\n Glucose\n 151\n 163\n 130\n 198\n 169\n Other labs: PT / PTT / INR:19.3/37.2/1.8, ALT / AST:20/24, Alk Phos / T\n Bili:99/1.7, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:162 IU/L, Ca++:9.4 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.7 mg/dL\n Imaging: CXR improved pulm vasc status, effusions less prominant,\n atelectasis at bases\n CXR as per me - increased congestion and increased effusion\n Microbiology: BAL GS 1+ polys, cults pending\n fungal cult pending\n A line and LIJ cult pending\n blood cult , , pending\n Urine NG\n sputum - rare oropharyngeal flora\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - Vent settings on ARDSnet protocol, pt oxygenating well\n - titrating down FiO2 and PEEP as tolerating\n - increased P02 after increased hydral dosage, consistant with CHF\n contributing to hypoxia, titrated hdryal up to 15 q8h. However d/ced\n hydralazine while getting CVVHD since BP dropping.\n - D/c nadolol and norvasc while on CVVHD\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continues to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx yesterday\n - minimal sedation to avoid hypotension\n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n - CVVHD has been intermittent line issues, yesterday pulled LIJ and\n placed femoral, now running well. Goal i/o -2L\n - 5of peep, will get RSBI 87 this am, doing well on , attempt\n extubation later today. However concerned given pt's high minute\n ventalation.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to maximize\n diuresis\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol prophylaxis held to increase BP while on CVVHD\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.4, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG consistantly elevated\n -discontinue Glargine + HISS.\n -started insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n -HRS meds stoped\n - Poor UO with lasix and diuril\n - on CVVHD diuresis as tolerated by BP, goal -2L today\n -monitor for UO, renal 50/50 changes of return of fxn\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - cont Vanc/Zosyn/Cipro at new renal dosages\n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. Will d/c\n abx, as may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n ICU Care\n Nutrition:\n Comments: Continue tube feeds at goal of 30ml/hr\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 332802,
"text": "Chief Complaint: Alert, c/o some anxiety\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:42 PM\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Midazolam (Versed) - 12:44 PM\n Hydralazine - 04:47 PM\n Pantoprazole (Protonix) - 07:58 AM\n Heparin Sodium (Prophylaxis) - 07:58 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Tachypnea\n Genitourinary: No(t) Dysuria, Foley, Dialysis\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:29 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98\n HR: 76 (76 - 92) bpm\n BP: 124/43(65) {110/36(58) - 142/51(76)} mmHg\n RR: 16 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 9 (3 - 15)mmHg\n Total In:\n 5,015 mL\n 293 mL\n PO:\n 220 mL\n TF:\n 335 mL\n IVF:\n 4,421 mL\n 73 mL\n Blood products:\n Total out:\n 6,628 mL\n 50 mL\n Urine:\n 15 mL\n 50 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -1,613 mL\n 243 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 453 (453 - 453) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: 7.38/42/85./22/0\n Ve: 12.3 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n holosystolic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : , Diminished: on R), scattered crackels\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 116 K/uL\n 109 mg/dL\n 4.1 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 99 mEq/L\n 137 mEq/L\n 26.7 %\n 17.7 K/uL\n [image002.jpg]\n 08:41 AM\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n WBC\n 17.7\n Hct\n 26.7\n Plt\n 116\n Cr\n 3.0\n 2.6\n 4.1\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 169\n 134\n 109\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:19/25, Alk Phos / T\n Bili:104/1.8, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:181 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n CIRRHOSIS OF LIVER, OTHER\n ANEMIA, OTHER\n DIABETES MELLITUS (DM), TYPE II\n RENAL FAILURE\n Now down to nc at 3lpm. Still do not have a good explanation for her\n respiratory failure - sequence of events was respiratory/renal failure\n after TIPS. When intubated she appeared to be in pulmonary edema/ ARDS\n but her response has been faster than expected and all we have done is\n start hydralazine and remove fluid by CVVH. Multiple sputums,\n including BAL are notable not only for no growth but not even many\n WBC. Remains low grade febrile w/o a source. We are converting to sq\n insulin, adding a standing anxiolytic, starting intermittent HD.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332760,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:42 PM\n INVASIVE VENTILATION - STOP 03:42 PM\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Fentanyl - 10:45 AM\n Midazolam (Versed) - 12:44 PM\n Hydralazine - 04:47 PM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.6\n HR: 83 (83 - 94) bpm\n BP: 126/42(64) {110/37(58) - 151/66(76)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 5,015 mL\n 152 mL\n PO:\n 120 mL\n TF:\n 335 mL\n IVF:\n 4,420 mL\n 32 mL\n Blood products:\n Total out:\n 6,628 mL\n 0 mL\n Urine:\n 15 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -1,613 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 453 (453 - 702) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.38/42/85./22/0\n Ve: 12.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 9.1 g/dL\n 109 mg/dL\n 4.1 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 99 mEq/L\n 137 mEq/L\n 26.7 %\n 17.7 K/uL\n [image002.jpg]\n 08:41 AM\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n WBC\n 17.7\n Hct\n 26.7\n Plt\n 116\n Cr\n 3.0\n 2.6\n 4.1\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 169\n 134\n 109\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:19/25, Alk Phos / T\n Bili:104/1.8, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:181 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n CIRRHOSIS OF LIVER, OTHER\n ANEMIA, OTHER\n DIABETES MELLITUS (DM), TYPE II\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332765,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:42 PM\n One of CVL ports clotted, put TPA through\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Fentanyl - 10:45 AM\n Midazolam (Versed) - 12:44 PM\n Hydralazine - 04:47 PM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.6\n HR: 83 (83 - 94) bpm\n BP: 126/42(64) {110/37(58) - 151/66(76)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 5,015 mL\n 152 mL\n PO:\n 120 mL\n TF:\n 335 mL\n IVF:\n 4,420 mL\n 32 mL\n Blood products:\n Total out:\n 6,628 mL\n 0 mL\n Urine:\n 15 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -1,613 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: PSV/\n Vt (Spontaneous): 453 (453 - 702) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.38/42/85./22/0\n Ve: 12.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 9.1 g/dL\n 109 mg/dL\n 4.1 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 99 mEq/L\n 137 mEq/L\n 26.7 %\n 17.7 K/uL\n [image002.jpg]\n 08:41 AM\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n WBC\n 17.7\n Hct\n 26.7\n Plt\n 116\n Cr\n 3.0\n 2.6\n 4.1\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 169\n 134\n 109\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:19/25, Alk Phos / T\n Bili:104/1.8, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:181 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - Vent settings on ARDSnet protocol, pt oxygenating well\n - titrating down FiO2 and PEEP as tolerating\n - increased P02 after increased hydral dosage, consistant with CHF\n contributing to hypoxia, titrated hdryal up to 15 q8h. However d/ced\n hydralazine while getting CVVHD since BP dropping.\n - D/c nadolol and norvasc while on CVVHD\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continues to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx yesterday\n - minimal sedation to avoid hypotension\n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n - CVVHD has been intermittent line issues, yesterday pulled LIJ and\n placed femoral, now running well. Goal i/o -2L\n - 5of peep, will get RSBI 87 this am, doing well on , attempt\n extubation later today. However concerned given pt's high minute\n ventalation.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to maximize\n diuresis\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol prophylaxis held to increase BP while on CVVHD\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.4, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG consistantly elevated\n -discontinue Glargine + HISS.\n -started insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n -HRS meds stoped\n - Poor UO with lasix and diuril\n - on CVVHD diuresis as tolerated by BP, goal -2L today\n -monitor for UO, renal 50/50 changes of return of fxn\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - cont Vanc/Zosyn/Cipro at new renal dosages\n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. Will d/c\n abx, as may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n ICU Care\n Nutrition:\n Comments: Continue tube feeds at goal of 30ml/hr\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333090,
"text": "This is a 62 y old female, with PMH of ascites, ESLD NASH cirrhosis\n stage IV, depression with self flagellation (cutting and burning),\n bipolar dz, and s/p multiple ECTs, OSA ( but does not like bipap) and\n chronic RF.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 333087,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper resp areas with diminished bases. No SOB/DOE noted.\n Pt on NC and weaned to 2 liters. Pt noted to be 93 % on RA.\n Action:\n Pt has been inc to DB&C while awake. Pt OOB to chair for 3\n hrs with\n good effect on resp status.\n Response:\n Plan:\n Continue to wean NC as tolerated by pt.\n Anxiety\n Assessment:\n Pt noted to be in a good spirit throughout the day. Pt very happy to be\n able to sit up in a chair today. No anxiety at this time.\n Action:\n N/A\n Response:\n Plan:\n Continue to evaluate for anxiety. Pt has Ativan prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n No fevers at this time.\n Action:\n Response:\n Plan:\n Continue to evaluate for fevers. ? need for PICC line once afebrile for\n 24hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatnine increased to 5.4 from 4.1 and pt had HD today. Pt has a HD\n line to Lt fem, which will be DC\nd by nephrology after HD.\n Action:\n Follow up labs in am.\n Response:\n Pt tolerated HD well.\n Plan:\n Plan for tunneled catheter to be placed on Monday for pt\ns next HD run.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS noted to be elevated this am before breakfast at 181.\n Action:\n FSBS covered per RISS and with lantus .\n Response:\n Awaiting effect.\n Plan:\n ? need to increase Lantus and RISS dosages if FSBS remains elevated.\n Anemia, other\n Assessment:\n Pt noted to have a hct drop to 24 from 26 this am.\n Action:\n Pt given epogen today.\n Response:\n Awaiting response.\n Plan:\n Follow up hct level in the am.\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333035,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly sedated today after\n receiving oxycodone.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n -CXR greatly improved PVC and effusion over last 2 days.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n -f/u hep panel and PPD (placed ) for beginning of transplant work\n up.\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 8.4, stable, type and screen sent this am for possible\n transfusion of pRBC with HD\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation\n -restarted Glargine + HISS and sugars well controlled.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n - For HD today, possibly get unit prbc.\n - Will keep in Central line until after HD completed in case\n hypotension develops. Should d/c IJ once leave floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333036,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly sedated today after\n receiving oxycodone.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n -CXR greatly improved PVC and effusion over last 2 days.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n -f/u hep panel and PPD (placed ) for beginning of transplant work\n up.\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 8.4, stable, type and screen sent this am for possible\n transfusion of pRBC with HD\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation\n -restarted Glargine + HISS and sugars well controlled.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n - For HD today, possibly get unit prbc.\n - Will keep in Central line until after HD completed in case\n hypotension develops. Should d/c IJ once leave floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Comments: TF stoped since OG pulled. Starting soft DM, renal, cardiac\n diet\n Glycemic Control: Glargine and ISS\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU, for transfer to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333037,
"text": "Chief Complaint:\n 24 Hour Events:\n - for HD am\n - wrist pain increased, gave the prn oxycodone\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:58 PM\n Heparin Sodium (Prophylaxis) - 10:04 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (76 - 86) bpm\n BP: 109/33(54) {101/32(52) - 151/54(78)} mmHg\n RR: 20 (14 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96 kg (admission): 103 kg\n Height: 66 Inch\n CVP: 1 (-12 - 15)mmHg\n Total In:\n 843 mL\n 100 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 93 mL\n Blood products:\n Total out:\n 125 mL\n 10 mL\n Urine:\n 125 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n 90 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly sedated today after\n receiving oxycodone.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 113 K/uL\n 8.4 g/dL\n 178 mg/dL\n 5.4 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 98 mEq/L\n 134 mEq/L\n 24.5 %\n 13.5 K/uL\n [image002.jpg]\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n 03:22 AM\n WBC\n 17.7\n 13.5\n Hct\n 26.7\n 24.5\n Plt\n 116\n 113\n Cr\n 2.6\n 4.1\n 5.4\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 134\n 109\n 178\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:16/20, Alk Phos / T\n Bili:112/1.5, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:194 IU/L, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n -CXR greatly improved PVC and effusion over last 2 days.\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n -f/u hep panel and PPD (placed ) for beginning of transplant work\n up.\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 8.4, stable, type and screen sent this am for possible\n transfusion of pRBC with HD\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation\n -restarted Glargine + HISS and sugars well controlled.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n - For HD today, possibly get unit prbc.\n - Will keep in Central line until after HD completed in case\n hypotension develops. Should d/c IJ once leave floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Comments: TF stoped since OG pulled. Starting soft DM, renal, cardiac\n diet\n Glycemic Control: Glargine and ISS\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU, for transfer to floor today\n ------ Protected Section ------\n Left wrist pain: continue prn oxycodone\n Consult OT for splint placement on left wrist\n ------ Protected Section Addendum Entered By: , MD\n on: 11:16 ------\n"
},
{
"category": "Nutrition",
"chartdate": "2152-09-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 333042,
"text": "Objective\n Labs:\n Value\n Date\n Glucose\n 178 mg/dL\n 03:22 AM\n Glucose Finger Stick\n 173\n 06:00 AM\n BUN\n 58 mg/dL\n 03:22 AM\n Creatinine\n 5.4 mg/dL\n 03:22 AM\n Sodium\n 134 mEq/L\n 03:22 AM\n Potassium\n 3.6 mEq/L\n 03:22 AM\n Chloride\n 98 mEq/L\n 03:22 AM\n TCO2\n 21 mEq/L\n 03:22 AM\n Calcium non-ionized\n 9.3 mg/dL\n 03:22 AM\n Phosphorus\n 5.0 mg/dL\n 03:22 AM\n Ionized Calcium\n 1.20 mmol/L\n 02:33 AM\n Magnesium\n 2.2 mg/dL\n 03:22 AM\n ALT\n 16 IU/L\n 03:22 AM\n Alkaline Phosphate\n 112 IU/L\n 03:22 AM\n AST\n 20 IU/L\n 03:22 AM\n Total Bilirubin\n 1.5 mg/dL\n 03:22 AM\n Current diet order / nutrition support: Regular, HH/CC/Renal- soft\n solids, thin lix w/ 750cc fluid restriction/day\n Assessment of Nutritional Status\n Pt w/ NASH cirrhosis S/P TIPS c/b respiratory/renal failure. On\n intermittent HD via central line. Pt extubated , was on TF while\n intubated. OGT out, TF DC\nd and diet advanced to Regular w/ HH/CC/Renal\n and fluid restrictions.\n BG mngt w/ RISS and glargine.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Encourage po intake\n 2. DC the Renal restriction from the diet order as protein\n restriction not indicated while pt on HD.\n 3. Monitor hydration status.\n 4. c/w BG mngt as you are.\n Will f/u with po intake/progress and need to re-start TF if necessary.\n 11:27\n"
},
{
"category": "Respiratory ",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 332628,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Expectorated / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt extubated s/p successful SBT and is currently on 50% cool aerosol\n tol well with spo2 mid to upper 90s. Good cuff leak noted. Prior to\n extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332712,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Continues on humidified face tent O2, able to wean FiO2 from 70->50%\n by ABG\nSats 96-100%, regular resp pattern, no distress. NP.\n Action:\n Wean FiO2 as tolerated. Enc C&DB. HOB^^30-45.\n Response:\n No pulmonary edema.\n Plan:\n AM CXR pending. Wean FiO2 as tol. Enc C&DB. ? HD today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Anuric. Pt is ~3L neg LOS. Creatinine ^^ 4.1 this AM.\n Action:\n Minimize intake where possible.\n Response:\n No resp distress. Continues in ARF.\n Plan:\n ? HD today . Minimize fluid intake .\n Hyperglycemia\n Assessment:\n FSBS q 1 hr 160s->100s.\n Action:\n Insulin gtt titrated to FSBS.\n Response:\n Blood sugars WNL on gtt\n Plan:\n Titrate gtt per FSBS.\n"
},
{
"category": "Respiratory ",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 332520,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Reason: Elective; Comments: Intubated for worsening resp\n distress and hypoxia\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Comments:\n Pt remains intubated on mechanical ventilation. MDI\ns continued as\n ordered. RSBI of 87.\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332517,
"text": "Anxiety\n Assessment:\n c/o anxiety when asked and occasionally c/o pain but unable to assess\n location or severity, restless and moving all extremities, does well\n with calm approach, requiring reminders not to touch tubes and lines,\n no restraints at this time, good effect with mild sedation, follows all\n commands, moving left leg and bending at knee frequently while CRRT\n connected to left femoral Quinton cath---knee immobilizer on\n Action:\n Versed 2 mg. Q2h-3hrs and Fentanyl 100mcgs Q2-3hrs, freq.\n reorientation, calm approach\n Response:\n Good effect from versed and fentanyl prn\n Plan:\n Continue prn dosing of versed and fentanyl, freq. safetly checks, may\n need wrist restraints, possible need for fentanyl and versed IV con\n gtt if prn dosing gets more frequent\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and tolerating CPAP+PS, Stable resp status on current\n vent settings, Lungs clear but diminished bilat and ETtube suctioned\n for scant amts of thin white sputum, less bronchospastic with prn\n sedation, Sats= 98-100%, ABG= 7.40-38-120\n Action:\n No vent changes overnight, pulmonary toileting prn, freq. ABG\ns, to do\n RSBI this am\n Response:\n Stable resp status\n Plan:\n RSBI this am, Attempt to wean vent further and possibly extubate today\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Oliguric, Total of 57 ml of urine overnight, Tolerating CVVHD with\n removal of 200ml/hr, Calcium and Potassium replacement continuous as\n per sliding scale, Left femoral Quinton site C/D/I and good access\n pressures at site, CVVHD filter intact with minimal clots, Creatinine\n back down this am to 3.4, requiring IV Levophed at 0.05mcgs/kg while on\n CVVHD, positive bilat DP/PT\n Action:\n Knee immobilizer in place to limit mobility of Left leg while on CVVHD\n via Quinton, CVVHD initiated at 2115\n Last eve and tolerating removal of 200ml/hr---currently neg. 1.6 liters\n for shift, lytes replaced as per sliding scale parameters, citrate and\n flush line effective\n Response:\n Creatinine decreasing, tolerating fluid removal, stable on CRRT\n Plan:\n Continue to remove 200ml/hr in attempt to be at least 1.5 liters neg by\n rounds (already achieved), Titrate levophed to MAP\ns >60, limit\n mobility of left leg and check distal pulses freq. , Await further\n renal recommendations as to fluid removal goal\n Hyperglycemia\n Assessment:\n Continue to require increased insulin requirement while on insulin gtt,\n Blood sugars= 120-180\n Action:\n Tube feedings remains at 30ml/hr, IV insulin increased to 12 units/hr\n Response:\n Blood sugars remain under 200, requiring large amt IV insulin dose\n Plan:\n Address insulin dosing this am with MICU team, ? if pt could benefit\n from Lantus, continue to titrate gtt to keep insulin goal <150\n"
},
{
"category": "Nursing",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332813,
"text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Patient received on face tent @ 50%\n Action:\n Weaned to n/c 3l, fluid restriction to 750cc/hr\n Response:\n Sats maintained > 95%\n Plan:\n Continue to monitor, TB test to be placed\n Anxiety\n Assessment:\n Patient verbalized she feels anxiety [ known at baseline]\n Action:\n Patient ordered lorazapam q6, verbally reassured by team, visited by\n family and priest\n Response:\n Comfortable at present\n Plan:\n Continue to monitor anxiety ? increase dose\n Hyperglycemia\n Assessment:\n Received on iv dose of insulin @ 5u/hr to maintain B/S < 150, hrly\n fingersticks\n Action:\n Given long acting insulin @ 1300hrs [ for b/d dose], and s/s q6\n Response:\n b/s maintained < 150\n Plan:\n Continue to monitor closely\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n No action\n Response:\n To continue to monitor\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient producing no urine, rising creat\n Action:\n Renal team have reviewd, for 750cc fluid restriction\n Response:\n Maintaining fluid balance\n Plan:\n For HD tomorrow on the unit in view of previous low b/ps on CRRT,\n possible tunnel line placement monday\n"
},
{
"category": "Physician ",
"chartdate": "2152-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332817,
"text": "Chief Complaint: Pt reports improved breathing. Denies abd or chest\n pain. Reports feeling anxious.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:42 PM\n One of CVL ports clotted, put TPA through\n Allergies:\n Erythromycin Base\n Unknown;\n Indomethacin\n Unknown;\n Actonel (Oral) (Risedronate Sodium)\n Unknown;\n Reglan (Oral) (Metoclopramide Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Fentanyl - 10:45 AM\n Midazolam (Versed) - 12:44 PM\n Hydralazine - 04:47 PM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.4\nC (97.6\n HR: 83 (83 - 94) bpm\n BP: 126/42(64) {110/37(58) - 151/66(76)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 5,015 mL\n 152 mL\n PO:\n 120 mL\n TF:\n 335 mL\n IVF:\n 4,420 mL\n 32 mL\n Blood products:\n Total out:\n 6,628 mL\n 0 mL\n Urine:\n 15 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -1,613 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 453 (453 - 702) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.38/42/85./22/0\n Ve: 12.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Gen: lying in NAD\n HEENT: warm mucus membranes\n CV: RRR, holosystolic murmur\n Lungs: Right basilar crackles\n Abd: obese abd, mildly distended, NT, +BS, reducible umbilical hernia\n Ext: no edema, warm to touch\n Neuro: Alert and oriented x3. pt seems mildly anxioius\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 9.1 g/dL\n 109 mg/dL\n 4.1 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 99 mEq/L\n 137 mEq/L\n 26.7 %\n 17.7 K/uL\n [image002.jpg]\n Micro:\n fungal cult pending\n LIJ cult pending\n BAL, GS 1+ polys, prelim cults negative\n and blood pending\n urine\n : sputum rejected\n CXR: \nbibasilar opacities atelectasis, small R pleural effusion\n : unread, decreased R opacity and effusion.\n 08:41 AM\n 08:53 AM\n 02:06 PM\n 02:17 PM\n 03:17 PM\n 04:51 PM\n 05:58 PM\n 11:14 PM\n 02:10 AM\n 02:33 AM\n WBC\n 17.7\n Hct\n 26.7\n Plt\n 116\n Cr\n 3.0\n 2.6\n 4.1\n TCO2\n 24\n 25\n 24\n 24\n 24\n 24\n 26\n Glucose\n 169\n 134\n 109\n Other labs: PT / PTT / INR:19.6/33.2/1.8, ALT / AST:19/25, Alk Phos / T\n Bili:104/1.8, Amylase / Lipase:29/40, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:10.0 %, Mono:6.2 %, Eos:0.1 %, Lactic Acid:1.7\n mmol/L, Albumin:4.4 g/dL, LDH:181 IU/L, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 62 yo F with history of NASH cirrhosis and ESLD, now with ESRD.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)L lobar PNA and R pleural\n effusion on Chest CT from 7.25. echo showed EF >55%, Mild to\n moderate (+) mitral regurgitation is seen. [Due to acoustic\n shadowing, the severity of mitral regurgitation may be significantly\n UNDERestimated.] therefore chf as cause of volume overload/hypoxia is\n likely. PE/pulmonary infarct also possible despite LENIs negative given\n recent TIPS placement and possible L portal vein thrombosis. Of note\n the pt was not tachycardic but has also been on nadalol. Pt hypoxia\n remains resistant to increasing O2, which is more consistant with PE or\n other intraparenchymal lung shunting. Pt intubated .\n - extubated . Temporarily desat to 85% after extubation, however,\n pt rapidly requiring less oxygen, now only on 3L NC\n - believe CHF contributing to hypoxia, had restarted hydralazine 5mg\n q8h after extubation since also Hypertensive at that time. However, am\n dose held low MAP, d/ced for now in anticipation of low BP with HD.\n - D/c nadolol and norvasc\n -Consulted IP for thoracentesis of BL plueral effusions, however,\n no tapable effusion noted on US.\n - CT Torso unchanged compared to prior\n - Tele monitoring\n - continued to spike fevers on prolonged Vanc, Zosyn, Cipro (start date\n 7.26), d/c these abx \n - Bronchoscopy , unimpressive for infection, GS just 1+ polys. f/u\n results\n MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Pt has MR, which might be underestimated per the echo on .\n - good response to increased Hydralazine, however holding to avoid\n hypotension\n CIRRHOSIS OF LIVER, OTHER - NASH, stage IV disease by biopsy.\n Recently s/p UGIB and banding of grade II varices\n - continue ursodiol, allopurinol, rifaximin,\n - nadolol no longer necessary with successful TIPS\n Abdominal discomfort: Likely related to pleural effusion irritation of\n abodomen. Pt with ? L Portal vein thrombosis on recent RUQ U/S. TIPS\n procedure complicated by slight injury to L portal vein. Abdomen\n tympanic but with no ascites on imaging or bedside. Recent abdominal CT\n shows no evidence of obstruction.\n - GI against proflaxtic anticoagulation of L portal vein thrombosis\n given high risk bleed\n - trend LFTs\n - serial abdominal exams\n - Lactulose decreased to 30 on since increased diarrhea, likely\n getting more since intubated cause was not reaching goal of 45mg \n nausea.\n -repeat abd US No flow is detected in the left\n portal vein or the anterior right portal vein on this exam, but this\n may be due to technical factors.\n - lack of portal vein flow does not elimate pt as canidate for liver\n transplant, liver will discuss possibity of future transplant as team\n ANEMIA, OTHER\n Pt's admit hct above baseline, but trended downward on admission.\n Transfused with PRBCs on . Follow daily hct.\n - HBG now 9.1, stable, consider transfusion if clinical situation\n worsen or hgb below 7.0\n DIABETES MELLITUS (DM), TYPE II\n BG more controlled, stoped TF with extubation yesterday, Insulin gtt\n turned down from to 5mg/hr.\n -restart Glargine + HISS.\n -d/c insulin gtt\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline creatinine\n 1.3-1.7; Creatinine was initially improving this admission, with a\n nadir of 1.9, then significantly worsenined after TIPS procedure, now\n downtrending to 3.1. Etiology of ARF felt be be contrast dye related\n as per renal. ARFrelated to sepsis/infection or Hepatorenal syndrome\n being less likely. HRS is less likely given that the patient likely has\n an active infectious process and that UNa > 10. FeNa is also in the\n pre-renal range. However since pt was improving on HRS meds GI wanted\n to continue. No evidence of hydronephrosis on CT abdomen.\n -Renal believes unlikely HRS, think ATN CIN\n - CVVHD stoped yesterday after -1.5 L neg for day.\n -Plan for HD tomorrow and if tolearates HD for tunneling line Monday\n -Will give Vit K on Sunday to minimize FFP needed for line placement\n -anuric at this time monitor for UO, renal 50/50 changes of return of\n fxn\n -If tolerate HD tomorrow will transfer to floor.\n Fever - PNA/pleural effusion related vs PE from portal vein thrombosis.\n New cough since TIPS procedure. CXR/CT confirm L lobar PNA and R sided\n pleural effusion.\n RUQ pain s/p TIPS, but stable and not changing. No abdominal ascites on\n previous imaging confirmed by bedside echo exam therefore SBP unlikely.\n - spiked again , pan cultured\n - pleural tap not possible, No fluid to tap as per IP\n - f/u Blood cult, urine, sputum\n - stool neg, UCx GNR 5000/ml and enterococcus 1000/ml\n - Vanc/Zosyn/Cipro d/ced on \n - C diff negative x 3, stoped precautions\n - source of continued fevers unclear, even after CT torso. d/c abx, as\n may be drug fever\n -f/u Bronch results, however did not look to be infectious.\n -f/u fungal cults\n Anxiety: pt complains of anxiety. However h/o abusing benzos in past\n -started ativan 1mg q6h prn. Will be reluctant to increase dose much\n with abuse h/o\n ICU Care\n Nutrition:\n Comments: TF stoped since OG pulled. Starting soft DM, renal, cardiac\n diet\n Glycemic Control: Glargine and ISS\n Lines:\n Arterial Line - 01:24 PM\n Multi Lumen - 01:25 PM\n Dialysis Catheter - 08:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU, for transfer to floor tomorrow if tolerates HD without\n hypotension\n"
}
] |
17,620 | 136,080 | The infant was admitted for management of oxygen requirement along with hypoglycemia. 1. Respiratory: Infant was somewhat tachypneic with an oxygen requirement upon arrival to the Neonatal Intensive Care Unit. Chest x-ray was obtained which was consistent with either transient tachypnea of the newborn or atypical mild Surfactant deficiency in a close to term infant of a diabetic mother. The infant had some mild retractions as well. Oxygen requirement dissipated after several hours. Our retrospective impression is that this infant had some mild transient tachypnea. This was probably responsible for some dusky episodes when feeding. Infant has been stable in room air without any other respiratory issues for the past 6 days. 2. Cardiovascular: Infant had a reasonably loud murmur which initially obscured the second heart sound. His murmur has subsequently disappeared. He has had an EKG which was within normal limits for age and a chest x-ray which was also unremarkable. His perfusion has remained good. There have been no other signs of cardiac problems. 3. Fluids, Electrolytes & Nutrition: The infant's major reason for hospitalization was very low blood sugars that required several boluses of IV Dextrose in order to be stabilized. Over the first few hours of life the infant received four IV boluses of D10W at 2 cc/kilo. With each of these boluses a continuous IV infusion of Dextrose was increased from D10 at 80 cc/kilo/day to 100 to 120 and then to D12.5 at 20 cc/kilo/day. Ultimately the infant was requiring 20% Dextrose via umbilical venous catheter which was placed on the evening of admission. Over the following several days of hospitalization his Dextrose index was weaned to the point where he was on full po with feedings supplemented to 24 calories per ounce using Polycose. For the past 48 hours he has been taking feedings only. For the past 24 hours he has been taking unsupplemented feedings. His blood sugars have been in the 60's to 90's on that regimen. He has shown no other signs of hypoglycemia during his hospitalization. Our plan is to send him home with ad lib breast feeding since this is what he has been taking primarily and he has been doing well with this. 4. Gastrointestinal: The infant has been stooling and voiding and taking a normal diet without any significant regurgitation. There have been no other issues. 5. Hematology: The infant had on admission hematocrit of 49.9 with platelet count of 231,000. The infant was slightly jaundiced with an indirect bilirubin of 8.5 on day of life #3 and 9.1 on day of life #4. This was not checked further. 6. Infectious Disease: The infant had a CBC drawn on admission which showed a white blood cell count of 15.1 with 43% polys, 7% bands, 32% lymphs, 10% monos. The infant received a 48 hour course of Ampicillin and Gentamycin. Blood cultures were subsequently negative. There have been no other concerns for sepsis. 7. Neurology: The infant is still premature but he passed his hearing test and car seat test and showed no signs of apnea of prematurity. | + pulses and cap refill. Latest temp 98.6Alert and active.Consolable with bounderies. O: INFANT remains on ampi & gent per order. I updated them briefly.A: Stable. EKG wnl. LS c+=. (BW 3975). B/P stable, pulses WNL. hx murmur. (+)murmur.Asymptomatic. s/p Amp /gent x 48h. Stable BSon D15 IVF. milestones.I/DO: CBC and blood cx sent, temp stable. Pt BF andsuppl with bottle. Infant tolerating dextrose wean. +b.s. P. Support and keepupdated. Decresing glucoes requirements. Resp. RR 60's withmild retractions noted. UVC in place. P;24 hr Lytes in am,Ac D'stix Q4h.#4. Temp stable onopen warmer. updates given. P: Continue to moniter.#3 O: Infant remained on D15W (with added lytes and hep),infusing via DUVC. Antibiotics d/'cd.A. Infant fed and post 63. A: D/S stable P: Continue towean IV as tolerated.4. Pt hasDL uvc infusing D10W with hep @ 1.0cc/hr and NS with hep @1.0cc/hr. Mildretraction. Will add K to IVF. Mild rtxns. Likely TTN now resolving. Transitional stools. Calms with bounderies. Wt 4090 grams (up 115).CBC benign. O: Murmur persists. A; Murmur heard. Check bili w/ next d-stick. InfantRuddy. abd benign. Sepsis ruled out. Mild retractions. A: Stable P:Continue to assess.3. Cl and =. P: cont to provideoptimal oxygenation.Potential for alt. Good tone andpulses. Maintaining good sat on RA. P- Will cont to monitor FEN.#4 G&D- temp stable on off warmer. retained fluid. LS clear bilaterally. Improved bottling, dtiscks stable. asking appropques. Nested with boundaaries. Wt 3880 grams (down 45).Bili 9.1/0.3 yestParents visiting and up to date. NPN#1 S. O. Lactation support in.Questions answered. IVF at 2. u.o 2.4. Known normal fetal echo.HEME: Looks ruddy--will follow-up on initial Hct of 49.ID: On ampi and genta approaching 48 hours. O: Wt.-150g 3940g. Continue ad lib feeds. P. Resolve problem.#2 S. O. Neonatology AttendingDOL 1Stable. MBP 43, consistent overnight. NPNOte:#1. BF well.P- Will cont to monitor G&D.#5 Pt sl jaund. CXR looks wet. BSCE bilaterally.A: Retracting and desat's requiring 02. Continueto moniter for potential s/s of sespis. Fluids now D15W with 2+1 at 60/kg. Off cannula. DS 74. and gent. Will start BM 22cal withpolycose this PM. Clear equalBS.P/ Cont to assess resp status#3 FEN Stable BS on D15 IVF plus PO feeds. P- Will cont to monitorresp status.#3 Pt ad lib. Mom BF. Total fluid Recieved 106cc/kg/day.A; feedstolerated. Becoming more active with cares, and sleeps wellin between.A; AGA P: Cont to support dev. HR 110's-160's. Took 120 cc/kg yest. Onetouch ac 71,68 an 61 throughout the shift Weaning infantinitially from D15w to D10 w iv fluid and then lowering ivfluid 2cc q feed. Good tone and pulses. P/ Cont to support G/D#5 CVNo murmur appreciated. helped with cares. P. Monitor and discuss withteam.#3 S. O. P:Continue to check ac d-sticks. P. continuewith plan.#6 S. O. LGA IDDM infant. P/ Cont to support G/D.#5 CVNo tachycardia. D10 w 2 Na via DL UVC at 12 cc/k/day, then po ad lib BF and BM w/ polycose. A: stable d sticks, feedingwell. D10W bolus given. effort, sats stable, resp40-60's. Pulses WNL.B/P stable. circ care reviewedwith . P: Continue tomoniter for milestones.#5 O: Soft murmur heard X 1. A: respiratory status stable P:monitor.3. a:stable, awaiting void for d/c. changingdiaper and checking temp indepnd. P: Cont to support andupdate. in CV; d/c'd done today with small amt ofbleeding remaining. in Resp. DS 59/68/99. supportive of oneanother. on adlib no greater than q4h feedings of BM, taking 70ccpo well, DS ac 59 on 22 cal, abd soft, voiding and passingstools, desitin applied to reddened area on bottom. A:breathing comfortably in roomair, desat X 1 with bottling.P: Continue to moniter.#3 O: IVF infusion of D10W with added lytes continues toinfuse via DUVC at ~ 12cc/k/d (at "KVO"). Taken from Recovery Room to LR 11. HR 130-150's, no murmur, pulses normal, colorpink/jaundice A: stable CVS P: monitor.6. A: Stable resp. Hypoglycemia resolved. DS 62/61/55/59 Voiding Stooling Wt 3785 grams (down 45).Desitin to buttocks in and up to date.A: Doing well. Temp stable onopen warmer. Lungs CTA, =. abd benign.voiding qs. Fetal echo reportedly normal. P; continue to monitor.#3.Todays weight=3.785, down 45gms, TF=minimum 120cc/kg/day,BM22cal with polycose, po feeds given q4h, feeds tolerated.BS+, no loops, voided and stooled. CV RRR, + sl vibratory murmur LLSB. cont to receive D10 via DLUVC at 1.0cc/hthrough each port. P: Continue to keep informed, reinforce d/cteaching.REVISIONS TO PATHWAY: 2 Alt. A: stable C/V status. 2. remains in RA, RR 40-60, clear, equal, no desats orbradys so far this shift. P: Continue to moniter ac d-sticksand continue IVF infusion for now.#4 O: Infant alert and active with cares. Given BBO2, suctioned by anesthesia. D'stix AC 62,61. Abd soft, +BS. D/c teachingcompleted. NPNote:#2.Remains in R.Air, easy resp. On our arrival infant pink, being given BBO2. Normal ECG. P: Cont to monitor.#3 O: Infant remains on ad lib amounts of BM with 4 cals/1oz of polycose. Further ac d-sticks have been 65 and82. hands to mouth and face.pku sent today. Awake andalert with cares; sucking on pacifier when offered. A:Tolerating feeds. p: continue tosupport as needed. A: AGA. A: AGA. A; stable in R.air. Follow murmur for now, if persistent will evaluate further. stable, placed in acrib, swaddled. Voiding andstooling adeq amts, stool heme neg. Neonatology FellowPt. area no oozing, Desitin applied to reddiaper area A; AGA P; continue dev. dstic58. umbi. A: low d-stick X 1, infant breast andbottle feeding better. Presented with PL and decels leading to C/S under spinal. seen and examined. teaching reviewedincluding circ care. A; feedstolerated.#4.Alert and active with care, temp. Neonatology AttendingExam AF soft, flat, clear bs, no murmur, benign abd, fresh circ, active Abdomenbenign; voiding and stooling. nursing d/c notept d/c to home accomp. P: Cont to monitor DS.#4 O: Maintaining temp swaddled on an off warmer. 2+FP. LS are clear and=. Neonatology AttendingDOL 6Stable in RA.Off IV glucose. Lung sounds remain clear and eqaul.Resp rates 40-70s with mild retractions at times. | 35 | [
{
"category": "Nursing/other",
"chartdate": "2171-04-20 00:00:00.000",
"description": "Report",
"row_id": 1927206,
"text": "NPN Days\n\n\n#1 O: Blood cultures remained negative at 48 hours therefore\nantibiotics were d/c'd. Temp and d-sticks have remained\nstable and infant is alert and active with cares. A/P:\nSepsis r/o completed with blood cultures negative. Continue\nto moniter for potential s/s of sespis. Problem resolved\nfor now.\n#2 O: Infant remains on roomair with O2 sats 96-100%. Lung\nsounds clear and eqaul, resp rates 50-60s, mild retractions\nnoted when infant upset. A: breathing comfortably in\nroomair. P: Continue to moniter.\n#3 O: Infant remained on D15W (with added lytes and hep),\ninfusing via DUVC. D-sticks have been 73-86 (greater than\n60) therefore were able to wean the IVF 2cc q feeding, and\nis currently infusing at ~ 35cc/k/day. Infant went to\nbreast X 1, latched on with some sucking. 2 cals of\npolycose have been to E 20 the last 2 feeds and infant has\nshown improved bottling and took 30-38cc. Abd remains\nsoft, +bs, no loops. Voiding adeq amts, stool heme neg.\nLytes and bili drawn - see flow sheet for results. A:\ninfant bottling well and is tolerating weaning of IVFs. P:\nContinue to check ac d-sticks. Wean IVF to D10W tonight and\nthen continue to wean IVF rate as tolerated (2cc per feed if\nd-stick >60).\n#4 O: Infant alert and active with cares. Temp stable on\nopen warmer. Improved bottling, dtiscks stable. A: AGA.\nP: Continue to moniter for milestones.\n#5 O: No murmur heard this shift. HR 120s-150s. Skin\npink/ruddy. B/P stable, pulses WNL. A: stable C/V status.\nP: Continue to moniter.\n#6 O: Infant's parents up to visit several times - both\nparents participating in cares, needed asst. with bottling\nand breastfeeding. Asking appr questions, they understand\nneed to bottle infant given his hypoglycemic issues. A:\ninvolved, concerned parents. P: Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-21 00:00:00.000",
"description": "Report",
"row_id": 1927207,
"text": "NPN\n\n#1 S. O. Blood cx's negative to date. Antibiotics d/'cd.\nA. Sepsis ruled out. P. Resolve problem.\n\n#2 S. O. Infant in room air. Breath sounds clear and\nequal. Resp. rates occasionaly up in the 80s' O2 sats\nwnl. A. ? retained fluid. P. Monitor and discuss with\nteam.\n\n#3 S. O. Weight down 15 grams. Voiding and stooling. One\ntouch ac 71,68 an 61 throughout the shift Weaning infant\ninitially from D15w to D10 w iv fluid and then lowering iv\nfluid 2cc q feed. Infant taking 35 to 38cc of enfamil with\npolycose. A. Infant tolerating dextrose wean. P. continue\nwith plan.\n\n#6 S. O. Mom and dad in with sibling . Asking appropraite\nquestions. Mom put infant to breast x 1. Mom calling x 1\nfor an update. A. Invested mom. P. Support and keep\nupdated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-21 00:00:00.000",
"description": "Report",
"row_id": 1927208,
"text": "1 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-21 00:00:00.000",
"description": "Report",
"row_id": 1927209,
"text": "Neonatology Attending Note\nDay 3\n\nRA for 48 hrs. Cl and =. RR 50-60s. Yet, can occass be tachypneic. Mild rtxns. No murmur. HR 110-140s. Mean BP 60. Ruddy/jaundiced. s/p Amp /gent x 48h. Wt 3925, down 15. D10 w 2 Na via DL UVC at 12 cc/k/day, then po ad lib BF and BM w/ polycose. TF past 24hrs at 100cc/k/day.\n\nOvernight able to wean IVF, yet this am low (<40). Infant fed and post 63. IVF at 2. u.o 2.4. On off warmer.\n\nHct 53.9\nBili 8.8/0.3 last night.\n137/4.2/99/20\n\nPreterm male, IDM, hypoglycemia.\nMonitor glc levels and wean IVF as tolerates. Check bili w/ next d-stick. Will add K to IVF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-20 00:00:00.000",
"description": "Report",
"row_id": 1927203,
"text": "NPN 1900-0700\n\n\n1. O: INFANT remains on ampi & gent per order. A; R/O sepsis\nP: Continue to await blood culture results.\n\n2. O: Infant remains in room air. O2 sats>95%. RR 60's with\nmild retractions noted. LS clear bilaterally. A: Stable P:\nContinue to assess.\n\n3. O: Wt.-150g 3940g. See flowsheet for IV fluid details Via\nDUVC.. Able to titrate IV throughout night. Bottling E20\n20-25cc every 3-4 hours. Abdomen soft. +b.s. D/S 68-83.\nVdg3.6 x 12 hours. stool x 1. A: D/S stable P: Continue to\nwean IV as tolerated.\n\n4. O: maintaining temperature on servo-controlled\nwarmer. Nested with boundaaries. Waking for some feeds.\nBottling improving. Active & alert with cares. A; AGA\nP:Continue to support development.\n\n5. O: Murmur persists. BP maps 40's. heart rate 130. Infant\nRuddy. A; Murmur heard. P: Continue to assess.\n\n6. O: Mom in for 2200 cares. Mom bottled infant. Mom eager\nto breastfeed infant. MOM swaddled infant. MOm brought\nup breastmilk to give infant. A: Involved, parents P:\nContinue to update,educate and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-20 00:00:00.000",
"description": "Report",
"row_id": 1927204,
"text": "NEONATOLOGY ATTENDING\nEXAM: Done ~4pm. Large, ruddy, IDM-cheeks. Comfortable RR, lungs clear, belly soft. I did not hear a murmur. Not edematous, but very chubby. Skin intact.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-20 00:00:00.000",
"description": "Report",
"row_id": 1927205,
"text": "NEONATOLOGY ATTENDING\n\nDay 2 for . LGA IDDM infant. 35 2/7th weeker.\n\nRESP: In RA for 24h. Off cannula. Good sats. Clear and equal. Mild retractions. No desats or bradys.\n\nCV: Murmur not noted this AM. ECG yesterday was okay. MBP 43, consistent overnight. Mild edema (or just chubbiness). Known normal fetal echo.\n\nHEME: Looks ruddy--will follow-up on initial Hct of 49.\n\nID: On ampi and genta approaching 48 hours. CBC was initially benign.\n\nFEN: 3940 -150g. (BW 3975). Fluids now D15W with 2+1 at 60/kg. Aiming to inch down on IVFs 2cc/hr with each feed. Bottling 20-25cc per feed (approximately 80-90/kg). DS 68-87, 81. Urine 3.6/k/h. Transitional stools. Willing to add polycose to attempt to get off IVFs.\n\nACCESS: UVL for high concentration glucose.\n\nDVLP: Open warmer. Active, waking for feeds, but mediocre feeding.\n\nPARENTS: Mom doing temp and diapers, would like to BF. Will need to PC.\n\nSee exam note below. Seems very ruddy.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-19 00:00:00.000",
"description": "Report",
"row_id": 1927200,
"text": "Neonatology Attending\n\nDOL 1\n\nStable. Required NCO2 until 11 am. Now in RA with sats >96%. R 50s-60s. CXR looks wet. No A/B.\n\nMurmur still present. EKG wnl. 4 ext BP equal.\n\nRequired D10W x 4 to get DS >50s. Currently on 120 cc/kg/d D15 via UV. Also feeding po ad lib E 20 20-30 cc q4. DS 60s-80s. Wt 4090 grams (up 115).\n\nCBC benign. BC sent. On A/G.\n\nParents visiting. I updated them briefly.\n\nA: Stable. Likely TTN now resolving. Likely hypertrophic cardiomyopathy +/- PDA but will follow for now. DS stabilizing.\n\nP: Monitor in RA\n Follow murmur\n Wean IV 2 cc/hr for each DS >60\n Feed ad lib\n 48 hour R/O\n Support parents\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-19 00:00:00.000",
"description": "Report",
"row_id": 1927201,
"text": "Neonatology Fellow\nAsleep easily aroused on open warmer in No distress.\n\nNo retractions. rr 60's.\nChest is clear. Murmur persists but is softer and occurs during systole but not harsh. S1 and S2 are heard well.\nAbdomen remains soft. UVC in place. Infant gained over 100 grams overnight on a gir of 12.5 mg/k.min. Blood glucose has stabilized.\n\nPlan discussed with Dr. and outlined in her note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-19 00:00:00.000",
"description": "Report",
"row_id": 1927202,
"text": "Nursing Progress Note\n\n\n#1 Sepsis\nNo acute S/S of sepsis on Amp and Gent.\n#2 RESP\nWeaned off NC at 1130. Maintaining good sat on RA. Mild\nretraction. No tachypnea. No acute distress. Clear equal\nBS.P/ Cont to assess resp status\n#3 FEN\n Stable BS on D15 IVF plus PO feeds. Tolerating PO ad lib E\n20cal 20-35cc Q 4 hours. Soft benign abdomen. Voiding\n6cc/k/hour. Stooling dark green heme neg stool. Stable BS\non D15 IVF. Lytes added on IVF this eve. Double lumen UVC\nintact and patent.P/ Cont to assess feeding tolerance. Will\ndecrease IVF to 2cc/hour for BS>60 as ordered. Cont to\nmonitor daily wt.\n#4 G/D\nRadiant warmer weaned to 35 for tmax 99.3. Latest temp 98.6\nAlert and active.Consolable with bounderies. Bringing hands\nto mouth. No pacifier per parents request.Sleeps in between\ncares. P/ Cont to support G/D.\n#5 CV\nNo tachycardia. (+)murmur.Asymptomatic. Team aware of wide\npulse pressure. No significant change with upper and lower\nextremity blood pressure. Warm and well perfused with 3 sec\ncap refill. Good tone and pulses. P/ Cont to assess CVR\nstatus\n#6 Parenting\n Mom and Dad in every care this shift.Participating with\ntemp check, diaper change and feeding . Updated by Dr\n .P/ Cont to update, educate and support family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-18 00:00:00.000",
"description": "Report",
"row_id": 1927198,
"text": "NICU nursing progress note\n\n\nResp\nO: Received in room air, desat's to 88% with mild sc\nretractions and placed on 200cc flow and fi02 30-70%,\ncurrently on 35%. RR 30-70's. Sat's >94%. BSCE bilaterally.\nA: Retracting and desat's requiring 02. P: cont to provide\noptimal oxygenation.\nPotential for alt. in hemodynamics / CV\nO: +Murmur, BP with means in 40's decreased to high 30's in\nafternoon and double lumen UVC placed by fellow and\nplacement verified by cxray. HR 110's-160's. A: Potential\nfor hemodynamic instability. P: Cont to monitor.\nFEN\nO: TF currently at 130cc/kg/day of D15w and 0.5units of\nHeparin infusing through both ports of UVC. Also taking ad\nlib amounts of E20 and tolerating well. Dstick initially 12\nupon arrival to NICU and received D10w x 4 to keep\ndstick >50. A: Infant of IDDM mom requiring for\nlow dsticks. P: Cont to provide optimal nutrition and\nhydration, monitor.\nG and D\nO: Temp stable on servo warmer. Sucking on pacifier when\noffered, tone is moderate/ is drowsy. Fontanels soft\nand flat. Becoming more active with cares, and sleeps well\nin between.A; AGA P: Cont to support dev. milestones.\nI/D\nO: CBC and blood cx sent, temp stable. On amp. and gent. IV.\nA: No s/s of infection. P: cont to assess and monitor.\nParents\nO: Mom and dad in today, updated at bedside by Fellow and\nNNP/ and RN, verbalizing understanding. Sibling is 4 year\nold brother who was also born prematurely with Dstick\nissues. Mom is an IDDM and has been on insulin for 20 years.\nA: Involved and caring/ concerned parents. P: Cont to\nupdate, support, and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-19 00:00:00.000",
"description": "Report",
"row_id": 1927199,
"text": "NPNOte:\n\n\n#1. Remains on ampicilline and gent, given as ordered.Hep.\nlock in situ Rt.anticube.\n\n#2.Remains on nasal cannula 02, 300cc-30-35%, BBS clear and\nequal, Resp 50-60's,mild interostal/subcostal retractions\npresent,no A's or B's.Sats stable. A; Required nasal cannula\n02 to maintain sat.P; continue to monitor.\n\n#3.Today's weight=4.090kg, up 115gms, TF= 120cc/kg/day,\n(Decreased from 130cc/kg, @ 12am),On D15 with Heparin 0.5\nu,infusing at double lumen UVC,patent. ON PO feed E20,adlib,\nbottled 30cc, BS+, no loops, D'stix Ac 75,68. voided and\nstooled. Total fluid Recieved 106cc/kg/day.A; feeds\ntolerated. P;24 hr Lytes in am,Ac D'stix Q4h.\n\n#4. alert and active with care, temp. stable, serve on\nwarmer, good suck and swallow co-ordination, loves pacifier.\nA;AGA AF small, flat.P; continue dev. support.\n\n#5.Ruddy, well perfused, loud murmur audiable, good pulses.\n\n#6.Dad visited, asking app. questions, involved in care, Mom\nis planning to breast feed. A; Dad.P; continue update\nand teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-23 00:00:00.000",
"description": "Report",
"row_id": 1927215,
"text": "NPN Nights\n\n\n#2 Pt received on RA and cont on RA. No spells or\ndesats so far this shift. LS c+=. P- Will cont to monitor\nresp status.\n#3 Pt ad lib. BM with 4cals of polycose. Pt BF and\nsuppl with bottle. Pt took 50cc after BF and 55cc with\nsecond care. abd benign. voiding large amounts in diaper and\nin bed. stooling. No spits. BS 71, 72 prior to feeds. Pt has\nDL uvc infusing D10W with hep @ 1.0cc/hr and NS with hep @\n1.0cc/hr. Wt 3.830 (down 50g). P- Will cont to monitor FEN.\n#4 G&D- temp stable on off warmer. alert and active with\ncares. Sleeps well b/w cares. sucking on pacifier. BF well.\nP- Will cont to monitor G&D.\n#5 Pt sl jaund. hx murmur. No murmur heard so far this\nshift. + pulses and cap refill. BP 74/41 (53) Pt has gen.\nedema. P- Will cont to monitor CV status.\n#6 Parenting- and sibling in this shift. Mom BF.\n helped with cares. and caring. asking approp\nques. updates given. P- Will cont to provide support,\neducate and encourage visits and calls.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-23 00:00:00.000",
"description": "Report",
"row_id": 1927216,
"text": "Neonatology Attending\n\nDOL 5\n\nStable in RA.\n\nNo murmur. MAP 53\n\nFeeding ad lib demand Breast feeding and getting BM with 4 cal/oz polycose. Took 120 cc/kg yest. UV with 1cc D10W and 1cc NS. DS 74. Voiding. Stooling. Wt 3830 grams (down 50).\n\nFamily visiting and up to date.\n\nA: Hypoglycemia resolving.\n\nP: D/C UV line\n Decrease polycose to 2 cal/oz\n Follow DS\n Desitin\n Family meeting today\n Likely D/C Thursday if he continues to do well\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-23 00:00:00.000",
"description": "Report",
"row_id": 1927217,
"text": "NURSING PROGRESS NOTE\n\n\n#2 RESP\nStable on RA. Clear equal BS. Normal WOB. No spells note.\nP/ Cont to assess resp status\n#3 FEN\nBreast feeding well Q3-4 hours and supplemented with 50-75cc\nBM 24 cal with polycose. No spit Benign abdomen.Voiding and\nstooling. Dstix above 70. Remains on D10 and NS with heparin\nto KVO infusion via double lumen UVC.P/ Cont to assess\nfeeding intolerance and daily wt. Will start BM 22cal with\npolycose this PM. Awaiting to DC line this PM. Cont to\nmonitor BS closely.\n#4 G/D\nStable temp on unheated warmer.Alert and active Sleeps in\nbetween care. Calms with bounderies. P/ Cont to support G/D\n#5 CV\nNo murmur appreciated. Warm and well perfused. Good tone and\npulses. No spells noted. P/ Cont to assess CVR status.\n#6 Parenting\nFamily meeting this PM with Dr. . Lactation support in.\nQuestions answered. P/ Cont to update, educate and support\nfamily.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-23 00:00:00.000",
"description": "Report",
"row_id": 1927218,
"text": "Neonatology Fellow\nAsleep comfortable in room air. Good air entry. No retractions. Slightly tachypneic abdomen soft. Decresing glucoes requirements. Will wean supplemental dextrose and monitor tachypnea. be candidate for discharge if hypoglycemia resolves.\n\nPlan discussed with Dr. and outlined in her note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-22 00:00:00.000",
"description": "Report",
"row_id": 1927212,
"text": "Neonatology Attending\n\nDOL 4\n\nStable in RA. Some desats to high 80s with bottle feeding (in transition from breast to bottle).\n\nIntermittent murmur. MAP 40s-50s\n\nStill requiring some IV glucose to maintain DS. On D10W at 2 cc/hr via double lumen UV. Feeding ad lib by breast for 10 min then E20 now with 4 cal/oz polycose 30-50 cc q feed. DS 57-67 with 2 cal/oz polycose. Voiding. Stooling. Wt 3880 grams (down 45).\n\nBili 9.1/0.3 yest\n\nParents visiting and up to date. Rooming in downstairs.\n\nA: Slowly resolving hypoglycemia\n\nP: D/C IV glucose and change to NS\n Maintain UV (secondary to poor IV access) until we are assured that he does not need IV glucose.\n Continue ad lib feeds.\n Monitor DS\n Once DS stable off IV will need to wean polycose\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-22 00:00:00.000",
"description": "Report",
"row_id": 1927213,
"text": "Neonatology Fellow\nAwake, Alert under warmer no retractions no tachypnea chest clear. heart regular with faint murmur heard. 2+ distal pulses. abdomen soft. uvc in place\n\nPt receiving minimal dextrose infusion in uvc, but is requiring feedings supplemented with pokycose. will continue to wean ivfluid and then think about tapering caloric density.\n\nparents at bedside.\n\nplan discussed with Dr. and outlined in her note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-22 00:00:00.000",
"description": "Report",
"row_id": 1927214,
"text": "NPN 0700-1900\n\n\n#2 O: Infant remains in RA with o2 sats 97-100%. RR\n30's-50's; comfortable without retractions. LS are clear and\n=. No a's or b's. A: Stable resp. P: Cont to monitor.\n\n#3 O: Infant remains on ad lib amounts of BM with 4 cals/1\noz of polycose. Breastfeeding q 3-4h and then supplementing\n20-50cc's of BM with polycose after every breastfeeding\nsession. Infant waking just under every 4 h on own. Abdomen\nbenign; voiding and stooling. DS 57,67, and 72 this shift\nprior to all feeds. cont to receive D10 via DLUVC at 1.0cc/h\nthrough each port. One port to be changed to just NS. A:\nTolerating feeds. P: Cont to monitor DS.\n\n#4 O: Maintaining temp swaddled on an off warmer. Awake and\nalert with cares; sucking on pacifier when offered. Waking\non own for most feeds. A: AGA. P: Cont to support\ndevelopment.\n\n#5 O: No murmur heard as yet this shift. coloring pink-\nruddy. A: Intermittent murmur. P: Cont to monitor.\n\n#6 O: Parents in throughout day to do cares. Mom\nbreastfeeding and dad offering bottle after. Asking\nappropriate questions. Parents plan to stay in parent room\nas mom was d/c'd today. A: Involved. P: Cont to support and\nupdate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-21 00:00:00.000",
"description": "Report",
"row_id": 1927210,
"text": "Neonatology Attending Note\nOn exam:\n\nLarge, IDM facies, resting comfortably under radiant warmer. AFSF. Lungs CTA, =. CV RRR, + sl vibratory murmur LLSB. 2+FP. Abd soft, +BS. Ext pink and well perfused.\n\nNo changes to hypoglycemic management. Follow murmur for now, if persistent will evaluate further.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-21 00:00:00.000",
"description": "Report",
"row_id": 1927211,
"text": "NPN Days\n\n\n#2 O: Infant remains in roomair with O2 sats 94-99%. Had\none episode of desat to 84% while bottling that resolved\nwith removal of bottle. Lung sounds remain clear and eqaul.\nResp rates 40-70s with mild retractions at times. A:\nbreathing comfortably in roomair, desat X 1 with bottling.\nP: Continue to moniter.\n#3 O: IVF infusion of D10W with added lytes continues to\ninfuse via DUVC at ~ 12cc/k/d (at \"KVO\"). D-stick this\nmorning was 34 - improved after bottling 40cc of BM with 2\ncals added polycose. Further ac d-sticks have been 65 and\n82. Infant went to breast several times today and did well\n- latched on and fed for ~10 minutes each time and then\nsupplemented with bottling of BM or E20 with 2 cals added\npolycose. ABd remains soft, +bs, no loops. Voiding and\nstooling adeq amts, stool heme neg. Bilirubin drawn today\nwas 9.1/.3/8.8. A: low d-stick X 1, infant breast and\nbottle feeding better. P: Continue to moniter ac d-sticks\nand continue IVF infusion for now.\n#4 O: Infant alert and active with cares. Temp stable on\nopen warmer. Infant bottling and breastfeeding well.\nSleeping well between cares. A: AGA. P: Continue to\nmoniter for milestones.\n#5 O: Soft murmur heard X 1. Heart 120s-130s. Pulses WNL.\nB/P stable. A: stable C/V status. P: Continue to moniter.\n#6 O: Infant's mother up for each feeding and FOB in this\nafternoon with extended family members. changing\ndiaper and checking temp indepnd. She is needing some help\nwith positioning of infant with breastfeeding. Parents\nasking appr questions and aware of need for continued\nmonitering of d-sticks. Mother plans to be d/c'd tomorrow\nbut has the \"familyroom\" on the postpartum unit reserved for\ntomorrow/Monday night. A: involved and invested parents.\nP: Continue to support. ?Plan family meeting for tomorrow or\nTuesday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-25 00:00:00.000",
"description": "Report",
"row_id": 1927225,
"text": "nurisng progress note 0700-1900\n\n\n#3 fen\no: ad lib feeding of bm 20 po q3-4 hours. abd benign.\nvoiding qs. no stools this shift. ag 29.5cm. no spits. dstic\n58. a: stable p: continue to monitor for feeding intolerance\nand support as needed.\n#4 g&d\no: pt in open crib with stable temps. and awake with\ncares. fontanelles soft and flat. hands to mouth and face.\npku sent today. circum. done today with small amt of\nbleeding remaining. clot noted to under side of penis. a:\nstable, awaiting void for d/c. p: continue to monitor for\nchanges and support as needed.\n#6 parenting.\no: into visit throughout the day. supportive of one\nanother. asking appropriate questions. circ care reviewed\nwith . a; involved and family. p: continue to\nsupport as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-25 00:00:00.000",
"description": "Report",
"row_id": 1927226,
"text": "nursing d/c note\n\n\npt d/c to home accomp. by . teaching reviewed\nincluding circ care. pt voiding without difficulty. tylenol\ngiven for discomfort and irritability. physical assessment\nbenign.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-18 00:00:00.000",
"description": "Report",
"row_id": 1927196,
"text": "Neonatology Attending\n\n3975 gram 35 week male admitted to NICU secondary to hypoglycemia and dusky episode\n\n3975 gram 35 week male born to a 32 yo G4 P1->2 white female\nPNS: O+/Ab-/RPR NR/RI/HBsAg-/GBS unknown\nMother is an insulin dependent diabetic managed with an insulin pump. Fetal echo reportedly normal. Presented with PL and decels leading to C/S under spinal. Vigorous male. Apgars .\n\nInitial DS in 20s. During feed became dusky. Taken from Recovery Room to LR 11. Given BBO2, suctioned by anesthesia. DS 10. On our arrival infant pink, being given BBO2. Brought to NICU for evaluation.\n\nExam LGA, ruddy male pink with O2\nT 97.4 P 132 R 56 BP 72/30 mean 46 O2 sat 94% with drop to 88%->O2\nWt 3975 grams (>90%) HC 35.5 cm (>90%) Lt 47 cm (60%)\n AF soft, flat, nondysmorphic, intact palate, clear bs, II/VI murmur LSB, heard best at LUSB, normal pulses, soft abd, 3 vessel cord, no hsm, normal male genitalia, hydroceles, patent anus, no sacral dimple, no hip click, active\n\nDS 12\nDifficulty in placing IV\nI placed 22 G IV in R antecubital vein. Good blood return. D10W bolus given. Required D10W bolus 3cc/kg x 3 and IV D10W to 140 cc/kg/d to obtain DS >40.\n\nA: LGA 35 week IDM male with significant hypoglycemia finally responding to IV glucose after multiple boluses. Dusky episode likely secondary to poor feeding coordination in combination with significant hypoglycemia. Murmur ? hypertrophic cardiomyopathy. At risk for sepsis with GBS unknown, fetal distress.\n\nP: Monitor respiratory status\n O2 as needed to maintain sats >/= 95%\n Check CXR\n Cardiac W/U including 4 ext BP, EKG. Consider cardiology consult if murmur persists\n IV fluids to keep DS 50s or above. need UV line to administer concentrated glucose\n Check CBC, BC.\n If polycythemic, may need partial exchange transfusion\n A/G for R/O pending clinical status and labs\n Support parents\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-18 00:00:00.000",
"description": "Report",
"row_id": 1927197,
"text": "Neonatology Fellow\nPt. seen and examined. Exam documented in newborn admission sheet. Plan discussed with Dr. and outlined in her admission note. Infant is now with a blood glucose of 60, on 140cc/k/d of D12.5\n\nCXR EKG obtained. Observe today. Start feedings. Consider cardiology consultation if murmur/tachypnea is persistent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-24 00:00:00.000",
"description": "Report",
"row_id": 1927219,
"text": "NPNote:\n\n\n#2.Remains in R.Air, easy resp. effort, sats stable, resp\n40-60's. No B's. A; stable in R.air. P; continue to monitor.\n\n#3.Todays weight=3.785, down 45gms, TF=minimum 120cc/kg/day,\nBM22cal with polycose, po feeds given q4h, feeds tolerated.\nBS+, no loops, voided and stooled. D'stix AC 62,61. A; feeds\ntolerated.\n\n#4.Alert and active with care, temp. stable, placed in a\ncrib, swaddled. umbi. area no oozing, Desitin applied to red\ndiaper area A; AGA P; continue dev. support.\n\n#5.Soft murmur +, pink with trace of Jaundice, well\nperfused.\n\n#6. Dad called for a update,asking app. questions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-24 00:00:00.000",
"description": "Report",
"row_id": 1927220,
"text": "Neonatology Attending\n\nDOL 6\n\nStable in RA.\n\nOff IV glucose. On BM with 2 cal/oz polycose. Takes 75 cc q 4. DS 62/61/55/59 Voiding Stooling Wt 3785 grams (down 45).\n\nDesitin to buttocks\n\n in and up to date.\n\nA: Doing well. Hypoglycemia resolving.\n\nP: D/C polycose and monitor DS\n If DS stable, discharge in am\n Hep B vaccine, hearing screen, car seat test, PKU #2 today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-24 00:00:00.000",
"description": "Report",
"row_id": 1927221,
"text": "2. remains in RA, RR 40-60, clear, equal, no desats or\nbradys so far this shift. A: respiratory status stable P:\nmonitor.\n3. on adlib no greater than q4h feedings of BM, taking 70cc\npo well, DS ac 59 on 22 cal, abd soft, voiding and passing\nstools, desitin applied to reddened area on bottom. P:\nchanging to 20 cal today, check DS, monitor.\n4. temps stable in open crib, waking q3-4h for feedings P:\ncontinue to support growth and development.\n5. HR 130-150's, no murmur, pulses normal, color\npink/jaundice A: stable CVS P: monitor.\n6. here, Mom planning to breast feed A: involved and\nconcerned P: cont to inform and support, prepare for baby's\ndc to home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-25 00:00:00.000",
"description": "Report",
"row_id": 1927222,
"text": "NICU NPN 1900-0700\n\n2 Alt. in Resp.\n5 Alt. in CV\n\n#3 FEN O: BABY is on ad lib feeds every 4 hrs, d sticks\nstable during the night(see flowsheet) >Bottling bm20 well.\nVoiding and stooling, nospits. A: stable d sticks, feeding\nwell. P: Continue feeding plan.\n\n#4 G&D O: Temps are stable, swaddled in crib. Baby is \nand active with cares, sleeps well in between cares, waking\nfor feeds. Fontanells are soft and flat. A: aga P: Continue\nto support development.\n\n#6 Parenting O: Mom in for evening feeds. D/c teaching\ncompleted. Baby passed car seat test. A: Involved, \n. P: Continue to keep informed, reinforce d/c\nteaching.\n\n\nREVISIONS TO PATHWAY:\n\n 2 Alt. in Resp.; d/c'd\n 5 Alt. in CV; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-25 00:00:00.000",
"description": "Report",
"row_id": 1927223,
"text": "Neonatology Attending\nExam AF soft, flat, clear bs, no murmur, benign abd, fresh circ, active\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-04-25 00:00:00.000",
"description": "Report",
"row_id": 1927224,
"text": "Neonatology Attending\n\nDOL 7\n\nStable in RA\n\nFeeding ad lib on BM 20 taking 75-120 cc q feed. Voiding. Stooling. DS 59/68/99. Wt 3820 grams (down 25).\n\nCar seat test passed. Hearing screen passed.\n\nFamily visiting and up to date.\n\nCircumcision scheduled for 1 pm.\n\nA: Doing well. Hypoglycemia resolved. Ready for discharge.\n\nP: Circ\n Hep B vaccine\n D/C home with \n f/u Dr w/i 1 week\n\n"
},
{
"category": "ECG",
"chartdate": "2171-04-18 00:00:00.000",
"description": "Report",
"row_id": 159575,
"text": "Normal sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-04-18 00:00:00.000",
"description": "BABYGRAM (CHEST & ABDOMEN)",
"row_id": 755210,
"text": " 5:53 PM\n BABYGRAM (CHEST & ABDOMEN) Clip # \n Reason: UVC placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 35 weeks severe hypoglycemia\n REASON FOR THIS EXAMINATION:\n UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant born at 35 weeks' gestational age with severe hyperglycemia.\n Assess UVC placement.\n\n FINDINGS: The current study is compared to the prior film obtained earlier the\n same day. The UVC tip is now high in the right atrium. The cardiac silhouette\n remains mildly-to-moderately enlarged and there has been no significant change\n in the moderate bilateral interstitial pulmonary edema. The abdominal bowel\n gas pattern appears normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-04-18 00:00:00.000",
"description": "P BABYGRAM (CHEST & ABDOMEN) PORT",
"row_id": 755207,
"text": " 5:14 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: s/p uv placement, ? uv position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 35 weeks severe hypoglycemia\n REASON FOR THIS EXAMINATION:\n s/p uv placement\n ? uv position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AND ABDOMEN \n\n CLINICAL HISTORY: Infant born at 35 weeks' gestational age with severe\n hypoglycemia. Assess UV position.\n\n FINDINGS: The current study is compared to the preceding film obtained\n earlier the same day. There is an umbilical venous catheter with its tip in\n the IVC below the diaphragm at the level of T9-10. The cardiac silhouette is\n mildly-to-moderately enlarged. There is persistent blurring of the pulmonary\n vascularity in keeping with interstitial edema. The degree of edema has\n increased slightly compared to the prior examination. There is mild\n irregularity of bowel loop aeration with several mildly-to-moderately dilated\n loops in the mid-abdomen and right lower quadrant. There is no radiographic\n evidence of pneumatosis or free intraperitoneal gas.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-04-18 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 755168,
"text": " 11:22 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: 35 week with O2 requirement and murmur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with see above\n REASON FOR THIS EXAMINATION:\n 35 week with O2 requirement and murmur\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35 week gestational age infant with oxygen requirement and heart\n murmer.\n\n FINDINGS: There is visceral situs solitus and a left aortic arch. The cardiac\n silhouette appears mildly-to-moderately enlarged. There is blurring of the\n vascular markings bilaterally in keeping with mild interstitial pulmonary\n edema. No other abnormality is noted.\n\n"
}
] |
15,958 | 114,927 | Respiratory status - The respiratory distress resolved within a few hours of admission to the Nursery Intensive Care Unit. The infant has always remained in room air. Lungsounds are clear and equal. Cardiovascular status - The infant has remained normotensive throughout her Nursery Intensive Care Unit stay. She has a normal S1, S2 heartsound and no murmur. There are no cardiovascular issues. Fluids, electrolytes and nutrition - Her weight at the time of transfer is 1,910 gm. She is eating Enfamil 20 or breastfeeding on an ad lib schedule. She has kept her glucoses in the 60s to 70s range during her Nursery Intensive Care Unit stay. Gastrointestinal status - The bilirubin drawn on is a total of 5.2, direct 0.3. She has passed meconium stool. Hematological status - Her hematocrit at the time of admission was 48, platelets 340,000. She has received no blood products during this Nursery Intensive Care Unit stay. Infectious disease status - Blood culture was sent at the time of admission for sepsis suspect, the infant is clinically well and blood culture remains negative at the time of transfer to the Nursery Intensive Care Unit. Social status - The mother was transferred here to from . The infant is in good condition on transfer to the Newborn Nursery for continuing care. Primary pediatric care will be provided in by Dr. , telephone . | stable on off warmer A: without signsof sepsis at present, AGA P: cont. Noapnea, bradaycardia, or spontaneous desat noted.A: No evidence of compromise.P: Transfer to newborn nursery.HEMODYNAMICSO: Cap refill brisk. No murmur appreciated.A: No evidence of compromise.P: Transfer to newborn nursery.NUTRITIONO: Abd exam benign. with close monitoringand assessment, provide developmental care and interventions#2 O: Lungs clear and equal with good aeration to basesnoted, breathing comfortably with mild retractions with O2saturations above 98 in room air consistently withoutdesaturations noted A: without compromise P: cont. P: Will continue to monitor.Child remains on ad lib amounts of e20. and stabled/s and infant po feeding well for 30cc without spits afterfeeding A: slow motility P: cont. withmonitring and assessing#3: BP stable as documented, perfusion good A: stable P:cont. CBC/BC drawn, diff reassuring, no abx due to C/Sfor maternal indications. Abd soft, active bowel sounds, no loops. Mild temp instability overnight. Vit K and Emycin given. DS remain ggod at 75.Abdomen round and soft. Minimal sepsis risk, CBC unremarkable. Still requiring open warmer.A&PPremature infant with feeding immaturity. BP stable. RRR, without murmur, pulses 2+ and symmetrical. Neonatology AttendingDOL 1In room air with no cardiorespiratory events and only mild intermittent tachypnea. Infantswaddled and warmer turned off but temp decreased to 97.5.Warmer back on servo at present with temp >99. Nursing progress note# O: Active, awake and alert with cares, sleeping wellbetween cares, temp. P: Willmonitor.#2 RESP O: Child remains on room air. nursing notecorrection to above note. abdomen soft, nontender, nondistended. Infant emergedpink with good tone at delivery, apgars 8 & 9. Mild temp instability. Initial intermittent murmer heard, but resolvedsince first hour of life. Active bowel sounds, without loops or masses, tolerating feeds well. She is pale pink, well perfused, no murmur auscultated. hips stable. She is tolerating ad-lib amts of E20. Brought to NICU for further evaluation.PE: weight=1985g (25-50%), HC=31cm (25%)T=96.7, HR=160's, RR=48, BP=62/32 (mean=40), oxygen saturation=93% RA initially and now 99% RAActive, AFOF, normal S1S2, no murmur, breath sounds clear, mild ic/sc retx. On ad lib E20, but slow intake. Tempstable on off warmer dressed in t-shirt, hat and 1 blanket.A; Appropriate behavior.P: Support development.PARENTINGO: Mom and Dad in to visit. NICU Nursing Progress NoteRESPO: Breath sounds, resp rate, and WOb are at baseline. Childvoiding well. Breath sounds clear and equal. child bottling pe20 not e 20 as stated. Mildsubcostal retractoins noted at times. Breath sounds clear and equal bilaterally. Sats mostly above 95.P: Will continue to monitor and support the child's respstatus.#3 CV O: Child continues pink and well perfused. ext warm, well perfused. Neonatology - NP Physical ExamAwake and alert with cares, temp stable in open crib. Without rashes. P: Will continue to supportthechild's coping skills.#6 Parenting O: mom and dad called once so far this shift.Given status update. down 75gm on ad lib feedings - took in 71cc/kg/d yesterday of E20Feedings well tolerated. Neonatology - NNP Progress NoteInfant is sleepy with exam, but responds appropriately to stimuli. Initially had very brief feeding intolerance with increased girth - this has resolved.Normal urine and stool output.Assessment/plan:Baby is doing very well.Will plan on transfer to the Newborn Nursery for further care.Feedings to be not less frequent than Q3H.Bili to be checked today. No desats or spells overnight. P: Will continue tobottle feed as tolerated. Good tone, AFSF, PFSF, +, +plantar, +suck, +Moro reflexes. Initial D/S69-->75. Will weigh child q day.#5 G+D O: Child remains in open crib. Normal female genitalia. Warmed, dried and bulb suctionned. Aware of impending transfer to newbornnursery.A; Involved parents.P: Supprot development. No on servo on open warmer with stable temp.A/P Well appearing 35 week . monitoring and assessing#4 O: Abdomen becoming softly full with soft palpable loopsnoted at 1300 assessment with infant spitting with 10ccaspirate-with aspirate discarded with infant rested one hourwith abdomen becoming softer with AG down 1.0 cm. No other s/s of infection noted. BP mean down to 35 briefly andtherafter in 40's-50's range...infant pink and wellperufsed. spine intact. Active bowel soundsheard. Tempremains WNL. Bottle fed beter at the 0200 feed. No desats or bradysnoted. See previousnote for details of DR prenatal history.Since admission, infant has been in RA with good sats inhigh 90's-100%. No loops noted. Please see attending neonatologist note for detailed plan of care. Infant emerged active with good respiratory effort. Updted regarding infant's statusand plan of care. At the 2130feed child took a while to get organized during the bottlingand then did well. Will obtain bp at 0600cares. tone aga. APGARS of 8 and 9 (1 and 5 minutes of life). Neonatology Attending Progress NoteNow day of life 2 for this 35 week gestation .In RA with RR 40-60s.No apnea and bradycardia.HR 130-140Wt. Please refer to neonatology attending note for detailed plan. In room air, BS clear and equal with symmetrical chest movement, color pink. P: Will continue to support theparents' coping skills. See flowsheet for detailed VS. LS clearand equal. Thriving.P: Change to feeds every 3 hrs and transfer to newbornnursery.DEVELOPMENTO: Sleeps between cares. Wt 1985g. Dad visitedbriefly, updated as to current status, Mom to visit on wayto floor. D-sticks 60-70. anus patent. normal premature female genitalia.dstx=69Imp/Plan: AGA triplet #3 with issues of prematurity and r/o sepsis.--monitor respiratory status--obtain CBC/diff and blood culture; start antibiotics if abnormal diff, persistent respiratory symptoms or positive blood culture--monitor for jaundice over next few days.--monitor dstx--assess ability to po feed when respiratory distress resolves--monitor BP--will update family Will monitor today and possibly to newborn nursery later if temp stable and po feeds progressing. EDC .Prenatal course significant for:1) triplet IVF2) PIH, normal labs, no meds except for Magnesium on day of delivery3) as per family, normal prenatal US.OB HX: --PIH, primary C/S --repeat C/S, 36 weeks -repeat C/S, 36 weeks --tubal ligation --failed reversal of tubal ligationMat Hx: history of seizure disorder, no medications during pregnancy, last seizure 1 1/2 years ago.Due to contractions noted today and maternal PIH, infants were delivered by C/S.Infant born at 9:39pm on . | 10 | [
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1903463,
"text": "nursing note\n\n\n#1 Sepsis O: Child remains in open crib, swaddled. Temp\nremains WNL. No other s/s of infection noted. P: Will\nmonitor.\n#2 RESP O: Child remains on room air. No desats or bradys\nnoted. Breath sounds clear and equal bilaterally. Mild\nsubcostal retractoins noted at times. Sats mostly above 95.\nP: Will continue to monitor and support the child's resp\nstatus.\n#3 CV O: Child continues pink and well perfused. Pulses\nequal times four. No murmur noted. Will obtain bp at 0600\ncares. P: Will continue to monitor.\nChild remains on ad lib amounts of e20. Bottled 40cc each\nfeed so far tonight. Used the yellow nipple. At the 2130\nfeed child took a while to get organized during the bottling\nand then did well. Bottle fed beter at the 0200 feed. Child\nvoiding well. No stools as yet. DS remain ggod at 75.\nAbdomen round and soft. No loops noted. Active bowel sounds\nheard. Weight decreased as noted. P: Will continue to\nbottle feed as tolerated. Will weigh child q day.\n#5 G+D O: Child remains in open crib. Sleeps between cares.\nLearning to bottle feed. P: Will continue to supportthe\nchild's coping skills.\n#6 Parenting O: mom and dad called once so far this shift.\nGiven status update. P: Will continue to support the\nparents' coping skills.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1903464,
"text": "nursing note\ncorrection to above note. child bottling pe20 not e 20 as stated. error. \n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1903465,
"text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. In room air, BS clear and equal with symmetrical chest movement, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops or masses, tolerating feeds well. Without rashes. Normal female genitalia. Good tone, AFSF, PFSF, +, +plantar, +suck, +Moro reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1903466,
"text": "Neonatology Attending Progress Note\n\nNow day of life 2 for this 35 week gestation .\n\nIn RA with RR 40-60s.\n\nNo apnea and bradycardia.\nHR 130-140\nWt. down 75gm on ad lib feedings - took in 71cc/kg/d yesterday of E20\nFeedings well tolerated. Initially had very brief feeding intolerance with increased girth - this has resolved.\nNormal urine and stool output.\n\nAssessment/plan:\nBaby is doing very well.\nWill plan on transfer to the Newborn Nursery for further care.\nFeedings to be not less frequent than Q3H.\nBili to be checked today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-03 00:00:00.000",
"description": "Report",
"row_id": 1903460,
"text": "Neonatology - NNP Progress Note\n\nInfant is sleepy with exam, but responds appropriately to stimuli. AFOF. She is pale pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No desats or spells overnight. She is tolerating ad-lib amts of E20. Abd soft, active bowel sounds, no loops. Voiding, no stool yet. Mild temp instability overnight. No on servo on open warmer with stable temp.\n\nA/P Well appearing 35 week . Minimal sepsis risk, CBC unremarkable. Mild temp instability. Will monitor today and possibly to newborn nursery later if temp stable and po feeds progressing. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-03 00:00:00.000",
"description": "Report",
"row_id": 1903461,
"text": "Nursing progress note\n\n\n# O: Active, awake and alert with cares, sleeping well\nbetween cares, temp. stable on off warmer A: without signs\nof sepsis at present, AGA P: cont. with close monitoring\nand assessment, provide developmental care and interventions\n#2 O: Lungs clear and equal with good aeration to bases\nnoted, breathing comfortably with mild retractions with O2\nsaturations above 98 in room air consistently without\ndesaturations noted A: without compromise P: cont. with\nmonitring and assessing\n#3: BP stable as documented, perfusion good A: stable P:\ncont. monitoring and assessing\n#4 O: Abdomen becoming softly full with soft palpable loops\nnoted at 1300 assessment with infant spitting with 10cc\naspirate-with aspirate discarded with infant rested one hour\nwith abdomen becoming softer with AG down 1.0 cm. and stable\nd/s and infant po feeding well for 30cc without spits after\nfeeding A: slow motility P: cont. with close assessment and\nmonitoring of feeding tolerance and intervention as\nindicated\n#6 O: Dad in numerous times thru shift for updates, mom\nstill in L&D, plans to visit on way to floor later A:\nInvolved P: Keep updated and informed, provide teaching and\nsupport\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-03 00:00:00.000",
"description": "Report",
"row_id": 1903462,
"text": "Neonatology Attending\nDOL 1\n\nIn room air with no cardiorespiratory events and only mild intermittent tachypnea. No murmur. Wt 1985g. On ad lib E20, but slow intake. D-sticks 60-70. Still requiring open warmer.\n\nA&P\nPremature infant with feeding immaturity. Continue to await consolidation of oral feeding skills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1903467,
"text": "NICU Nursing Progress Note\n\nRESP\nO: Breath sounds, resp rate, and WOb are at baseline. No\napnea, bradaycardia, or spontaneous desat noted.\nA: No evidence of compromise.\nP: Transfer to newborn nursery.\n\nHEMODYNAMICS\nO: Cap refill brisk. BP stable. No murmur appreciated.\nA: No evidence of compromise.\nP: Transfer to newborn nursery.\n\nNUTRITION\nO: Abd exam benign. Voiding and passing large amounts of\nmeconium. Bottle feeding every 4 hrs with volufeed and\nyellow nipple taking 50-60cc PE 20 without spitting.\nA: No evidence of intolerance. Thriving.\nP: Change to feeds every 3 hrs and transfer to newborn\nnursery.\n\nDEVELOPMENT\nO: Sleeps between cares. Active and alert during cares. Temp\nstable on off warmer dressed in t-shirt, hat and 1 blanket.\nA; Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom and Dad in to visit. Updted regarding infant's status\nand plan of care. Aware of impending transfer to newborn\nnursery.\nA; Involved parents.\nP: Supprot development.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-02 00:00:00.000",
"description": "Report",
"row_id": 1903458,
"text": "Neonatology Attending Note:\n\n35 week triplet #3 female-- asked by Dr. to assess due to prematurity.\n\nInfant born to a 28 year old G6P4 mother negative/RI, RPR NR, antibody negative and blood type O positive. EDC .\n\nPrenatal course significant for:\n1) triplet IVF\n2) PIH, normal labs, no meds except for Magnesium on day of delivery\n3) as per family, normal prenatal US.\n\nOB HX: --PIH, primary C/S\n --repeat C/S, 36 weeks\n -repeat C/S, 36 weeks\n --tubal ligation\n --failed reversal of tubal ligation\n\nMat Hx: history of seizure disorder, no medications during pregnancy, last seizure 1 1/2 years ago.\n\nDue to contractions noted today and maternal PIH, infants were delivered by C/S.\n\nInfant born at 9:39pm on . APGARS of 8 and 9 (1 and 5 minutes of life). Infant emerged active with good respiratory effort. Warmed, dried and bulb suctionned. Brought to NICU for further evaluation.\n\nPE: weight=1985g (25-50%), HC=31cm (25%)\nT=96.7, HR=160's, RR=48, BP=62/32 (mean=40), oxygen saturation=93% RA initially and now 99% RA\nActive, AFOF, normal S1S2, no murmur, breath sounds clear, mild ic/sc retx. abdomen soft, nontender, nondistended. ext warm, well perfused. tone aga. hips stable. anus patent. spine intact. normal premature female genitalia.\n\ndstx=69\n\nImp/Plan: AGA triplet #3 with issues of prematurity and r/o sepsis.\n--monitor respiratory status\n--obtain CBC/diff and blood culture; start antibiotics if abnormal diff, persistent respiratory symptoms or positive blood culture\n--monitor for jaundice over next few days.\n--monitor dstx\n--assess ability to po feed when respiratory distress resolves\n--monitor BP\n--will update family\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-03 00:00:00.000",
"description": "Report",
"row_id": 1903459,
"text": "Nursing Admit/Progress Note (2200-0700)\n\n\nBaby girl #3 admitted for prematurity of 35 weeks.\nMom 28 y.o, G3 P6 with PIH, PTL on MgSO4. Infant emerged\npink with good tone at delivery, apgars 8 & 9. See previous\nnote for details of DR prenatal history.\n\nSince admission, infant has been in RA with good sats in\nhigh 90's-100%. See flowsheet for detailed VS. LS clear\nand equal. Initial intermittent murmer heard, but resolved\nsince first hour of life. BP mean down to 35 briefly and\ntherafter in 40's-50's range...infant pink and well\nperufsed. Feeds of PE20 ad lib amounts started this am...\ntaking 20-12cc po. Vdg well, no stools as yet. Initial D/S\n69-->75. CBC/BC drawn, diff reassuring, no abx due to C/S\nfor maternal indications. Vit K and Emycin given. Infant\nswaddled and warmer turned off but temp decreased to 97.5.\nWarmer back on servo at present with temp >99. Dad visited\nbriefly, updated as to current status, Mom to visit on way\nto floor.\n\n\n"
}
] |
98,402 | 190,856 | Patient presented to OSH on and was found to have a Right SDH with midline shift and a traumatic right SAH and was transferred to for further care. She was admitted to the ICU with plans to wean to extubation, and was successfully extubated on the morning of after AM rounds were completed. She was found to have thrombocytopenia and as such was administered platelets. Her follow up platelet count after the administration actually dropped. Her coagulation status was complicated by her liver disease and as such parameters were put in place of keeping her platelet count greater than 80 and her INR <1.5. Also on this date she developed a fever to 101.4 and was pancultured by the ICU team. Her exam improved steadily with her only deficit being slight confusion at times. On she was evaluated by physical therapy for discharge planning and was deemed able to go home with home PT. | Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0218 21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0218 21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0218 21. Level 15.3 -- Hypertonic saline (taper off ). Febrile 101.4 (axillary) - pancultured. Febrile 101.4 (axillary) - pancultured. Repeat CT showed +SDH. Level 15.3 -- Hypertonic saline (consider d/c'ing today as Na 140). Transferred to Chief complaint: Right subdural hematoma PMHx: 1. Propofol mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 2031 8. Propofol mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 2031 8. Hypertonic saline weaned to off. Famotidine 20 mg IV Q12H Order date: @ 0216 19. Famotidine 20 mg IV Q12H Order date: @ 0216 19. Famotidine 20 mg IV Q12H Order date: @ 0216 19. Now off 3% Hypertonic saline Hematology: -- s/p FFP, vit k, ?pentoxyfylline, platelets on admission -- : 2 U prbcs, 1 plt -- Hct 26 Monitor. IV access: PICC, heparin dependent Location: Right Subclavian, Date inserted: Order date: @ 0059 12. IV access: PICC, heparin dependent Location: Right Subclavian, Date inserted: Order date: @ 0059 13. IV access: PICC, heparin dependent Location: Right Subclavian, Date inserted: Order date: @ 0059 13. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654 7. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654 7. B12 and iron deficiencies 7. hyponatremia Current medications: 1. B12 and iron deficiencies 7. hyponatremia Current medications: 1. B12 and iron deficiencies 7. hyponatremia Current medications: 1. B12 and iron deficiencies 7. hyponatremia Current medications: 1. OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain Order date: @ 1654 4. OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain Order date: @ 1654 4. Docusate Sodium 100 mg PO BID Order date: @ 1654 18. Docusate Sodium 100 mg PO BID Order date: @ 1654 18. Docusate Sodium 100 mg PO BID Order date: @ 1654 18. Chief complaint: Right subdural hematoma PMHx: 1. Chief complaint: Right subdural hematoma PMHx: 1. -- seizure prophylaxis: Dilantin 100mg TID. Febrile 101.4 (axillary) - pancultured. Febrile 101.4 (axillary) - pancultured. Level 15.3 -- Hypertonic saline (taper off ). Hypertonic saline weaned to off. Transferred to Chief complaint: Right subdural hematoma PMHx: 1. Known subdural hematoma and dropping hematocrit. also stable right subarachnoid hameorrhage. Granuloma annulare 4. Granuloma annulare 4. Granuloma annulare 4. Level 15.3 -- Hypertonic saline (consider d/c'ing today as Na 140). Minimal retrocardiac atelectasis. IV access: PICC, heparin dependent Location: Right Subclavian, Date inserted: Order date: @ 0059 12. There is effacement of the right lateral ventricle. Chief complaint: right SDH PMHx: 1. Stable extensive right-sided subarachnoid hemorrhage. Coronal and sagittal reformats were performed. Skin w+d. Skin w+d. B12 and iron deficiencies 7. hyponatremia Current medications: 1. B12 and iron deficiencies 7. hyponatremia Current medications: 1. +bs., tol sm amt pos. +bs., tol sm amt pos. Extubated. Extubated. Fibromyalgia 3. Fibromyalgia 3. Fibromyalgia 3. 2 units PRBCs, 1 unit PLT. 2 units PRBCs, 1 unit PLT. Hypothyroidism 5. Hypothyroidism 5. Hypothyroidism 5. Glucagon 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0218 21. -- F/u BCX, UCX and Sputum cx. -- F/u head CT no acute change. Pulm hygiene. Head ct done. PMHx: 1. The gallbladder is distended. slight increase sdh along falx. c/o intermittent HA. neurogenic. FINDINGS: As compared to the previous examination, the patient has been extubated. Furosemide 11. +pp. +pp. Multivitamins 17. Neutra-Phos 19. Moderate amount of free fluid is identified consistent with (Over) 4:47 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: CRIT DROP Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA Field of view: 32 FINAL REPORT (Cont) ascites. FINDINGS: Consistent with the given history, an endotracheal tube has been introduced with the distal tip at the ostium of the left main stem bronchus. Perrl. Perrl. Dr. was paged. | 30 | [
{
"category": "Physician ",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 522569,
"text": "SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Chief complaint:\n Right subdural hematoma\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. IV access: PICC, heparin dependent Location: Right Subclavian, Date\n inserted: Order date: @ 0059 13. Multivitamins 1 TAB\n PO/NG DAILY Order date: @ 1654\n 2. IV access: Peripheral line Order date: @ 1654 14. Nadolol 20\n mg PO DAILY Order date: @ 1654\n 3. OK to use line Order date: @ 0133 15. OxycoDONE (Immediate\n Release) 5 mg PO/NG Q6H:PRN pain Order date: @ 1654\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL VAP bundle\n Order date: @ 0223 16. Phytonadione 10 mg IV ONCE Duration: 1\n Doses Start: Stat\n Infuse over 15 to 30 minutes INR goal < 1.5 Order date: @ 1749\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0218 17. Phenytoin Sodium (IV) 1000 mg IV ONCE Duration: 1 Doses\n Order date: @ 1654\n 6. Docusate Sodium 100 mg PO BID Order date: @ 1654 18.\n Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654\n 7. Famotidine 20 mg IV Q12H Order date: @ 0216 19. Propofol \n mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 2031\n 8. Fish Oil (Omega 3) 1000 mg PO DAILY Order date: @ 1654 20.\n Senna 1 TAB PO/NG HS Order date: @ 1654\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0218 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1654\n 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 0059 22.\n Sodium Chloride 3% (Hypertonic) - 500 mL\n Continuous at 15 ml/hr\n Please hold for NA>150 and Osm>320 Order date: @ 1654\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0218 23. Spironolactone 50 mg\n PO/NG DAILY Order date: @ 1654\n 12. Levothyroxine Sodium 60 mcg IV DAILY Order date: @ 0204 24.\n Vitamin D 400 UNIT PO/NG DAILY Order date: @ 1654\n 24 Hour Events:\n MULTI LUMEN - START 12:53 AM\n FEVER - 101.9\nF - 09:00 PM\n Post operative day:\n N/A\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.7\nC (99.9\n HR: 65 (65 - 98) bpm\n BP: 99/64(71) {89/54(62) - 141/76(90)} mmHg\n RR: 18 (17 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.9 kg (admission): 52.9 kg\n Total In:\n 2,424 mL\n 633 mL\n PO:\n Tube feeding:\n IV Fluid:\n 109 mL\n 502 mL\n Blood products:\n 515 mL\n 131 mL\n Total out:\n 990 mL\n 370 mL\n Urine:\n 330 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,434 mL\n 263 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 346 (346 - 472) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 73\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///27/\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: Diffuse ecchymoses\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 22 K/uL\n 7.5 g/dL\n 167 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 101 mEq/L\n 135 mEq/L\n 20.6 %\n 2.8 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n WBC\n 2.9\n 2.8\n Hct\n 19.2\n 20.6\n Plt\n 28\n 22\n Creatinine\n 0.8\n Glucose\n 167\n Other labs: PT / PTT / INR:14.8/33.8/1.3, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.4 mg/dL, Mg:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 55F HCV cirrhotic anticoagulated with\n supratherapeutic INR with right subdural hematoma\n Neurologic: Q1hr neuro checks. Sedation with propofol. Dilantin for\n seizure prophylaxis. Hypertonic saline. Repeat head CT improved.\n Cardiovascular: HD stable, no issues, keep SBP <160\n Pulmonary: Minimal vent settings. Wean to extubate\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley, Adequate UO, Hypertonic saline @ 15 cc/hr. Check urine Na\n q6h\n Hematology: Received FFP, vit k, ?pentoxyfylline, platelets. Recheck\n labs: hct 20.6, plt 22. Transfused 2 U prbcs and 1 plt\n Endocrine: RISS\n Infectious Disease: Febrile\n neurogenic?. Will send sputum culture\n prior to extubation\n Lines / Tubes / Drains: R subclavian CVL, PIV x2, ETT, Foley\n Wounds:\n Imaging:\n Fluids: Hypertonic saline @ 15cc/hr\n Consults: Neuro surgery, Transplant\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:00 PM\n Multi Lumen - 12:53 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522782,
"text": "Acute Pain\n Assessment:\n Pt c/o headache and generalized pain. Pt with bruising on head, arms,\n hips and legs. Pt unable to use number scale.\n Action:\n Medicated with 5mg of oxycodone with minimal response. .Dr. \n aware and oxycodone increased to 5-10mg. pt medicated with additional\n 5mg for a total of 10mg.\n Response:\n Pt better. Pt able to sleep. Vital signs are unchanged.\n Plan:\n Monitor for pain. Medicate as needed.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Urine output low. Less than 30cc/hr. Dr. aware. Foley irrigated\n for amber urine. Urine output improved x several hours. Dr. \n aware and fluid bolus of 500cc given with no response.\n Action:\n Bladder scan done and bladder holding 46cc. lasix 10g iv given\n Response:\n Good response to lasix.\n Plan:\n Monitor fluid output.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but arousable. Follow commands. Pupils are equal and\n reactive to light. Normal strength in all extremities. Pt oriented x1\n to person. Pt c/o headache and medicated with oxydcodone. Pt\n continues on 3% saline at 15cc/hr. current na is 140\n Action:\n Repeat na q6 while on hypertonic salilne.\n Response:\n No up to 140. pt more awake this am. Asking for gingerale. Still\n confused to place and time. Impulsive at times and trying to get out of\n bed.,\n Plan:\n Monitor labs q6. montior neuro exam q1\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522667,
"text": "HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal venous thrombosis x2 last year. INR on initial check was 5.2.\n Subarachnoid hemorrhage (SAH), SDH\n Assessment:\n Received patient lightly sedated on Propofol at 5 mcg/kg and on CPAP\n with 5 peep\n Following simple commands\n Able to lift and hold with right side, moves left side on bed\n Unable to open eyes although she does attempt to open them\n Pupils 3-4mm with brisk reaction\n 3% NS infusing at 15cc/hr\n Pt transfused with platlets x1 for plt count of 22\n Febrile to 101.4 axillary\n HUO 15-40\n Action:\n Pt extubated at 0900\n Neuro checks q1hr\n Repeat plt count sent at 0930\n Serum NA checks q6hrs\n Pan cx\nd and CXR done for temp\n IVF started = D5\n ns with 20 KCL at 75cc/hr\n Response:\n Neuro= lethargic but arousable post-extubation\n Currently- awake, following commands, oriented to person and place\n Right side stronger than left side but patient able to lift and hold\n with left arm\n Plt count 37, hct stable at 26.6\n NA level stable at 136\n Plan:\n Continue neuro checks q1hr\n Reorient as necessary\n Continue to check NA q6hr\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 523142,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n Alert and oriented x3\n Impulsive at times\n Action:\n Seen by pt noted to list to left side when ambulating\n Neuro checks q4hrs\n Response:\n stable\n Plan:\n Pt discharged home with instructions given to sister \n consult placed\n"
},
{
"category": "Respiratory ",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 522486,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 522471,
"text": "Chief Complaint: Right subdural hematoma\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal venous thrombosis x2 last year. INR on initial check was 5.2.\n Post operative day:\n N/A\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Formerly worked in contract negotiation Financial. No\n longer working, lives with sister . No smoking,\n drinking, or drug use.\n Flowsheet Data as of 02:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.8\nC (101.8\n HR: 91 (82 - 98) bpm\n BP: 105/75(81) {105/68(78) - 141/76(90)} mmHg\n RR: 22 (17 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.9 kg (admission): 52.9 kg\n Total In:\n 2,424 mL\n 212 mL\n PO:\n TF:\n IVF:\n 109 mL\n 212 mL\n Blood products:\n 515 mL\n Total out:\n 990 mL\n 100 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,434 mL\n 112 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 472 (403 - 472) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 9.2 L/min\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 55F liver transplant candidate with right subdural hematoma and midline\n shift in the setting of supratherapeutic INR. Anticoagulated for portal\n venous thrombosis\n Neurologic: Q1hr neuro checks. Sedation with propofol. Dilantin for\n seizure prophylaxis. Hypertonic saline. Repeat head CT.\n Cardiovascular: HD stable, no issues, keep SBP <160\n Pulmonary: Minimal vent settings. Wean to extubate if repeat CT\n unchanged.\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Hypertonic saline @ 15 cc/hr. Check urine Na q6h\n Hematology: Received FFP, vit k, ?pentoxyfylline, platelets. Recheck\n labs.\n Endocrine: Levothyroxine for hypothyroidism. RISS\n ID: No issues\n T/L/D: R subclavian CVL, PIV x2, ETT, Foley\n Wounds: None\n Imaging: Head CT\n Fluids: Hypertonic saline @ 15cc/hr\n Consults: Neurosurg, transplant\n Billing Diagnosis: SDH\n Prophylaxis:\n DVT: HSQ\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: Consent signed\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Assessment And Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal:\n Renal:\n Hematology:\n Infectious Disease:\n Endocrine:\n Fluids:\n Electrolytes:\n Nutrition:\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:00 PM\n Multi Lumen - 12:53 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 522520,
"text": "SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Chief complaint:\n Right subdural hematoma\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. IV access: PICC, heparin dependent Location: Right Subclavian, Date\n inserted: Order date: @ 0059 13. Multivitamins 1 TAB\n PO/NG DAILY Order date: @ 1654\n 2. IV access: Peripheral line Order date: @ 1654 14. Nadolol 20\n mg PO DAILY Order date: @ 1654\n 3. OK to use line Order date: @ 0133 15. OxycoDONE (Immediate\n Release) 5 mg PO/NG Q6H:PRN pain Order date: @ 1654\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL VAP bundle\n Order date: @ 0223 16. Phytonadione 10 mg IV ONCE Duration: 1\n Doses Start: Stat\n Infuse over 15 to 30 minutes INR goal < 1.5 Order date: @ 1749\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0218 17. Phenytoin Sodium (IV) 1000 mg IV ONCE Duration: 1 Doses\n Order date: @ 1654\n 6. Docusate Sodium 100 mg PO BID Order date: @ 1654 18.\n Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654\n 7. Famotidine 20 mg IV Q12H Order date: @ 0216 19. Propofol \n mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 2031\n 8. Fish Oil (Omega 3) 1000 mg PO DAILY Order date: @ 1654 20.\n Senna 1 TAB PO/NG HS Order date: @ 1654\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0218 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1654\n 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 0059 22.\n Sodium Chloride 3% (Hypertonic) - 500 mL\n Continuous at 15 ml/hr\n Please hold for NA>150 and Osm>320 Order date: @ 1654\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0218 23. Spironolactone 50 mg\n PO/NG DAILY Order date: @ 1654\n 12. Levothyroxine Sodium 60 mcg IV DAILY Order date: @ 0204 24.\n Vitamin D 400 UNIT PO/NG DAILY Order date: @ 1654\n 24 Hour Events:\n MULTI LUMEN - START 12:53 AM\n FEVER - 101.9\nF - 09:00 PM\n Post operative day:\n N/A\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.7\nC (99.9\n HR: 65 (65 - 98) bpm\n BP: 99/64(71) {89/54(62) - 141/76(90)} mmHg\n RR: 18 (17 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.9 kg (admission): 52.9 kg\n Total In:\n 2,424 mL\n 633 mL\n PO:\n Tube feeding:\n IV Fluid:\n 109 mL\n 502 mL\n Blood products:\n 515 mL\n 131 mL\n Total out:\n 990 mL\n 370 mL\n Urine:\n 330 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,434 mL\n 263 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 346 (346 - 472) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 73\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///27/\n Ve: 6.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: Diffuse ecchymoses\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 22 K/uL\n 7.5 g/dL\n 167 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 101 mEq/L\n 135 mEq/L\n 20.6 %\n 2.8 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n WBC\n 2.9\n 2.8\n Hct\n 19.2\n 20.6\n Plt\n 28\n 22\n Creatinine\n 0.8\n Glucose\n 167\n Other labs: PT / PTT / INR:14.8/33.8/1.3, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.4 mg/dL, Mg:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 55F HCV cirrhotic anticoagulated with\n supratherapeutic INR with right subdural hematoma\n Neurologic: Q1hr neuro checks. Sedation with propofol. Dilantin for\n seizure prophylaxis. Hypertonic saline. Repeat head CT.\n Cardiovascular: HD stable, no issues, keep SBP <160\n Pulmonary: Minimal vent settings. Wean to extubate if repeat CT\n unchanged.\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley, Adequate UO, Hypertonic saline @ 15 cc/hr. Check urine Na\n q6h\n Hematology: Received FFP, vit k, ?pentoxyfylline, platelets. Recheck\n labs: hct 20.6, plt 22. Transfused 2 U prbcs and 1 plt\n Endocrine: RISS\n Infectious Disease: Febrile - neurogenic\n Lines / Tubes / Drains: R subclavian CVL, PIV x2, ETT, Foley\n Wounds:\n Imaging:\n Fluids: Hypertonic saline @ 15cc/hr\n Consults: Neuro surgery, Transplant\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:00 PM\n Multi Lumen - 12:53 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522650,
"text": "HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal venous thrombosis x2 last year. INR on initial check was 5.2.\n Subarachnoid hemorrhage (SAH), SDH\n Assessment:\n Received patient lightly sedated on Propofol at 5 mcg/kg and on CPAP\n with 5 peep\n Following simple commands\n Able to lift and hold with right side, moves left side on bed\n Unable to open eyes although she does attempt to open them\n Pupils 3-4mm with brisk reaction\n 3% NS infusing at 15cc/hr\n Pt transfused with platlets x1 for plt count of 22\n Action:\n Pt extubated at 0900\n Neuro checks q1hr\n Repeat plt count sent at 0930\n Serum NA checks q6hrs\n Response:\n Neuro= lethargic but arousable post-extubation\n Currently- awake, following commands, oriented to person and place\n Right side stronger than left side but patient able to lift and hold\n with left arm\n Plt count 37, hct stable at 26.6\n Plan:\n Continue neuro checks q1hr\n Reorient as necessary\n Continue to check NA q6hr\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522624,
"text": "HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal venous thrombosis x2 last year. INR on initial check was 5.2.\n Subarachnoid hemorrhage (SAH), SDH\n Assessment:\n Received patient lightly sedated on Propofol at 5 mcg/kg and on CPAP\n with 5 peep\n Following simple commands\n Able to lift and hold with right side, moves left side on bed\n Unable to open eyes although she does attempt to open them\n Pupils 3-4mm with brisk reaction\n 3% NS infusing at 15cc/hr\n Pt transfused with platlets x1 for plt count of 22\n Action:\n Pt extubated at 0900\n Neuro checks q1hr\n Repeat plt count sent at 0930\n Serum NA checks q6hrs\n Response:\n Neuro= lethargic but arousable\n Following commands R> L side\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 523115,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: e888.9 / fall\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 55 f adm from osh\n s/p fall down stairs in setting of low lighting and +coumadin use\n (inr on admit 5.2). went home neg head CT. had syncopal episode in\n PCP office the next day. Repeat CT showed +SDH.\n Past Medical / Surgical History: HCV cirrhosis with portal htn,\n fibromyalgia, granuloma anulare, hypothyroidism, cervical and lumbar\n disc disease, B12 and iron def, hyponatremia\n Medications:\n Radiology:\n Labs:\n 26.6\n 9.2\n 38\n 3.4\n [image002.jpg]\n Other labs:\n Activity Orders: oob ok'd by sicu team\n Social / Occupational History: lives with very devoted sister who was\n recently laid off and can provide 24 hour sup\n Living Environment: bedroom on . plans to change bedrooms\n with her sister who's bedroom is on the \n Prior Functional Status / Activity Level: I PTA, neg fall history.\n sister provides all care\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert and oriented x\n 3. cooperative and pleasant but somewhat impulsive at times\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 69\n 107/73\n Activity\n /\n Stand\n 69\n 104/69\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: strong cough, mildly congested, effective and\n productive by patient\n Integumentary / Vascular: racoon eyes facial brusiing, jaundice\n throughout. brusing t/o UE and LE\n Sensory Integrity: denies parathesias\n Pain / Limiting Symptoms: reports baseline LBP\n Posture: received sitting in chair\n Range of Motion\n Muscle Performance\n wfl\n grossly wfl. LLE slightly weaker than R\n Motor Function: isolates movements throughout\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: L lateral sway with cga to recover. narrow bos, even\n cadence.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: static balance intact with no sway with perturbations.\n dynamic balance with mulitple lob iwth gait with cg to recover.\n Education / Communication: pt ed: home safety, 24 hour supervision,\n home PT\n case discussed with rn\n Intervention:\n Other: pt repeatedly expressing wishes to go home\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Gait, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performace, Impaired\n Clinical impression / Prognosis: 55 f s/p fall with sdh presents with\n above impairments consistent with nonprogressive cns d/o. She presents\n at risk to fall and will require 24 hour supervision at home, which her\n sister has agreed to provide. I expect that she will continue to\n progress to baseline with continued walking but recommend home PT to\n ensure progression and assess need for further AD at home. I\n recommended a bedside commode for frequent nighttime urination but the\n patient declined. Her sister is capable to providing an appropriate\n level of assist.\n Goals\n Time frame: 1 week\n 1.\n amb I without AD without LOB x 350 feet\n 2.\n defer goals to home PT\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: d/c PT\n d/c PT. recommend home safety eval and 24 hour supervision to be\n provided by the patient's sister.\n time: 11:05-11:35\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522621,
"text": "Subarachnoid hemorrhage (SAH), SDH\n Assessment:\n Received patient lightly sedated on Propofol at 5 mcg/kg and on CPAP\n with 5 peep\n Following simple commands\n Able to lift and hold with right side, moves left side on bed\n Unable to open eyes although she does attempt to open them\n Pupils 3-4mm with brisk reaction\n 3% NS infusing at 15cc/hr\n Pt transfused with platlets x1 for plt count of 22\n Action:\n Pt extubated at 0900\n Neuro checks q1hr\n Repeat plt count sent at 0930\n Serum NA checks q6hrs\n Response:\n Neuro= lethargic but arousable\n Following commands R> L side\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522993,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam pt is more awake. Follows commands. Normal strength in all\n extremities. Pupils are equal and reactive to light. Pt confused at\n times trying to get out of bed and asking\nwhere the Dogs are and \n let any one set them on fire\n. Oriented to person and place. Recalls\n falling down the stairs. Pt c/o headache and medicated with oxycodone\n with good response. Urine output low (15 and 17 cc for 2 hours.) pt\n tolerating liquids well.\n Action:\n Neuro q4. lasix 10mg iv x1 medicate for pain as needed.\n Response:\n Oxycodone effective in relieving pain. Pt more awake tonight.\n Plan:\n Transfer to floor when bed available\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 523090,
"text": "SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to \n Chief complaint:\n Right subdural hematoma\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. 2. 3. 4. 20 mEq Potassium Chloride / 1000 mL D5NS 5. 500 mL NS 6.\n Dextrose 50% 7. Docusate Sodium 8. Famotidine 9. Fish Oil (Omega 3)\n 10. Furosemide 11. Furosemide 12. Glucagon 13. Insulin 14.\n Levothyroxine Sodium\n 15. Magnesium Sulfate 16. Multivitamins 17. Nadolol 18. Neutra-Phos 19.\n OxycoDONE (Immediate Release) 20. Phenytoin Sodium Extended 21. Senna\n 22. Sodium Chloride 3% (Hypertonic) - 500 mL 23. Sodium Chloride 0.9%\n Flush 24. Spironolactone 25. Vitamin D\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : Weaned off 3% hypertonic saline\n FEVER - 101.2\nF - 04:00 PM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 10:00 AM\n Famotidine (Pepcid) - 08:07 PM\n Furosemide (Lasix) - 11:15 PM\n Other medications:\n Flowsheet Data as of 04:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.2\nC (99\n HR: 68 (62 - 88) bpm\n BP: 84/48(57) {84/42(54) - 120/88(94)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 57.2 kg (admission): 52.9 kg\n Total In:\n 4,191 mL\n 439 mL\n PO:\n 2,340 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 1,851 mL\n 39 mL\n Blood products:\n Total out:\n 944 mL\n 510 mL\n Urine:\n 944 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,247 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 38 K/uL\n 9.2 g/dL\n 144 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.6 %\n 3.4 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n 09:14 AM\n 03:49 PM\n 03:12 AM\n 02:18 AM\n WBC\n 2.9\n 2.8\n 4.5\n 3.6\n 2.9\n 3.4\n Hct\n 19.2\n 20.6\n 26.9\n 26.6\n 23.8\n 26.6\n Plt\n 28\n 22\n 36\n 37\n 44\n 38\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n 0.7\n Glucose\n 154\n 167\n 150\n 168\n 170\n 144\n Other labs: PT / PTT / INR:15.5/31.1/1.4, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.1 mg/dL, Mg:1.6 mg/dL,\n PO4:1.4 mg/dL\n Assessment and Plan\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK), ACUTE PAIN, .H/O\n HEPATITIS, CHRONIC VIRAL, SUBARACHNOID HEMORRHAGE (SAH), SUBDURAL\n HEMORRHAGE (SDH)\n Assessment and Plan: 55F HCV cirrhotic anticoagulated with\n supratherapeutic INR with right subdural hematoma\n Neurologic:\n -- Q4hr neuro checks. AOx3. Moves all extremities, follows commands.\n -- Seizure prophylaxis: Dilantin 100mg TID. Level 15.3\n -- Hypertonic saline (taper off ).\n -- F/u head CT no acute change. f/up final read\n -- pain control: oxycodone prn\n Cardiovascular: -- HD stable, no issues, goal SBP <160\n Pulmonary:\n -- extubated , no issues\n Gastrointestinal / Abdomen:\n -- hx of HCV cirrhosis c/b portal hypertension, ascites, and variceal\n bleed: cont nadolol 20mg qd, spironolactone 50mg qd\n -- GI prophy: famotidine\n -- bowel regimen: senna, colace\n Nutrition:\n -- Regular\n -- cont fish oil, MVN, Vit D\n Renal:\n --Creat stbel, Hx of Hyponatremia 128 o admission. Now off 3%\n Hypertonic saline\n Hematology:\n -- s/p FFP, vit k, ?pentoxyfylline, platelets on admission\n -- : 2 U prbcs, 1 plt\n -- Hct 26 Monitor.\n Endocrine:\n -- Hx of Hypothyroidims: cont levothyroxine\n -- RISS\n Infectious Disease: -- AFebrile\n -- F/u BCX, UCX and Sputum cx.\n Lines / Tubes / Drains:\n R subclavian CVL, PIV x2, Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Transplant\n Billing Diagnosis: Other: SDH\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:53 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to other facility\n Total time spent: 25 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 522833,
"text": "TITLE:\n SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to .\n Chief complaint:\n right SDH\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. IV access: PICC, heparin dependent Location: Right Subclavian, Date\n inserted: Order date: @ 0059\n 12. Levothyroxine Sodium 60 mcg IV DAILY Order date: @ 0204\n 2. IV access: Peripheral line Order date: @ 1654\n 13. Multivitamins 1 TAB PO/NG DAILY Order date: @ 1654\n 3. OK to use line Order date: @ 0133\n 14. Nadolol 20 mg PO DAILY Order date: @ 1654\n 4. 20 mEq Potassium Chloride / 1000 mL D5NS\n Continuous at 75 ml/hr Order date: @ 1738\n 15. OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain Order date:\n @ 1654\n 5. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0406\n 16. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0218\n 17. Senna 1 TAB PO/NG HS Order date: @ 1654\n 7. Docusate Sodium 100 mg PO BID Order date: @ 1654\n 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1654\n 8. Famotidine 20 mg IV Q12H Order date: @ 0216\n 19. Sodium Chloride 3% (Hypertonic) - 500 mL\n Continuous at 15 ml/hr\n Please hold for NA>150 and Osm>320 Order date: @ 1654\n 9. Fish Oil (Omega 3) 1000 mg PO DAILY Order date: @ 1654\n 20. Spironolactone 50 mg PO/NG DAILY Order date: @ 1654\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0218\n 21. Vitamin D 400 UNIT PO/NG DAILY Order date: @ 1654\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0218\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : CVL placed for administration of hypertonic saline. Head CT\n repeated - unchanged. Abd CT - no evidence of hemorrhage. 2 units\n PRBCs, 1 unit PLT. Extubated. Started on sips. Febrile 101.4 (axillary)\n - pancultured.\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Other medications:\n Flowsheet Data as of 04:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.1\nC (98.8\n HR: 77 (65 - 85) bpm\n BP: 107/59(79) {82/40(50) - 109/73(81)} mmHg\n RR: 17 (17 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.9 kg (admission): 52.9 kg\n Total In:\n 2,570 mL\n 1,215 mL\n PO:\n 100 mL\n 650 mL\n Tube feeding:\n IV Fluid:\n 1,709 mL\n 565 mL\n Blood products:\n 761 mL\n Total out:\n 920 mL\n 120 mL\n Urine:\n 920 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,650 mL\n 1,095 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 364 (364 - 364) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 5 cmH2O\n SPO2: 100%\n ABG: ///23/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 44 K/uL\n 8.7 g/dL\n 170 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 140 mEq/L\n 23.8 %\n 2.9 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n 09:14 AM\n 03:49 PM\n 03:12 AM\n WBC\n 2.9\n 2.8\n 4.5\n 3.6\n 2.9\n Hct\n 19.2\n 20.6\n 26.9\n 26.6\n 23.8\n Plt\n 28\n 22\n 36\n 37\n 44\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n Glucose\n 154\n 167\n 150\n 168\n 170\n Other labs: PT / PTT / INR:14.3/30.5/1.2, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:1.5 mg/dL\n Imaging: CT Head: Extensive subarachnoid and subdural hematoma as\n described above. Interval decrease in leftward shift, now measuring\n only 2 mm.\n CT Abd/Pelv: No evidence of retroperitoneal hematoma. Findings c/w\n cirrhosis and portal hypertension, including splenomegaly and ascites.\n Ascending colonic wall thickening and stranding likely due to portal\n colopathy. Differential diagnosis includes infectious, inflammatory or\n ischemic causes. Evaluation of known portal vein thrombus was not able\n to be performed given non-contrast study.\n Assessment and Plan\n .H/O HEPATITIS, CHRONIC VIRAL, SUBARACHNOID HEMORRHAGE (SAH), SUBDURAL\n HEMORRHAGE (SDH)\n ASSESSMENT: 55F HCV cirrhotic anticoagulated with supratherapeutic INR\n with right subdural hematoma\n Neurologic:\n -- Q1hr neuro checks. AOx1-2. Moves all extremities, follows commands.\n -- seizure prophylaxis: Dilantin 100mg TID. Level 15.3\n -- Hypertonic saline (consider d/c'ing today as Na 140).\n -- f/u head CT to assess for interval change\n -- pain control: oxycodone prn\n Cardiovascular:\n -- HD stable, no issues, goal SBP <160\n Pulmonary:\n -- extubated , no issues\n Gastrointestinal / Abdomen:\n -- hx of HCV cirrhosis c/b portal hypertension, ascites, and variceal\n bleed: cont nadolol 20mg qd, spironolactone 50mg qd\n -- GI prophy: famotidine\n -- bowel regimen: senna, colace\n Nutrition:\n -- started on sips -> advance as tolerated\n -- cont fish oil, MVN, Vit D\n Renal:\n -- Hypertonic saline @ 15 cc/hr (consider d/c'ing this AM as Na 140).\n Check serum Na q6h\n -- given 500cc NS bolus this AM for low UOP (10-20cc/hr)\n Hematology:\n -- s/p FFP, vit k, ?pentoxyfylline, platelets on admission\n -- : 2 U prbcs, 1 plt\n -- Hct downtrending 23.8\n Endocrine:\n -- Hx of Hypothyroidims: cont levothyroxine\n -- RISS\n ID:\n -- Febrile - ? neurogenic.\n -- F/u BCX, UCX and Sputum cx.\n T/L/D: R subclavian CVL, PIV x2, Foley\n Wounds: None\n Imaging: Head CT\n Fluids: Hypertonic saline @ 15cc/hr, D5NS+20KCL@75cc/hr\n Consults: Neurosurg, transplant\n Billing Diagnosis: SDH\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication: ICU Consent completed\n Code status:FULL\n Disposition:floor.\n Time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522920,
"text": "HPI:\n 55F s/p fall down the stairs 0n . She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She was anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to .\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : CVL placed for administration of hypertonic saline. Head CT\n repeated - unchanged. Abd CT - no evidence of hemorrhage. 2 units\n PRBCs, 1 unit PLT. Extubated. Started on sips. Febrile 101.4 (axillary)\n - pancultured.\n Subdural hemorrhage (SDH)\n Assessment:\n pt a+o x 2. confused in conversation at times. Mae. Follows commands.\n Perrl. Hr/bp stable. Skin w+d. +pp. o2 sat 97% on 4lnc. Ls clear with\n some faint rales in left base. Nard noted. abd softly distended. +bs.,\n tol sm amt po\ns. has multi areas of ecchymosis. + black eyes. Voiding\n via foley approx 15 cc/hr of amber urine. c/o intermittent HA.\n Action:\n neuro checks. Head ct done. Hypertonic saline weaned to off. Labs\n followed. Pulm hygiene. Team aware of low u/o. declined oob.\n Response:\n remains confused in conversation. Head ct unchanged.\n Plan:\n con\nt with current plan. To floor when bed avail.\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522921,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n pt a+o x 2. confused in conversation at times. Mae. Follows commands.\n Perrl. Hr/bp stable. Skin w+d. +pp. o2 sat 97% on 4lnc. Ls clear with\n some faint rales in left base. Nard noted. abd softly distended. +bs.,\n tol sm amt po\ns. has multi areas of ecchymosis. + black eyes. Voiding\n via foley approx 15 cc/hr of amber urine. c/o intermittent HA.\n Action:\n neuro checks. Head ct done. Hypertonic saline weaned to off. Labs\n followed. Pulm hygiene. Team aware of low u/o. declined oob. Oxycodone\n for pain.\n Response:\n remains confused in conversation. Head ct unchanged. Reports improved\n pain control\n Plan:\n con\nt with current plan. To floor when bed avail.\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 522741,
"text": "TITLE:\n SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to .\n Chief complaint:\n right SDH\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. IV access: PICC, heparin dependent Location: Right Subclavian, Date\n inserted: Order date: @ 0059\n 12. Levothyroxine Sodium 60 mcg IV DAILY Order date: @ 0204\n 2. IV access: Peripheral line Order date: @ 1654\n 13. Multivitamins 1 TAB PO/NG DAILY Order date: @ 1654\n 3. OK to use line Order date: @ 0133\n 14. Nadolol 20 mg PO DAILY Order date: @ 1654\n 4. 20 mEq Potassium Chloride / 1000 mL D5NS\n Continuous at 75 ml/hr Order date: @ 1738\n 15. OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain Order date:\n @ 1654\n 5. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0406\n 16. Phenytoin Sodium (IV) 100 mg IV Q8H Order date: @ 1654\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0218\n 17. Senna 1 TAB PO/NG HS Order date: @ 1654\n 7. Docusate Sodium 100 mg PO BID Order date: @ 1654\n 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1654\n 8. Famotidine 20 mg IV Q12H Order date: @ 0216\n 19. Sodium Chloride 3% (Hypertonic) - 500 mL\n Continuous at 15 ml/hr\n Please hold for NA>150 and Osm>320 Order date: @ 1654\n 9. Fish Oil (Omega 3) 1000 mg PO DAILY Order date: @ 1654\n 20. Spironolactone 50 mg PO/NG DAILY Order date: @ 1654\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 0218\n 21. Vitamin D 400 UNIT PO/NG DAILY Order date: @ 1654\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0218\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : CVL placed for administration of hypertonic saline. Head CT\n repeated - unchanged. Abd CT - no evidence of hemorrhage. 2 units\n PRBCs, 1 unit PLT. Extubated. Started on sips. Febrile 101.4 (axillary)\n - pancultured.\n FEVER - 101.2\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:33 PM\n Other medications:\n Flowsheet Data as of 04:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.1\nC (98.8\n HR: 77 (65 - 85) bpm\n BP: 107/59(79) {82/40(50) - 109/73(81)} mmHg\n RR: 17 (17 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.9 kg (admission): 52.9 kg\n Total In:\n 2,570 mL\n 1,215 mL\n PO:\n 100 mL\n 650 mL\n Tube feeding:\n IV Fluid:\n 1,709 mL\n 565 mL\n Blood products:\n 761 mL\n Total out:\n 920 mL\n 120 mL\n Urine:\n 920 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,650 mL\n 1,095 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 364 (364 - 364) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 5 cmH2O\n SPO2: 100%\n ABG: ///23/\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 44 K/uL\n 8.7 g/dL\n 170 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 140 mEq/L\n 23.8 %\n 2.9 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n 09:14 AM\n 03:49 PM\n 03:12 AM\n WBC\n 2.9\n 2.8\n 4.5\n 3.6\n 2.9\n Hct\n 19.2\n 20.6\n 26.9\n 26.6\n 23.8\n Plt\n 28\n 22\n 36\n 37\n 44\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n Glucose\n 154\n 167\n 150\n 168\n 170\n Other labs: PT / PTT / INR:14.3/30.5/1.2, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL,\n PO4:1.5 mg/dL\n Imaging: CT Head: Extensive subarachnoid and subdural hematoma as\n described above. Interval decrease in leftward shift, now measuring\n only 2 mm.\n CT Abd/Pelv: No evidence of retroperitoneal hematoma. Findings c/w\n cirrhosis and portal hypertension, including splenomegaly and ascites.\n Ascending colonic wall thickening and stranding likely due to portal\n colopathy. Differential diagnosis includes infectious, inflammatory or\n ischemic causes. Evaluation of known portal vein thrombus was not able\n to be performed given non-contrast study.\n Assessment and Plan\n .H/O HEPATITIS, CHRONIC VIRAL, SUBARACHNOID HEMORRHAGE (SAH), SUBDURAL\n HEMORRHAGE (SDH)\n ASSESSMENT: 55F HCV cirrhotic anticoagulated with supratherapeutic INR\n with right subdural hematoma\n Neurologic:\n -- Q1hr neuro checks. AOx1-2. Moves all extremities, follows commands.\n -- seizure prophylaxis: Dilantin 100mg TID. Level 15.3\n -- Hypertonic saline (consider d/c'ing today as Na 140).\n -- f/u head CT to assess for interval change\n -- pain control: oxycodone prn\n Cardiovascular:\n -- HD stable, no issues, goal SBP <160\n Pulmonary:\n -- extubated , no issues\n Gastrointestinal / Abdomen:\n -- hx of HCV cirrhosis c/b portal hypertension, ascites, and variceal\n bleed: cont nadolol 20mg qd, spironolactone 50mg qd\n -- GI prophy: famotidine\n -- bowel regimen: senna, colace\n Nutrition:\n -- started on sips -> advance as tolerated\n -- cont fish oil, MVN, Vit D\n Renal:\n -- Hypertonic saline @ 15 cc/hr (consider d/c'ing this AM as Na 140).\n Check serum Na q6h\n -- given 500cc NS bolus this AM for low UOP (10-20cc/hr)\n Hematology:\n -- s/p FFP, vit k, ?pentoxyfylline, platelets on admission\n -- : 2 U prbcs, 1 plt\n -- Hct downtrending 23.8\n Endocrine:\n -- Hx of Hypothyroidims: cont levothyroxine\n -- RISS\n ID:\n -- Febrile - ? neurogenic.\n -- F/u BCX, UCX and Sputum cx.\n T/L/D: R subclavian CVL, PIV x2, Foley\n Wounds: None\n Imaging: Head CT\n Fluids: Hypertonic saline @ 15cc/hr, D5NS+20KCL@75cc/hr\n Consults: Neurosurg, transplant\n Billing Diagnosis: SDH\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication: ICU Consent completed\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522978,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam pt is more awake. Follows commands. Normal strength in all\n extremities. Pupils are equal and reactive to light. Pt confused at\n times trying to get out of bed and asking\nwhere the Dogs are and \n let any one set them on fire\n. Oriented to person and place. Recalls\n falling down the stairs. Pt c/o headache and medicated with oxycodone\n with good response. Urine output low (15 and 17 cc for 2 hours.) pt\n tolerating liquids well.\n Action:\n Neuro q4. lasix 10mg iv x1 medicate for pain as needed.\n Response:\n Oxycodone effective in relieving pain. Pt more awake tonight.\n Plan:\n Transfer to floor when bed available\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522905,
"text": "HPI:\n 55F s/p fall down the stairs 0n . She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She was anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to .\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : CVL placed for administration of hypertonic saline. Head CT\n repeated - unchanged. Abd CT - no evidence of hemorrhage. 2 units\n PRBCs, 1 unit PLT. Extubated. Started on sips. Febrile 101.4 (axillary)\n - pancultured.\n Subdural hemorrhage (SDH)\n Assessment:\n pt a+o x 2. confused in conversation at times. Mae. Follows commands.\n Perrl. Hr/bp stable. Skin w+d. +pp. o2 sat 97% on 4lnc. Ls clear with\n some faint rales in left base. Nard noted. abd softly distended. +bs.,\n tol sm amt po\ns. has multi areas of ecchymosis. + black eyes.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2111-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 522965,
"text": "SICU\n HPI:\n 55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n Brought to and intubated. Transferred to \n Chief complaint:\n Right subdural hematoma\n PMHx:\n 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and\n ribavirin with clearance of hepatitis virus in , c/b portal\n hypertension, ascites, and variceal bleed\n 2. Fibromyalgia\n 3. Granuloma annulare\n 4. Hypothyroidism\n 5. Disc disease in the cervical and lumbar spine\n 6. B12 and iron deficiencies\n 7. hyponatremia\n Current medications:\n 1. 2. 3. 4. 20 mEq Potassium Chloride / 1000 mL D5NS 5. 500 mL NS 6.\n Dextrose 50% 7. Docusate Sodium 8. Famotidine 9. Fish Oil (Omega 3)\n 10. Furosemide 11. Furosemide 12. Glucagon 13. Insulin 14.\n Levothyroxine Sodium\n 15. Magnesium Sulfate 16. Multivitamins 17. Nadolol 18. Neutra-Phos 19.\n OxycoDONE (Immediate Release) 20. Phenytoin Sodium Extended 21. Senna\n 22. Sodium Chloride 3% (Hypertonic) - 500 mL 23. Sodium Chloride 0.9%\n Flush 24. Spironolactone 25. Vitamin D\n 24 Hour Events:\n EXTUBATION - At 10:26 AM\n SPUTUM CULTURE - At 10:42 AM\n sent prior to extubation\n BLOOD CULTURED - At 04:30 PM\n via central line\n URINE CULTURE - At 05:10 PM\n : Weaned off 3% hypertonic saline\n FEVER - 101.2\nF - 04:00 PM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 10:00 AM\n Famotidine (Pepcid) - 08:07 PM\n Furosemide (Lasix) - 11:15 PM\n Other medications:\n Flowsheet Data as of 04:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.2\nC (99\n HR: 68 (62 - 88) bpm\n BP: 84/48(57) {84/42(54) - 120/88(94)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 57.2 kg (admission): 52.9 kg\n Total In:\n 4,191 mL\n 439 mL\n PO:\n 2,340 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 1,851 mL\n 39 mL\n Blood products:\n Total out:\n 944 mL\n 510 mL\n Urine:\n 944 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,247 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 38 K/uL\n 9.2 g/dL\n 144 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 135 mEq/L\n 26.6 %\n 3.4 K/uL\n [image002.jpg]\n 02:18 AM\n 03:33 AM\n 09:14 AM\n 03:49 PM\n 03:12 AM\n 02:18 AM\n WBC\n 2.9\n 2.8\n 4.5\n 3.6\n 2.9\n 3.4\n Hct\n 19.2\n 20.6\n 26.9\n 26.6\n 23.8\n 26.6\n Plt\n 28\n 22\n 36\n 37\n 44\n 38\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.7\n 0.7\n Glucose\n 154\n 167\n 150\n 168\n 170\n 144\n Other labs: PT / PTT / INR:15.5/31.1/1.4, ALT / AST:25/35, Alk-Phos / T\n bili:40/2.2, Lactic Acid:1.6 mmol/L, Ca:8.1 mg/dL, Mg:1.6 mg/dL,\n PO4:1.4 mg/dL\n Assessment and Plan\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK), ACUTE PAIN, .H/O\n HEPATITIS, CHRONIC VIRAL, SUBARACHNOID HEMORRHAGE (SAH), SUBDURAL\n HEMORRHAGE (SDH)\n Assessment and Plan: 55F HCV cirrhotic anticoagulated with\n supratherapeutic INR with right subdural hematoma\n Neurologic:\n -- Q4hr neuro checks. AOx3. Moves all extremities, follows commands.\n -- Seizure prophylaxis: Dilantin 100mg TID. Level 15.3\n -- Hypertonic saline (taper off ).\n -- F/u head CT no acute change. f/up final read\n -- pain control: oxycodone prn\n Cardiovascular: -- HD stable, no issues, goal SBP <160\n Pulmonary:\n -- extubated , no issues\n Gastrointestinal / Abdomen:\n -- hx of HCV cirrhosis c/b portal hypertension, ascites, and variceal\n bleed: cont nadolol 20mg qd, spironolactone 50mg qd\n -- GI prophy: famotidine\n -- bowel regimen: senna, colace\n Nutrition:\n -- Regular\n -- cont fish oil, MVN, Vit D\n Renal:\n --Creat stbel, Hx of Hyponatremia 128 o admission. Now off 3%\n Hypertonic saline\n Hematology:\n -- s/p FFP, vit k, ?pentoxyfylline, platelets on admission\n -- : 2 U prbcs, 1 plt\n -- Hct 26 Monitor.\n Endocrine:\n -- Hx of Hypothyroidims: cont levothyroxine\n -- RISS\n Infectious Disease: -- AFebrile\n -- F/u BCX, UCX and Sputum cx.\n Lines / Tubes / Drains:\n R subclavian CVL, PIV x2, Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Transplant\n Billing Diagnosis: Other: SDH\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:53 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to other facility\n Total time spent: 25 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2111-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 522550,
"text": "55F s/p fall down the stairs last night. She was taken to by her sister where she was discharged home after a head CT\n was negative. She then went to her PCP the following morning and\n collapsed in the waiting room and and underwent another CT which showed\n a right subdural hematoma. She is anticoagulated with coumadin for\n portal vein thrombosis x2 last year. INR on initial check was 5.2.\n .H/O hepatitis, chronic viral\n Assessment:\n Pt is listed on transplant list\n Abd soft scattered bruises over body, elevated INR\n Action:\n Transfused 1 u FFP, 1 u platelets,\n Response:\n Hct down to 20 from 27, platelets 28\n CT of abd and Head done at 0445\n Plan:\n Transfused 2 u pc with I u platelets to follow\n Subdural hemorrhage (SDH)\n Assessment:\n Pt intubated at osh , remained int all night, on propofol drip.\n Pt responding to commands, right stronger than left, nodding slightly\n to questions.\n Pt restless, pulling at tubes, attempting to sit up in bed\n Action:\n Propofol increased to maintain sedation during central line placement\n and repeat ct scan.\n Response:\n Sedation adequate most of the night, awakens when propofol decreased.\n Plan:\n Neuro checks q 1 hr\n 3% ns for low sodium\n Update family, provide emotional support\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1123283,
"text": " 4:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 55 year old woman with R SDH, evaluate for interval changes\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with R SDH, evaluate for interval changes\n REASON FOR THIS EXAMINATION:\n 55 year old woman with R SDH, evaluate for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SAT 5:42 AM\n PFI: Extensive subarachnoid and subdural hematoma as described above.\n Interval decrease in leftward shift, now measuring only 2 mm.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: .\n\n HISTORY: Evaluate for interval change. Known subdural hematoma and dropping\n hematocrit.\n\n TECHNIQUE: MDCT axially-acquired images through the brain were obtained. No\n IV contrast administered.\n\n FINDINGS: Again identified is a large right-sided subdural hematoma measuring\n approximately 11 mm in greatest thickness. Extensive right-sided subarachnoid\n hemorrhage is also identified and not significantly changed. There is\n cerebral edema primarily involving the right cerebral hemisphere. Subdural\n hematoma is also identified layering along the tentorium, right greater than\n left, as well as overlying the left frontal lobe. This is not significantly\n changed when compared to prior exam. No new foci of hemorrhage are\n identified. The ventricles and sulci are prominent, but unchanged. There has\n been decreased shift of normally midline structures toward the left, now\n measuring approximately 2 mm. The basilar cisterns are preserved. A small\n subcutaneous hematoma over the left frontal bone is noted. There is no\n definite evidence of acute fracture.\n\n IMPRESSION:\n 1. Extensive subarachnoid and subdural hematoma as described above. Interval\n decrease in leftward shift, now measuring only 2 mm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1123284,
"text": ", W. NSURG SICU-B 4:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 55 year old woman with R SDH, evaluate for interval changes\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with R SDH, evaluate for interval changes\n REASON FOR THIS EXAMINATION:\n 55 year old woman with R SDH, evaluate for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Extensive subarachnoid and subdural hematoma as described above.\n Interval decrease in leftward shift, now measuring only 2 mm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1123437,
"text": " 10:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Right subdural hematoma\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known right subdural hematoma, please evaluate for interval\n change.\n\n COMPARISON: and 27, .\n\n TECHNIQUE: Contiguous axial CT images were acquired through the head without\n the use of intravenous contrast.\n\n FINDINGS: Extra-axial blood layers over the right cerebral convexity, most\n prominent over the right parietal lobe where it measures 9 mm in greatest\n depth, slightly decreased from previous measurement of 11 mm, most recently.\n Additionally, blood extends into the subarachnoid space again on the right,\n unchanged from the previous study. Blood layering along the right leaflet of\n the tentorium is unchanged. There is no new hemorrhage. Ventricles are\n notable for mild effacement of the right lateral ventricle, presumably related\n to right cerebral edema, the degree of which is unchanged. There is no\n evidence of herniation. A small hematoma over the frontal bone on the left is\n unchanged. There is no underlying skull fracture. Mastoid air cells are\n clear.\n\n IMPRESSION:\n 1. Extra-axial hemorrhage layering over the right cerebral convexity extending\n into that middle cranial fossa and layering along the right leaflet of the\n tentorium, as above, appears significantly improved, overall, since the\n admission studies of .\n 2. Persistent subarachnoid hemorrhage in right frontoparietal sulci, with no\n new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123362,
"text": " 5:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: CVL placement\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with CVL pulled back\n REASON FOR THIS EXAMINATION:\n CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the patient has been\n extubated. The right-sided central venous access line is in unchanged\n position. No evidence of newly appeared focal parenchymal opacities\n suggesting pneumonia. Minimal retrocardiac atelectasis. No pleural\n effusions. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1123274,
"text": " 12:55 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement and r/o pneumothorax\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with new right subclavian line\n REASON FOR THIS EXAMINATION:\n confirm line placement and r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:16 A.M., \n\n HISTORY: New right subclavian line, confirm placement.\n\n IMPRESSION: AP chest compared to 1:46 p.m. on :\n\n Tip of the new right internal jugular line projects roughly 1.5 cm beyond the\n estimated location of the superior cavoatrial junction. No pneumothorax,\n pleural effusion or mediastinal widening. Tip of the endotracheal tube is\n still at the orifice of the left main bronchus, approximately 4 cm below\n optimal placement. Nevertheless lungs are clear, free of substantial\n atelectasis. Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123202,
"text": " 1:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with intubated\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 1346 HOURS\n\n HISTORY: Intubated.\n\n COMPARISON: .\n\n FINDINGS: Consistent with the given history, an endotracheal tube has been\n introduced with the distal tip at the ostium of the left main stem bronchus.\n The lungs are clear; however, lung volumes overall are diminished from the\n prior exam. Linear atelectasis is seen in the retrocardiac left lower lobe.\n No effusion or pneumothorax is seen. The mediastinum is otherwise\n unremarkable. The cardiac silhouette is within normal limits for size.\n Minimal gaseous distention of the stomach is noted. The osseous structures\n are unremarkable.\n\n IMPRESSION: Distal tip of the endotracheal tube is at the ostium of the left\n main stem bronchus. Recommend retracting by approximately 4 cm for optimal\n placement.\n\n Dr. was informed at ~2:20 pm on the day of study via phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1123203,
"text": " 1:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with known subdural\n REASON FOR THIS EXAMINATION:\n Eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MTCf FRI 3:39 PM\n no sig change in right SDH with r to l midline shift of 6mm. slight increase\n sdh along falx. r>l sdh along tentorium. also stable right subarachnoid\n hameorrhage. possible small amount of SAH on left.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known traumatic intracranial hemorrhage. Evaluate for change.\n\n Technique: CT of the head was performed without contrast. Multiplanar\n reformats were performed.\n\n COMPARISON: Outside study from earlier the same day.\n\n FINDINGS: Again noted is the extensive hemispheric right-sided subdural\n hematoma involving the right frontal, parietal, and temporal regions. The\n largest diameter of this is approximately 12 mm which is stable from the\n prior. There is some slight evolution of blood products. There has been\n slight interval increase in the amount of subdural hematoma seen along the\n falx and in the midline. There also was stable right greater than left\n subdural hemorrhage along the tentorium bilaterally. The left frontal subdural\n hematoma is stable. Extensive subarachnoid hemorrhage on the right is grossly\n unchanged as well. There may be a trace amount of subarachnoid hemorrhage on\n the left that is better appreciated on the current study on series 2, 19.\n Again, there is right to left midline shift of approximately 6 mm which is\n stable. There is effacement of the right lateral ventricle. There is trace\n effacement of the right side of the suprasellar cistern. The quadrigeminal\n plate cistern and ambient cisterns remain patent. The fourth ventricle is of\n normal caliber. No intraventricular blood is clearly seen.\n\n There is no evidence of skull fracture. Small scalp hematoma is noted in the\n left frontal region.\n\n IMPRESSION:\n\n 1. No significant change in extensive right-sided subdural hematoma.\n Increased subdural hematoma along the falx. Stable right greater than left\n bilateral tentorial hematoma.\n\n 2. Stable extensive right-sided subarachnoid hemorrhage.\n\n 3. Stable right to left midline shift of approximately 6 mm.\n\n 4. Stable small left frontal subdural hematoma.\n (Over)\n\n 1:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 5. Probable new area of subarachnoid hemorrhage in the left frontotemporal\n area.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1123287,
"text": " 4:47 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CRIT DROP\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with SDH and significant hct drop since admission with\n increasing abdominal distention\n REASON FOR THIS EXAMINATION:\n intrathoracic or intraabdominal source of bleeding (?RP bleed).\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SAT 5:49 AM\n PFI:\n 1. No evidence of retroperitoneal hematoma.\n 2. Findings consistent with cirrhosis including splenomegaly and ascites.\n 3. Ascending colonic wall thickening and stranding likely due to portal\n colopathy. Differential diagnosis includes infectious, inflammatory or\n ischemic causes.\n 4. Evaluation of known portal vein thrombus was not able to be performed\n given non-contrast study.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS.\n\n COMPARISON: .\n\n HISTORY: Significant hematocrit drop since admission with increasing\n abdominal distention, evaluate for retroperitoneal bleed.\n\n TECHNIQUE: MDCT axially-acquired images through the abdomen and pelvis were\n obtained. No IV contrast was administered. Coronal and sagittal reformats\n were performed.\n\n FINDINGS: There is mild bibasilar atelectasis, left greater than right.\n There is no large pleural or pericardial effusion. Within the limitations of\n a non-contrast exam, the kidneys and adrenal glands are unremarkable. The\n spleen is enlarged and measures 14.2 cm. The liver appears nodular and\n shrunken consistent with cirrhosis. The gallbladder is distended. There is a\n small-to-moderate amount of free fluid within the abdomen, which measures\n simple. The pancreas is unremarkable. Extensive collaterals and varices are\n identified. There is likely edema of the ascending colon with fat stranding,\n which may be due to portal colopathy. There is no definite evidence of\n obstruction. Small periportal lymph nodes are again identified, not\n significantly changed. There is no evidence of free air. There is diffuse\n anasarca.\n\n There is no evidence of retroperitoneal hematoma or intraperitoneal\n hemorrhage.\n\n CT OF THE PELVIS: The rectum, sigmoid colon, bladder and uterus are\n unremarkable. Moderate amount of free fluid is identified consistent with\n (Over)\n\n 4:47 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CRIT DROP\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 32\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ascites. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n There is no definite evidence of acute fracture.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal hematoma.\n 2. Findings consistent with cirrhosis and portal hypertension, including\n splenomegaly and ascites.\n 3. Ascending colonic wall thickening and stranding likely due to portal\n colopathy. Differential diagnosis includes infectious, inflammatory or\n ischemic causes.\n 4. Evaluation of known portal vein thrombus was not able to be performed\n given non-contrast study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1123288,
"text": ", W. NSURG SICU-B 4:47 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: CRIT DROP\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Field of view: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with SDH and significant hct drop since admission with\n increasing abdominal distention\n REASON FOR THIS EXAMINATION:\n intrathoracic or intraabdominal source of bleeding (?RP bleed).\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No evidence of retroperitoneal hematoma.\n 2. Findings consistent with cirrhosis including splenomegaly and ascites.\n 3. Ascending colonic wall thickening and stranding likely due to portal\n colopathy. Differential diagnosis includes infectious, inflammatory or\n ischemic causes.\n 4. Evaluation of known portal vein thrombus was not able to be performed\n given non-contrast study.\n\n"
}
] |
88,356 | 130,447 | 66 y/o male with hypertension who was transferred from an OSH with an NSTEMI. He was treated with a Heparin drip, Aspirin, Metoprolol, Atorvastatin and Clopidogrel. Cardiac catheterization revealed a right dominant system with left main and three vessel coronary disease involving the LMCA, LCx (including the OM1 and OM2) and RCA. Based on the catheterization findings, a CABG was recommended. As he had received Clopidogrel, he was unable to proceed directly to surgery and required a washout period. He was continue on the Heparin drip up to surgery. During the cardiac catherization, there was noted difficulty in passing the catheter into the aorta. An aortic ultrasound revealed a large abdominal aortic aneurysm. CT of the abdomen and pelvis confirmed these findings, revealing a maximal diameter of 8.6 cm. Vascular surgery was consulted for the AAA. After discussions between the CT surgery and vascular surgery teams, it was decided that the patient would proceed with the CABG, go home for several weeks and then return for repair of his AAA. On he was brought to the operating room and underwent coronary artery bypass graft surgery, see operative report for further details. He received cefazolin and vancomycin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. That evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on betablockers and diuretics. He continued to progress and was transferred to the floor. Physical therapy worked with him on strength and mobility. On post operative day two his creatinine increased to 2.1 from baseline 1 preoperatively. He was treated with fluids and foley reinserted to monitor urine output. All nephrotoxic medications were stopped and he had BUN/Cr monitored daily. Acute kidney injury with peak cr 2.1 on and bun 60 on . Additionally he had post operative atrial fibrillation treated with betablockers and amiodarone which he continued to go in and out of requiring increased betablockers. Coumadin was started on , then held due to elevated INR. He did receive FFP for supratherapeutic INR. Postoperatively he developed a colonic ileus. Transplant Surgery and General Surgery assisted with management. He was kept NPO and narcotics discontinued. A rectal tube was placed and was discontinued when the patient had a bowel movement. A KUB was followed and diet was advanced slowly when ileus showed improvement. Upon discharge he was not placed on a statin due to his chemical pancreatitis. Resuming a statin will need to be reevaluated as an out patient. He was placed on Vancomycin and cipro for cellulitus along his left saphenous vein harvest site. Per Dr., antibiotics should continue through his out patient follow up with Dr. in clinic, to be re-evaluated at that time. Additionally, he was noted to have a non-occlusive DVT on the LLE. Coumadin was continued. He continued to progress and was ready for discharge to home with a PICC line, antibiotic infusion arranged, and INR/Coumadin follow up with his PCP, office, as discussed with RN-, for postoperative atrial fibrillation. On post operative day 18 he was cleared for discharge to home. | CT OF THE PELVIS: There is sigmoid diverticulosis without diverticulitis. CT ANGIOGRAM OF THE AORTA: The celiac axis and SMA are widely patent, though there is mild dilation of the proximal celiac axis, possibly just after the median arcuate ligament. There is a fat-containing right inguinal hernia. There is sigmoid colon diverticulosis without diverticulitis. flow from the aorta does appear to enter the the (4:87), though retrograde back bleeding is not entirely excluded. IMPRESSION: AP chest compared to through : Consolidation persists at the base of the left lung accompanied by new or newly apparent small left pleural effusion. Non-occlusive thrombus within the left deep femoral vein. bilateral adrenal adenomas. Bilateral adrenal adenomas. The remaining left and right sided veins including the common femoral, superficial femoral, and popliteal veins are patent with normal compressibility and respiratory variation in flow. There is a non-occlusive thrombus within the left deep femoral vein, which is noncompressible. (Over) 6:05 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: Per vascular request, CTA Aorta with MMS Reconstruction for Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION Contrast: OPTIRAY Amt: 90 FINAL REPORT (Cont) This dominant caudal portion of the AAA measures 7.3 cm TRV x 7.4 cm AP x 8.6 cm SI for a volume of 335 cc. The iliac arteries are patent and non-aneurysmally dilated. FINDINGS: The quantity of air within the transverse colon is not significantly changed compared to the most recent abdominal radiograph from , but significantly decreased compared to . FINDINGS: Portable supine and left lateral decubitus views of the abdomen were obtained. No contraindications for IV contrast WET READ: JMGw MON 6:51 PM complex AAA with a saccular infrarenal component measuring 4.2 (AP) x 4.2 (TRV) x 3 (CC) cm and a more inferior fusiform component measuring 7 (AP) x 7.3 (TRV) x 8.6 (CC) cm with a large amount of mural thrombus in the sac. There are bilateral adrenal adenomas, measuring 16 x 14 mm on the right and 29 x 21 mm on the left. There are single renal arteries bilaterally with early branching of the right renal artery. IMPRESSION: Findings suggest large bowel ileus or partial colonic obstruction. No interval increase in most likely present small bilateral pleural effusion is noted. common, internal and external iliac arteries are patent bilaterally. Stool is seen throughout the ascending, descending, and sigmoid colon. The portal vein is patent with normal hepatopetal flow. soft tissue stranding with several locules of air are present in the right groin likley from prior intervention, but no hematoma. There isno pericardial effusion.IMPRESSION: Mild symmetric LVH with mild regional left ventricular systolicdysfunction, c/w CAD. No TEErelated complications.Conclusions:PRE-BYPASS: The left atrium is mildly dilated. Mild symmetric left ventricularhypertrophy with preserved global biventricular systolic function. Normal ascending aorta diameter. Unchanged left and right ventricular systolic function2. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (?#). Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. There is mild symmetric left ventricularhypertrophy with normal cavity size. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is mild regional left ventricularsystolic dysfunction with mid-anterior hypokinesis. The mitral valve appearsstructurally normal with trivial mitral regurgitation. Mildpulmonary hypertension. Trivial mitral regurgitation is seen.There is no pericardial effusion.POST CPB:1. There is mild regional left ventricularsystolic dysfunction with very mild inferolateral hypokinesis. Mild regional LVsystolic dysfunction.LV MOTION: Regional LV motion abnormalities include: basalinferolateral - hypo; mid inferolateral - hypo; remaining LV segments contractnormally.RIGHT VENTRICLE: Normal RV chamber size and free motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Normal aortic diameter at the sinus level. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate tortuosity of the thoracic aorta. Mildly dilated ascendingaorta. The descending thoracic aorta is mildly dilated.There are simple atheroma in the descending thoracic aorta. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free motion.AORTA: Mildy dilated aortic root. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is elongated. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No resting LVOT gradient.LV MOTION: Regional LV motion abnormalities include: basalinferolateral - hypo; mid inferolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free motion.AORTA: Normal aortic diameter at the sinus level. The mitral valve appears structurally normal with trivial mitralregurgitation. Hypertension.Height: (in) 66Weight (lb): 150BSA (m2): 1.77 m2BP (mm Hg): 114/74HR (bpm): 66Status: InpatientDate/Time: at 10:31Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. There is moderate pulmonaryartery systolic hypertension. There is mild pulmonary artery systolic hypertension. Mitral valve disease.Status: InpatientDate/Time: at 08:14Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Central mild to moderate mitral regurgitation3. Left ventricular thicknesses are normal. The presence of minimal bilateral dorsal pleural effusions cannot be excluded. The diameters of aorta at the sinus, ascendingand arch levels are normal. The aortic valve leaflets (3) are mildly thickened.There is no aortic valve stenosis. Normal size of the cardiac silhouette. Normal LV thickness. Mild regional LVsystolic dysfunction. | 28 | [
{
"category": "Radiology",
"chartdate": "2147-06-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1193952,
"text": " 9:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm left picc. call result to barb iv 95307pgr\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 44cm left picc. call result to barb iv 95307pgr\n ______________________________________________________________________________\n WET READ: AJy TUE 10:09 PM\n\n new left PICC extends to mid SVC. Little change in left basilar opacities\n with associated small effusion.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:22 P.M., \n\n HISTORY: New left PIC line.\n\n IMPRESSION: AP chest compared to through :\n\n Consolidation persists at the base of the left lung accompanied by new or\n newly apparent small left pleural effusion. Whether the pulmonary abnormality\n is atelectasis alone or the patient has developed pneumonia postoperatively is\n radiographically indeterminate and would depend upon clinical findings. New\n left PIC line ends in the mid to low SVC. Dr. reported findings to IV\n nurse, , at the time of original review.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-03 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1193433,
"text": " 9:36 PM\n ABDOMEN (SUPINE & ERECT); -76 BY SAME PHYSICIAN # \n Reason: following colonic distension\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with abdominal distension\n REASON FOR THIS EXAMINATION:\n following colonic distension\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen supine and erect films .\n\n CLINICAL HISTORY: 66-year-old man with abdominal distention.\n\n FINDINGS: A comparison is made to previous study from .\n\n There is again seen prominence of gas within the transverse colon; however,\n the degree of distention has decreased slightly since the prior study.\n Maximal dimension measures 7.7 cm, 8.4 cm on the prior study and 9.7 cm on the\n previous study before that. There is air and stool seen throughout the colon\n extending into the rectum. No dilated loops of small bowel are seen. There\n is no free intra-abdominal gas.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-05 00:00:00.000",
"description": "UNILAT LOWER EXT VEINS",
"row_id": 1193672,
"text": " 11:38 AM\n UNILAT LOWER EXT VEINS Clip # \n Reason: increased lower ext pain/swelling\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p CABGx4 POD#10 with lower ext pain/swelling\n REASON FOR THIS EXAMINATION:\n increased lower ext pain/swelling\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old with CABG, postop day 10, and lower extremity\n swelling. Evaluate for DVT.\n\n COMPARISON: Venous mapping study, .\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler examinations of the\n right and left veins were performed. There is a non-occlusive thrombus within\n the left deep femoral vein, which is noncompressible. The remaining left and\n right sided veins including the common femoral, superficial femoral, and\n popliteal veins are patent with normal compressibility and respiratory\n variation in flow.\n\n There is also a small saphenectomy bed hematoma along the greater saphenous\n venous harvest site which measures approximately 1.6 cm TRV x 1.3 cm AP and\n extends along the entire medial thigh.\n\n IMPRESSION:\n 1. Non-occlusive thrombus within the left deep femoral vein.\n 2. Small hematoma within the greater saphenous venous harvest site.\n\n Findings were discussed with , NP, at 5:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-03 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1193390,
"text": " 2:55 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: evaluate ileus\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG w post-op ileus\n REASON FOR THIS EXAMINATION:\n evaluate ileus\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen supine and erect films, .\n\n CLINICAL HISTORY: 66-year-old man status post CABG with postoperative ileus.\n\n FINDINGS: Comparison is made to previous film from at 10:25\n p.m.\n\n There is again noted prominent dilation of the transverse colon with largest\n diameter measuring 8.4 cm, 9.7 cm on the prior study. There are no dilated\n loops of small bowel, however, they could be fluid filled. Some air is seen\n within the rectum. Overall, there has been no appreciable change. There is\n no free air underneath the hemidiaphragms.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193197,
"text": " 11:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sob\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Cardiomegaly is moderate, unchanged. Bibasal atelectasis/infectious process\n is unchanged. Mediastinum is unchanged. Extensive upper lung emphysema is\n re-demonstrated. Post-sternotomy wires are unremarkable. No interval\n increase in most likely present small bilateral pleural effusion is noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1194923,
"text": " 9:36 AM\n CHEST (PA & LAT) Clip # \n Reason: evla for effusion or infiltrate\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pod 17 s/p cabg\n REASON FOR THIS EXAMINATION:\n evla for effusion or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative CABG.\n\n FINDINGS: In comparison with study of , there is little overall change in\n the mediastinal contours and the appearance of the heart and lungs.\n Opacification at the left base is consistent with pleural effusion and\n atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-02 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1193306,
"text": " 10:21 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: 66 year old man with Ogilve's\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with Ogilve's\n REASON FOR THIS EXAMINATION:\n 66 year old man with Ogilve's\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen supine and erect films .\n\n CLINICAL HISTORY: 66-year-old man with syndrome.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a prominent amount of air seen throughout the transverse and\n descending colon. A prominent air-fluid level within the ascending colon\n measures 9.7 cm in transverse dimension. There is some air within non-dilated\n loops of small bowel within the mid to the left abdomen. There is no free\n intra-abdominal gas. Overall, these findings appear stable since the previous\n study and may represent large bowel ileus versus partial colonic obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-04 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1193511,
"text": " 11:59 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: follow ileus\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG, post-op colonic ileus\n REASON FOR THIS EXAMINATION:\n follow ileus\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen supine and erect films, .\n\n CLINICAL HISTORY: 66-year-old man status post CABG. Post-colonic ileus.\n\n FINDINGS: Comparison is made to the prior study from .\n\n There is been continued reduction in the size of the previously dilated\n transverse colon. The amount of gas continues to decrease and now the bowel\n gas pattern is more of a normal state. There remains some gas within the\n transverse colon. Stool is seen within the cecum and within the descending\n colon and rectum. No dilated loops of small bowel are seen. There is no free\n intra-abdominal gas.\n\n IMPRESSION:\n\n Improving colonic ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-02 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1193195,
"text": " 11:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: abd distension\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with abd distension\n REASON FOR THIS EXAMINATION:\n abd distension\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg FRI 2:47 PM\n Findings suggest large bowel ileus or partial colonic obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention.\n\n COMPARISON: CT and CXR .\n\n FINDINGS: Portable supine and left lateral decubitus views of the abdomen were\n obtained. There is gaseous distention of the large bowel, predominantly in\n the transverse colon up to 10 cm. Gas is seen in nondistended loops of small\n and large bowel as well as the rectum. Evaluation for free air is limited on\n the left lateral decubitus film, but there is no large pneumoperitoneum or\n secondary signs of free air. Osseous structures are intact.\n\n IMPRESSION: Findings suggest large bowel ileus or partial colonic\n obstruction.\n\n Discussed with by phone at time of interpretation .\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-02 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1193196,
"text": ", CSURG FA6A 11:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: abd distension\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with abd distension\n REASON FOR THIS EXAMINATION:\n abd distension\n ______________________________________________________________________________\n PFI REPORT\n Findings suggest large bowel ileus or partial colonic obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-07 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1194020,
"text": " 8:44 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: r/o choleycystitis\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o choleycystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man status post CABG. Please rule out cholecystitis.\n\n TECHNIQUE:\n Grayscale and color ultrasound images of the liver and gallbladder were\n obtained.\n\n COMPARISON: CT of the abdomen from .\n\n FINDINGS:\n The liver architecture is normal without focal lesions. There is no intra- or\n extra-hepatic biliary dilatation with the common bile duct measuring 5 mm.\n The portal vein is patent with normal hepatopetal flow. The gallbladder is\n nondistended and shows no thickening. There are no gallstones. No upper\n quadrant ascites is identified.\n\n IMPRESSION: No evidence of gallstones. No cholecystitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194849,
"text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for widening - hct\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p cabg POD 17\n REASON FOR THIS EXAMINATION:\n eval for widening - hct\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative CABG, to assess for widening.\n\n FINDINGS: In comparison with the study of , the mediastinal contours are\n unchanged, and there is no evidence of widening superiorly. Increasing\n opacification at the left base laterally is consistent with enlarging small\n left pleural effusion. Retrocardiac opacification is again consistent with\n atelectasis. In the appropriate clinical setting, the possibility of\n supervening pneumonia would have to be considered.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-06-05 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1193617,
"text": " 9:28 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval ileus\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with post-op ileus\n REASON FOR THIS EXAMINATION:\n eval ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postoperative ileus, evaluate ileus.\n\n COMPARISON: Abdominal radiograph from .\n\n FINDINGS: The quantity of air within the transverse colon is not\n significantly changed compared to the most recent abdominal radiograph from\n , but significantly decreased compared to . Stool\n is seen throughout the ascending, descending, and sigmoid colon. There is no\n free air in the abdomen. Surgical clips overlie the heart. There is mild\n elevation of the right hemidiaphragm.\n\n IMPRESSION: Resolution of colonic ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-22 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1191472,
"text": " 6:05 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Per vascular request, CTA Aorta with MMS Reconstruction for\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with NSTEMI with MVD and AAA of 7.1 cm.\n REASON FOR THIS EXAMINATION:\n Per vascular request, CTA Aorta with MMS Reconstruction for likely\n intervention.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw MON 6:51 PM\n complex AAA with a saccular infrarenal component measuring 4.2 (AP) x 4.2\n (TRV) x 3 (CC) cm and a more inferior fusiform component measuring 7 (AP) x\n 7.3 (TRV) x 8.6 (CC) cm with a large amount of mural thrombus in the sac. the\n celica, SMA, and renal arteries are patent. flow from the aorta does appear\n to enter the the (4:87), though retrograde back bleeding is not entirely\n excluded. common, internal and external iliac arteries are patent bilaterally.\n soft tissue stranding with several locules of air are present in the right\n groin likley from prior intervention, but no hematoma. bilateral adrenal\n adenomas. left renal cyst, simple. spleen granulomas. moderate to severe\n bibasilar emphysema. right L5 pars defect. 3D recons pending\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NSTEMI, with AAA. Please perform CT for operative planning.\n\n COMPARISON: Abdominal ultrasound performed one day prior.\n\n TECHNIQUE: Multidetector helical scanning of the abdomen and pelvis was\n performed prior to and following the administration of 90 cc IV Optiray\n contrast. Coronal, sagittal curved and volume-rendered reformats were\n displayed.\n\n CT OF THE ABDOMEN: There are moderate-to-severe emphysematous changes at the\n lung bases, worse in the right lower lobe. The liver is normal in\n attenuation, with no focal lesions. There is completely replaced left hepatic\n artery arising from the left gastric artery. The spleen, gallbladder,\n pancreas are normal. There are bilateral adrenal adenomas, measuring 16 x 14\n mm on the right and 29 x 21 mm on the left. The kidneys enhance and excrete\n contrast symmetrically, with a 22-mm simple cyst arising from the interpolar\n region of the left kidney. The small bowel loops are normal. There is\n sigmoid colon diverticulosis without diverticulitis. No ascites.\n\n CT ANGIOGRAM OF THE AORTA: The celiac axis and SMA are widely patent, though\n there is mild dilation of the proximal celiac axis, possibly just after the\n median arcuate ligament. There is no collateralization from the SMA to\n suggest a hemodynamically significant stenosis. There are single renal\n arteries bilaterally with early branching of the right renal artery. There is\n a juxtarenal abdominal aortic aneurysm which starts at the level of the left\n renal artery and is bilobed. The more superior component measures 4.2 cm AP x\n 4.2 cm TRV x 3 cm CC. There is a waist and then a larger AAA inferiorly.\n (Over)\n\n 6:05 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Per vascular request, CTA Aorta with MMS Reconstruction for\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n This dominant caudal portion of the AAA measures 7.3 cm TRV x 7.4 cm AP x 8.6\n cm SI for a volume of 335 cc. There is a large amount of mural thrombus\n within the aneurysm sac of this more caudal AAA. The inferior mesenteric\n artery traverses the anterior thrombus. There is approximately 2 cm between\n the end of the AAA and the aortic bifurcation. The iliac arteries are patent\n and non-aneurysmally dilated. The superficial femoral arteries are also\n patent and of normal caliber.\n\n There is gas within the subcutaneous right groin and fat stranding, likely\n from recent vascular access.\n\n CT OF THE PELVIS: There is sigmoid diverticulosis without diverticulitis. The\n rectum and prostate are normal. There is a fat-containing right inguinal\n hernia.\n\n No concerning lytic or sclerotic lesions. There are severe degenerative\n changes in the lower lumbar spine, particularly with facet hypertrophy at L4-5\n and L5-S1. There is a right L5 pars defect.\n\n IMPRESSION:\n 1. Large AAA measuring up to 7.4 cm. The aneurysm starts at the level of\n the left renal artery and is bilobed, with a significant amount of soft plaque\n within the inferior portion of it. There is no extension into the iliac\n arteries or branch vessels.\n\n 2. Soft tissue stranding and air in the right groin from prior intervention.\n No hematoma.\n\n 3. Bilateral adrenal adenomas.\n\n 4. Moderate-to-severe bibasilar emphysema.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1192257,
"text": " 10:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube removal, to assess for pneumothorax.\n\n FINDINGS: In comparison with study of , the monitoring and support\n devices have all been removed except for the right IJ Swan-Ganz sheath. No\n evidence of pneumothorax. Mild atelectatic changes are seen at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1192374,
"text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Hypotensive and wheezing\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hypotension and wheezing\n REASON FOR THIS EXAMINATION:\n Hypotensive and wheezing\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension and wheezing.\n\n FINDINGS: In comparison with the study of , there is some increasing\n opacification at the left base with poor definition of the hemidiaphragm,\n consistent with worsening effusion and underlying atelectasis. An area of\n ill-defined opacification at the left base is asymmetric with the opposite\n side and could represent a developing consolidation.\n\n The right IJ sheath has been removed. No evidence of vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-23 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1191593,
"text": " 3:10 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with multivessel CAD who needs pre-OP CXR prior to CABG.\n REASON FOR THIS EXAMINATION:\n Pre-OP CXR.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multivessel CAD, pre-operative chest x-ray.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: Severe pulmonary emphysema. The presence of minimal bilateral\n dorsal pleural effusions cannot be excluded. No evidence of pneumonia.\n Normal size of the cardiac silhouette. Moderate tortuosity of the thoracic\n aorta. No lung nodules or masses. No evidence for hilar or mediastinal\n abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-21 00:00:00.000",
"description": "AORTA AND BRANCHES",
"row_id": 1191351,
"text": " 3:02 PM\n AORTA AND BRANCHES Clip # \n Reason: rule out AAA\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ntemi w concern for abd aneurysm durin cardiac cath\n earlier today\n REASON FOR THIS EXAMINATION:\n rule out AAA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post NSTEMI with concern for abdominal aneurysm during\n cardiac catheterization earlier today. Assess for AAA.\n\n COMPARISON: None.\n\n FINDINGS: There is a large abdominal aortic aneurysm spanning approximately\n 15 cm and measuring up to 7.5 cm in diameter. Intramural thrombus is noted.\n The bilateral proximal common iliac arteries are ectatic measuring\n approximately 1.4 cm in diameter.\n\n The kidneys are normal appearing bilaterally. The right kidney measures 12.3\n cm and the left kidney also measures 12.3 cm. The bladder is unremarkable.\n\n IMPRESSION:\n 1. Large abdominal aortic aneurysm, spanning approximately 15 cm and\n measuring up to 7.1 cm in diameter. There is intraluminal thrombus present.\n 2. Ectatic proximal bilateral common iliac arteries.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-23 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 1191507,
"text": " 8:05 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: Pre-operative evaluation for CABG.\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with NSTEMI s/p cath with MVD with plans to go to CABG.\n REASON FOR THIS EXAMINATION:\n Pre-operative evaluation for CABG.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old gentleman with MRI, status post cath with plans to go\n to CABG.\n\n TECHNIQUE: Venous mapping of the superficial veins in the bilateral lower\n extremities was performed with B-mode ultrasound.\n\n FINDINGS: The right great saphenous vein presented patent and compressible\n with diameters ranging between 0.20 and 0.30 cm.\n\n The left great saphenous vein presented patent and compressible with diameters\n ranging between 0.20 and 0.45 cm.\n\n COMPARISON: None available.\n\n IMPRESSION: Patent bilateral great saphenous veins, with diameters described\n above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-23 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1191505,
"text": " 8:01 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Pre-operative evaluation for CABG. Stenosis?\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p NSTEMI here for CABG.\n REASON FOR THIS EXAMINATION:\n Pre-operative evaluation for CABG. Stenosis?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 66-year-old gentleman status post MI, preop for CABG.\n\n TECHNIQUE: Evaluation of the bilateral extracranial carotid arteries was\n performed with grayscale, color and spectral Doppler ultrasound.\n\n FINDINGS: Mild amount of plaque was seen at the proximal internal carotid\n arteries, bilaterally.\n\n On the right side, peak systolic velocities were 68 cm/sec for the internal\n carotid artery, 77 cm/sec for the common carotid artery and 76 cm/sec for the\n external carotid artery. The right ICA/CCA ratio was 0.88.\n\n On the left side, peak systolic velocities were 72 cm/sec for the ICA, 79\n cm/sec for the CCA, and 62 cm/sec for the ECA. The left ICA/CCA ratio was\n 0.91.\n\n Both vertebral arteries presented antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION: Less than 40% stenosis of the bilateral extracranial internal\n carotid arteries.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-05-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1192117,
"text": " 1:27 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;c\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;contact NP\n # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after cardiac surgery.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 4.5 cm above the carina. The NG tube tip is in the\n stomach. Left chest tube is in place. Swan-Ganz catheter tip is in the right\n main pulmonary artery. Mediastinal drains are in place.\n\n Cardiomediastinal silhouette is stable. Left retrocardiac opacity most likely\n consistent with post-surgical atelectasis. There is small amount of left\n pleural effusion. There is no pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2147-05-29 00:00:00.000",
"description": "Report",
"row_id": 91937,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. S/p CABGx4 1 week ago. Left ventricular function. Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 112/70\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 16:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%\ndecrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV motion\nabnormality cannot be fully excluded. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Due to suboptimal technical quality,\na focal motion abnormality cannot be fully excluded. The estimated\ncardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and\nfree motion are normal. The asscending aorta is dilated at the sinus\nlevel. The aortic valve leaflets (?#) appear structurally normal with good\nleaflet excursion. There is no aortic valve stenosis. No aortic regurgitation\nis seen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. There is moderate pulmonary\nartery systolic hypertension. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global biventricular systolic function. Pulmonary\nartery hypertension. Dilated aortic sinus.\n\nCompared with the prior study (images reviewed) of , global left\nventricular systolic function is improved and the estimated pulmonary artery\nsystolic pressure is higher.\nThese findings are suggestive of a primary pulmonary process.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2147-05-26 00:00:00.000",
"description": "Report",
"row_id": 91938,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 08:14\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of\nthe LAA. No spontaneous echo contrast or thrombus in the body of the \n LAA. All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: thickness and cavity dimensions were obtained from 2D\nimages. Normal LV thickness. Normal LV cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV MOTION: Regional LV motion abnormalities include: basal\ninferolateral - hypo; mid inferolateral - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nNormal aortic diameter at the sinus level. Mildly dilated descending aorta.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast is\nseen in the body of the left atrium or left atrial appendage. No spontaneous\necho contrast or thrombus is seen in the body of the left atrium or left\natrial appendage. Left ventricular thicknesses are normal. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction with mid-anterior hypokinesis. The remaining left\nventricular segments contract normally. Right ventricular chamber size and\nfree motion are normal. The diameters of aorta at the sinus, ascending\nand arch levels are normal. The descending thoracic aorta is mildly dilated.\nThere are simple atheroma in the descending thoracic aorta. There are three\naortic valve leaflets. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nPOST CPB:\n\n1. Unchanged left and right ventricular systolic function\n\n2. Central mild to moderate mitral regurgitation\n\n3. Intact aorta\n\n\n"
},
{
"category": "Echo",
"chartdate": "2147-05-23 00:00:00.000",
"description": "Report",
"row_id": 91939,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension.\nHeight: (in) 66\nWeight (lb): 150\nBSA (m2): 1.77 m2\nBP (mm Hg): 114/74\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:31\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV MOTION: Regional LV motion abnormalities include: basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with very mild inferolateral hypokinesis. The remaining\nsegments contract normally (LVEF = 50%). Right ventricular chamber size and\nfree motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: Mild symmetric LVH with mild regional left ventricular systolic\ndysfunction, c/w CAD. No clinically-significant valvular disease seen. Mild\npulmonary hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-05-28 00:00:00.000",
"description": "Report",
"row_id": 248016,
"text": "Sinus rhythm. Modest low amplitude lateral lead T wave changes are\nnon-specific. Since the previous tracing of left axis deviation is now\nabsent.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-05-26 00:00:00.000",
"description": "Report",
"row_id": 248017,
"text": "Baseline artifact. Sinus rhythm. Leftward axis. Consider left anterior\nfascicular block. Borderline low voltage throughout. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. T waves are\nimproved.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-05-23 00:00:00.000",
"description": "Report",
"row_id": 248018,
"text": "Sinus rhythm. T wave flattening in the inferior and anterolateral leads.\nCompared to the previous tracing of the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-05-20 00:00:00.000",
"description": "Report",
"row_id": 248019,
"text": "Sinus bradycardia with minor non-diagnostic repolarization abnormalities. No\nprevious tracing available for comparison.\n\n"
}
] |
92,005 | 114,220 | This is a yo F with h/o a fib s/p recent 2nd cardioversion on , HTN, ? CAD s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w afib w/ RVR, persistent weakness, lightheadedness, vertigo and DOE. . 1. Afib w/ RVR. Pt. was admitted with presyncopal symptoms and vertigo, likely from central hypoperfusion, though cerebellar dysfunction could not be ruled out given positive romberg in setting of intact proprioception. She was HD stable on admission and her INR was 3.6. Her Afib recurrence was felt to be exacerbating CHF as evident on last TEE. Patient was restarted on Verapamil of 180mg, her BB was increased to 37.5mg and her coumadin was held. On HD#2, patient developed afib with slow VR, chest pain, diaphoresis and nausea, her ECG was unchanged and her CE were negative x1. She subsequently developed hypotension to mid 70s mmHgs, which did not respond to IVF and required dopamine for HD stability. She was temporarily transferred to CCU where pressors were weaned within few hours of arrival. It was felt that her hypotension was secondary to poor inotropy in setting of bradycardia from multiple nodal blocking agents. Throughout stay in CCU she was borderline tachycardic and was eventually placed back on small dose of lopressor for HR control. On HD#3 she was transferred to the floor w/ HR of 100bpm and only on 12.5mg of metoprolol. She remained HD stable and converted to atrial tachycardia vs. slow aflutter. Her BB was increased and she was started on low dose digoxin without loading, 0.125 mg EOD. . On this regiment her HR was difficult to control. She continued to remain in Afib/flutter with HR in 100s despite 50mg TID of BB, digoxin. She was started on amiodarone and underwent cardioversion on . This was successful, pt. was in sinus rhythm. Her BB was decreased to 12.5 due to temporary bradycardia to high 40s, digoxin was discontinued and amiodarone decreased to 200mg . With this regimen, HR maintained in 50s, her DOE improved significantly and her lightheadedness and dizziness resolved. On at ~ 11pm patient was noted be unable to speak. Her neurological deficits included R facial droop and eye lid muscle weakness. Code stroke was called, CT head showed a L distal MCA stroke in insular region. No tPA was administered due to INR of 2.9. Her INR became supratherapeutic with INR 3.9 on her day of discharge hence Coumadin is held for now. It needs to be restarted at 1mg once daily once INR <3.0 and needs daily monitoring until stable. Dosing may need to go up once Amiodarone dosing decreases to daily dosing on . Also, patient should be started on lisinopril for heart protection on . . 2. CAD - Pt. had h/o CAD with no h/o MI, CABG or PCI. She had a clean cath in . Based on above PMHx it was not suspected that she had flow limiting CAD, especially with no elevation of CEs in setting of cardiogenic shock. She ruled out for MI. She was continued on BB as above. . 3. Systolic CHF. Pt. had a nl EF in Echo, but no other imaging except a TEE, where it was noted that she had mild systolic dysfunction. TTE here prior to hypotensive episode showed global vertricular dysfunction w/ EF of 20-25% Given lack of significant CAD, this was felt to be most likely tachycardia-related cardiomyopathy and treatment was focused on HR control. Pt. was volume overloaded on exam, likely contributed by the tachycardia and poor filling. She was continued on home dose of lasix. She was started on ACE-I, Lisinopril 5mg daily, however due to renal failure, Cr. 1.5 this was discontinued. Her lasix was held on . This should be restarted within a day as tolerated by volume status, likely (home lasix dose of 40mg PO). . 4. Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased CO w/ LV CHF in setting of afib. Cr recovered to 1.1, near baseline after complications with hypotension, however bumpted back up s/p cardioversion in setting of receiving extra 10mg IV lasix. Cr improved to 1.2 on . Her lasix is currently being held. . 5. Left MCA infarct in the setting of therapeutic INR: Most likely cardioembolic given the risk factor and patient returned to Afib rhythm from sinus after cardioversion. Pt was not a thrombolytic or endovascular therapy candidate due to high INR hence high bleeding risk. Patient was transferred to the neurology service on and MRI showed that she has acute superior division of L MCA infarct (precentral gyrus) but not a large infarct hence safe for anticoagulation. Patient remains unable to speak, but can make vocalizations, and is able to swallow. She has mild R facial droop with weakness, more in the arm than leg. Physical and occupational therapy recommended acute rehab. | # Supratherapeutic INR: Now resolved. # Bradycardia: currently resolved # Afib w/ RVR. # baseline HTN - currently hypotensive. # baseline HTN - currently hypotensive. # baseline HTN - currently hypotensive. # baseline HTN - currently hypotensive. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. # Bradycardia: currently resolved. # Bradycardia: currently resolved. # Bradycardia: currently resolved. # Bradycardia: currently resolved. # Hypotension: Ddx includes 1. # Hypotension: Ddx includes 1. # Hypotension: Ddx includes 1. # baseline HTN - currently normotensive. Right ventricular function.Height: (in) 60Weight (lb): 115BSA (m2): 1.48 m2BP (mm Hg): 124/96HR (bpm): 90Status: InpatientDate/Time: at 10:46Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness and cavity size. The right ventricular cavity is moderately dilated with moderate globalfree wall hypokinesis. There is no pericardial effusion.IMPRESSION: Severe global LV systolic dysfunction with somewhat betterfunction of the basal inferior and inferolateral segments and the apicalsegments. pt with + pp by doppler. rehab stay with complications incl cellulitis, PNA. rehab stay with complications incl cellulitis, PNA. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. Hypovolemic shock, in the setting of diuresis. Hypovolemic shock, in the setting of diuresis. Hypovolemic shock, in the setting of diuresis. Was rate controlled with metoprolol and diuresed with lasix. Was rate controlled with metoprolol and diuresed with lasix. Was rate controlled with metoprolol and diuresed with lasix. Was rate controlled with metoprolol and diuresed with lasix. # Supratherapeutic INR: Now resolved. baseline HTN - currently hypotensive. # Bradycardia: currently resolved. # Bradycardia: currently resolved. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Admitted with AF/RVR, complicated by mild CHF. Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. # baseline HTN - currently normotensive. # Hypotension: Ddx includes 1. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. FEN: NPO ACCESS: PIV's PROPHYLAXIS: -DVT PNB. Since the previous tracing of atrial fibrillation hasreplaced atrial flutter.TRACING #1 Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. rehab stay with complications incl cellulitis, PNA. Added metoprolol for rate control. Check CXR to r/o pneumothorax. Was rate controlled with metoprolol and diuresed with lasix. Remains on coumadin (caution with INR level if starting amiodarone). Remains on coumadin (caution with INR level if starting amiodarone). Remains on coumadin (caution with INR level if starting amiodarone). Sincethe previous tracing of atrial fibrillation is absent.TRACING #2 Hypovolemic shock, in the setting of diuresis. Compared to TEE on (performed in setting of DCCV for AF/RVR), the depressed EF is new. -Bowel regimen with colace/senna prn. TITLE: Procedure note RIJ vein central line performed with site rite guidance, aseptic seldinger technique. TITLE: CCU fellow brief admit note yo F with HTN, persistent transferred to CCU for hypotension, bradycardia. Modest ST-T wave changes. For now 1) stop IVF 2) Wean dopamine if possible 3) Central access with 2 units FFP. Likely medication induced. Chief Complaint: Hypotension, bradycardia HPI: Please see admission H&P for full details. RSR' pattern in lead V2. takes lasix prn for this. s/p b/l tonsillectomy #. Sclera anicteric. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. Compared to the previous tracing Wenckebach conduction is nowpresent. Will add back home antiHTN meds when hypotension resolves. Non-specific T wave changes.Prolongation of the QTc interval to 473 milliseconds.TRACING #1 Slow atrial flutter with Wenckebach conduction. Will reases cre in setting of pressure support. Typical atrial flutter with predominant 2:1 conduction and a ventricular rateof about 120. Restart coumadin today. Chronic renal failure - baseline Cr 1.0 #. For now will continue dopamine since SBP >100. Reportedly her EF from a TEE done in early was near normal (reported as mild depressed LVEF. Significant pulmonic regurgitation is seen. Significant pulmonic regurgitation is seen. | 34 | [
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 568573,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned dopa, pressures 90-100\n - femoral line placed\n - HCT 26 from 30, rechecking HCT\n - Cx ngtd\n - wbc improved\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 106 (99 - 122) bpm\n BP: 126/69(84) {75/35(51) - 134/69(84)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 60 Inch\n Total In:\n 1,052 mL\n 25 mL\n PO:\n TF:\n IVF:\n 476 mL\n 25 mL\n Blood products:\n 576 mL\n Total out:\n 1,480 mL\n 220 mL\n Urine:\n 1,480 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -428 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n GENERAL: Oriented x3. Mood, affect appropriate, very pleasant elderly\n woman.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry oral mucosa. No\n xanthalesma.\n NECK: Supple with JVP of 8 cm.\n CTAb. No wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: Warm, dry, strong distal pulses, RLE pitting edema 1+ \n up tibia.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 212 K/uL\n 8.3 g/dL\n 76 mg/dL\n 1.3 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.2 %\n 7.0 K/uL\n [image002.jpg]\n 08:02 PM\n 03:46 AM\n WBC\n 7.0\n Hct\n 30.9\n 26.2\n Plt\n 212\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 76\n Other labs: PT / PTT / INR:26.4/31.7/2.6, CK / CKMB /\n Troponin-T:43//<0.01, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR\n New left pleural effusin and retrocardiac opacity, could reflect\n pneumonia,\n correlation with lateal view will be helpful. Mild worsening of\n intersitial\n edema.\n TTE\n The left atrium is dilated. Left ventricular wall thicknesses and\n cavity size are normal. There is severe global left ventricular\n hypokinesis (LVEF = 20-25 %). The right ventricular cavity is\n moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n was transfered to the CCU.\n # Hypotension: Most likely cardiogenic shock, precipitated by nodal\n blockade. Has been doing well off dopa. Considering cath but the most\n likely cause for decompensation are medications as opposed to\n ischemia. No evidence for septic/hypovolemic shock. Call out later\n today.\n # Bradycardia: currently resolved. Likely medication induced.\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Added metoprolol for rate control. Would be cautious\n with dosing of verapramil and flecanide. Consider starting amiodarone\n today as will give beta blockade and rhythm control and failed DCCV and\n flecainide already. Will monitor for medication interactions especially\n coumadin.\n # Supratherapeutic INR: Now resolved. Restart coumadin today.\n # Pump: decreased pump function on tte yesterday. Suggest repeat tte in\n a few months to see if resolves as likely from acute bradycardia and\n hypotension yesterday.\n # baseline HTN - currently normotensive. Will add back home antiHTN\n meds when necessary.\n # Acute on Chronic RF: Cr on admission up to 1.5 Likely due decreased\n forward flow. Urine output much improved and creatinine coming down\n (1.3 today) Will monitor.\n ICU Care\n Nutrition: HH diet\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n 20 Gauge - 03:00 PM\n Multi Lumen - 05:45 PM->pull fem line today prior to\n transfer to floor\n Prophylaxis:\n DVT: systemic anticoagulation with coumadin\n Stress ulcer: PPI\n Communication: with patient\n Code status: full\n Disposition: to floor today\n"
},
{
"category": "Echo",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Report",
"row_id": 103858,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function. Right ventricular function.\nHeight: (in) 60\nWeight (lb): 115\nBSA (m2): 1.48 m2\nBP (mm Hg): 124/96\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:46\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid leaflets do not\nfully coapt. Moderate [2+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses and cavity size\nare normal. There is severe global left ventricular hypokinesis (LVEF = 20-25\n%). The right ventricular cavity is moderately dilated with moderate global\nfree wall hypokinesis. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets fail to\nfully coapt. Moderate [2+] tricuspid regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Severe global LV systolic dysfunction with somewhat better\nfunction of the basal inferior and inferolateral segments and the apical\nsegments. There is akinesis of the anterior and anterolateral segments. The\nright ventricle is dilated and hypokinetic. Mild mitral and moderate tricuspid\nregurgitation.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 568549,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned dopa, pressures 90-100\n - femoral line placed\n - HCT 26 from 30, rechecking HCT\n - Cx ngtd\n - wbc improved\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 106 (99 - 122) bpm\n BP: 126/69(84) {75/35(51) - 134/69(84)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 60 Inch\n Total In:\n 1,052 mL\n 25 mL\n PO:\n TF:\n IVF:\n 476 mL\n 25 mL\n Blood products:\n 576 mL\n Total out:\n 1,480 mL\n 220 mL\n Urine:\n 1,480 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -428 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n GENERAL: Oriented x3. Mood, affect appropriate, very pleasant elderly\n woman.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry oral mucosa. No\n xanthalesma.\n NECK: Supple with JVP of 8 cm.\n CTAb. No wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: Warm, dry, strong distal pulses, RLE pitting edema 1+ \n up tibia.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 212 K/uL\n 8.3 g/dL\n 76 mg/dL\n 1.3 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.2 %\n 7.0 K/uL\n [image002.jpg]\n 08:02 PM\n 03:46 AM\n WBC\n 7.0\n Hct\n 30.9\n 26.2\n Plt\n 212\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 76\n Other labs: PT / PTT / INR:26.4/31.7/2.6, CK / CKMB /\n Troponin-T:43//<0.01, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR\n New left pleural effusin and retrocardiac opacity, could reflect\n pneumonia,\n correlation with lateal view will be helpful. Mild worsening of\n intersitial\n edema.\n TTE\n The left atrium is dilated. Left ventricular wall thicknesses and\n cavity size are normal. There is severe global left ventricular\n hypokinesis (LVEF = 20-25 %). The right ventricular cavity is\n moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n is transfered to the CICU.\n # Hypotension: Most likely cardiogenic shock, precipitated by nodal\n blockade. Has been doing well off dopa. Considering cath but the most\n likely cause for decompensation are medications as opposed to\n ischemia. No evidence for septic/hypovolemic shock. Call out later\n today.\n # Bradycardia: currently resolved\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Added metoprolol for rate control. Would be cautious\n with dosing of verapramil and flecanide.\n # Supratherapeutic INR: holding warfarin, INR 2.6\n .\n # baseline HTN - currently hypotensive. Will add back home antiHTN meds\n when hypotension resolves.\n # Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased\n forward flow. Urine output much improved. Will monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n 20 Gauge - 03:00 PM\n Multi Lumen - 05:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 568507,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned dopa, pressures 90-100\n - femoral line placed\n - HCT 26 from 30, rechecking HCT\n - Cx ngtd\n - wbc improved\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 106 (99 - 122) bpm\n BP: 126/69(84) {75/35(51) - 134/69(84)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 60 Inch\n Total In:\n 1,052 mL\n 25 mL\n PO:\n TF:\n IVF:\n 476 mL\n 25 mL\n Blood products:\n 576 mL\n Total out:\n 1,480 mL\n 220 mL\n Urine:\n 1,480 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -428 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 212 K/uL\n 8.3 g/dL\n 76 mg/dL\n 1.3 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.2 %\n 7.0 K/uL\n [image002.jpg]\n 08:02 PM\n 03:46 AM\n WBC\n 7.0\n Hct\n 30.9\n 26.2\n Plt\n 212\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 76\n Other labs: PT / PTT / INR:26.4/31.7/2.6, CK / CKMB /\n Troponin-T:43//<0.01, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR\n New left pleural effusin and retrocardiac opacity, could reflect\n pneumonia,\n correlation with lateal view will be helpful. Mild worsening of\n intersitial\n edema.\n TTE\n The left atrium is dilated. Left ventricular wall thicknesses and\n cavity size are normal. There is severe global left ventricular\n hypokinesis (LVEF = 20-25 %). The right ventricular cavity is\n moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n 20 Gauge - 03:00 PM\n Multi Lumen - 05:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 568510,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned dopa, pressures 90-100\n - femoral line placed\n - HCT 26 from 30, rechecking HCT\n - Cx ngtd\n - wbc improved\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 106 (99 - 122) bpm\n BP: 126/69(84) {75/35(51) - 134/69(84)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 60 Inch\n Total In:\n 1,052 mL\n 25 mL\n PO:\n TF:\n IVF:\n 476 mL\n 25 mL\n Blood products:\n 576 mL\n Total out:\n 1,480 mL\n 220 mL\n Urine:\n 1,480 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -428 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n GENERAL: Oriented x3. Mood, affect appropriate, very pleasant elderly\n woman.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry oral mucosa. No\n xanthalesma.\n NECK: Supple with JVP of 8 cm.\n CTAb. No wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: Warm, dry, strong distal pulses, RLE pitting edema 1+ \n up tibia.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 212 K/uL\n 8.3 g/dL\n 76 mg/dL\n 1.3 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.2 %\n 7.0 K/uL\n [image002.jpg]\n 08:02 PM\n 03:46 AM\n WBC\n 7.0\n Hct\n 30.9\n 26.2\n Plt\n 212\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 76\n Other labs: PT / PTT / INR:26.4/31.7/2.6, CK / CKMB /\n Troponin-T:43//<0.01, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR\n New left pleural effusin and retrocardiac opacity, could reflect\n pneumonia,\n correlation with lateal view will be helpful. Mild worsening of\n intersitial\n edema.\n TTE\n The left atrium is dilated. Left ventricular wall thicknesses and\n cavity size are normal. There is severe global left ventricular\n hypokinesis (LVEF = 20-25 %). The right ventricular cavity is\n moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n is transfered to the CICU.\n # Hypotension: Ddx includes 1. Cardiogenic shock, in the setting of\n depressed EF (unlear if this is acute or chronic). No ECG or CE changes\n to support acute infarction or ishcemic changes. Cath in 96 negative\n but this cant fully exclude CAD and thus some form of ischemic\n cardiomyopathy. Also possible is that the decreased ionotropy caused by\n BB/CCB may have contributed to the depressed EF. If this is the case\n this should improve with tincture of time. No clinical evidence of CHF\n at this time. 2. Septic shock, in the setting of WBC elevation, and\n lactate elevation (although lactate would be increased in other causes\n of decreased perfusion). 3. Hypovolemic shock, in the setting of\n diuresis. However, she doesn\nt look dry on exam, BUN/Cre barely 20. No\n evidence of hemorrhage or HCT drop. She received IVF on the floor and\n currently on pressor support. Currently BP is better on dopamine. Will\n place new RIJ for pressure support and monitoring. Will check CE and\n repeat ECG if CP. Will send for blood cx, UA/cx, CXR, differential and\n will monitor fever curve. If spikes will add broad spectrum abx. For\n now will continue dopamine since SBP >100. Will consider changing to\n norepinephrine (a and b effects) if her blood pressure becomes low on\n dopamine. Will most likely require cath to eval possibility of ischemic\n disease.\n # Bradycardia: currently resolved. Most likely to nodal blocking\n agents. Will monitor.\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Will hold nodal blockers for brady, but if she has RVR\n and pressure tolerates will add metoprolol.\n # Supratherapeutic INR: holding warfarin, FFP to reverse for procedure.\n Will monitor.\n # ?? CAD - h/o CAD is questionable with no h/o MI, CABG, PCI. Clean\n cath in . She has not had recent ETT or cath to eval for CAD or\n ischemic disease.\n # baseline HTN - currently hypotensive. Will add back home antiHTN meds\n when hypotension resolves.\n # Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased\n forward flow. Will reases cre in setting of pressure support. Will\n monitor U/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n 20 Gauge - 03:00 PM\n Multi Lumen - 05:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 568513,
"text": "Chief Complaint: Hypotension, bradycardia\n HPI:\n Please see admission H&P for full details. Briefly, Mrs. is a\n very pelasant yo woman with CAD, paroxysmal atrial fibrillation s/p\n failed cardioversion (most recent on ), CKD (Stage III) who\n initially presented with 4 weeks of lightheadedness and vertigo\n and 3 days of SOB, found to be in afib, and now is transferred to CCU\n for hypotension and bradycardia.\n She was seen by her primary cardiologist , at which time her\n flecainide was d/c'ed and her metoprolol and diltiazem were increased\n for rate control. Apparently she had not been taking the prescribed\n doses of BB/CCB and presented to the ED with chest pressure and\n atrial fibrillation with RVR. Initially she was admitted to where\n she was noted to be in volume overload and diuresed with lasix, 40 mg\n IV. She was also given metoprolol (at increased dose from 12.5 to 25\n then 50 over the course of two days) and verapramil (180 mg qd) to\n control her afib. This morning she complained of chest pain, was noted\n to be bradycardic (60s) and hypotensive (SBP in mid 70s). He was given\n 1.5 lt of IVF bolus and started on dopamine (uptitrated to 20 mcg).\n After these interventions her pressure improved to the 100s but then\n decreased again to the 90s. Her urine output remained low. She had\n cardiac enzymes drawn, the first set being negative, an ECG without ST\n changes, and an TTE, which showed global hypokinesis with EF of 25%.\n Reportedly her EF from a TEE done in early was near normal\n (reported as mild depressed LVEF. Last ECHO before that was in 90s with\n normal EF. Also has had a cath in the 90s with normal coronaries, per\n report. Notably her INR is also elevated to 3.7, presumably secondary\n to warfarin.\n Several days prior to presnetation her VNA found her to be tachycardic\n to 120s, and was referred Dr. saw her and d/ced her\n fleicanide and increased her metoprolol, which the patient did not take\n as she did not pick up prescirption. She also reports having chest\n pain/pressure o/n 4d PTA, non-radiating, no n/v/diaphoresis resolved w/\n burping. Patient was recently admitted with Afib w/ RVR, was\n cardioverted on and discharged home on flecainide, verapamil,\n metroprolol. She has had no palpitations, no syncope, no PND or\n orthopnea. Pt. also reports persistent RLE edema, since her rehab\n discharge, this is unchaged, pt. takes lasix prn for this.\n In the CCU, the patient admits to feeling cold. She denies, chest pain,\n palpitations, fevers, chills, cough, abdominal pain, or bleeding. There\n is no difficulty w/ speech. No dysuria, no abdominal pain,\n constipation/diarrhea.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MEDS ON TRANSFER\n Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY\n Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN\n Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN\n Aspirin 325 mg PO DAILY\n Metoprolol Tartrate 50 mg PO Q8H\n Calcium Carbonate 500 mg PO BID\n Multivitamins 1 TAB PO DAILY\n Nitroglycerin SL 0.3 mg SL PRN\n Cyanocobalamin 1000 mcg IM/SC QMONTHLY\n Omeprazole 20 mg PO DAILY\n DOPamine 2-20 mcg/kg/min IV DRIP TITRATE TO HR >60\n Ranitidine 150 mg PO HS\n Furosemide 40 mg IV ONCE\n Verapamil SR 180 mg PO Q24H\n Vitamin D 400 UNIT PO DAILY\n Past medical history:\n Family history:\n Social History:\n .\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: NONE\n -PERCUTANEOUS CORONARY INTERVENTIONS: Clean coronaries on C Cath \n .\n -PACING/ICD: None.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n #. a-fib- cardioversion , on flecainide, verapamil and\n metoprolol at home.\n #. HTN - on Metoprolol, Imdur and hydralazine at home\n #. ? coronary artery disease - clean coronaries on C Cath .\n #. Chronic renal failure - baseline Cr 1.0\n #. Left distal femur fracture w/ ORIF during hospitalization\n . rehab stay with complications incl\n cellulitis, PNA.\n #. ? hyperparathyroidism\n #. Osteoporosis\n #. Cervical disc disease\n #. Osteoarthritis\n #. GERD\n #. B12 deficiency\n Surgical history:\n #. s/p b/l tonsillectomy\n #. Cholecystectomy\n #. Left knee replacement\n #. Appendectomy\n #. Colon resection with colostomy (since reversed) -\n patient\n does not recall specifics\n #. Hysterectomy for excessive bleeding\n Denies h/o HTN, DM, hyperlipidemia, heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives alone in apt in with VNA. She is a retired\n accountant having graduated from . She has no children.\n Her neice is her only family, is involved, and lives in . Is\n independent in ADLs and uses walker. -Tobacco history: Never -ETOH:\n None -Illicit drugs: Never\n Review of systems:\n Flowsheet Data as of 05:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.6\n Tcurrent: 35.3\nC (95.6\n HR: 109 (102 - 109) bpm\n BP: 110/38(56) {75/38(56) - 113/64(72)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 663 mL\n PO:\n TF:\n IVF:\n 87 mL\n Blood products:\n 576 mL\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 613 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316\n 1.5\n 33\n 21\n 107\n 4.3\n 140\n 33.2\n 13.3\n [image002.jpg]\n Fluid analysis / Other labs: Lactate:3.1\n CK: 33 MB: Notdone Trop-T: <0.01\n PT: 34.7 PTT: 33.1 INR: 3.7\n Ca: 8.5 Mg: 2.1 P: 3.8\n LDH: 393\n Imaging: TTE: The left atrium is dilated. Left ventricular wall\n thicknesses and cavity size are normal. There is severe global left\n ventricular hypokinesis (LVEF = 20-25 %). The right ventricular cavity\n is moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n CXR: Relatively stable examination with marked cardiomegaly and no\n acute pulmonary process.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n is transfered to the CICU.\n # Hypotension: Ddx includes 1. Cardiogenic shock, in the setting of\n depressed EF (unlear if this is acute or chronic). No ECG or CE changes\n to support acute infarction or ishcemic changes. Cath in 96 negative\n but this cant fully exclude CAD and thus some form of ischemic\n cardiomyopathy. Also possible is that the decreased ionotropy caused by\n BB/CCB may have contributed to the depressed EF. If this is the case\n this should improve with tincture of time. No clinical evidence of CHF\n at this time. 2. Septic shock, in the setting of WBC elevation, and\n lactate elevation (although lactate would be increased in other causes\n of decreased perfusion). 3. Hypovolemic shock, in the setting of\n diuresis. However, she doesn\nt look dry on exam, BUN/Cre barely 20. No\n evidence of hemorrhage or HCT drop. She received IVF on the floor and\n currently on pressor support. Currently BP is better on dopamine. Will\n place new RIJ for pressure support and monitoring. Will check CE and\n repeat ECG if CP. Will send for blood cx, UA/cx, CXR, differential and\n will monitor fever curve. If spikes will add broad spectrum abx. For\n now will continue dopamine since SBP >100. Will consider changing to\n norepinephrine (a and b effects) if her blood pressure becomes low on\n dopamine. Will most likely require cath to eval possibility of ischemic\n disease.\n # Bradycardia: currently resolved. Most likely to nodal blocking\n agents. Will monitor.\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Will hold nodal blockers for brady, but if she has RVR\n and pressure tolerates will add metoprolol.\n # Supratherapeutic INR: holding warfarin, FFP to reverse for procedure.\n Will monitor.\n # ?? CAD - h/o CAD is questionable with no h/o MI, CABG, PCI. Clean\n cath in . She has not had recent ETT or cath to eval for CAD or\n ischemic disease.\n # baseline HTN - currently hypotensive. Will add back home antiHTN meds\n when hypotension resolves.\n # Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased\n forward flow. Will reases cre in setting of pressure support. Will\n monitor U/O.\n MD PhD \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n PE addendum for previous note:\n GENERAL: Oriented x3. Mood, affect appropriate, very pleasant elderly\n woman.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry oral mucosa. No\n xanthalesma.\n NECK: Supple with JVP of 8 cm.\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Resp were unlabored, no accessory muscle use. Fine crackles\n bibasilar, with inability to examine back. No wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: Warm, dry, strong distal pulses, RLE pitting edema 1+ \n up tibia.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n ------ Protected Section Addendum Entered By: , MD\n on: 05:55 ------\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1074797,
"text": ", J. 2:01 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Assess for CVA progression, please obtain without gadolliniu\n Admitting Diagnosis: RAPID AFIB\n Contrast: MAGNEVIST Amt: 24\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L CVA o/n now with new deficits in R arm and L arm\n REASON FOR THIS EXAMINATION:\n Assess for CVA progression, please obtain without gadollinium\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Acute infarct involving subcortical white matter within the left frontal\n and temporal lobes, without evidence of hemorrhagic transformation or mass\n effect.\n\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 568581,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU service\n for hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metropolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU,\n weaned off dopamine shortly after arrival\n Aflutter 90-110s. No\n further complaints of CP or GI discomfort. Am HCT 26.2 (30.2-33). K 3.5\n given 40meq KCL via central line this morning.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n This am HR 90-100 without ectopy in AFib.\n Action:\n Hemodynamic monitoring. Re-peat HCT and potassium level sent at 10 am.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Starting amiodarone.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568528,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU for\n hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metoprolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU,\n weaned off dopamine shortly after arrival\n Aflutter 90-110s. No\n further complaints of CP or GI discomfort. Am HCT 26.2 (30.2-33). K 3.5\n given 40meq KCL via central line this morning.\n PLAN: repeat HCT and K level at 9am per CCU team.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n HR 120s on arrival to CCU last evening. Dopamine @ 12mcg/kg/min w/ SBP\n 120-130s.\n Action:\n Weaned dopamine shortly after arrival to CCU.\n Response:\n HR decreased to 90-110s, EKG done overnite, seems to be Aflutter. CCU\n team aware. EKGs and rhythm strips put in chart. Started on lopressor\n 12.5mg po BID this morning at 5am. Am HCT 26.2. K 3.5 (repleated with\n 40meq KCL)\n Plan:\n Con\nt betablocker. Recheck HCT and K level at 9am per CCU intern.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568523,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU for\n hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metoprolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU,\n weaned off dopamine shortly after arrival\n Aflutter 90-110s. No\n further complaints of CP or GI discomfort. Am HCT 26.2 (30.2-33). K 3.5\n given 40meq KCL via central line this morning.\n PLAN: repeat HCT and K level at 9am per CCU team.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n HR 120s on arrival to CCU last evening. Dopamine @ 12mcg/kg/min w/ SBP\n 120-130s.\n Action:\n Weaned dopamine shortly after arrival to CCU.\n Response:\n HR decreased to 90-110s, EKG done overnite, seems to be Aflutter. CCU\n team aware. EKGs and rhythm strips put in chart. Started on lopressor\n 12.5mg po BID this morning at 5am. Am HCT 26.2. K 3.5 (repleated with\n 40meq KCL)\n Plan:\n Con\nt betablocker. Recheck HCT and K level at 9am per CCU intern.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568527,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU for\n hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metoprolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU,\n weaned off dopamine shortly after arrival\n Aflutter 90-110s. No\n further complaints of CP or GI discomfort. Am HCT 26.2 (30.2-33). K 3.5\n given 40meq KCL via central line this morning.\n PLAN: repeat HCT and K level at 9am per CCU team.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n HR 120s on arrival to CCU last evening. Dopamine @ 12mcg/kg/min w/ SBP\n 120-130s.\n Action:\n Weaned dopamine shortly after arrival to CCU.\n Response:\n HR decreased to 90-110s, EKG done overnite, seems to be Aflutter. CCU\n team aware. EKGs and rhythm strips put in chart. Started on lopressor\n 12.5mg po BID this morning at 5am. Am HCT 26.2. K 3.5 (repleated with\n 40meq KCL)\n Plan:\n Con\nt betablocker. Recheck HCT and K level at 9am per CCU intern.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 568446,
"text": "Chief Complaint: Hypotension, bradycardia\n HPI:\n Please see admission H&P for full details. Briefly, Mrs. is a\n very pelasant yo woman with CAD, paroxysmal atrial fibrillation s/p\n failed cardioversion (most recent on ), CKD (Stage III) who\n initially presented with 4 weeks of lightheadedness and vertigo\n and 3 days of SOB, found to be in afib, and now is transferred to CCU\n for hypotension and bradycardia.\n She was seen by her primary cardiologist , at which time her\n flecainide was d/c'ed and her metoprolol and diltiazem were increased\n for rate control. Apparently she had not been taking the prescribed\n doses of BB/CCB and presented to the ED with chest pressure and\n atrial fibrillation with RVR. Initially she was admitted to where\n she was noted to be in volume overload and diuresed with lasix, 40 mg\n IV. She was also given metoprolol (at increased dose from 12.5 to 25\n then 50 over the course of two days) and verapramil (180 mg qd) to\n control her afib. This morning she complained of chest pain, was noted\n to be bradycardic (60s) and hypotensive (SBP in mid 70s). He was given\n 1.5 lt of IVF bolus and started on dopamine (uptitrated to 20 mcg).\n After these interventions her pressure improved to the 100s but then\n decreased again to the 90s. Her urine output remained low. She had\n cardiac enzymes drawn, the first set being negative, an ECG without ST\n changes, and an TTE, which showed global hypokinesis with EF of 25%.\n Reportedly her EF from a TEE done in early was near normal\n (reported as mild depressed LVEF. Last ECHO before that was in 90s with\n normal EF. Also has had a cath in the 90s with normal coronaries, per\n report. Notably her INR is also elevated to 3.7, presumably secondary\n to warfarin.\n Several days prior to presnetation her VNA found her to be tachycardic\n to 120s, and was referred Dr. saw her and d/ced her\n fleicanide and increased her metoprolol, which the patient did not take\n as she did not pick up prescirption. She also reports having chest\n pain/pressure o/n 4d PTA, non-radiating, no n/v/diaphoresis resolved w/\n burping. Patient was recently admitted with Afib w/ RVR, was\n cardioverted on and discharged home on flecainide, verapamil,\n metroprolol. She has had no palpitations, no syncope, no PND or\n orthopnea. Pt. also reports persistent RLE edema, since her rehab\n discharge, this is unchaged, pt. takes lasix prn for this.\n In the CCU, the patient admits to feeling cold. She denies, chest pain,\n palpitations, fevers, chills, cough, abdominal pain, or bleeding. There\n is no difficulty w/ speech. No dysuria, no abdominal pain,\n constipation/diarrhea.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MEDS ON TRANSFER\n Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY\n Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN\n Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN\n Aspirin 325 mg PO DAILY\n Metoprolol Tartrate 50 mg PO Q8H\n Calcium Carbonate 500 mg PO BID\n Multivitamins 1 TAB PO DAILY\n Nitroglycerin SL 0.3 mg SL PRN\n Cyanocobalamin 1000 mcg IM/SC QMONTHLY\n Omeprazole 20 mg PO DAILY\n DOPamine 2-20 mcg/kg/min IV DRIP TITRATE TO HR >60\n Ranitidine 150 mg PO HS\n Furosemide 40 mg IV ONCE\n Verapamil SR 180 mg PO Q24H\n Vitamin D 400 UNIT PO DAILY\n Past medical history:\n Family history:\n Social History:\n .\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: NONE\n -PERCUTANEOUS CORONARY INTERVENTIONS: Clean coronaries on C Cath \n .\n -PACING/ICD: None.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n #. a-fib- cardioversion , on flecainide, verapamil and\n metoprolol at home.\n #. HTN - on Metoprolol, Imdur and hydralazine at home\n #. ? coronary artery disease - clean coronaries on C Cath .\n #. Chronic renal failure - baseline Cr 1.0\n #. Left distal femur fracture w/ ORIF during hospitalization\n . rehab stay with complications incl\n cellulitis, PNA.\n #. ? hyperparathyroidism\n #. Osteoporosis\n #. Cervical disc disease\n #. Osteoarthritis\n #. GERD\n #. B12 deficiency\n Surgical history:\n #. s/p b/l tonsillectomy\n #. Cholecystectomy\n #. Left knee replacement\n #. Appendectomy\n #. Colon resection with colostomy (since reversed) -\n patient\n does not recall specifics\n #. Hysterectomy for excessive bleeding\n Denies h/o HTN, DM, hyperlipidemia, heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives alone in apt in with VNA. She is a retired\n accountant having graduated from . She has no children.\n Her neice is her only family, is involved, and lives in . Is\n independent in ADLs and uses walker. -Tobacco history: Never -ETOH:\n None -Illicit drugs: Never\n Review of systems:\n Flowsheet Data as of 05:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.6\n Tcurrent: 35.3\nC (95.6\n HR: 109 (102 - 109) bpm\n BP: 110/38(56) {75/38(56) - 113/64(72)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 663 mL\n PO:\n TF:\n IVF:\n 87 mL\n Blood products:\n 576 mL\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 613 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316\n 1.5\n 33\n 21\n 107\n 4.3\n 140\n 33.2\n 13.3\n [image002.jpg]\n Fluid analysis / Other labs: Lactate:3.1\n CK: 33 MB: Notdone Trop-T: <0.01\n PT: 34.7 PTT: 33.1 INR: 3.7\n Ca: 8.5 Mg: 2.1 P: 3.8\n LDH: 393\n Imaging: TTE: The left atrium is dilated. Left ventricular wall\n thicknesses and cavity size are normal. There is severe global left\n ventricular hypokinesis (LVEF = 20-25 %). The right ventricular cavity\n is moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n CXR: Relatively stable examination with marked cardiomegaly and no\n acute pulmonary process.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n is transfered to the CICU.\n # Hypotension: Ddx includes 1. Cardiogenic shock, in the setting of\n depressed EF (unlear if this is acute or chronic). No ECG or CE changes\n to support acute infarction or ishcemic changes. Cath in 96 negative\n but this cant fully exclude CAD and thus some form of ischemic\n cardiomyopathy. Also possible is that the decreased ionotropy caused by\n BB/CCB may have contributed to the depressed EF. If this is the case\n this should improve with tincture of time. No clinical evidence of CHF\n at this time. 2. Septic shock, in the setting of WBC elevation, and\n lactate elevation (although lactate would be increased in other causes\n of decreased perfusion). 3. Hypovolemic shock, in the setting of\n diuresis. However, she doesn\nt look dry on exam, BUN/Cre barely 20. No\n evidence of hemorrhage or HCT drop. She received IVF on the floor and\n currently on pressor support. Currently BP is better on dopamine. Will\n place new RIJ for pressure support and monitoring. Will check CE and\n repeat ECG if CP. Will send for blood cx, UA/cx, CXR, differential and\n will monitor fever curve. If spikes will add broad spectrum abx. For\n now will continue dopamine since SBP >100. Will consider changing to\n norepinephrine (a and b effects) if her blood pressure becomes low on\n dopamine. Will most likely require cath to eval possibility of ischemic\n disease.\n # Bradycardia: currently resolved. Most likely to nodal blocking\n agents. Will monitor.\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Will hold nodal blockers for brady, but if she has RVR\n and pressure tolerates will add metoprolol.\n # Supratherapeutic INR: holding warfarin, FFP to reverse for procedure.\n Will monitor.\n # ?? CAD - h/o CAD is questionable with no h/o MI, CABG, PCI. Clean\n cath in . She has not had recent ETT or cath to eval for CAD or\n ischemic disease.\n # baseline HTN - currently hypotensive. Will add back home antiHTN meds\n when hypotension resolves.\n # Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased\n forward flow. Will reases cre in setting of pressure support. Will\n monitor U/O.\n MD PhD \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568440,
"text": "pt recently admitted due to afib -> cardioverted on and discharged\n home on lopressor, flecainide and verapamil.\n pt readmitted on -> presented to the ED with SOB, weakness and in\n afib -> to 3.\n This morning, pt\ns BP was 100, with HR 70-80 AF. Received 180mg po\n verapamil and 50mg metoprolol om the morning. At 12pm, pt developed\n heavy substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. pt also c/o abd pain -> treated\n with prilosec, tums and maloxx. Pt was started on dopamine and\n transferred to the ICU for management\n Atrial fibrillation (Afib)\n Assessment:\n Pt alert and orienated x3. MAE and able to follow commands, pt\n hypothermic on arrival. Pt remains in afib, HR 90-120\ns. pt arrived to\n CVICU on dopamine at 20 mcg/kg/min. pt with + pp by doppler. Hct\n stable. INR 3.7 (from this am) last dose coumadin was . LS clear\n with crackles on left side, pt on 4 L NC, o2 sats 95-100%. + bs. Pt\n NPO. Foley draining clear yellow urine. Skin intact. Pt c/o pain \n on pain scale in chest and abdominal area describes pain as sharp.\n Glucose levels 200-260\n Action:\n Pt given 2 \n Pt given 20 mg laisx at 17:30\n attempted R IJ multi lumen -> unable to place\n left femoral multi lumen placed\n CXR done\n Dopamine gtt weaned to keep mean on cuff pressure > 60 per\n cardiology fellow\n Elvated bs treated with ss regular insulin\n UA and culture sent\n 1^st Blood cultures sent\n MRSA screening sent\n Response:\n Pt remains in afib, HR 90-120\ns. SBP ~ 120\ns. Dopamine gtt down to 12.0\n mcg/kg/min. pt diuersing well. Pt reports\nthe pain is all gone\n Plan:\n Monitor for pain, keep NPO for possible cath, wean dopamine gtt as\n tolerated, monitor CK\ns and troponins\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568441,
"text": "Pt Hemodynamically stable. Report called to CCU RN. Dopamine remains at\n 12mcg/kg/min, and afib on tele in 120\ns. Pt denies any pain, and states\nim comfortable.\n Temp 96.9 orally. Tranfsfered on monitor to CCU.\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568438,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 568439,
"text": " yo F with HTN, persistent transferred to CCU for hypotension,\n bradycardia. Admitted with AF/RVR, complicated by mild CHF.\n Was rate controlled with metoprolol and diuresed with lasix. Remained\n hemodynamically stable throughout, with SBP 120s while in AF/RVR of\n 120. This morning, pt\ns BP was 100, with HR 70-80 AF. Received 180mg po\n verapamil and 50mg metoprolol om the morning. At 12pm, pt developed\n heavy substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Pt was started on dopamine and\n transferred to the ICU.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1074796,
"text": " 2:01 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Assess for CVA progression, please obtain without gadolliniu\n Admitting Diagnosis: RAPID AFIB\n Contrast: MAGNEVIST Amt: 24\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L CVA o/n now with new deficits in R arm and L arm\n REASON FOR THIS EXAMINATION:\n Assess for CVA progression, please obtain without gadollinium\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:27 PM\n PFI: Acute infarct involving subcortical white matter within the left frontal\n and temporal lobes, without evidence of hemorrhagic transformation or mass\n effect.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old female with left CVA, with new deficits in the right arm\n and left arm. Assess for CVA progression.\n\n COMPARISON: Head CT .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained\n without IV contrast. Three-dimensional MR arteriography was performed.\n\n FINDINGS: There is an area of restricted diffusion within the left frontal\n and temporal lobe subcortical white matter, compatible with an acute infarct.\n There is no evidence of hemorrhagic transformation. No mass effect is\n identified. No additional foci of infarct is identified. There is\n periventricular white matter T2 hyperintensities bilaterally, compatible with\n chronic small vessel ischemic disease. The ventricles and sulci are\n prominent, compatible with atrophy. There is no evidence of hemorrhage, mass,\n or mass effect. Visualized paranasal sinuses and mastoid air cells reveal\n scattered foci of fluid within the right mastoid air cells and mild mucosal\n thickening of the ethmoidal sinuses.\n\n The intracranial vertebral and internal carotid arteries and major branches do\n appear normal without clear stenosis, occlusion, or aneurysm formation\n identified.\n\n IMPRESSION: Acute infarct involving the subcortical white matter within the\n left frontal and temporal lobes. No evidence of hemorrhagic transformation or\n mass effect.\n\n (Over)\n\n 2:01 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: Assess for CVA progression, please obtain without gadolliniu\n Admitting Diagnosis: RAPID AFIB\n Contrast: MAGNEVIST Amt: 24\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 568612,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU service\n for hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metropolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU\n evening of - weaned off dopamine shortly after arrival\n Aflutter\n 90-110s. No further complaints of CP or GI discomfort. Am HCT 26.2\n (30.2-33). K 3.5\n given 40meq KCL via central line this early morning.\n hemodynamically stable off of dopamine gtt, left femoral line\n removed without incident. Tolerating sitting in chair. Called out to\n F3/ service.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n This am HR 90-100 without ectopy in AFib.\n Action:\n Hemodynamic monitoring. Re-peat HCT and potassium level sent at 10 am.\n Response:\n Hemodynamically stable w/ SBP >100 and HR and rhythm as above. Repeat\n K+ level 5.0 and Repeat HCT level 29.7\n Plan:\n Continue to monitor hemodynamic status. ? Starting amiodarone for rate\n control ( none ordered at this time). Remains on coumadin (caution with\n INR level if starting amiodarone).\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 568613,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU service\n for hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metropolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU\n evening of - weaned off dopamine shortly after arrival\n Aflutter\n 90-110s. No further complaints of CP or GI discomfort. Am HCT 26.2\n (30.2-33). K 3.5\n given 40meq KCL via central line this early morning.\n hemodynamically stable off of dopamine gtt, left femoral line\n removed without incident. Tolerating sitting in chair. Called out to\n F3/ service.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n This am HR 90-100 without ectopy in AFib.\n Action:\n Hemodynamic monitoring. Re-peat HCT and potassium level sent at 10 am.\n Response:\n Hemodynamically stable w/ SBP >100 and HR and rhythm as above. Repeat\n K+ level 5.0 and Repeat HCT level 29.7\n Plan:\n Continue to monitor hemodynamic status. ? Starting amiodarone for rate\n control ( none ordered at this time). Remains on coumadin (caution with\n INR level if starting amiodarone).\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure. Am CR 1.3 (which is improved from prior\n level of 1.5). Likely decreased forward flow per team.\n Action:\n Monitored intake and output- poor urine output (<30 cc/hr)- CCU team\n notified.\n Response:\n Poor urine output (<30 cc/hr)- CCU team notified. Encouraging po\n intake.\n Plan:\n Contninue to monitor labs,renal function, I and O and daily weight.\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n RAPID AFIB\n Code status:\n Height:\n 60 Inch\n Admission weight:\n 58.2 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: afib, left femur fx with ORIF, hyperparathyroidism,\n osteoporosis, cervical disc disease, B 12 deficiency, GERD, s/p bil\n tonsilectomy, s/p cholecystectomy, left knee replacement, s/p\n appendectomy, colon resection with colostomy (reversed) , s/p\n hysterectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:45\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 103 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 293 mL\n 24h total out:\n 330 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 03:46 AM\n Potassium:\n 5.0 mEq/L\n 09:36 AM\n Chloride:\n 107 mEq/L\n 03:46 AM\n CO2:\n 28 mEq/L\n 03:46 AM\n BUN:\n 28 mg/dL\n 03:46 AM\n Creatinine:\n 0.0\n 10:00 AM\n Glucose:\n 76 mg/dL\n 03:46 AM\n Hematocrit:\n 29.7 %\n 09:36 AM\n Finger Stick Glucose:\n 78\n 11:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: wearing gold-colored hoop earrings.\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 13:00 PM\n"
},
{
"category": "Nursing",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 568616,
"text": " yo F with HTN, persistent AF, h/o PAF (multiple cardioversions\n recently, on fleconide and coumadin at home) transferred to CCU service\n for hypotension, bradycardia.\n Admitted with AF/RVR, complicated by mild CHF. Was rate controlled\n with metropolol and diuresed with lasix. Remained hemodynamically\n stable throughout, with SBP 120s while in AF/RVR of 120.\n pt\ns BP was 100, with HR 70-80 AF. Received 180mg po verapamil and\n 50mg metoprolol in am. Echo showed EF 25%. At 12pm, pt developed heavy\n substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Also c/o of GI pain\n GI cocktails\n given with no relief. Pt was started on dopamine and transferred to the\n CVICU under CCU service. Dopamine titrated 12-20mcg/kg/min, given 2L\n IVF and 2 units FFP for elevated INR (on coumadin at home) with SBP\n 100, HR 100 AF. BC x2 sent. Lt femoral TLC placed after failed attempt\n in RIJ. LS crackles to bases, given lasix 20mg IVP. Transferred to CCU\n evening of - weaned off dopamine shortly after arrival\n Aflutter\n 90-110s. No further complaints of CP or GI discomfort. Am HCT 26.2\n (30.2-33). K 3.5\n given 40meq KCL via central line this early morning.\n hemodynamically stable off of dopamine gtt, left femoral line\n removed without incident. Tolerating sitting in chair. Called out to\n F3/ service.\n Atrial fibrillation/ Atrial Flutter (Afib/Aflutter)\n Assessment:\n This am HR 90-100 without ectopy in AFib.\n Action:\n Hemodynamic monitoring. Re-peat HCT and potassium level sent at 10 am.\n Response:\n Hemodynamically stable w/ SBP >100 and HR and rhythm as above. Repeat\n K+ level 5.0 and Repeat HCT level 29.7\n Plan:\n Continue to monitor hemodynamic status. ? Starting amiodarone for rate\n control ( none ordered at this time). Remains on coumadin (caution with\n INR level if starting amiodarone).\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure. Am CR 1.3 (which is improved from prior\n level of 1.5). Likely decreased forward flow per team.\n Action:\n Monitored intake and output- poor urine output (<30 cc/hr)- CCU team\n notified.\n Response:\n Poor urine output (<30 cc/hr)- CCU team notified. Encouraging po\n intake.\n Plan:\n Contninue to monitor labs,renal function, I and O and daily weight.\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n RAPID AFIB\n Code status:\n Height:\n 60 Inch\n Admission weight:\n 58.2 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: afib, left femur fx with ORIF, hyperparathyroidism,\n osteoporosis, cervical disc disease, B 12 deficiency, GERD, s/p bil\n tonsilectomy, s/p cholecystectomy, left knee replacement, s/p\n appendectomy, colon resection with colostomy (reversed) , s/p\n hysterectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:45\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 103 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 293 mL\n 24h total out:\n 330 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 03:46 AM\n Potassium:\n 5.0 mEq/L\n 09:36 AM\n Chloride:\n 107 mEq/L\n 03:46 AM\n CO2:\n 28 mEq/L\n 03:46 AM\n BUN:\n 28 mg/dL\n 03:46 AM\n Creatinine:\n 0.0\n 10:00 AM\n Glucose:\n 76 mg/dL\n 03:46 AM\n Hematocrit:\n 29.7 %\n 09:36 AM\n Finger Stick Glucose:\n 78\n 11:00 PM\n Valuables / Signature\n Patient valuables: Glasses, \n valuables: purse with checkbook (declined safe)\n Clothes: sent with patient:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: wearing gold-colored hoop earrings.\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 13:00 PM\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 568619,
"text": "Chief Complaint:\n 24 Hour Events:\n - weaned dopa, pressures 90-100\n - femoral line placed\n - HCT 26 from 30, rechecking HCT\n - Cx ngtd\n - wbc improved\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36\nC (96.8\n HR: 106 (99 - 122) bpm\n BP: 126/69(84) {75/35(51) - 134/69(84)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 60 Inch\n Total In:\n 1,052 mL\n 25 mL\n PO:\n TF:\n IVF:\n 476 mL\n 25 mL\n Blood products:\n 576 mL\n Total out:\n 1,480 mL\n 220 mL\n Urine:\n 1,480 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -428 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n GENERAL: Oriented x3. Mood, affect appropriate, very pleasant elderly\n woman.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry oral mucosa. No\n xanthalesma.\n NECK: Supple with JVP of 8 cm.\n CTAb. No wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n EXTREMITIES: Warm, dry, strong distal pulses, RLE pitting edema 1+ \n up tibia.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 212 K/uL\n 8.3 g/dL\n 76 mg/dL\n 1.3 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.2 %\n 7.0 K/uL\n [image002.jpg]\n 08:02 PM\n 03:46 AM\n WBC\n 7.0\n Hct\n 30.9\n 26.2\n Plt\n 212\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 76\n Other labs: PT / PTT / INR:26.4/31.7/2.6, CK / CKMB /\n Troponin-T:43//<0.01, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR\n New left pleural effusin and retrocardiac opacity, could reflect\n pneumonia,\n correlation with lateal view will be helpful. Mild worsening of\n intersitial\n edema.\n TTE\n The left atrium is dilated. Left ventricular wall thicknesses and\n cavity size are normal. There is severe global left ventricular\n hypokinesis (LVEF = 20-25 %). The right ventricular cavity is\n moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n was transfered to the CCU.\n # Hypotension: Most likely cardiogenic shock, precipitated by nodal\n blockade. Has been doing well off dopa. Considering cath but the most\n likely cause for decompensation are medications as opposed to\n ischemia. No evidence for septic/hypovolemic shock. Call out later\n today.\n # Bradycardia: currently resolved. Likely medication induced.\n # Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy. Added metoprolol for rate control. Would be cautious\n with dosing of verapramil and flecanide. Consider starting amiodarone\n today as will give beta blockade and rhythm control and failed DCCV and\n flecainide already. Will monitor for medication interactions especially\n coumadin.\n # Supratherapeutic INR: Now resolved. Restart coumadin today.\n # Pump: decreased pump function on tte yesterday. Suggest repeat tte in\n a few months to see if resolves as likely from acute bradycardia and\n hypotension yesterday.\n # baseline HTN - currently normotensive. Will add back home antiHTN\n meds when necessary.\n # Acute on Chronic RF: Cr on admission up to 1.5 Likely due decreased\n forward flow. Urine output much improved and creatinine coming down\n (1.3 today) Will monitor.\n ICU Care\n Nutrition: HH diet\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n 20 Gauge - 03:00 PM\n Multi Lumen - 05:45 PM->pull fem line today prior to\n transfer to floor\n Prophylaxis:\n DVT: systemic anticoagulation with coumadin\n Stress ulcer: PPI\n Communication: with patient\n Code status: full\n Disposition: to floor today\n ------ Protected Section ------\n I rerviewed overnight events and examined Pt and data.\n Agree that simplification of meds is appropriate.Start amiodarone and\n continue coumadin.Can be transferred to .,Spent 35 mins on case.\n \n ------ Protected Section Addendum Entered By: \n on: 13:04 ------\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 568408,
"text": "Chief Complaint: Hypotension, bradycardia\n HPI:\n Please see admission H&P for full details. Briefly, Mrs. is a\n very pelasant yo woman with CAD, paroxysmal atrial fibrillation s/p\n failed cardioversion (most recent on ), CKD (Stage III) who\n initially presented with 4 weeks of lightheadedness and vertigo\n and 3 days of SOB, found to be in afib, and now is transferred to CCU\n for hypotension and bradycardia.\n She was seen by her primary cardiologist , at which time her\n flecainide was d/c'ed and her metoprolol and diltiazem were increased\n for rate control. Apparently she had not been taking the prescribed\n doses of BB/CCB and presented to the ED with chest pressure and\n atrial fibrillation with RVR. Initially she was admitted to where\n she was noted to be in volume overload and diuresed with lasix, 40 mg\n IV. She was also given metoprolol (at increased dose from 12.5 to 25\n then 50 over the course of two days) and verapramil (180 mg qd) to\n control her afib. This morning she complained of chest pain, was noted\n to be bradycardic (60s) and hypotensive (SBP in mid 70s). He was given\n 1.5 lt of IVF bolus and started on dopamine (uptitrated to 20 mcg).\n After these interventions her pressure improved to the 100s but then\n decreased again to the 90s. Her urine output remained low. She had\n cardiac enzymes drawn, the first set being negative, an ECG without ST\n changes, and an TTE, which showed global hypokinesis with EF of 25%.\n Reportedly her EF from a TEE done in early was near normal\n (reported as mild depressed LVEF. Last ECHO before that was in 90s with\n normal EF. Also has had a cath in the 90s with normal coronaries, per\n report. Notably her INR is also elevated to 3.7, presumably secondary\n to warfarin.\n Several days prior to presnetation her VNA found her to be tachycardic\n to 120s, and was referred Dr. saw her and d/ced her\n fleicanide and increased her metoprolol, which the patient did not take\n as she did not pick up prescirption. She also reports having chest\n pain/pressure o/n 4d PTA, non-radiating, no n/v/diaphoresis resolved w/\n burping. Patient was recently admitted with Afib w/ RVR, was\n cardioverted on and discharged home on flecainide, verapamil,\n metroprolol. She has had no palpitations, no syncope, no PND or\n orthopnea. Pt. also reports persistent RLE edema, since her rehab\n discharge, this is unchaged, pt. takes lasix prn for this.\n In the CCU, the patient admits to feeling cold. She denies, chest pain,\n palpitations, fevers, chills, cough, abdominal pain, or bleeding. There\n is no difficulty w/ speech. No dysuria, no abdominal pain,\n constipation/diarrhea.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n lip swelling;\n Quinidine/Quinine\n lip swelling;\n Norvasc (Oral) (Amlodipine Besylate)\n LE edema;\n Pravachol (Oral) (Pravastatin Sodium)\n muscle aches;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MEDS ON TRANSFER\n Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY\n Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN\n Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN\n Aspirin 325 mg PO DAILY\n Metoprolol Tartrate 50 mg PO Q8H\n Calcium Carbonate 500 mg PO BID\n Multivitamins 1 TAB PO DAILY\n Nitroglycerin SL 0.3 mg SL PRN\n Cyanocobalamin 1000 mcg IM/SC QMONTHLY\n Omeprazole 20 mg PO DAILY\n DOPamine 2-20 mcg/kg/min IV DRIP TITRATE TO HR >60\n Ranitidine 150 mg PO HS\n Furosemide 40 mg IV ONCE\n Verapamil SR 180 mg PO Q24H\n Vitamin D 400 UNIT PO DAILY\n Past medical history:\n Family history:\n Social History:\n .\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: NONE\n -PERCUTANEOUS CORONARY INTERVENTIONS: Clean coronaries on C Cath \n .\n -PACING/ICD: None.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n #. a-fib- cardioversion , on flecainide, verapamil and\n metoprolol at home.\n #. HTN - on Metoprolol, Imdur and hydralazine at home\n #. ? coronary artery disease - clean coronaries on C Cath .\n #. Chronic renal failure - baseline Cr 1.0\n #. Left distal femur fracture w/ ORIF during hospitalization\n . rehab stay with complications incl\n cellulitis, PNA.\n #. ? hyperparathyroidism\n #. Osteoporosis\n #. Cervical disc disease\n #. Osteoarthritis\n #. GERD\n #. B12 deficiency\n Surgical history:\n #. s/p b/l tonsillectomy\n #. Cholecystectomy\n #. Left knee replacement\n #. Appendectomy\n #. Colon resection with colostomy (since reversed) -\n patient\n does not recall specifics\n #. Hysterectomy for excessive bleeding\n Denies h/o HTN, DM, hyperlipidemia, heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives alone in apt in with VNA. She is a retired\n accountant having graduated from . She has no children.\n Her neice is her only family, is involved, and lives in . Is\n independent in ADLs and uses walker. -Tobacco history: Never -ETOH:\n None -Illicit drugs: Never\n Review of systems:\n Flowsheet Data as of 05:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.6\n Tcurrent: 35.3\nC (95.6\n HR: 109 (102 - 109) bpm\n BP: 110/38(56) {75/38(56) - 113/64(72)} mmHg\n RR: 26 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 663 mL\n PO:\n TF:\n IVF:\n 87 mL\n Blood products:\n 576 mL\n Total out:\n 0 mL\n 50 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 613 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316\n 1.5\n 33\n 21\n 107\n 4.3\n 140\n 33.2\n 13.3\n [image002.jpg]\n Fluid analysis / Other labs: Lactate:3.1\n CK: 33 MB: Notdone Trop-T: <0.01\n PT: 34.7 PTT: 33.1 INR: 3.7\n Ca: 8.5 Mg: 2.1 P: 3.8\n LDH: 393\n Imaging: TTE: The left atrium is dilated. Left ventricular wall\n thicknesses and cavity size are normal. There is severe global left\n ventricular hypokinesis (LVEF = 20-25 %). The right ventricular cavity\n is moderately dilated with moderate global free wall hypokinesis. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\n fail to fully coapt. Moderate [2+] tricuspid regurgitation is seen. The\n estimated pulmonary artery systolic pressure is normal. Significant\n pulmonic regurgitation is seen. There is no pericardial effusion.\n IMPRESSION: Severe global LV systolic dysfunction with somewhat better\n function of the basal inferior and inferolateral segments and the\n apical segments. There is akinesis of the anterior and anterolateral\n segments. The right ventricle is dilated and hypokinetic. Mild mitral\n and moderate tricuspid regurgitation.\n CXR: Relatively stable examination with marked cardiomegaly and no\n acute pulmonary process.\n Assessment and Plan\n This is a yo F with h/o a fib s/p recent 2nd CV on , HTN, ? CAD\n s/p clean cath , s/p recent femur fx, PNA and cellulitis who p/w\n afib w/ RVR and most recently developed bradycardia and hypotension and\n is transfered to the CICU.\n # Hypotension: Ddx includes 1. Cardiogenic shock, in the setting of\n depressed EF (unlear if this is acute or chronic). No ECG or CE changes\n to support acute infarction or ishcemic changes. Cath in 96 negative\n but this cant fully excude CAD and thus some form of ICM. Also possible\n is that the decreased ionotropy caused by BB/CCB may have contributed\n to the depressed EF. If this is the case this should improve with time.\n No clinical evidence of CHF at this time. 2. Septic shock, in the\n setting of WBC elevation, and lactate elevation (although lactate would\n be increased in other causes of decreased perfusion. 3. Hypovolemic\n shock, in the setting of diuresis. However, she doesnt look dry on\n exam, BUN/Cre barely 20. No evidence of hemorrhage or HCT drop. She\n received IVF on the floor and currenly on pressor support. Currently BP\n is better on dopamine. Will place new RIJ for pressure support and\n monitoring. Will check CE and repeat ECG if CP. Will send for blood cx,\n UA/cx, CXR, differential and will monitor fever curve. If spikes will\n add broad spectrum abx. For now will continue dopamine since SBP >100.\n Will consider changing to norepinephrine (a and b effects) if her blood\n pressure becomes low on dopamine. Will most likely require cath to eval\n possibility of ischemic disease.\n # Bradycardia: currently resolved. Most likely to nodal blocking\n agents. Will monitor.\n #. Afib w/ RVR. Currently rate of 107 in the setting of positive\n chronotropy.\n - will hold nodal blockers for brady, but if she has RVR and pressure\n tolerates will add metoprolol.\n # Supratherapeutic INR: holding warfarin, FFP to reverse for procedure.\n Will monitor.\n #. CAD - h/o CAD questionable with no h/o MI, CABG, PCI. Clean cath in\n . She has not had recent ETT or cath to eval for CAD or ischemic\n disease.\n #. baseline HTN - currently hypotensive. Will add back home antiHTN\n meds when hypotension resolves.\n # Acute on Chronic RF: Cr on admission up to 1.3 Likely due decreased\n forward flow. Will reases cre in setting of pressure support. Will\n monitor U/O.\n FEN: NPO\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT PNB.\n -Pain management with Tylenol prn.\n -Bowel regimen with colace/senna prn.\n CODE: Full\n DISPO: Cardiology floor service for now\n MD PhD \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2140-05-18 00:00:00.000",
"description": "procedure note",
"row_id": 568410,
"text": "TITLE: Procedure note\n RIJ vein central line performed with site rite guidance, aseptic\n seldinger technique. Vessel punctured first pass with good flows but\n unable to pass guidewire through due to kink in vessel. Procedure\n abandoned.\n L femoral vein line placed. Uncomplicated, first pass, good flows.\n Check CXR to r/o pneumothorax.\n"
},
{
"category": "Physician ",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Cardiology fellow admit note",
"row_id": 568399,
"text": "TITLE: CCU fellow brief admit note\n yo F with HTN, persistent transferred to CCU for hypotension,\n bradycardia. Admitted with AF/RVR, complicated by mild CHF. Was\n rate controlled with metoprolol and diuresed with lasix. Remained\n hemodynamically stable throughout, with SBP 120s while in AF/RVR of\n 120. This morning, pt\ns BP was 100, with HR 70-80 AF. Received 180mg po\n verapamil and 50mg metoprolol om the morning. At 12pm, pt developed\n heavy substernal CP a/w HR 40s in AF, SBP 70. No EKG changes to suggest\n ischemia. 1^st troponin at 12pm neg. Pt was started on dopamine and\n transferred to the ICU.\n Currently, on dopamine 20mcg/kg/min, s/p 2L IVF and 2 units FFP with\n SBP 100, HR 100 AF. Pain improved to but still present.\n Clinically, pt is mentating well, although peripheries are cool and\n clamped down. There are no new murmurs and serial EKGs have remained\n negative, including posterior and R sided leads. Echo this morning\n (prior to onset of CP) demonstrated EF 25%, globally hypokinetic with\n akinesis of anterior segment. In addition, RV was enlarged and\n hypokinetic. Compared to TEE on (performed in setting of DCCV\n for AF/RVR), the depressed EF is new.\n The concern is that the pt may have multivessel CAD vs nonischemic CM\n with acute worsening high doses of negatively ionotropic nodal\n agents. PE is a possibility, but less likely given supratherapeutic\n INR. Discussed with Dr , pt\ns primary cardiologist, and Dr .\n The consensus is that pt should be medically stabilized and get a\n cardiac catheterization once INR decreases.\n Plan discussed with CCU team. For now\n 1) stop IVF\n 2) Wean dopamine if possible\n 3) Central access with 2 units FFP.\n 4) Cycle enzymes\n 5) Continue aspirin 325\n 6) Hold nodal agents for now. No calcium channel blockers.\n 7) Will likely develop ARF due to hypotension, therefore monitor\n closely\n 8) Will likely develop CHF given 3L IVF, may need diuresis. Hold\n further FFP until timing of cardiac cath is determined.\n 9) Pt is full code, gave informed consent for ICU related\n procedures and cardiac catheterization.\n Plan discussed with Dr , CCU attending.\n"
},
{
"category": "ECG",
"chartdate": "2140-05-25 00:00:00.000",
"description": "Report",
"row_id": 297897,
"text": "Irregular bradycardia of uncertain mechanism but may be sinus bradycardia with\nsinus arrhythmia, junctional escape beats, and possible sinus capture beats.\nProlonged QTc interval. ST-T wave changes. Clinical correlation is suggested\nfor possible, drug/electrolyte/metabolic effect. Since the previous tracing\nof the rhythm as outlined is now present.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-26 00:00:00.000",
"description": "Report",
"row_id": 297896,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing sinus rhythm is now consistently present. The Q-T interval is shorter.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-24 00:00:00.000",
"description": "Report",
"row_id": 298130,
"text": "Baseline artifact. Sinus rhythm with atrial premature beats in a bigeminal\npattern. QTc interval appears borderline prolonged but is difficult to\nmeasure. Modest ST-T wave changes. Findings are non-specific. Clinical\ncorrelation is suggested for possible drug/electrolyte/metabolic effect. Since\nthe previous tracing of atrial fibrillation is absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-24 00:00:00.000",
"description": "Report",
"row_id": 298131,
"text": "Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave\nchanges. Since the previous tracing of atrial fibrillation has\nreplaced atrial flutter.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-21 00:00:00.000",
"description": "Report",
"row_id": 298132,
"text": "Typical atrial flutter with predominant 2:1 conduction and a ventricular rate\nof about 120. Intermittent variable conduction and occasional ventricular\npremature beats. Non-specific ST-T wave changes. Compared to the previous\ntracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-20 00:00:00.000",
"description": "Report",
"row_id": 298133,
"text": "Slow atrial flutter with Wenckebach conduction. Non-specific ST-T wave\nchanges. Compared to the previous tracing Wenckebach conduction is now\npresent.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Report",
"row_id": 298134,
"text": "Possible atrial flutter with 2:1 A-V block at a ventricular rate of 123.\nNon-specific T wave changes. Compared to the previous tracing of \nno diagnostic interval change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Report",
"row_id": 298135,
"text": "Atrial fibrillation, rate 118. RSR' pattern in lead V2. Markedly decreased\nvoltage in leads V3-V6. These changes may be related to lead placement.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-18 00:00:00.000",
"description": "Report",
"row_id": 298136,
"text": "Atrial fibrillation, rate 71. Leftward axis. Non-specific T wave changes.\nProlongation of the QTc interval to 473 milliseconds.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-17 00:00:00.000",
"description": "Report",
"row_id": 298137,
"text": "Probable atrial fibrillation versus flutter with rapid ventricular response\nNonspecific ST-T abnormalities\nSince previous tracing of , atrial fibrillation/?flutter now present\n\n"
}
] |
25,225 | 150,221 | She presented to the ED where she was given a fluid bolus and pan-cultured. WBC was 6.1 on admission. IV Vancomycin was administered. Transplant surgery was consulted for her access issue and recommendations were made for a RUE ultrasound which was done. This showed an ill defined 1.3 x 0.5 cm fluid collection within the superficial subcutaneous tissues of the right antecubital fossa. She was transferred to the ICU for care where BP responded to small fluid bolus. Dialysis was done via the L tunnelled line. Nephrology was consulted and followed her throughout this hospital stay. On she required small fluid boluses x 3 for BP as low as 74/39 with response. CVVHD was performed. IV Vanco was changed to Dapto per ID recommendations. These included serial blood cultures. Repeat blood cultures were done almost on a daily basis with all negative until . Blood cultures from and were negative to date. On , a TTE was performed revealing mild symmetric LVH(LVEF 70%). There was no ventricular septal defect. The aortic valve, mitral and tricuspid valve leaflets were mildly thickened. No masses or vegetations were seen. There was severe mitral annular calcification. Significant pulmonic regurgitation was seen. There was no pericardial effusion. Compared with the findings of the prior study (images reviewed)from , a vegetation on the mitral valve was no longer seen. The open areas on her right upper arm was packed with Nu Guaze. She was given IV dilaudid for pain management. The wound was cultured. Antibiotic coverage was broadened switched backt to vanco on as there was no GN growth and the wound grew MRSA. Gentamycin and Aztreonam were stopped on . She was transferred out of the ICU on . She continued on vanco at HD sessions on a Tuesday-Thursday-Sat schedule. Right arm dressings were continued with persistent purulence noted in wounds. Endocrine was consulted for low basal cortisol levels and she was found to have secondary adrenal insufficiency based cosyntropin stim test. Recommendations included increasing prednisone to 10mg qd and giving stress dose steroids if she is febrile or hypotensive. She did not require this. Recs included: -Prednisone 10mg PO x3 days for minor illness, would not recommend starting this now as pt is clinically improving. -If the patient is undergoing surgery or has severe illness would recommend stress dose steroids -d/c prednisone and start Hydrocortisone 100mg iv q 8 hours then taper. -Recommend discharging pt with dexamethasone 4mg IM to take PRN when having emesis and unable to keep down PO meds. -Follow like features and once pt fully recovers from this hospitalization would slowly taper steroids as pt tolerates but also steroids may be for ITP so her labs would need to be followed closely if a taper is attempted. 3. Osteoporosis prevention: last bone density test was in and showed osteopenia. Pt is currently a dialysis pt and on calcium and vit D. Pt needs repeat DEXA scan as outpatient and follow up with bone clinic. Her risk for fracture is high given she has amenorrhea, is weak from recent stroke, and is on steroid treatment. Prednisone was increased to 10mg qd starting on . On , she spiked a temperature to 101. Repeat blood cultures were sent were negative to date. On , the avg site was I&D'd at the bedside for purulent areas. She bled extensively requiring suturing with cessation of bleeding. Pain in R arm worsened after I&D. Fentanyl patch was increased to 125mcg and prn dilaudid was increased to 6mg prn q 4 hours with intermittent doses of dilaudid 0.5-1mg prn q 3. A Pain consult was obtained with recommendations to not increase fentanyl, resume neurontin and increase po dose of dilaudid as well as premed for dressing changes with 1mg iv dilaudid. She did not tolerate neurontin due to "twitching". This was discontinued. On , she was taken to the OR the following day to remove remnant infected graft and a patch angioplasty was placed. Patient was extubated and transferred to the post anesthesia care unit in stable condition. Patient remained in the hospital due to poor pain control and persistent oozing of blood at incision sites. Hct dropped to 20 and PRBC were transfused on several days. Platelets and cryo were also administered. Right arm incisions continued to ooze necessitating in patient management. Bleeding was partially due to a hematoma of the more distal incision. Oozing decreased to one dressing change per day. VNA was arrange to do dressing changes. Incisions appeared without redness or purulence. PT evaluated and recommended ace wrapping of R leg to decrease edema. Home PT was recommended for strength, balance and safety. Homecare was arrange for right arm dressings,PT and social work. Samaritan Ambulance was arrange for transort. She was discharged home on . Last hemodialysis was . Vancomycin was to continue until for MRSA. | PredniSONE 19. PredniSONE 19. PredniSONE 19. Daptomycin 7. Daptomycin 7. PredniSONE 17. PredniSONE 17. PredniSONE 17. PredniSONE 17. Prismasate (B32 K2)* 18. Prismasate (B32 K2)* 18. Monitor vs for hypotension. Renal considering CVVH today. Arrived normotensive, denying pain with temp 98.3. Prismasate (B32 K2) 19. Prismasate (B32 K2) 19. Action: CRRT d/cd after filter issues this am. Action: CRRT d/cd after filter issues this am. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. Daptomycin 9. Daptomycin 9. Daptomycin 9. Daptomycin 9. hyperkalemic. hyperkalemic. Nephrocaps 17. Nephrocaps 17. Nephrocaps 17. Calcitriol 7. Calcitriol 7. Calcitriol 7. Calcitriol 7. Gentamicin 11. Gentamicin 11. Aspirin 4. Aspirin 4. Lactulose 13. Lactulose 13. Lactulose 13. Lactulose 13. hypotensive to 70s, febrile to 103. Heme: Hct stable Endocrine: RISS Infectious Disease: Dapto/aztreonam per ID. Heme: Hct stable Endocrine: RISS Infectious Disease: Dapto/aztreonam per ID. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Docusate Sodium 10. Significantpulmonic regurgitation is seen. Lidocaine 1% 16. Neurologic: A+O x 3 Cardiovascular: Hypotensive in ED Stable here TTE on , fluid boluses as needed. LeVETiracetam 14. LeVETiracetam 14. LeVETiracetam 14. LeVETiracetam 14. Response: Hypotension resolved. Response: Hypotension resolved. Lactulose 14. Lactulose 14. Lactulose 14. Transferred to Ed for further eval. Aspirin 5. Aspirin 5. Aspirin 5. Topiramate (Topamax) 21. HYDROmorphone (Dilaudid) 13. Afebrile. Afebrile. Afebrile. HYDROmorphone (Dilaudid) 12. HYDROmorphone (Dilaudid) 12. HYDROmorphone (Dilaudid) 12. Gentamicin 10. Gentamicin 10. Gentamicin 10. Lorazepam 16. Lorazepam 16. Aspirin 6. Aspirin 6. Gentamicin 9. Gentamicin 9. Gentamicin 9. R tunneled HD cath in place. Pantoprazole 18. Pantoprazole 18. Pantoprazole 18. Action: Aztreonam added and Gentamycin discontinued. Docusate Sodium 8. Docusate Sodium 8. Docusate Sodium 8. Amitriptyline 3. Amitriptyline 3. LeVETiracetam 15. LeVETiracetam 15. LeVETiracetam 15. Tricuspid valve prolapse is present. Nephrocaps 15. Nephrocaps 15. Nephrocaps 15. Nephrocaps 15. Calcium Acetate 7. If blood cx positive, will remove HD line, ID following. Tizanidine 20. Aztreonam 6. Aztreonam 6. Response: Pt. Response: Pt. Focal calcifications in ascendingaorta. Pt admitted to Sicu with question of line infection. Calcitriol 6. Focal calcifications inaortic root. Insulin 13. Insulin 13. Plan: Dialysis today. Acetaminophen 4. Acetaminophen 4. Pt. Pt. Pt. Amitriptyline 4. Amitriptyline 4. Amitriptyline 4. A& O x3. (Ampicillin Sodium/Sulbactam Na) Rash; Cephalosporins Rash; Levaquin (Intraven.) Neurologic: A+O x 3 Cardiovascular: Hypotensive in ED Stable here TTE on , fluid boluses as needed. Heme: Hct stable Endocrine: RISS Infectious Disease: Dapto/aztreonam per ID. Neurologic: A+O x 3 Cardiovascular: Hypotensive in ED Stable here ? Retrocardiac airspace opacity likely representing early alveolar edema. Patient is status post right BKA. PredniSONE 19. PredniSONE 19. Underwent excision of rue avg. Underwent excision of rue avg. Underwent excision of rue avg. PA and lateral upright chest radiograph was compared to . Topiramate (Topamax) 24 Hour Events: CVVH started, gentamycin discontinued, aztreonam started Allergies: Demerol (Injection) (Meperidine Hcl) Anaphylaxis; Wh Unasyn (Intraven.) hyperkalemic. Renal diet Renal: Dialyzed ; renal recs: leave dialysis cath in place Hematology: hct stable, plt low Endocrine: RISS Infectious Disease: Vanco Genta; Follow up cultures. COMPARISON: Right lower extremity venous ultrasound was last performed on . eval access, and for collection REASON FOR THIS EXAMINATION: eval afor collection WET READ: 1:14 PM superficial 1.3 x 0.5 cm hypoechoic collection in rt antecub fossa likely representing phlegmon vs early abcess formation. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. HYDROmorphone (Dilaudid) 11. (Ampicillin Sodium/Sulbactam Na) Rash; Cephalosporins Rash; Levaquin (Intraven.) (Ampicillin Sodium/Sulbactam Na) Rash; Cephalosporins Rash; Levaquin (Intraven.) (Ampicillin Sodium/Sulbactam Na) Rash; Cephalosporins Rash; Levaquin (Intraven.) Prismasate (B32 K2)* 18. Sinus rhythm with ventricular premature complexLeft atrial abnormalityIndeterminate axisBorderline prolonged Q-Tc intervalModest ST-T wave changesThese findings are nonspecific but clinical correlation is suggestedSince previous tracing of , precordial lead QRS voltage less prominentand ST-T wave changes decreased Pt admitted to Sicu with question of line infection. TITLE: SICU HPI: 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal masses, Also MSSA endocarditis mitral valve. Prismasate (B32 K2) 19. PredniSONE 17. Neurologic: dilaudid, topamax CV: intermittent episodes of symptomatic hypotension, await TEE Pulm: Stable GI: renal diet Nutrition: renal diet Renal: anephrenic and no transplant kidney. 9:47 AM US EXTREMITY NONVASCULAR RIGHT Clip # Reason: Right upper arm. Action: Aztreonam added and Gentamycin discontinued. SICU HPI: 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal masses, Also MSSA endocarditis mitral valve. | 38 | [
{
"category": "Echo",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Report",
"row_id": 64003,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis?. Valvular heart disease\nHeight: (in) 67\nBP (mm Hg): 80/43\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 11:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. Normal aortic arch diameter. Focal calcifications in aortic arch. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Severe mitral annular calcification. Mild thickening of mitral\nvalve chordae. Calcified tips of papillary muscles. Trivial MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TVP. No masses or\nvegetations are seen on the tricuspid valve, but cannot be fully excluded due\nto suboptimal image quality. Thickened/fibrotic tricuspid valve supporting\nstructures. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No PS. Significant PR. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The ascending aorta is mildly dilated. There are focal\ncalcifications in the aortic arch. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No masses or vegetations are\nseen on the aortic valve, but cannot be fully excluded due to suboptimal image\nquality. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. No masses or vegetations are\nseen on the mitral valve, but cannot be fully excluded due to suboptimal image\nquality. There is severe mitral annular calcification. Trivial mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. Tricuspid valve prolapse is present. No masses\nor vegetations are seen on the tricuspid valve, but cannot be fully excluded\ndue to suboptimal image quality. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. The estimated pulmonary artery systolic pressure\nis normal. No vegetation/mass is seen on the pulmonic valve. Significant\npulmonic regurgitation is seen. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , a vegetation on the mitral valve is no longer seen.\n\nIMPRESSION: no definite vegetations seen\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366344,
"text": "SICU\n HPI:\n 30 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n Chief complaint:\n fever, hypotension\n PMHx:\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n . 1000 mL NS 2. 500 mL NS 3. Acetaminophen 4. Amitriptyline 5. Aspirin\n 6. Calcitriol 7. Calcium Acetate\n 8. Daptomycin 9. Docusate Sodium 10. Gentamicin 11. HYDROmorphone\n (Dilaudid) 12. Insulin 13. Lactulose\n 14. LeVETiracetam 15. Lorazepam 16. Nephrocaps 17. Pantoprazole 18.\n PredniSONE 19. Topiramate (Topamax)\n 24 Hour Events:\n : 250cc fluid bolus x 3 for hypotension, tizanidine stopped,\n changed vanco to dapto\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 11:00 PM\n Other medications:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 35.8\nC (96.5\n HR: 77 (72 - 97) bpm\n BP: 99/65(72) {74/39(47) - 125/83(92)} mmHg\n RR: 15 (13 - 24) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,170 mL\n 74 mL\n PO:\n 1,180 mL\n Tube feeding:\n IV Fluid:\n 990 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,170 mL\n 74 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 61 K/uL\n 11.5 g/dL\n 76 mg/dL\n 8.1 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 38 mg/dL\n 100 mEq/L\n 137 mEq/L\n 36.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n WBC\n 5.4\n 5.0\n Hct\n 39.3\n 36.2\n Plt\n 69\n 61\n Creatinine\n 4.7\n 6.2\n 8.1\n Glucose\n 99\n 73\n 76\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Ca:9.0 mg/dL, Mg:2.3 mg/dL,\n PO4:4.7 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), HYPOTENSION (NOT SHOCK),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 30 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n Cardiovascular: intermittent episodes of symptomatic hypotension,\n responds well to small fluid boluses of 250cc\n Pulmonary: Stable\n Gastrointestinal / Abdomen: renal diet\n Nutrition: renal diet\n Renal: Dialyzed \n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/Gent; Follow up cultures. If blood cx\n positive, will remove HD line\n Lines / Tubes / Drains: PIV, HD line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366582,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n BUN, Creat rising\n Pt has bibasilar rales,\n face is edematous\n Pt had drop in BP during day shift,\n pt would not tolerate another day without dialysis\n Action:\n CVVHDF started at 2145\n Removing 50 cc/hr\n BP stable all night\n Response:\n Pt tolerating dialysis with removal of fluid\n Plan:\n Continue CRRT\n Check labs drawn at 0400, rpt at 1000.\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366357,
"text": "SICU\n HPI:\n 30 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n Chief complaint:\n fever, hypotension\n PMHx:\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n . 1000 mL NS 2. 500 mL NS 3. Acetaminophen 4. Amitriptyline 5. Aspirin\n 6. Calcitriol 7. Calcium Acetate\n 8. Daptomycin 9. Docusate Sodium 10. Gentamicin 11. HYDROmorphone\n (Dilaudid) 12. Insulin 13. Lactulose\n 14. LeVETiracetam 15. Lorazepam 16. Nephrocaps 17. Pantoprazole 18.\n PredniSONE 19. Topiramate (Topamax)\n 24 Hour Events:\n : 250cc fluid bolus x 3 for hypotension, tizanidine stopped,\n changed vanco to dapto\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 11:00 PM\n Other medications:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 35.8\nC (96.5\n HR: 77 (72 - 97) bpm\n BP: 99/65(72) {74/39(47) - 125/83(92)} mmHg\n RR: 15 (13 - 24) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,170 mL\n 74 mL\n PO:\n 1,180 mL\n Tube feeding:\n IV Fluid:\n 990 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,170 mL\n 74 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 61 K/uL\n 11.5 g/dL\n 76 mg/dL\n 8.1 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 38 mg/dL\n 100 mEq/L\n 137 mEq/L\n 36.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n WBC\n 5.4\n 5.0\n Hct\n 39.3\n 36.2\n Plt\n 69\n 61\n Creatinine\n 4.7\n 6.2\n 8.1\n Glucose\n 99\n 73\n 76\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Ca:9.0 mg/dL, Mg:2.3 mg/dL,\n PO4:4.7 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), HYPOTENSION (NOT SHOCK),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 30 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n Cardiovascular: intermittent episodes of symptomatic hypotension,\n responds well to small fluid boluses of 250cc\n Pulmonary: Stable\n Gastrointestinal / Abdomen: renal diet\n Nutrition: renal diet\n Renal: Dialyzed \n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/Gent; Follow up cultures. If blood cx\n positive, will remove HD line, ID following.\n Lines / Tubes / Drains: PIV, HD line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 12 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366462,
"text": "SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n Chief complaint:\n hypotension\n PMHx:\n SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD on\n HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n . Acetaminophen 2. Amitriptyline 3. Aspirin 4. Calcitriol 5. Calcium\n Acetate 6. Daptomycin 7. Docusate Sodium\n 8. Gentamicin 9. Gentamicin 10. HYDROmorphone (Dilaudid) 11. Insulin\n 12. Lactulose 13. LeVETiracetam\n 14. Nephrocaps 15. Pantoprazole 16. PredniSONE 17. Topiramate (Topamax)\n 24 Hour Events:\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:30 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 11:00 AM\n Pantoprazole (Protonix) - 08:09 PM\n Other medications:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 35.5\nC (95.9\n HR: 70 (64 - 97) bpm\n BP: 107/70(78) {75/42(49) - 118/78(86)} mmHg\n RR: 13 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 839 mL\n 69 mL\n PO:\n 429 mL\n Tube feeding:\n IV Fluid:\n 290 mL\n 69 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 839 mL\n 69 mL\n Respiratory support\n SPO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 60 K/uL\n 11.7 g/dL\n 76 mg/dL\n 9.5 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 54 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.5 %\n 5.2 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n 04:36 AM\n WBC\n 5.4\n 5.0\n 5.2\n Hct\n 39.3\n 36.2\n 36.5\n Plt\n 69\n 61\n 60\n Creatinine\n 4.7\n 6.2\n 8.1\n 9.5\n Glucose\n 99\n 73\n 76\n 76\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Ca:8.9 mg/dL, Mg:2.5 mg/dL,\n PO4:5.1 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD), .H/O SYSTEMIC LUPUS ERYTHEMATOSUS\n (SLE), HYPOTENSION (NOT SHOCK), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 31 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n Cardiovascular: intermittent episodes of symptomatic hypotension,\n responds well to small fluid boluses of 250cc\n Pulmonary: no issues\n Gastrointestinal / Abdomen: renal diet\n Nutrition: renal diet\n Renal:\n Dialyzed . Dialysis machine malfunction on . Renal\n considering CVVH today.\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/Gent; Follow up cultures. If blood cx\n positive, will remove HD line\n Lines / Tubes / Drains: PIV; dialysis cath\n Wounds: R AV graft site drained\n Imaging:\n Fluids: KVO\n Consults: Transplant, renal, ID\n Billing Diagnosis: Other: hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366473,
"text": "SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n Chief complaint:\n hypotension\n PMHx:\n SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD on\n HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n . Acetaminophen 2. Amitriptyline 3. Aspirin 4. Calcitriol 5. Calcium\n Acetate 6. Daptomycin 7. Docusate Sodium\n 8. Gentamicin 9. Gentamicin 10. HYDROmorphone (Dilaudid) 11. Insulin\n 12. Lactulose 13. LeVETiracetam\n 14. Nephrocaps 15. Pantoprazole 16. PredniSONE 17. Topiramate (Topamax)\n 24 Hour Events:\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:30 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 11:00 AM\n Pantoprazole (Protonix) - 08:09 PM\n Other medications:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 35.5\nC (95.9\n HR: 70 (64 - 97) bpm\n BP: 107/70(78) {75/42(49) - 118/78(86)} mmHg\n RR: 13 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 839 mL\n 69 mL\n PO:\n 429 mL\n Tube feeding:\n IV Fluid:\n 290 mL\n 69 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 839 mL\n 69 mL\n Respiratory support\n SPO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 60 K/uL\n 11.7 g/dL\n 76 mg/dL\n 9.5 mg/dL\n 29 mEq/L\n 5.5 mEq/L\n 54 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.5 %\n 5.2 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n 04:36 AM\n WBC\n 5.4\n 5.0\n 5.2\n Hct\n 39.3\n 36.2\n 36.5\n Plt\n 69\n 61\n 60\n Creatinine\n 4.7\n 6.2\n 8.1\n 9.5\n Glucose\n 99\n 73\n 76\n 76\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Ca:8.9 mg/dL, Mg:2.5 mg/dL,\n PO4:5.1 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD), .H/O SYSTEMIC LUPUS ERYTHEMATOSUS\n (SLE), HYPOTENSION (NOT SHOCK), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 31 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n Cardiovascular: intermittent episodes of symptomatic hypotension,\n responds well to small fluid boluses of 250cc\n Pulmonary: no issues\n Gastrointestinal / Abdomen: renal diet\n Nutrition: renal diet\n Renal: Dialyzed . Dialysis machine malfunction on . Will\n repeat PM lytes and consider HD vs CVVHD if urgent need, otherwise will\n get HD tomorrow AM.\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/Gent; Follow up cultures. If blood cx\n positive, will remove HD line\n Lines / Tubes / Drains: PIV; dialysis cath\n Wounds: R AV graft site incised and drained\n Imaging:\n Fluids: KVO\n Consults: Transplant, renal, ID\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 12\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366203,
"text": "Hypotension (not Shock)\n Assessment:\n SBP down to 80s with maps 50s. A&Ox3 and easily arousable despite\n hypotension. Denies any lightheadedness. HR70s-80s SR with occasional\n PVCs. Afebrile.\n Action:\n Given NS 250cc bolus.\n Response:\n SBP up to 120s after bolus.\n Plan:\n Continue to monitor BP.\n Problem\n (R arm infection)\n Assessment:\n R upper arm with dsds covering I&D sites where old fistula was. Pt.\n states arm is sore and swollen. Dilaudid prn for pain.\n Action:\n R arm elevated on pillow.\n Response:\n Good relief with Dilaudid.\n Plan:\n Continue to monitor. ECHO this am.\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366204,
"text": "Pt. at HD . hypotensive to 70s, febrile to 103. Transferred to\n Ed for further eval. R old AV fistula graft site noted to have\n fluid collection on ultrasound. Transferred to SICU for closer\n monitoring.\n Hypotension (not Shock)\n Assessment:\n SBP down to 80s with maps 50s. A&Ox3 and easily arousable despite\n hypotension. Denies any lightheadedness. HR70s-80s SR with occasional\n PVCs. Afebrile.\n Action:\n Given NS 250cc bolus.\n Response:\n SBP up to 120s after bolus.\n Plan:\n Continue to monitor BP.\n Problem\n (R arm infection)\n Assessment:\n R upper arm with dsds covering I&D sites where old fistula was. Pt.\n states arm is sore and swollen. Dilaudid prn for pain.\n Action:\n R arm elevated on pillow.\n Response:\n Good relief with Dilaudid.\n Plan:\n Continue to monitor. ECHO this am.\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Surgical Intensive Care Intensivist",
"row_id": 366284,
"text": "TITLE:\n SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg. During dialysis pt become hypotensive and spiked a temp. Abscess\n found in RUE and drained. Pt admitted to Sicu with question of line\n infection.\n Chief complaint:\n line infection\n PMHx:\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 250 mL NS 2. Acetaminophen 3. Amitriptyline 4. Aspirin 5. Calcitriol\n 6. Calcium Acetate 7. Docusate Sodium\n 8. Gentamicin 9. Gentamicin 10. HYDROmorphone (Dilaudid) 11.\n HYDROmorphone (Dilaudid) 12. HYDROmorphone (Dilaudid)\n 13. Lactulose 14. LeVETiracetam 15. Lidocaine 1% 16. Nephrocaps 17.\n Pantoprazole 18. PredniSONE\n 19. Tizanidine 20. Topiramate (Topamax) 21. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:05 PM\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.7\nC (98\n HR: 83 (67 - 92) bpm\n BP: 95/55(65) {80/41(51) - 121/82(92)} mmHg\n RR: 17 (9 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 582 mL\n 84 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 342 mL\n 84 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 582 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), BKA\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 69 K/uL\n 12.9 g/dL\n 73 mg/dL\n 6.2 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 39.3 %\n 5.4 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n WBC\n 5.4\n Hct\n 39.3\n Plt\n 69\n Creatinine\n 4.7\n 6.2\n Glucose\n 99\n 73\n Other labs: PT / PTT / INR:13.5/29.3/1.2, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:5.2 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), HYPOTENSION (NOT SHOCK),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 31 y/o F with multiple medical problems including\n SLE complicated by lupus nephritis and ESRD requiring hemodialysis,\n likely presents with line infection.\n Neurologic: A+O x 3\n Cardiovascular: Hypotensive in ED Stable here TTE on , fluid\n boluses as needed.\n Pulmonary: stable\n Gastrointestinal / Abdomen: renal diet\n Nutrition: :? Renal diet\n Renal: Dialyzed ; renal recs: leave dialysis cath in place\n Hematology: hct stable, plt low\n Endocrine: RISS\n Infectious Disease: Vanco Genta; Follow up cultures. If blood cx\n positive, will remove HD line; follow up vanc and genta levels in AM\n Lines / Tubes / Drains: PIV; dialysis cath\n Wounds: R AV graft site drained\n Imaging:\n Fluids: KVO\n Consults: Transplant renal ID\n Billing Diagnosis: Other: line infection ; Hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:51 PM\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366451,
"text": "Ms has an infected graft site : Right upper arm has 2 open\n areas. Upper area is packed with approx 2 inches of plain inch\n packing. This is draining creamy pink drainage in small amts. Lower\n open area is over a hard lump, quarter sized. 2 small openings over\n this lump are draining creamy white exudate, no packing. Dr is\n aware.\n Hypotension (not Shock)\n Assessment:\n Bp stable all night., 92-118 systolic\n Action:\n No intervention needed\n Response:\n Pt sleeping, stable night\n Plan:\n ? transfer to floor today\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt anuric\n Lungs clear\n Pt mentating well.\n Action:\n Labs sent this am\n Response:\n Labs pending\n Plan:\n Check lab results for need to start CVVHD, probably ok to wait until\n Monday am for HD\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366194,
"text": "Pt admitted from ED at 1400 for hypotension and temp 103 at HD today.\n Arrived normotensive, denying pain with temp 98.3. R old AV graft site\n with fluid collection per ultrasound. Opened by Dr. with minimal\n drainage. R tunneled HD cath in place. If cx\ns +, will d/c tunneled\n cath but await direction from primary team. Currently VSS, comfortable.\n Provide comfort and support and closely monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366281,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Continues on CRRT.\n Action:\n Negative fluid status goal increased to 2-2.5L/day per Renal service.\n Labs drawn as ordered.\n Response:\n Stable labs and acid base balance. Diuresing small amounts. Tolerating\n fluid removal without hypotension.\n Plan:\n Continue to remove fluid as above, labs per CRRT protocol.\n ------ Protected Section------\n Written on wrong pt\n ------ Protected Section Error Entered By: , RN\n on: 17:56 ------\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366537,
"text": "Pt waiting for HD or CRRT depending on pm labs.\n Hypotension (not Shock)\n Assessment:\n Episode of hypotension\n 62/44\n during shift today. Pt c/o\n feeling well\n and\nfeeling dizzy.\n Action:\n HOB put flat\n Response:\n Pt remained hypotensive for approx\n hour and then resolved with no\n further intervention.\n Plan:\n Continue to monitor BP, especially during HD/CRRT. If no hypotension\n then transfer to floor.\n Infection\n Assessment:\n Pt remains afebrile, incision sites draining purulent matter, culture\n results back.\n Action:\n Aztreonam added and Gentamycin discontinued.\n Response:\n n/a at this time\n Plan:\n Continue to monitor for s/s of worsening infection. Continue with\n current antibiotic regimen. On days HD is scheduled, antibiotics should\n be given s/p HD.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 366650,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt\ns labs normalized after 9-10 hours CRRT overnight. Fluid balance\n even @ 2400. Few crackles to bilat. Lung bases. Sats 100% on 2L NC.\n Action:\n CRRT d/c\nd after filter issues this am.\n Response:\n Pt. stable at this time.\n Plan:\n Pt. to have HD tomorrow.\n Hypotension (not Shock)\n Assessment:\n SBP 90-120s.\n Action:\n None taken.\n Response:\n Hypotension resolved.\n Plan:\n HD tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 366666,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt\ns labs normalized after 9-10 hours CRRT overnight. Fluid balance\n even @ 2400. Few crackles to bilat. Lung bases. Sats 100% on 2L NC.\n Action:\n CRRT d/c\nd after filter issues this am.\n Response:\n Pt. stable at this time.\n Plan:\n Pt. to have HD tomorrow.\n Hypotension (not Shock)\n Assessment:\n SBP 90-120s.\n Action:\n None taken.\n Response:\n Hypotension resolved.\n Plan:\n HD tomorrow.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n FEVERS\n Code status:\n Full code\n Height:\n 67\n Admission weight:\n 54 kg\n Daily weight:\n 55.8 kg\n Allergies/Reactions:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Precautions: Contact\n PMH: HEMO or PD, Renal Failure\n CV-PMH:\n Additional history: kidney transplant , bilateral nephrectomy .\n RLE BKA d/t osteomyelitis. heart surgery age 13, left oophorectomy.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:90\n D:51\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,517 mL\n 24h total out:\n 865 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 03:51 AM\n Potassium:\n 4.8 mEq/L\n 03:51 AM\n Chloride:\n 99 mEq/L\n 03:51 AM\n CO2:\n 29 mEq/L\n 03:51 AM\n BUN:\n 48 mg/dL\n 03:51 AM\n Creatinine:\n 7.5 mg/dL\n 03:51 AM\n Glucose:\n 55 mg/dL\n 03:51 AM\n Hematocrit:\n 32.7 %\n 03:51 AM\n Finger Stick Glucose:\n 160\n 04:00 PM\n Valuables / Signature\n Patient valuables: pt. has cell phone w/her. bag of clothing,\n prosthetic leg.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu\n Transferred to: tx floor, 10\n Date & time of Transfer: 1700\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366319,
"text": "Hypotension (not Shock)\n Assessment:\n VSS. Afebrile. A& O x3. MAE.follows all commands. One self limiting\n episode of anxiety which she said that she could not breath.\n Action:\n Reassurance given, repositioned and 1mg Ativan po\n Response:\n Resting/sleeping comfortably.\n Plan:\n Dialysis today. Monitor vs for hypotension.\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366402,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt anuric, scheduled for HD today\n Action:\n HD canceled d/t equipment problems\n Response:\n Pt stable all day, labs ok\n Plan:\n CVVH tomorrow pending a.m. labs. If labs WNL then wait for HD on\n Monday.\n Hypotension (not Shock)\n Assessment:\n Hypotensive to 77/42 MAP 49.\n Action:\n MD aware, notified, transfer to floor cancelled.\n Response:\n Pt now became normo-tensive with no intervention.\n Plan:\n Continue to monitor overnoc, tx with fluid bolus as indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366598,
"text": "SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W 2. Acetaminophen 3.\n Amitriptyline 4. Aspirin 5. Aztreonam\n 6. Calcitriol 7. Calcium Acetate 8. Daptomycin 9. Docusate Sodium 10.\n HYDROmorphone (Dilaudid) 11. Insulin\n 12. Lactulose 13. LeVETiracetam 14. Nephrocaps 15. Pantoprazole 16.\n PredniSONE 17. Prismasate (B32 K2)*\n 18. Prismasate (B32 K2) 19. Sodium CITRATE 4% 20. Topiramate (Topamax)\n 24 Hour Events:\n CVVH started, gentamycin discontinued, aztreonam started\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:30 PM\n Aztreonam - 04:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 35.7\nC (96.2\n HR: 78 (62 - 94) bpm\n BP: 107/60(71) {62/46(49) - 128/92(101)} mmHg\n RR: 13 (12 - 27) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.8 kg (admission): 54 kg\n Total In:\n 1,238 mL\n 849 mL\n PO:\n 660 mL\n Tube feeding:\n IV Fluid:\n 398 mL\n 849 mL\n Blood products:\n Total out:\n 159 mL\n 865 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,079 mL\n -16 mL\n Respiratory support\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral lower lung fields)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: right upper ext wound bandaged and draining\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 53 K/uL\n 10.5 g/dL\n 55 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 4.8 mEq/L\n 48 mg/dL\n 99 mEq/L\n 135 mEq/L\n 32.7 %\n 5.1 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n 04:36 AM\n 04:56 PM\n 03:51 AM\n WBC\n 5.4\n 5.0\n 5.2\n 5.1\n Hct\n 39.3\n 36.2\n 36.5\n 32.7\n Plt\n 69\n 61\n 60\n 53\n Creatinine\n 4.7\n 6.2\n 8.1\n 9.5\n 10.2\n 7.5\n Glucose\n 99\n 73\n 76\n 76\n 104\n 55\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Albumin:3.0 g/dL, Ca:9.1\n mg/dL, Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD), .H/O SYSTEMIC LUPUS ERYTHEMATOSUS\n (SLE), HYPOTENSION (NOT SHOCK), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 31 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n CV: intermittent episodes of symptomatic hypotension, await TEE\n Pulm: Stable\n GI: renal diet\n Nutrition: renal diet\n Renal: anephrenic and no transplant kidney. hyperkalemic. CVVH started\n per renal evening for hyperK. likely to transition to HD soon.\n Heme: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/aztreonam per ID. right arm graft wound\n coag+staph. blood cx negative so far.\n Lines/Tubes/Drains: PIV; dialysis cath\n Wounds: R AV graft site bandaged, wound incised and draining\n Imaging: None\n Fluids: KVO\n Prophylaxis: Boots, PPI\n Consults: Transplant, renal, ID\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366599,
"text": "SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W 2. Acetaminophen 3.\n Amitriptyline 4. Aspirin 5. Aztreonam\n 6. Calcitriol 7. Calcium Acetate 8. Daptomycin 9. Docusate Sodium 10.\n HYDROmorphone (Dilaudid) 11. Insulin\n 12. Lactulose 13. LeVETiracetam 14. Nephrocaps 15. Pantoprazole 16.\n PredniSONE 17. Prismasate (B32 K2)*\n 18. Prismasate (B32 K2) 19. Sodium CITRATE 4% 20. Topiramate (Topamax)\n 24 Hour Events:\n CVVH started, gentamycin discontinued, aztreonam started\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:30 PM\n Aztreonam - 04:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 35.7\nC (96.2\n HR: 78 (62 - 94) bpm\n BP: 107/60(71) {62/46(49) - 128/92(101)} mmHg\n RR: 13 (12 - 27) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.8 kg (admission): 54 kg\n Total In:\n 1,238 mL\n 849 mL\n PO:\n 660 mL\n Tube feeding:\n IV Fluid:\n 398 mL\n 849 mL\n Blood products:\n Total out:\n 159 mL\n 865 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,079 mL\n -16 mL\n Respiratory support\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral lower lung fields)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: right upper ext wound bandaged and draining purulent matter\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 53 K/uL\n 10.5 g/dL\n 55 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 4.8 mEq/L\n 48 mg/dL\n 99 mEq/L\n 135 mEq/L\n 32.7 %\n 5.1 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n 04:36 AM\n 04:56 PM\n 03:51 AM\n WBC\n 5.4\n 5.0\n 5.2\n 5.1\n Hct\n 39.3\n 36.2\n 36.5\n 32.7\n Plt\n 69\n 61\n 60\n 53\n Creatinine\n 4.7\n 6.2\n 8.1\n 9.5\n 10.2\n 7.5\n Glucose\n 99\n 73\n 76\n 76\n 104\n 55\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Albumin:3.0 g/dL, Ca:9.1\n mg/dL, Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD), .H/O SYSTEMIC LUPUS ERYTHEMATOSUS\n (SLE), HYPOTENSION (NOT SHOCK), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 31 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n CV: intermittent episodes of symptomatic hypotension, await TEE\n Pulm: Stable\n GI: renal diet\n Nutrition: renal diet\n Renal: anephrenic and no transplant kidney. hyperkalemic. CVVH started\n per renal evening for hyperK. likely to transition to HD soon.\n Heme: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/aztreonam per ID. right arm graft wound\n coag+staph. blood cx negative so far.\n Lines/Tubes/Drains: PIV; dialysis cath\n Wounds: R AV graft site bandaged, wound incised and draining\n Imaging: None\n Fluids: KVO\n Prophylaxis: Boots, PPI\n Consults: Transplant, renal, ID\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366520,
"text": "Pt waiting for HD or CRRT depending on pm labs.\n Hypotension (not Shock)\n Assessment:\n Episode of hypotension\n 62/44\n during shift today. Pt c/o\n feeling well\n and\nfeeling dizzy.\n Action:\n HOB put flat\n Response:\n Pt remained hypotensive for approx\n hour and then resolved with no\n further intervention.\n Plan:\n Continue to monitor BP, especially during HD/CRRT. If no hypotension\n then transfer to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366521,
"text": "Pt waiting for HD or CRRT depending on pm labs.\n Hypotension (not Shock)\n Assessment:\n Episode of hypotension\n 62/44\n during shift today. Pt c/o\n feeling well\n and\nfeeling dizzy.\n Action:\n HOB put flat\n Response:\n Pt remained hypotensive for approx\n hour and then resolved with no\n further intervention.\n Plan:\n Continue to monitor BP, especially during HD/CRRT. If no hypotension\n then transfer to floor.\n Infection\n Assessment:\n Pt remains afebrile, incision sites draining purulent matter, culture\n results back.\n Action:\n Aztreonam added and Gentamycin discontinued.\n Response:\n n/a at this time\n Plan:\n Continue to monitor for s/s of worsening infection. Continue with\n current antibiotic regimen. On days HD is scheduled, antibiotics should\n be given s/p HD.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 366617,
"text": "SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 20 gm Calcium Gluconate/ 500 mL D5W 2. Acetaminophen 3.\n Amitriptyline 4. Aspirin 5. Aztreonam\n 6. Calcitriol 7. Calcium Acetate 8. Daptomycin 9. Docusate Sodium 10.\n HYDROmorphone (Dilaudid) 11. Insulin\n 12. Lactulose 13. LeVETiracetam 14. Nephrocaps 15. Pantoprazole 16.\n PredniSONE 17. Prismasate (B32 K2)*\n 18. Prismasate (B32 K2) 19. Sodium CITRATE 4% 20. Topiramate (Topamax)\n 24 Hour Events:\n CVVH started, gentamycin discontinued, aztreonam started\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:30 PM\n Aztreonam - 04:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 35.7\nC (96.2\n HR: 78 (62 - 94) bpm\n BP: 107/60(71) {62/46(49) - 128/92(101)} mmHg\n RR: 13 (12 - 27) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.8 kg (admission): 54 kg\n Total In:\n 1,238 mL\n 849 mL\n PO:\n 660 mL\n Tube feeding:\n IV Fluid:\n 398 mL\n 849 mL\n Blood products:\n Total out:\n 159 mL\n 865 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,079 mL\n -16 mL\n Respiratory support\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral lower lung fields)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace) s/p amp\n Skin: right upper ext wound bandaged and draining purulent matter\n Neurologic: (Awake / Alert / Oriented: x 3), , (Responds to: Verbal\n stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 53 K/uL\n 10.5 g/dL\n 55 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 4.8 mEq/L\n 48 mg/dL\n 99 mEq/L\n 135 mEq/L\n 32.7 %\n 5.1 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n 02:50 AM\n 04:36 AM\n 04:56 PM\n 03:51 AM\n WBC\n 5.4\n 5.0\n 5.2\n 5.1\n Hct\n 39.3\n 36.2\n 36.5\n 32.7\n Plt\n 69\n 61\n 60\n 53\n Creatinine\n 4.7\n 6.2\n 8.1\n 9.5\n 10.2\n 7.5\n Glucose\n 99\n 73\n 76\n 76\n 104\n 55\n Other labs: PT / PTT / INR:14.4/32.3/1.3, Albumin:3.0 g/dL, Ca:9.1\n mg/dL, Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD), .H/O SYSTEMIC LUPUS ERYTHEMATOSUS\n (SLE), HYPOTENSION (NOT SHOCK), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 31 yo F with ESRD due to SLE, s/p failed txplt\n requiring explant, ITP, with pulm HTN, s/p bilat nephrectomies\n for bilat renal masses, Also MSSA endocarditis mitral valve; R\n BKA\n Underwent excision of rue avg.\n Neurologic: dilaudid, topamax\n CV: intermittent episodes of symptomatic hypotension, await TEE\n Pulm: Stable\n GI: renal diet\n Nutrition: renal diet\n Renal: anephrenic and no transplant kidney. hyperkalemic. CVVH started\n per renal evening for hyperK. likely to transition to HD soon.\n Heme: Hct stable\n Endocrine: RISS\n Infectious Disease: Dapto/aztreonam per ID. right arm graft wound\n coag+staph. blood cx negative so far.\n Lines/Tubes/Drains: PIV; dialysis cath\n Wounds: R AV graft site bandaged, wound incised and draining\n Imaging: None\n Fluids: KVO\n Prophylaxis: Boots, PPI\n Consults: Transplant, renal, ID\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Surgical Critical Care Intensivist",
"row_id": 366231,
"text": "TITLE:\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Surgical Intensive Care Intensivist",
"row_id": 366232,
"text": "TITLE:\n SICU\n HPI:\n 30 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg.\n Chief complaint:\n line infection\n PMHx:\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 250 mL NS 2. Acetaminophen 3. Amitriptyline 4. Aspirin 5. Calcitriol\n 6. Calcium Acetate 7. Docusate Sodium\n 8. Gentamicin 9. Gentamicin 10. HYDROmorphone (Dilaudid) 11.\n HYDROmorphone (Dilaudid) 12. HYDROmorphone (Dilaudid)\n 13. Lactulose 14. LeVETiracetam 15. Lidocaine 1% 16. Nephrocaps 17.\n Pantoprazole 18. PredniSONE\n 19. Tizanidine 20. Topiramate (Topamax) 21. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:05 PM\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.7\nC (98\n HR: 83 (67 - 92) bpm\n BP: 95/55(65) {80/41(51) - 121/82(92)} mmHg\n RR: 17 (9 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 582 mL\n 84 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 342 mL\n 84 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 582 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 69 K/uL\n 12.9 g/dL\n 73 mg/dL\n 6.2 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 39.3 %\n 5.4 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n WBC\n 5.4\n Hct\n 39.3\n Plt\n 69\n Creatinine\n 4.7\n 6.2\n Glucose\n 99\n 73\n Other labs: PT / PTT / INR:13.5/29.3/1.2, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:5.2 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), HYPOTENSION (NOT SHOCK),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 31 y/o F with multiple medical problems including\n SLE complicated by lupus nephritis and ESRD requiring hemodialysis,\n likely presents with line infection.\n Neurologic: A+O x 3\n Cardiovascular: Hypotensive in ED Stable here ? TEE on \n Pulmonary: stable\n Gastrointestinal / Abdomen: :? reg diet to disscuss with team\n Nutrition: :? reg diet to disscuss with team\n Renal: Dialyzed ; renal recs: leave dialysis cath in place\n Hematology: hct stable\n Endocrine: RISS\n Infectious Disease: Vanco Genta; Follow up cultures. If blood cx\n positive, will remove HD line; follow up vanc and genta levels in AM\n Lines / Tubes / Drains: PIV; dialysis cath\n Wounds: R AV graft site drained\n Imaging:\n Fluids: KVO\n Consults: Transplant renal ID\n Billing Diagnosis: Other: line infection\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:51 PM\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Surgical Intensive Care Intensivist",
"row_id": 366237,
"text": "TITLE:\n SICU\n HPI:\n 31 yo F with ESRD due to SLE, s/p failed txplt requiring explant,\n ITP, with pulm HTN, s/p bilat nephrectomies for bilat renal\n masses, Also MSSA endocarditis mitral valve. Underwent excision of rue\n avg. During dialysis pt become hypotensive and spiked a temp. Abscess\n found in RUE and drained. Pt admitted to Sicu with question of line\n infection.\n Chief complaint:\n line infection\n PMHx:\n PMH: SLE c/b lupus nephritis, anemia, serositis and ascites now w/ ESRD\n on HD T/Th/Sat, s/p CRT on c/b rejection and capsule rupture\n , B/L renal solid masses s/p resection pathology was negative\n for carcinoma, RUE AVG excision, hx of VSD s/p corrective\n surgery at age 13, HTN, ITP, h/o MSSA endocarditis, sickle cell trait,\n s/p left oophorectomy related to IUD associated infection, Restrictive\n lung disease, GERD, Right pelvic abscess s/p TAH/BSO, R tib/fib fx with\n ORIF c/b wound/Hardware infection requiring BKA \n Current medications:\n 1. 250 mL NS 2. Acetaminophen 3. Amitriptyline 4. Aspirin 5. Calcitriol\n 6. Calcium Acetate 7. Docusate Sodium\n 8. Gentamicin 9. Gentamicin 10. HYDROmorphone (Dilaudid) 11.\n HYDROmorphone (Dilaudid) 12. HYDROmorphone (Dilaudid)\n 13. Lactulose 14. LeVETiracetam 15. Lidocaine 1% 16. Nephrocaps 17.\n Pantoprazole 18. PredniSONE\n 19. Tizanidine 20. Topiramate (Topamax) 21. Vancomycin\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:05 PM\n Allergies:\n Demerol (Injection) (Meperidine Hcl)\n Anaphylaxis; Wh\n Unasyn (Intraven.) (Ampicillin Sodium/Sulbactam Na)\n Rash;\n Cephalosporins\n Rash;\n Levaquin (Intraven.) (Levofloxacin/Dextrose 5%-Water)\n Itchiness above\n Moexipril\n Rash; Fixed-\n Morphine\n Hives; Rash;\n Cyclosporine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.7\nC (98\n HR: 83 (67 - 92) bpm\n BP: 95/55(65) {80/41(51) - 121/82(92)} mmHg\n RR: 17 (9 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 582 mL\n 84 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 342 mL\n 84 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 582 mL\n 84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), BKA\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 69 K/uL\n 12.9 g/dL\n 73 mg/dL\n 6.2 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 39.3 %\n 5.4 K/uL\n [image002.jpg]\n 12:30 PM\n 03:13 AM\n WBC\n 5.4\n Hct\n 39.3\n Plt\n 69\n Creatinine\n 4.7\n 6.2\n Glucose\n 99\n 73\n Other labs: PT / PTT / INR:13.5/29.3/1.2, Ca:8.8 mg/dL, Mg:2.2 mg/dL,\n PO4:5.2 mg/dL\n Assessment and Plan\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT), HYPOTENSION (NOT SHOCK),\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 31 y/o F with multiple medical problems including\n SLE complicated by lupus nephritis and ESRD requiring hemodialysis,\n likely presents with line infection.\n Neurologic: A+O x 3\n Cardiovascular: Hypotensive in ED Stable here TTE on , fluid\n boluses as needed.\n Pulmonary: stable\n Gastrointestinal / Abdomen: renal diet\n Nutrition: :? Renal diet\n Renal: Dialyzed ; renal recs: leave dialysis cath in place\n Hematology: hct stable, plt low\n Endocrine: RISS\n Infectious Disease: Vanco Genta; Follow up cultures. If blood cx\n positive, will remove HD line; follow up vanc and genta levels in AM\n Lines / Tubes / Drains: PIV; dialysis cath\n Wounds: R AV graft site drained\n Imaging:\n Fluids: KVO\n Consults: Transplant renal ID\n Billing Diagnosis: Other: line infection\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:51 PM\n 22 Gauge - 02:51 PM\n Dialysis Catheter - 03:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366263,
"text": ".H/O transplant, kidney (Renal transplant)\n Assessment:\n Continues on CRRT.\n Action:\n Negative fluid status goal increased to 2-2.5L/day per Renal service.\n Labs drawn as ordered.\n Response:\n Stable labs and acid base balance. Diuresing small amounts. Tolerating\n fluid removal without hypotension.\n Plan:\n Continue to remove fluid as above, labs per CRRT protocol.\n"
},
{
"category": "Nursing",
"chartdate": "2179-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 366297,
"text": "Hypotension (not Shock)\n Assessment:\n Patient SBP 80\ns-100\ns this am. SBP down to 70\ns in afternoon, patient\n c/o lightheadedness and not feeling well, however mentating well.\n Action:\n Patient given 250 cc bolus x 3 for symptomatic hypotension.\n Patient eating meals well with adequate po intake.\n Response:\n SBP back up to 90\ns-110\n Plan:\n Continue to monitor, treat symptomatic hypotension, keep SBP above 85.\n"
},
{
"category": "ECG",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 122465,
"text": "Sinus rhythm with ventricular premature complex\nLeft atrial abnormality\nIndeterminate axis\nBorderline prolonged Q-Tc interval\nModest ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , precordial lead QRS voltage less prominent\nand ST-T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2179-01-28 00:00:00.000",
"description": "Report",
"row_id": 122466,
"text": "Sinus rhythm with ventricular premature beats. Rightward QRS axis. Delayed\nR wave transition. Mildly prolonged QTc interval. Non-specific anterior\nST-T wave changes. Compared to the previous tracing of anterior\nST-T wave changes are more prominent and ventricular ectopy is new. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-01-28 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 1063611,
"text": " 12:31 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: EVAL FOR A FLUID COLLECTION\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with RUE access for dialysis. eval access, and for collection\n REASON FOR THIS EXAMINATION:\n eval afor collection\n ______________________________________________________________________________\n WET READ: 1:14 PM\n superficial 1.3 x 0.5 cm hypoechoic collection in rt antecub fossa likely\n representing phlegmon vs early abcess formation.\n ______________________________________________________________________________\n FINAL REPORT\n NON-VASCULAR ULTRASOUND OF THE RIGHT UPPER EXTREMITY DATED \n\n HISTORY: 31-year-old female with right upper extremity access for dialysis\n and pus draining from access site. Clinical concern for abscess.\n\n FINDINGS: Ultrasound examination of the superficial soft tissues in the\n region of the right antecubital fossa was performed. There is an ill-defined\n hypoechoic region within the right antecubital fossa measuring 1.3 x 0.5 cm\n which is thought to represent a small focal fluid collection. No additional\n fluid collections are identified.\n\n IMPRESSION:\n\n Ill defined 1.3 x 0.5 cm fluid collection within the superficial subcutaneous\n tissues of the right antecubital fossa. Infection cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063585,
"text": " 10:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with hypotension, fevers\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY, DATED .\n\n HISTORY: 31-year-old female with hypotension and fever on dialysis.\n\n COMPARISON: .\n\n FINDINGS: A single AP upright view of the chest was obtained. The\n cardiomediastinal silhouette is stably enlarged. The main pulmonary artery is\n enlarged consistent with chronic pulmonary hypertension. There is\n cephalization of the pulmonary vasculature and stable appearing increased\n interstitial changes noted within the lungs bilaterally, which most likely\n represent pulmonary edema. Also noted is airspace opacification in the left\n lung base. There is a right-sided central venous catheter terminating in the\n proximal right atrium, which is unchanged in appearance. Median sternotomy\n wires and surgical clips in the upper abdomen are again identified. The\n osseous structures are intact.\n\n IMPRESSION:\n\n Stable cardiomegaly and increased interstitial markings consistent with\n pulmonary edema. Retrocardiac airspace opacity likely representing early\n alveolar edema. However, infection cannot entirely be excluded. Clinical\n correlation is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064210,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval exam\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with admit for hypotension/fever\n REASON FOR THIS EXAMINATION:\n interval exam\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr MON 10:23 AM\n PFI: Repeat radiograph is required since the study is somewhat limited by the\n motion. Mild improvement the right lung opacity and increased opacification\n of the left lung base.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with hypertension and fever, evaluate interval\n change.\n\n Comparison is made to the prior study of .\n\n PORTABLE CHEST RADIOGRAPH: There has been interval improvement in the right\n lung base consolidation. The consolidation in the left lung base has\n progressed. This study is somewhat limited by the motion and needs to be\n repeated. The remainder of the study including diffuse interstitial edema is\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064211,
"text": ", J. SICU-B 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval exam\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with admit for hypotension/fever\n REASON FOR THIS EXAMINATION:\n interval exam\n ______________________________________________________________________________\n PFI REPORT\n PFI: Repeat radiograph is required since the study is somewhat limited by the\n motion. Mild improvement the right lung opacity and increased opacification\n of the left lung base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-03 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1064652,
"text": " 9:57 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PAIN AND SWELLING BLE // ASSESS FOR DVT\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with LUPUS, ESRD on HD admitted with infected former RUE avg\n site/bacteremia now with complaints of bilateral leg pain R >L. s/p R BKA\n REASON FOR THIS EXAMINATION:\n assess for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc WED 11:34 AM\n No evidence of DVT seen in either lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 31-year-old female with lupus, end-stage renal disease on\n hemodialysis, admitted with infected former right upper extremity AV graft\n site with bacteremia, now with complaints of bilateral lower extremity pain,\n right greater than left. Patient is status post right BKA.\n\n COMPARISON: Right lower extremity venous ultrasound was last performed on\n .\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and color and pulsed\n wave Doppler examination was performed over bilateral common femoral,\n superficial femoral and popliteal veins, demonstrating normal flow,\n compressibility, respiratory variation, and augmentation. No evidence of\n intraluminal thrombus is seen. Flow is also demonstrated in the calf veins on\n the left and in the posterior tibial vein on the right.\n\n IMPRESSION: No evidence of DVT seen in either lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1066474,
"text": " 5:23 PM\n CHEST (PA & LAT) Clip # \n Reason: assess retrocardiac opacity seen on previous exams\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with intermittent fever. Recent removal of infected leftover\n graft material right arm\n REASON FOR THIS EXAMINATION:\n assess retrocardiac opacity seen on previous exams\n ______________________________________________________________________________\n WET READ: CXWc FRI 8:02 PM\n Overall slight worsening vs. stable appearance of interstitial opacities\n bilaterally, with slightly more dense retrocardiac opacity as on prior PA and\n lateral radiographs. No new regions of abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Intermittent fever.\n\n PA and lateral upright chest radiograph was compared to .\n\n The heart size is moderately enlarged, stable. Significant pulmonary\n hypertension signs such as bulging of main pulmonary artery and dilated right\n and left pulmonary arteries are unchanged. The patient continues to be in\n mild pulmonary edema that has slightly improved in the interim. Left\n retrocardiac opacity seen on both PA and lateral view might represent an area\n of infection given its persistence since and worsening of\n the consolidation in this area compared to . There is no\n appreciable pleural effusion. There is no pneumothorax. The dialysis\n catheter tip is at the cavoatrial junction/right atrium. Sternotomy wires are\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-03 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1064653,
"text": ", J. FA10 9:57 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PAIN AND SWELLING BLE // ASSESS FOR DVT\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with LUPUS, ESRD on HD admitted with infected former RUE avg\n site/bacteremia now with complaints of bilateral leg pain R >L. s/p R BKA\n REASON FOR THIS EXAMINATION:\n assess for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT seen in either lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1065635,
"text": " 1:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, pre-op film\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman pre-op for OR \n REASON FOR THIS EXAMINATION:\n interval change, pre-op film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative radiograph.\n\n Comparison is made to the prior study of .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The heart size is mildly enlarged.\n The aorta is tortuous. Severely enlarged pulmonary arteries are unchanged.\n Mild interval worsening of the pulmonary vascular congestion is noted. The\n left retrocardiac consolidation is unchanged. No pleural effusion or\n pneumothorax is detected. The right hemodialysis catheter is unchanged in\n position.\n\n IMPRESSION: Mild interval worsening of the pulmonary vascular congestion.\n Unchanged left retrocardiac consolidation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-04 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 1064899,
"text": " 9:47 AM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: Right upper arm.\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with ligated dialysis access./fevers. Assess for\n collection/hematoma\n REASON FOR THIS EXAMINATION:\n Right upper arm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female with fevers and two sites of swelling and\n draining on the right upper arm.\n\n FINDINGS: Transverse and sagittal images of the subcutaneous tissues in the\n right upper arm were performed. At the site of the open wound in the\n antecubital space, there is a collection of echogenic material measuring 2.1 x\n 1.0 x 2.4 cm. Only a scant trace of clear fluid is identified on one aspect\n of the space. No drainable fluid is identified.\n\n At the site of the open sore in the more proximal area of the right upper arm\n just inferior to the axilla, there is a second collection of echogenic\n material measuring about 1.1 x 2.8 x 1.6 cm. Note is made that there is a\n shadowing echogenic structure within this space thought to be a gauze pad.\n Again, no drainable fluid is identified within this space.\n\n IMPRESSION: Two sites of echogenic collections in the right upper arm as\n described above. No drainable fluid is identified in either site. The sites\n may represent infectious material or hematoma.\n\n These findings were conveyed to Dr. at noon on .\n\n\n"
}
] |
21,072 | 152,181 | Given the adenocarcinoma complicated by bleeding, the family and the patient decided to proceed with surgery. Two nights prior to the operation, he had a nonsustained run of ventricular tachycardia, 22 beats in length. Cardiology evaluated the patient and recommended no further workup. His only other cardiac rhythm abnormality was a short run of atrial bigeminy on postoperative day number six which was also self limited. On , the patient was taken to the operating room after a bowel prep and underwent a low anterior resection, permanent end colostomy. Preoperatively, a Foley catheter could not be placed secondary to urethral strictures. Urology service placed a suprapubic tube preoperatively in the operating room. The patient received 24 hours of perioperative antibiotics. His remaining postoperative course was unremarkable. He was started on tube feeds three days postoperatively and slowly advanced to a goal rate of 70cc per hour. His wound looked swell and there was no evidence of a wound infection. His stoma began to function on postoperative day number six and he will require a bowel regimen to keep his colon empty. We have suggested discharging him on Colace 100 mg p.o. twice a day, Senna two tablets p.o. twice a day and p.r.n. Lactulose. This regimen may be adjusted to effect as needed. He has been on a ventilator for several years and his discharge ventilator settings were a respiratory rate of 12, tidal volume 550, FIO2 30%, and PEEP 5. His staples should be discontinued in one week. He had a negative urinalysis on the day of discharge. He will be at risk for developing urinary tract infection and, if he develops a fever, this should be considered. We recommend follow-up with Dr. in two weeks. Please call his office for an appointment, telephone number is supplied on page one. | + generalized anasarca noted.Resp. + generalized anasarca.Resp.- Pt. AM LABS WNL.GI/GU: ABD SOFT DISTENDED, +BS. (-)MAE.C/ Pt. Albuterol MDI Q vent check. remains intubated and vented via trach. LS clear>diminished. t/o shift for sm.-mod. Hct stable- 28.2. AM HCT 29.5. of bowel today. intubated and vented via trach. vented via trach. Plan is to d/c pt. Resp. Post op MG+ 1.4, KCL 3.7. IVF WERE D/C THEN RESTARTED THIS AM. soft, NTND, with +BS. ABx' started in . Again noted, is a left pleural effusion. - Pt. Incision well approximated; staples in place. RECTAL BAG INPLACE. Peripheral pulses palpable. Peripheral pulses palpable. LS COARSE.CV: HR 58-70'S NO ECTOPY. MICU-B, NPN:Neuro: A&OX3, PERRLA, responds to verbal stimulous, communicates w/ eye movements, no movement in extremities.CV: HR 70's NSR w/o ectopy, SBP 80's-120's.Resp: Received pt. Care NotePt trached and vented per settings on resp. COARSE PRIOR TO SUCTIONING. amts. amts. CA 8.2 WHICH IS 9.2 WHEN CORRECTED WITH HYPOALBUMINEMIA.GI- ABD SOFT ABSENT BS. TECHNIQUE: Helically acquired contiguous axial images of the chest, abdomen and pelvis without and with IV contrast. RESP CARE: PT CONTINUES ON PRIOR SETTINGS. Communicates w/ eye movements.CV: HR high 50's-70's, SB- NSR w/o ectopy. Case management and RN contact facility yest. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. 2 completed yest. (-)MAE secondary to ALS. A central venous line is seen with its tip in the mid-SVC. Continues to have moderate amts. is to d/c . Staples CDI, well approximated. Lungs cs r upper/ clears post sx. TF started yest. VENT SETTINGS UNCHG'D. + generalized anasarca.Resp. BS COARSE UPPER THIS AM WHICH CLEARED WITH SUCTIONING. ORAL SECRETIONS .LUNG SOUNDS CLEAR.T 99.8 PO. movmement in extremities, non-verbal @ baseline.CV: HR 70's-80's NSR w/o ectopy. remains intubated and vented via trach. Hypoactive BS.GU: U/O remains to wax/ wane via suprapubic cath. HR 58-70 NSR.GI: Kept NPO for now. LS clear t/o. 's dgtr. around trach stoma. Sx'd for mod amnts of same, and white from trach. R sided pnx. Req. PG1/2 done ?dictate. BBS clear to coarse, x 4. Even chest exp. - Remains on A/C/.30/vT 500/12/PEEP 5. F/U with case mgmt. MDI given as per order. Pt had restful noc. Trache care done. Vent settings as per careview.CV: HR 60-70's SR no ect. +BS this shift. Lungs clear upper fields, diminished @ bases. PASSING FLATUS.GU: DIAPER IN PLACE. Per GI this should subside as pt. MAG 1.7 REPLETED WITH 2 GMS MAG IV. CURRENT VENT SETTINGS: CMV/12/650/21%. Communicates w/ eye movements/eye sensor.CV: HR 70's-90's NSR w/ very rare PVCs. Trach care done. CONT TO HAVE COPIOUS AMT'S OF CLEAR ORAL SECRETIONS WITH CLEAR SECRETIONS DRAINING AROUND TRACH SITE.NEURO STATUS UNCHG'D, CONT TO COMMUNINCATE WITH EYE MOVEMENTS, C/O ABD X1 AND WAS MED WITH MSO4 X 1 WITH RELIEF.CV: HR CONT TO BE IN THE 60'S WHEN ASLEEP AND IN THE 70'S WHILE AWAKE, NO ECTOPY NOTED. EXT FLACCID.RESP- REMAINS ON SAME VENT SETTINGS FIO2 21%/ TV 650/ RATE OF 12 BREATHING 12 AND PEEP OF 5. Mod amt oral secretions.GI - Tolerating TF well. + generalized edema t/o. Min vent ectopy. incision w/ well approx. VSS.Resp - BS cl bilat. Albuterol MDI Q vent check. Gave pt. Resp. SPUTM CX SENT. STABLE THRU/ THE NOC. SXN FOR SM PALE NO CHANGES WIIL CONT TO RESP. bagged/lavaged/sxn'd. As mentioned above, pt. AMBU X2 @PT'S REQUEST FOR C/O SOB. Was given breathing tx by RT w/o results. Able to communicate that he felt SOB- RT assessed pt. spelled out the word "ambu". RN & MD informed. and vent., made temporary changes w/o results. MD ALEXOPOLOUS CALLED. ABG results 7.61/16/180/17/-1. Received pt. d/c back to . denied pain/chest pain @ this time. Will f/u w/ ABG when team able. C/o pain X1 and tx'd effectively with MSO4 2mg. IF CARDIAC ECHO NOT NORMAL FURTHER CARDIAC W/U WILL BE REUIRED.GI- ABD SOFT WITH HYPOACTIVE BS. Stoma as mentioned above.Dispo: Pt is a full code. 2+ general edema. IV RN called, assessed pt. Mag. PERRLA/unable to move q 4 extremities.CV: HR 90's- 120-130, NSR w/ new onset of ectopy- vent. NSR 68-98 occas. MDI given as per order. MDI given as per order. BS present. Per team p.o. CXR done revealed R sided/RLL infiltrate. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. PT. 2+ edema to q 4 extremities. Tolerating well. Receiving Golytely prep for colonscopy. Pt had restful noc with sedation. Pt requests to have suprapubic cath d/c'd as soon as possible. + generalized anasarca noted.Resp. Suxn'd via trach. LSC triple-lumen dc'd last . Moderate output noted over/noc. + generalized anasarca. Peripheral pulses palpable.Resp. t/o shift for moderate amts. Resp. A.M. HCT and lytes. - Pt. - Pt. ET by yest. soft, NTND with hypoactive BS noted. Also, pt. vented via trach on A/C 650 X 12/ .21/PEEP 5 with LS clear-coarse/clear. Afebrile this shift.GI: Cont. Expressed pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. ABG drawn - 7.55/20/106/18/-1. left colostomy supplies for pt. amts. following as consult- pt. Peripheral pulses palpable. Repeat ABG-- 7.52/20/107/17/-3. Pending ABG.GI: Abd sof nontender Positive bowel sounds. Denies pain.C/ Pt. remains intubated and vented via trach. tip sent for cx. Restart TF if pt. soft, ND with +BS. LS clear>coarse. Able to comunicate w/ eye movement.CV: HR 60's-70's NSR w/o ectopy. Sx. Sx. VBG ON THIS 7.40/34/44.22. Pts. Pts. Pts. Given Ca+, KCL, and Mg. repletion. + BS. STOMA INTACT. remained NPO over/noc. Moderate amt. Preserved basal left ventricularsystolic function. There is mildmitral annular calcification.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. Mild (1+) aortic regurgitation is seen. results final. PALPABLE PUSLES NOTED TO BILATERAL DORSALIS AND RADIALS. Afebrile t/o shift. t/o shift for mod. runs low @ baseline (systolic 80's-90's). Abd. Abd. Abd. Lungs sound coarse throughout.Heme/lytes/micro: Hct 29.8, lytes WNL. Afebrile this shift. EKG unchanged from those previously obtained. (-)MAE secondary to ALS. | 72 | [
{
"category": "Radiology",
"chartdate": "2104-02-27 00:00:00.000",
"description": "P CHEST (PA & LAT) PORT",
"row_id": 786864,
"text": " 9:27 PM\n CHEST (PA & LAT) PORT Clip # \n Reason: requesting AP and LATERAL portable films to follow-up on pos\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ALS, admitted here for w/u of lower Gi bleed\n\n REASON FOR THIS EXAMINATION:\n requesting AP and LATERAL portable films to follow-up on possible\n pneumomediastinum/pneumopericardium seen on prior portable AP film\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: ALS, Lower GI Bleed, f/u on possible\n pneumomediastinum/pneumopericardium seen on portable ap film.\n\n CHEST PA AND LATERAL: Comparison with prior studies from two hours earlier.\n\n FINDINGS: Once again seen is a tracheostomy tube in satisfactory position.\n The tip of the subclavian central venous line is in the distal SVC. The heart\n is normal in size. The pulmonary vessels are unremarkable. Again seen is a\n left retrocardiac opacity which has not changed in the interval. There is a\n faint linear lucent line paralleling the left heart border, seen at the level\n of the left pulmonary hilum which appears much smaller compared to prior\n study. There is a small amount of pleural fluid. The lateral view is limited\n due to overlying arms and under penetration. The bones are unremarkable.\n\n IMPRESSION:\n 1) Interval improvement in lucency adjacent to the left heart border which\n likely represents a pneumothorax.\n\n 2) No change in the left retrocardiac opacity (atelectases vs pneumonia) and\n the small left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786861,
"text": " 7:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please verify left subclavian central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ALS, admitted here for w/u of lower Gi bleed\n REASON FOR THIS EXAMINATION:\n please verify left subclavian central line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest radiograph from at 19:14.\n\n CLINICAL INDICATION: Subclavian line placement. There is no prior study for\n comparison.\n\n The patient has a tracheostomy which is in appropriate position. A left\n subclavian central venous line is seen with tip at the confluence of the\n brachiocephalic and SVC. The heart size is normal. There is central\n prominence of the pulmonary vasculature but there is no upper lung zone\n redistribution. There is an ill defined opacity in the left perihilar region\n and also an opacity at the left base which obscures the left hemidiaphragm.\n There is also an unusual curvilinear density paralleling the left heart\n border. The extreme right CPA is not included in the study. There is no\n pneumothorax.\n\n IMPRESSION: 1. Central line tip at junction of left brachiocephalic vein and\n SVC; no pneumothorax.\n\n 2. Nonspecific left perihilar and left basilar densities.\n\n 3. See above comments regarding an unusual curvilinear density paralleling the\n left heart border. Recommend repeat examination with lateral view.\n\n Findings were communicated to the house staff.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-03 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 787228,
"text": " 9:44 AM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: pt seen to have 5 cm ? sigmoid colon mass on colonoscopy; pl\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ALS, admitted with dropping Hct, evaluate by EGD and\n colonoscopy, found to have 5 cm ? massin sigmoid colon\n REASON FOR THIS EXAMINATION:\n pt seen to have 5 cm ? sigmoid colon mass on colonoscopy; please evaluate\n extend of mass (involvement of nodes, involvmeent outside the colon, etc)\n PLEASE PERFORM ABD AND PELVIS FOR STAGING on monday \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO, :\n\n INDICATION: Sigmoid mass seen on colonoscopy.\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest, abdomen\n and pelvis without and with IV contrast.\n\n CONTRAST: Oral contrast and 100 cc Optiray IV due to patient debility.\n\n CHEST CT WITH IV CONTRAST FINDINGS: The patient is s/p tracheostomy tube\n placement. There is mucous seen in the superior trachea. There is left lower\n lobe consolidation. Small flecks of high density material are identified\n which may be the result of prior aspiration. There is minimal peripheral\n atelectasis seen in the lingula. There is minimal ground-glass opacity in the\n right lower lobe posteriorly with minimal atelectasis. There is a small right\n pleural effusion. There is minimal scarring or atelectasis identified in the\n right middle lobe, medial segment. There are small scattered mediastinal\n lymph nodes. None appear pathologically enlarged. The great vessels are\n unremarkable. There is no pericardial effusion.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST FINDINGS: There are no enhancing\n liver lesions. The pancreas, spleen, and adrenal glands are unremarkable.\n There is mild atrophy of the pancreas. The common bile duct is not dilated.\n There are bilateral renal cysts. There is moderate to severe right\n hydronephrosis with cortical thinning and multiple renal stones. There is an\n obstructing 1.3 cm right UPJ stone. There is a filter in the infrarenal IVC.\n There are scattered small retroperitoneal lymph nodes.\n\n CT PELVIS WITH IV CONTRAST FINDINGS: There is a rectal tube. There is\n thickening of the sigmoid colon. There is no evidence of obstruction. There\n is asymmetric soft tissue density seen in the sigmoid, this may represent the\n mass identified on colonoscopy. There is mild stranding in the presacral fat.\n Bone windows demonstrate no suspicious lytic or blastic bone lesions. There\n are mild degenerative changes of the lumbar spine.\n\n CONCLUSION:\n 1) There is thickening of the sigmoid colon with asymmetric soft tissue\n (Over)\n\n 9:44 AM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: pt seen to have 5 cm ? sigmoid colon mass on colonoscopy; pl\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n density, this may represent the mass seen on colonoscopy. No evidence of\n metastatic disease to liver.\n 2) Moderate to severe right hydronephrosis with cortical thinning and\n nephrolithiasis. There is an obstructing right UPJ stone.\n 3) Left lower lobe consolidation. Small right pleural effusion. No\n pulmonary nodules are identified.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 787229,
"text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for any changes in this intubated patient si\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ALS, admitted here for w/u of lower Gi bleed\n\n REASON FOR THIS EXAMINATION:\n please evaluate for any changes in this intubated patient since prior CXR\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Admitted for lower GI bleed.\n\n CHEST, PORTABLE: Comparison is made to a prior study of .\n\n The heart is normal in size. Mediastinal and hilar contours are unremarkable.\n The pulmonary vasculature is normal. There is continued improvement in the\n lucency over the right heart border. Again noted, is a left pleural effusion.\n There is consolidation at the left base which might be due to atelectasis or\n pneumonia. A central venous line is seen with its tip in the mid-SVC. The ET\n tube is 3.5 cm from the carina.\n\n IMPRESSION:\n 1) Continued improvement in the lucency over the right heart border which is\n presumed to represent a pneumothorax.\n\n 2) No change in the retrocardiac opacity which might represent atelectasis or\n pneumonia, as well as in the small left pleural effusion.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-08 00:00:00.000",
"description": "Report",
"row_id": 1538819,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVEIW OF SYSTEMS-\nNEURO- PATIENT CONTINUES TO COMMUNICATE WITH HIS EYES. UP MEANS YES DOWN OR TO THE SIDE MEANS NO. USIJNG EYE SCANNER TO COMMUNICATE WITH FAMILY WHEN THEY WERE IN. DOES NOT MOVE EXT.\nRESP- REMAINS ON VENT SETTINGS 50% FIO2/ TV 650/ AC RATE 12 BREATHING 12 AND 5 PEEP. BS CLEAR. COARSE PRIOR TO SUCTIONING. SUCTIONED FOR SMALL AMOUNTS WHITE SPUTUM.\nCARDIAC- HR 70-80 NSR WITH OUT ECTOPI. MAP 68-93. K 3.6 REPLETED. MG UP TO 2.4 AFTER TREATMENT LAST PM. CA 8.2 WHICH IS 9.2 WHEN CORRECTED WITH HYPOALBUMINEMIA.\nGI- ABD SOFT ABSENT BS. STOMA PINK AND WARM TO THE TOUCH. OSTOMY APPLIANCE INTACT. PEG TUBE TO GRAVITY DRAINAGE DRAINING BILIOUS MATERIAL PH =5 GASTRO NEG. PUT OUT 120CC IN 8 HOURS.\nGU- SUPRAPUBIC TUBE IN PLACE DRAINING YELLOW URINE WITH SMALL AMOUNTS BROWN SEDIMENT. UO 45-160CC/HR.\nID- PATIENT AFEBRILE. WBC UP TO 29.1 TODAY. DR FROM GREEN TEAM SURGERY NOTIFIED. NO TREATMENT ORDERED.\nHEME- HCT STABLE POSTOP AT 32.7.\nPAIN- ORDER FOR MSO4 MADE SO THAT PATINET COULD RECEIVE IT MORE FREQUENTLY. MOST OF THE TIME PATIENT DENIES HAVING PAIN BY COMMUNICATING WITH HIS EYES. HE HAS BEEN PREMEDICATED PRIOR TO TURNS WITH 2MG MSO4 IV AND DOES WELL DURING TURNING. HE DID C/O OF PAIN X1 WHEN HIS BROTHER WAS HERE AND HE RECEIVED A TOTAL OF 4MG IV MSO4 WITH GOOD EFFECT.\n BROTHER IN TO VISIT THIS AFTERNOON. UPDATED ON THE PATIENT'S\n CONDITION.\nDISPO- REMAINS IN THE MICU A FULL CODE BEING COVERED BY THE NSICU TEAM. FOLLOWING RECOVERY FROM HIS SURGERY HE WILL MOST LIKELY RETURN TO NE \n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-08 00:00:00.000",
"description": "Report",
"row_id": 1538820,
"text": "57 male with ALS,patient went to OR yesterday for removal of intestinal mass. Placed on A/c post surgery; remains on present setting since. No recent ABG patient passively resting on vent. Hypotensive with BP 92/49.suctioned for moderate amount of clear sputum. Will attempt to place patient on routine vent setting in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-27 00:00:00.000",
"description": "Report",
"row_id": 1538784,
"text": "MICU Brief Nursing Admission Note:\n57y.o. male transferred from N.E. Hospital with GI bleeding which has required 6 units PRBC's in the past three weeks. He is vent dependent from ALS and has lived at the rehab for the past 5 years.\n\nPMH: ALS with vent dependency, GI Bleeding, Pneumonia, S/P PEG, Pt with very difficult IV access, currently only has one peripheral in his foot.\n\nAllergies: None\n\nPt was transferred to Hospital last Thursday for Upper endoscopy and Colonoscopy for this same problem. tolerated the upper endoscopy well and findings were normal. He did not tolerate the colonoscopy, became hypotensive and bradicardic. He had been prepped very poorly. He was sent back to the rehab without an answer. He continues to require transfusions for low hct and comes here today for another attempt to find source of bleeding.\n\nNeuro: Awake. Moves eyes up to answer \"yes\" and grinds his teeth to indicate discomfort of need to be suctioned.\n\nCV: BP 90's on admission. HR 60-70.\n\nIV: VERY POOR ACCESS. Has one peripheral IV at present in his right foot. need central line tonight. Currently has IVF D51/2NS with 20meq K at 75cc/hr infusing upon admission.\n\nResp: Vent settings are AC 18, TV 700, FIO2 35% with 5cm peep. Lungs have some coarse sounds and wheezes noted. Suctioned frequently for thick yellow sputum. Large amts oral secretions noted.\n\nGI: Passing black OB+ stool. NPO. Has PEG in left side of abdomen. Will be seen by GI service and possibly prepped tonight for colonoscopy tomorrow.\n\nGU: Condom catheter put on pt upon arrival.\n\nSkin: Seems to be intact. Lower extremities are edematous, feet swollen.\n\nSocial: Brother is spokesperson and has come to visit pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-28 00:00:00.000",
"description": "Report",
"row_id": 1538785,
"text": "NURSING MICU NOTE 2300-7A\n\nNEURO: PT ALERT, OPENS EYES SPONTANEOUSLY. NO MVT IN EXTREMITIES. PT WILL YES/NO QUESTIONS WITH EYE MVT AND WILL GRIND TEETH FOR DISCOMFORT. PT TURNED AND POSITIONED FOR COMFORT.\n\nRESP: PT IS ON AC 750X18 5PEEP, 35%. O2 STATS 100%. PT Q3HRS FOR SMALL AMT THICK YELLOW SECREATIONS. LS COARSE.\n\nCV: HR 58-70'S NO ECTOPY. SBP 90-120'S. PT WAS RECEIVING KPHOS OVERNIGHT. IVF WERE D/C THEN RESTARTED THIS AM. D5NS AT 150CC/HR. AM HCT 29.5. AM LABS WNL.\n\nGI/GU: ABD SOFT DISTENDED, +BS. PT RECEIVING GOLYTELY 4L VIA PEG. PT HAVING BLACK TARRY STOOL. ~700CC FOR SHIFT. RECTAL BAG INPLACE. PT URINE, TEAM AWARE THAT PT REFUSING FOLEY. NOT ABLE TO MEASURE U/O.\n\nDISPO: PLAN IS FOR COLONOSCOPY THIS AM. DEPENDING ON RESULTS, PT WILL GO BACK TO RESIDENCE AT N.E. FROM MICU. PT IS A FULL CODE. NO CONTACT FROM FAMILY OVERNIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-13 00:00:00.000",
"description": "Report",
"row_id": 1538834,
"text": "MICU-B, NPN:\nNeuro: A&OX3, no spontaneous movement to q 4 extremities, PERRLA. Communicates w/ eye movements.\n\nCV: HR high 50's-70's, SB- NSR w/o ectopy. SBP 80's-120's, MAPs in 60's. Pt. has SBP down to mid-80's, SB while in deep sleep.\n\nResp: A/C FiO2 30%, RR 12, TV 500, O2Sat 98%-100%. Lungs are coarse upper lobes, diminished @ bases. Suxn'd q 3-4 hrs for scant amnts. white sputum. Pt. has copious salivary/oral secretions, and copious yellow/mucousy secretions from trach. site- drsng. to trach. site is changed frequently throughout shift.\n\nHeme/lytes/micro: Mg this a.m. 1.5, repleted w/ 4g MgSo4 IV. Hct stable- 28.2. Afebrile.\n\nGI: TF's Promote w/ Fiber Full Strength, able to advance from 40cc/hr to 50cc/hr this shift- will continue towards goal of 70cc/hr. No evidence of flatus- scant amnt. clear brown fluid in colostomy bag. Stoma site is pale pink. BS active.\n\nGU: Suprapubic catheter draining clear lt. yellow- straw yellow urine. Scant drainage from urethra.\n\nDerm: Lower abdominal/midline incision has well approximated edges/staples intact w/o drainage. C/o incisional pain- given 2mg MSo4 X 1 w/ positive results.\n\nSocial: FULL CODE. Plan is to d/c pt. back to where he was previously a resident. Discharge plan/Page 2 near completion. Family/friends are aware of plan. Team is aware of need to complete d/c summary/Page 1. RN case management has contact facility and they will be expecting pt. .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-14 00:00:00.000",
"description": "Report",
"row_id": 1538835,
"text": "MICU-B NPN 1900-0700\n Pt. AxOx3. (-)MAE secondary to ALS. Communicating with eyes, using yes & no signals. Pt. with c/o incisional pain x1 over/noc; given MSO4 4 mg. x1 with noted relief.\n\nC/ Pt. with HR 50's-60's, SB-NSR, with no ectopy noted. NIBP 80'S-100/40'S-60'S. Peripheral pulses palpable. + generalized anasarca.\n\nResp.- Pt. intubated and vented via trach. with vent settings unchanged from previous shift. A/C .30/12/500/ with O2Sats. 99-100%/ LS clear/coarse> diminished. Sx. prior to turning for small amts. thick, yellow secretions.\n\n Pt. s/p bowel resection/colostomy placement. Stoma pale, pink. No flatus or stool noted in pouch to date. ET by last . to change colostomy bag. Supplies left for pt. transfer to today. Per ET, colostomy pouch to be changed twice a week. Abd. soft, ND, tender to palpation near incision site. Incision well approximated; staples in place. Open to air with no ooze noted. Site pink. PEG tube patent and delivering TF (Promote with fiber) @ goal rate 70/hr. with 60-70cc residual noted Q4.\n\n Pt. s/p supra-pubic catheter placement. Catheter patent and draining amber, yellow urine. Pt. does continue to leak urine out of urethra.\n\n Pt. with grossly intact skin.\n\nSocial - No contact with family over/noc.\n\nDispo- Plan is for d/c to rehab today. Pg. 2 completed yest. Case management and RN contact facility yest. and they are expecting pt. today. Awaiting page (1) and d/c note from team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-07 00:00:00.000",
"description": "Report",
"row_id": 1538816,
"text": "npn 7-7am\n\nNo changes overnight.\n\nneuro: Pt communicates yes/no using eye movements. Indicates displeasure by grinding teeth. Does not move. is not receiving sedation. Does complain of neck pain that is relieved with repositioning.\n\nresp: trached with vent setting 650/21%/rr 12 PEEp 5. LS coarse. suctioned several times for a small amt of thin white secretions. Copious oral secretions.\n\nCV: SR 55-70, no ectopy.\n\nAccess: TLC in LSC.\n\nGI/GU: Golytely being administered through PEG tube via TF pump. Rate currently is 100cc/h. No effects as of yet. pt received 1 fleets enema at 2am. Dr is aware that pt is not moving bowels and want Golytely to continue at 100/h. Incontinent of large amt of urine; refuses foley and is wearing diaper.\n\nSkin: intact\n\nSocial: Spoke with brother last .\n\nFull code.\n\nPlan: Bowel resection this afternoon.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-07 00:00:00.000",
"description": "Report",
"row_id": 1538817,
"text": "NPN MICU-B 7AM-7PM\nS/O: Respir: Remains on A/C 650/14/21%, with Peep-5, O2 sats 95-99%. Requiring frequ suctioning q2-3hr for lrge amt thick yellow sputum, also requiring frequ oral suctioning lrge amts clear secretions.\n\nC/V: BP-120-140's/70, HR 60's SR with no ectopy noted. K+ 4.1.\n\nGI: Did not clear overnight with GOlytley per PEG infusion, required Fleets Enema times one overnight, and required 3 soaps suds enemas today pre-op, with light brown liquid stool noted. NPO for . TO OR @ 4PM.\n\nGU: IVF continued until left for OR. Incon urine using adult diapers.\n\nNeuro: Alert and interacitve using eye movements to communicate, eyes up means \"YES\" and moved to the side means \"NO\". Likes and dislikes are on the board in his room. Likes his covers up to just below his chin, his arms on his stomach, and the TV sound near his ear. Brother in all day will check on his condition this evening.\n\nSkin: No decubs or open areas noted.\n\nA/P: Await for pt s/ .\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-08 00:00:00.000",
"description": "Report",
"row_id": 1538818,
"text": "nsg progress note 7p-7a\nPt in OR/ most of shift. Accepted pt from RN @ 0400. Pt awake, moving eyes according to questions. Expresses pain. MSO4 2mg IVP given with no effect, repeat x1 with effect. Pt now resting.\n\nPt was in the OR for ~ 8hrs and received a suprapubic catheter which is draining clear yellow. Has put out adequate amounts, see OR urine out. Urine is clear. Dsg for suprapubic is clean/dry and intact. Some old bloody drainage noted on catheter.\nCV: Upon arrival pt's SBP was 140. Dropped to 90's after MSO4. Pt with 2+ lower extremity edema.\n\nPt also received a colostomy. Ostomy bag intact. No stool. Stoma pink/red and moist. Abd soft with no bowels sounds at present. PEG tube to gravity drainage with bile outputs.\n\nReceived on chronic vent settings AC 650 X12 PEEP 5 Fio2 50%. Lungs are clear. Sats 100%.\n\nElectrolyte replacement infusing at present. Post op MG+ 1.4, KCL 3.7. Pt received KCL 20meq, MGSO4 4 Gm , and Ca+ 2 Gm. Otherwise receiving LR @ 150cc/hr. ABx' started in . Current HCT 32.4.\nDISPO: pt is a full code. Brother phoned several times t/o night. Reassurance given. Procedure took longer than expected. Brother to call in late AM and to visit.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-06 00:00:00.000",
"description": "Report",
"row_id": 1538812,
"text": "MICU-B NPN 1900-0700\n Pt. remains intubated and vented via trach. On no sedation. Alert & oriented, answering questions with movement of eyes with yes/no cues. Eyes upward for \"yes\", and side to side for \"no\". Family uses ocular device for communication during the day when they visit. Able to express pt. needs. (-)MAE.\n\nC/ Pt. with HR 50's, SB with no ectopy noted. NIBP 80'S-132/40'S-60'S. Peripheral pulses palpable. + generalized anasarca noted.\n\nResp. - Pt. vented via trach. on 21%/vT 650/RR 12/ PEEP 5, with O2Sats. 98-100%. LS clear>diminished. Sx. t/o shift for sm.-mod. amts. thick, yellow secretions. Per. pts. family, pt. likes to be suctioned prior to any repositioning. Continues to have moderate amts. oral secretions.\n\n Pt. with PEG tube in place; patent and delivering Promote w/fiber @ goal 85/hr with residuals 30-40. Adb. soft, NTND, with +BS. Mushroom catheter remains in place, with sm. amts. liquid, brown stool noted. Pt. to undergo resection of bowel on Friday. Will need to begin prep. of bowel today.\n\n Pt. incontinent of yellow urine in diaper. Changed x2 this shift for estimated large volume.\n\nSkin - Pt. with grossly intact skin.\n\nAccess- LSC triple-lumen line in place; flushed for patency. Positional draw.\n\nSocial - Brother in until last eve. Able to communicate pt. desire to be sx. prior to turning, to have pillow tucked under, and to have blankets pulled up to chin. Assurance given to both and pt. that needs would be met.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-06 00:00:00.000",
"description": "Report",
"row_id": 1538813,
"text": "Resp. Care Note\nPt trached and vented per settings on resp. flowsheet. No vent changes made, no ABG's drawn. Albuterol MDI Q vent check.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-06 00:00:00.000",
"description": "Report",
"row_id": 1538814,
"text": "NPN MICU-B 7AM-7PM\nS/O: NEURO: Awake and interactive, able to answer questions by eye movements, eyes upward for yes, moves to the side for no. Brother not in today so the eye movement machine @ bedside not used. Is aware of surgery tomorrow 1-3pm.\n\nRespir: Remains trached and vented on A/C 14/650/21%, peep-5, O2 sats 95-99%. Suctioning q2-3hr for lrge amts thick yellow sputum, also having lrge amts oral secretions requiring very frequent oral suctioning. L/S course bilat.\n\nC/V: VS stable BP- 90-128/70, HR 56-68 SB with no ectopy noted, no runs of VT noted. Lytes repleted as needed.\n\nGI: TF's stopped and started on Golytely @ 75cc/hr, and IVF @ 75cc/hr. Having mod amts liquidy brown stool noted with Mushroom rectal cath in place. HCT stable.\n\nGU: Hard to assess U/O due to no foley in place pt refuses one, using adult diapers, changing them q2-3hrs. Mg+ and K+ repleted.\n\nSocial: Friends in visiting today, brother not in to visit but did call and was updated. Consents for were obtained by MD by phone with brother. To go to OR tomorrow afternoon.\n\nA/P: Continue with aggressive pulmon tiolet, prepare for in AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-06 00:00:00.000",
"description": "Report",
"row_id": 1538815,
"text": "RESP CARE: PT CONTINUES ON PRIOR SETTINGS. SECRETIONS CONTINUE TO BE COPIOUS ,THICK REQUIRING FREQUENT SUCTIONING. PT GOING TO O.R TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-12 00:00:00.000",
"description": "Report",
"row_id": 1538832,
"text": "MICU-B, NPN:\nNeuro: A&OX3, PERRLA, responds to verbal stimulous, communicates w/ eye movements, no movement in extremities.\n\nCV: HR 70's NSR w/o ectopy, SBP 80's-120's.\n\nResp: Received pt. on A/C 30%FiO2, TV 500, RR12, PEEP 5, vent. settings unchanged throughout shift. Suxn'd q 3-4 hrs for scant amnts thin white sputum. Lungs clear all fields.\n\nHeme/lytes/micro: Hct this a.m. 28.2, Mg this a.m. 1.5- repleted w/ 2g IV. Afebrile.\n\nGI: C/o incisional pain, responded well to 2mg MSo4 IV. Stoma pale pink- no flatus, no BM. Disconnected PEG from suxn @ 9:00. Started TF's @ 14:00- Promote w/ fiber @ 20cc/hr. Pt. able to tolerate for rest of shift. Will increase rate to goal as tolerated.\n\nGU: Suprapubic catheter draining amber yellow urine- cont.'s to urinate through urethra.\n\nDerm: Lower abd. incision has staples- well approximated.\n\nSocial: Multiple visitors today. is to d/c .\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-13 00:00:00.000",
"description": "Report",
"row_id": 1538833,
"text": "MICU-B NPN 1900-0700\n Pt. remains intubated and vented via trach. On no sedation. Received MSO4 2 mg. x1 over/noc for incisional pain with relief noted. Pt. AxOx3. Continues to interact using eyes for \"yes\" & \"no\" to communicate needs.\n\nC/ Pt. with HR 60'S-70'S, NSR with no ectopy noted. NIBP 80'S-102/ 40'S-60'S. CVP 10-12. Peripheral pulses palpable. + generalized anasarca.\n\nResp. - Remains on A/C/.30/vT 500/12/PEEP 5. LS clear t/o. Sx. prior to repositioning for sm. amts. thick, yellow secretions. O2Sats. 99-100%.\n\nGI- PEG tube in place; patent. TF started yest. @ 1400. Minimal residuals noted. Curently running @ 30/hr, with goal rate 70/hr of Promote with Fiber. Abd. incision with staples in place, healing nicely, no drainage noted. Stoma pink, no output noted. +BS this shift.\n\n Pt. with suprapubic catheter in place; patent draining clear, yellow urine. Slight amt. urine noted from penis over/noc.\n\nAccess- LSC triple-lumen line remains; unable to draw. No peripheral access.\n\nSocial- No contact from family over/noc.\n\nDispo- Plan is for pt. d/c today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-01 00:00:00.000",
"description": "Report",
"row_id": 1538797,
"text": "MICU NPN 7AM-3PM:\nNeuro: Pt slept until 11AM this AM. When awake he uses his eyes to communicate. Eyes up means \"YES\" eyes down or to the right means \"NO\". Teeth grinding indicates discomfort or displeasure. His visitor used the eye writer with him when she visited and asked to speak to me about what he wrote. He was not happy with the way I turned him this morning, complaining I was rough and treated him as if he was stupid. He complained that I pulled out the rectal tube and \"Shit went all over ther floor\". I explained that yes, the rectal tube did come out but it had been an accident when we were turning. It is common for this to happen and was certainly not done on purpose. I also told her that I explained to him what I was doing and I was not rude. I explained that it is necessary to turn him to change the dirty diaper and although it is uncomfortable I must do this to prevent his skin from breaking down. I have explained this to the pt as well.\n\nCV: BP down to 80's when asleep. Pt given 500cc's NS bolus with good effect. HR 58-70 NSR.\n\nGI: Kept NPO for now. have abdominal CT this evening if he consents. Team wants to check abdominal CT due to the findings on the colonoscopy which showed a small tumor. We are consulting surgery and are awaiting path report on the tumor. Rectal tube in place and draining dark black liquid stool.\n\nGU: Diaper changed Q3-4hrs for large amts urine. It is his choice to not have foley catheter placed and to use diaper.\n\nID: Afebrile.\n\nSocial: brother is spokesperson and will be in later this afternoon to help pt make up his mind if he will have the abdominal CT today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-01 00:00:00.000",
"description": "Report",
"row_id": 1538798,
"text": "Brief Addendum NPN 3p-7P:\nPt stable and has consented to have Abdominal CT this evening. Will need to be prepped with barocat but no oreder for this yet. Made slight vent change. Dropped AC rate to 10. All other vent setting same. Will need intern to get ABG this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-16 00:00:00.000",
"description": "Report",
"row_id": 1538844,
"text": "MICU-B, NPN:\nNeuro: Pt. A&OX3, PERRLA, no sponatneous movement in extremities. Communicates w/ eye movements/eye sensor.\n\nCV: HR 70's-90's NSR w/ very rare PVCs. PT> HAS NO IV ACCESS/TEAM PLANS TO DRAW LABS IN A.M.\n\nResp: Vent settings unchanged throughout shift: A/C 30%, RR 12, PEEP 5, TV 500, O2Sat 98%-100%. Lungs clear upper fields, diminished @ bases. Ambu'd/suxn'd q 1-2hrs throughout shift for mod.-copious amnts. thick white sputum. Indicated that he was comfortable afterwards. 16:00 pt. indicated to visiting friend that he has been SOB all day/requested higher FiO2. Have made multiple attempts to contact surgical team for vent. changes. Response received from SICU team @ 18:30- covering resident stated that he would come to unit and speak to pt./family.\n\nHeme/lyes/micro: WBC 15.1, Hct 28.0. Afebrile. Levoquin 500mg po qd for ? R sided pnx. Sputum spec. from grew polys.\n\nGI: TF's via PEG @ goal Promote w/ Fiber Full Strength @ 70cc/hr. No c/o abd. discomfort. Stooling liquid brown into colostomy.\n\nGU: Yellow urine w/ sediment via suprapubic catheter.\n\nDerm: Staples to lower ab.d surgical incision are intact, edges well approx., no drainage.\n\nSocial: FULL CODE. Family members have been visiting throughout the p.m. Plan is for d/c to where pt. is a resident. D/C Summary/Page 2 completed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-02 00:00:00.000",
"description": "Report",
"row_id": 1538799,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT HAS BEEN CALM AND COOPERATIVE DURING THE SHIFT. REQUESTED SOMETHING TO TAKE THE EDGE OFF AND TO FACILITATE SLEEP- GIVEN ATIVAN WITH GOOD RESULTS. PLS. SEE FOR MD ORDER. ABLE TO COMMUNICATE WITH EYE SIGNALS WITHOUT DIFFICULTY. AFEBRILE. UNABLE TO MOVE EXTREMETIES.\n\nRR: PT C/O OF NOT BEING ABLE TO BREATHE. RATE INCREASED FROM , LAST ABG WNL. SP02 > OR = TO 95% ON 21% FI02. CURRENT VENT SETTINGS: CMV/12/650/21%. BBS+, ESSENTIALLY CLEAR. SUCTIONING AT PT'S REQUEST FOR TAN, THICK SECRETIONS. PT HAS AMOUNTS OF ORAL AND STOMA SECRETIONS. TRACH CARE DONE NUMEROUS TIMES, PT TOLERATED WITHOUT DIFFICULTY.\n\nCV: PT REMAINS IN NSR, HR 70-80'S. NO SIGNS OF ECTOPY. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIAL AND DORSALIS PEDIS. DENIES ANY CHEST PAIN. S1 ADN S2 AS PER AUSCULTATION.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER. BS X 4 QUADRANTS. RECTAL TUBE IS STILL IN PLACE WITH BLACK-GREENISH STOOL NOTED. PASSING FLATUS.\n\nGU: DIAPER IN PLACE. CHANGING Q 2-4 HOURS FOR PT. COMFORT. LARGE AMOUNTS OF INCONTINENT URINE NOTED.\n\nINTEG: NO BREAKDOWN NOTED TO BACK OR BUTTOCKS. T&R AGGRESSIVELY FOR PT. COMFORT.\n\nSOCIAL: FAMILY IN TO VISIT.\n\nPLAN: CONTINUE TO MONITOR CRIT- CALL OUT IF STABLE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-29 00:00:00.000",
"description": "Report",
"row_id": 1538793,
"text": "MICU-B Procedure note 1700\nPt. underwent colonoscopy. Given a total of 150 mcg. Fentanyl & 4.5 mg. Versed with good effect. GI was able to view all of large bowel. Polyp removed, and large mass noted for which biopsy(s) were obtained and sent for pathology. See GI note for details. Pt. tolerated procedure well with appropriate sedation. No hypotensive episodes noted. Adb. quite firm post procedure. Per GI this should subside as pt. expells gas. Large amt. flatus passed with reinsertion of mushroom catheter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-17 00:00:00.000",
"description": "Report",
"row_id": 1538845,
"text": "Resp Care Note:\n\nPt cont trached on mech vent as per Carevue. Lung sounds coarse suct sm-th white sput. MDI given as per order. No vent changes made overnoc. Pt had restful noc. Cont mech vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-17 00:00:00.000",
"description": "Report",
"row_id": 1538846,
"text": "MICU B RN Note 7P-7A\n\nNeuro: exam unchanged. C/O pain in legs resolved with roxicet given @0300. Continues to express concern over Vent- wanting FIO2 increased. Reassured pt and family.\n\nCV: SBP Hypotensive x1 to upper 70's when asleep- happens 2 hs post roxicet administration. Pt arrouses with verbal, and SBP to 90-100's. Tele NSR 70-80's no VEA.\n\nResp: Vent settings unchanged on ACx12 with 30%FIO2. See careview. SX Q3-4 for thick white. Lungs cs r upper/ clears post sx. Sat 100%. c/o feelng SOB. Trach care done. With copious yellow sec. around trach stoma. Following ?RLL PNA on Levoquin, afebrile.\n\n\nGI: Promote with fiber FS @gola 70cc/hr no residule via PEG. Staples CDI, well approximated. Colostomy cherry red, minimal liquid brown stool out. Hypoactive BS.\n\nGU: U/O remains to wax/ wane via suprapubic cath. Yellow/ cloudy\n\nskin: no breakdown on air bed. No IV access.\n\nPlan: Family will call @0900 to inquire about dc status to NESI. PG1/2 done ?dictate. Ambulance not booked until dc status finalized. F/U with case mgmt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-02 00:00:00.000",
"description": "Report",
"row_id": 1538800,
"text": "Nursing Progress Note\nNeuro: Pt awake most of day, appears alert and oriented when asked questions by staff and family. Using Eye writer prn, and communicates well w/family. Moves few fingers on occaision, moves head some by use of jaw, eye movements. Smiles on occaision. Reassured often, PERL, frequent TROM, q2hr turns, and diaper changes if needed. Grits teeth if uncomfortable, or if he doesnt like what is being done. Eyes move upward for yes, and down and to left for no. TV on to watch movies, slept for 2 hrs today after family visit.\n\nREsp: Trache midline, stoma intact. Copious amnts of tenacious, clear secr. Sx'd for mod amnts of same, and white from trach. BBS clear to coarse, x 4. Sl dim at L base. Even chest exp. O2 sats 97-100%. Trache care done. Vent settings as per careview.\n\nCV: HR 60-70's SR no ect. Skin pale to pink, w/d/i. Pulses palp, socks to feet, venous sleeves on, no evid of dvt. BP via cuff 90-120's/70's.\n\nGI/GU: Incont of urine, diaper w/ yellow urine. No evid of skin breakdown, barrier cream to perineal area often. Small amnt watery /green d/c for mushroom cath. NPO, new order for Promote w/ fiber to begin, and then d/c at MN for CT of abd w/ contr in am. Abd soft, denies pain.\n\nNo evidence infect, afebrile.\nCont to monitor vs, asked resident about checking h/h, and she will address w/ team (H. ).\nWould benefit from pm sleep , did not appear to require anything today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538808,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- PATIENT IS ALERT. ABLE TO COMMUNICATE BY ANSWERING YES OR NO WITH HIS EYES. UP WITH THE EYES MEANS YES DOWN OR TO THE SIDE MEANS NO. USING EYE SCAN WITH FAMILY WHEN THEY ARE IN TO VISIT. DOES NOT MOVE EXT. EXT FLACCID.\nRESP- REMAINS ON SAME VENT SETTINGS FIO2 21%/ TV 650/ RATE OF 12 BREATHING 12 AND PEEP OF 5. BS COARSE UPPER THIS AM WHICH CLEARED WITH SUCTIONING. THEY ARE DIMINISHED AT THE BASES.SUCTIONED FOR THICK WHITE SPUTUM Q 3-4 HOURS.\nCARDIAC- HR 50-60 SB TO NSR WITH OUT ECTOPI. MAP 70-80. K 3.4 TODAY TREATED WITH 40MEQ KCL PER PEG. MAG 1.7 REPLETED WITH 2 GMS MAG IV. CA 7.9 BUT WHEN CALCULATED FOR HYPOALBUMIN HE WAS 8.9 WHICH DID NOT REQUIRE TREATMENT.\nGI- ABD SOFT WITH BS PRESENT. MUSHROOM CATHETER IN PLACE DRAINING BROWN LIQUID STOOL IN SMALL AMOUNTS THAT IS GUIAC POS. TF VIA PEG FS PROMOTE WITH FIBER AT 75CC/HR WITH MINIMAL RESIDUALS. GOAL TF RATE IS 85CC./HR WHICH THE PATIENT SHOULD REACH AT THE END OF THIS SHIFT.\nGU- VOIDING INTO DIAPER MEDIUM TO LARGE AMOUNTS YELLOW URINE.\nHCT STABLE AT 30.9.\nID- AFEBRILE.\nSOCIAL- HAD A TOTAL OF 4 VISITORS TODAY INCLUDING HIS DAUGHTER. HE SMILED ALOT WHILE HIS DAUGHTER VISITED WITH HIM. HIS BROTHER CALLED AND IS AWAITING THE SURGEONS PHONE CALL.\nDISPO- REMAINS IN THE MICU A FULL CODE. HE IS AWAITING TO HEAR THE SURGEONS OPTIONS FOR HIM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538809,
"text": "FOCUS; ADDENDUM\nDR UP TO SPEAK WITH THE PATIENT AND FAMILY CONCERNING OR. PLAN IS FOR OR ON FRIDAY. PATIENT WILL NEED TO BE CLEANED OUT PRIOR TO PROCEDURE. OR CONSENT SIGNED BY BROTHER. OSTOMY NURSE TO SEE PATIENT PREOP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538810,
"text": "FOCUS; ADDENDUM\nCARDIAC- HAD 10 BEAT RUN VTACH AT 1830. SBP 110 AT THE TIME. STRIP OF RHYTHMN PRINTED AND GIVEN TO DR . PATIENT WITHOUT C/O AT THE TIME. NO FEELING IN HIS CHEST. STAT LYTES SENT AND ARE PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-11 00:00:00.000",
"description": "Report",
"row_id": 1538827,
"text": "NURSING PROGRESS NOTE:\nPT CONT TO BE TRACH/VENT, SAME VENT SETTINGS, PT SX FOR MOD AMT'S OF THICK WHITE SECRETIONS. LRG AMT OF SECRETIONS AROUND TRACH SITE. CONT WITH COPIOUS AMT'S OF ORAL SECRETIONS.\nPT CONT TO COMMUNICATE WITH EYE MOVEMENTS. C/O ABD PAIN AND WAS MED WITH 2MG MSO4 IV WITH RELIEF. PT VISITED WITH BROTHER AND USED EYE MACHINE.\nVITAL SIGNS STABLE, BP IN THE 80'S WHEN ASLEEP, 90 AND ABOVE WHEN AWAKE OR STIMULATED. HR NS IN 60'S TO 70'S WITHOUT ECTOPY. TEMP 99.1 PO. NO ANTIBIOTIC COVERAGE.\nSTOMA SITE PINK NO BLEEDING, APPLIANCE INTACT NO STOOL OR FLATUS AT THIS TIME. SUTURE LINE C/D.\nURINE OUTPUT VIA SPT CLEAR YELLOW WITH INCONT NOTED FROM URETHRA.\nTUBE FEEDS HELD DUE TO ABDOMINAL DISCOMFORT.\nNO BREAKDOWN NOTED ON COCCYX. COMPRESSION SLEEVES ON. SLEPT WELL OVERNIGHT. REMAINS FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-11 00:00:00.000",
"description": "Report",
"row_id": 1538828,
"text": "NPN 0700-1500;\nPT WITH ALS VENT DEPENDENT/PARALYSED COMMUNICATING WITH EYE MOVEME WITH GOOD RESPONSENTS TO YES NO QUESTIONS.\nNO CHANGES NOTED ON NEURO EXAM.\n\nVENT CHANGED TO NEW VENT SETTING ARE UNCHANGED SATS ARE 97-99% SUCTIONED FOR THICK WHITE SECRETIONS. ORAL SECRETIONS .LUNG SOUNDS CLEAR.\n\nT 99.8 PO. NSR BP 85-95/44 TEAM STATES THAT THIS IS BASELINE. U/O VIA SUPRAPUBIC TUBE DOWN TO 30 MLS FOR 2 HRS. IV FLUID INCREASED TO 80 MLS PER HOUR. U/O IMPROVED INCONTINENT OF URINE THERFORE CONDOM CATH PLACED.\n\nGI; NPO T.F ON HOLD UNTIL FLATUS OR STOOL PASSED VIA COLOSTOMY. STOMA PINK AND WARM APPEARS TO HAVE INCISIONAL PAIN SETTLED WITH MSO4 2 MGS BELLY FIRM IN LOWER QUADS. HYPOACTIVE BOWEL SOUNDS.NOTED.\n\nHEME HCT 25.5 WBC 9.5\n\nBELLY WOUND OPEN TO AIR PINK AROUD BELLY BUTTON PEG INTACT NTO LWS DRAINING GREEN BILE.\nSKIN UNCHANGED.\nNO FAMILY PHONECALLS OR VISITS.\n .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-11 00:00:00.000",
"description": "Report",
"row_id": 1538829,
"text": "ALS patient,chronic vent dependent. Patient recently had surgery for intestinal mass. S/P colostomy. Complains of mild abdominal pain,off ativan,on MSO4 PRN. I/O 1640/1010 (+)630ccs. patient suctioned for small to moderate amount of thick clear sputum,BS diminished clear. Temp 99.9,labile PB 88/44,alert,coop will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-12 00:00:00.000",
"description": "Report",
"row_id": 1538830,
"text": "NURSING PROGRESS NOTE:\nPT UNCHANGED, REMAINS ON NEW VENTILATOR WITHOUT DIFF. VENT SETTINGS UNCHG'D. SX FOR SM AMT'S OF THICK WHITE SECRETIONS. LUNG SOUNDS CLEAR WITH O2 SAT'S 99-100%. CONT TO HAVE COPIOUS AMT'S OF CLEAR ORAL SECRETIONS WITH CLEAR SECRETIONS DRAINING AROUND TRACH SITE.\nNEURO STATUS UNCHG'D, CONT TO COMMUNINCATE WITH EYE MOVEMENTS, C/O ABD X1 AND WAS MED WITH MSO4 X 1 WITH RELIEF.\nCV: HR CONT TO BE IN THE 60'S WHEN ASLEEP AND IN THE 70'S WHILE AWAKE, NO ECTOPY NOTED. MAINTAINED GOOD BP THROUGHOUT THE NIGHT.\nPT RECEIVED ONE UNIT OF PACKE CELLS DURING THE NIGHT. HCT CHECKED THIS AM, WAITING FOR RESULTS.\nPEG CONT TO DRAIN MOD AMT'S OF BILE, NO BOWEL SOUNDS HEARD. NO STOOL/FLATUS DURING THE NIGHT.\nPT'S INCISION C/D AND PINK. STOMA PINK.\nSKIN ELSEWHERE INTACT.\nIV FLUID CONT AT 8OCC/HR. FAMILY INTO VISIT LAST NIGHT. REMAINS FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-12 00:00:00.000",
"description": "Report",
"row_id": 1538831,
"text": "69 yrs old male HX ALS, vent dependent; S/P LAR,Colostomy days ago. BS clear,patient suctioned for minimal amount of thick clear sputum. No ABG drawn maintaining good saturation, NSR with labile BP 84/41 will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-01 00:00:00.000",
"description": "Report",
"row_id": 1538794,
"text": "MICU-B, NPN:\nNeuro: Very lethargic this shift- communicates minimally w/ eye movements. PERRLA, no spont. movmement in extremities, non-verbal @ baseline.\n\nCV: HR 70's-80's NSR w/o ectopy. SBP 70's-low 100's, was bolused X1 500cc NS for hypotension, MAP < 60- responded well. 1+-2+ pedal edema.\n\nResp: Vent. settings to trach. A/C TV600, FiO2 21%, RR12, PEEP 5, O2Sat 98%-100%. Lungs coarse throughout, suxn'd q 3 hrs for mod. amnts. thick white sputum.\n\nHeme/lytes/micro: Awaiting a.m. labs. Afebrile this shift.\n\nGI: Bx's taken are pending. Likely malignant- not yet discussed w/ pt. or his proxy. Need to start TF's- team aware. Polyp bx found in room following procedure- team notified. Req. slip written, bx sent to lab @ 21:00. Minimal amnt. green liquid stool this shift.\n\nGU: Incontinent into diapers.\n\nDerm: D&I, turn q 2hrs.\n\nSocial: Brother is proxy and will visit w/ pt.'s dgtr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-01 00:00:00.000",
"description": "Report",
"row_id": 1538795,
"text": "MICU-B ADDENDUM TO NPN:\nPt. indicated that he was uncomfortable w/ vent. settings by eye movements. Asked RT to see pt. Decision made to increase TV to 650 to relieve feeling of air hunger. RT made attempt to obtain blood gas prior to vent. change but unable. Will f/u w/ ABG when team able. Pt. indicates that he is more comfrotable w/ this TV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-01 00:00:00.000",
"description": "Report",
"row_id": 1538796,
"text": "pt c/o sob tv. 6 to 650 stable thru/ out the noc will follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-15 00:00:00.000",
"description": "Report",
"row_id": 1538838,
"text": "Resp Care Note:\n\nPt cont trached on mech vent as per Carevue. Lung sounds coarse scat rhonchi improving suct mod th yellow sput. MDI given as per order. No vent changes made overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-15 00:00:00.000",
"description": "Report",
"row_id": 1538839,
"text": "MICU-B Event Note\nPt. with increased HR up to 100's-one-teens @ 0600, SBP up to 160's. Team paged, 12-lead EKG performed, Stat labs obtained from Femoral stick by MD since only access (LSC) triple-lumen dc'd last per physician . A.m. labs had also been dc'd last / MD. Per team p.o. Mag. 400 mg. given through PEG since pt. without IV access. EKG abnormal, atrial bigeminy noted. Labs pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-15 00:00:00.000",
"description": "Report",
"row_id": 1538840,
"text": "MICU-B, NPN:\nNeuro: Pt. very agitated @ start of shift. Able to communicate that he felt SOB- RT assessed pt. and vent., made temporary changes w/o results. Pt. having increasing difficulty communicating- atttempted to use eye movement sensor w/ no results. Began mouthing words but needs still unclear. Assessed w/ team in room. Pt. denied pain/chest pain @ this time. Gave pt. bath/changed linens/repositioned in an effort to comfort him- pt. able to sleep for few hours afterwards. 14:00 pt. had visitor, was awake and agitated once agian. Cont. to have dificulty communicating needs- friend unable to understand him as well. After multiplt attempts @ using eye sensor pt. spelled out the word \"ambu\". Pt. bagged/lavaged/sxn'd. for large amnt. thick white sptutum. Resquested pain med. for leg pain. Responded well to 10cc Roxicet elixir. Pt. now comfortable. PERRLA/unable to move q 4 extremities.\n\nCV: HR 90's- 120-130, NSR w/ new onset of ectopy- vent. bigeminy/PVC's. Became hypertensive to 170's w/ episodes of agitation, hypotensive to 80's while asleep. 2+ edema to q 4 extremities. Pt. is w/o IV access. Attempted to place access to either UE- unable to visualize decent vein. IV RN called, assessed pt. and also unable to place access- team aware.\n\nResp: Lungs coarse all fields. Received pt. on A/C, RR 12, TV 500, PEEP 5, O2Sat 98%-100%. As mentioned above, pt. c/o SOB, air hunger. Was given breathing tx by RT w/o results. CXR done revealed R sided/RLL infiltrate. SOB relieved by ambu'ing X 5\"-10\" followed by lavaging/suxn'ing. Pt. has copious thick, white secretions. Does not want to receive CPT to facilitate suxn'ing of secretions. Cough reflex is absent. Cont. to have thick yellow secretions from trach. site. requiring frequent drsng changes.\n\nHeme/lytes/micro: Mg Oxide given per PEG for Mg 1.4. WBC 17.0. T-max 98.8 rectally. Will send sputum cx next time suxn'd. No other spec.'s pending. Levoquin 500mg po qd for ? R sided pnx.\n\nGI: TF's Promote w/ Fiber Full Strength @ goal- 70cc/hr, tolerates well. Active BS. Passing brown liquid- semi-formed stool via colostomy. Stoma is cherry red.\n\nGU: Yellow urine w/ sediment via suprapubic catheter. Cont. to pass urine via urethra.\n\nDerm: Staples to lower abd. . incision w/ well approx. edges- 0 drainage. Otherwise D&I.\n\nSocial: Friend visited. Brother, , called @ home and informed of pt.'s distress/difficulty communicating. Stated that he would be into visit pt. this p.m. Poss. d/c back to . FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-16 00:00:00.000",
"description": "Report",
"row_id": 1538841,
"text": "Resp Care Note:\n\nPt cont trached on mech vent as per Carevue. Lung sounds sl coarse suct sm-mod th pale yellow (sput spec obt). MDI given as per order. Pt had restful noc with sedation. No vent changes made overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538811,
"text": "FOCUS; ADDENDUM\nCARDIAC- VTACH STRIP WAS FROM 2 DAYS AGO. HE DID NOT HAVE A 10 BEAT RUN TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-16 00:00:00.000",
"description": "Report",
"row_id": 1538842,
"text": "MICU B RN NOTE 7P-7A\n\nNEURO: EXAM UNCHANGED. C/O BILAT LEG PAIN RELIEVED WITH ROXICET/ ROM/ POSITION CHANGE. C/O ANXIETY/ SOB @ START OF SHIFT GIVEN 2MG MSO4 SUB Q WITH POSITIVE EFFEST. SLEPT INTERMITTENTLY T/O NIGHT, SEEMED TO HAVE A RESTFUL NIGHT.\n\nCV: TELE NSR 60'S W/O VEA. WITH HYPOTENSION WHILE ASLEEP TO AS LOW AS 68/40-80/48. MD ALEXOPOLOUS CALLED. GIVEN 500CC FREE WATER H20 BOLUS @0500. BP WHEN AWAKE 90-110/ 50'S. REMAINS W/O IV ACCESS, AND MD AWARE.\n\nRESP: VENT SETTINGS UNCHANGED. AMBU X2 @PT'S REQUEST FOR C/O SOB. SATS REMAINED 99-100% PT SUPPORTED EMOTIONALLY RE: C/O SOB ?R/T PT DID SAY HE FELT ANXIOUS OVER THIS- RESOLVED POST 2MG SUB Q MSO4. SPUTM CX SENT. SX Q4 FOR THICK WHITE SECRETIONS. TRACH SITE CLEANSED, NEW GAUZE APPLIED. AFEBRILE.\n\nGI: TOLERATING PROMOTE WITH FIBER @70CC/H, NO RESIDULE. COLOSTOMY CHERRY RED AND DRAINING LIQUID BROWN STOOL. STAPLES TO ABDOMEN CDI, INCISION WELL APPROXIMATED.\n\nGU: U/O 30CC/ Q2HS WITH LEAKING OF URINE @ URETHRA. MD AWARE OF LOW U/O.\n\nSOCIAL: MD ALEXOPOLOUS CALLED @ TO SPEAK WITH PT AND HIS BROTHER RE: PT'S RESP CO'S. PROVIDED SOME RELIEF OF ANXIETY. CALLED LATER IN NIGHT TO CHECK ON PT.\n\nPLAN: FOLLOW RESP STATUS WITH NEW RLL PNA, EMOTIONL SUPPORT, NO AM LABS DUE TO MD AWARE AND DO FEM STICK, ?IF PT NEEDS PLACEMENT OF PICC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-16 00:00:00.000",
"description": "Report",
"row_id": 1538843,
"text": "Respiratory Note:\nPt ventilated on settings as noted on flowsheet. Suctioned small to moderate amounts of white secretions. Pt complained at end of day to family members that he was uncomfortable with his breathing. RN & MD informed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-10 00:00:00.000",
"description": "Report",
"row_id": 1538825,
"text": "nsg progress note 7p-7a\nneuro: alert and communicating via eye movements. Medicated for pain X1 overnoc with MSO4 2mg IV. with good effect. PERLA.\n\nCV: VSS. Bp drops to SBP 80's while in deep sleep but increases with any with stimulation. NSR 70's no ectopy. 2+ general edema. Good pedal pulses.\n\nHEME: Hct down this am to 26.4 from yesterday 27.7. Dr. notified, will discuss in rounds but states no active signs of bleeding.\n\nID: Cont on cefazolin and flagyl. Tmax 99.8 ax. WBC's down to 11.5 from 14.8 yesterday. Incisions clean, dry and pink.\n\nGI: Started tube feeds yesterday, Promote with fiber @ 20cc/hr. Do not advance until ordered. Tolerating well. Residuals 5cc but difficult to aspirate due to position of peg tube. No active bowel sounds. Team aware and not expecting due to disease process.\n\nGU: Suprapubic tube intact and draining adequate amounts of clear yellow urine 30-50cc/hr. Dsg changed and has been dry and intact.\n\nResp: cont on AC 500X12 30% PEEP 5. No abg done today. Pt states with eye communication device \"do not play with settings.\" Denies feeling SOB. Lungs are clear with scant secretions via suctioning. Lg. amounts of yellow/green tinged sputum around trach site. Trach care done X2 and gauze pads placed between skin and trach collar for comfort per pt. request. Copious oral secretions, clear + thin.\n\nSkin: Stoma device intact, stoma pale pink with no stool yet. Surgery assessed this am and happy with appearance. Midline sutures intact, no drainage, pink. Coccyx intact no breakdown.\n\nDISPO: Pt is a full code. family in early . to visit. Pt requests to have suprapubic cath d/c'd as soon as possible. Team and nursing discussed advantages but pt refuses. Plan to keep pt @ until bowels start functioning, increase TF's per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-10 00:00:00.000",
"description": "Report",
"row_id": 1538826,
"text": "NPN MICU-B 7AM-7PM\nS/O: RESPIR: Remains on A/C 500/12/30% Peep-5, no changes made. O2 sats 96-99%. L/S clear suctioning q2-3hr for mod amts thick yellow sputum. Also having mod amts oral secretions, requiring frequent suctioning.\n\nGI: Had been rec'ing TF's Promote with Fiber @ just 20cchr but started to c/o intense pain and bloating. SICU team in to assess pt, ordered to stop TF's and medicate with MSO4 rec'd 4mg IV over 1/2hr and pain did resolve. TF's have been off most of day will attempt to restart this evening. No BS's noted, no stool noted from colostomy. No asprirates noted. Colostomy RN in and changed the colostomy bag and assessed it, HCT low-26.4, so site is pink.\n\nGU: U/O 30-40cchr, BUN/CRE WNL's. Team aware of u/o.\n\nID: Temp 99.3AX max, WBC- 11.4(14.2), IV antibx's d/c'd.\n\nSkin: Suture site clean and dry, no drainge noted open to air. No open areas noted.\n\nNeuro: Alert and communicating with eye movements eyes \"up\" for yes, to the \"side\" for no. Also has the eye machine in the room that his brother and friend uses. Refer to the board in his room for his particular needs.\n\nC/V: BP- 87-100/60, HR 60-78 SR with no ectopy noted. Continues on IVF @ 40cchr. Was repleted with 2gm Mag+S.\n\nA/P: Continue with pulmon toilet, assess site, and monitor VS. Attempt to restart TF's and assess for pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-28 00:00:00.000",
"description": "Report",
"row_id": 1538786,
"text": "PT. STABLE THRU/ THE NOC. SXN FOR SM PALE NO CHANGES WIIL CONT TO RESP. STATUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-28 00:00:00.000",
"description": "Report",
"row_id": 1538787,
"text": "Resp. Care Note\nPt received trached and vented on settings AC 750x 18x 35% peep 5. ABG drawn as TCO2 17. ABG results 7.61/16/180/17/-1. Rate lowered to 14, FiO2 lowered to 30%, and MD plans to repeat ABG. Sxn for small amount white secretions. Albuterol MDI Q vent check.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-28 00:00:00.000",
"description": "Report",
"row_id": 1538788,
"text": "MICUB 7A-7P\n\nNeuro: Opens eyes to verbal command, AOX3. Able to communicate by eye movement. Initially agitated and ginding teeth (indicating discomfort)... very difficulty to determine pt's needs. Attempts made to understand eye movement to put patient at ease. Eye dectection device brought in by brother to facilitate communication with good results. Pt less agitated and more cooperative, yet anxious about unfamilar surroundings and staff. Reassured patient of plan. Refer to assessment Carevue.\n\nCV: Denies CP, HS S1&S2. NSR 68-98 occas. PAC's and rare PVC noted.\nSBP 112-134. DP/DT difficult to palapate. 1+ pitting pedal edema.\n\nResp: Ventilated on A/C mode, 750x18-35% 5cm peep. Lungs: coarse BS throughout. Sats 95-100% Suctioned via trach for mod white to thick yellow secretions. Orally suctioned for copious clear secretions. ABG results of 7.61 16 180 17 indicate respiratory alkalosis, metabolic acidosis, Rate Decreased to 14, FIO2 to 30%. Repeat ABG somewhat improved at 7.56 19 129 18. After consulting with NESH, baseline vent settings found to be 21% 700 x 14 with 5CM PEEP. These changes were made. Sats maintained at 100%...ABG to be rechecked later this evening.\n\nGI: Abd firm to softly distended, positive bowel sounds. C/o diffuse abd pain to palpation. Receiving Golytely prep for colonscopy. Mushroom cath placed as pt passing very large amts of liquid black melena to dark green stool.\n@1700 bedside EGD and colonscopy performed by Dr . Pt. received a total of 75mcg fentanyl and 1.5mg versed in incremental doses during procedure. Patient tolerated procedure well. Per GI, EGD negative and colonoscopy to be repeated in AM due to poor prep. (large polyp was visulized, however). Plan is to continue golytely until clear. Mushroom Cath replaced and drainin lig green stool.\n\nEndocrine: AM Glu 65, 1800 Glu 110.\n\nF and E: Receiving D5NS at 100cc/hr. Fluid balance inaccurate as pt. has refused foley insertion. Incontinent,diaper in place.\n\nDerm: Refer to carevue. Color pale skin warn and dry. Constant oral secretions and drooling, dressing around trach and neck changed frequently to keep area dry.\n\nSOCIAL: Brother, , in most of the day. He is a great source of support to pt. and is able to help staff in assessing pt's needs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-04 00:00:00.000",
"description": "Report",
"row_id": 1538805,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVEIW OF SYSTEMS-\nNEURO- PATIENT ABLE TO COMMUNICATE BY MOVING EYES. ABLE TO GET HIS NEEDS KNOWN BY HAVING NURSE ASK HIM YES AND NO QUESTIONS. DOES NOT MOVE EXT.\nRESP- CONTINUES ON VENT. NO VENT CHANGES MADE. VENT SETTINGS AS PER FLOWSHEET. SUCTIONED FOR THICK YELLOW SECRETIONS IN SMALL TO MODERATE AMOUNTS. BS CLEAR.\nCARDIAC- HR 50'S SB WITHOUT ECTOPI. HR DOWN TO 52 AT ONE POINT. DR NOTIFIED NO TREATMENT ORDERED WILL LET HIM KNOW IF HR STAYS LESS THAN 50. K 3.9 THIS AM MG 2.0 AND CA 7.7. CALCIUM SUSPENSION GIVEN X1. REPEAT LYTES TO BE CHECKED TONIGHT AT . CARDIAC ECCHO DONE TODAY SECONDARY TO 22 BEAT RUN V TACH YESTERDAY. RESULTS PENDING. IF ECHO NL NO NEED FOR FURTHER CARDIAC W/U. IF CARDIAC ECHO NOT NORMAL FURTHER CARDIAC W/U WILL BE REUIRED.\nGI- ABD SOFT WITH HYPOACTIVE BS. MUSHROOM CATHETER DRAINING SMALL AMOUNTS DARK BROWN GUIAC POS STOOL. CHIEF SURGICAL RESIDENT UP TO SPEAK WITH BROTHER ABOUT POTENTIAL FOR SURGERY. MICU TEAM AND SURGERY TO DISCUSS BENEFITS OF SURGERY VS CONS AND THEN TO DISCUSS THIS WITH THE PATIENT AND HIS FAMILY. TF RESTARTED VIA PEG AT 15CC/HR. TF TO BE ADVANCED BY 10CC Q 4 HOURS TO GOAL OF 85CC/HR AS LONG AS RESIDUALS LESS THAN 100. HAVING MINIMAL RESIDUALS AT PRESENT RATE OF 25CC/HR. CEA LEVEL SENT TODAY. RESULTS PENDING.\nGU- VOIDING MEDIUM TO LARGE AMOUNTS OF YELLOW URINE IN DIAPER.\nFLUIDS- IV OF D5NS TO CONTINUE FOR 2 MORE LITERS AT 125 CC/HR. 1ST OF THOSE 2 LITER UP.\n BROTHER AND SISTER IN TO VISIT TODAY.\nDISPO- REMAINS IN THE MICU A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538806,
"text": "Respiratory Care:\n\nPatient trached with 8.O Portex. Vent settings Vt 650, A/c 12, Fio2 21%, 5cm peep. PAP/Plateau 21/19. Bs clear R Lung, slightly coarse L Lung. Sx'd for sm amount of thick white sputum. O2 sats 99-100%. Pt. appears comfortable on above settings. No further changes made. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-05 00:00:00.000",
"description": "Report",
"row_id": 1538807,
"text": "CV - Pt stable throughout night. Min vent ectopy. VSS.\n\nResp - BS cl bilat. Suctioned q 3-4 hrs for sm amt thick tan secretions. Mod amt oral secretions.\n\nGI - Tolerating TF well. Rate is up to 55 cc/hr with approx 25cc residual. BS present. Only sm amt liq stool from mushroom cath.\n\nGU - Continues to be incontinent via depends - changes q 3-4 hours for mod amt cl yellow urine.\n\nNeuro - Easily arousible. Responding very appropriately with eyes.\nAble to communicate positioning and others things fairly well.\n\nA: Stable\n\nP: Continue to support and explain all procedures.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-09 00:00:00.000",
"description": "Report",
"row_id": 1538821,
"text": "nsg progress note 7p-7a\nNeuro: Pt alert and interacting appropriately with eye movements. C/o pain X1 and tx'd effectively with MSO4 2mg. Otherwise he was premedicated with MSO4 prior to turning. Appears comfortable and able to sleep.\n\nCV: hemodynamically stable.see careview. HR NSR 70's no ectopy. + generalized edema t/o. Good pedal pulses. Left TLC patent. Dsg dry and intact.\n\nHeme: am Hct 27.7 down from 32 yesterday. Pt was greater than 5 liters positive at midnoc. 32 since admission. No active signs of bleeding and hemodynamically stable. Will notify team as they round early.\n\nID: Pt continues on Flagyl and cefazolin abx's. Am WBC 14.8 down from yesterday 24.1. tmax 99.8\n\nRESP:cont on AC. ABG drawn on AC 650 X12 Fio2 50% was 7.53/23/258. Changed to current settings of AC 500 X12 Fio2 30% Peep 5. Am ABG pending. Sats remain 100%. Lungs are clear t/o with no secretions via suctioning.\n\nGI: Peg tube to gravity draining bile. Pt remains NPO. Surgery discussed possibly waiting till tomorrow to start to feed tube feedings. Stoma light pink somewhat pale. Surgery aware and ok with appearance. No stool.\n\nGU: suprapubic catheter in place, draining adequate amounts clear yellow. IVF's changed to d51/2ns with 20meqKCL @ 75/hr.\n\nSkin: backside intact. Midline dsg above suprapubic intact but appears somwhat damp. with ser. sang. drainage. Will change when team rounds. Stoma as mentioned above.\nDispo: Pt is a full code. Brother called last night to be updated with pt's progress. Reassurance given. Family to visit today. Pt has denied and feelings of anxiety and slept all noc.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-29 00:00:00.000",
"description": "Report",
"row_id": 1538789,
"text": "MICU-B, NPN:\nNeuro: A&OX3, PERRLA, no spont. movement in extrems. Able to comunicate w/ eye movement.\n\nCV: HR 60's-70's NSR w/o ectopy. SBP 80's-low 100's, occ. dips to low 80's while pt. sleeping- resolved independently.\n\nResp: Vent. settings unchanged throughout shift- AC TV 700, RR 18, FiO2 30, PEEP 5, O2Sat 98%-100%. Suxn'd via trach. q 2-3 hrs for very small amnts. thick white sputum. Lungs coarse throughout.\n\nHeme/lytes/micro: Awaiting a.m. labs. Afebrile this shift.\n\nGI: Cont. Go-Lytely throughout shift via PEG. Pt. stooling liquid green stool. + BS. No evidence of frank bleeding in rectal tube/bag. Plan is to repeat colonscopy .\n\nGU: Incontinent into diapers. Changed q 2 hrs.\n\nDerm: D&I, turned q 2 hrs.\n\nSocial: Brother called to check in- will visit . Is hoping that pt. will be able to return to NES . FULL CODE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-29 00:00:00.000",
"description": "Report",
"row_id": 1538790,
"text": "RESP CARE\nPt remains on a/c 700x14 21% 5peep with peak/plat 24/18. No vent changes required throughout the night. Pt given alb mdi as ordered.Will follow with vent care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-29 00:00:00.000",
"description": "Report",
"row_id": 1538791,
"text": "MICUB 7A-3P\n\nNeuro: Opens eyey to verbal command, AOX3, Communicates with eye and eye detection device. Refer to assessment Care Vue.\n\nCV: NSR to SB No ectopy noted, SBP 88 while asleep to 118. DP/DT difficult to palpate, 1+ pitting pedel edema.\n\nResp: Vent on A/C mode, 700x14x21 5 peep. Lungs: Coarse BS throughput. Sats 95-100%. Suctioned via trach for mod white to yellow secretions. Orally suctioned copious amts of clear secretions. ABG PH-7.55, Paco2-20 Pao2-106 Bicarb 18 -1 Changed to TV 650 Rate 12 Plan ABG @ 1500. Pending ABG.\n\nGI: Abd sof nontender Positive bowel sounds. C/o diffuse abd pain on palpation. Receiving Golytely prep Peg intact. Mushroom cath inplace draining liquid. Plan: colonoscopy @ 1600 today.\n\nEndocrin: BS 89\n\nF and E: Receiving D5NS At 100cc/hr. Fluid balance inaccurate due to inc. of urine, diaper inplace.\n\nDerm: Refer to carevue. Color pale skin W&D, Constant oral secretions and drooling, Trach care and drsy \n\nSocial: Brother, in most of the day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-02-29 00:00:00.000",
"description": "Report",
"row_id": 1538792,
"text": "Resp. Care Note\nPt trached, received on vent settings AC 700x 14x 21% peep 5. ABG drawn - 7.55/20/106/18/-1. TV lowered to 650 and rate decreased to 12. Repeat ABG-- 7.52/20/107/17/-3. TV now at 600. Settings AC 600x 12x 21% peep 5. Plan for repeat colonoscopy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-09 00:00:00.000",
"description": "Report",
"row_id": 1538822,
"text": "Resp Care: Pt continues trached and on ventilatory support with A/C changed to 500x12/fio2 .3/+5 peep as result of resp alkalotic abg with good oxygenation; BS coarse, scant secretions, attempted subsequent abg on new settings, unable to obtain, spo2 cont 100%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-09 00:00:00.000",
"description": "Report",
"row_id": 1538823,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVEIW OF SYSTEMS-\nNEURO- CONTINUES TO COMMUNICATE WITH HIS EYES TO GET HIS NEEDS ACROSSED. DOES NOT MOVE ANYTHING EXCEPT HIS EYES AND MOUTH. SLEPT A GOOD PART OF THE DAY.\nRESP- REMAINS ON 30% FIO2 TV 500CC, RATE OF 12 BREATHING 12 ON 12 AND PEEP OF 5. VBG ON THIS 7.40/34/44.22. SUCTIONED FOR SMALL AMOUNTS OF WHITE THICK SPUTUM. BS CLEAR.\nCARDIAC- HR 70'S NSR WITHOUT ECTOPI. MAP DOWN TO 59 WHEN SLEEPING UP TO THE 80'S WHILE AWAKE. MG 1.7 THIS AM REPLETED WITH 2GMS MAG. REPEAT LYTES SENT AT 1600 RESULTS PENDING. K 3.7 THIS AM. IV CONTINUES D51/2 NS WITH 20MEQ KCL AT 40CC/HR.\nGI- ABD SOFT WITH ABSENT BS. COLOSTOMY STOMA PALE PINK AND WARM TO THE TOUCH. OSTOMY APPLIANCE INTACT. TF VIA PEG STARTED AT 20CC/HR. RATE TO REMAIN AT 20CC/HR THROUGH OUT TONIGHT. HE HAS HAD MINIMAL RESIDUALS.\nGU- SUPRAPUBIC TUBE INTACT DRAING CLEAR YELLOW URINE AT 30-200CC/HR. HAS HAD NO LEAKAGE OF URINE AROUND SPT OR FROM PENIS.\nHEME- HCT 27.2 THIS AM DOWN FROM 32 YESTERDAY. WILL CHECK HCT IN AM.\nID- TEMP MAX 99. WBC DOWN TO 14.8 TODAY. CONTINUES ON ANTIBIODICS.\nSOCIAL- NO VISITORS OR CALLS SO FAR TODAY.\nDISPO- REMAINS IN THE MICU A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-09 00:00:00.000",
"description": "Report",
"row_id": 1538824,
"text": "FOCUS; ADDENDUM\nPAIN- ONLY HAD C/O OF PAIN X 1 TODAY. HE WAS MEDICATED WITH 2MG MSO4 WITH GOOD EFFECT. DENIED PAIN ALL OTHER TIMES HE WAS ASKED. HE APPEARED COMFORTABLE AS HE WAS EASILY ABLE TO FALL BACK TO SLEEP AFTER POSITION CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-14 00:00:00.000",
"description": "Report",
"row_id": 1538836,
"text": "NURSING NOTE 7A-7P\nNEURO: Sleeping in naps, communicates with \"eyebrow lift\" for \"yes\" and \"looking down\" for \"No\". PERL no movement of extremities D/T PMH of ALS. Medicated X 1 with MSO4 4mg with good effect.\nC/V: SB to SR rate 50-60's no ectopy noted. SBP 80-100/40-50. Pulses palpable.\nRESP: AC settings unchanged at tv500 X 12 X30%. Suctioned X3 scant amts thick tan secretions. Lungs clear upper airways diminished bases.\nGI: Continues on Promote with fiber at goal rate 70cc/hr via PEG tube. Colostomy intact no flatus or stool this shift. Bisacodyl 20mg given via feeding tube without results.\nGU: SP cath patent draining clear yellow urine 20-30cc/hr.\nSKIN: Intact no problems noted.\nSOCIAL: Brother into visit this PM waiting to speak with surgical resident.\nDISPO: Discharge held for today d/t no colostomy output. Bed will be available on Monday. Case management involved arranging transfer when appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-15 00:00:00.000",
"description": "Report",
"row_id": 1538837,
"text": "MICU-B NPN 1900-0700\nNeuro - Pt. AxOx3. Continues to use eye signals to express needs. (-)MAE secondary to ALS. No c/o incisional pain this shift.\n\nC/ Pt. with HR 60's-90's, NSR with no ectopy noted. NIBP 100-180's/50's-90's. + generalized anasarca. Peripheral pulses palpable.\n\nResp. - Pt. remains intubated and vented via trach. on A/C/.30/500/12 with O2Sats. 99-100%. Sx. t/o shift for moderate amts. thick, yellow secretions. Copious amts. oral secretions appreciated. LS clear>coarse.\n\n Pt. s/p bowel resection/ colostomy placement. Transfer to rehab held off until pt. started passing flatus or stool through new stoma. This . appreciated 300+cc brown, liquid stool from stoma, heme (-) Stoma red. ET by yest. . left colostomy supplies for pt. to take to rehab. Per ET, colostomy to be changed twice a week and as needed. Changed this . secondary to stool leakage. PEG tube patent; delivering goal TF (Promote with fiber) @ 70/hr. with minimal residuals noted. Abd. soft, ND with +BS. No c/o incisional pain. Incision well approximated, sutures remain in place, C&D.\n\nGU- Suprapubic catheter in place; patent draining clear, yellow urine. Pt. continues to have urine output through urethra. Urine very musty smelling. U/A obtained and sent via suprapubic catheter.\n\n Pts. LSC triple-lumen dc'd last . per team. Cath. tip sent for cx. Pt. now with no access. Team aware.\n\n Pts. skin grossly intact.\n\n Pts. brother in early . Spoke with team regarding pt. status and continued plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-03 00:00:00.000",
"description": "Report",
"row_id": 1538801,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED AT 1900. ALL MONITORS ON VENTILATOR AND MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 57 YRS OLD MALE PATIENT THAT HAS BEEN VENT DEPENDENT AT HOSPITAL FOR THE PAST FIVE YEARS. PRESENTED TO DUE TO HAVING HX OF LOWER GI BLEED WITH DROPPING HCT. REQUIRED 6 UNITS OF PRBC'S IN THE PAST 3 WEEKS.\n\nNEURO: AFEBRILE. PT IS ABLE TO COMMUNICATE WITH NON-VERBAL SIGNALS. LOOKING UP OR RAISING OF EYEBROWS MEANS \"YES\", GRITTING OF TEETH AND LOOKING TO SIDE MEANS \"NO\". NO SPONTANEOUS MOVEMENT NOTED TO ANY EXTREMETIES.\n\nRR: VENT SETTINGS HAVE REMAINED THE SAME. CMV/12/650/21%/5. NO C/O OF SOB OR DIFFICULTY BREATHING. TRACH IS MIDLINE AND SECURE. STOMA INTACT. COPIOUS AMOUNTS OF ORAL SECRETIONS AND SECRETIONS TO STOMA SITE. FREQUENT SUCTIONING REQUIRED. SP02 > OR = TO 95%. BBS= COARSE RHONCHI THROUGHOUT ALL LOBES. BILATERAL CHEST EXPANSION NOTED.\n\nCV: NSR, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PUSLES NOTED TO BILATERAL DORSALIS AND RADIALS. S1 AND S2 AS PER AUSCULTATION. DENIES ANY CHEST PAIN. HCT HAS BEEN STABLE.\n\nGI: PEG TUBE IS SECURE AND PATENT. PT HAS BEEN NPO SINCE MIDNIGHT DUE TO ABD CT WITH CONTRAST TO BE DONE THIS AM. BS X 4 QUADRANTS. SOFT, NON-DISTENDED. RECTAL TUBE IS IN PLACE- DRAINING MINIMAL AMOUNTS OF GREENISH STOOL. PASSING FLATUS.\n\nGU: PT REFUSES A FOLEY CATHETER. DIAPERS INTACT. YELLOW URINE IN LG AMOUNTS NOTED. DIAPER CHANGES Q 3-4 HOURS FOR PT'S COMFORT.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. BARRIER CREAM APPLIED DUE TO FREQUENT CHANGES OF DIAPER. FREQUENT T&P.\n\nSOCIAL: BROTHER CALLED TO CHECK ON PT. ALL QUESTIONS ANSWERED.\n\nPLAN: ABD CT THIS AM- POSSIBLE CALL OUT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-03 00:00:00.000",
"description": "Report",
"row_id": 1538802,
"text": "Pt. remains on vent. support see careview stable shift will follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-03 00:00:00.000",
"description": "Report",
"row_id": 1538803,
"text": "MICU-B, NPN:\nNeuro: A&OX3, PERRLA, no spontaneous movements in extremities. Communicates w/ eye movements/uses eye detection device w/ family. Able to express needs to staff.\n\nCV: HR 60's-70's, NSR w/o ectopy. SBP 80's-130's- SBP does drop while pt. sleeps but MAPs remain in 60's.\n\nResp: Vent. settings as follows and are unchanged throughout this shift: A/C, TV 650, RR 12, PEEP 5, FiO2 21%, O2Sat 98%-100%. Suxn'd q 2-3 hrs for moderate-copious amnts. thin yellow sputum. Lungs sound coarse throughout.\n\nHeme/lytes/micro: Hct 29.8, lytes WNL. Afebrile this shift. No antbx coverage @ this time.\n\nGI: NPO- will discuss w/ team restarting TF's this shift. Abd. CT done this a.m. w/ 2.5 bottles of Barri-cat + IV contrast for tumor staging, waiting for official read. Bx done via colonoscopy on has pending pathology- GI feels it is likely malignant but have told pt. and family that dx will be made after path. results final. . following as consult- pt. will likely pursue tx.\n\nGU: Incontinent in diapers.\n\nDerm: D&I, turn q 2 hrs.\n\nSocial: Niece here w/ husband. Expressed pt.'s concerns re: issues of discomfort while being transported to CT scan. Explained to her that process of transporting pt. was explained to him prior to leaving unit and that d/t his vent. dependency the only option available for O2 support is ambu bagging per RT, which was performed throughout transfer. Also, pt. expressed aggravation over attempts made by CT techs. to position his arms over his head- he found this very uncomfortable. It was explained to him @ the time, and consequently to his niece, that this is standard practice for abd. scans in an effort to facilitate clearer imaging. Pt.'s brother, , also visited for most of shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-03-04 00:00:00.000",
"description": "Report",
"row_id": 1538804,
"text": "MICU-B NPN 1900-0700\nPt. is a 57 y/o male pt; vent dependent secondary to ALS. Presented to from NE where he has resided for past 5 years for hx. lower GI bleed and dropping HCT. Has received 6U PRBCs over past three weeks. Pt. underwent colonoscopy on which appreciated a mass that GI believes to be a malignancy. Biopsy was obtained and is pending. Surgical consult obtained for ? resection of affected bowel. ?Risks vs. benefits with progression of ALS. Pt. would be willing to undergo surgical resection if +prognosis.\n\nROS:\n Pt. AxOx3. Able to communicate only with eyes. Moving eyes upward to answer \"yes\" and sided to side to answer \"no\". Pt. also has communication device at bedside. (-)MAE. Denies pain.\n\nC/ Pt. with HR 58- 90's, SB-NSR with 22 beat run of VT noted @ 2100. Pt. asymptomatic at time of alarm. EKG unchanged from those previously obtained. CBC, CHEM 10 obtained and sent. Given Ca+, KCL, and Mg. repletion. A.M. labs pending. No other episodes ectopy noted remainder of shift. NIBP 70'S-LOW/100'S/ 40'S-60'S. Pt. runs low @ baseline (systolic 80's-90's). Per team goal MAP >55. Peripheral pulses palpable. + generalized anasarca noted.\n\nResp. - Pt. vented via trach on A/C 650 X 12/ .21/PEEP 5 with LS clear-coarse/clear. O2Sats. 98-100%. Sx. t/o shift for mod. amts. thick, yellow secretions. Moderate amt. oral secretions as well; using yankauer frequently.\n\n Pt. remained NPO over/noc. ? potential bowel resection today. Pt. has PEG tube in place; patent. Abd. soft, NTND with hypoactive BS noted. Mush. catheter in place with minimal output green. liquid stool this shift.\n\n Pt. incontinent yellow, urine into diaper. Moderate output noted over/noc. Pt. does not want foley catheter placed.\n\nHeme/Lytes - Last HCT over/noc 29.7. A.M. HCT and lytes. pending. No active bleeding noted. WBC bumped from 8.6 early yest. a.m. to 13 over/noc. Team aware. Afebrile t/o shift.\n\n Pt. with grossly intact skin. First step mattress ordered.\n\nAccess- LSC triple-lumen line in place; patent, site wnl. Difficult draw this a.m., positional.\n\nPsych/ Pt. had initially requested not to be turned all eve. His brother conferred during phone conversation. Pt. however seemed amenable over/noc to be repositioned and requested repositioning quite frequently for discomfort Q1-2 hrs.\n\nDispo- ? surgical resection of affected bowel today. Awaiting pathology results on biopsy obtained from mass on . Monitor lytes/HCT closely. ? Restart TF if pt. not going for surgery today.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 788248,
"text": " 10:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrates, consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ALS, admitted here for w/u of lower Gi bleed\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrates, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ALS, lower GI bleed.\n\n Reference Exam: \n\n FINDINGS: Tracheostomy tube is unchanged. There is hazy increased opacity over\n the left lung consistent with an effusion. There is retrocardiac increased\n opacity consistent with volume loss/infiltrate. The appearance to the right\n lower lobe has slightly improved but there continues to be some volume loss in\n that region.\n\n IMPRESSION: No signficant change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-03-04 00:00:00.000",
"description": "Report",
"row_id": 74686,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 107/63\nStatus: Inpatient\nDate/Time: at 15:41\nTest: Portable TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is not well visualized.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded.\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is mildly dilated. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild\nmitral annular calcification.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and basal systolic function are normal. The distal half of the left\nventricle is not well seen. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. The aortic root and ascending\naorta are mildly dilated. The aortic valve leaflets (3) are mildly thickened\nbut not stenotic. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. Mitral regurgitation was not seen, but\nminimally assessed. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal technical quality. Preserved basal left ventricular\nsystolic function. Mild aortic regurgitation.\nIf more definitive information regarding left ventricular systolic function is\nneeded,a radionuclide study is suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-03-15 00:00:00.000",
"description": "Report",
"row_id": 167725,
"text": "Ectopic atrial rhythm with bigeminal PACs.\nPossible anterior infarct - age undetermined\nNonspecific ST-T abnormalities\nSince previous tracing, the bigeminal atrial premature complexes are new\n\n"
},
{
"category": "ECG",
"chartdate": "2104-03-03 00:00:00.000",
"description": "Report",
"row_id": 167726,
"text": "Possible ectopic atrial rhythm (versus junctional rhythm)\nPoor R wave progression - probable normal variant\nModest nonspecific ST-T wave changes - the slight inferior ST elevation may be\ndue to atrial repolarization - clinical correlation is suggested\nSince previous tracing of : right precordial ST-T wave changes are\nevident\n\n"
},
{
"category": "ECG",
"chartdate": "2104-02-27 00:00:00.000",
"description": "Report",
"row_id": 167946,
"text": "Ectopic atrial rhythm versus junctional rhythm - clinical correlation is\nsuggested\nOtherwise probably normal ECG\nNo previous tracing for comparison\n\n"
}
] |
13,592 | 180,169 | Mrs. was a 79 year-old Caucasian female who was referred from an outlying facility having been approximately several days status post an acute myocardial infarction. The patient experienced a low flow state during this period of time. In addition she was receiving steroid therapy for exacerbation of her chronic lung disease. Prior to being transferred to the medical Intensive Care Unit at the the patient had undergone a CT scan which revealed free intraperitoneal air. At this point in time the patient had a stat transfer to the surgical service arranged. The patient was then a direct admit to the trauma surgical Intensive Care Unit where appropriate intravenous access was achieved. Because of the nature of the patient's comorbidity the family was cautioned that both intraoperative and postoperative course were likely to be quite stormy. The patient was taken to the operating room where upon laparotomy an extension infarction of the colon was noted. She underwent a total abdominal colectomy and an end ileostomy. The patient was returned to the trauma surgical Intensive Care Unit in critical condition. The patient was maintained over the next 24 hours with extensive coverage with inotropic agents and vasopressors. The patient essentially made no meaningful physiologic recovery. Approximately 12 hours after her surgical procedure an extensive discussion was held with the family regarding the fact that it will be unlikely that she will recovery. The patient's family then asked the patient be made Do Not Resuscitate and receive comfort measures. This was done. The patient subsequently expired quietly. , M.D. Dictated By: MEDQUIST36 D: 17:16:26 T: 18:00:14 Job#: | Mild (1+) mitral regurgitation is seen. Mild (1+) MR. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There is mildpulmonary artery systolic hypertension. Mild to moderate (+) aorticregurgitation is seen. Mild mitralannular calcification. able to wean levophed slightly t/o day. abd firm, distended absent bowel sounds.GU: marginal u/o with minimal improvement after start of dobutamine. Mildlydepressed LVEF. LS clear, diminished at bases. R sided ileostomy pale. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Frequent atrial premature beats.Conclusions:The left atrium is mildly dilated. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Probable sinus rhythm at upper limits of normal ratewith atrial premature beats. The aortic valve leaflets are moderately thickened.There is mild aortic valve stenosis. Right bundle-branch block.ST-T wave abnormalities. sq heparin started, pneumoboots in place. Mild thickening of mitral valve chordae. The leftventricular inflow pattern suggests impaired relaxation. Normaltricuspid valve supporting structures. Left ventricular wall thicknesses arenormal. Lytes repletedGI:on admission remarkable firm, tender abdomen. Nephrotic syndrome. RESP CARE: pt recieved from OR intubated/on vent settings per carevue flowsheet. Moderately thickened aortic valveleaflets. The IVC is normal in diameterwith appropriate phasic respirator variation.LEFT VENTRICLE: Normal LV wall thickness. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 64Weight (lb): 160BSA (m2): 1.78 m2BP (mm Hg): 110/50HR (bpm): 89Status: InpatientDate/Time: at 09:41Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. remains critically ill on full vent support. BP supported with levophed, then vasopressin added. continues with metabolic acidosis, with very slight improvement. PERLA CV: hemodynamically very labile with continuous pressor and fluid bolus requirements. t/SICU Nursing Note ContinuedReview of systems:Neuro: on arrival, pt was alert, a little confused but cleared after a while. Normal LV cavity size. addendumpatient made comfort measures at 1830. patient was extubated and drips were turned off. Peripheral pulses present but extremities are cool and mottled. afebrileSKIN: dime sized area of breakdown to left buttock, duoderm applied. The left ventricular cavity size is normal. After , pt loaded with amio and gtt started. + edema.RESP: remains orally intubated and vented on AC, as charted in carevue. Lungs coarse bilat. Resp CarePt remains on A/C. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. extremities cool, slightly mottled. Calcified tipsof papillary muscles. suppport given. Hct 27, received 1 u prbcID: on flagyl and levofloxacin, wbcs elevatedskin: had coccyx decub on admission, red with broken area right on coccyx. She was admitted to on following a syncopal episode. with multiple arrhythmias. Mild AS. midline abdominal incision with primary surgical dressing intact, draining s/s fluid, reinforced x1. Also c/o nausea. Postop abdomen softer but increased over coarse of shift. They spoke with Dr. . Low voltage. ABGs consistent with met acidosis,high lactate levels noted. Overall left ventricularsystolic function is mildly depressed (ejection fraction 40-50 percent)secondary to hypokinesis of the inferior, posterior, and lateral walls (theanterior septum and anterior free wall are hyperdynamic). Rightventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. Pt cardioverted x2. There is no pericardial effusion.Impression: inferoposterolateral myocardial infarct HR irregular 80-90s with frequent PACs and PVCs. Clinical correlation is suggested. Multiple vent changes made. Perrla @ 5, +resp, no cough.CVS: Unstable night. T/SICU Nursing Admission NoteMrs. On famotidine.endo:ssriHeme: multiple bruised areas over all of body. Dr. & ICU team aware and in agreement with plan.PLAN: withdraw care when family ready, maintain comfort with fentanyl drip. Pt. lytes WNLENDO: insulin drip started to maintain BS <120 with good effect.ID: IV ABX as ordered. npn ROS: see carevue for detailsNEURO: patient sedated on fentanyl and ativan drips for comfort. dobutamine started in attempt to better CO, with fair effect. INR 1.5. Sxd no sputum. After the OR she was sedated with low dose propofol and fentanyl and did not respond to stimuli. Poor quality tracing. O2 sat 100%GI: OGT remains to LWS with bilious output. Focal calcifications in aortic root.AORTIC VALVE: Three aortic valve leaflets. No LV mass/thrombus. Pt on mult pressors, 2 episodes of V-tach noted. Also dime side area at R of coccyxLines: VIP PA catheter in rij, r radial art line placed, two peripheral ivs.social: son and daughter in law in and spoke with pt initially. was lightened first thing this morning and was able to nod head appropriately and follow simple commands. family at bedside with . pedal pulses difficult to palpate. There are threeaortic valve leaflets. Thereis no mitral valve prolapse. Following admission she was taken to the OR for a subtotal colectomy with an end ileostomy.PMH & PSH: s/p appi, s/p hiatal hernia repair, s/p lumpectomy followed by radiation therapy, s/p total hip replacement, s/p lami 98 with new L1 fx. Decreased FIO2 from 70 to 50 due to ABG results.No other changes noted. They requested sacrament of the sick.A: ischemic bowel with massive multisystem organ involvementP: continue to support patient and family during this difficult time s/p choleMeds at home: prednisone, cyclosporin,oxycodoneMeds on transfer: solumedrol, protonix, morphine, plavix, asa, zocor, gentREVIEW of SYSTEMS:Neuro: No resting LVOT gradient. She then r/i for an interior wall MI. They understand the gravity of the situation. family decided to make patient DNR and will make patient comfort measures only when arrives. No RSBI this am due to hemodynamic instability. clear yellow output. Cycling cpksRESP: multiple vent changes made. Persistent metabolic acidosis, no secretions.RENAL: baseline cr 2.1, postop 1.2, received 5000cc lr in 500cc boluses to support bp and baseline fluid of lr@125/hr. There is no ventricular septal defect. Urine output 5-20cc/hr since or. Decreasing co and ci over the course of the night. No MVP. emotional support to family. On she developed excruciating abdominal pain and CT scan of her abdomen revealed perforated bowel. | 8 | [
{
"category": "Echo",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 81119,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 64\nWeight (lb): 160\nBSA (m2): 1.78 m2\nBP (mm Hg): 110/50\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 09:41\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter\nwith appropriate phasic respirator variation.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF. No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent atrial premature beats.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed (ejection fraction 40-50 percent)\nsecondary to hypokinesis of the inferior, posterior, and lateral walls (the\nanterior septum and anterior free wall are hyperdynamic). No masses or thrombi\nare seen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. There are three\naortic valve leaflets. The aortic valve leaflets are moderately thickened.\nThere is mild aortic valve stenosis. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nImpression: inferoposterolateral myocardial infarct\n\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 199354,
"text": "Poor quality tracing. Probable sinus rhythm at upper limits of normal rate\nwith atrial premature beats. Low voltage. Right bundle-branch block.\nST-T wave abnormalities. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439132,
"text": "T/SICU Nursing Admission Note\nMrs. is a 79 year old woman transferred to from via ground critical care transport. She was admitted to on following a syncopal episode. She then r/i for an interior wall MI. On she developed excruciating abdominal pain and CT scan of her abdomen revealed perforated bowel. She was tranferred to for further treatment During transport she had a 6 minute run of vtach. Following admission she was taken to the OR for a subtotal colectomy with an end ileostomy.\nPMH & PSH: s/p appi, s/p hiatal hernia repair, s/p lumpectomy followed by radiation therapy, s/p total hip replacement, s/p lami 98 with new L1 fx. Nephrotic syndrome. s/p chole\nMeds at home: prednisone, cyclosporin,oxycodone\nMeds on transfer: solumedrol, protonix, morphine, plavix, asa, zocor, gent\nREVIEW of SYSTEMS:\nNeuro:\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439133,
"text": "RESP CARE: pt recieved from OR intubated/on vent settings per carevue flowsheet. Multiple vent changes made. ABGs consistent with met acidosis,high lactate levels noted. Lungs coarse bilat. Sxd no sputum. Pt on mult pressors, 2 episodes of V-tach noted. Pt cardioverted x2. remains critically ill on full vent support. No RSBI this am due to hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439134,
"text": "t/SICU Nursing Note Continued\nReview of systems:\nNeuro: on arrival, pt was alert, a little confused but cleared after a while. Moved all extremities, followed commands, c/o pain as a severe band across her lower abdomen. Also c/o nausea. Able to talk with her family and agreed to surgery and seemed to understand the gravity of the situation. After the OR she was sedated with low dose propofol and fentanyl and did not respond to stimuli. Perrla @ 5, +resp, no cough.\nCVS: Unstable night. Pt. with multiple arrhythmias. Very frequent pvcs, runs of and then two prolonged runs of just after 5 am which required cardioversion with 200 joules and then 300 joules. Decreasing co and ci over the course of the night. BP supported with levophed, then vasopressin added. After , pt loaded with amio and gtt started. Peripheral pulses present but extremities are cool and mottled. Cycling cpks\nRESP: multiple vent changes made. Persistent metabolic acidosis, no secretions.\nRENAL: baseline cr 2.1, postop 1.2, received 5000cc lr in 500cc boluses to support bp and baseline fluid of lr@125/hr. Urine output 5-20cc/hr since or. Lytes repleted\nGI:on admission remarkable firm, tender abdomen. Postop abdomen softer but increased over coarse of shift. R sided ileostomy pale. On famotidine.\nendo:ssri\nHeme: multiple bruised areas over all of body. sq heparin started, pneumoboots in place. INR 1.5. Hct 27, received 1 u prbc\nID: on flagyl and levofloxacin, wbcs elevated\nskin: had coccyx decub on admission, red with broken area right on coccyx. Also dime side area at R of coccyx\nLines: VIP PA catheter in rij, r radial art line placed, two peripheral ivs.\nsocial: son and daughter in law in and spoke with pt initially. They understand the gravity of the situation. They spoke with Dr. . After the , Dr called and spoke with the family to update them. They requested sacrament of the sick.\nA: ischemic bowel with massive multisystem organ involvement\nP: continue to support patient and family during this difficult time\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439135,
"text": "Resp Care\n\nPt remains on A/C. Decreased FIO2 from 70 to 50 due to ABG results.\nNo other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439136,
"text": "npn \nROS: see carevue for details\n\nNEURO: patient sedated on fentanyl and ativan drips for comfort. was lightened first thing this morning and was able to nod head appropriately and follow simple commands. PERLA \n\nCV: hemodynamically very labile with continuous pressor and fluid bolus requirements. HR irregular 80-90s with frequent PACs and PVCs. dobutamine started in attempt to better CO, with fair effect. able to wean levophed slightly t/o day. pedal pulses difficult to palpate. extremities cool, slightly mottled. + edema.\n\nRESP: remains orally intubated and vented on AC, as charted in carevue. LS clear, diminished at bases. continues with metabolic acidosis, with very slight improvement. able to wean FiO2 to 50%. O2 sat 100%\n\nGI: OGT remains to LWS with bilious output. abd firm, distended absent bowel sounds.\n\nGU: marginal u/o with minimal improvement after start of dobutamine. clear yellow output. lytes WNL\n\nENDO: insulin drip started to maintain BS <120 with good effect.\n\nID: IV ABX as ordered. WBC climbing. afebrile\n\nSKIN: dime sized area of breakdown to left buttock, duoderm applied. midline abdominal incision with primary surgical dressing intact, draining s/s fluid, reinforced x1. multiple skin tears to arms > adaptic applied, paper tape when needed.\n\nsocial: son, daughter and daughter-in-law at bedside t/o day. multiple discussions with team regarding plan of care and code status. suppport given. family decided to make patient DNR and will make patient comfort measures only when arrives. Dr. & ICU team aware and in agreement with plan.\n\nPLAN: withdraw care when family ready, maintain comfort with fentanyl drip. emotional support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1439137,
"text": "addendum\npatient made comfort measures at 1830. patient was extubated and drips were turned off. family at bedside with . pronounced dead at 1850 by Dr. .\n"
}
] |
61,648 | 146,254 | 57M with DM-II, HTN, CAD s/p MI in , and ESRD not on HD who presented with SOB and CP and had flash pulmonary edema in the setting of hypertensive urgency in the ED. . # CORONARIES: Known CAD s/p MI in . As the pat is new to our system, his anatomy is unknown to us. During this hospitalization, pt recieved ASA 325mg PO daily instead of his usual home 81mg. No acute ECG changes were found during hospitalization. Cardiac enzymes were followed and ruled out MI. Lipid panel showed an LDL of 31 and a slightly elevated total cholesterol of 166, so no statin was started. . # PUMP: Pt clinically presented with flash pulmonary edema. Echo showed EF 45-55%, mild concentric left ventricular hypertrophy, regional systolic dysfunction c/w CAD, mild mitral regurgitation, and moderate pulmonary hypertension. Patient was able to be weaned off the ventilator and successfully extuibated day 2 of hospitalization. Pt has vigorous response to IV Lasix initially and was euvolemic for the rest of the admission. . # RHYTHM: Patient was in NSR until day 2 of admission when rates of 140s-150s were seen on tele. ECG showed A Fib. Patient had no known diagnosis of A Fib. Given his HTN and cardiac disease, it was felt that the patient likely had undiagnosed paroxysmal A Fib. He was already on a BBlocker for rate control, and coumadin was started. INRs were follwed by CCU team and pharmacy. Pt's PCP made aware of new Dx of A Fib and anti-coagulation. Pt given a prescription to have INR checked in dialysys the day after discharge with results to be faxed to Dr. at . . # HTN / Hypertensive urgency: Blood pressures were difficult to control. Clonidine was switched to a patch to prevent rebound from missing a dose, but ultimately d/c as made pt sommulent. Able to decrease home dose of hydralazine from 100mg to 50mg TID by adding amlodipine 10mg daily. Patient had been titrated up to max BBlocker dose prior to the initiation of HD, but with HD the dose was lowered to metoprolol 75mg . Pt got his home dose of Lasix as requested by renal, 40mg daily. Renal US showed no revidence of renal vascular disease as a cause of refractory HTN. . # ESRD: Renal follow the patient throughout admission. Cr rose from 4.8 to 5.7 ultimately before the initiation of dialysis. Pt began HD . Nephrocaps were continues throught admission, and calcium acetate was started per renal recs. He had three days of a row of uneventful diaysis, but did experience hypertension follwing the third HD treatment. During his 4th HD treatment on , he had an episode of tacycardia into the 120s that resolved with his usual AM dose of metoprolol. pt is on an afternoon outpatient dialysys schedule, so will have morning meds on board prior to dialysis to prevent HTN and tachycardia during HD. Patient is scheduled for regular Tuesday, Thursday, and Saturday dialysis at - Dialysis Center. . # Nausea: Intermittent complaint throughout admission. Normal ECG and cardiac enzymes during episodes of nausea, so unlikely an anginal equivalent. Episodes oftern required anti-emetics and anxiolytics to resolve. The afternoon after the third course of HD, the patient began to feel nauseated and have shaking chills. SBP was 190s as he had not recieved his BP meds prior to dialysis. Pan cultures were negative. Symptoms were managed with hydralazine, NTG, and Ativan. CT was done to rule out an intraabdominal infection or process; it showed 2 enlarged mesenteric lymph nodes, likely reactive. No evidence of mesenteric ischemia or infection. Patient should have f/u CT in 3 months to re-evalute lymph nodes. No nausea was reported on day of discharge. . # Diabetes: The patient's home dose of Lantus was given during admission. Elevated blood sugars were covered with sliding scale humolog. His glucoses were well-controlled throughout admission. . # Hepatitis: Hepatitis panels were sent as part of routine pre-dialysis labs. Hepatitis C antibody was positive. Hep C viral load was 8,670,000 IU/mL. patietn was instucted to call Liver Clinic to make an appointment for follow up. Medications on Admission: toprol XL 300 mg QD, hydralazine 100 mg TID, clonidine 0.2 mg TID, ASA 81, calcitriol 0.25 mg QG, phoslo 667 TID with meals, nephrocaps, aranesp monthly, lasix 40 mg QD, hydroxizine 25 mg TID PRN, chantix, vit D weekly, viagra PRN Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please take half () a pill on Monday , and then take a whole pill daily after that. Disp:*30 Tablet(s)* Refills:*2* 10. Outpatient Physical Therapy Please evaluate and treat patient for any difficultly in ambulating independently. Medical Dx: ESRD on dialysis, hypertension Discharge Disposition: Home Discharge Diagnosis: Hypertension Hepatitis C ESRD on dialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Thank you for coming to . We diagnosed a new condition this admission, Hepatitis C. Please make an appointment to see a liver doctor. You started dialysis this admission. We discontinued your clonidine; please stop taking it. We changed your doses of metoprolol (Toprol) and hydralazine. Please fill the new prescriptions and discard the old ones. We started 3 new medicines. Amlodipine is for your blood pressure. Calcium acetate helps your kidney balance the salts in your body. Coumadin (warfarin) was started because of an abnormal heart rhythm. It helps prevent blood clots from forming. It is very important to keep your appointments with your doctor while on this medicine. Weigh yourself every morning, MD if weight goes up more than 3 lbs. Followup Instructions: Dialysis tomorrow (Tuesday) Department: Internal Medicine Name: Dr. When: Wednesday at 1: 15 PM Address: , , Phone: Department: Cardiology Name: Dr. When: Wednesday at 11:00 Location: Address: 4TH FL, , Phone: (Reminder that patient has an appointment with Neurology on the same day at 2:30 PM) Physical therapy has recommended you go to an outpatient physical therapist near you. Please call to make an apointment. You will need to bring the prescription we give you to that appointment. It is important that you call the liver clinic to make an apointment at (. MD, | There is mildregional left ventricular systolic dysfunction with focal hypokinesis of thebasal inferior septum and basal inferior wall. Mild (1+) mitral regurgitation is seen. False LV tendon (normal variant). Right ventricular function.Height: (in) 73Weight (lb): 190BSA (m2): 2.11 m2BP (mm Hg): 129/67HR (bpm): 83Status: InpatientDate/Time: at 13:34Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Moderate pulmonaryhypertension. There is moderate pulmonaryartery systolic hypertension. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Mild mitral regurgitation. There is mild symmetric left ventricularhypertrophy. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Minimal retrocardiac opacity likely minimal atelectasis. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Slight unfolding of the thoracic aorta with mural calcification, but the mediastinal silhouette is otherwise normal. The ascending aorta is mildly dilated. Mild [1+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. No resting LVOTgradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Heart size is borderline or slightly enlarged, with a calcified unfolded aorta. The lateral limb of the right adrenal gland appears nodular. The left ventricular cavity is mildly dilated. Mildly dilated LV cavity. Mild regional LVsystolic dysfunction. There is no pericardial effusion.IMPRESSION: Mild concentric left ventricular hypertrophy. PFI REPORT PFI: Largely improved chest radiograph with no acute cardiopulmonary process. IMPRESSION: Findings consistent with mild CHF. FINDINGS: There is interval placement of an endotracheal tube. Left ventricular hypertrophy. Mild thickeningof mitral valve chordae. FINDINGS: There has been interval development of bilateral confluent bibasilar opacities, in keeping with pulmonary edema. An NG tube is present, tip beneath diaphragm, overlying the upper fundus. Evaluate acute intrathoracic process. The pre-void bladder is moderately distended and unremarkable. The cardiac silhouette is mildly enlarged. Again, bibasilar homogeneous opacities are present, more so on the right than the left with associated upper lobe venous congestion. Likely mild mesenteric adenopathy, which could be reactive. Likely mild mesenteric adenopathy, which could be reactive. Faint sclerosis along a few lower thoracic endplates is suggestive of early changes associated with renal osteodystrophy, akin to a Rugger-Jersey spine. The heart and mediastinal contours appear within normal limits. Indeterminate exophytic left upper pole renal lesion, too small to definitely characterize, but statistically simple cyst. The caliber of the abdominal aorta is normal. IMPRESSION: Largely improved chest radiograph with no worsening acute cardiopulmonary process. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The imaged lung bases are clear. Non-specific inferolateralST-T wave change and Q-T interval prolongation. FINDINGS: Since the prior study, the patient has been extubated and there has been removal of the endogastric tube. The abdominal aorta and branches demonstrate atherosclerotic calcifications. The endotracheal tube and nasogastric tube are unchanged in position and appropriately sited. 6:07 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: Any abdominal pathology? Right ventricular chamber size and free wall motionare normal. The right lower chest wall and costophrenic angle are excluded from the film. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Flash pulmonary edema. Vascular calcification is seen, though no definite calcification is appreciated within the urinary tract. Mild upper lobe venous congestion is also present. UPRIGHT AP VIEW OF THE CHEST: There is increased interstitial opacity consistent and mild central pulmonary vascular engorgement. No contraindications for IV contrast PFI REPORT 1. Atrial fibrillation. PROVISIONAL FINDINGS IMPRESSION (PFI): 1:34 PM PFI: Largely improved chest radiograph with no acute cardiopulmonary process. Compared to the previous tracing Q-T interval is normal.TRACING #2 There is upper zone redistribution and diffuse vascular blurring, with areas of more confluent opacity, consistent with CHF and pulmonary edema. Three views show the bowel gas pattern to be within normal limits without evidence of obstruction. 12:01 PM CHEST (PORTABLE AP) Clip # Reason: acute process? A nasogastric tube lies below the diaphragm. The appendix is normal. Thetricuspid valve leaflets are mildly thickened. There remains some confluent areas of opacity in the lower lung fields. , S. 12:01 PM CHEST (PORTABLE AP) Clip # Reason: acute process? The lungs are clear of masses or consolidations; the previously described pulmonary edema has improved. FINDINGS: The right kidney measures 9.8 cm and the left kidney measures 11.0 cm. FINAL REPORT HISTORY: Hypertensive urgency, on dialysis with nausea. CHEST, SINGLE AP PORTABLE VIEW. Abdominal loops of large and small bowel are normal, without small bowel dilatation or bowel wall thickening. | 19 | [
{
"category": "Radiology",
"chartdate": "2180-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1141542,
"text": " 1:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for acute infectious process, ptx, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cp and cough\n REASON FOR THIS EXAMINATION:\n Please eval for acute infectious process, ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male with chest pain and cough. Evaluate for acute\n infectious process.\n\n COMPARISON: No prior study available for comparison.\n\n UPRIGHT AP VIEW OF THE CHEST: There is increased interstitial opacity\n consistent and mild central pulmonary vascular engorgement. The heart size is\n slightly enlarged. Slight unfolding of the thoracic aorta with\n mural calcification, but the mediastinal silhouette is otherwise normal. No\n focal consolidation or appreciable pleural effusion or pneumothorax.\n\n IMPRESSION:\n\n Findings consistent with mild CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-11 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1142598,
"text": " 9:56 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: 57 year old man with ESRD on HD and persistent intractable H\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESRD on HD and persistent intractable HTN. Please do\n dopplers and eval for renal artery stenosis.\n REASON FOR THIS EXAMINATION:\n 57 year old man with ESRD on HD and persistent intractable HTN. Please do\n dopplers and eval for renal artery stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 57-year-old man with intractable hypertension, evaluate for\n renal artery stenosis.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The right kidney measures 9.8 cm and the left kidney measures 11.0\n cm. There is no hydronephrosis. No cyst or stone or solid mass is seen in\n either kidney. The pre-void bladder is moderately distended and unremarkable.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. Appropriate venous flow is seen in the main renal vein of each\n kidney. Arterial waveforms with sharp upstrokes are seen in the main renal\n artery of each kidney. Resistive indices of the intraparenchymal arteries are\n elevated. On the right, these measure from 0.83-0.91 and on the left from\n 0.84-0.88.\n\n IMPRESSION:\n 1. No hydronephrosis.\n 2. No evidence of renal artery stenosis. Substantially elevated resistive\n indices bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1141559,
"text": " 4:55 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with pulmonary edema s/p ett placemnt\n REASON FOR THIS EXAMINATION:\n ett tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with pulmonary edema, status post ET tube\n placement.\n\n Comparison is made to previous chest radiograph dated ; time\n 04:20.\n\n FINDINGS:\n There is interval placement of an endotracheal tube. The tip of the tube lies\n 6.4 cm above the carina.\n\n Again, bibasilar homogeneous opacities are present, more so on the right than\n the left with associated upper lobe venous congestion. Less fluid is present\n in the minor fissure than before. No pleural effusions are present. New\n atelectasis in the left lower lobe is seen. Retrocardiac opacity is likely\n due to atelectasis; however, pneumonia cannot be excluded.\n\n A nasogastric tube lies below the diaphragm. The tip is not visualized on\n this radiograph.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-05 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1141568,
"text": " 7:42 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ET tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with flash pulmonary edema\n REASON FOR THIS EXAMINATION:\n eval ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate ET tube placement. Flash pulmonary edema.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube has been placed -- the tip lies approximately 7.6 cm above the\n carina, at the level of mid-clavicular heads. An NG tube is present, tip\n beneath diaphragm, overlying the upper fundus.\n\n There is upper zone redistribution and diffuse vascular blurring, with areas\n of more confluent opacity, consistent with CHF and pulmonary edema. The right\n lower chest wall and costophrenic angle are excluded from the film. Allowing\n for this, no gross effusion is identified on either side. Heart size is\n borderline or slightly enlarged, with a calcified unfolded aorta.\n\n Compared with the earlier film, CHF findings have improved to a small degree.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1141641,
"text": " 8:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: 57 year old man, intubated for flash pulm edema; febrile; c/\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man, intubated for flash pulm edema; febrile; c/f pneumonia.\n Please evaluate for infiltrates, effusions and other changes.\n REASON FOR THIS EXAMINATION:\n 57 year old man, intubated for flash pulm edema; febrile; c/f pneumonia.\n Please evaluate for infiltrates, effusions and other changes.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: Man with respiratory distress and intubated for flash pulmonary\n edema. Patient is also febrile. Evaluate for pneumonia or effusions.\n\n FINDINGS: Comparison is made to prior study from at 8:32 a.m.\n\n There has been some improvement of the pulmonary edema since the previous\n study. There remains some confluent areas of opacity in the lower lung\n fields. The endotracheal tube and nasogastric tube are unchanged in position\n and appropriately sited.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1141545,
"text": " 4:13 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval acute intrathoracic process\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute respiratory decompensation\n REASON FOR THIS EXAMINATION:\n eval acute intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with acute respiratory decompensation. Evaluate\n acute intrathoracic process.\n\n Comparison is made to previous chest radiograph dated , time\n 01:58.\n\n FINDINGS:\n\n There has been interval development of bilateral confluent bibasilar\n opacities, in keeping with pulmonary edema. The costophrenic angles are not\n included on the radiograph. The cardiac silhouette is mildly enlarged. Mild\n upper lobe venous congestion is also present. The upper lobes of the lungs\n are clear. Fluid is present within the horizontal fissure, which is new.\n\n CONCLUSION: Interval development of pulmonary edema with fluid overload with\n upper lobe venous congestion, and fluid in the minor fissure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1142427,
"text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with chf, esrd, recently initiated on HD. now with HTN, chest\n pain, N/V\n REASON FOR THIS EXAMINATION:\n acute process?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:34 PM\n PFI: Largely improved chest radiograph with no acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with CHF, end-stage renal disease on hemodialysis,\n now with hypertension and chest pain.\n\n STUDY: Portable AP upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: Since the prior study, the patient has been extubated and there has\n been removal of the endogastric tube. The heart and mediastinal contours\n appear within normal limits. The hila are normal appearing bilaterally. The\n lungs are clear of masses or consolidations; the previously described\n pulmonary edema has improved. There is no large pleural effusion or\n pneumothorax. The osseous structures are grossly intact.\n\n IMPRESSION: Largely improved chest radiograph with no worsening acute\n cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1142428,
"text": ", S. 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with chf, esrd, recently initiated on HD. now with HTN, chest\n pain, N/V\n REASON FOR THIS EXAMINATION:\n acute process?\n ______________________________________________________________________________\n PFI REPORT\n PFI: Largely improved chest radiograph with no acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-12 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1142823,
"text": " 6:07 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Any abdominal pathology?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hypertensive urgency, on dialysis, with nausea.\n REASON FOR THIS EXAMINATION:\n Any abdominal pathology?\n ______________________________________________________________________________\n WET READ: IPf SAT 7:16 PM\n Nonobstructive bowel gas pattern. No free air under the diaphragm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypertensive urgency, on dialysis with nausea.\n\n FINDINGS: No previous images. Three views show the bowel gas pattern to be\n within normal limits without evidence of obstruction. Vascular calcification\n is seen, though no definite calcification is appreciated within the urinary\n tract.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1142907,
"text": " 1:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 57 year old man with ESRD on HD, leukocytosis, low grade tem\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESRD, leukocytosis, low grade temp, eval for infectious\n process in abd.?need contrast?\n REASON FOR THIS EXAMINATION:\n 57 year old man with ESRD on HD, leukocytosis, low grade temp, eval for\n infectious process in abd. ?need contrast?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 8:21 PM\n 1. No abdominal or pelvic abscess or other evidence of infection in the\n abdomen and pelvis.\n 2. Likely mild mesenteric adenopathy, which could be reactive.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST\n\n INDICATION: 57-year-old male with end-stage renal disease, leukocytosis,\n fever.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained\n following administration of oral and intravenous contrast. Coronal and\n sagittal reformatted images were obtained.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The imaged lung bases are clear. There\n is no consolidation, pleural effusion, or mass at the visualized lung bases.\n There is plate-like atelectasis at the left base.\n\n The liver, spleen, adrenal glands, pancreas are normal. The kidneys enhance\n equally and excrete contrast normally. There is an exophytic lesion arising\n from the upper pole of the left kidney, which is too small to definitely\n characterize, measuring 15 mm, but statistically likely representing a cyst.\n The lateral limb of the right adrenal gland appears nodular. The abdominal\n aorta and branches demonstrate atherosclerotic calcifications. The caliber of\n the abdominal aorta is normal. There is no ascites or free intraperitoneal\n air. Abdominal loops of large and small bowel are normal, without small bowel\n dilatation or bowel wall thickening. There is no retroperitoneal\n lymphadenopathy. In the lower right abdomen near the midline, (series 2,\n image 55) there is an oval solid structure, measuring 14 x 12 mm, likely\n representing an enlarged lymph node. In close proximity, another 15x12 mm\n lymph node is seen.\n\n The appendix is normal.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, distal ureters,\n prostate, seminal vesicles, rectum, sigmoid colon are unremarkable. There is\n (Over)\n\n 1:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 57 year old man with ESRD on HD, leukocytosis, low grade tem\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n no free pelvic fluid and no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: Demonstrate no lytic or sclerotic lesions concerning for\n malignancy. Small sclerotic focus in the right ilium probably represents tiny\n bone islands. Faint sclerosis along a few lower thoracic endplates is\n suggestive of early changes associated with renal osteodystrophy, akin to a\n Rugger-Jersey spine.\n\n Subcutaneous stranding in the anterior abdominal wall, probably related to\n recent injections.\n\n IMPRESSION:\n\n 1. No evidence for abdominal or pelvic fluid collection.\n\n 2. Two enlarged mesenteric lymph nodes. These are probably reactive;\n clinical correlation with history of malignancy and 3 months follow up to\n document stability or improvement are recommended.\n\n 3. Indeterminate exophytic left upper pole renal lesion, too small to\n definitely characterize, but statistically simple cyst. Although the patient\n had a renal ultrasound examination recently that did not depict the lesion, an\n additional focussed ultrasound examination is suggested to see whether it can\n be visualized, although its location may be somewhat difficult to access\n son. In that event, an MR may be clinically appropriate since\n differential considerations include a solid renal mass such a renal cell\n carcinoma.\n\n 4. Findings suggestive of early renal osteodystrophy.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1142819,
"text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for consolidation or other sources of leukoc\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with increasing leukocytosis\n REASON FOR THIS EXAMINATION:\n Please evaluate for consolidation or other sources of leukocytosis\n ______________________________________________________________________________\n WET READ: IPf SAT 7:33 PM\n No evidence of pneumonia on CXR. Minimal retrocardiac opacity likely minimal\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing white blood count, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is no evidence of acute\n pneumonia. The patient has taken a much better inspiration. Mild atelectatic\n changes persist at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1142908,
"text": ", S. 1:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 57 year old man with ESRD on HD, leukocytosis, low grade tem\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESRD, leukocytosis, low grade temp, eval for infectious\n process in abd.?need contrast?\n REASON FOR THIS EXAMINATION:\n 57 year old man with ESRD on HD, leukocytosis, low grade temp, eval for\n infectious process in abd. ?need contrast?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No abdominal or pelvic abscess or other evidence of infection in the\n abdomen and pelvis.\n 2. Likely mild mesenteric adenopathy, which could be reactive.\n\n"
},
{
"category": "Echo",
"chartdate": "2180-08-05 00:00:00.000",
"description": "Report",
"row_id": 96381,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 73\nWeight (lb): 190\nBSA (m2): 2.11 m2\nBP (mm Hg): 129/67\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Mild regional LV\nsystolic dysfunction. False LV tendon (normal variant). No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening\nof mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is mildly dilated. There is mild\nregional left ventricular systolic dysfunction with focal hypokinesis of the\nbasal inferior septum and basal inferior wall. The remaining segments contract\nnormally (LVEF = 45-50 %). Right ventricular chamber size and free wall motion\nare normal. The ascending aorta is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild concentric left ventricular hypertrophy. Regional systolic\ndysfunction c/w CAD. Mild mitral regurgitation. Moderate pulmonary\nhypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-13 00:00:00.000",
"description": "Report",
"row_id": 265499,
"text": "Sinus rhythm. Left ventricular hypertrophy. Non-specific inferolateral\nST-T wave change and Q-T interval prolongation. Compared to the previous\ntracing of inferolateral ST-T wave abnormalities have improved in the\ncontext of an increase in rate. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-06 00:00:00.000",
"description": "Report",
"row_id": 265500,
"text": "Sinus rhythm. Prolonged Q-T interval. Compared to the previous tracing the\nrhythm has changed and the Q-T interval is prolonged.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-06 00:00:00.000",
"description": "Report",
"row_id": 265501,
"text": "Atrial fibrillation. Compared to the previous tracing the rhythm has changed.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-05 00:00:00.000",
"description": "Report",
"row_id": 265502,
"text": "Sinus rhythm. Prolonged Q-T interval. Compared to the previous tracing\nQ-T interval has increased.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-05 00:00:00.000",
"description": "Report",
"row_id": 265503,
"text": "Sinus rhythm. Compared to the previous tracing Q-T interval is normal.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-05 00:00:00.000",
"description": "Report",
"row_id": 265504,
"text": "Sinus rhythm. Prolonged Q-T interval. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
70,069 | 150,715 | 38M with h/o schizophrenia p/w severe pancreatitis c/b acute respiratory failure requiring intubation, increased abdominal pressures, and acute kidney injury. | Mild symmetric left ventricularhypertrophy with normal cavity size and global systolic function. Unchanged appearance of the heart and the lung parenchyma, with small bilateral pleural effusions, retrocardiac atelectasis, and borderline size of the cardiac silhouette. An endotracheal tube and right-sided PICC with tip in the low SVC are unchanged. A moderate amount of subcutaneous edema is visualized bilaterally. Symmetric left ventricular hypertrophywith gossly normal biventricular cavity sizes and global systolic function. Unchanged bilateral pleural effusions with bilateral lower lobe dependent consolidation which most likely represents atelectasis though infection is not excluded. FINDINGS: One abdominal radiograph in supine position was obtained. Endotracheal tube is unchanged. Bilateral, moderate pleural effusions and bibasilar atelectasis are unchanged. FINDINGS: Single AP view of the chest, with an ET tube to be 4.1 cm above the carina. Unchanged peripancreatic stranding and moderate simple ascites. Moderate body wall edema is noted. FINDINGS: As compared to the previous radiograph, the endotracheal tube and the right internal jugular vein catheter are in unchanged position. More recently with decreased hematocrit and question of retroperitoneal hemorrhage. The ascending aorta is mildly dilated at the sinus level. There is a small amount of intra-abdominal ascites. Intra-abdominal free fluid and peripancreatic stranding consistent with the provided history of pancreatitis. Note is made of bilateral subcutaneous and presacral edema. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root.AORTIC VALVE: Normal aortic valve leaflets (?#).MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Continued low lung volumes with bibasilar opacifications that appear slightly more prominent bilaterally. Right upper extremity PICC terminates in the low SVC. Uncanged bilateral pleural effusions are present. Indeterminate PA systolicpressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. An esophageal catheter is in place coursing inferior to the diaphragm with tip out of view of the radiograph. Right IJ catheter extends to the mid portion of the SVC. A central venous catheter is seen with its tip in the low SVC. IMPRESSION: Tip of endotracheal tube ends approximately 4 cm above the carina and is adequately placed. Suboptimalimage quality - ventilator.Conclusions:The left atrium is normal in size. FINDINGS: Single AP views of the chest show an ET tube to be 4.4 cm above the carina. Bibasilar atelectasis and left pleural effusion. Another tube is seen along the course of esophagus and terminates approximately at the level of the gastroesophageal junction. A left IJ catheter terminates in the mid-to-low SVC. The remainder of the colon is normal appearing. Only at the left lung base, a residual parenchymal opacity is still seen. IMPRESSION: Unremarkable abdominal radiograph. The gallbladder is normal in appearance. Normal bowel gas pattern, without evidence of free air. Ascites, consistent with known pancreatitis. Borderline size of the cardiac silhouette without overt pulmonary edema. A left IJ catheter tip terminates within the mid SVC. Left IJ catheter tip is in the upper SVC. FINDINGS: One supine abdominal radiograph was obtained. Again seen are bilateral pleural effusions and bibasilar atelectasis which are unchanged since this a.m. The orogastric tube is seen coursing below the diaphragm; however, the tip including the distal end is beyond the view of radiograph Another tube coursing along with OGT is seen to end approximately at the level of the gastroesophageal junction and its position and course is unchanged since the prior radiograph. FINDINGS: Following reexpansion of the right lower lobe collapse, residual atelectasis and minimal right pleural effusion is unchanged since . Mild gastric distension in left upper quadrant with associated slight elevation of left hemidiaphragm. Again seen is a left pleural effusion and retrocardiac atelectasis. Left internal jugular line ends at the mid SVC. Patchy and linear opacities are present in the right mid and both lower lungs, new on the right and minimally improved on the left. Atelectasis at the left base and small left pleural effusion remain. IMPRESSION: PA and lateral chest compared to through 10: Residual opacification in the left lower lobe is largely atelectasis. FINDINGS: As compared to the previous radiograph, the patient has received a new left-sided PICC line. Right-sided PICC line tip is in the SVC. Bilateral pleural effusions and left lower lobe retrocardiac large atelectasis are unchanged. The tip of endotracheal tube terminates approximately 3.2 cm above the carina and is adequately placed. A left internal jugular venous catheter is unchanged with tip reaching the SVC. Following reexpansion of the right lower lobe collapse, the right lung base atelectasis and the minimal right pleural effusions have remained stable. IMPRESSION: An NG tube tip terminates within the stomach and another within the distal GE junction. FINAL REPORT CHEST RADIOGRAPH INDICATION: New PICC line. FINDINGS: Single AP view of the chest shows two NG tubes, one terminating within the stomach and one within the distal esophagus. IMPRESSION: Properly positioned right upper extremity PICC. Normal tracing.TRACING #1 3:58 AM CHEST (PORTABLE AP) Clip # Reason: please assess for interval change. An ET tube, two esophageal catheters and left IJ catheter are unchanged in location. Check ET tube placement. CM and bibasilar opacity unchanged. Sinus rhythm. Sinus rhythm. Sinus rhythm. feeding tube and tube with sideholes in esophagus unchanged. Fenestrated esophageal monitoring device has been withdrawn from the lower esophagus to the cervical esophagus and hypopharynx. A second OJ tube tip is in unchanged position with the tip at the GE junction. The tip of the line projects over the mid to lower SVC. | 38 | [
{
"category": "Echo",
"chartdate": "2140-08-26 00:00:00.000",
"description": "Report",
"row_id": 60519,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Large A-a gradient. ? Intracardiac shunt.\nHeight: (in) 70\nWeight (lb): 250\nBSA (m2): 2.30 m2\nBP (mm Hg): 112/72\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 14:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#).\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. No intracardiac shunt is suggested after\nintravenous saline injection at rest. Mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function. (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Right ventricular chamber size and free wall motion are\ngrossly normal. The ascending aorta is mildly dilated at the sinus level. The\naortic valve leaflets (?#) appear structurally normal with good leaflet\nexcursion. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The pulmonary artery systolic pressure could not be determined.\nThere is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Symmetric left ventricular hypertrophy\nwith gossly normal biventricular cavity sizes and global systolic function. No\nintracardiac shunt identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1204520,
"text": " 11:01 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for abnormalties\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with acute pancreatitis.\n REASON FOR THIS EXAMINATION:\n please assess for abnormalties\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old man with acute pancreatitis, please assess for\n abnormalities.\n\n COMPARISON: CT of the torso .\n\n FINDINGS: One abdominal radiograph in supine position was obtained. Quality\n of the film is compromised due to exclusion of pelvic area and right\n peridiaphragmatic region. Normal bowel gas pattern, without evidence of free\n air. No abnormal calcifications.\n\n IMPRESSION: Unremarkable abdominal radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205133,
"text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated patient\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatiti, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubated patient\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis, now with respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: Single AP view of the chest, with an ET tube to be 4.1 cm above the\n carina. A left IJ catheter terminates in the mid-to-low SVC. Two esophageal\n catheters are seen extending off the screen. Compared to prior, there has\n been worsening of the left pleural effusion, now moderate in size. No\n pulmonary edema seen. The right lower lobe atelectasis and small pleural\n effusion are also increased.\n\n IMPRESSION: Worsening atelectasis and bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-28 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1204754,
"text": " 1:36 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for abnormalities.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with acute pancreatitis and marked abdominal distention.\n REASON FOR THIS EXAMINATION:\n Please assess for abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n REASON FOR EXAM: Acute pancreatitis with marked abdominal distention.\n\n Single portable supine view of the abdomen shows two feeding tubes, one with\n the tip at the level of the hemidiaphragm, the second at the level of the\n distal antrum or proximal duodenum. There is paucity of the bowel gas\n pattern. There is air in the transverse colon. The pelvis was not included\n in this radiograph. There are no large intraabdominal calcifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205252,
"text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress.\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis.\n\n COMPARISON: .\n\n FINDINGS: Single AP views of the chest show an ET tube to be 4.4 cm above the\n carina. Two Dobbhoffs are seen overlying the esophagus and extending into the\n stomach off the screen. Right upper extremity PICC terminates in the low SVC.\n Bilateral, moderate pleural effusions and bibasilar atelectasis are unchanged.\n Cardiac silhouette is normal. No pneumothorax.\n\n IMPRESSION: No change in bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205686,
"text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new pna, resolving edema\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with severe pancreatitis on ventilator\n REASON FOR THIS EXAMINATION:\n ? new pna, resolving edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Pancreatitis, on ventilator. Question new pneumonia, resolving\n edema.\n\n REFERENCE EXAM: .\n\n Compared to the study from the prior day, there is no significant interval\n change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206398,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis and respiratory distress.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices are essentially unchanged. Continued low lung volumes with bibasilar\n opacifications that appear slightly more prominent bilaterally. Although much\n of this could represent atelectasis with effusion, the possibility of\n superimposed pneumonia would have to be considered in the appropriate clinical\n setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206070,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with pancreatitis and respiratory distress.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: Lung volumes remain low with bibasilar atelectasis and pleural\n effusions which appear to layer on this examination as the patient is now in\n supine position. There is mild vascular congestion. No pneumothorax is seen.\n The cardiac size is within normal limits. Widening of the mediastinum likely\n reflects vascular engorgement. An endotracheal tube and right-sided PICC with\n tip in the low SVC are unchanged. An esophageal catheter is in place coursing\n inferior to the diaphragm with tip out of view of the radiograph. An\n esophageal monitoring device is in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206546,
"text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia interval progression\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress, extubated today\n REASON FOR THIS EXAMINATION:\n pneumonia interval progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pancreatitis, respiratory distress. Evaluation for interval\n progression.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is an improvement.\n The monitoring and support devices have been removed. The pre-existing\n parenchymal opacities have mostly resolved. Only at the left lung base, a\n residual parenchymal opacity is still seen. Borderline size of the cardiac\n silhouette without overt pulmonary edema. No larger pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-03 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1205568,
"text": " 5:34 AM\n PORTABLE ABDOMEN Clip # \n Reason: Distended loops of bowel\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38yo M with h/o paranoid schizophrenia who initially presented to in on with new DKA and then developed\n severe pancreatitis/bandemia with possible HCAP with bilat lower lobe\n infiltrates s/p intubation now transferred here for further management\n REASON FOR THIS EXAMINATION:\n Distended loops of bowel\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: DKA and pancreatitis.\n\n FINDINGS: There is a feeding tube with the tip in the distal portion of the\n duodenum. Another tube ends in the distal esophagus. There is a relative\n paucity of bowel gas.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-30 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1205036,
"text": " 12:48 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please advance dobhoff to be post pyloric, would like to be\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with severe pancreatitis, needs -jejunal tubes for feeds\n REASON FOR THIS EXAMINATION:\n Please advance dobhoff to be post pyloric, would like to be done either or\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe pancreatitis with requirement for enteric tube feedings.\n\n COMPARISON: None available.\n\n FINDINGS: The patient arrived in the fluoroscopy suite and was placed in a\n supine position on the fluoroscopy table. Pre-existing Dobbhoff tube was\n removed. Thereafter, - feeding tube was inserted, and\n advanced under fluoroscopic observation into the distal duodenum.\n Confirmation of tip location was confirmed with injection of a small amount of\n Optiray water-soluble contrast under fluoroscopic observation. Thereafter,\n the tube was secured. The patient was transferred in stable condition from\n the fluoroscopy suite.\n\n IMPRESSION: Successful placement of a post-pyloric - feeding\n tube, with the tip terminating in the distal duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-29 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1204924,
"text": " 5:33 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: RP bleed\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory failure, abdominal hypertension\n with HCT drop and worsening creatinine\n REASON FOR THIS EXAMINATION:\n RP bleed\n CONTRAINDICATIONS for IV CONTRAST:\n worsening creatinine\n ______________________________________________________________________________\n WET READ: SJBj MON 6:05 PM\n Small to moderate b/l pleural effusions and atelectasis. Unchanged\n peripancreatic stranding and moderate simple ascites. No retroperitoneal\n hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatitis and respiratory failure. More recently with\n decreased hematocrit and question of retroperitoneal hemorrhage.\n\n COMPARISON: CT from .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis\n without intravenous contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n CT ABDOMEN WITHOUT CONTRAST: There are small bilateral pleural effusions,\n both increased from the comparison study, as is overlying atelectasis. The\n imaged portion of the heart is normal. A nasogastric tube terminates in the\n stomach. The spleen is enlarged, measuring 15 cm in length. The adrenal\n glands, kidneys, and liver are normal. The gallbladder is nondistended, and\n notable for layering density within it, suggesting sludge. As before, there\n is a large amount of stranding surrounding the body and tail of the pancreas,\n as well as a moderate amount of free fluid. The extent of fluid is unchanged\n from the previous study. There is no definite evidence of organization as yet\n into a pseudocyst. The fluid is simple in attenuation, without evidence of\n intraperitoneal or retroperitoneal hemorrhage. A moderate amount of\n subcutaneous edema is visualized bilaterally.\n\n CT PELVIS WITHOUT CONTRAST: The urinary bladder is collapsed around a Foley\n catheter. The prostate, seminal vesicles, rectum, colon and appendix are\n normal. There is no pelvic sidewall or inguinal lymphadenopathy. Note is\n made of bilateral subcutaneous and presacral edema. There is no hematoma.\n\n OSSEOUS FINDINGS: Note is made of an occult dysraphism posteriorly at L5.\n There is no suspicious sclerotic or lytic osseous lesion.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal or other hematoma.\n 2. Intra-abdominal free fluid and peripancreatic stranding consistent with\n the provided history of pancreatitis.\n (Over)\n\n 5:33 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: RP bleed\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Increase in small pleural effusions bilaterally.\n 4. Splenomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-26 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1204514,
"text": " 10:32 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please assess for abnormality\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with acute pancreatitis.\n REASON FOR THIS EXAMINATION:\n please assess for abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis.\n\n COMPARISON: Outside hospital CT scan dated .\n\n ABDOMINAL ULTRASOUND\n\n Only portions of the pancreatic neck and head are visualized and demonstrate\n normal echotexture. The liver is also normal in echotexture without focal\n lesions. There is no intra- or extra-hepatic biliary dilatation. The portal\n vein is patent with appropriate hepatopetal flow. The gallbladder is\n unremarkable without stones or wall edema. The common bile duct is not\n dilated measuring 3 mm.\n\n The right kidney measures 12.7 cm. The left kidney measures 14.7 cm. There\n are no stones or hydronephrosis. The spleen is enlarged measuring 15.6 cm.\n There is a small amount of intra-abdominal ascites. In addition, there are\n three fluid collections anterior to the right kidney with one of the largest\n measuring 5.4 x 3.9 cm. These demonstrate no peristalsis and may represent\n non-peristalsing bowel or pseudocysts.\n\n IMPRESSION:\n\n 1. Ascites, consistent with known pancreatitis.\n\n 2. Pseudocysts versus non-peristalsing bowel anterior to the right kidney.\n\n 3. Splenomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206241,
"text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 38-year-old man with pancreatitis.\n\n COMPARISON: Multiple priors including most recently from .\n\n FINDINGS: An ET tube is seen in correct position. An NG tube is seen\n coursing into the esophagus with its tip not visualized on this film. The\n lungs show bilateral pleural effusions with layering. There is also a\n question of developing air bronchograms within the right lower lung field,\n which could be representative of an early pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-05 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1205841,
"text": " 2:31 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ?complications of pancreatitis? any evidence of infection, a\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress, continued fevers. One\n week following onset of symptoms.\n REASON FOR THIS EXAMINATION:\n ?complications of pancreatitis? any evidence of infection, abscess,\n collections. please also image chest for evaluation of pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 38-year-old male with pancreatitis, respiratory\n distress and continuing fevers.\n\n COMPARISON: and Reference CT torso .\n\n FINDINGS: There is bilateral dependent lower lobe consolidation which is very\n similar in appearance when compared with . Linear atelectasis is seen\n in the right lower lobe. Uncanged bilateral pleural effusions are present.\n There is no mediastinal, hilar, or axillary lymph node enlargement. The heart\n is normal in size without pericardial effusion. The great vessels appear\n normal. A central venous catheter is seen with its tip in the low SVC. The\n patient is intubated with the endotracheal tube 6.7 cm from the carina. This\n should be advanced.\n\n ABDOMEN: The liver is fatty. There is no intra-hepatic or extra-hepatic\n biliary ductal dilation. The gallbladder is normal in appearance. The spleen,\n adrenals, and kidneys are unremarkable. Note is again made of pancreatitis,\n though there are no hypoenhancing portions of the pancreas to suggest a\n necrotizing process. Fluid surrounds the tail of the pancreas and extends\n along the left anterior perirenal fascia and lateral conal ligament, though\n this is not well contained or drainable at this point in time.\n\n A feeding tube is in place with its tip in the third portion of the duodenum.\n An esophageal drain is stable in appearance. The stomach is collapsed and\n therefore not well evaluated. Loops of small bowel are normal in caliber and\n enhancement.\n\n The aorta is normal in caliber, its major branches appear patent. There is no\n retroperitoneal lymphadenopathy, though shotty retroperitoneal lymph nodes are\n seen the largest of which measures up to 7 mm in short axis.\n\n PELVIS: The bladder contains a Foley catheter and is decompressed. There is\n a rectal tube in place. The rectosigmoid is otherwise unremarkable. Mild\n stranding is seen adjacent to the left colon secondary to the pancreatitis.\n The remainder of the colon is normal appearing. There is no pelvic side wall\n lymphadenopathy. Moderate body wall edema is noted.\n\n BONE WINDOWS: There are no concerning lytic or blastic osseous lesions.\n (Over)\n\n 2:31 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ?complications of pancreatitis? any evidence of infection, a\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Similar appearance to acute pancreatitis with fluid surrounding the tail\n of the pancreas and extending inferiorly along anterior perirenal fascia. This\n is slightly more better contained when compared with , but no\n significant change from .\n 2. Unchanged bilateral pleural effusions with bilateral lower lobe dependent\n consolidation which most likely represents atelectasis though infection is not\n excluded.\n 3. Endotracheal tube 6.7 cm from the carina. This should be advanced.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204461,
"text": " 9:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position, pneumothorax or other acute process\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with severe pancreatitis s/p intubation now with hypoxia\n REASON FOR THIS EXAMINATION:\n eval ETT position, pneumothorax or other acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For endotracheal tube position.\n\n FINDINGS: In comparison with study of , the endotracheal tube lies\n approximately 5.4 cm above the carina. Right IJ catheter extends to the mid\n portion of the SVC. Continued low lung volumes may account for much of the\n prominence of the transverse diameter of the heart. Atelectatic changes and\n effusion are seen at the left base. No definite vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205421,
"text": " 6:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Patient with pancreatitis, respiratory distress and intubated.\n\n TECHNIQUE: AP upright portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through to\n the most recent from .\n\n IMPRESSION:\n\n Tip of endotracheal tube ends approximately 4 cm above the carina and is\n adequately placed. The right PICC line terminates at the lower SVC. The\n feeding tube is seen coursing below the level of the diaphragm, however, the\n distal end is beyond the view of radiograph. Another tube is seen along the\n course of esophagus and terminates approximately at the level of the\n gastroesophageal junction. Since , moderate-to-large left\n pleural effusion and minimal right effusions with associated lung atelectasis\n are similar in appearance. Heart size, mediastinal and hilar contours are\n normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206306,
"text": " 12:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: S/P AIRWAY EXCHANGE, CHECK FOR ASPIRATION, INFILTRATE\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with pancreatitis and respiratory distress.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated ,\n obtained approximately eight hours prior.\n\n FINDINGS: Lung volumes remain low with bibasilar atelectasis and\n small-to-moderate pleural effusion on the left. Increased opacity at the\n right base could represent aspiration or increased atelectasis. A small\n amount of right pleural fluid is also likely present. No significant change\n in mild vascular congestion. The cardiomediastinal silhouette is unchanged.\n No pneumothorax is seen. A right-sided PICC is unchanged with tip within the\n SVC. An esophageal catheter terminates within the stomach. Endotracheal tube\n is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1204584,
"text": " 6:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please evaluate for placement of OGT and left IJ\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis s/p intubation, and left sided IJ and OGT\n placement\n REASON FOR THIS EXAMINATION:\n please evaluate for placement of OGT and left IJ\n ______________________________________________________________________________\n WET READ: DLrc FRI 8:27 PM\n Left sided IJ with tip demonstrated in the upper SVC. No pneumothorax. Enteric\n tube courses below the diaphragm. Larger bore enteric tube with tip in the\n gastroesophageal junction. ET tube in standard position. Bibasilar atelectasis\n and left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pancreatitis, status post intubation, line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the endotracheal tube and\n the right internal jugular vein catheter are in unchanged position. In the\n interval, the patient has received a nasogastric tube. The tip of the tube is\n not included in the image, the course of the tube is unremarkable. The second\n nasogastric tube with thickened diameter projects with its tip over the\n gastroesophageal junction. In addition, a left internal jugular vein catheter\n has been inserted. The tip projects over the mid SVC.\n\n No evidence of complications, notably no pneumothorax.\n\n Unchanged appearance of the heart and the lung parenchyma, with small\n bilateral pleural effusions, retrocardiac atelectasis, and borderline size of\n the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204808,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with acute pancreatitis and pneumonia.\n REASON FOR THIS EXAMINATION:\n please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old man with acute pancreatitis and pneumonia, please\n assess for interval change.\n\n TECHNIQUE: Portable semi-upright radiograph of chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n FINDINGS:\n\n Following reexpansion of the right lower lobe collapse, residual atelectasis\n and minimal right pleural effusion is unchanged since . The\n left moderate pleural effusion with adjacent lung atelectasis has increased.\n Heart size is normal and mediastinal contours are unchanged.\n\n The tip of endotracheal tube terminates approximately 3.2 cm above the carina\n and is adequately placed. Left internal jugular line ends at the mid SVC.\n The orogastric tube is seen coursing below the diaphragm; however, the tip\n including the distal end is beyond the view of radiograph Another tube\n coursing along with OGT is seen to end approximately at the level of the\n gastroesophageal junction and its position and course is unchanged since the\n prior radiograph.\n\n IMPRESSION:\n\n 1. Interval increase in moderate left pleural effusion and adjacent\n atelectasis.\n\n 2. Following reexpansion of the right lower lobe collapse, the right lung base\n atelectasis and the minimal right pleural effusions have remained stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204977,
"text": " 4:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? resolution vs pna\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis & pulm edema\n REASON FOR THIS EXAMINATION:\n ? resolution vs pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with pancreatitis. Followup examination.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Prior examinations ranging from to .\n\n FINDINGS: As compared to the prior examination, consolidation at the right\n base is increased. Atelectasis at the left base and small left pleural\n effusion remain. Lung volumes remain low. No pneumothorax is seen. The\n cardiomediastinal silhouette is unchanged. Endotracheal tube is in\n satisfactory position. Two esophageal catheters are present, one with tip in\n the distal esophagus and one coursing inferior to the diaphragm with tip out\n of view of the radiograph. A left internal jugular venous catheter is\n unchanged with tip reaching the SVC.\n\n IMPRESSION: Increased consolidation at the right base, atelectasis versus\n developing pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205858,
"text": " 6:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET tube placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38yo M with h/o paranoid schizophrenia now here with severe pancreatitis and\n respiratory failure hospital-acquired vs aspiration pneumonia.\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n WET READ: NATg MON 8:31 PM\n ETT 3.9cm from carina. feeding tube and tube with sideholes in esophagus\n unchanged. RUE Picc stable. CM and bibasilar opacity unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:27 P.M. :\n\n HISTORY: Severe pancreatitis and respiratory failure. Hospital acquired or\n aspiration pneumonia. Check ET tube placement.\n\n IMPRESSION: AP chest compared to through at 5:55 a.m.:\n\n ET tube and right PIC line are in standard placements. Fenestrated esophageal\n monitoring device has been withdrawn from the lower esophagus to the cervical\n esophagus and hypopharynx. Alongside its tip is a radiopaque marker that\n could represent another device with which I am not familiar. Clinical\n correlation is advised.\n\n Small left effusion and left lower lobe consolidation are improving,\n relatively mild right basal atelectasis is not. No pneumothorax. Heart size\n normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205548,
"text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, resolving but fevers\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Pancreatitis with fevers.\n\n FINDINGS: The endotracheal tube tip is 5.8 cm above the carina. Right-sided\n PICC line tip is in the SVC. There is a small left effusion and bibasilar\n volume loss/infiltrate worse on the left than the right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205802,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Respiratory distress.\n\n REFERENCE EXAM: .\n\n Compared to the prior exam there is no significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1205198,
"text": " 3:17 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r dl power picc 48cm iv \n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 48cm iv \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n COMPARISON: at 5:30 a.m.\n\n HISTORY: Single AP view of the chest shows a right upper extremity PICC whose\n tip terminates within the atriocaval junction. An ET tube, two esophageal\n catheters and left IJ catheter are unchanged in location. Again seen are\n bilateral pleural effusions and bibasilar atelectasis which are unchanged\n since this a.m.\n\n IMPRESSION: Properly positioned right upper extremity PICC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204889,
"text": " 1:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis, NGT\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: NG tube placement.\n\n COMPARISONS: at 4:14 a.m.\n\n FINDINGS: Single AP view of the chest shows two NG tubes, one terminating\n within the stomach and one within the distal esophagus. ET tube is 2.6 cm\n above the carina. A left IJ catheter tip terminates within the mid SVC.\n Compared to prior there is increased aeration of the right lung base. Again\n seen is a left pleural effusion and retrocardiac atelectasis. No\n pneumothorax.\n\n IMPRESSION: An NG tube tip terminates within the stomach and another within\n the distal GE junction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204720,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with severe pancreatitis, intubated\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient with severe pancreatitis.\n\n Comparison is made to prior study .\n\n ET tube tip is in standard position 3.5 cm above the carina. Left IJ catheter\n tip is in the upper SVC. NG tube tip is out view below the diaphragm.\n Cardiac silhouette is obscured by parenchymal abnormalities. Right lower lobe\n collapse has improved.\n\n A second OJ tube tip is in unchanged position with the tip at the GE junction.\n Bilateral pleural effusions and left lower lobe retrocardiac large atelectasis\n are unchanged. Of note the right lateral CP angle was not included in the\n film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-30 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1205021,
"text": " 11:03 AM\n PORTABLE ABDOMEN Clip # \n Reason: dobhoff tube place yesterday, please check to see if it is i\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with pancreatitis\n REASON FOR THIS EXAMINATION:\n dobhoff tube place yesterday, please check to see if it is in his duodenum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old man with pancreatitis. Dobbhoff tube placed\n yesterday. Please check location of the Dobbhoff tube.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: One supine abdominal radiograph was obtained. There is a paucity\n of bowel gas with scattered air seen in the colon. No abnormal\n calcifications. Dobbhoff tube is seen with the tip ending in the stomach.\n Bibasilar pulmonary opacifications can be better assessed in portable chest\n radiograph from .\n\n IMPRESSION: Dobhoff tube tip in stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-10 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1206572,
"text": " 9:24 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 60cm left picc. tip?\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 60cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line. Confirm placement.\n\n COMPARISON: , 5:12 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new left-sided PICC line. The course of the line is unremarkable. The tip of\n the line projects over the mid to lower SVC. There is no evidence of\n complications, notably no pneumothorax. Otherwise, the radiograph is\n unchanged as compared to the previous image.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-06 00:00:00.000",
"description": "Report",
"row_id": 110717,
"text": "Normal sinus rhythm. Within normal limits. Compared to the previous tracing\nof no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-31 00:00:00.000",
"description": "Report",
"row_id": 110718,
"text": "Similar to tracing #1.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-30 00:00:00.000",
"description": "Report",
"row_id": 110719,
"text": "Similar to tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-30 00:00:00.000",
"description": "Report",
"row_id": 110720,
"text": "Sinus rhythm. Normal tracing.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-27 00:00:00.000",
"description": "Report",
"row_id": 110721,
"text": "Sinus rhythm. Baseline artifact. Normal tracing. Compared to the previous\ntracing of the precordial voltage has diminished consistent with\n14 year difference, while the rate has slowed. Otherwise, no diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-13 00:00:00.000",
"description": "Report",
"row_id": 110660,
"text": "Sinus tachycardia. Early R wave progression. Prominent T wave abnormalities.\nSince the previous tracing of the rate is faster and diffuse T wave\nabnormalities are new. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-07 00:00:00.000",
"description": "Report",
"row_id": 110661,
"text": "Baseline artifact. Sinus rhythm. Probably normal tracing. Since the previous\ntracing of the rate is slower.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1207107,
"text": " 9:07 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for infection.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with schizophrenia and delirium s/p prolonged intubation for\n pneumonia and pancreatitis s/p fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infection.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: Schizophrenia and delirium. Prolonged intubation for pneumonia and\n pancreatitis.\n\n IMPRESSION: PA and lateral chest compared to through 10:\n\n Residual opacification in the left lower lobe is largely atelectasis.\n Previous large regions of pneumonia have substantially cleared. Heart size is\n normal and pleural effusion is minimal, if any. No pneumothorax. No evidence\n of central adenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1207808,
"text": " 1:01 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O worsening PNA\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with complex recent medical history including HAP, now off\n antibiotics, reports increasing shortness of breath\n REASON FOR THIS EXAMINATION:\n R/O worsening PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n COMPARISON: .\n\n FINDINGS: Lung volumes are low, resulting in crowding of bronchovascular\n structures. Cardiomediastinal contours are similar in appearance allowing for\n differences in lung volumes. Patchy and linear opacities are present in the\n right mid and both lower lungs, new on the right and minimally improved on the\n left. No pleural effusion. Mild gastric distension in left upper quadrant\n with associated slight elevation of left hemidiaphragm.\n\n IMPRESSION: Multifocal patchy and linear opacities favoring atelectasis over\n infectious pneumonia.\n\n\n"
}
] |
8,710 | 195,139 | In the emergency room, the patient was given 2 units of FFP and Vitamin K in order to decreased his INR. The patient was evaluated by neurosurgery for possible surgical drainage of his hemorrhage. They felt no intervention was warranted. The patient was admitted to the neuro ICU intubated on cardiac telemetry. He was placed on dilantin for seizure prophylaxis. He was extubated after 1 day in the ICU. Due to the patient's history of DVT along with his present intracranial hemorrhage, the decision was made to place an IVC filter. The patient tolerated this procedure well without complications. The patient was transferred from ICU to a stepdown unit on the neurology floor. His blood pressure was controlled for a SBP < 140. The patient was on clonidine, lisinopril, and metoprolol. His BP eventually normalized and he was maintained only on metoprolol and lisinopril. The patient had an interval CT scan on that showed a decreased size of his hemorrhage. His course was complicated by an aspiration pneumonia for which he was treated with levofloxacin and flagyl for a 10 day course. There was some difficulty maintaining therapeutic levels of dilantin thus the patient was switched to trileptal. His seizure prophylaxis is only meant to continue for 30 days since the hemorrhage. It can be stopped on . The patient was initially nourished with tube feeds via an NG tube. He was eventually evaluated by speech therapy and was cleared to take pureed thin liquids. His strength markedly improved on his right side throughout the course of his hospitalization. The etiology of his bleed was unclear at the time of d/c. DDz included an AVM, aneurysm, hemorrhage secondary to a mass, and amyloid angiopathy. The patient was scheduled for a f/u MRI study on to better assess the etiology of his bleed. He was given an appointment with Dr. in stroke clinic on . | There has been interval removal of an endotracheal and nasogastric tube. IMPRESSION: Stable appearance of left temporal intraparenchymal hemorrhage, with slight interval decrease in the intraventricular component. Stable appearance of left temporal intraparenchymal hemorrhage with extension into the left ventricle. CT HEAD WITHOUT IV CONTRAST: There is an intraparenchymal hemorrhage which appears to originate in the left temporal lobe with intraventricular extension. There is partial opacification of the ethmoid air cells bilaterally as well as complete opacification of the sphenoid sinuses. advancement No contraindications for IV contrast FINAL REPORT HISTORY: Intracranial hemorrhage. There is bibasilar linear opacity consistent with atelectasis, and more dense opacity in the left retrocardiac region with obscuration of the medial aspect of the left hemidiaphragm. FINDINGS: An endotracheal tube is in place with tip terminating approximately 4.3 cm from the carina. 2.Tiny amount of hemorrhage noted within the sulci of both temporal lobes. Chronic area of low density is again noted within the right posterior parietal lobe consistent with chronic infarction. Right apical and bibasilar opacities as previously demonstrated. UpdateO: Pt lg intraparenchymal bleed by mra. The size of the intraparenchymal hemorrhage and the surrounding edema is unchanged. Small amount of new hemorrhage within the occipital of the right lateral ventricle. TECHNIQUE/FINDINGS: A single AP upright chest radiograph was reviewed. IMPRESSION: Left temporal hematoma with extension to the ventricular system without evidence of hydrocephalus. There is a small amount of surrounding hypoattenuation consistent with edema. No signif response to either -> HO made aware.Plan repeat ffp 2units and attempt to keep sbp closer to 140 for renal perfus.Heme/ID: Tmax 99.8 hct/wbc stable.Iv access/Lines: 3periph iv's . There has been some resorption of the intraventricular component of the hemorrhage. Chronic right parietal infarct is noted. There has been interval development of a small amount of blood within the right occipital . The right costophrenic angle has been excluded from this radiograph. There is mild mass effect with the left uncus abutting the midbrain and partial obliteration of the ambient cistern on the left. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. There is opacification of the sphenoid sinus. Venogram was performed through the catheter which demonstrated patent left common iliac vein and patent single inferior vena cava. Again demonstrated is a small amount of blood within the interhemispheric fissure, unchanged since the prior examination. The inflow of solitary renal veins bilaterally could be visualized at the level of mid pedicle of L2, counting from below. The guidewire was then repositioned in the inferior vena cava and the Omniflush catheter removed under fluoroscopic guidance. The heart size and mediastinal contours are within normal limits. The heart size and mediastinal contours are within normal limits. ALT IN NEURO STATUS.P-CON'T WITH CURRENT PLAN. Right bundle-branch block with ST-T wave changes. nsg notesee flowsheet for specifics.NEURO-PROP GTT OFF SINCE THIS AM. +HYPO BS. POST EXTUBATION ABG ACCPETABLE. SKIN W+D. SKIN W+D. Non-specificST-T wave changes. Left atrial abnormality. Left atrial abnormality. Old right posterior MCA infarct. PT LETHARGIC. PERRL. PERRL. There is again noted an old infarct in the posterior aspect of the right MCA distribution. Interval improvement in bilateral patchy opacities. APAHASIC. +PP. +PP. sbp stable on prpfol. Mae spont and to command.D/T htn while awake pt resedated w propfol.Cv status: sbrady rare pvc. REMAINS ON DILANTIN, BOLUS DOSE GIVEN. PROTONIX CHANGED TO . There is an IVC filter noted. LS CLEAR, DECREASED AT BILAT BASES. +BS. Sinus rhythm. Sinus rhythm. Lung sounds ess clear after suct sm=>mod th tan sput. nsg noteSEE FLOWSHEET FOR SPECIFICS.NEURO-PT SEDATED ON PROP GTT. PT OFF PRESSORS. IMPRESSION: 1. SEE CAREVUE FOR Q1H VS AND Q4H ASSESSMENTS. Ventricularpremature beats. TOL WELL. DFDgf wean sedation if tolerates and wean vent. There is interval improvement of bilateral multifocal opacities. Possible old inferior myocardialinfarction. # 18 INSYTE INSERTED R ARM.ENDO: Q6H FSBS WITH SSRI COVERAGE. NO SZ CTIVITY NOTED.CV- AFEB. sw/swallow nystatin. Interval improvement in multifocal opacities. Copious oral secretions, freq mouth care given.Gi status: ogt to lws w bilious drng in decr amts now on protonix.Abd soft distended+ bowel snds.Gu status: foley to gd w qs cl/y/u/Heme/ID: hct stable at 29. NEURO CHECKS. NEURO CHECKS. PT TO REMAIN DNR AT THIS TIME. There is minimal right convex scoliosis of the thoracolumbar spine and degenerative changes of the spine. LEFT MORE THAN RIGHT. Compared to the previous tracing of no change. Probableprior inferior wall myocardial infarction. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. NPO. Sinus bradycardia. Sinus bradycardia. The alignment of the vertebral bodies is otherwise anatomic. Distal pulses+.Resp status: lavage suct for thick yellw secretions. The visualized portions of the mastoid air cells are normally aerated. However, the vertebral bodies are of normal height, and the alignment appears to be anatomic. ABD SOFT. KEEP SBP <140. OPENS EYES SPONT. Interval slight decrease in the size of the left temporal/intraventricular hemorrhage. Sagittal reformations were performed. FOLLOW COAGS. ? ? SBP MAINTAINED <140. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt overbreathing vent on occas. LS COARSE. LABETALOL, HYDRALAZINE, METOPROLOL IV TO KEEP SBP < 150. Similar appeareance of the mass effect caused by the uncus into the suprasellar cystern. There is ossification of the anterior longitudinal ligament. REMAINS ON DILANTIN, NO SZ ACTIVITY NOTED.CV-AFEB. The mediastinal and hilar contours are stable. A similar amount of mass effect displaces the left uncus toward the suprasellar cistern. STUCK OUT TONGUE ON COMMAND. Status post fall. LABETALOL, LOPRESSOR AND HYDRALAZINE IV TO KEEP SBP <150. Otherwise, no diagnostic interim change. ORIENTED TO PERSON ONLY. Will probably need swallow eval.PLAN: Keep INR<1.4 Keep sbp<150 ?swallow eval Neuro checks Notify H.O. | 29 | [
{
"category": "Radiology",
"chartdate": "2169-07-29 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 879804,
"text": " 5:08 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST Clip # \n Reason: r/o aneurysm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with atraumatic L temporal lobe intraparenchymal bleed. r/o\n aneurysm\n REASON FOR THIS EXAMINATION:\n r/o aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with atraumatic hemorrhage in the left temporal\n lobe, for further evaluation to exclude aneurysm.\n\n TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion axial images\n of the brain were obtained. 3D time-of-flight MRA of the circle of was\n acquired.\n\n FINDINGS BRAIN MRI:\n\n As seen on the CT, there is an acute hematoma seen in the left temporal lobe\n with surrounding edema and extension to the left lateral ventricle. There is\n no evidence of slow diffusion seen in this region to indicate acute infarct.\n There is evidence of chronic infarct seen in the right parietal watershed\n distribution. There is no midline shift or hydrocephalus identified. Mild-to-\n moderate changes of small vessel disease are seen in the subcortical and\n periventricular white matter.\n\n IMPRESSION: Left temporal hematoma with extension to the ventricular system\n without evidence of hydrocephalus. It should be noted that on the current\n examination gadolinium-enhanced images were not obtained. Gadolinium-enhanced\n images are recommended to exclude underlying mass. No abnormal flow voids are\n seen to indicate an associated aneurysm or arteriovenous malformation. No\n acute infarct is seen. Chronic right parietal infarct is noted.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates normal flow signal within the arteries of anterior\n and posterior circulation.\n\n IMPRESSION: Normal MRA of the head.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 879793,
"text": " 2:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ich s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage status post intubation, evaluate\n endotracheal tube position.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating approximately\n 4.3 cm from the carina. A nasogastric tube extends below the diaphragm with\n tip terminating below the borders of the radiograph. The heart size and\n mediastinal contours are within normal limits. Slight prominence of the upper\n zone pulmonary vasculature likely relates to supine positioning. There is\n bibasilar linear opacity consistent with atelectasis, and more dense opacity\n in the left retrocardiac region with obscuration of the medial aspect of the\n left hemidiaphragm. No pneumothorax. The osseous structures appear\n unremarkable.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n\n 2. Bibasilar atelectasis.\n\n 3. Left lower lobe atelectasis versus consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879795,
"text": " 2:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with large IPH from OSH\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SGA SAT 3:37 PM\n left temporal lobe intraparenchymal hemorrhage with intraventricular extension\n - effacment of left ambient cistern by left uncus, no other significant mass\n effect\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large intraparenchymal hemorrhage seen at outside hospital.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial noncontrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: There is an intraparenchymal hemorrhage which\n appears to originate in the left temporal lobe with intraventricular\n extension. Hemorrhage is seen within the left lateral ventricle. There is\n also a small amount of subarachnoid hemorrhage seen within the\n intraventricular sulcus anteriorly. There is a small amount of surrounding\n hypoattenuation consistent with edema. There is mild mass effect with the\n left uncus abutting the midbrain and partial obliteration of the ambient\n cistern on the left. There is no significant shift of normally midline\n structures. There is no evidence of hydrocephalus although the left lateral\n ventricle appears dilated. No other intracranial hemorrhage is identified.\n There is opacification of the sphenoid sinus. The rest of the paranasal\n sinuses are well aerated. An ET tube is seen within the oropharynx.\n\n IMPRESSION: Left temporal lobe intraparenchymal hemorrhage with extension\n into the left lateral ventricle. There is mild surrounding mass effect with\n the left uncus abutting the midbrain on the left.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880403,
"text": " 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with O2 requirement and retrocardiac opacity on prior CT\n REASON FOR THIS EXAMINATION:\n CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with retrocardiac opacity on prior CT.\n\n COMPARISONS: Comparison is made to AP chest radiographs from .\n\n TECHNIQUE/FINDINGS: A single AP upright chest radiograph was reviewed. A\n nasogastric tube courses towards the stomach then out of view. Moderate\n cardiomegaly is unchanged. The mediastinal and hilar contours are stable.\n Interval increase in bilateral apical and basilar heterogeneous opacities is\n concerning for developing multifocal pneumonia. Small bilateral pleural\n effusions are unchanged in size. No pneumothorax is identified.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. Developing multifocal pneumonia.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880296,
"text": " 3:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Position of NG tube.\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ich s/p intubation s/p NG tube placement\n\n REASON FOR THIS EXAMINATION:\n Position of NG tube.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of NG tube placement.\n\n NG tube is in fundus of stomach. Right CPA region not included on the film.\n Right apical and bibasilar opacities as previously demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880240,
"text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ich s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with intracranial hemorrhage status post\n intubation. Evaluate for infiltrate.\n\n COMMENTS: A single AP semi upright view of the chest was reviewed and\n compared with an AP chest radiograph from .\n\n There has been interval removal of an endotracheal and nasogastric tube.\n Moderate cardiomegaly is stable. The mediastinal and hilar contours are\n stable. There has been interval increase in pulmonary vascular congestion\n with associated bibasilar pleural effusions which reflects likely worsening\n congestive heart failure. No pneumothorax is identified. Left retrocardiac\n consolidation could reflect atelectasis and/or pneumonia.\n\n IMPRESSION:\n\n 1. No pneumothorax.\n 2. Interval increase in pulmonary interstitial edema reflecting likely\n worsening CHF.\n 3. Left lower lobe opacification, which could reflect atelectasis and/or\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-01 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 880053,
"text": " 7:56 AM\n IVC GRAM/FILTER Clip # \n Reason: Please place filter\n Admitting Diagnosis: INTRACRANIAL BLEED\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * C1769 GUID WIRES INCL INF C1880 VENA CAVA FILTER *\n * C1887 CATHETER GUIDING INF/PERF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with DVt and head bleed\n REASON FOR THIS EXAMINATION:\n Please place filter\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 75-year-old man with left lower extremity DVT and head\n bleed. Needs IVC filter placement.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist was present and supervising\n throughout the procedure.\n\n After the risks and benefits were explained to the patient, written informed\n consent was obtained. The patient was placed supine on the angiographic\n table. The right groin was prepped and draped in the standard sterile\n fashion. Using a combination of palpatory and fluoroscopic guidance, the\n right common femoral vein was punctured with a 19-gauge needle. The guidewire\n was advanced through the needle into the inferior vena cava under fluoroscopic\n guidance. The needle was removed and Omniflush catheter was placed over the\n wire. Venogram was performed through the catheter which demonstrated patent\n left common iliac vein and patent single inferior vena cava. The inflow of\n solitary renal veins bilaterally could be visualized at the level of mid\n pedicle of L2, counting from below. The guidewire was then repositioned in\n the inferior vena cava and the Omniflush catheter removed under fluoroscopic\n guidance. A 6-French vascular sheath was placed over the wire and then a\n Venatech inferior vena cava filter was deployed through the vascular sheath\n with its superior aspect below the level of renal venous inflow. Final\n positioning of the vena cava filter was confirmed with abdominal radiography.\n The vascular sheath was removed and hemostasis secured with 10 minutes of\n direct manual compression.\n\n COMPLICATIONS: There were no immediate complications.\n\n IMPRESSION: Successful placement of a permanent Venatech inferior vena cava\n filter placed immediately below the renal veins.\n (Over)\n\n 7:56 AM\n IVC GRAM/FILTER Clip # \n Reason: Please place filter\n Admitting Diagnosis: INTRACRANIAL BLEED\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879907,
"text": " 3:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? advancement\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intraparenchimal bleed\n REASON FOR THIS EXAMINATION:\n ? advancement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There has been no significant interval change in\n the appearance of the intraparenchymal hemorrhage originating from the left\n temporal lobe with left intraventricular extension. The extent of surrounding\n edema and mass effect is not changed, and there continues to be partial\n obliteration of the ambient cistern on the left.\n\n There has been interval development of a small amount of blood within the\n right occipital . Again demonstrated is a small amount of blood within\n the interhemispheric fissure, unchanged since the prior examination. Tiny\n amount of blood is also demonstrated within the sulci of both temporal lobes,\n which appears new in the interval. There is no hydrocephalus or significant\n midline shift noted. Chronic area of low density is again noted within the\n right posterior parietal lobe consistent with chronic infarction.\n\n There is partial opacification of the ethmoid air cells bilaterally as well as\n complete opacification of the sphenoid sinuses. Remaining visualized paranasal\n sinuses and mastoid air cells are clear. Surrounding osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n 1. Stable appearance of left temporal intraparenchymal hemorrhage with\n extension into the left ventricle. Small amount of new hemorrhage within the\n occipital of the right lateral ventricle. No hydrocephalus.\n\n 2.Tiny amount of hemorrhage noted within the sulci of both temporal lobes.\n\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 880258,
"text": " 12:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?further bleeding?shift\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75yo man with L temp bleed, MS not improving\n REASON FOR THIS EXAMINATION:\n ?further bleeding?shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup left intraparenchymal hemorrhage.\n\n COMPARISONS: CT head of .\n TECHNIQUE: Axial MDCT images of the brain without IV contrast.\n\n FINDINGS: Again seen is a large left temporal intraparenchymal hemorrhage,\n with extension into the left lateral ventricle. The size of the\n intraparenchymal hemorrhage and the surrounding edema is unchanged. There has\n been some resorption of the intraventricular component of the hemorrhage.\n Again demonstrated is a small amount of blood bilaterally within the temporal\n lobe sulci, which appears less prominent compared to . There is no\n evidence of new foci of hemorrhage. There is no shift of normally midline\n structures. The -white matter differentiation remains preserved.\n\n IMPRESSION: Stable appearance of left temporal intraparenchymal hemorrhage,\n with slight interval decrease in the intraventricular component. Trace\n bitemporal subarachnoid hemorrhage. No change in surrounding edema or mass\n effect. No hydrocephalus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880276,
"text": " 2:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Location of feeding tube in abdomen.\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ich s/p intubation s/p feeding tube placement (Dobhoff\n tube)\n REASON FOR THIS EXAMINATION:\n Location of feeding tube in abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with ICH, status post feeding tube placement.\n\n COMMENTS: A single AP view of the chest was reviewed and compared with serial\n chest radiographs from to the most recent of at 11:01 am.\n\n The right costophrenic angle has been excluded from this radiograph. A\n feeding tube is seen coiled within the pharynx. The heart size and mediastinal\n contours are within normal limits. Left retrocardiac opacification may reflect\n atelectasis and/or pneumonia. No pleural effusions or pneumothoraces are\n identified. Pulmonary vasculature congestion with associated bibasilar hazy\n opacities reflects likely mild pulmonary interstitial edema. The osseous\n structures appear unremarkable.\n\n IMPRESSION:\n 1. Feeding tube coiled within the pharynx. Recommend feeding tube removal\n and replacement.\n 2. Left retrocardiac consolidation, which could be atelectasis and/or\n pneumonia.\n 3. Mild pulmonary interstitial edema, consistent with congestive heart\n failure.\n\n These findings were discussed with the medical staff caring for the patient on\n the date of study.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-29 00:00:00.000",
"description": "Report",
"row_id": 1377568,
"text": "nursing care note\nReport rec'd from ER RN in MRI at 1815. VSS throughout MRI/MRA. Propofol gtt infusing. Intubated. Transported to SICU with RRT at . Pt stable upon arrival. Family at the bedside. Questions answered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-30 00:00:00.000",
"description": "Report",
"row_id": 1377569,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear suct for sm loose white sput. Pt in NARD on currebt vent settings; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-01 00:00:00.000",
"description": "Report",
"row_id": 1377577,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPEICIFCS.\n\nNEURO: ALERT AND OCC ORIENTED TO NAME ONLY, APHASIC, MAE SPONT/PURP, FOLLOWING COMMANDS INCONSISTENTLY. VERY AGITATED AT TIMES AND HALDOL 2.5MG IV GIVEN AND CLONIDINE 0.1MG PATCH STARTED.\n\nCV: HR 70-90'S, SBP PARAMETERS <160, HYDRALAZINE AND LOPRESSOR ATC GIVEN TO CONTROL SBP. IVC FILTER PLACED IN ANGIO, ANGIO STE C/D/I, NO HEMATOMA, + PULSES.\n\nRESP: LUNG SOUNDS CLEAR BUT DIMINISHED AT BASES, RR 17-33, O2 SAT 93-96% ON 6L VIA NC AND 40% VIA FACE TENT.\n\nGI: ABD SOFT NT/ND, + BOWEL SOUNDS, REMAINS NPO, UNABLE TO DO SWALLOW EVAL SEC TO PT INCONSISTENTLY FOLLOWING COMMANDS.\n\nGU: FOLEY DRAINING ADEQ CLEAR YELLOW URINE.\n\nID: TMAX 99.2\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. SBP PARAMETERS <160. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-30 00:00:00.000",
"description": "Report",
"row_id": 1377570,
"text": "Update\nO: Pt lg intraparenchymal bleed by mra. DNR code status obtained by HO after d/w hcp-wife .\nNeuro status: perl @ 2mm to slt slugg rt pupil response this a.m.This a.m. pt mae spont but not to command, while off prpfol.Ppf resumed for pt agitation/restlessness per ho.Withdraws to nailbed pressure all 4 extrems.cough intact, gag impaired.\n\nCV status: sb to sr w occ pvc noted.Initial htnive on labetolol,hydralazine -> snp started to manage sbp but spo2 dipping into low 90's -> changed to iv ntg. Cuff and lt rad art line pressures correlating initially after art line placed -> develop discrepancy in sbp, noted at 0400 w recalibration of art line-> art sbp 170 just prior to recal ->70 after recal-> iv ntg dc'd immed.& HO notified. 250cc ns bolus^ & neo gtt started to goal sys bp ~110-140.\n\nResp status: remained on cmv overnight w adeq abg.Lavage suct for thick pale yellow secretions. Bbs clear but diminsh at bases bilat.\n\nGi status: copious amts coffee grnd drng via ogt. Pantoprzole started.Abd soft slt distended w hypoactive bwl snds noted.Glucoses wnl.\n\nGu status: oliguric since 0100. HO aware-> fld boluses w ns, ffp. No signif response to either -> HO made aware.Plan repeat ffp 2units and attempt to keep sbp closer to 140 for renal perfus.\n\nHeme/ID: Tmax 99.8 hct/wbc stable.\n\nIv access/Lines: 3periph iv's . Lt radial art line\n Pysch/Social Family: family requests mtg w team re: plan, more in depth explan of mri findings.\nA/P: q1h neuro checks. Notify HO re: low uop if persists. Transfuse 2 more units ffp and recheck pt/ptt inr after bl products.Facilitate sched mtg w icu team and family for today.taper neo to off as tol goal sbp closer to 140 range in view of marginal uop.? Pantoprozole vs qd as pt still w copious dk brwn drng..Pulm toilet.? compression sleeves hx dvt recently on coumadin prior to adm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-30 00:00:00.000",
"description": "Report",
"row_id": 1377571,
"text": "Respiratory Care\nPt remains on current ventilator settings as noted in Careview, no changes made this shift. Transport to head CT and back without incident. Bilateral breath sounds equal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-30 00:00:00.000",
"description": "Report",
"row_id": 1377572,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT SEDATED ON PROP GTT. WHEN OFF GTT, PT OPENS EYES TO VOICE, MAE SPONT ON BED. STUCK OUT TONGUE ON COMMAND. DID NOT FOLLOW OTHER COMMANDS. PERRL. PUPILS BRISK, RIGHT PUPIL SLUGGISH AT TIMES. HAD CT TODAY, REPORTEDLY NO INCREASE IN BLEED. REMAINS ON DILANTIN, NO SZ ACTIVITY NOTED.\n\nCV-AFEB. HR 50-60'S, SINUS. NO ECTOPY. SBP MAINTAINED <140. PT OFF PRESSORS. SKIN W+D. +PP. INR 1.5.\n\nRESP-NO VENT CHANGES MADE TODAY. LS CLEAR, DECREASED AT BILAT BASES. SXN PRN FOR THICK TAN SPUTUM. O2 SAT 100%.\n\nGI-ABD SOFT, NT/ND. +HYPO BS. OGT IN PLACE WITH COFFEE GROUND TO DARK BLOODY DRG. TEAM AWARE. PROTONIX CHANGED TO . WILL MONITOR.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nSOCIAL-FAMILY MEETING HAD WITH PT'S WIFE AND CHILDREN, AND NEUROLOGY RESIDENT. PT'S CONDITION DISCUSSED AND FAMILY'S QUESTIONS ANSWERED. PT TO REMAIN DNR AT THIS TIME. WILL CON'T TO UPDATE FAMILY PRN.\n\nA-S/P HEAD BLEED.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. NEURO CHECKS. ? IVC FILTER TOMORROW. FOLLOW COAGS. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-02 00:00:00.000",
"description": "Report",
"row_id": 1377578,
"text": "NEURO: OPENS EYES SPONTANEOUSLY AND TO VOICE, MAE, LIFTS AND HOLDS ALL EXTREMITIES, RUE WEAKER THAN LUE. APAHASIC. INTERMITTENTLY CALM ALTERNATING WITH RESTLESSNESS, PULLS AT AND FOLEY WHEN AGITATED. HANDS RESTRAINED. NO SEIZURE ACTVITY NOTED, DILANTIN LEVEL SUBTHERAPEUTIC, 300MG BOLUS DILANTIN AT 0100. SEE CAREVUE FOR Q2H ASSESSMENTS.\n\nPULM: ON N/C AT 6L AND FACE TENT AT 12L WITH SATS >95%. LUNGS FAIRLY CLEAR.RR 20-25.\n\nCV: NSR WITH PAC'S. SEE CAREVUE FOR Q1H VS AND Q4H ASSESSMENTS. LABETALOL, LOPRESSOR AND HYDRALAZINE IV TO KEEP SBP <150. PALPABLE PEDAL PULSES. #20 INSYTE INFILTRATED L ARM, DC'D. # 18 INSYTE INSERTED R ARM.\n\nENDO: Q6H FSBS WITH SSRI COVERAGE. 2 UNITS REGULAR INSULIN SC AT 2200.\n\nGI: ABDOMEN SOFT, + BS. NO FLATUS OR BM.\n\nGU: FOLEY TO CD DRAINING QS AMTS YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: CONTINUE NEURO ASSESSMENTS Q2H. LABETALOL, HYDRALAZINE, METOPROLOL IV TO KEEP SBP < 150. DILANTIN IV TO PREVENT SEIZURES. MONITOR LABS AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-31 00:00:00.000",
"description": "Report",
"row_id": 1377573,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct sm=>mod th tan sput. Pt in NARD on current vent settings; no vent changes made overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-31 00:00:00.000",
"description": "Report",
"row_id": 1377574,
"text": "Update\nO: See carevue flowsheet for specifics.\nNeuro: Propfol off q4h for in depth neuro exam. Following simple commands and mae w 4am exam. Lift and hold head off pillow. Perl 2mm brisk react. Mae spont and to command.D/T htn while awake pt resedated w propfol.\n\nCv status: sbrady rare pvc. sbp stable on prpfol. When ppf off for neuro exam sbp >140-> ppf resumed. Distal pulses+.\n\nResp status: lavage suct for thick yellw secretions. cmv mode Fio2 40% tv700 rr 14 peep 5. Pt overbreathing vent on occas. Copious oral secretions, freq mouth care given.\n\nGi status: ogt to lws w bilious drng in decr amts now on protonix.Abd soft distended+ bowel snds.\n\nGu status: foley to gd w qs cl/y/u/\n\nHeme/ID: hct stable at 29. Tmax 99. wbc wnl.\n\nA/P: ? wean sedation if tolerates and wean vent. Goal sbp 140, utilize prn hydralazine if nec.Pulm toilet freq lavage and suct for thick secretions. ? sw/swallow nystatin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-07-31 00:00:00.000",
"description": "Report",
"row_id": 1377575,
"text": "nsg note\nsee flowsheet for specifics.\n\nNEURO-PROP GTT OFF SINCE THIS AM. PT LETHARGIC. OPENS EYES SPONT. PERRL. MAE SPONT PURPOSEFULLY. LEFT MORE THAN RIGHT. FOLLOWS SIMPLE COMMANDS MOST OF THE TIME. ORIENTED TO PERSON ONLY. SPEECH SLOW AND SOMEWHAT GARBLED. ONLY SAYS FEW WORDS. REMAINS ON DILANTIN, BOLUS DOSE GIVEN. NO SZ CTIVITY NOTED.\n\nCV- AFEB. HR 50'S THIS AM, NOW MOSTLY 60'S, SINUS. FEW DOSES HYDRALAZINE NEEDED TO KEEP SBP <140. SBP UP TO 160'S WHEN STIMULATED. SKIN W+D. +PP. PBOOTS ON.\n\nRESP-EXTUBATED THIS AM OVER COOK CATH. TOL WELL. HAS BEEN ON FACE TENT SINCE. POST EXTUBATION ABG ACCPETABLE. 02 SAT 94-98%. LS COARSE. PT WITH STRONG COUGH.\n\nGI-OGT D/'C. NPO. ABD SOFT. +BS. REMAINS ON PROTONIX.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-PT FIDGETING ALL OVER BED.\n\nENDO-SSRI.\n\nA-STABLE S/P EXTUBATION. ALT IN NEURO STATUS.\n\nP-CON'T WITH CURRENT PLAN. NEURO CHECKS. KEEP SBP <140. FOLLOW LABS. LIKELY IVC FILTER TOMORROW. SUPPORT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-01 00:00:00.000",
"description": "Report",
"row_id": 1377576,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient slowly became more awake throughout the night and ~2am became very aggitated-order received from NMed for haldol .25mg mrx1 (both doses were given). QTC was checked prior to dose .42. Haldol had some effect but pt still very restless and pulls at lines/sheets etc.\n Neurologically pt inconsistently follows commands has expressive aphasia with garbled speech. Moving all extremeties with excellent strength and pupils are reactive.\n NMED wants to keep sbp <150 which has required multiple doses of prn labetalol and hydralazine iv. IV access is really poor and had to be re-established last shift by IV RN d/t poor access. 2 units of FFP were given for INR of 1.5-am INR pending at this time.\n Has been receiving maintenance IVF but unsure at this time if patient is going to be okay for PO's and pt does not have an NGT or dobhoff in place. Will probably need swallow eval.\nPLAN:\n Keep INR<1.4\n Keep sbp<150\n ?swallow eval\n Neuro checks\n Notify H.O. with any changes\n"
},
{
"category": "ECG",
"chartdate": "2169-08-11 00:00:00.000",
"description": "Report",
"row_id": 212745,
"text": "Sinus bradycardia. Left atrial abnormality. Right bundle-branch block. Probable\nprior inferior wall myocardial infarction. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-08-04 00:00:00.000",
"description": "Report",
"row_id": 212746,
"text": "Sinus bradycardia. Right bundle-branch block. Possible old inferior myocardial\ninfarction. Compared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-07-29 00:00:00.000",
"description": "Report",
"row_id": 212747,
"text": "Sinus rhythm. Right bundle-branch block with ST-T wave changes. Ventricular\npremature beats. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-07-29 00:00:00.000",
"description": "Report",
"row_id": 212748,
"text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Non-specific\nST-T wave changes. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-11 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 881453,
"text": " 2:54 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with hx of pna now s/p fall.\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with history of pneumonia status post fall.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: Moderate cardiomegaly is unchanged when compared to prior study.\n The mediastinal and hilar contours are stable. Interval improvement in\n bilateral patchy opacities. There is residual diffuse increase in\n interstitial markings, which most likely represent CHF. There is interval\n improvement of bilateral multifocal opacities. No pleural effusions can be\n identified in this supine radiograph. There is minimal right convex scoliosis\n of the thoracolumbar spine and degenerative changes of the spine.\n\n IMPRESSION:\n\n Diffuse increase in lung markings bilaterally most likely representing CHF.\n Interval improvement in multifocal opacities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-11 00:00:00.000",
"description": "T-SPINE",
"row_id": 881454,
"text": " 2:54 AM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p fall w/T/L spine ttp\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Status post fall. Evaluate for fracture or subluxation.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: THORACIC SPINE, TWO VIEWS/LUMBAR SPINE, TWO VIEWS.\n\n FINDINGS: There is mild right convex scoliosis of the thoracic spine. There\n is ossification of the anterior longitudinal ligament. However, the vertebral\n bodies are of normal height, and the alignment appears to be anatomic. There\n are degenerative changes of the lumbar spine with osteophyte formation. There\n is disk space narrowing at L5/S1. There is an IVC filter noted. There are\n densities overlying the kidneys bilaterally that could represent renal stones.\n The patient is status post total hip replacement on the right side. There are\n severe degenerative changes on the left hip joint.\n IMPRESSION:\n 1. Degenerative changes of the spine. No evidence of fracture or subluxation.\n 2. Bilateral renal stones.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 881451,
"text": " 2:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fall\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh FRI 2:45 AM\n Interval decrease in the size of the left temporal intraparenchymal\n hemorrhage. No new hemorrhage seen. The interventricular component is also\n decreased. There is similar amount of edema in the right temporal lobe.\n Similar appeareance of the mass effect caused by the uncus into the\n suprasellar cystern. Old right posterior MCA infarct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male status post fall, evaluate for intracranial\n hemorrhage.\n\n COMPARISON: Comparison is made to seven .\n\n FINDINGS: There is interval decrease in the size of intraparenchymal\n hemorrhage in the left temporal lobe. There is also decrease in size of the\n intraventricular component in the temporal of the left lateral ventricle.\n There is similar amount of edema around the hemorrhage when compared to the\n prior study. There is again noted mass effect within the left lateral\n ventricle, which appears expanded. A similar amount of mass effect displaces\n the left uncus toward the suprasellar cistern. No new intraparenchymal\n hemorrhage is seen. There is again noted an old infarct in the posterior\n aspect of the right MCA distribution. There is no shift of normally midline\n structures.\n\n IMPRESSION: No new hemorrhage identified. Interval slight decrease in the\n size of the left temporal/intraventricular hemorrhage. There is a similar\n amount of edema around the hemorrhage, but the amount of mass effect appears\n to be slightly decreased.\n\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-11 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 881452,
"text": " 2:20 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for cspine fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fall. recent ICH\n REASON FOR THIS EXAMINATION:\n eval for cspine fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh FRI 2:55 AM\n no fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: CT of the cervical spine without IV contrast. Sagittal\n reformations were performed.\n\n FINDINGS: There is no paravertebral soft tissue swelling. There is\n degenerative changes of the cervical spine which are more prominent at the\n level of C5/C6 where there is severe disc space narrowing and osteophytic\n changes. The alignment of the vertebral bodies is otherwise anatomic. No\n fractures are identified. The visualized outline of the thecal sac is\n preserved. The visualized portions of the parotid and salivary glands are\n unremarkable. The visualized portions of the mastoid air cells are normally\n aerated.\n\n IMPRESSION: Degenerative changes of the cervical spine, but no evidence of\n fracture.\n\n\n"
}
] |
7,908 | 169,006 | The patient was admitted to the Intensive Care Unit overnight for observation. The patient did well on hospital day No. 2. The patient's heparin drip at 500 units an hour was shut off and the patient was placed on Plavix and aspirin alone and the patient's liver function tests were perfectly normal and the patient underwent a follow up ultrasound which was normal and the patient was keen and ready for discharge on . Prior to discharge the patient was afebrile and vital signs were stable. Neurologically the patient was alert and oriented x 3. Chest was clear. Heart was regular rate and rhythm. Abdomen was soft, nontender and non-distended. Extremities - no edema. The patient is to be discharged home and the patient is instructed to have his full set of lab drawn on Thursday, , and the patient is to follow up in the Clinic next week. Discharge medications including aspirin 325 mg po qd, Plavix 75 mg po qd, CellCept mg po bid, Bactrim single strength one tab po qd and atenolol 50 mg po qd, Epogen 10, 000 units subcutaneous q Saturday, Prednisone 7.5 mg po q d and Prevacid 30 mg po qd and cyclosporin or Neoral 125 mg po bid. The patient is to have his full set of lab including cyclosporin level drawn on Thursday. | Normal flow, direction and waveforms are identified within the main, anterior right, posterior right, and left portal veins. Normal flow and waveforms are identified within the hepatic arteries. Normal flow and waveforms are identified within the main, right and left hepatic arteries. Evaluate status of hepatic artery. This is concerning for hepatic arterial compromise. CONDITION UPDATEASSESSMENT: PT ARRIVED TO SICU FROM ANGIO S/P HEPATIC ARTERY STENT PLACEMENT. Normal liver doppler ultrasound examination. Doppler Liver Ultrasound: Normal flow and waveforms are identified within the main, left, and right hepatic veins. Flow in the hepatic veins and portal veins is normal, and demonstrate normal right waveforms and are in the appropriate direction. The main and left hepatic arteries demonstrate a parvus tardus configuration with resistive indices of less than 0.5. IMPRESSION: In comparison with the prior study, there has been a change in the Doppler waveforms of the main and left hepatic artery with a parvus-tardus appearance and a decrease in the resistive indices. TRANSFER TO FLOOR IF REMAINS STABLE. Note is made again of a simple cyst within the liver. GROIN SITE INTACT, + PEDAL PULSES. VITALS STABLE (SEE FLOWSHEET) AND BREATHING UNLABORED.PLAN: RECHECK COAGS THIS EVENING, CONTINUE WITH HEPARIN GTT. The right hepatic artery could not be visualized. The right hepatic artery could not be visualized. IMPRESSION 1. f/u doppler to assess flow and vessel patency FINAL REPORT INDICATION: Status post liver transplant complicated by hepatic artery stenosis. FINDINGS: COMPARISON: . The liver is homogeneous with the exception of a small simple cyst in the right lobe measuring 2.2 cm. Comparison: . The IVC is patent. The IVC is patent. Further investigation with CTA of the liver or angiography may be indicated. The RIs of the hepatic arteries measure from 0.65 to 0.67. 19/07 PT A/O RELAXED NO PAIN OR DISCOMFORT MAE AMBULATES WELL NO SOB COLOR PINK SKIN WARM AND DRY RESP CLEAR R/A SAO2 100% HEART S1S2 NO ISSUES NSR PULSES POS THRU OUT ANGIO SEAL RIGHT GROIN IN PLACE NO BLEEDING NOTED GI PO WELL NO N/V NOTED SOFT ABD NOTE LIVER 1 INCH BELOW SUPPORTIVE CARE MONITOR BLOOD SURGAR V/S There is no intrahepatic ductal dilatation. 2. ? 12:30 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: doppler eval of artery, portal vein, and hepatic veins and u Admitting Diagnosis: HEPATIC ARTERY STENOSIS MEDICAL CONDITION: 47 year old man with s/p liver transplant: last duplex demonstrated decrease art flow REASON FOR THIS EXAMINATION: doppler eval of artery, portal vein, and hepatic veins and us of ducts WET READ: SGA SUN 3:52 PM normal doppler exam of liver, patent hepatic arteries with RI of 0.65-0.67 FINAL REPORT Indication: Status-post liver transplant, new hepatic arterial stent. This report was telephoned to Dr. 16:15 on . There is no ascites. TO 19/07 PT RELAXED SLEPT WELL NO PAIN OR DISCOMFORT NOTED IN FAIR SPIRITS WANTS TO GO HOME RESP CLEAR R/A 100% SAO2 NO SOB HEART S1S2 SB RATES 50 TO 58 TOL WELL NEG NVD LIVER 2 BELOW RIB AREA SOFT ABD SOFT POS BS U/O QS NON TENDOR GOOD GAS PATTERN NOTE RIGHT GROIN SOFT NO BLEEDING AT FEM SITE PULSES POS 3 THRU OUT HEP DRIP IN PROGRESS SUPPORTIVE CARE There is no evidence of ascites. 9:38 AM DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: pt s/p liver transplant complicated by hepatic artery stenos MEDICAL CONDITION: 47 year old man with s/p liver transplant complicated by hepatic artery stenosis REASON FOR THIS EXAMINATION: pt s/p liver transplant complicated by hepatic artery stenosis. HEPARIN GTT STARTED @ 500 UNITS/HR, TO CHECK COAGS @ 11PM. | 5 | [
{
"category": "Radiology",
"chartdate": "2168-08-12 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 833544,
"text": " 9:38 AM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: pt s/p liver transplant complicated by hepatic artery stenos\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with s/p liver transplant complicated by hepatic artery\n stenosis\n REASON FOR THIS EXAMINATION:\n pt s/p liver transplant complicated by hepatic artery stenosis. f/u doppler to\n assess flow and vessel patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant complicated by hepatic artery\n stenosis.\n\n Evaluate status of hepatic artery.\n\n FINDINGS:\n\n COMPARISON: .\n\n The liver is homogeneous with the exception of a small simple cyst in the\n right lobe measuring 2.2 cm. There is no intrahepatic ductal dilatation.\n\n Flow in the hepatic veins and portal veins is normal, and demonstrate normal\n right waveforms and are in the appropriate direction. The main and left\n hepatic arteries demonstrate a parvus tardus configuration with resistive\n indices of less than 0.5. The right hepatic artery could not be visualized.\n The IVC is patent.\n\n There is no ascites.\n\n IMPRESSION:\n\n In comparison with the prior study, there has been a change in the Doppler\n waveforms of the main and left hepatic artery with a parvus-tardus appearance\n and a decrease in the resistive indices. The right hepatic artery could not\n be visualized.\n\n This is concerning for hepatic arterial compromise. Further investigation\n with CTA of the liver or angiography may be indicated. This report was\n telephoned to Dr. 16:15 on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-08-14 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 833756,
"text": " 12:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: doppler eval of artery, portal vein, and hepatic veins and u\n Admitting Diagnosis: HEPATIC ARTERY STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with s/p liver transplant: last duplex demonstrated decrease\n art flow\n REASON FOR THIS EXAMINATION:\n doppler eval of artery, portal vein, and hepatic veins and us of ducts\n ______________________________________________________________________________\n WET READ: SGA SUN 3:52 PM\n normal doppler exam of liver, patent hepatic arteries with RI of 0.65-0.67\n ______________________________________________________________________________\n FINAL REPORT\n Indication: Status-post liver transplant, new hepatic arterial stent.\n\n Comparison: .\n\n Doppler Liver Ultrasound: Normal flow and waveforms are identified within the\n main, left, and right hepatic veins. Normal flow, direction and waveforms are\n identified within the main, anterior right, posterior right, and left portal\n veins. Normal flow and waveforms are identified within the main, right and\n left hepatic arteries. The RIs of the hepatic arteries measure from 0.65 to\n 0.67. The IVC is patent. There is no evidence of ascites. Note is made\n again of a simple cyst within the liver.\n\n IMPRESSION\n 1. Normal liver doppler ultrasound examination.\n 2. Normal flow and waveforms are identified within the hepatic arteries.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-08-14 00:00:00.000",
"description": "Report",
"row_id": 1367784,
"text": " TO 19/07\n\n PT RELAXED SLEPT WELL NO PAIN OR DISCOMFORT NOTED IN FAIR SPIRITS WANTS TO GO HOME\n\n RESP CLEAR R/A 100% SAO2 NO SOB HEART S1S2 SB RATES 50 TO 58 TOL WELL NEG NVD LIVER 2 BELOW RIB AREA SOFT\n\n ABD SOFT POS BS U/O QS NON TENDOR GOOD GAS PATTERN NOTE RIGHT GROIN SOFT NO BLEEDING AT FEM SITE PULSES POS 3 THRU OUT HEP DRIP IN PROGRESS\n SUPPORTIVE CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-08-14 00:00:00.000",
"description": "Report",
"row_id": 1367785,
"text": " 19/07\n\n PT A/O RELAXED NO PAIN OR DISCOMFORT MAE AMBULATES WELL NO SOB COLOR PINK SKIN WARM AND DRY\n\n RESP CLEAR R/A SAO2 100%\n\n HEART S1S2 NO ISSUES NSR PULSES POS THRU OUT ANGIO SEAL RIGHT GROIN IN PLACE NO BLEEDING NOTED\n\n GI PO WELL NO N/V NOTED SOFT ABD NOTE LIVER 1 INCH BELOW\n\n SUPPORTIVE CARE MONITOR BLOOD SURGAR V/S\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-08-13 00:00:00.000",
"description": "Report",
"row_id": 1367783,
"text": "CONDITION UPDATE\nASSESSMENT:\n PT ARRIVED TO SICU FROM ANGIO S/P HEPATIC ARTERY STENT PLACEMENT. HEPARIN GTT STARTED @ 500 UNITS/HR, TO CHECK COAGS @ 11PM. GROIN SITE INTACT, + PEDAL PULSES. PT COMPLAINING OF BACK PAIN (POSITIONAL) BUT CURRENTLY DOZING ON/OFF. VITALS STABLE (SEE FLOWSHEET) AND BREATHING UNLABORED.\nPLAN:\n RECHECK COAGS THIS EVENING, CONTINUE WITH HEPARIN GTT. ? TRANSFER TO FLOOR IF REMAINS STABLE.\n"
}
] |
13,990 | 175,912 | 75 y/o female with PMH breast ca s/p R sided mastectomy, interstitial lung disease, h/o pna, presented w/ 1 week h/o cough, was intubated at , and transferred to at family's request, septic with hypothermia, hypotensive on pressors, and with shock liver and renal failure. . # Respiratory Failure: She was intubated at for hypoxic respiratory failure. Her CT scan suggests interstitial lung disease. ECHO showed normal ejection fractio. She was intubated from admission on , and had a tracheostomy placed on . Susupected cause for decompensation was underlying pneumonia . Sputum cultures were negative. Viral Bronchoalveolar lavage showed no increase number of macrophages or eosinophils. She completed a 14 day course of Vancomycin and Zosyn for empiric pneumonia. Prednisone 1 mg/kg was given for treatment of possible cryptogenic organizing pneumonia. Patient became progressively more hypercapnic and had a respiratory acidosis soon after trying to wean from Assist /Control Mechanical Ventilation and placed on PS ventilation. For this reason, a tracheostomy tube was placed on (day # 14 of intubation) with no complications. She tolerated BIPAP with optimal titration parameters between 15/5 cmH2O. She should continue Prednisone 1 mg/kg for 4 weeks and her outpatient Pulmonologist should taper Prednisone to 0.5 mg/kg after this period to continue for at least 6-8 weeks total. She will need Mechanical Ventilation at rehab facility. Current vent settings are BiPAP with pressure support of 10 and PEEP of 5 with .40 FiO2. . # Sepsis: She presented with hypotension, hypothermia (T 95.0 on admission), leukocytosis with bandemia, end-organ failure (shock liver c AST/ALT > , ARF). Initially required pressors (on levophed which were discontinued within 24 hours. Likely etiologies included infectious- PNA considering UA was not abnormal and a CT scan of the abdomen done at an OSH did not show abscess , diverticulitis, perforation, mesenteric ischemia. She was given broad spectrum antibiotics vancomycin and zosyn to cover infectious etiologies. Urine, sputum, and blood cultures did not grow out any organisms. She completed a 14 day course of antibiotics on . . # Leukocytosis/C Diff Infection: Patient had an elevated WBC count of 12 K c 10 % bands on admission . She received full course of broad spectrum atb. After D # 4 of admission WBC peaked at despite atb treatment. Two C diff toxin A were negative but a second C diff toxin B came back positive. She was started on Flagyl and should complete a 14 day course on . . # ARF: She has no history of underlying renal disease. She presented with elevated Cr of 3 which peaked to 7 during admission. UA showed muddy brown casts. Urine lytes c/w ATN. US showed normal sized kidneys SHe had oliguria which resolved with time and her urine output is back to baseline. She had also received Gentamycin and contrast at the outside hosptial, which may have contributed. There was no need for dialysis. Creatinine was 3.6 on discharge , with normal Urine output. She should continue on phosphate binders until renal function returns to baseline. . # Altered mental status: Presented intubated, non-responsive. Likely Toxic/metabolic (renal failure with uremia, hepatic encephalopathy, infectious) vs Medication effect given renal failure and transaminitis as she received sedating medications at OSH. She regained responsiveness and was alert and oriented throughout most of her admission. . # Elevated Amylase/Lipase: Amylase/lipase trending up after tube feeds initiated. Enxymes came back to normal after improvement of renal function. . # Transaminitis: Presented with highly elevated LFT's, Bili, LDH. Likely due to shock liver. Acetamenophen level not elevated. Hepatitis serologies, EBV, CMV negative for acute infection. No evidence of portal vein or hepatic vein thrombosis on U/S. Anti-SM Ab positive. Enzymes trended down to normal on discharge. . # Metabolic Acidosis: Patient had elevated anion gap on admission . AFter fluid resuscitation her metabolic acidosis turned was worsened by respiratory acidosis. Both improved after treatment of sepsis and lung infection. . # Diverticular Bleed: Patient had massive hematochezia on HD # 11. Hc remained stable near 28-32 %.EGD wnl. Lower GI scope with diverticulosis and evidence of earlier bleeding. She received 2 U PRBC. HCT remained stable during rest of hospitalization. She should avoid NSAIDs and aspirin. High fiber diet recommended. . # NSTEMI: Pt w/out known h/o cardiac disease. Had demand ischemia in setting of sepsis, with elevated trop due to renal failure. Echo showed EF 50% with large LA and diated RV with Mod TR and Significant PR, PAP 33. ASA was started due to coagulopathy on admission and later GI bleed. start ASA in th future if no further episodes of bleeding. . # Bradycardia: Patient's HR ranged from 40 -60 after sepsis treated. Patient was never symptomatic. EKG without conduction abnormalities. . # Anemia: Normocytic. Iron studies show elevated iron and ferritin levels, low TIBC. . # Nutrition: She has a PEG placed on . She should get Nepro full strength @ 30 cc /h. . #Communication: Daughter - H , C . The patient has a hearing aid and wears glasses to comunicate. | Abnormal septal motion/position consistent with RV pressure/volumeoverload.AORTA: Normal aortic root diameter. Mild(1+) aortic regurgitation is seen. Moderate [2+] TR.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. Mild (1+) mitral regurgitation is seen. There isabnormal septal motion/position consistent with right ventricularpressure/volume overload. Normal ascending aorta diameter. There is mild global left ventricular hypokinesis. PATIENT/TEST INFORMATION:Indication: Left ventricular function.BP (mm Hg): 117/67HR (bpm): 72Status: InpatientDate/Time: at 09:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. areas of low density are noted in the right temporal lobe- these may represent enlarged sulci v. chronic cortical infarcts. FINDINGS: Consistent with the prior exam, the previously noted right internal jugular approach line has been removed. FINDINGS: Non-dilated gas-filled colon is identified. Borderline normal RV systolic function. Mild (1+) MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The aortic arch is mildly dilated. There ismild symmetric left ventricular hypertrophy. There is a small, probable retention cyst in the right maxillary sinus, with opacification of a few ethmoid air cells, and mild mucosal thickening in the frontal sinus. Cortisol pnding, first random high.Skin: w/d/i.ID:> afeb. Weaned off Levophed gtt this am. CXR w/ RML and LLL PNA.CV:> HR 68-120, occ. RSBI done on 0 peep/5 ips 77.4.HR occ PVC'S.Will cont to monmitor resp status. to follow, likely hypovolemia.GI/GU:> Abd soft, slightly distended, +BS. FINISHED UNIT OF PRBC'S, POST HCT 29.5.GI: PT NPO EXCEPT OF MEDS. Hypotension, Dopa. NPN 7a-7p(Continued)mmonia level sent.HYPOTENSION- Likely sepsis/shock liver/ARF. broad spectrum abx, and follow lactate. Bld cx pnding. Combivent MDI given with some effect noted. COMPARISON: Serial chest x-rays from till . Pt has been NPO for colonoscopy. LUNG SOUNDS COARSE THROUGHOUT.CV: PT IN NSR WITH OCC PVC'S. Had US of Renal/ Liver w/ prelim. Suctioned for copious amts of tan secrections. (received Vanco, Gent., and Levo. LS RHONCHEROUS THROUGHOUT. hepatic encephalopathy. Tip of the right subclavian line projects over the low SVC. Last abg 730/40/158/20/-. REMAINS NPO FOR COLONOSCOPY.ID: TMAX 96.8 WITH WBC 19 DOWN FROM 28.6. FS Q6HRS WITH SSRI. The airways are patent to the level of segmental bronchi. CXR DONE THIS MORNING.GI/GU: ABD SOFT AND DISTENDED WITH +BS. bigeminy, and pvc's. LS Rhonchorus. PPP WITH +RIGHT FEMORAL PULSE. SPEC SENT FOR C/S. tf's off d/t lgib. Combivent MDI given Q4hr. MAE, upper > lower.Resp: LS rhonchorus. LYTES PER CAREVUE. cx pndinga. Pt has required freq. Albuterol MDI given Q vent check. and nasal aspirate pnding. ciff.. all cx ngtd. to follow BUN/CRE.Resp. ID: afebrile on zosyn/flagyl for pna, ? Will follow for Combivent Q4 and Albuterol MDI Q4prn. MDIs given per . FS Q6HRS WITH SSRI. Resp. Resp. toilet.Sepsis- VS stable, cx data pnding, cont. ABG drawn and now 7.24/67/100. infiltrates.CV: NSR 75-97, rare pvc's noted. regurgitation, and dilated RV. signed consent for endoscopy. CXR w/ bilat. CV: as noted above. Lungs rhonci and crackles cxr takencvs HR 70-80 nsr freq pvc lytes wnl K+ 4.3, phosp 5.8 bp 109/-125/60-70. Begin TF when OGT is confirmed. RSBI 95.GI/GU: ABD SOFT AND DISTENDED WITH +BS. Receiving D5W maintenance fluids. ECHO done today, signifcant for significant pul. gI: as noted above. Some peripheral edema.GI/GU: PEG placed; may use immediately for meds/TF. on abx. switched to and received protonix. STOOL HEME+. please f/u . MDIs given as ordered. See MDIs given as ordered. Decreased PS to this am and ahe became acidotic 7.24 with a CO2 of 66-- placed back on PS 15/5.neuro: Pt is alert, follows commands intermittently. PT PLACED BACK TO PS/PEEP THIS AM. Since it has been comnnected to LIWS. c-diff (cx negative), vanco and Zosyn for pna. Currently tol PSV 5/12 appears comf. Access: R subclavian tlc. CONTINUES ON ZOSYN AND FLAGYL. CV: hR 50's-60's SB/NSR, cvp 8-9 and bp 130's-150's systolic. Remains on prednisone. LYTES PER CAREVUE. LYTES PER CAREVUE. GI: ab softly distended, bs +. RESP: remains vented PSV 12/5/.40. Zosyn, azithromycin, and Vanco dosed by level. FS Q6HRS WITH SSRI.ID: TMAX 97.3 WITH WBC 18. CONTINUUES ON ZOSYN AND FLAGYL. BP with MAP 70-75.access: L radail aline, RSC tlc, 1 piv.gi/gu: Abdomen is soft, distended with + BS. r/t sedation kicking in. RSBI 57.GI/GU: ABD SOFT AND DISTENDED WITH +BS. ABD SOFT/DISTENDED WITH POS BOWEL SOUNDS.GU: PT 80MG LASIX IVP OVERNIGHT. Pulses palpable.ID: Afebrile; continued coverage with Flagyl and Zosyn.GI/GU: Feeding tube out; will replace if continues on vent; will reassess today. BP with MAP >65.access: RIJ tlc, R radail aline, 1 piv.gi/gu: Abdomen is soft distended with + BS. LS crackles throughout.. CV: HR 70's NSR with occasional PAC's. Last ABG reveals partially compensated respiratory acidosis. REsP: vented via ETT. TUBE FEEDS @30CC/HR AND WITH SCANT RESIDUALS. found with ETT partially out, successfully resecured at the appropriate placement and pt. Frequent sx for mod amt wht/thk sputum.C/V: CP as stated above. A/P: pt with continued vent dependency. agitation and copious secretions, modality returned to A/C for rest. her TF have been restarted after the decision was mad enot to extubate her.GU: pt renal function is about the sme with BUN/CR of 108/7. C/O dyspnea when RSBI trial finished, PSV titrated to pt. LS remain course.. returned to A/C and eventually able to settle out. TRACH SITE OOZING SM AMT'S OF DK BLD. MSO4 1mg given with effect. she cont on flagyl. No appreciable edema; pulses palpable.ID: Afebrile; covered with Flagyl, Zosyn for pna.GI/GU: OGT replaced and TF restarted; tolerating Nepro @ 20cc/hr with goal of 30cc/hr; no residual. Pt receiving MDI's per order. Flagyl added to cover possible c-diff. wbc 23.4. on flagyl po (suspect cdiff)and zosyn ( pna) respiratory carept started shift A/C setting as charted on flowsheet. repleated with kcl 40meq pogt. PT HAS BEEN SX'D FOR MOD AMT'S OF BLD TINGED SPUTUM. continue to sx pt. will remain intubated o/n and f/u with family r/e final decisions. tol PSV 5/10 well and w/o complaints. | 84 | [
{
"category": "Echo",
"chartdate": "2137-10-10 00:00:00.000",
"description": "Report",
"row_id": 82233,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 117/67\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 09:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR]. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. There is mild global left ventricular hypokinesis. The right\nventricular cavity is dilated. Right ventricular systolic function is\nborderline normal. [Intrinsic right ventricular systolic function is likely\nmore depressed given the severity of tricuspid regurgitation.] There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 206748,
"text": "Sinus rhythm. Atrial ectopy. There is a late transition which is probably\nnormal. Compared to the previous tracing atrial ectopy is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-16 00:00:00.000",
"description": "Report",
"row_id": 206749,
"text": "Sinus bradycardia\nPossible septal infarct - age undetermined\nSince previous tracing of , no atrial premature complexes seen\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-09 00:00:00.000",
"description": "Report",
"row_id": 206750,
"text": "Sinus rhythm\nAtrial premature complex\nNonspecific precordial/anterior T wave abnormalities - cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of the same date, T wave changes more prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-09 00:00:00.000",
"description": "Report",
"row_id": 206751,
"text": "Sinus rhythm\nNonspecific precordial/anterior T wave abnormalities - clinical correlation is\nsuggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-14 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 932680,
"text": " 11:15 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: needs yeyunal tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with COPD and recurrent aspiration PNA\n REASON FOR THIS EXAMINATION:\n needs yeyunal tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with COPD and recurrent aspiration pneumonia.\n\n FINDINGS: After anesthetizing the right nostril with lidocaine jelly, a\n weighted feeding tube was advanced into the stomach. Under fluoroscopic\n guidance, the tube was then advanced past the pylorus, through the duodenum,\n and into the proximal jejunum. Contrast was injected confirming placement of\n the tube past the ligament of Treitz in the proximal jejunum. The tube was\n then secured with tape. The patient tolerated the procedure well, and there\n are no immediate post-procedure complications.\n\n IMPRESSION: Successful placement of nasojejunal feeding tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932457,
"text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval lung for improvement in pulm edema as wel\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, hypoxic.\n REASON FOR THIS EXAMINATION:\n please eval lung for improvement in pulm edema as well as line position\n and ET tube position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Evaluate lung fields for improving pulmonary edema.\n\n FINDINGS: The prior study is from . The ETT is better\n positioned at this time with its tip 3 cm to the carina. The right central\n line is in place at the SVC junction. There are multiple overlying\n monitoring leads that decrease the accuracy of this study, but similar\n reticular bilateral pattern at the lungs is seen, unchanged compared to the\n prior study. The cardiac and mediastinal silhouettes also remain unchanged. No\n pleural effusions are again seen.\n\n IMPRESSION: Tubes and line in place. Bilateral reticular nodular pattern at\n the lungs, unchanged in considering technicalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 932481,
"text": " 10:07 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for bowel obstruction.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with respiratory failure on ventilator, no bowel movements\n since admission, not tolerating tube feeds due to high residuals\n REASON FOR THIS EXAMINATION:\n Please assess for bowel obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, SINGLE VIEW, AT 10:11 A.M.\n\n HISTORY: No bowel movements since admission.\n\n COMPARISON: None.\n\n FINDINGS: Non-dilated gas-filled colon is identified. No dilated small bowel\n loops are seen. Nasogastric tube is evident with the side hole projected over\n the gastric body. Respiratory motion obscures visualization of the\n hemidiaphragms. No gross free intraperitoneal air is identified, although\n this is a supine radiograph with limited sensitivity. Increased density is\n noted in the retrocardiac region. An acute pulmonary process cannot be\n excluded. Correlate with recent chest x-rays. Extensive degenerative disease\n is noted throughout the thoracolumbar spine.\n\n IMPRESSION: No radiographic evidence for bowel obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 932104,
"text": " 1:22 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please evaluate catheter position\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, clinical PNA, s/p placement of Right Subclavian\n central venous catheter IJ\n REASON FOR THIS EXAMINATION:\n please evaluate catheter position\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, POST LINE PLACEMENT, @ 13:28 HOURS.\n\n HISTORY: Sepsis and pneumonia. Post-right subclavian central venous catheter\n line placement.\n\n COMPARISON: Earlier same day.\n\n FINDINGS: Consistent with the prior exam, the previously noted right internal\n jugular approach line has been removed. A right subclavian approach central\n venous catheter is now present with the tip projecting in the region of the\n right atrium-superior vena cava junction. In addition, the endotracheal tube\n has been retracted to approximately 2.5 cm, in appropriate position.\n Nasogastric tube is again identified with the side hole within the gastric\n fundus. Extensive diffuse bilateral reticular nodular interstitial opacities\n are again identified. Additional history helps narrow the previously offered\n differential diagnosis as likely diffuse atypical pneumonia. The radiograph\n is otherwise stable.\n\n IMPRESSION: New right subclavian central line after removal of right internal\n jugular central line. No pneumothorax. Extensive parenchymal disease as\n described above likely secondary to atypical pneumonia, consider mycoplasma as\n a potential etiology.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932573,
"text": " 10:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, hypoxic, with inc O2 requirement and\n increased secretions.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 10:35 A.M.\n\n HISTORY: Sepsis and pneumonia.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are mildly diminished. This likely results in\n relative coalescing of the previously noted extensive bilateral pulmonary\n opacities. However, superimposed edema cannot be excluded. Support tubes and\n lines remain stable. No effusion or pneumothorax is seen.\n\n IMPRESSION: Slightly increased opacity and confluence of the previously noted\n extensive bilateral pulmonary opacities. Review of the patient's Radiology\n jacket reveals prior history of pulmonary fibrosis. If true, this likely\n represents a combination of an acute superimposed edema like process on the\n background of extensive pulmonary fibrosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932789,
"text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, hypoxic, intubated\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:01 A.M., \n\n HISTORY: Sepsis, pneumonia and hypoxia.\n\n IMPRESSION: ET tube is at the upper margin of the clavicles, at least 6 cm\n from the carina, 2-3 cm above optimal placement. Severe infiltrative\n pulmonary abnormality persists, unchanged since , when the patient\n was admitted, after resolution of transient component of pulmonary edema.\n Heart is mildly enlarged. There is no pleural effusion. Central adenopathy\n may be present particularly around the right hilus.\n\n The generalized pulmonary abnormality could be disseminated carcinoma.\n Correlation with clinical history and previous imaging studies is recommended.\n\n The tip of the right subclavian line projects over the superior cavoatrial\n junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 932036,
"text": " 6:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: UNRESPONSIVE. ? ICH\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with unresponsiveness\n REASON FOR THIS EXAMINATION:\n eval for ICH\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n WET READ: ACKe WED 6:45 AM\n no acute ICH or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsiveness.\n\n NONCONTRAST HEAD CT: No prior for comparison. Patient is markedly tilted\n within the scanner gantry.\n\n FINDINGS: No hydrocephalus, shift of normally midline structures, intra- or\n extra- axial hemorrhage, or acute major vascular territorial infarct is\n identified. Lacunar infarcts, chronic in age, are noted in both basal ganglia\n and subinsular cortices reflects chronic microvascular infarction. A few\n subcm. areas of low density are noted in the right temporal lobe- these may\n represent enlarged sulci v. chronic cortical infarcts.\n\n The patient is intubated. No fractures are seen. There is a small, probable\n retention cyst in the right maxillary sinus, with opacification of a few\n ethmoid air cells, and mild mucosal thickening in the frontal sinus. Mastoid\n air cells are poorly pneumatized and aerated. Sphenoid sinus shows moderate\n mucosal thickening. There is fluid and aerosolized secretions in the\n nasopharynx and oropharynx, likely due to intubation.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect. See above\n report for additional findings.\n\n Sinusitis, likely chronic in age.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932318,
"text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening infiltrates.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, pulmonary fibrosis hypoxic.\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with sepsis, pulmonary fibrosis, and hypoxia.\n\n Portable AP view of the chest dated is compared to the prior from\n ___days prior. The endotracheal tube terminates 1.8 cm above the carina. The\n right subclavian central line is seen at the cavoatrial junction. Nasogastric\n tube terminates below the diaphragm. The heart remains stable in size. Again\n seen are a few interstitial abnormality consistent with the patient's history\n of pulmonary fibrosis. Superimposed on this background of interstitial\n disease is a retrocardiac opacity which probably represents a consolidation.\n There is no significant pleural effusion or pneumothorax.\n\n IMPRESSION: Superimposed left retrocardiac opacity on a background of\n pulmonary fibrosis. Lines and tubes not significantly changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 932026,
"text": " 5:21 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new R IJ\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n WET READ: ACKe WED 6:19 AM\n ETT should be withdrawn 1cm.\n R IJ line is in L brachiocephalic vein (still central)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New right internal jugular vein line.\n\n SINGLE VIEW CHEST: No prior for comparison. Diffuse patchy opacities\n throughout both lungs without significant pleural effusions. Cardiac,\n mediastinal, and hilar borders not well evaluated due to diffuse opacities.\n Endotracheal tube should be withdrawn approximately a centimeter for optimal\n position. Right internal jugular vein line crosses the midline and probably\n terminates in the left brachiocephalic vein. Nasogastric tube is seen\n coursing below the diaphragm. Degenerative changes of the glenohumeral joint.\n\n IMPRESSION: Diffuse severe patchy airspace opacities representing ARDS,\n atypical pneumonia, lymphangiitic carcinomatosis or multiple other etiologies.\n Clinical context should help narrow the differential diagnosis. Element of\n superimposed edema suspected.\n\n Findings regarding the ET tube and the internal jugular vein line were relayed\n to the ED dashboard at time of image interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-11 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 932359,
"text": " 9:34 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: SEPSIS ELEVATED ALP EVAL PANCREATITIS AND CBD DIL\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis now with pancreatitis and elevated ALP\n REASON FOR THIS EXAMINATION:\n evaluate for pancreatitis and CBD dilatation\n ______________________________________________________________________________\n WET READ: SMLe FRI 3:15 PM\n Neg.\n WET READ VERSION #1 SMLe FRI 1:12 PM\n Gallstones. No gallbladder wall edema, thickness, or pericholecystic fluid.\n WET READ VERSION #2 SMLe FRI 2:49 PM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with sepsis, now with pancreatitis.\n\n ABDOMINAL ULTRASOUND STUDY: Comparison was made to recent prior study of\n . Examination was done portably. The gallbladder is not\n visualized. The liver is of normal echogenicity, and there are no focal\n lesions seen. The main portal vein is patent. The pancreatic head and body\n are well visualized. The pancreatic tail is not well visualized secondary to\n patient body habitus and overlying bowel gas. No peripancreatic fluid\n collections are seen. The common bile duct measures 1.2-1.3 cm in size.\n\n IMPRESSION:\n 1. No peripancreatic fluid collections or definite pancreatic ductal\n dilatation. Ultrasound is not a very specific test to assess for acute\n pancreatitis. If there is continued clinical concern for this diagnosis, a\n dedicated CT study could be performed.\n\n 2. Common bile duct size as described above, relatively unchanged from recent\n prior study. Gallbladder nonvisualized. Raises the possibility of prior\n cholecystectomy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932413,
"text": " 4:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for infiltrates, effusions, lung aeration\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, hypoxic, with inc O2 requirement and\n increased secretions.\n REASON FOR THIS EXAMINATION:\n please eval for infiltrates, effusions, lung aeration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, pneumonia, hypoxia.\n\n Bedside AP chest radiograph dated , compared to bedside AP\n chest radiograph dated .\n\n ET tube located at the carina. Right subclavian line terminates at the\n expected location of the distal SVC. NG tube passes below the diaphragm and is\n out of view. There is no pneumothorax. Cardiomediastinal silhouettes are\n unchanged. There is persistent bilateral reticular nodular pattern, unchanged\n from the previous examination. No evidence of pleural effusions on this\n single AP view.\n\n IMPRESSION: ET tube at the level of the carina. Unchanged appearance of\n bilateral reticular nodular pattern.\n\n Findings were discussed with at 6 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933108,
"text": " 1:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, intubated\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n IMPRESSION: Sepsis, pneumonia.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: ET tube approximately 4.5 cm above the carina. Nasogastric tube\n terminates in the proximal stomach. Right subclavian line in distal SVC.\n\n There has been interval worsening of extensive bilateral pulmonary opacities,\n especially on the right. This worsening could represent associated component\n of aspiration or superimposed pneumonia. Cardiac size is unchanged. A\n central hilar lymphadenopathy cannot be excluded, especially on the right.\n There is no pneumothorax.\n\n IMPRESSION: Interval worsening of bilateral pulmonary opacities could\n represent superimposed infection or aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 933037,
"text": " 2:02 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess lung fields r/o carcinomatosis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hypoxic respiratory failure, acidosis, chronic lung dz ?\n of carcinomatosis on CXR\n REASON FOR THIS EXAMINATION:\n assess lung fields r/o carcinomatosis\n CONTRAINDICATIONS for IV CONTRAST:\n NO IV Contrast please - RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxic respiratory failure, acidosis, suspected\n chronic lung disease.\n\n COMPARISON: Serial chest x-rays from till .\n\n TECHNIQUE: MDCT of the chest without injection of IV contrast from\n thoracic inlet to upper abdomen was obtained with subsequent 1.25- and 5-mm\n collimation axial images reviewed as well as coronal reconstructions added.\n\n FINDINGS:\n\n The patient has been intubated with the tip of the ET tube 2.5 cm above the\n carina. The NG tube terminates within the stomach. The aorta and the\n pulmonary arteries are unremarkable within the limitation of this unenhanced\n study. Multiple enlarged mediastinal lymph nodes are present in the right\n paratracheal, supracarinal, subcarinal, aortopulmonic, and prevascular areas\n measuring up to 1.5 cm in the right paratracheal station. The heart size is\n normal. Coronary calcifications involve all the coronary arteries. The heart\n size is mildly enlarged, and there is no pericardial effusion.\n\n The airways are patent to the level of segmental bronchi. Widespread\n bilateral areas of intersttial density consitent with fibrosis involve both\n the peripheral and the central lungs as well as both upper and lower lung\n zones. Mostly involved areas are the apices bilaterally, the right middle\n lobe, and the lower lobes. In addition to this intersitial appearance, there\n are focal areas of speradded consolidation in the right juxtahilar area, lower\n lobes bilaterally, and part of the left upper lobe. There is no\n interlobular septal thickening or discrete lung nodules. There is no sizeable\n pleural effusion.\n\n The imaged portion of the upper abdomen is unremarkable except for aortic\n calcifications and mild perirenal stranding. There are no bone lesions\n suspicious for malignancy.\n\n IMPRESSION:\n 1. Proabable hronic interstitial lung disease with fibrosis. In addition,\n there are focal consolidations most likely due to superadded infection,\n aspiration, or chronic ARDS. Overall appearnces are not highly suggestive for\n lymphangitis carcinomatosis or hematogenous metastases.\n (Over)\n\n 2:02 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess lung fields r/o carcinomatosis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Coronary artery calcifications.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933796,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, intubated\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for interval change in a patient with\n known sepsis and pneumonia.\n\n Portable AP chest radiograph compared to .\n\n IMPRESSION:The severe infiltrated pulmonary abnormality is unchanged since the\n previous exam, most likely due to underlying pulmonary fibrosis. There is no\n superimposed pulmonary edema. The heart is enlarged but stable. The\n dilated mediastinal and hilar vessels suggest pulmonary arterial hypertension,\n unchanged. There is no sizable pleural effusion. The ET tube tip, the right\n subclavian line tip and the NG tube courses are in standard position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933056,
"text": " 3:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval new OG tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, intubated new OG tube placed \n\n REASON FOR THIS EXAMINATION:\n eval new OG tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, pneumonia, intubated, new OG tube placed, check position.\n\n The tip of the orogastric tube lies within the stomach, the side hole in the\n region of the gastroesophageal junction, and therefore, further advancement\n should be considered.\n\n There has been no significant change in the appearances of either lungs since\n the prior chest x-ray.\n\n IMPRESSION: Side hole of OG tube at gastroesophageal junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-20 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 933595,
"text": "GI BLEEDING STUDY Clip # \n Reason: BRBPR AND RLQ PAIN ? SOURCE OF BLEED\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 16.4 mCi Tc-m RBC ();\n HISTORY: Recent bright red blood per rectum, in the setting of sepsis and\n multiorgan failure in the MICU.\n\n DECISION:\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for minutes\n were obtained. A left lateral view of the pelvis was also obtained.\n\n Blood flow images are unremarkable. The iliac arteries are ectactic.\n\n Dynamic blood pool images show no definite early bleeding on images obtained\n over 0-60 minutes. Subsequently, after repositioning the patient over a \n minute period, imaging shows evidence of hemorrhage in the sigmoid colon over\n the subsequent hour.\n\n IMPRESSION: Late dynamic images demonstrating extravasation into the sigmoid\n colon, but no evidence of brisk bleeding within the first hour. This is most\n suggestive of a slow intermittent hemorrhage in the sigmoid colon. These\n findings were discussed with Dr. from the MICU shortly after the study.\n\n\n\n\n , M.D.\n , M.D. Approved: TUE 3:38 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933646,
"text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, intubated\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:33 A.M., \n\n HISTORY: Sepsis, pneumonia, intubated.\n\n IMPRESSION: AP chest compared to through 26.\n\n Severe infiltrated pulmonary abnormality not changed appreciably since the\n appearance on admission, , largely pulmonary fibrosis. No areas of\n new consolidation or reason to suspect superimposed pulmonary edema. The\n heart is enlarged but stable. Dilated mediastinal and hilar vessels suggest\n pulmonary arterial hypertension.\n\n Pleural effusion, if any, is small. ET tube, nasogastric tube, and right\n subclavian central venous line are in standard placements. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-09 00:00:00.000",
"description": "P DUPLEX DOPP ABD/PEL PORT",
"row_id": 932098,
"text": " 1:10 PM\n DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (PORTABLE) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please assess liver and remainder abdomen, please assess por\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, shock liver\n REASON FOR THIS EXAMINATION:\n Please assess liver and remainder abdomen, please assess portal and hepatic\n veins with doppler flow studies\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with sepsis and shock liver.\n\n PORTABLE DUPLEX OF THE ABDOMEN: This is a limited study due to patient's\n intubated status. The gallbladder is not visualized. The liver shows normal\n echogenicity with no focal masses. The intrahepatic branches of the hepatic\n artery and hepatic vein are patent. The main portal vein is patent. The\n intrahepatic portal veins are difficult to assess. The pancreas is poorly\n visualized but shows no gross abnormality. The right kidney measures 12 cm.\n There is a cyst in the superior portion of the right kidney measuring 1.2 x\n 1.1 x 1.2 cm. The left kidney measures 12 cm, and there is a cyst in the mid\n to upper pole measuring 2.4 x 1.8 x 1.4 cm. The aorta is of normal caliber.\n The spleen is unremarkable.\n\n IMPRESSION:\n 1. Patent main portal vein and hepatic artery and vein. 2. Bilateral renal\n cysts.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932945,
"text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sepsis, PNA, hypoxic\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:20 a.m. \n\n HISTORY: Sepsis, pneumonia and hypoxia.\n\n IMPRESSION: AP chest compared to through 24:\n\n An overlay of mild pulmonary edema has recurred since . Severe\n generalized interstitial pulmonary abnormality could be fibrosis or\n disseminated metastases. There is the suggestion of a 2.5 cm wide oval\n opacity in the left upper lobe projecting over the first anterior rib, which\n could be a mycetoma in a cavity or ectatic bronchus, probably not contributory\n to the patient's current clinical situation.\n\n Heart is top normal size. Fullness in the right hilar area could represent\n adenopathy or alternatively vascular engorgement. Tip of the right subclavian\n line projects over the low SVC. ET tube is in standard placement. There is\n no appreciable pleural effusion or indication of pneumothorax.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-09 00:00:00.000",
"description": "Report",
"row_id": 1444696,
"text": "NPN 7a-7p\n(Continued)\nmmonia level sent.\nHYPOTENSION- Likely sepsis/shock liver/ARF. Acidosis improving. Presently off Levophed, and bolus' to CVP goal >8 and Map >60. Following HCT and montioring for s&s of bleeding. Cont. broad spectrum abx, and follow lactate. Cont. to monitor urine output. consider chest CT to further assess cxr findings.\nTRANSAMINITIS- Liver enzymes trending down, likely etiology is shock liver. Hepatitis serologies pnding, portal clot ruled out.\nCOAGULOPATHY- Likely r/t liver failure, DIC labs sent, f/u w/ results.\nNSTEMI- Cont. to check serial enzymes, next set due at 23:00. Awaiting ECHO, consider BB when vs stable, no anticoagulation at this time.\nCont. providing supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-21 00:00:00.000",
"description": "Report",
"row_id": 1444746,
"text": "MICU NPN 7P-7A\nNEURO: AWAKE AND ALERT. DOZING INTERMITTENTLY. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES. C/O'D RLG/GROIN PAIN. MEDICATED WITH 50MCG FENTANYL WITH EFFECT. LATER C/O LEFT CHEST PAIN ASSOCIATED WITH HEARTBURN, WHICH SHE WROTE SHE TAKES TUMS FOR. HEARTBURN BE R/T RECEIVING 3L OF PREP OVERNOC.\n\nCARDIAC: HR 44-66 SB/SR WITH NO ECTOPY. BP 126-156/49-76. PPP WITH +RIGHT FEMORAL PULSE. LE'S COOL WITH NORMAL COLOR. MONITORING HCT Q4HRS, DID NOT RECEIVE ANY UNITS, HAS HAD A TOTAL OF 4UNITS. HCT 35.6/34/33.1.\n\nRESP: RECEIVED ON CPAP 10/5 40% BUT BREATHING 30'S WITH COPIOUS SECRETIONS. SPOKE WITH MD AND CHANGED BACK TO A/C 450X18 +5PEEP. RR 18-30 AND SATS 99-100%. LS RHONCHEROUS THROUGHOUT. SXTED FOR COPIOUS WHITE THICK SPUTUM. RSBI 88. CXR DONE THIS MORNING.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. GOLYTELY PREP STARTED VIA OGT. HAD LGE LOOSE BROWN AND BRB STOOL THEN PLACED MUSHROM CATH WITH DK RED TO NEARLY CLEAR, LIGHT BROWN LIQUID, 1200CC. STOPPED PREP AFTER 3L AS SHE WAS C/O HEARTBURN. OGT IN PLACE AND PATENT. UOP 10-55CC/HR YELLOW AND CLEAR. CREAT PENDING.\n\nFEN: NO FLUIDS OTHER THAN PREP. PERIPHERAL EDEMA. LYTES PENDING. FS Q6HRS WITH SSRI. NO COVERAGE NEEDED. REMAINS NPO FOR COLONOSCOPY.\n\nID: TMAX 96.8 WITH WBC 19 DOWN FROM 28.6. REMAINS ON ZOSYN AND FLAGYL.\n\nSKIN: YEAST RASH IN PERINEUM.\n\nACCESS: CVL.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. NEEDS SW TO REINFORCE VISITING PARAMETERS AS MANY FAMILY MEMBERS HAVE SHOWN UP AT TIMES. ALSO DAUGHTER WANTS POA AS ? OF MISMANAGEMENT OF PATIENT'S MONEY BY SON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-21 00:00:00.000",
"description": "Report",
"row_id": 1444747,
"text": "npn micu west 0700-1900\nnkda\n\nfull code\n\nNeuro: Pt is A+Ox3, moves all extremeties well, pupils 2-3mm pearl, complains of no pain today but had RLQ pain last night tx w/ 50mcg/hr of Fentanyl, and also experienced some heart burn with last night's GoLytly Prep for her colonoscopy this morning. Pt received 150mcg Fentanyl and 2 mg Versed for Colonsocopy today.\n\nResp: Received on Ac/.40/TV 450/RR 18/5Peep, O2>96%, LS coarse > in left lung, suctioned copious amounts of thick white sputum, risbi 88 this AM. Tolerated CPAP 10/5/.40% for the last few days, but was put back on AC yesterday for increased RR and secretions. CXR done today, and plan for TRACH (& PEG) tomorrow morning @ bedside.\n\nCV: HR 46-65 sb-ns, sbp 113-150s, multi-R-SC intact ecchymotic around edges, PLT 188(178), HCt 33.4(33.8) following q 8hrs, watch for s/s of bleeding, if no outward signs of bleeding transfuse if hct<25. Pulses palpable in all four extremeties, cool extremeties, but normal color.\nReceiving D5W for 2 Liters @ 75cc/hr for hypernatremia.K+ 4.6, desmopressin x 1 given, and Vit K SQ x 1 given for tomorrow's trach/peg procedure.Not on Hep SQ for GI Bleed, Comp Boots ON.\n\ngu/gi: Foley output 45cc/hr yellow/cloudy, ARF resolving, mushroom cath was outputing bright red blood last night for which she received 4 units PRBCs w/ good bump in HCt (2units still reserved), but since 3L of GOLYtly Prep output has turned to golden, and is now brown liquid w/ some bloody clots. Red Tag Study done showing + slow sigmoid colon bleed. Pt has been NPO for colonoscopy. Colonoscopy done at noon, Dr. visualized a bleeding/clotted diverticulum, no intervention done or ordered; please watch HCT and for any blood via mushroom cath. BS +, + flatus. On PPI.\n\nendo: fsbs q 6hrs, requiring coverage.\n\nid: T=96, WBC 20(19), Zosyn/Flagyl\n\nsocial: family visited today, updated on plan for trach tomorrow morning\n\nplan: Trach tomorrow morning\n Check HCt at midnght\n Monitor bleeding via mushroom\n Cont IVF\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-21 00:00:00.000",
"description": "Report",
"row_id": 1444748,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on A/C ventilation w/ PIP/Pplat = 26/21. BLBS slightly coarse, suctioned for small amounts of thick white sputum. SpO2 90s. Colonoscopy at bedside revealed bleeding/clotted diverticulum. No intervention. See resp flowsheet for specifics.\n\nPlan: maintain support; trach at bedside in AM \n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-22 00:00:00.000",
"description": "Report",
"row_id": 1444749,
"text": "RESP CARE:Pt remains intubated/on vent AC\u0013 450/18/.40/5 PEEP.. Breathing over set rate. Lungs coarse rhonchi bilat, crackles, wheezes throughout. Sxd mod amts thick white sputum. Combivent MDI given with some effect noted. RSBI this am on 0 PEEP/5 PS was 96. Plan is for trach/PEG today, then wean vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-09 00:00:00.000",
"description": "Report",
"row_id": 1444697,
"text": "Respiratory Care\nPt remains on ac vent without changes. Last abg 730/40/158/20/-. Suctioned for copious amts of tan secrections.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-10 00:00:00.000",
"description": "Report",
"row_id": 1444698,
"text": "Resp Care Note,Weaned down fi02 to 40% for good PaO2. Suctioned mod amts thick yellow secretions.Nasal aspirate done. RSBI done on 0 peep/5 ips 77.4.HR occ PVC'S.Will cont to monmitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-10 00:00:00.000",
"description": "Report",
"row_id": 1444699,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT MORE AWAKE AS NIGHT WORE ON. ABLE TO FALL BACK TO SLEEP AFTER TURNING WITHOUT DIFFICULTY. WHEN STIMULATED PT WOULD ATTEMPT TO BRING HANDS UP TO ETT. OPENS EYES SPONTANEOUSLY. BECOMES AGITATED WITH SX'ING. PEARL BRISKLY. MOVES UPPER EXTREMETIES WELL, MOVES LOWER EXTREMETIES SLIGHTLY ON THE BED.\n\nRESP: PT /VENT, FIO2 DROPPED TO 40% THIS AM. AM ABG 7.30/42/174/21 -5. O2 SAT'S IN THE HIGH 90'S OVERNIGHT. SX'D FOR MOD AMT'S OF THICK TAN/YELLOW SPUTUM. SPEC SENT FOR C/S. NASAL ASPIRATES SENT FOR VIRAL CHECK. NO OTHER CHANGES MADE IN VENTILATION. LUNG SOUNDS COARSE THROUGHOUT.\n\nCV: PT IN NSR WITH OCC PVC'S. HR IN THE 70'S TO 80'S. BP 110-120/60-70. AFEBRILE. TEMP 97.3. CVP 6-17, NO FLUID BOLUSES GIVEN OVERNIGHT. RECEIVED VANCO X 1 TONIGHT. FINISHED UNIT OF PRBC'S, POST HCT 29.5.\n\nGI: PT NPO EXCEPT OF MEDS. OGT CLAMPED BUT OCC PLACED TO SX AND DRAINED ABOUT 300CC BILIOUS MATERIAL. PT RECEIVED LACTULOSE X 2 OVERNIGHT, NO STOOL OVERNIGHT. ABD SOFT/DISTENDED. POS BOWEL SOUNDS.\n\nGU: FOLEY CATH PATENT DRAINING MINIMAL AMTS OF CLEAR YELLOW URINE.\n\nENDO: RECEIVING SSRI TO COVER ELEVATE BLD SUGARS.\n\nACCESS. PT WITH MLC AND ALINE, BOTH WORKING WELL, WNL.\n\nSKIN: INTACT. TOES ON LEFT FOOT CYANOTIC AND COLD. HO AWARE.\n\nSOCIAL: CHILDREN IN AND WERE UPDATED BY RESIDENT. SON STAYED OVERNIGHT IN WAITING AREA. PT IS FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-10 00:00:00.000",
"description": "Report",
"row_id": 1444700,
"text": "resp care - Pt remains intubated with #7.5ETT on AC 500/20/5 40%. A trial PSV of 15/5 was attempted for 2 1/2 hours. Pt returned to AC due to increasing CO2. I&E crackles were heard bilaterally t/o with bronchial BS in the left base. Continued weaning planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-09 00:00:00.000",
"description": "Report",
"row_id": 1444695,
"text": "NPN 7a-7p\nPlease see carevue and FHP for additional data.\nNKDA\nCode Status: Full at this time, however, some conflicting opinions on patients wishes between different children. Resident to confirm code status this evening.\n\nBreifly: Pt is 75yo F who p/t OSH s/p several weeks of productive cough. Pt went to primary care MD , Dr. , and was reportedly given Azithromycin, for PNA, taken for one day before presentation. At 11am on the day before admit patient was found to have mild resp. distress, at home by grandson. that day was found to be in more severe resp. distress, w/ confusion and disorientation. Grandson activated EMS, and patient brought to hosp. On presentation at OSH wbc 14.4, w/ 61% bands, and Cr 3.8. Tx w/ Vanco, Levo, Gent. Pt was also agitated, and was given Morphine and Ativan. Resp distress worsened, patient was intubated. Hypotension, Dopa. initiated w/ two piv's in feet. Transferred to .\n\nNeuro:> Patient's level of responsive has increased over coarse of day. On admit, was unresponsive to sternal rub, but did wdw to deep nail bed pressure. Perrl 2mm/slg. Presently opening eyes to stimuli, and attempting to lift arms to ETT with turning/stimulation. CT of head (-) for bleed. No sedation at this time, and none since OSH.\n\nResp:> A/C 50%/500/20/5. Acidosis improving. LS Rhonchorus. Sxned frequently for copious amounts of thick, tan sputum, spec. sent. Sats 99-100%. CXR w/ RML and LLL PNA.\n\nCV:> HR 68-120, occ. episodes of vent. bigeminy, and pvc's. Sbp 94-133. Weaned off Levophed gtt this am. Maps >60. CVP 16-17. Received 1.5L NS bolus' for bp and low u/o. Also received 2 FFP for INR of 2.6 prior to line placement. Presently awaiting one unit PRBC's for drifting HCT of 27.1, down from 33.2. (some component of dilution) HCT goal >30. NSTEMI- cycling enzymes next set due at 23:00. Awaiting ECHO. Hyponatremia trending up, cont. to follow, likely hypovolemia.\n\nGI/GU:> Abd soft, slightly distended, +BS. OGT patent. Had US of Renal/ Liver w/ prelim. results indicative of bilat. renal cysts and patent portal veins. Foley patent draining small amounts of sedimented, yellow, urine. Urine lytes sent.\n\nEndo:> RISS, no coverage thus far. Cortisol pnding, first random high.\nSkin: w/d/i.\nID:> afeb. WBC down to 7.6 from 12. U/A from ED negative. Bld cx pnding. Sputum spec. sent. Zoysn and Azithromycin started, will likely start Vanco as well. (received Vanco, Gent., and Levo. at OSH)\nSocial:> Daughter, , is spokesperson. Also Son, here to visit all day, both children updated by Dr. and this RN. Awaiting arrival of another daughter from . Several grandchildren also in to visit. Strict limit setting encouraged as far as calling in to unit and two visitors at a time.\n\nA/P:> ALTERED MS- Improving, likely inability to clear Ativan and Morphine given at OSH in setting of toxic/metabolic w/ RF. Cont.to monitor no sedation meds at this time. TID Lactulose to tx ? hepatic encephalopathy. A\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-20 00:00:00.000",
"description": "Report",
"row_id": 1444742,
"text": "NPN 7a-2p:\n Pt c/o R groin/RLQ pain this am.. stool noted to be brown at bottom of fecal incontinence bag, and maroon at top of bag... team aware. am hct stable at 28.5. Decision made by team to follow stools at that time. However, 2 hrs later, pt noted to have large amt BRBPR with clots. team into evaluate. GI team in stat for endoscopy which showed no evidence of upper GIB. Stat hct 28.2. cvp 8. received 500cc ns bolus x 2. Pt continued with brbpr with clots in large amts. cvp remained , sbp 106-120's throughout, Hr 50's-60's SB/NSR throughout. Pt received 2uprbc's, with repeat hct after first unit .5. lactate 1.1. Pt ordered for and down for tagged red blood cell study. Surgery into evaluate. await results tagged scan.\n Neuro: pt med with 1.5mg versed and 50mcg fentanyl for endoscopy. slept x 1.5 hrs after this. no other pain med given this am. MS , using dry erase board to communicate. signed consent for endoscopy.\n RESP: switched from psv to A/C after sedation for endoscopy, as was apneic. Current settings, 450 x 18 peep 5/.40. sats 99-100%. sx for thick white secretions in moderate amts.\n CV: as noted above.\n gI: as noted above. ab soft, bs hyperactive. tf's off d/t lgib. ogt flushed, aspirated, no s/s bleeding in stomach. switched to and received protonix. continues to c/o mild RLq pain.\n ID: afebrile on zosyn/flagyl for pna, ? ciff.. all cx ngtd. wbc increased to 24.3 from 18. vanco being dosed per level.\n FE: fsbs covered by ssi.\n GU: foley intact UO 15-80cc's/hr.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-20 00:00:00.000",
"description": "Report",
"row_id": 1444743,
"text": "Integ: intact.\nSocial: pt's dtr and hct notified of changes. dtr also called and was updated. Spoke to dtr r/e meeting with sw tomorrow in order to discuss the stress surrounding her mom's illness/family dynamics, etc. please f/u .\n A/P: pt with new LGIB.. has now returned from red tag study.. LGIB identified on scan.. await word from team r/e ? angio procedure. 3rd uprbc's have infused await 4 unit prbc's from BB. will now send repeat hct as pt continues with large amts clots brbpr. team aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-20 00:00:00.000",
"description": "Report",
"row_id": 1444744,
"text": "Respiratory Therapy\n\nPt remains orally intubated/mechanically ventilated. Initially on PSV, but pt developed bloody stools and had stat endoscopy, pt sedated and placed on A/C for prodecure. Pt noted to have LGIB, travelled to and from nuclear med for red tag study. Pt now back on PSV +10/+5, tolerating well. SpO2 90s. Moderate amounts of thick white secretions. See MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-21 00:00:00.000",
"description": "Report",
"row_id": 1444745,
"text": "RESP CARE: Pt remains intubated/on vent settings per carevue. Changed mode to AC mD overnight to rest. Pt awake most of noc, asking for H20.Lungs coarse bilat. Sxd copious amts white secretions during the noc. MDIs given per . RSBI this am on 0 PEEP/5 PS was 88.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-10 00:00:00.000",
"description": "Report",
"row_id": 1444701,
"text": "NPN 7a-7p\nFull Code\nPlease see carevue and FHP for additional data.\nNKDA\n\nNeuro: Patient arouses with stimulation, but still not following commands. Agitated with sxning, but settles out shortly after. PRN order for Haldol obtained if needed, MD's would prefer to try this before trying Fent/Midaz. Perrl 3mm/bsk. MAE, upper > lower.\n\nResp: LS rhonchorus. Sxned frequently for THICK, yellowish/tan secretions, mod. to copious amounts. Attempted to wean to PS today, not well tolerated lower VT's and RR, thus became acidotic. CXR w/ bilat. infiltrates.\n\nCV: NSR 75-97, rare pvc's noted. Sbp 115-139. CVP 10-14. HCT stable. ECHO done today, signifcant for significant pul. regurgitation, and dilated RV. EF 50%. Cardiac enzymes trending down. Received 40mg iv Lasix with fair effect.\n\nGI/GU: Order for TF obtained. abd soft, distended, +BS. Continues on Lactulose, no stool. Foley patent, marginal sedimented, yellow, urine out.\n\nID: afeb. sputum spec. and nasal aspirate pnding. WBC 13.2, up from 10.3. Vanco dosed by level, also on Zoysn and Azithro.\n\nSocial: Large family in to visit today, continue with limit setting as far as visiting hours and number of visitors in room at a time. Updated on poc by resident.\n\nA/P: RF- Poor urine output, fair response to Lasix, cont. to follow BUN/CRE.\nResp. Failure- Likely PNA, attempted vent wean unsuccessful. Cont. w/ aggressive pul. toilet.\nSepsis- VS stable, cx data pnding, cont. on abx. Bolus for CVP <8.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-11 00:00:00.000",
"description": "Report",
"row_id": 1444702,
"text": "Respiratory Care\nPt remains intubated with 7.5 ETT. Pt currently on full vent support with no ventilator changes made this shift. BS coarse/diminished bilaterally. Pt had increasing secretion production throughout shift, currently suctioning for copious thick yellow secretions. Morning RSBI= 200 on 0peep, 5 PS. See CareVue for other details and specifics.\nPlan: ? weaning vent. Often suctioning needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-11 00:00:00.000",
"description": "Report",
"row_id": 1444703,
"text": "O. Neuro opens eyes to stimuli, she does not appear to track, pupils equal and reactive. Not FC, mae, able to lift arms and hold. Given lactulose as ordered. Not requiring sedation.\nResp AC 40%/500/20/5 abg 7.30/41/138/21/-5 sx copious amt of yellow thick sputum RISBI > 200. Lungs rhonci and crackles cxr taken\ncvs HR 70-80 nsr freq pvc lytes wnl K+ 4.3, phosp 5.8 bp 109/-125/60-70. cvp 14-18 hct 31.7\nGI TF held x2 hr high residuals now on 20cc TF q hr abd soft bs+ no stool. amylase 318/ldh 441/ alk phos 148 total bili .9, ast 1184 alt 2366\ngu u/o 20-50cc qhr bun 83 cr 5.0 urine sent for esonophils\nID wbc 21.4 on zoysn and azithromax, vanco level 19.8 yest renal dosed. cx pnding\na. pna, ?chf\nARF, shock liver- ? enceph\np. vigorous pulm toliet pt with increase secretions MS not very responsive with high RISBI does not appear ready to wean today. ? CHF cr increasing ? lasix ? renal consult monitor lytes, bun, cr, monitor temp, wbc await cx results, antibx, dose vanco according to levels, monitor liver enzymes, coag, ms give haldol prn, lactulose as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-22 00:00:00.000",
"description": "Report",
"row_id": 1444750,
"text": "MICU NPN 7P-7A\nNEURO: REMAINS AWAKE AND ALERT. ABLE TO MAKE NEEDS KNOWN. MOVING ALL EXTREMITIES AND FOLLOWING COMMANDS CONSISTENTLY. C/O RLQ PAIN THIS MORNING AND WAS MEDICATED WITH 50MCG OF FENTANYL WITH EFFECT. HAS SLEP BETTER TONIGHT. AWARE OF TRACH/PEG TODAY.\n\nCARDAIC: HR 48-61 SB/SR WITH NO ECTOPY. BP 117-138/46-66. HCT 31.2/31.4, WAS 33.4 @1700 YESTERDAY. STOOL HEME+. PPP WITH LE'S WARM AND NORMAL COLOR.\n\nRESP: NO VENT CHANGES, A/C 450X18 40% +5PEEP. RR 18-25 AND SATS 97-100%. ADVENTITIOUS LUNG SOUNDS THROUGHOUT. COARSE, RHONCHEROUS WITH BIBASILAR CRACKLES AND WHEEZES. MDI'S AS ORDERED. SXTED FOR THICK WHITE SPUTUM. CXR DONE THIS MORNING. RSBI 95.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. SMALL AMOUNT OF DK BROWN WITH SPECKLED RED, HEME+ VIA MUSHROOM CATH. OGT IN PLACE. UOP 30-40CC/HR YELLOW WITH SEDIMENT. CREAT CONTINUES TO IMPROVE, NOW 4.\n\nFEN: CONTINUES ON D5W @75CC/HR. +9.2L LOS. PERIPHERAL EDEMA. LYTES PER CAREVUE. NA+ 145. FS Q6HRS WITH SSRI. REMAINS NPO FOR TRACH/PEG.\n\nID: TMAX 97.2 WITH WBC 16 (COMING DOWN). CONTINUES ON ZOSYN AND FLAGYL.\n\nSKIN: YEAST RASH TO PERINEUM.\n\nACCESS: CVL.\n\nSOCIAL/DISPO: NO CONTACT FROM FAMILY. FULL CODE. BEDSIDE TRACH AND PEG ~NOON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-22 00:00:00.000",
"description": "Report",
"row_id": 1444751,
"text": "Nursing Note: 0700-1900\nSignificant events:\n\nTrached/Peg at bedside without incident.\n\n\nNEURO: Alert/following commands/able to make needs known by writing. C/O incisional abdominal pain after procedure requiring Fentanyl 25mcg with desired effect. MAE. Safety awareness intact; no pulling at lines. Cough/gag intact. Received Propofol 240mg, Vecuronium 5mg and Fentanyl 50mcg during procedure.\n\nRESP: Portex #8 trach placed. Remains vented on A/C 450X18/5/40% maintaining sats in high 90s-100. Sx for mod amt thick, now blood tinged, sputum. Additional cannulas at bedside.\n\nC/V: HR 41-80s, SR. NBP 110s-150s. Occasional PVC. Receiving D5W maintenance fluids. Na trending down. Received DDAVP X 1 before procedure. Heparin SQ being held secondary to GIB. Hct stable. LOS > 10L positive. Some peripheral edema.\n\nGI/GU: PEG placed; may use immediately for meds/TF. Mushroom cath patent for liquid, grn stool; OB positive. U/O 15-80cc/hr.\n\nENDO: Covered with ss insulin.\n\nID: Afebrile; continues on Vanco and Zosyn for septic pna. Culture data negative so far; will send additional C-Diff spec.\n\nDISPO: Full code; micu green; grandson in to visit and dtr updated by phone. Active screening for rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-16 00:00:00.000",
"description": "Report",
"row_id": 1444724,
"text": "Respiratory Care\nPt. remains intubated on ventilatory support. Had a comfortable night with less congestion then previously though still suctioned for significant amounts. RSBI 69 but pt unable to maintain adequate minute ventilation on SBT. Has been requiring ventilation of lpm to maintain good acid base balance and could only aquire lpm on SBT (CPAP 0/5) therefor vent settings returned to PSV 5/15. SpO2 values in high 90's all shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-12 00:00:00.000",
"description": "Report",
"row_id": 1444709,
"text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. Pt given trial on PSV today, placed on 18 for TV 350 range. Maintained MV of .5L but ABG with resp acidosis. Placed back on AC settings. Pt has required freq. sxn for thick yellow-green secretions. Albuterol MDI given Q vent check. Cont current support, re-eval in AM for readiness to wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-16 00:00:00.000",
"description": "Report",
"row_id": 1444725,
"text": "npn 0700-1900\n\nPt had a CT of abdomen this afternoon; results pending. Decreased PS to this am and ahe became acidotic 7.24 with a CO2 of 66-- placed back on PS 15/5.\n\nneuro: Pt is alert, follows commands intermittently. She is very HOH (even with hearing aid in) and has trouble seeing. Sedation has been off since 8am .\n\nresp: PS 15/5/40%. LS coarse and continues with large amounts of white, frothy secretion. Being suctioned q1-2hours; sometimes several times per hour.\n\ncv: SR in the 60-70, rare PVC. BP with MAP >70.\n\naccess: RIJ tlc.\n\ngi/gu: OGT re-placed this afternoon--awaiting confirmation in placement. Patent foley with adequate u/o.Recatal bag in place for liquid brown stool.\n\nskin: Intact. Rash in groin that looks like yeast. Miconazole powder being ordered.\n\nID: Continues on zosyn, flagyl, and daily dosed Vanco.\n\nsocial:Family in visiting this afternoon.\n\ndispo: Full code.\n\nPlan: Continue to wean vent as tolerated. Begin TF when OGT is confirmed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-16 00:00:00.000",
"description": "Report",
"row_id": 1444726,
"text": "Resp. Care Note\nPt received intubated and vented on PSV settings of 15/5 and 40%. Cont to run MV of 7.5-8L PaCO2 60. Pt alert and asking for water . Pt placed on PSV 10 during rounds, cont to run MV 7L until afternoon when TV 280-300 and MV down to 5-6L. ABG drawn and now 7.24/67/100. VD/VT calculated at 70%. Attempted to ^PSV back to 15 but required change to AC to get MV back to 7-8L range. Cont to require sxn to thin white secretions. Will follow for Combivent Q4 and Albuterol MDI Q4prn. Also pt to rest on AC and return to PSV when more awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 1444727,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Pt. continues on A/c with settings Vt 450, A/c rate 18, Fio2 40% and Peep 5. Bs crackles R base and L lung. Sx'd for sm amount of thick yellow secretions. Combivent MDI given Q4hr. Minimal auto peep. Low plateau pressures. Attempted RSBI this am but no spont effort.\nPlan: Continue with mechanical support. Will wean back to PSV when patient more awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-13 00:00:00.000",
"description": "Report",
"row_id": 1444710,
"text": "Respiratory Care\nPt. remains intubated on ventilatory support. A.M. RSBI 112. Pt remains very congested, suction for copious amounts of secretions ranging from thick to tenacious. Pt. becomes agitated and attempts to pull out ETT and OG tubes. Pt appears lucid and aware of what she is doing, stated to this therapist that she is frightened and is uncomfortable (with the tubes and being restrained). This therapist explained why she is intubated, restrained and being suctioned so frequently. Pt. appears to understand and calms somewhat after reassurances but this therapist again caught pt. bending her head and torso down toward her restrained hand attempting to extubate herself.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-13 00:00:00.000",
"description": "Report",
"row_id": 1444711,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND SOMEWHAT IRRITATED WITH BEING INTUBATED AND RESTRAINED. CONSTANTLY MOUTHING FOR HELP AND TO TAKE THE TUBE OUT AND LET HER HANDS FREE. PT REACHES FOR THE TUBES AT ANY OPPURTINITY. PT MOVING ALL EXTREMETIES. PEARL. PT ON DRIP AT 30MCQ'S. PT SLEPT IN SHORT NAPS.\n\nRESP: REMAINS AND NO VENT CHG'S MADE OVERNIGHT. PT HAS BEEN SX'D FOR COPIOUS AMT'S OF THICK YELLOW SECERTIONS. LUNG SOUNDS COARSE WITH SOME CRACKLES AT THE BASES. O2 SAT'S IN THE MID TO HIGH 90'S. PT REFUSES TO LET YOU DO MOUTH CARE OR EVEN TAKING HER TEMP IN HER MOUTH.\n\nCV: HR IN NSR WITH OCC PVC'S. BP WITHIN NORMAL LIMITS. AFEBRILE.\n\nGI: PT RECEIVING TUBE FEEDS VIA OGT. INC TO 20CC/HR. TOLERATED WELL WITH MINIMAL RESIDUALS. PT PASSED COPIOUS AMT'S OF LIQ BROWN STOOL VIA MUSHROOM CATH. CATH DID NOT CONTAIN THE STOOL SO FECAL INCON BAG WAS APPLIED. SO FAR THIS IS INTACT. ABD LRG SOFT, WITH POS BOWEL SOUNDS.\n\nGU: FOLEY CATH PATENT AND DRAINING GOOD AMT'S OF CLOUDY URINE. PT 80MG IV LASIX WITH FAIR RESPONSE.\n\nENDO: NO SSRI OVERNIGHT.\n\nACCESS: PT WITH LEFT RAD ALINE WHICH DAMPENS OUT FREQ. RSC TLC PATENT AND WORKING WELL. SITES WNL.\n\nSKIN: INTACT.\n\nSOCIAL: HAVE NOT HEARD FROM FAMILY OVERNIGHT. PT IS FULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-19 00:00:00.000",
"description": "Report",
"row_id": 1444739,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. IPS weaned to +15, maintaining Ve ~7-8L. SpO2 90s. BLBS coarse, suctioned for moderate amounts of thick white secretions. MDIs given as ordered. See resp flowsheet for specifics. RSBI = 89 on +5/+0 checked this AM.\n\nPlan: maintain support; plan for trach placement\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-20 00:00:00.000",
"description": "Report",
"row_id": 1444740,
"text": "Resp: pt on psv 14/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS are coarse bilaterally. Suctioned for moderate amounts of thick white secretions. MDI's administered as ordered combivent with no adverse reactions. Vt's 400. ve's . RSBI=57, decreased ps to 10 with 02 sat's @ 96%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-20 00:00:00.000",
"description": "Report",
"row_id": 1444741,
"text": "MICU NPN 7P-7A\nNEURO: AWAKE AND ALERT, ABLE TO MAKE NEEDS KNOWN BY WRITING. C/O PAIN IN RIGHT GROIN AREA, NO HEMATOMA NOTED, HAS YEASTY RASH IN AREA. MD AWARE. GIVEN 25MCG FENTANYL @0030 AND ANOTHER 50MCG FENTANYL @0400 WITH GOOD EFFECT. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES. HAVE LEFT RESTRAINTS OFF AND PATIENT DOING WELL NOT TOUCHING TUBES.\n\nCARDIAC: HR 44-75 SB/SR WITH NO ECTOPY. BO 114-150/43-81. PPP. HCT STABLE @30.\n\nRESP: RECEIVED ON CPAP 14/+5 40% WITH TV'S 450-500CC. RR 18-33 WITH SATS 97-100%. THIS MORNING HAVE DROPPED HER PS TO 10 AND SHE IS MAINTAINING TV'S 350CC WITH MV ~7. RR TEENS AND MAINTAINING SATS IN THE UPPER 90'S. LS COARSE WITH FEW BIBASILAR CRACKLES. STRONG COUGH, SXTED FOR THICK WHITE SPUTUM. RSBI 57.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. LOOSE BROWN STOOL VIA FIB. OGT IN PLACE AND PATENT. UOP 30-55CC/HR YELLOW WITH SEDIMENT. CREAT DOWN TO 5.5.\n\nFEN: +4.2L BUT PERIPHERAL EDEMA PERSISTS. LYTES PER CAREVUE. LFT'S IMPROVING BUT AMYLASE WAS UP. CONTINUES ON TUBE FEEDS @30CC/HR WITH MINIMAL RESIDUALS. FS Q6HRS WITH SSRI.\n\nID: TMAX 97.1 WITH WBC BUMPED TO 24.3 FROM 18. CONTINUES ON ZOSYN AND FLAGYL. VANCO LEVEL PENDING.\n\nSKIN: W/D/I WITH YEAST RASH IN PERINEUM.\n\nACCESS: CVL.\n\nSOCIAL/DISPO: FULL CODE. AWAITING PEG AND TRACH, POSSIBLY .\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-15 00:00:00.000",
"description": "Report",
"row_id": 1444722,
"text": "NPN 7a-7p:\n Neuro: fentanyl gtt dc'd this am. Pt denies pain, is calm, opens eyes to voice. Med with fentanyl 25mcg iv x 2 for bronchoscopy with good effect. Pt is HOH, but able to communicate best by staff asking pt questions via dry erase board, and pt gesturing yes/no.. wears glasses.. family to bring in hearing aid. OOB to chair via x 2 hrs, tolerated well.\n RESP: remains vented PSV 12/5/.40. tv's 300's x 20-15, sats high 90's. MV 7.5, which is goal. did not retrial weaning today. Bronchoscopy was done, showed small amts yellow secretions. Pt sx for copoius thick, yellow secretions throughout the day. LS crackles.\n CV: HR 70's-80's, nsr. sbp 1teens to 130's. CVP 3-5. no further lasix today.\n GI: no ngt, will reevaluate ability to wean/extubate tomorrow, if not, will replace ngt. fecal incontinence bag intact. 100cc's stool out. sent for cdiff.\n iD: afebrile. wbc 26.5. UA sent, stool sent. all other cx ngtd.\n GU: foley intact, urine with sediment, yellow, adequate amts. bun/creat remain elevated. team to discuss starting allopurinol as uric acid 13.8.\n Social: visited by several family members in short visits. Family spoke to Dr. and informed him pt would want a trache at least for a transitional period, so her code status was reversed. pt now a full code.\n Integ: intact except for yeast like rash to groin. aloe vesta cream with anitfungal ointment applied.\n A/P: secretions/resp acidosis remain barrier to extubation. pt s/p bronch, oob to chair today. Plan to reevaluate ability to wean vent tomorrow. If no, would replace feeding tube and soon would address issue of trach/peg.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-16 00:00:00.000",
"description": "Report",
"row_id": 1444723,
"text": "Nursing Note: 1900-0700\nNo significant events.\n\nNEURO: Alert/following commands intermittently. Denies pain. MAE and able to nod head to yes/no questions. Cough/gag intact.\n\nRESP: Remains vented on PSV 15/5/40% maintaining sats mid to high 90s and goal MVs . LS coarse throughout; sx frequently for mod - copious amt of thick, yellow sputum. RR 20s.\n\nC/V: HR 60s-80s with few episodes of bradycardia to high 50s; SR. NBP 100s/50s. CVP 5-12. Receiving maintenance fluids @ 100/hr. Pulses palpable.\n\nID: Afebrile; continued coverage with Flagyl and Zosyn.\n\nGI/GU: Feeding tube out; will replace if continues on vent; will reassess today. Abdomen soft, fecal bag active for liquid stool. U/O ~ 50cc/hr.\n\nSKIN: Intact; yeast like rash at perianal area.\n\nENDO: Covered with ss insulin.\n\nDISPO: Full code; micu green; no contact from family overnight.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-19 00:00:00.000",
"description": "Report",
"row_id": 1444737,
"text": "MICU NPN 7P-7A\nNEURO: AWAKE AND ALERT, EASILY AROUSABLE WHEN ASLEEP. MAKING NEEDS KNOWN BY WRITING. ALWAYS ASKING FOR WATER. NO C/O OF PAIN BUT DOES NOT LIKE LYING FLAT FOR TURNS/CARE AS SHE FEESL LIKE SHE CAN'T BREATH. MOVING ALL EXTREMITIES. FOLLOWS COMMANDS APPROPIATELY. RESTRAINTS IN PLACE FOR SAFETY OF LINES/TUBES AS SHE WILL REACH FOR HER ETT DESPITE REMINDERS.\n\nCARDIAC: HR 34-66 SB/SR WITH NO ECTOPY. HR <50 WHEN ASLEEP, BP STABLE. BP 118-141/47-67. PPP. HCT STABLE @29.\n\nRESP: REMAINS ON CPAP 18/+5 40%. TV'S 400-500CC, RR 19-27 AND SATS 96-98%. LS COARSE WITH BIBASILAR CRACKLES. SXTED FOR WHITE TO YELLOW THICK SPUTUM. NO PLANS FOR FURTHER WEANING.\n\nGI/GU: ABD OSFT AND DISTENDED WITH +BS. LOOSE BROWN STOOL VIA MUSHROOM. OGT IN PLACE AND PATENT. UOP 17-120CC/HR, YELLOW AND CLEAR. CREAT IMPROVED TO 6.1.\n\nFEN: NO LASIX GIVEN OVERNOC. +3.7L LOS. PERIPHERAL EDEMA PRESENT. LYTES PER CAREVUE. TUBE FEEDS @30CC/HR AND WITH SCANT RESIDUALS. FS Q6HRS WITH SSRI.\n\nID: TMAX 97.3 WITH WBC 18. CONTINUUES ON ZOSYN AND FLAGYL. VANCO LEVEL PENDING.\n\nSKIN: W/D/I.\n\nACCESS: CVL.\n\nSOCIAL/DISPO: PATIENT NOW FULL CODE. PLAN IS FOR TRACH/PEG SOMETIME THIS WEEK PER PATIENT'S WISHES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-19 00:00:00.000",
"description": "Report",
"row_id": 1444738,
"text": "NPN 7a-7P:\n Neuro: Pt awake, alert, following commands, communicating by dry erase board, appropriate in conversation. reporting mild discomfort in back intermittently which was alleviated with change in position. Pt oob to chair via lift.\n CV: hR 50's-60's SB/NSR, cvp 8-9 and bp 130's-150's systolic.\n REsP: vented via ETT. PSV 18/5/.40 with tv's 450 x 20-24.. plan to gently wean PS with goal MV about 7.5. Remains on prednisone.\n GI: ab soft, bs +. fecal incontinence collector applied. tf's nepro at 30 at goal.\n ID: WBC 18.1 today. remains on flagyl po for ? c-diff (cx negative), vanco and Zosyn for pna. am vanco level 12.1.. vanco dose given today. afebrile.\n GU: foley intact, uo adequate with sediment.\n Integ: groin/buttocks with yeast like rash.. improved from 48 hrs ago... mycostatin powder applied with double guard over this. pt received 1x dose diflucan for s/s vaginal yeast infection.. pt with white vaginal discharge and reporting itchiness.\n Social: pt with several family members visiting.. HCP and Daughter requesting to speak to SW in order to find out r/e gaining power of attorney over pt's finances, so that pt's money can be used for pt's own bills. will contact SW.\n FE: fsbs covered by ssi q 6 hrs. fluid balance 500cc's + so far today.\n A/P: pt with minimal weaning today. plan to contact surgery on r/e trach/peg. f/u re/ SW consult. cont skincare. follow cx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-12 00:00:00.000",
"description": "Report",
"row_id": 1444707,
"text": "NPN 7p-7a:\n Nuero: pt remains lightly sedated on Fentanyl 50mcg/hr gtt. opens eyes to stimuli, initially following commands intermittently, but not doing so later in shift.. ? r/t sedation kicking in. MAE. PERRLA. Earlier in shift, shook head \"no\" when asked r/e pain.\n RESP: vented A/C 450 x 25/peep 5/.40. Sats low to mid 90's with ABG: 7.33/38/122/21. SX for moderate to large amts greenish/yellow secretions. LS crackles throughout..\n CV: HR 70's NSR with occasional PAC's. SBP 90's-1teens. CVP 13.\n ID: all cx ngtd.. EBV and CMV show past exposure, no active infection. pt continues on vanco (received 1xdose at 8pm, am level pending), azithro, pip. afebrile. am wbc pending.\n GU: UO 20-80cc's/hr. ua sent. urine yellow with sediment.\n GI: ab softly distended, bs +. on Lactulose. small smearing of stool, + flatus. tf's held d/t elevated pancreatic enzymes and pt vomited bile yesterday. 300 cc's bile out via ngt since yesterday, now clamped. on lansoprazole.\n Integ: intact.\n Social: visited by dtr and several grandchildren.\n Access: R subclavian tlc. aline replaced as waveform dampened and line not drawing back.\n A/P: 75 yr old vented on abx for sepsis unknown origin. cont to follow cx, cont abx. to hold tf's and follow pancreatic enzymes/liver enzymes for now. am labs pending. need bronch today to assist in clearing thick secretions. cont to support pt/family as doing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-12 00:00:00.000",
"description": "Report",
"row_id": 1444708,
"text": "npn 0700-1900\n\nPt failed PS trial again today; she became acidotic to 7.21 and hypercarbic.\nOtherwise, no changes today.\n\nneuro: Sedation weaned from 50mcg/h fentanyl to 30mvg/h fentantyl and is being tolerated well. Pt responds to verbal stimuli, follows commands intermittently. She is very HOH and nearly blind from cataracts (per daughter). MAE on the bed, PERL @ 3mm.\n\nresp: AC 450/25/40% PEEP 5. Copious secretions that are thick and yellow. LS coarse throughout with crackles at bases. Crackles are thought to be from interstital lung disease, as opposed to fluid.\n\ncv: SR with PAC's with a rate in the 70-80's. BP with MAP 70-75.\n\naccess: L radail aline, RSC tlc, 1 piv.\n\ngi/gu: Abdomen is soft, distended with + BS. Pt now has liquid brown stools following 3 days of lactulose. Mushroom cath in place. Started on reglan to help with increased residuals. TF off since yesterday because patient was vomitting. need a post-pyloric tube.\nPatent foley with sedimented yellow urine. Pt is in ATN per renal consult yesterday, but u.o has increased today.\n\nskin: No issues.\n\nendo: RISS.\n\nSocial: Very large family; boundaries have been established for visiting; noon-8 pm and 2 visitors at a time. Social work is involved.\n\ndispo: Full code.\n\nplan: Re-start TF at low rate tonite and see if it is tolerated. Continue with frequent suctioning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-15 00:00:00.000",
"description": "Report",
"row_id": 1444719,
"text": "pmicu nursing progress 7p-7a\nreview of systems\nCV-vs have been stable.\n\nRESP-rested on a/c to rest overnight- x 40% x 18 breaths x 450 ccs with 5 peep.os sats have been >95%.abg last evening was good with po2 118, pco2 50 and pH 7.35. lungs are coarse throughout bilaterally.has required sx for large amts thick white yellow sputum, also copious amts oral secretions.RSBI this am was 95.\n\nID-afebrile. wbc for this am is pnd. receiving iv antibx overnight, po held as patient d/cd her NGT.vanco being renally dosed.\n\nGI-abd is soft with positive bowel sounds.as above she pulled out her feeding tube despite being restrained. HO aware.has been npo since.passing liquid brown stool via rectal bag.is on a ppi.\n\nF/E-was tx with 80 mgs iv lasix with a poor diuresis.has minimal peripheral edema. am labs pnd.\n\nNEURO-seemed tired after family left.has been alert most of the night.removed her ngt despite being restrained.was restarted on her fentanyl drip at 30 mcgs/hr, was bolused x 1 for bath. slept poorly. has been batting hands away and biting down on thermometers, mouth care swabs.shaking her head \"no\"\n\nSKIN-is grossly intact.her perineal area is starting to look red and yeasty-\n\nIV ACCESS-has a triple lumen R subclavian-dresssing change done.\n\nSOCIAL-had several family members in till 8 pm, then a few till 8:30. they seem very devoted.i do think that their visits tire out the pt as she seemed exhausted after they left.\n\na-uneventful night\n\nP-would consider carefully extubating her as she is loaded with secretions.assess need to replace NGT again.monitor i's and o's, labs.\nnystatin powder for rash\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-15 00:00:00.000",
"description": "Report",
"row_id": 1444720,
"text": "Respiratory Care\npt. intubated on ventilatory support. Suctioned for copious amounts of secretions. A.M. RSBI 95 but pt. unable to tol SBT, C/O not getting enough air, titrated PSV to pt minute ventilation requirements. Currently tol PSV 5/12 appears comf. Last ABG reveals partially compensated respiratory acidosis. Plan is to continue to attempt to wean from ventilatory support as pnx improves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-15 00:00:00.000",
"description": "Report",
"row_id": 1444721,
"text": "respiratory care\npt is on CPAP+PS 12/5, 40%. Tolerating PSV well. Bronched for few secretions, but previously had copious secretions. MDI changed to combivent Q4. Reassess for extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 1444733,
"text": "resp care\nPt remained on a/c 450x18 40% 5peep with peak/plat 28/24. BS coarse bil. Suct for sml amts of thick white sput. combivent mdi given as ordered.Rsbi done =108, spont breathing trial not started.Pt with frequent coughing spells and c/o of sob. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 1444734,
"text": "Respiratory Therapy\n\nPt remains orally intubated weaned to PSV this shift. SpO2 remained 90s. BLBS coarse, suctioned for moderate amounts of thick white sputum. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support; trach placement soon\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 1444735,
"text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable, hr in the 60's nsr with no ectopy noted.bp also stable. no c/o chest pain.\n\nRESP-has remained on same vent settings, a/c x 40% x 450 ccs x 18 breaths with 5 peep.o2 sats have been good.has been sx q3-4 hours for thick white sputum, lungs sound coarse throughout.pt has decided upon trach and PEG as discussed on rounds with pt and team.\n\nGI-abd soft with positive bowel sounds.tube feeds of nepro infusing at goal rate, minimal residuals.passing liquid brown stool via mushroom catheter.is on ppi.\n\nF/E-no further lasix given today-has been voiding yellow cloudy urine.\nno peripheral edema noted.BUN/creat= 106/66, improving slowly.pt always begging for water\n\nID-afebrile. wbc=20.9. on zosyn and po flagyl for pna, flagyl dose decreased to . nystatin powder to perineal area for yeasty looking rash.\n\nSKIN-grossly intact.rash as above.\n\nENDO-receiving regular insulin as per sliding scale.\n\nIV ACCESS-has a triple lumen R neck-dressing changed.attempted a-line x 2- unsuccessful.\n\nSOCIAL-various family members in today-met with team and patient- patient able to express her feelings by writing and her wishes are known.\n\na-uneventful day\n\nP-will not aggressively wean as plans for trach are being made.continue with good pulm toilet, skin care.assess need for further lasix all though pt is constantly THIRSTY!!keep family updated as to all plans, procedures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-19 00:00:00.000",
"description": "Report",
"row_id": 1444736,
"text": "Resp: pt on psv 18/5/40%. Ett #7.5, 21 @ lip. Alarms on and functioning. Ambu/syringe @ hob. BS are coarse bilaterally. Suctioning for moderate amounts of thick white secretions. MDI's administered combivent with no adverse reactions. No abg's/no aline. Code status changes, plans to be trached.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-14 00:00:00.000",
"description": "Report",
"row_id": 1444714,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT RECEIVED BY THIS RN TO BE VERY LETHARGIC, DIFF TO RESPOND. INF AT 30MCQ'S AND WAS DECREASED TO 20MCQ'S. PT BECAME MORE ALERT AND RESPONSIVE. PT MOVING ALL EXTREM. PEARL. INC BACK TO 30MCQ TO HELP PT GET SOME REST AND TO TOLERATE BEING BETTER. PT MOUTHING WORDS APPROPRIATELY TO MAKE HER NEEDS KNOWN. PT MORE COOPERATIVE WITH CARE THIS EVENING.\n\nRESP: PT RECEIVED ON PT NOT OVERBREATHING RATE OF 20. O2 SAT'S DROPPED TO THE 80'S, ABG SENT AND PT WAS IN METABOLIC ACIDOSIS. PT THEN PLACED BACK ON A/C WITH RATE OF 25, AND 5 PEEP, O2 SAT BACK UP INTO THE HIGH 90'S. PT COUGHING AND SX FOR COPIOUS AMT'S OF YELLOW SPUTUM. INITIALLY SPUTUM VERY THICK AND THEN BECAME VERY FROTHY. LUNG SOUNDS VERY COARSE WITH RALES AT THE BASES. ETT HANGING OUT OF MOUTH AND NEEDED TO BE REPOSITIONED BACK TO 21CM. ONCE ETT POSITION SECURED PT SEEMED TO BE COUGHING LESS. PT HAD A GOOD RISBI\nTHIS AM. PT PLACED BACK TO PS/PEEP THIS AM. NO APPARENT DISTRESS AT THIS TIME.\n\nCV: HR NSR WITH OCC PVC'S. 70'S-80'S. OCC WOULD HAVE SHORT BURSTS OF RAPID HR UP TO THE 130'S. BP WITHIN NORMAL LIMITS ALL NOC. AFEBRILE.\n\nGI: CONT WITH TUBE FEEDS AT 40/HR OF NEPRO. MINIMAL RESIDUALS. PASSING MOD AMT'S OF LIQ BROWN STOOL. FECAL BAG REPLACED. ABD SOFT/DISTENDED WITH POS BOWEL SOUNDS.\n\nGU: PT 80MG LASIX IVP OVERNIGHT. FOLEY PATENT DRAINING MOD AMT'S OF YELLOW URINE WITH SEDIMENT.\n\nACCESS: PT WITH TLC. ALL PORTS PATENT.\n\nENDO: RECEIVED SSRI OVERNIGHT. CHECKING FINGERSTICKS Q 6/HRS.\n\nSKIN: INTACT. PNEUMOBOOTS ON.\n\nSOCIAL: FAMILY VISITED LAST EVENING. PT CONT TO BE A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-11 00:00:00.000",
"description": "Report",
"row_id": 1444704,
"text": "npn 0700-1900\n\nneuro: Pt was started on 50mcg/h of fentanyl at 1630 for increasing agitation and she appeared uncomfortable. MAE on the bed, PERL @ 2mm.\n\nresp: AC 450/25/40% PEEP 5. Pt sats currently 90-93%. CXR done at 1700 because of decreased sats. Results pending. Pt failed PS trial twice this am; became acidotic to 7.19 with Co2 of 58. Copiuis secretions, thick yellow. So thick at times it is difficult to get secretions to pass thru the catheter. Suctioning every 30-45 minutes.\n\ncv: SR in the 70's, no ectopy. BP with MAP >65.\n\naccess: RIJ tlc, R radail aline, 1 piv.\n\ngi/gu: Abdomen is soft distended with + BS. No BM this shift, is reciving lactulose for ? of encephalopathy at time of admission. TF has been off since 6am. This am patient vommitted copious amounts of bilious drainage. Since it has been comnnected to LIWS. Patent foley with 20-40cc/h of urine. received 80mg IV lasix this am. renal consult today.\n\nskin: No issues.\n\nendo: RISS. No coverage required.\n\nID; Afebrile. Zosyn, azithromycin, and Vanco dosed by level. receiving a dose of Vanco this evening.\n\nSocial: family has expressed some frustration around the visiting policy beginning at noon and 2 visitors at a time(inability to visit in the am because of rounds in the unit/pt care). This RN attempted to explain the rationale, they spoke with social work and also were updated by Dr. .\n\nPlan: CXR results, aggressive suctioning, please hang vanco whn calcium is finished.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-11 00:00:00.000",
"description": "Report",
"row_id": 1444705,
"text": "Patient switched from PS to A/c due to copious amount of thick green sputum and ABG with low Ph 7.19.Requested bronchoscopy but MD does not think is necessary @ moment.Being treated with albuterol and mucomyst,will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-12 00:00:00.000",
"description": "Report",
"row_id": 1444706,
"text": "Respiratory Care\nPt. intubated on ventilatory support. ABGs with a Respiratory compensated metabolic acidosis, good oxygenation. continue to sx pt. for yellow-green secretions, but are less tenacious. RSBI 102 this a.m., pt. quickly become restless and HR increase from 76-88 during the minute trial very small Vt 68-220 cc with inconsistent volumes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-22 00:00:00.000",
"description": "Report",
"row_id": 1444752,
"text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 96 this morning but no weaning done due to bedside trache. Trached at bedside with #8 portex, inner cannula in place, sxn for some bloody secretions post trache. Combivent MDI Q4. Cont current support, assess for readiness to wean in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-23 00:00:00.000",
"description": "Report",
"row_id": 1444753,
"text": "Resp: pt on a/c 18/450/+5/40%. Pt has #8 portex trach. Alarms on and functioning. Ambu/syringe @ hob. BS are coarse bilaterally. Suctioned for moderate amounts of thick bloody secretions to tannish. MDI's administered as ordered combivent with no adverse reactions. No abg's this shift. RSBI=169. Will attempt to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-14 00:00:00.000",
"description": "Report",
"row_id": 1444715,
"text": "Respiratory Care\nPt. remains intubated on ventilatory support. At beginning of shift pt very agitated, chewing on tubes and attempting to pull out OG and ETT. Pt. found with ETT partially out, successfully resecured at the appropriate placement and pt. quieted. Pt ABGs on revealed a respiratory acidosis, combined with pt. agitation and copious secretions, modality returned to A/C for rest. Pt. suction ealier in shift for copious amounts of thick yellow secretions, lessened over duration of shift. Good A.M. RSBI @ 55, but pt. C/O dyspnea when RSBI trial finished, PSV titrated to pt. comfort. At present pt. tol PSV 5/10 well and w/o complaints.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-14 00:00:00.000",
"description": "Report",
"row_id": 1444716,
"text": "NPN-MICU\nMrs cont to make slow progress.\n\nResp:pt was weaned to PSV of she did well with RR of 18-24 and TV of 350-400cc. She had O2 sats of >97%. She cont to have a mod amt of thick secretions require sx q2-4hrs. She looked comf on vent but her ABG showed her to bee increasingly acidotic again. Her renal function is slow to return. So she will remain intubated overnight and be reevaluated in the am. She was placed back on A/C for now.\n\nNeuro:pt was taken off fentanyl after her pedi tube was placed. she is awake and interactive with her family. she will not always particiupate in her care and she still tries to refuses things like:mouth care and turning. She will follow simple commands.\n\nGI: pt had post pyloric pedi tube placed under fluro without incident.\nshe hasno asp and cont to pass liq stool. 2nd stool spec sent for c.diff. she cont on flagyl. her TF have been restarted after the decision was mad enot to extubate her.\n\nGU: pt renal function is about the sme with BUN/CR of 108/7. She is about equal sl neg but the renal team wants to allow pt to auto diures on her own. CXR still suggest she is vol overloaded.\n\nCV: pt has been maintaining BP on her own 100-130's/ 70's, her Hr has been in the 80's\n\nID:pt is afebrile but WBC ct is still up at 28.she will cont on x3 IVAB and vanco level is pnd\n\nSocial:family meeting with pt's son and x2 daughters. Dr. explained plan that if she was ready to be extubated than we would. He also asked about what their mom would want if they had to reintubate her and how she would feel about long term care/trach in the event that she failed her extubation. All agreed that the pt would not want to be in long term care or have a trach. There is now one daughter that does not agree with this. They were reassured by nsg that the medical team would cont to talk daily about her care and that they need to keep in mind what the pt really wants.\n\na/P:Will rest overnight and cont with aggressive pulm. re evaluate ability to be extubated in the am.\n Follow vanco levels and\n Follow stool amt and send 3rd stool spec tomorrow.\n Follow renal fucntion and watch for autodiuresis\n Restart fentanyl if needed for comf on vent.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-14 00:00:00.000",
"description": "Report",
"row_id": 1444717,
"text": "Respiratory Care Note:\n Patient weaned to PSV of today for several hours. ABG with uncompensated respiratory acidosis and patient was placed back on A/C mode. See Carevue flowsheet for settings. Plan to wean again in am. Suctioned for moderate amount of thick yellow sputum and receiving albuterol MDI Q4. BS coarse bilat.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-14 00:00:00.000",
"description": "Report",
"row_id": 1444718,
"text": "Respiratory Care\nABG drawn from Left radial artery successfully and w/o incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 1444728,
"text": "Nursing Note: 1900-0700\nSignificant events: Bradycardic to 40s.\n\nNEURO: Alert/following commands. Mouthing words in attempt to make needs known; nods to yes/no questions. MAE. Denies pain. Sleeping intermittently. Cough/gag intact.\n\nRESP: Received on A/C 450X18/5/40% maintaining sats high 90s. Mode changed from PSV previous shift secondary to acidosis. Has remained on A/C entire shift. Failed RSBI (no spontaneous breath for 30 sec). LS coarse throughout; sx frequently for mod amt thick sputum. Chest CT today to further evaluate respiratory status.\n\nC/V: Several episodes of bradycardia to 40s but resolving spontaneously. HR on slow but consistent decline last 24hrs ranging 50s-60s. EKG from previous shift unchanged. Team aware. NBP 110s-120s and not reactive to bradycardia. Hct stable at 30. Bun/Creat $ enzymes continue elevated. No appreciable edema; pulses palpable.\n\nID: Afebrile; covered with Flagyl, Zosyn for pna.\n\nGI/GU: OGT replaced and TF restarted; tolerating Nepro @ 20cc/hr with goal of 30cc/hr; no residual. Abdomen soft with hyperactive sounds; brn liquid stool via mushroom cath. U/O 25-60cc/hr.\n\nENDO: Covered with ss insulin.\n\nSKIN: Intact; perineal redness.\n\nDISPO: Full code; micu green. Grandchildren visiting beginning of shift; appropriate and appreciative of care. No other contact from family overnight.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 1444731,
"text": "NPN 7a-7p (cont)\n GI: ab soft, bs +. tf's at goal. liquid brown stool out via mushroom catheter.\n GU: foley catheter leaking. changed to 18 french. urine clear, yellow at this time. await response to lasix. bun 104/creat 6.8.\n Integ: yeast infection to groin. mycostatin powder and double guard applied.\n fe: am k repleated. pm labs pending.\n Social: conversation had this am by team, this RN and pt.. pt consistently writing by dry erase board that she wants her ett out, even though that means she will soon pass away. Pt understands and still wishes to have ETT out. family meeting held with pt's HCP (dtr), and pt's son (alternate hcp), Dr. , this RN and team.. Discussed pt's poor prognosis/life expectency, that she will be chronically vent dependent, and pt's wishes for extubation. and in agreement to extubate pt and make her comfortable. Plan is for to discuss with her mother if she would like to wait until after pt's sister returns from a cruise on saturday to have ett out. and to call pt's other children to come to be present as well as other family who pt would like to see. pt to remain intubated at this time until these decisions made.\n A/P: pt with continued vent dependency. Stating desire to be extubated and made comfortable.. and in agreement.. PLan is for to discuss this with pt this eve, ask pt r/e timing of this. will remain intubated o/n and f/u with family r/e final decisions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 1444732,
"text": "Nursing Note: 1900-0700\nSignificant events: C/O chest pain; EKG done with no significant changes. MSO4 1mg given with effect. No further complaints.\n\nNEURO: Alert/following commands consistently. Able to make needs known by writing on white board. MAE. Strong cough/gag.\n\nRESP: Continues on A/C 450X18/5/40% maintaining sats mid to high 90s. Overbreathing 1-3 breaths. LS coarse throughout. Frequent sx for mod amt wht/thk sputum.\n\nC/V: CP as stated above. Few episodes of sinus brady to 50s; generally HR in 60s with occasional PVC. NBP 110s-120s. Hct stable @ 30. No appreciable edema.\n\nGI/GU: Tolerating TF Nepro at goal rate of 30cc/hr via ogt; no residual. Abdomen soft; mushroom cath active for liquid brn stool. Received Lasix at end of previous shift and u/o reflective with adequate amt.\n\nENDO: Covered with ss insulin.\n\nID: Afebrile; receiving Zosyn/Flagyl for PNA.\n\nDISPO: Family mtg on indicating extubation and possible cmo status; family informed this RN of patient's wishes to continue to live and would want trach placement. Patient wrote \"I want to live but I can't breathe\" to this RN. Team informed of patient's wishes; family to have mtg with attending MD to discuss options.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-23 00:00:00.000",
"description": "Report",
"row_id": 1444754,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT DOZING INTERMITTENTLY AT BEGINING OF SHIFT BUT WAS EASILY AROUSED. AFTER TURNING AND COUGHING PT C/O NECK AND ABD PAIN. PT MED WITH TOTAL OF 100MCQ OF OVERNIGHT. PT ABLE TO MAKE NEEDS KNOWN. ABLE TO WRITE MESSAGES ON BOARD. PEARL. MOVING ALL EXTREMETIES AND ABLE TO HELP WITH TURNING IN THE BED.\n\nRESP: PT AND REMAINS ON VENT WITH NO VENT CHG'S MADE OVERNIGHT. PT HAS BEEN SX'D FOR MOD AMT'S OF BLD TINGED SPUTUM. TRACH SITE OOZING SM AMT'S OF DK BLD. TRACH CARE DONE. O2 SAT'S IN THE HIGH 90'S.\n\nCV: PT IN NSR WITH OCC PAC'S HR DROPPING DOWN INTO THE LOW 40'S. BP UNAFFECTED BY LOW HR. AFEBRILE. NO ISSUES.\n\nGI: PT STARTED ON TUBE FEEDS, INC RATE BY 1OCC/Q4-6/HRS. TOL WELL. PASSING LOOSE GREEN STOOL VIA MUSHROOM CATH. NO OBVIOUS BLEEDING. ABD SOFT WITH POS BOWEL SOUNDS.\n\nGU: FOLEY CATH PATENT DRAINING SMALL AMT'S OF YELLOW URINE WITH SEDIMENT.\n\nENDO: COVERED WITH SSRI OVERNIGHT.\n\nIV ACCESS: PT WITH TLC WITH ONE PORT CLOTTED OFF. KL\n\nSOCIAL: PT HAD VISITORS LAST EVENING NO CALLS OVERNIGHT. PT IS FULL CODE. PLAN FOR REHAB. CONT TO WEAN OFF VENT IF ABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 1444729,
"text": "respiratory care\npt started shift A/C setting as charted on flowsheet. RSBI (89) placed on CPAP+PS 10/5 on 40%. An increase WOB and cough required a change back to A/C 450*18/5 on 40%. Pt requires frequent suctioning leading to moderate thick, clear secretions. Pt receiving MDI's per order. Family meeting to discuss possible extubation. Will continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 1444730,
"text": "NPN 7a-7P:\nREview of Systems:\n NEUro: Pt alert, able to communicate needs by writing on dry erase board.. able to read conversation and respond by gesturing and writing. REporting some pain in bladder area.. states feels like bladder infection. cx are pending. foley catheter changed today. sleeping this afternoon, appears comfortable. assisting with turns. oob to chair x 3 hrs.\n RESP: remains vented a/C 450 x 18/peep5/.40.. sats high 90's.. attempted change to psv, but pt with 2 hrs coughing jag.. sx for thick white secretions in moderate amts. LS remain course.. returned to A/C and eventually able to settle out.\n CV: HR 60's bp 120's-130's. cvp 9-13.\n FE: pt 1L fluid balance positive yesterday, and 1L positive as of 12 pm today. treated with lasix 20mg iv x 1, then 80mg iv lasix x 1 as minimal response to 20mg dose. repleated with kcl 40meq pogt.\n ID: tmax 100. #3 cdiff spec sent. foley changed. wbc 23.4. on flagyl po (suspect cdiff)and zosyn ( pna)\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-13 00:00:00.000",
"description": "Report",
"row_id": 1444712,
"text": "npn 0700-1900\n\nPt changed to MMV this am and has been tolerating well.\nFamily meeting today to discuss plan of care. This morning Mrs. was clearly mouthing to the nurse: \"Stop\", \"No\", \"Leave me alone\" when nurse was trying to provide care. Family has stated that pt would not want this treatment. Stated that she \"is going to kill us for doing this\" when she wakes up. Patient did not express any of her wishes to the MD. She is nearly deaf and doesn't see well which made communication difficult.\n\nneuro: Pt is alert, opens eyes spontaneously, follows commands. Was off sedation for 4 hours today so that she could participate in family meeting. Sedation re-started at 1500 at fentanyl 30 mcg/h. PERL @2mm.\n\nresp: MMV 450/20/40% PEEP 5. Still with copious secretions, although they have thinned.\n\ncv: SR in the 70-80 with occasional to frequent PVC's. BP with MAP 70-80.\n\naccess: Aline was removed this am- unable to obatin a tracing. R SC tlc.\n\ngi/gu: Abdomen is soft with + BS. TF at 40cc/h which is being tolerated with minimal residuals. Patent foley with sedimented yellow urine. Received 80mg IV lasix this afternoon. Goal is for 1 liter negative today.\n\nskin: Intact, no issues.\n\nendo: RISS, no coverage required.\n\nid: WBC increased this am. Flagyl added to cover possible c-diff. Remains on azithromycin, zosyn and vanco dosed by level.\n\nsocial: Many family members visiting today.\n\ndispo: full code.\n\nplan: Continue to wean as tolerated.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-10-13 00:00:00.000",
"description": "Report",
"row_id": 1444713,
"text": "Resp. Care Note\nPt remains intubated and vented on vent settings as charted on resp flowsheet. Pt awake and restless in AM, mouthing NO,NO, reaching for ETT. Sedation increased and pt appearing more comfortable, awake but not as restless. Vent settings changed to MMV during rounds,periods of primarily spont breathing and then periods of complete vent support. Cont to require freq sxn for looser yellow secretions, copious at times. Albuteorl MDI Q4. Cont current support, assess daily for readiness to wean.\n"
}
] |
64,694 | 106,790 | 78 yo F with PAF on coumadin, dementia, ESRD on HD, CAD who presents with posterior nasal bleed. Pt was initially admitted to OSH last Friday for epistaxis in the setting of elevated INR 3.2 and taking ASA, Plavix and coumadin. She received 3 units PRBC and 4 units FFP. She was stable until rebleeding on at dialysis and transferred to . . # Epistaxis: Patient was transferred to for epistaxis requiring multiple transfusions. She was initially admitted to the MICU, where ENT placed balloon in left nostril for posterior bleed. Her hematocrit remained stable while in MICU and she did not require further transfusion. She remained hemodynamically stable and the nasal balloon was removed from her left nostril on without complication. Per ENT, if the patient has any additional epistaxis, use afrin in each nostril, lean head forward, pinch nostrils closed for 20 minutes. Patient should return to the hospital for any bleeding that does not resolve with these measures. Coumadin should continue to be held for two weeks, and restarted thereafter. ASA should be held for an additionally week, and restarted at 81 mg daily thereafter. Plavix should be discontinued permanently. . # ESRD: Pt on TTS schedule, last HD . Next dialysis planned for Tuesday, . She should continue nephrocaps and sevelamer. She will also continue to receive epogen with dialysis. Additionally, patient should continue to receive fluconazole with dialysis for a total four week course. . # HTN: Antihypertensive medications were additionally, held and gradually restarted for goal systolic BP of 110. She should continue home anti-hypertensive regimen with amlodipine, metoprolol, hydralazine and Imdur at discharge. . # Dementia/ Hx of embolic CVA: Coumadin and antiplatelet agents were held during this admission, given significant nasal bleed. The patient should resume anticoagulation with coumadin 2 weeks after discharge, and should restart ASA 81 mg 1 week after discharge. . # CAD: S/p PCI with stent placement . All antiplatelet agents were held on this admission. She was continued on statin and antihypertensive regimen. Given that last PCI was greater than one year ago, the patient may discontinue plavix completely at discharge. She should restart ASA 81 mg one week after discharge for coronary artery protection. . # Hx COPD: Continued on inhalers prn. . # Hx childhood seizures: The patient was continued on home dose keppra for seizure prophylaxis. . # COMM: and Daughter , MD and son are HCP. Daughter's phone numbers: | Was seen by ENT and Epistat packing with resolution of bleeding until this AM when she rebled during HD. .H/O epistaxis (Nosebleed) Assessment: Action: Response: Plan: # h/o CVA- hold anticoagulants and antiplatelets given epistaxis recently . # h/o CVA- hold anticoagulants and antiplatelets given epistaxis recently . Monitor for recurrent epitaxis. Monitor for recurrent epitaxis. Candidemia unclear source; continue fluconazole with HD. # Recent candidemia- continue fluconazole with HD - CIS . .H/O epistaxis (Nosebleed) Assessment: Admitted from OSH ( see admission Assessment for PMH) S/p recurrent epistaxis yesterday. .H/O epistaxis (Nosebleed) Assessment: Admitted from OSH ( see admission Assessment for PMH) S/p recurrent epistaxis yesterday. .H/O epistaxis (Nosebleed) Assessment: Pt recd with Vasoline packing in L nare around Epistat packing. .H/O epistaxis (Nosebleed) Assessment: Pt recd with Vasoline packing in L nare around Epistat packing. .H/O epistaxis (Nosebleed) Assessment: Pt recd with Vasoline packing in L nare around Epistat packing. # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy initially. # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy initially. # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy initially. # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy initially. Transfuse to maintain Hct >27 ESRD continue T/Th/Sat schedule; renal adjusted medications. Po eve meds held. Po eve meds held. .H/O altered mental status (not Delirium) Assessment: Pt lethargic, O X 2(person, hospital). .H/O altered mental status (not Delirium) Assessment: Pt lethargic, O X 2(person, hospital). # h/o CVA- hold AC and anti plt given epistaxis . Pt to place PICC at bedside with ultrasound, then to start on TPN, at least until nasal packing removed. Chief Complaint: Epistaxis (transfer from hospital) HPI: 78 F with ESRD, CAD, h/o CVA, COPD admitted from NH to with epistaxis in the setting of ASA, Plavix, Coumadin. COAGULOPATHY hold coumadin while active bleeding. # Recent candidemia- continue fluconazole with HD - culture if spikes - Also question of an aortic mass per patients daughter on a previous ECHO. # Recent candidemia- continue fluconazole with HD - culture if spikes - Also question of an aortic mass per patients daughter on a previous ECHO. .H/O altered mental status (not Delirium) Assessment: Pt lethargic, O X 1. Also put in restraints briefly for picking at nasal packing Allergies: Codeine Unknown; Meperidine Unknown; Ace Inhibitors Unknown; Hydrocodone Unknown; Sulfa (Sulfonamides) Unknown; Penicillins Unknown; Last dose of Antibiotics: Infusions: Other ICU medications: Lorazepam (Ativan) - 08:21 PM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:52 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since AM Tmax: 36.8C (98.3 Tcurrent: 36.2C (97.2 HR: 99 (79 - 105) bpm BP: 168/46(76) {128/41(67) - 168/91(96)} mmHg RR: 21 (11 - 22) insp/min SpO2: 94% Heart rhythm: SR (Sinus Rhythm) Total In: PO: TF: IVF: Blood products: Total out: 0 mL 0 mL Urine: NG: Stool: Drains: Balance: 0 mL 0 mL Respiratory support O2 Delivery Device: Aerosol-cool room air SpO2: 94% ABG: ///27/ Physical Examination General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Labs / Radiology 263 K/uL 11.7 g/dL 126 mg/dL 4.1 mg/dL 27 mEq/L 4.0 mEq/L 21 mg/dL 103 mEq/L 144 mEq/L 37.0 % 13.5 K/uL [image002.jpg] Blood culture X1 NGTD 08:42 PM 05:19 AM WBC 13.6 13.5 Hct 34.5 37.0 Plt 251 263 Cr 4.1 Glucose 126 Other labs: PT / PTT / INR:12.6/24.7/1.1, Differential-Neuts:88.9 %, Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL Assessment and Plan 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with recurrent epistaxis . ?1:1 sitter .H/O epistaxis (Nosebleed) Assessment: Left nare posterior packing in place by ENT; right nare packing removed by ptteam aware Action: Close monitoring of left nare packing. ?1:1 sitter .H/O epistaxis (Nosebleed) Assessment: Left nare posterior packing in place by ENT; right nare packing removed by ptteam aware Action: Close monitoring of left nare packing. ?1:1 sitter .H/O epistaxis (Nosebleed) Assessment: Left nare posterior packing in place by ENT; right nare packing removed by ptteam aware Action: Close monitoring of left nare packing. ?1:1 sitter .H/O epistaxis (Nosebleed) Assessment: Left nare posterior packing in place by ENT; right nare packing removed by ptteam aware Action: Close monitoring of left nare packing. ?1:1 sitter .H/O epistaxis (Nosebleed) Assessment: Left nare posterior packing in place by ENT; right nare packing removed by ptteam aware Action: Close monitoring of left nare packing. Action: Response: Plan: .H/O altered mental status (not Delirium) Assessment: Pt lethargic, O X 1. Given no active bleeding currently, holding on embolization . Mild (1+) mitral regurgitation is seen. Consider TPN if pos not tolerated or daily intake suboptimal. Consider TPN if pos not tolerated or daily intake suboptimal. Consider TPN if pos not tolerated or daily intake suboptimal. Consider TPN if pos not tolerated or daily intake suboptimal. .H/O epistaxis (Nosebleed) Assessment: Pt recd with Vasoline packing in L nare around Epistat packing. Mild(1+) MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Hx AOV Mass.Height: (in) 63Weight (lb): 124BSA (m2): 1.58 m2BP (mm Hg): 107/39HR (bpm): 78Status: InpatientDate/Time: at 15:46Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. .H/O epistaxis (Nosebleed) Assessment: Pt recd with Vasoline packing in L nare around inflated packing. NoASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. H/O altered mental status (not Delirium) Assessment: Received pt in bilateral wrist restraints; easily awoken; disorientated to time and place. H/O altered mental status (not Delirium) Assessment: Received pt in bilateral wrist restraints; easily awoken; disorientated to time and place. .H/O altered mental status (not Delirium) Assessment: Received pt in bilateral wrist restraints; easily awoken; disorientated to time and place. .H/O altered mental status (not Delirium) Assessment: Received pt in bilateral wrist restraints; easily awoken; disorientated to time and place. | 27 | [
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518150,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Pt rec\nd with Vasoline packing in L nare around Epistat packing.\n Coughed up one small red clot. Denied nausea. HCt 34. HR 66-78 w/\n occasional PVCs/PACs. Afebrile. O2 at 94-96% on RA with RR 12-18. LS\n clear.\n Action:\n Unable to obtain labs. Intern attempted arterial stick but was unable\n to obtain labs. At 0630, IV RN able to obtain labs. Pt able to swallow\n PO meds but started to coughed with water. Continued Hydralazine IV.\n Mouth moisturizer used for dry mouth.\n Response:\n Hemodynamically stable. No further evidence fresh bleeding.\n Plan:\n F/U labs. Cont to observe for evidence re-bleed. Per ENT packing to\n remain in place until Monday. Pt to place PICC at bedside with\n ultrasound, then to start on TPN, at least until nasal packing removed.\n Cont emotional support to pt and family.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt lethargic, O X 2(person, hospital). Follows commands. Moving all\n extremities. Continues to reach towards nasal packing/IV\ns. Denies\n pain.\n Action:\n Pt on aspiration precautions. Reoriented frequently. Soft wrist\n restraints in place- order done.\n Response:\n No change in mental status.\n Plan:\n Cont aspiration prec. PICC tomorrow for TPN. Cont freq reorientation.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 517855,
"text": "Chief Complaint: Anemia, blood loss (Epistaxis)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78 yof chronic anticoagulation and antiplatelet agents, resident of\n nursing home, in USOH until 4 days PTA when developed severe epistaxis\n of left nares. Evaluated at Hospital ER, noted INR= 3.2 -->\n administered FFP, left nares packed and admitted to MICU. ENT\n evaluation raised concern for posterior bleed. Received FFP, 3 U PRBC\n and antibiotic. ON the day of admission, exhibited recurrent epistaxis\n despite packing, Hct= 30, INR= 1.6. Transferred to with concern\n for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, CVA, dementia\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n ESRD --> HD\n A-FIB, paraoxysmal --> coumadin\n Patent Foramen Ovale\n CAD --> s/p stent\n COPD\n HTN\n NIDDM\n HTN\n s/p CVA\n PVD\n Fungemia ()\n Unable to obtain history due to dementia.\n Occupation: Retired.\n Drugs: Reportedly none\n Tobacco: Reportedly none\n Alcohol: Reportedly none\n Other: Nursing home resident\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 98 (79 - 105) bpm\n BP: 138/91(96) {128/42(67) - 157/91(96)} mmHg\n RR: 18 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Appears stated age\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Nasal packing\n bilaterally\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, Hyperdynamic), (S1: Normal, No(t) Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 251 K/uL\n 34.5 %\n 11.2 g/dL\n 126 mg/dL\n 4.1 mg/dL\n 21 mg/dL\n 27 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 144 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 08:42 PM\n WBC\n 13.6\n Hct\n 34.5\n Plt\n 251\n Cr\n 4.1\n Glucose\n 126\n Other labs: PT / PTT / INR:13.7/23.9/1.2, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, A-FIb (anticoagulation, antiplatelet\n agents), prior CVA, now with severe recurrent epistaxis.\n # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy\n initially. Patient re-bled this AM in setting of INR 1.2, upon\n evaluation by ENT here in the ICU she is currently not bleeding.\n - maximize BP control, aim to SBP 100-110 per ENT\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis.\n - plan to remove packing in 5 days, aiming for Monday with IR\n available in the event of bleed\n - type and screen\n # ESRD- TRS schedule, dialyzed today\n - continue renal meds\n - consult HD renal team in AM\n # Recent candidemia- continue fluconazole with HD\n - CIS\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n # HTN- continue home meds\n # h/o CVA- hold AC and anti plt given epistaxis\n # h/o COPD- not on any inhalers, monitor\n # Child seizures- continue daily Keppra\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 07:55 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 517857,
"text": "Chief Complaint: Anemia, blood loss (Epistaxis)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78 yof chronic anticoagulation and antiplatelet agents, resident of\n nursing home, in USOH until 4 days PTA when developed severe epistaxis\n of left nares. Evaluated at Hospital ER, noted INR= 3.2 -->\n administered FFP, left nares packed and admitted to MICU. ENT\n evaluation raised concern for posterior bleed. Received FFP, 3 U PRBC\n and antibiotic. ON the day of admission, exhibited recurrent epistaxis\n despite packing, Hct= 30, INR= 1.6. Epistat packing reinforced,\n received dDAVP, FFP. Transferred to with concern for possible\n need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n Patient admitted from: Transfer from other hospital, \n Hospital\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, CVA, dementia\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n ESRD --> HD\n A-FIB, paraoxysmal --> coumadin\n Patent Foramen Ovale\n CAD --> s/p stent\n COPD\n HTN\n NIDDM\n HTN\n s/p CVA\n PVD\n Fungemia ()\n CHF (reportedly diastolic per report)\n Depression\n Aortic valve mass seen on TTE \n Dementia\n Glaucoma\n Childhood seizures\n s/p hysterectomy\n s/p cholecystectomy\n s/p appendectomy\n s/p exploratory laparotomy -age 18\n Unable to obtain history due to dementia.\n Occupation: Retired.\n Drugs: Reportedly none\n Tobacco: Reportedly none\n Alcohol: Reportedly none\n Other: Nursing home resident\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 98 (79 - 105) bpm\n BP: 138/91(96) {128/42(67) - 157/91(96)} mmHg\n RR: 18 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic,\n Appears stated age\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Nasal packing\n bilaterally\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, Hyperdynamic), (S1: Normal, No(t) Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, Paradoxical), (Percussion:\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 251 K/uL\n 34.5 %\n 11.2 g/dL\n 126 mg/dL\n 4.1 mg/dL\n 21 mg/dL\n 27 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 144 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 08:42 PM\n WBC\n 13.6\n Hct\n 34.5\n Plt\n 251\n Cr\n 4.1\n Glucose\n 126\n Other labs: PT / PTT / INR:13.7/23.9/1.2, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, A-FIb (anticoagulation, antiplatelet\n agents), prior CVA, now with severe recurrent epistaxis.\n EPISTAXIS\n severe, persistent. Source unclear (ant vs. post).\n Exacerbated by concurrent use of anticoagulation and antiplantelet\n agents. Plan continue to maintain nasal packing, ENT to follow,\n empirical antimicrobials while packing in place. IR notified in event\n that angiography required.\n ANEMIA\n blood loss, due to epistaxis. Monitor Hct serially.\n Transfuse to maintain Hct >27\n ESRD\n continue T/Th/Sat schedule; renal adjusted medications.\n COAGULOPATHY\n hold coumadin while active bleeding.\n Candidemia\n unclear source; continue fluconazole with HD.\n CAD\n no active disease. Hold ASA, hold Plavix (stents placed >1 year\n ago). Continue statins, beta blocker.\n HTN -- continue home medications\n CHILDHOOD SEIzures -- continue daily Keppra\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 07:55 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR/DNI (elective intubation OK)\n Disposition: ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-14 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 517845,
"text": "Chief Complaint: Epistaxis (transfer from hospital)\n HPI:\n 78 F with ESRD, CAD, h/o CVA, COPD admitted from NH to with epistaxis in the setting of ASA, Plavix, Coumadin. She\n was admitted on Friday with INR 3.2 has required 3 units PRBC and 4\n units FFP. Was seen by ENT and Epistat packing with resolution of\n bleeding until this AM when she rebled during HD. ENT replaced the\n Epistat packing with control of the bleeding and labs from this morning\n HCT 30, plt 221, INR 1.2 and she did not receive any further blood\n products. Patient was transferred to for ENT and possible\n embolization by neuro-interventional radiology.\n Upon arrival to the ICU ENT arrived and confirmed no active bleeding.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Coumadin 2mg daily\n Norvasc 10mg daily\n Aspirin 81mg daily\n Keppra 500mg daily\n Paxil 40mg daily\n Plavix 75mg daily\n MiraLax daily\n Hydralazine 25mg three times daily\n Lopressor 25mg three times daily\n Lipitor 80mg at bedtime\n Senokot at bedtime\n Travatan eye drops both eyes at bedtime\n Trazodone 75mg at bedtime\n Dalyvite vitamin daily\n Imdur 60mg daily\n Renvela 80mg three times daily with meals\n Nitroglycerin 1/150 for chest discomfort\n Ativan as needed\n Lactulose as needed\n Fluconazole 200mg after dialysis for 4 weeks. Once positive blood\n cultures are negative, can be stopped after 4 weeks\n Past medical history:\n Family history:\n Social History:\n ESRD- patient on TTS schedule\n CAD- stents last in \n Candidemia- on 4 wks\n CVA\n COPD\n DM\n Heart failure- unknown EF (diastolic per report)\n Depression\n h/o epistaxis\n HTN\n Aortic valve mass seen on TTE \n PVD\n Patent foramen ovale\n Dementia\n Glaucoma\n Atrial fibrillation\n Childhood seizures\n s/p hysterectomy\n s/p cholecystectomy\n s/p appendectomy\n s/p exploratory laparotomy -age 18\n CAD, DM, unknown cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in Nursing Home.\n - Tobacco: none currently prior 45 pack year\n - Alcohol: none\n - Illicits: none\n Review of systems:\n Ear, Nose, Throat: Epistaxis\n Nutritional Support: NPO\n Genitourinary: Dialysis\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:27 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 84 (84 - 105) bpm\n BP: 139/57(74) {139/57(74) - 139/57(74)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Epistat nasal packing\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), S3\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, scars midline\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with\n recurrent epistaxis\n .\n # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy\n initially. Patient re-bled this AM in setting of INR 1.2, upon\n evaluation by ENT here in the ICU she is currently not bleeding.\n - maximize BP control, aim to SBP 100-110 per ENT\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis.\n - plan to remove packing in 5 days, aiming for Monday with IR\n available in the event of bleed\n - type and screen\n .\n # ESRD- TRS schedule, dialyzed today\n - continue renal meds\n - consult HD renal team in AM\n .\n # Recent candidemia- continue fluconazole with HD\n - CIS\n .\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n .\n # HTN- continue home meds\n .\n # h/o CVA- hold AC and anti plt given epistaxis\n .\n # h/o COPD- not on any inhalers, monitor\n .\n # Child seizures- continue daily Keppra\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517911,
"text": "78 yof chronic anticoagulation and antiplatelet agents, resident of\n nursing home, in USOH until 4 days PTA when developed severe epistaxis\n of left nares. Evaluated at Hospital ER, noted INR= 3.2 -->\n administered FFP, left nares packed and admitted to MICU. ENT\n evaluation raised concern for posterior bleed. Received FFP, 3 U PRBC\n and antibiotic. ON the day of admission, exhibited recurrent epistaxis\n despite packing, Hct= 30, INR= 1.6. Epistat packing reinforced,\n received dDAVP, FFP. Transferred to with concern for possible\n need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Admitted from OSH ( see admission Assessment for PMH) S/p recurrent\n epistaxis yesterday. Arrived to micu 7 with bilat nasal packing in\n place which was reinforced earlier that day.. Seen by ENT and no active\n bleeding noted at this time.\n Action:\n Exam by ENT. New vasaline gauze placed around packing. O2 face tent\n till 0300 then dc\nd. o2 sat > 92% on room air. Required .5 ivp ativan\n to cooperate for ent exam. Restraints needed due to confusion, trying\n to pick at packing. Aggressive mouth care given . Some old blood noted\n in oropharynx.\n Response:\n Pt became too lethargic to take po meds. Po eve meds held.\n Plan:\n Continue plan. Monitor for recurrent epitaxis. Ensure that packing is\n not disturbed. monitor hct. HD next on Thursday.\n ------ Protected Section ------\n Bright red blood noted coming from pt.s mouth(pt. drooling blood) after\n taking a few sips of ice water this am. Oral cavity suctioned and\n rinsed until no further bleeding noted. H.O. aware. VSS. O2 sat 93%\n Room air.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:21 ------\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518089,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Pt rec\nd with Vasoline packing in L nare around Epistat packing.\n Coughed up one small red clot. Denied nausea. HCt 34. HR 66-78 w/\n occasional PVCs/PACs. Afebrile. O2 at 94-96% on RA with RR 12-18. LS\n clear.\n Action:\n Unable to obtain labs. Intern attempted arterial stick but was unable\n to obtain labs. Pt able to swallow PO meds but started to coughed with\n water. Continued Hydralazine IV. Mouth moisturizer used for dry mouth.\n Response:\n Hemodynamically stable. No further evidence fresh bleeding.\n Plan:\n Cont to observe for evidence re-bleed. Per ENT packing to remain in\n place until Monday. Pt to IR tomorrow for PICC line placement, then to\n start on TPN, at least until nasal packing removed. Cont emotional\n support to pt and family.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt lethargic, O X 2(person, hospital). Follows commands. Moving all\n extremities. Continues to reach towards nasal packing/IV\ns. Denies\n pain.\n Action:\n Pt on aspiration precautions. Reoriented frequently. Soft wrist\n restraints in place- order done.\n Response:\n No change in mental status.\n Plan:\n Cont aspiration prec. PICC tomorrow for TPN. Cont freq reorientation.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 517972,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:18 AM\n .\n After taking sips of ice water this morning, bright red blood noted\n drooling out of patient mouth. Oral cavity suctioned and rinsed until\n no further bleeding noted. Poor visualization of posterior oropharynx\n yesterday so ?blood clot collected there and remanifested with sips of\n water.\n .\n IR aware of patient. Given no active bleeding currently, holding on\n embolization\n .\n Did not get PO medications yesterday night as patient too lethargic to\n safely take them (also got 0.5mg IV Ativan). Also put in restraints\n briefly for picking at nasal packing\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 99 (79 - 105) bpm\n BP: 168/46(76) {128/41(67) - 168/91(96)} mmHg\n RR: 21 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n room air\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 263 K/uL\n 11.7 g/dL\n 126 mg/dL\n 4.1 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 103 mEq/L\n 144 mEq/L\n 37.0 %\n 13.5 K/uL\n [image002.jpg]\n Blood culture X1 NGTD\n 08:42 PM\n 05:19 AM\n WBC\n 13.6\n 13.5\n Hct\n 34.5\n 37.0\n Plt\n 251\n 263\n Cr\n 4.1\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6/24.7/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with\n recurrent epistaxis\n .\n # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy\n initially. Patient re-bled yesterday AM in setting of INR 1.2, upon\n evaluation by ENT here in the ICU she was not bleeding. Blood elicited\n from posterior oropharynx this morning, ?blood clot vs. re-bleed\n - maximize BP control, aim to SBP 100-110 per ENT (will get PO\n medications today for better control)\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis\n - plan to remove packing in 5 days, aiming for Monday with IR available\n in the event of bleed\n - type and screen\n - For patient , start standing Tylenol and oxycodone for\n PRN pain; will also request Nutrition consult and likely start patient\n on TPN over the week/weekend given nasal packing making it\n uncomfortable and difficult for patient to take in PO\n - Switch difficult to ingest pills to IV for now\n .\n # ESRD- TRS schedule, dialyzed yesterday\n - continue renal meds\n - consult HD renal team in AM\n .\n # Recent candidemia- continue fluconazole with HD\n - culture if spikes\n - Also question of an aortic mass per patient\ns daughter on a previous\n ECHO. Will order repeat ECHO today to evaluate\n .\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n .\n # HTN- continue home meds\n .\n # h/o CVA- hold anticoagulants and antiplatelets given epistaxis\n recently\n .\n # h/o COPD- not on any inhalers, monitor\n - Start albuterol/ipratroprium and Advair MDI\n .\n # Child seizures- continue daily Keppra\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Consult and likely TPN\n Glycemic Control:\n Lines:\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n .H/O EPISTAXIS (NOSEBLEED)\n"
},
{
"category": "Nutrition",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518218,
"text": "78 year old female transferred from w/ recurrent\n epistaxis- nose packed, no bleeding today. TPN planned to begin\n yesterday as uncomfortable to eat and unable to place NGT. PICC not\n placed yesterday, therefore patient did not receive TPN. Will order\n Day 1 Starter TPN again, and advance to TPN goal of 1400mL(295\n dextrose/70 gr protein/40 lipids) to provide 1683 kcals. Please page\n w/ questions #.\n"
},
{
"category": "Nutrition",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 517969,
"text": "Subjective\n Patient asking for water. Per discussion w/ sister, large amounts of\n weight loss over past year, but unable to quantify.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 56.4 kg\n 19.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 63.6 kg\n 87%\n unknown\n Diagnosis: Epistaxis\n PMHx:\n ESRD- patient on TTS schedule\n CAD- stents last in \n Candidemia- on 4 wks\n CVA\n COPD\n DM\n Heart failure- unknown EF (diastolic per report)\n Depression\n h/o epistaxis\n HTN\n Aortic valve mass seen on TTE \n PVD\n Patent foramen ovale\n Dementia\n Glaucoma\n Atrial fibrillation\n Childhood seizures\n s/p hysterectomy\n s/p cholecystectomy\n s/p appendectomy\n s/p exploratory laparotomy -age 18\n Food allergies and intolerances: NKFA\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 05:19 AM\n Glucose Finger Stick\n 193\n 08:00 AM\n BUN\n 29 mg/dL\n 05:19 AM\n Creatinine\n 5.0 mg/dL\n 05:19 AM\n Sodium\n 144 mEq/L\n 05:19 AM\n Potassium\n 4.1 mEq/L\n 05:19 AM\n Chloride\n 103 mEq/L\n 05:19 AM\n TCO2\n 26 mEq/L\n 05:19 AM\n Calcium non-ionized\n 9.8 mg/dL\n 05:19 AM\n Phosphorus\n 3.8 mg/dL\n 05:19 AM\n Magnesium\n 1.9 mg/dL\n 05:19 AM\n WBC\n 13.5 K/uL\n 05:19 AM\n Hgb\n 11.7 g/dL\n 05:19 AM\n Hematocrit\n 37.0 %\n 05:19 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/nbs\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to: NPO, weight loss PTA, low %IBW, borderline low\n BMI\n Estimated Nutritional Needs\n Calories: 1580-1805 (28-32 cal/kg)\n Protein: 56-70 (1-1.4 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate as is NPO\n Specifics:\n 78 year old female transferred from w/ recurrent\n epistaxis for ENT and ? interventional embolization. Plan for PICC\n placement to begin TPN for nutrition as NGT cannot be placed. Agree w/\n TPN as temporary nutrition support.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Once PICC placed and checked, start w/ Day 1 Starter TPN\n (recommendation entered in POE)\n Will advance TPn daily, based on glycemic control, to goal\n of 1400mL (295 dextrose/70 gr proteon/40 lipids) to provide 1683 kcals\n Please check trig\n SS insulin as ordered\n Will enter TPn recommendations daily, please page w/\n questions #\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518046,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Pt rec\nd with Vasoline packing in L nare around Epistat packing. Pt\n with occas cough productive of small clots blood. C/O nausea in\n afternoon, resolved spont. No blood evident in oral cavity. AM hct 37.\n VSS with HR 104\n73SR with occas PAC\ns/PVC\ns. SBP initially 160\ns as pt\n had not rec\nd her lopressor overnight. Afebrile. O2 at 94-97% on RA\n with RR 14-25 and regular. Lungs clear throughout with rare scattered\n wheezes.\n Action:\n Repeat hct 34.4. Pt able to swallow all po cardiac meds. Also started\n on Hydralazine IV. Cardiac ECHO done. Pt\ns family updated by RN and MD.\n Response:\n Stable. No further evidence fresh bleeding. BP stable 107/39-133/52.\n Plan:\n Cont to observe for evidence re-bleed. Per ENT packing to remain in\n place until Monday. Pt to IR tomorrow for PICC line placement, then to\n start on TPN at least until nasal packing removed. Cont emotional\n support to pt and family.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt lethargic, O X 1. Follows commands, but reaching for nasal packing\n so soft wrist restraints in place bilat. Denies pain. Pt was able to\n swallow cardiac meds, but when given water appears to intermit have\n delayed swallow. Occas cough after po water.\n Action:\n Pt on aspiration precautions. Freq reoriented.\n Response:\n Pt D/C\nd 1 periph IV despite wrist restraints. She remains confused and\n lethargic, freq requesting water.\n Plan:\n Cont aspiration prec. PICC tomorrow for TPN. Cont freq reorientation.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517868,
"text": ".H/O epistaxis (Nosebleed)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517871,
"text": "78 yof chronic anticoagulation and antiplatelet agents, resident of\n nursing home, in USOH until 4 days PTA when developed severe epistaxis\n of left nares. Evaluated at Hospital ER, noted INR= 3.2 -->\n administered FFP, left nares packed and admitted to MICU. ENT\n evaluation raised concern for posterior bleed. Received FFP, 3 U PRBC\n and antibiotic. ON the day of admission, exhibited recurrent epistaxis\n despite packing, Hct= 30, INR= 1.6. Epistat packing reinforced,\n received dDAVP, FFP. Transferred to with concern for possible\n need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Admitted from OSH ( see admission Assessment for PMH) S/p recurrent\n epistaxis yesterday. Arrived to micu 7 with bilat nasal packing in\n place which was reinforced earlier that day.. Seen by ENT and no active\n bleeding noted at this time.\n Action:\n Exam by ENT. New vasaline gauze placed around packing. O2 face tent\n till 0300 then dc\nd. o2 sat > 92% on room air. Required .5 ivp ativan\n to cooperate for ent exam. Restraints needed due to confusion, trying\n to pick at packing. Aggressive mouth care given . Some old blood noted\n in oropharynx.\n Response:\n Pt became too lethargic to take po meds. Po eve meds held.\n Plan:\n Continue plan. Monitor for recurrent epitaxis. Ensure that packing is\n not disturbed. monitor hct. HD next on Thursday.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518173,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 02:30 PM\n :\n - Updated daughter regarding plan for patient. Other HCP, son \n coming to hospital to visit. Daughter inquiring about the amount of\n heparin being used at HD because epistaxis occurs\n every night following HD at (not so much with her\n outpatient of ).\n - Hct 37 in AM -> 34.5 at 4pm -> 37\n - pulled nasal packing but not balloon at 0730\n - getting HD\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.4\nC (97.5\n HR: 100 (66 - 104) bpm\n BP: 134/44(94) {90/31(49) - 169/72(94)} mmHg\n RR: 18 (10 - 25) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 590 mL\n 177 mL\n PO:\n 540 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 77 mL\n Blood products:\n Total out:\n 50 mL\n 0 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 540 mL\n 177 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 11.6 g/dL\n 136 mg/dL\n 5.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 29 mg/dL\n 103 mEq/L\n 144 mEq/L\n 37.0 %\n 13.9 K/uL\n [image002.jpg]\n 08:42 PM\n 05:19 AM\n 04:30 PM\n 12:20 AM\n WBC\n 13.6\n 13.5\n 13.9\n Hct\n 34.5\n 37.0\n 34.4\n 37.0\n Plt\n \n Cr\n 4.1\n 5.0\n Glucose\n 126\n 136\n Other labs: PT / PTT / INR:12.7/25.0/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O EPISTAXIS (NOSEBLEED)\n 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with\n recurrent epistaxis\n .\n # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy\n initially. Patient re-bled yesterday AM in setting of INR 1.2, upon\n evaluation by ENT here in the ICU she was not bleeding. Blood elicited\n from posterior oropharynx this morning, ?blood clot vs. re-bleed\n - maximize BP control, aim to SBP 100-110 per ENT (will get PO\n medications today for better control)\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis\n - plan to remove packing in 5 days, aiming for Monday with IR available\n in the event of bleed\n - type and screen\n - For patient , start standing Tylenol and oxycodone for\n PRN pain; will also request Nutrition consult and likely start patient\n on TPN over the week/weekend given nasal packing making it\n uncomfortable and difficult for patient to take in PO\n - Switch difficult to ingest pills to IV for now\n .\n # ESRD- TRS schedule, dialyzed yesterday\n - continue renal meds\n - consult HD renal team in AM\n .\n # Recent candidemia- continue fluconazole with HD\n - culture if spikes\n - Also question of an aortic mass per patient\ns daughter on a previous\n ECHO. Will order repeat ECHO today to evaluate\n .\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n .\n # HTN- continue home meds\n .\n # h/o CVA- hold anticoagulants and antiplatelets given epistaxis\n recently\n .\n # h/o COPD- not on any inhalers, monitor\n - Start albuterol/ipratroprium and Advair MDI\n .\n # Child seizures- continue daily Keppra\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 517928,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:18 AM\n .\n After taking sips of ice water this morning, bright red blood noted\n drooling out of patient mouth. Oral cavity suctioned and rinsed until\n no further bleeding noted. Poor visualization of posterior oropharynx\n yesterday so ?blood clot collected there and remanifested with sips of\n water.\n .\n IR aware of patient. Given no active bleeding currently, holding on\n embolization\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 99 (79 - 105) bpm\n BP: 168/46(76) {128/41(67) - 168/91(96)} mmHg\n RR: 21 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 263 K/uL\n 11.7 g/dL\n 126 mg/dL\n 4.1 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 103 mEq/L\n 144 mEq/L\n 37.0 %\n 13.5 K/uL\n [image002.jpg]\n 08:42 PM\n 05:19 AM\n WBC\n 13.6\n 13.5\n Hct\n 34.5\n 37.0\n Plt\n 251\n 263\n Cr\n 4.1\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6/24.7/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n .H/O EPISTAXIS (NOSEBLEED)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 517933,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 06:18 AM\n .\n After taking sips of ice water this morning, bright red blood noted\n drooling out of patient mouth. Oral cavity suctioned and rinsed until\n no further bleeding noted. Poor visualization of posterior oropharynx\n yesterday so ?blood clot collected there and remanifested with sips of\n water.\n .\n IR aware of patient. Given no active bleeding currently, holding on\n embolization\n .\n Did not get PO medications yesterday night as patient too lethargic to\n safely take them (also got 0.5mg IV Ativan)\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 99 (79 - 105) bpm\n BP: 168/46(76) {128/41(67) - 168/91(96)} mmHg\n RR: 21 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 263 K/uL\n 11.7 g/dL\n 126 mg/dL\n 4.1 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 103 mEq/L\n 144 mEq/L\n 37.0 %\n 13.5 K/uL\n [image002.jpg]\n Blood culture X1 NGTD\n 08:42 PM\n 05:19 AM\n WBC\n 13.6\n 13.5\n Hct\n 34.5\n 37.0\n Plt\n 251\n 263\n Cr\n 4.1\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6/24.7/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with\n recurrent epistaxis\n .\n # Epistaxis- in setting of dual antiplatelet and anticoagulant therapy\n initially. Patient re-bled yesterday AM in setting of INR 1.2, upon\n evaluation by ENT here in the ICU she was not bleeding. Blood elicited\n from posterior oropharynx this morning, ?blood clot vs. re-bleed\n - maximize BP control, aim to SBP 100-110 per ENT (will get PO\n medications today for better control)\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis.\n - plan to remove packing in 5 days, aiming for Monday with IR available\n in the event of bleed\n - type and screen\n .\n # ESRD- TRS schedule, dialyzed yesterday\n - continue renal meds\n - consult HD renal team in AM\n .\n # Recent candidemia- continue fluconazole with HD\n - CIS\n .\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n .\n # HTN- continue home meds\n .\n # h/o CVA- hold AC and anti plt given epistaxis\n .\n # h/o COPD- not on any inhalers, monitor\n .\n # Child seizures- continue daily Keppra\n .\n # FEN: No IVF, replete electrolytes, NPO\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n .H/O EPISTAXIS (NOSEBLEED)\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 518329,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of\n embolization.Upon transfer to MICU, poorly communicative.\n Evaluated by ENT\n no evidence for active bleed.\n Called out to floor today; will need telemetry, continuous o2\n monitoring, and possibly sitter.\n H/O altered mental status (not Delirium)\n Assessment:\n Received pt in bilateral wrist restraints; easily awoken; disorientated\n to time and place. Pleasant; able to make needs known very well.\n Found bloody right nare gauze on bedsheets on initial assessment. Pt\n making frequent attempts to get OOB without assist\n Action:\n Close supervison throughout shift with freq reassurance ;; wrist\n restraints removed temporarily to appease pt;\n Response:\n Pt able to pull out PIV but making no noted attempts to pull at left\n nare posterior packing; wiping at nares gently and appropriately.\n Plan:\n Called out to floor; will need close supervision to maintain safety and\n left nare packing. benefit from mitts. ?1:1 sitter\n .H/O epistaxis (Nosebleed)\n Assessment:\n Left nare posterior packing in place by ENT; right nare packing removed\n by pt\nteam aware\n Action:\n Close monitoring of left nare packing. O2 saturation monitored. Daily\n hematocrits\n Response:\n Small amt of oozing from right nare with one clot approx dime size\n noted. O2 sat >93% room air. Hematocrit stable.\n Plan:\n Cont to monitor tolerance of packing. Daily hcts. ENT following.\n Plan to maintain packing until Monday\n Alteration in Nutrition\n Assessment:\n Scheduled for TPN once PICC placed. Some dysphagia noted overnight\n with water however taking pills without difficulty. Nasal packing\n planned to remain until Monday\n Action:\n PO\ns introduced slowly and closely monitored\n Response:\n Tolerated po\ns with minimal resp distress. No s/s of aspiration.\n Tolerating renal diet, teeth in place\n Plan:\n Renal diet with fld restriction, as tolerated. Consider TPN if po\ns not\n tolerated or daily intake suboptimal.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 518327,
"text": "H/O altered mental status (not Delirium)\n Assessment:\n Received pt in bilateral wrist restraints; easily awoken; disorientated\n to time and place. Pleasant; able to make needs known very well.\n Found bloody right nare gauze on bedsheets on initial assessment. Pt\n making frequent attempts to get OOB without assist\n Action:\n Close supervison throughout shift with freq reassurance ;; wrist\n restraints removed temporarily to appease pt;\n Response:\n Pt able to pull out PIV but making no noted attempts to pull at left\n nare posterior packing; wiping at nares gently and appropriately.\n Plan:\n Called out to floor; will need close supervision to maintain safety and\n left nare packing. benefit from mitts. ?1:1 sitter\n .H/O epistaxis (Nosebleed)\n Assessment:\n Left nare posterior packing in place by ENT; right nare packing removed\n by pt\nteam aware\n Action:\n Close monitoring of left nare packing. O2 saturation monitored. Daily\n hematocrits\n Response:\n Small amt of oozing from right nare with one clot approx dime size\n noted. O2 sat >93% room air. Hematocrit stable.\n Plan:\n Cont to monitor tolerance of packing. Daily hcts. ENT following.\n Plan to maintain packing until Monday\n Alteration in Nutrition\n Assessment:\n Scheduled for TPN once PICC placed. Some dysphagia noted overnight\n with water however taking pills without difficulty. Nasal packing\n planned to remain until Monday\n Action:\n PO\ns introduced slowly and closely monitored\n Response:\n Tolerated po\ns with minimal resp distress. No s/s of aspiration.\n Tolerating renal diet, teeth in place\n Plan:\n Renal diet with fld restriction, as tolerated. Consider TPN if po\ns not\n tolerated or daily intake suboptimal.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518324,
"text": ".H/O altered mental status (not Delirium)\n Assessment:\n Received pt in bilateral wrist restraints; easily awoken; disorientated\n to time and place. Pleasant; able to make needs known very well.\n Found bloody right nare gauze on bedsheets on initial assessment. Pt\n making frequent attempts to get OOB without assist\n Action:\n Close supervison throughout shift with freq reassurance ;; wrist\n restraints removed temporarily to appease pt;\n Response:\n Pt able to pull out PIV but making no noted attempts to pull at left\n nare posterior packing; wiping at nares gently and appropriately.\n Plan:\n Called out to floor; will need close supervision to maintain safety and\n left nare packing. benefit from mitts. ?1:1 sitter\n .H/O epistaxis (Nosebleed)\n Assessment:\n Left nare posterior packing in place by ENT; right nare packing removed\n by pt\nteam aware\n Action:\n Close monitoring of left nare packing. O2 saturation monitored. Daily\n hematocrits\n Response:\n Small amt of oozing from right nare with one clot approx dime size\n noted. O2 sat >93% room air. Hematocrit stable.\n Plan:\n Cont to monitor tolerance of packing. Daily hcts. ENT following.\n Plan to maintain packing until Monday\n Alteration in Nutrition\n Assessment:\n Scheduled for TPN once PICC placed. Some dysphagia noted overnight\n with water however taking pills without difficulty. Nasal packing\n planned to remain until Monday\n Action:\n PO\ns introduced slowly and closely monitored\n Response:\n Tolerated po\ns with minimal resp distress. No s/s of aspiration.\n Tolerating renal diet, teeth in place\n Plan:\n Renal diet with fld restriction, as tolerated. Consider TPN if po\ns not\n tolerated or daily intake suboptimal.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518326,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of\n embolization.Upon transfer to MICU, poorly communicative.\n Evaluated by ENT\n no evidence for active bleed.\n Called out to floor today; will need telemetry, continuous o2\n monitoring, and possibly sitter.\n .H/O altered mental status (not Delirium)\n Assessment:\n Received pt in bilateral wrist restraints; easily awoken; disorientated\n to time and place. Pleasant; able to make needs known very well.\n Found bloody right nare gauze on bedsheets on initial assessment. Pt\n making frequent attempts to get OOB without assist\n Action:\n Close supervison throughout shift with freq reassurance ;; wrist\n restraints removed temporarily to appease pt;\n Response:\n Pt able to pull out PIV but making no noted attempts to pull at left\n nare posterior packing; wiping at nares gently and appropriately.\n Plan:\n Called out to floor; will need close supervision to maintain safety and\n left nare packing. benefit from mitts. ?1:1 sitter\n .H/O epistaxis (Nosebleed)\n Assessment:\n Left nare posterior packing in place by ENT; right nare packing removed\n by pt\nteam aware\n Action:\n Close monitoring of left nare packing. O2 saturation monitored. Daily\n hematocrits\n Response:\n Small amt of oozing from right nare with one clot approx dime size\n noted. O2 sat >93% room air. Hematocrit stable.\n Plan:\n Cont to monitor tolerance of packing. Daily hcts. ENT following.\n Plan to maintain packing until Monday\n Alteration in Nutrition\n Assessment:\n Scheduled for TPN once PICC placed. Some dysphagia noted overnight\n with water however taking pills without difficulty. Nasal packing\n planned to remain until Monday\n Action:\n PO\ns introduced slowly and closely monitored\n Response:\n Tolerated po\ns with minimal resp distress. No s/s of aspiration.\n Tolerating renal diet, teeth in place\n Plan:\n Renal diet with fld restriction, as tolerated. Consider TPN if po\ns not\n tolerated or daily intake suboptimal.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517989,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Pt rec\nd with Vasoline packing in L nare around inflated packing.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517991,
"text": "78 yo f with PMH: ESRD on HD Tues/Th/Sat, CAD (stents ),\n Candidemia, CVA, COPD, DM, heart failure, aortic valve mass seen on TTE\n , HTN, PVD, depression, dementia, glaucoma, childhood seizures,\n AFib, chronic anticoagulation and antiplatelet agents, epistaxis. A\n resident of nursing home, she was in USOH until 4 days PTA when\n developed severe epistaxis of left nares. Evaluated at \n Hospital ER, noted INR= 3.2 --> administered FFP, left nares packed and\n admitted to MICU. ENT evaluation raised concern for posterior\n bleed. Received FFP, 3 U PRBC and antibiotic. ON the day of\n admission, exhibited recurrent epistaxis despite packing, Hct= 30,\n INR= 1.6. Epistat packing reinforced, received dDAVP, FFP.\n Transferred to with concern for possible need of embolization.\n Upon transfer to MICU, poorly communicative. Evaluated by ENT\n no evidence for active bleed.\n .H/O epistaxis (Nosebleed)\n Assessment:\n Pt rec\nd with Vasoline packing in L nare around Epistat packing. Pt\n with occas cough productive of small clots blood. No blood evident on\n oral exam.\n Action:\n Response:\n Plan:\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt lethargic, O X 1. Follows commands, but reaching for nasal packing\n so soft wrist restraints in place bilat. Denies pain. Pt was able to\n swallow cardiac meds, but when given water appears to have delayed\n swallow. Occas cough after po water.\n Action:\n Pt NPO, oral swabs only.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518320,
"text": ".H/O altered mental status (not Delirium)\n Assessment:\n Received pt in bilateral wrist restraints; easily awoken; disorientated\n to time and place. Pleasant; able to make needs known very well.\n Found bloody right nare gauze on bedsheets on initial assessment. Pt\n making frequent attempts to get OOB without assist\n Action:\n Close supervison throughout shift with freq reassurance ;; wrist\n restraints removed temporarily to appease pt;\n Response:\n Pt able to pull out PIV but making no noted attempts to pull at left\n nare posterior packing; wiping at nares gently and appropriately.\n Plan:\n Called out to floor; will need close supervision to maintain safety and\n left nare packing. benefit from mitts. ?1:1 sitter\n .H/O epistaxis (Nosebleed)\n Assessment:\n Left nare posterior packing in place by ENT; right nare packing removed\n by pt\nteam aware\n Action:\n Close monitoring of left nare packing. O2 saturation monitored. Daily\n hematocrits\n Response:\n Small amt of oozing from right nare with one clot approx dime size\n noted. O2 sat >93% room air. Hematocrit stable.\n Plan:\n Cont to monitor tolerance of packing. Daily hcts. ENT following.\n Plan to maintain packing until Monday\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518200,
"text": "Chief Complaint: Epistaxis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n No bleeding. Attempted to pull out packing\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 02:30 PM\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.3\nC (95.5\n HR: 100 (66 - 104) bpm\n BP: 119/48(65) {90/31(49) - 162/57(94)} mmHg\n RR: 17 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 590 mL\n 198 mL\n PO:\n 540 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 98 mL\n Blood products:\n Total out:\n 50 mL\n 0 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 540 mL\n 198 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Packing\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic), 2-3/6 SEM\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 0, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 316 K/uL\n 143 mg/dL\n 6.8 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 50 mg/dL\n 101 mEq/L\n 143 mEq/L\n 37.0 %\n 13.9 K/uL\n [image002.jpg]\n 08:42 PM\n 05:19 AM\n 04:30 PM\n 12:20 AM\n WBC\n 13.6\n 13.5\n 13.9\n Hct\n 34.5\n 37.0\n 34.4\n 37.0\n Plt\n \n Cr\n 4.1\n 5.0\n 6.8\n Glucose\n 126\n 136\n 143\n Other labs: PT / PTT / INR:12.7/25.0/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL,\n PO4:5.1 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O EPISTAXIS (NOSEBLEED)\n No further bleeding. Now off coumadin, ASA, Plavyx. Will discuss\n management with ENT. Plan to leave packing in place for 5 d. If she\n bleeds will add DDAVP and PLts.\n ICU Care\n Nutrition:\n Comments: TPN to start today\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 07:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518201,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 02:30 PM\n :\n - Hct 37 in AM -> 34.5 at 4pm\n :\n - Hct 37 in AM\n - pulled nasal packing but not balloon at 0730\n - getting HD\n Allergies:\n Codeine\n Unknown;\n Meperidine\n Unknown;\n Ace Inhibitors\n Unknown;\n Hydrocodone\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.4\nC (97.5\n HR: 100 (66 - 104) bpm\n BP: 134/44(94) {90/31(49) - 169/72(94)} mmHg\n RR: 18 (10 - 25) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 590 mL\n 177 mL\n PO:\n 540 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 77 mL\n Blood products:\n Total out:\n 50 mL\n 0 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 540 mL\n 177 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 316 K/uL\n 11.6 g/dL\n 136 mg/dL\n 5.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 29 mg/dL\n 103 mEq/L\n 144 mEq/L\n 37.0 %\n 13.9 K/uL\n [image002.jpg]\n 08:42 PM\n 05:19 AM\n 04:30 PM\n 12:20 AM\n WBC\n 13.6\n 13.5\n 13.9\n Hct\n 34.5\n 37.0\n 34.4\n 37.0\n Plt\n \n Cr\n 4.1\n 5.0\n Glucose\n 126\n 136\n Other labs: PT / PTT / INR:12.7/25.0/1.1, Differential-Neuts:88.9 %,\n Lymph:6.9 %, Mono:3.5 %, Eos:0.4 %, Ca++:9.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.8 mg/dL\n Echo: No aortic or atrial masses, stiff LV\n Assessment and Plan\n 78 F with ESRD, CAD, PVD, prior CVA, known PFO, COPD, transferred with\n recurrent epistaxis\n .\n # Epistaxis- No bleeding, even after pulled anterior packing of gauze\n on right. Stable Hematocrit. Question is whether she could go to the\n floor with this.\n - aim for SBP 110\n - empiric cephazolin with HD\n - keep vaseline gauze dressing around alar to prevent necrosis\n - plan to remove packing on Monday, with IR available in the event of\n bleed\n - type and screen\n - note that daughter feels HD at one site may use more heparin than\n another and this may be driving epistaxis events\n # ESRD- Getting HD this AM.\n - continue renal meds\n .\n # Aortic mass: This question raised by patient\ns daughter who cited a\n previous Echo we \nt have access to, repeat Echo here normal. No\n aortic mass.\n # CAD- continue statin and lopressor\n - hold ASA, hold Plavix for now (stents placed >1 year ago)\n # HTN- continue home meds\n # h/o CVA- holding anticoagulants and antiplatelets. Ask ENT when can\n restart, from their .\n .\n # h/o COPD- not on any inhalers, monitor\n - Start albuterol/ipratroprium and Advair MDI\n # Child seizures- continue daily Keppra\n .\n # FEN: No IVF, replete electrolytes, NPO, plan is to get PICC and TPN\n today\n # Prophylaxis: Pneumoboots\n # Access: peripherals\n # Communication: Patient\n Daughter , MD and son are HCP. Daughter's phone numbers:\n \n # Code: DNR/DNi but ok for elective intubation\n # Disposition: ICU but pending discussion with ENT she may be call out\n to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Echo",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Report",
"row_id": 85118,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. Hx AOV Mass.\nHeight: (in) 63\nWeight (lb): 124\nBSA (m2): 1.58 m2\nBP (mm Hg): 107/39\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 15:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF >75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild\n(1+) MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Physiologic\nTR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is unusually small. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Left ventricular\nsystolic function is hyperdynamic (EF>75%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation. The tricuspid valve\nleaflets are mildly thickened. The pulmonary artery systolic pressure could\nnot be determined. There is no pericardial effusion.\n\nIMPRESSION: No aortic valve mass seen. If indicated, a TEE would be better to\nassess aortic valve structure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120669,
"text": " 8:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess cardiopulm status\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with ESRD and epistaxis\n REASON FOR THIS EXAMINATION:\n assess cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:59 P.M, .\n\n HISTORY: End-stage renal disease and epistaxis. Assess cardiopulmonary\n status.\n\n IMPRESSION: AP chest compared to :\n\n Mild cardiomegaly may be smaller. No pulmonary edema, pulmonary vascular\n engorgement. A flame-shaped opacity projecting over the right first rib\n anteriorly is probably calcification, better appreciated on the \n radiograph. Lungs are otherwise clear. There is no pleural effusion.\n Mediastinal and hilar silhouettes are unremarkable. Vascular stent and clips\n project over the left axilla.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1121004,
"text": " 4:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl power picc 43cm\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 43cm\n ______________________________________________________________________________\n WET READ: 7:50 PM\n R PICC tip over RA could retract 2cm Otherwise similar chest d/w GWlms\n 7:45p\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:01 P.M. \n\n HISTORY: PIC line.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new right PIC line projects over the right atrium approximately 2\n cm below the superior cavoatrial junction. Lungs clear. Heart size normal.\n No pneumothorax or pleural effusion. Vascular stent and clips project over\n the left axilla.\n\n\n"
}
] |
3,719 | 145,342 | Respiratory: The infant remained in room air throughout his hospital course. There were no episodes of apnea or bradycardia of prematurity. | Min asps. Po/Pg feeds.Abd benign. Temps stable in opencrib. A: Toleratingfeeds. A/ Updatedand involved. P:cont. P:cont. P:cont. P:cont. Voiding and stooling.Circumsion done by OB this am. P-Continue to followcurrent regimen.DEV: O/A-Temp stable in OAC. Swaddledwith boundaries in place. Toleratingfeedings well. Voiding and passing lgmeconium. NICU NSG NOTEFEN. A/ Tolerating feeds. Abd soft, bs +. AGA. Encourage po's.G&D. updated by Dr. . Minimalresiduals. A/AGA. Nospits. O: Infant remains on TF's of 120cc/k/d of BM/SC20. TF 120cc/k/d BM/SC. MAEW. AGA.3. AGA.3. AFOF. A:AGA P: cont to support dev.milestones.ParentingPlease refer to trip # 1 note. Sucks fingers.3 ParentingNo contact thus far this shift. to support nutritionalneeds.2remains swaddled in OAC, temp stable, a/a with cares, occwakes, likes pacifier, fonts soft/flat. Nursing Progress Note#1. Removed NG tube. Abd soft and round with activebowel sounds. NPN DAYS1. Stools heme neg. AF-flat. P: Continue toinform and support. AG stable. Voiding qs, med trans stool negheme. to suportgrowth and development.3no known contact thus far this shift. PO fed 27/52cc. Wakes for feeds. A:stable. CAlms with containment and pacifier. Bottle feeding withease. Needs52cc q4h. Askingappropriate questions. Active bowel sounds. P-Continue to support G/D. All po this shift. HE isalert and active with cares. ?Mom d/c today. Continue with plan and monitor.2. MAE. Tolerating feeds. Cont to offer support and updates. NPN 0700-19001. Voiding and stooling. AFSF. A: AGA P:Support developmental needs, am PKU#3 No contact thus far overnoc. voiding q diaper change. TF remain at 140cc.kg of Neosure 22cal/BM20. Waking for feeds. Residual max5.2cc of partially digested formula. A: AGA P: Continue to assess and supportdevelopmental needs.#3. Abd pink,soft, no loops, active bs. TF 140cc/k/d ofNeosure 22. A: Involved family. P: cont to support and follow.GDO: temp stable in oac, active and alert with cares. Momd/c'd home today. Infant isvoiding and stooling. nsgagree with above co-worker's note Abd exambenign. Min asp, no spits.Voiding. P: Cont support, ongoing teaching. Circ care provided per protocol.Tylenol given as ordered. made aware of infant's 14cc partially digested residual. Area reddend with small amtbloody drainage noted. P/ Cont to monitor for feedingintolerances. tol pg feeds well for remainder each time.Abd benign, vdg and passing guiac neg stools. to monitor.2remains in OAC, temp stable, a/a with cares, settles well inbetween, fonts soft/flat, likes pacifier, right eye drainageclear>yellow warm soak applied. Tylenol as ordered. Mae.fonts soft, flat. P: Continue to encourage po feeds as tolerated.#2. Roots. Weight down 15g. Alert and active withcares. Not yet waking on own for feeds. Learning to po. No spits.Abd is soft and round with active bs. TF remain at120cc/kg/day of BM/SC 20. I have examined infant and agree with above documentation. NICU nursing progress noteplease refer to flowsheet for specific info.FENO TF of 120cc/k/d of sc or bm 20, bottling skills aredecreased r/t drowsiness. O/ Awake and alert with cares. A: all po's P: Follow weight andenc po feeds as tol#2 Temps stable in crib. : No contact thus far this shift. Infant placed in prone position with decrease to 1.4cc residual. P: cont to follow.GDO: TEMp stable in oac, active and alert with cares.MAE.Fonts soft, flat. Erythro and Vit K given as ordered. Will recheck bili levelin am. Active, alert, AFOF, sutures opposed, good . carseat test passed.#3 parentingno contact thus far this shift. O: Infant remains NPO on TF's of 60cc/k/d of D10W. MIn asp. Schecnter will do discharge summary. Neoantology-NNP Physical ExamInfant remains in RA. NPO while infant transitions with maintenance IVFs. DSstable thus far. Abd pink, noloops, active bs.Voiding/ stooling mec. abd benign. Abd benign. Nursing Progress Note#1. Bottling skillsimproving. Moved to crib; temp stable. h/o +PPD. BBS =/clear. Tolerating fdgs well w/o spits; minimal residuals. Neo AttendDay 9 CGA 35.5wkRespr 40-50s, RA,CV: soft murmur (intermittent); P and BP wnl.TW 2530gm, up 30gmNeosure 22 cal/ Intake 160 cc/kg/day po ad lib feed.circ is finetemp stable.Plan is to discharge today. D/S89. Calms withcontainment and pacifier. WT=2570, 60 cc/kg/d D10W.A/P: Infant with transient resp distress, now resolving. Dr. .Dr. P- Cont toassess for FEN needs.#2-O/A- cont to be awake and active with clustercares q4hrs. Calms with containment andpacifier. wt. Nursing Progress Note#1-O/A- TF=140cc/kg/d of Neosure via po/pg. Not yet waking for feeds; bottling well. D/S stable. See triplet #1 for details. A: stable. A: stable. A: stable. Infant ismeeting min 140cc/kg/d requirement. Learningto bottle. P: Attempt pofeeds once RR <70x3hrs. Infant deep suctioned gastric contents for mod amt clear fluid, initially BBS coarse, however presently weaned to RA with BBS clear and equal. P: cont to follow.GDO: TEMp stable on warmer with servo control. Start PG/PO feeds. waking for feedingq2-4hours. Newborn Med AttendingDOL#1. A: NPO. IVFD 10w, infusing through PIV, at 30cc/k/d.Abd pink, no loops,active bs. po 163cc/kg in past 24hours.#2 g&dpt in oac with stable temps. O: Infant has stable temp on radiant warmer. Delivery by Cesarean section. P: cont toupdate, support, educate.BILIO: Sl jaundiced to ruddy at times. maew. MAEW. Active andalert with cares. Remains NPO at this time.Abd benign, no void or stool. Voiding/ stooling mec. P: cont to update,support, educate. No loops.Voiding 4.4cc/k/hr. P: Continue to assess and support developmentalneeds.#3. in . P: cont to follow. A: AGA P: cont to supportdev.milestones.ParentingO: Mom and dad in and updated at bedside, verbaliizngunderstanding. P- Cont to assess for G&Dneeds.#3-O/A- No parental contact so far this shift. Tol feeds. Will keep family updated.OB and delivering OB: Dr. Pediatrician: Dr. , A: Loving and invested . Exam unremarkable and appropriate for GA.Impression/Plan:Preterm male newborn transitioning well. Cardiorespiratory monitoring. Please see above attending note for details. TF=60cc/kg/d; 26cc SC-20 q 4 h via PO/PG. Initially required blow by 02 for 02 sats in 80's with duskiness noted, rr 80's with mild to mod retractions. Temp stable inopen crib. Sucking on pacifier intermittently.A: AGA. No audible murmur, b/p normal, pink and well perfused, pulses normal. Good . Nursing Progress NoteFEN: TF min 140cc/kg/d Neosure 22 cals/oz. BP=52/30 (38). . Monitor for RDS, apnea. Will investigate further maternal history of positive PPD. | 37 | [
{
"category": "Nursing/other",
"chartdate": "2150-10-02 00:00:00.000",
"description": "Report",
"row_id": 1730687,
"text": "PCA 1900-0700\n\n\n1\nBW 2575g, CW 2455g up 45g, TF 140cc/kg/d of bm20/neosure24,\nneeds 60cc q4h, po/pg feeds, bottled 38cc and 35cc, abd\nsoft, bs+, no loops, max asp 1.4cc, voiding qs, no stool\nthus far, no spits. P:cont. to monitor.\n\n2\nremains in OAC, temp stable, a/a with cares, settles well in\nbetween, fonts soft/flat, likes pacifier, right eye drainage\nclear>yellow warm soak applied. P:cont. to support growth\nand development.\n\n3\ndad in to visit, botllted infant, asked appropriate\nquestions, very loving, updated at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-02 00:00:00.000",
"description": "Report",
"row_id": 1730688,
"text": " Nurse Case Manager\nA referral was made to the VNA of Greater (phone , fax ) for a skilled nursing visit after discharge home. The baseline medical and demographic information has been called in to the agency. When the discharge date is made definite, please call and notify the agency and fax the completed page 1 and 2 referral forms to the above fax number. The mother is aware of the above referral and is in agreement with the plan of care. If you have any questions, please page me at beeper .\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-02 00:00:00.000",
"description": "Report",
"row_id": 1730689,
"text": "/NEON DOL 7 CGA 35 \nRA, RR 40's, HR 130's, no AOP\nWt 2455 up 55 on 140 cc/kg Neo/MM\nTaking PO remainder PG.\nNo aspirates.\nDr. to do circ today or tomorrow.\nSpoke with and updated mom.\nNeon to cover \n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-02 00:00:00.000",
"description": "Report",
"row_id": 1730690,
"text": "NPN DAYS\n\n\n1. TF remain at 140cc.kg of Neosure 22cal/BM20. Po/Pg feeds.\nAbd benign. No residuals. No spits. Voiding and stooling.\nCircumsion done by OB this am. Area reddend with small amt\nbloody drainage noted. Circ care provided per protocol.\nTylenol given as ordered. Continue with plan and monitor.\n\n2. Temp stable in open crib. AFOF. Alert and active with\ncares. AGA.\n\n3. No contact thus far from .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-03 00:00:00.000",
"description": "Report",
"row_id": 1730691,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.500, ^ 45gm. TF 140cc/k/d of\nNeosure 22. All po this shift. Removed NG tube. Infant is\nvoiding and stooling. Active bowel sounds. Minimal\nresiduals. No spits. Tolerating feeds. P-Continue to follow\ncurrent regimen.\n\nDEV: O/A-Temp stable in OAC. Waking for feeds. Alert and\nactive. Sleeps well. MAE. AF-flat. Roots. Circ site swollen\nand red. Tylenol as ordered. AGA. P-Continue to support G/D.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-03 00:00:00.000",
"description": "Report",
"row_id": 1730692,
"text": "nsg\nagree with above co-worker's note\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-29 00:00:00.000",
"description": "Report",
"row_id": 1730678,
"text": "NICU NSG NOTE\n\n\nFEN. No change in tonights wt. TF 120cc/k/d BM/SC. Needs\n52cc q4h. Took 50cc at 1st feed, then only 15cc at second\nfeed. Uses yellow nipple. Gavaged over 30 mins. Abd exam\nbenign. Voiding and stooling. Stools heme neg. Min asps. No\nspits. A/ Tolerating feeds. P/ Cont to monitor for feeding\nintolerances. Encourage po's.\n\nG&D. O/ Awake and alert with cares. Temps stable in open\ncrib. Learning to po. Not yet waking on own for feeds. A/\nAGA. P/ Cont to support developmental needs of infant.\n\nParenting. O/ Mom and dad in briefly after CPR course. Mom\nd/c'd home today. will be in tomorrow. A/ Updated\nand involved. P/ Cont to provide info and support to family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-30 00:00:00.000",
"description": "Report",
"row_id": 1730679,
"text": "NPN 2300-0700\n\n\n1 FEN\nCurrent weight 2.385 kg, no change. TF remain at\n120cc/kg/day of BM/SC 20. PO fed 27/52cc. Tolerating\nfeedings well. Abd soft, bs +. Min asp, no spits.\nVoiding. No stool thus far this shift.\n\n2 DEV\nTemp stable in open crib. Wakes for feeds. Sucks fingers.\n\n\n3 Parenting\nNo contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-28 00:00:00.000",
"description": "Report",
"row_id": 1730671,
"text": "NPN 7p-7a\n\n\n#1 TF's 100cc/k=43cc of SC20 q 4hrs. Bottle feeding with\nease. Abdominal exam unremarkable. No emesis. Residual max\n5.2cc of partially digested formula. Voiding and passing lg\nmeconium. Weight down 15g. A: all po's P: Follow weight and\nenc po feeds as tol\n\n#2 Temps stable in crib. Beginning to stir to feed. Swaddled\nwith boundaries in place. Sleeps peacefully. A: AGA P:\nSupport developmental needs, am PKU\n\n#3 No contact thus far overnoc.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-28 00:00:00.000",
"description": "Report",
"row_id": 1730672,
"text": "/NEON DOL 3\nRA, RR 40-60, no AOP, HR 130-150\nWt 2360 down 15 on 100cc/kg > 120cc/kg PO/PG SC20.\nHeme: Mom Apos, 6.3/0.3\nTo go to mom's room and speak with .\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-30 00:00:00.000",
"description": "Report",
"row_id": 1730680,
"text": "Nursing Progress Note\n\n\n#1 O: TF inc to 140cc/k/d now Neosure 20 or MM. attempted to\npo each feed but infant only taking 10-15cc and w/much\nencouragement. tol pg feeds well for remainder each time.\nAbd benign, vdg and passing guiac neg stools. A: no interest\nin po feeds yet P: offer if interested and pg otherwise.\n#2 O: temp sl cool at 0900 but better w/2 blankets and hat.\nwakes for some feeds but still not bottling with any\ninterest. Hep B vaccine given. still needs hearing screen,\ncar seat. A: acting like a premie p: cont to assess and\nsupport.\n#3 O: mom to be in later this afternoon to take home triplet\n1. updated by Dr. .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-30 00:00:00.000",
"description": "Report",
"row_id": 1730681,
"text": "NURSING\n#1 FEN\ns/o: Very little interest in BF or po feeding-- abd exam\nbenign. Wt up 25 gms to 2410 A: cont on NEosure 20\nP: Cont to mtr tol, support BF effort, document po\n#2 DEV\ns/o: Temp stable in opne crib. To breast x1- not latching.\nA: Dev CGA--35-1/7 P; cont dev supportive cares\n#3 PARENT\ns/o: in and participating in cares. 20mo old at home\na: 4 babies under 2. P: Cont support, ongoing teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-01 00:00:00.000",
"description": "Report",
"row_id": 1730682,
"text": "PCA 1900-0700\n\n\n1\nBW 2575g CW 2410g, TF 140cc/kg/d of neosure 20, 59cc q4h,\nPO/PG feeds, bottles 10-25cc, abd soft, bs+, no loops, max\nasp 14cc refed to infant and full feed given, voiding\nstooling qs, no spits. P:cont. to support nutritional\nneeds.\n\n2\nremains swaddled in OAC, temp stable, a/a with cares, occ\nwakes, likes pacifier, fonts soft/flat. P:cont. to suport\ngrowth and development.\n\n3\nno known contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-01 00:00:00.000",
"description": "Report",
"row_id": 1730683,
"text": "I have examined infant and agree with above documentation. made aware of infant's 14cc partially digested residual. Abdominal exam unremarkable. Infant placed in prone position with decrease to 1.4cc residual.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-01 00:00:00.000",
"description": "Report",
"row_id": 1730684,
"text": "/NEON DOL 6 CGA 35 \nRA, no AOP, RR 40-60, HR 130-150\nWt 2410 up 25 on 140 cc/kg Neos\nPO/PG\nHad 1, 14 cc asp overnite, refed, no problems, abd benign this am.\nCirc within the next few days.\nCalled and left message for mom.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-28 00:00:00.000",
"description": "Report",
"row_id": 1730673,
"text": "NPN 0700-1900\n\n\n1. FEN: TF increased this am to 120cc/k/day SC/BM20.\nBottled 43cc this am then nothing at 1300 due to lethargy.\nFeeds gavaged without incident. Max asp = 8.8cc. No spits.\nAbd is soft and round with active bs. V&S mec stools with\neach diaper change.\n\n2. G&D: was alert and active this am, but lethargic\nat 1300 feeding. Temps stable swaddled in open crib.\nBrings hands to face. AFSF. AGA.\n\n3. Parenting: Mom came up for 1300 feeding and was updated\nat bedside. Attempted to bottle , but he was too\ntired. Cont to offer support and updates.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-29 00:00:00.000",
"description": "Report",
"row_id": 1730674,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on TF's of 120cc/k/d of BM/SC20. PO\nfed 20cc's x1 tonight thus far. Tires quickly. No spits.\nMInimal aspirates. AG stable. Abd soft and round with active\nbowel sounds. No loops. Voiding qs, med trans stool neg\nheme. Wgt is up 25gms tonight to 2385gms. A: Tolerating\nfeeds. P: Continue to encourage po feeds as tolerated.\n\n#2. O: Infant remains in open crib with stable temp. HE is\nalert and active with cares. MAEW. Poor po feeder-tires\nquickly. A: AGA P: Continue to assess and support\ndevelopmental needs.\n\n#3. O: in briefly this evening with visitors. Asking\nappropriate questions. A: Involved family. P: Continue to\ninform and support. ?Mom d/c today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-29 00:00:00.000",
"description": "Report",
"row_id": 1730675,
"text": "/NEON DOL 4 , CGA 4\nRA, no AOP, RR 40-60, HR 130-150\nWt 2385 up 25 on 120 cc/kg SC 20 PO/PG\nMom A pos, last 6.3, to repeat in am\nMom to be discharged today, will speak with her.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-29 00:00:00.000",
"description": "Report",
"row_id": 1730676,
"text": "NICU nursing progress note\n\n\nplease refer to flowsheet for specific info.\nFEN\nO TF of 120cc/k/d of sc or bm 20, bottling skills are\ndecreased r/t drowsiness. Bottled full amount of 52cc at\n1300. Starts slowly then increases in pacing. Abd pink,\nsoft, no loops, active bs. voiding q diaper change. A:\nstable. P: cont to support and follow.\nGD\nO: temp stable in oac, active and alert with cares. Mae.\nfonts soft, flat. CAlms with containment and pacifier. A:\nAGA P: cont to support dev.milestones.\nParenting\nPlease refer to trip # 1 note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-29 00:00:00.000",
"description": "Report",
"row_id": 1730677,
"text": "NPN\n in for infant CPR class this afternoon. See triplet #1 for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-03 00:00:00.000",
"description": "Report",
"row_id": 1730693,
"text": "Neonatology Attending\n\n\nNow day of life 8, CA 4/7 weeks.\nIn RA, RR 40-50s no apnea and bradycardia.\nHR 130-150s\n\nWt. up 45gm to 2500gm on ad lib feedings Neosure 22 - taking feedings well for the past 24 hours.\nNormal urine and stool output.\n\nAssessment/plan:\nPremature infant doing well and now with apparent maturation of feeding skills.\nDischarge teaching and screening in progress.\nPossible discharge to home tomorrow or Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-03 00:00:00.000",
"description": "Report",
"row_id": 1730694,
"text": "Nursing Progress Note\n\n\nFEN: TF min 140cc/kg/d Neosure 22 cals/oz. Infant is\nmeeting min 140cc/kg/d requirement. Abd exam benign.\nVoiding QS, passing yellow/green stools. Circ site is clean\nand healing well, slightly edemitous, circ care done.\n\nDev: Temp stable swaddled in crib. Infant is waking for\nfeedings and is alert with cares. Sleeping well between\nfeedings. Plan to cont to support dev needs.\n\n: Mother in visiting. Ask mother to bring in car\nseat for testing. Some d/c teaching done as documented on\nflow sheet.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-04 00:00:00.000",
"description": "Report",
"row_id": 1730695,
"text": "npn 1900-0700\n\n\n#1 fen\ntf min 140cc/kg neosure po ad lib. waking for feeding\nq2-4hours. wt. 2.530kg (+30gms). abd benign. voiding and\nstooling yellow guiac neg stools. circumcision clean with\nno drainage or bleeding. vaseline gauze applied with each\ndiaper change. no spits. po 163cc/kg in past 24hours.\n#2 g&d\npt in oac with stable temps. alert and active with cares,\nwaking for feedings on own. sucking on binki and hands.\nfontanelles soft and flat. maew. carseat test passed.\n#3 parenting\nno contact thus far this shift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-04 00:00:00.000",
"description": "Report",
"row_id": 1730696,
"text": "Neo Attend\nDay 9 CGA 35.5wk\nRespr 40-50s, RA,\nCV: soft murmur (intermittent); P and BP wnl.\nTW 2530gm, up 30gm\nNeosure 22 cal/ Intake 160 cc/kg/day po ad lib feed.\ncirc is fine\ntemp stable.\nPlan is to discharge today.\n in . Dr. .\nDr. . Schecnter will do discharge summary.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-04 00:00:00.000",
"description": "Report",
"row_id": 1730697,
"text": "NICU NUrsing Discharge note:\nBaby boy 3 remains on RA, rr easy and unlabored, BBS equal and clear, VSS, no spells, no murmur audible, abd soft and nondistended, good bowel sounds, voiding and stooling, circ site looks good, healing without bleeding or drainage, bottling well q 3-4 hours Neosure 22, no spits. Mom to be in shortly to discharge infant to home. Infant had PKU test done today and passed car seat test.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-04 00:00:00.000",
"description": "Report",
"row_id": 1730698,
"text": "NICU Nursing Discharge note:\nMom in to take infant home, discharge teaching reviewed, Wic form given to , mom put infant in car seat and states she understands use of infant car seat. Mom states she is comfortable taking infant home. VNA to visit on Monday. Mom to make pedi appt for Tuesday and will call for follow up hearing screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-01 00:00:00.000",
"description": "Report",
"row_id": 1730685,
"text": "Nursing Progress Note\n\n\n#1-O/A- TF=140cc/kg/d of Neosure via po/pg. Abd exam\nbenign. Voiding and stooling. Tol feeds. P- Cont to\nassess for FEN needs.\n#2-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nopen crib. Sucks on pacifier. P- Cont to assess for G&D\nneeds.\n#3-O/A- No parental contact so far this shift. P- Cont to\nenc parental calls and visits.\nSee flowsheet for further details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-10-02 00:00:00.000",
"description": "Report",
"row_id": 1730686,
"text": "PCA 1900-0700\nI have examined this infant and agree with note and assessment of PCA, .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-26 00:00:00.000",
"description": "Report",
"row_id": 1730666,
"text": "NICU nursing progress note\n\n\nFEN\nO: , infant boy, remains on TF of 60cc/k/d. 30cc/k/d of\nSC 20cal/oz bottling fairly well, though slow to start. IVF\nD 10w, infusing through PIV, at 30cc/k/d.Abd pink, no loops,\nactive bs. Voiding/ stooling mec. No spits. MIn asp. DS\nstable thus far. A: stable. P: cont to follow.\nGD\nO: TEMp stable on warmer with servo control. Active and\nalert with cares. MAE.Fonts soft, flat. Calms with\ncontainment and pacifier. A: AGA P: cont to support\ndev.milestones.\nParenting\nO: Mom and dad in and updated at bedside, verbaliizng\nunderstanding. Very pleased and happy to have three healthy\nbabies. A: Loving and invested . P: cont to update,\nsupport, educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-27 00:00:00.000",
"description": "Report",
"row_id": 1730667,
"text": "NPN:\n\nRESP: Sats 99-100% in RA. RR=40-60s. BBS =/clear. No desats or A&Bs thus far tonight; no A&Bs over past 24 h.\n\nCV: No murmur. HR=130-140s. BP=52/30 (38). Color pink w/good perfusion.\n\nFEN: Wt=2375g (- 200g). TF=60cc/kg/d; 26cc SC-20 q 4 h via PO/PG. Bottled well x 2 for entire volume. Hep-locked IV. Tolerating fdgs well w/o spits; minimal residuals. Abd benign. Voiding qs; no stool since yesterday. Elec yesterday: 146/ 4.9/ 113/ 24.\n\nG&D: CGA=34 wk. Moved to crib; temp stable. Active and alert w/cares. Not yet waking for feeds; bottling well. Swaddled, nested and resting well. Circ consent signed.\n\nBILI: Bili from yesterday-4.3/ 0.2/ 4.1.\n\n\nSOCIAL: Father in w/members of extended family. Involved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-27 00:00:00.000",
"description": "Report",
"row_id": 1730668,
"text": "Attending Note\nDay of life 2 CGA 34 \nin room air sat above 99% RR 40-60\nno drifts no spells\nHr 150-170's 52/30 mean 38\nweight 2375 down 200 SSC 20 cal/oz all po's\nvoiding and stooling\nD-stick 75\nNa 146 K 4.9 Cl 113 CO2 24\nbili 4.3/0.2\nin open air crib\n\nImp-stable\nwill have a minimum of 100 cc/kg/day\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-27 00:00:00.000",
"description": "Report",
"row_id": 1730669,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nFEN\nO: TF min of 100cc/k/d of SC 20 cal/oz. Bottling skills\nimproving. This morning took 32cc ~80cc/k/d. need to\ngavage full volume needed to meet 100cc/k/d. Abd pink, no\nloops, active bs.Voiding/ stooling mec. A: stable. Learning\nto bottle. P: cont to follow.\nGD\nO: TEMp stable in oac, active and alert with cares.\nMAE.Fonts soft, flat. Good . Calms with containment and\npacifier. A: AGA P: cont to support dev.milestones.\nParenting\nO: Mom and dad in and updated at bedside, verbalizing\nunderstanding. A: Involved and loving . P: cont to\nupdate, support, educate.\nBILI\nO: Sl jaundiced to ruddy at times. Will recheck bili level\nin am. A: stable. P: cont to follow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-27 00:00:00.000",
"description": "Report",
"row_id": 1730670,
"text": "Neoantology-NNP Physical Exam\n\nInfant remains in RA. Active, alert, AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-25 00:00:00.000",
"description": "Report",
"row_id": 1730662,
"text": "Neonatology Attending Admission Note\n\nInfant is a 34 week, 2570 gm male newborn (triplet III) who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 36 y.o. G2P1 now 4 mother. Prenatal screens: A+, antibody negative, HBsAg negative, RPR NR, RI, GBS negative. Prior OB history - , c/s, FT male. +tubal factor infertility, myomectomy , +fibroids. h/o +PPD. Meds: PNV.\n\nThis pregnancy notable for:\n-- IVF triplets, dichorionic, triamniotic\n-- PTL at 30 weeks, controlled with PO terbutaline\n-- Presented today in OB office with 3+ proteinuria\n\nDue to proteinuria, decision made to deliver infants. Delivery by Cesarean section. Apgars 8,9. Infant shown to parents then transported to NICU for further management.\n\nExam:\nVS per CareView\nMeasurements: weight 2570 gms = 75%, L 48 cm = > 75%, HC 33.5 cm = <90%.\nExam noted in bedside chart on newborn exam form. Exam unremarkable and appropriate for GA.\n\nImpression/Plan:\nPreterm male newborn transitioning well. Cardiorespiratory monitoring. Monitor for RDS, apnea. No perinatal sepsis risk factors or concerns, so no sepsis evaluation at this time. Will investigate further maternal history of positive PPD. NPO while infant transitions with maintenance IVFs. Temperature regulation. Will keep family updated.\n\nOB and delivering OB: Dr. \nPediatrician: Dr. , \n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-25 00:00:00.000",
"description": "Report",
"row_id": 1730663,
"text": "NICU NURSING ADMISSION NOTE:\nBaby boy admitted from L&D s/p C/S at 34+ wks. Please see above attending note for details. Infant alert and active, crying, good , . Initially required blow by 02 for 02 sats in 80's with duskiness noted, rr 80's with mild to mod retractions. Infant deep suctioned gastric contents for mod amt clear fluid, initially BBS coarse, however presently weaned to RA with BBS clear and equal. RR now 50-70's with mild retractions. No audible murmur, b/p normal, pink and well perfused, pulses normal. Remains NPO at this time.Abd benign, no void or stool. IV placed of D10 at 60cc/kday with 24 gauge catheter per NICU protocol. D/S stable. Erythro and Vit K given as ordered. No contact from at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-26 00:00:00.000",
"description": "Report",
"row_id": 1730664,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains NPO on TF's of 60cc/k/d of D10W. D/S\n89. ABd soft and flat with quiet bowel sounds. No loops.\nVoiding 4.4cc/k/hr. No mec thus far. A: NPO. P: Attempt po\nfeeds once RR <70x3hrs. RR has been <70 since 0500.\n\n#2. O: Infant has stable temp on radiant warmer. Alert and\nactive with cares. MAEW. Sucking on pacifier intermittently.\nA: AGA. P: Continue to assess and support developmental\nneeds.\n\n#3. No contact thus far from .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-09-26 00:00:00.000",
"description": "Report",
"row_id": 1730665,
"text": "Newborn Med Attending\n\nDOL#1. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2570, 60 cc/kg/d D10W.\nA/P: Infant with transient resp distress, now resolving. Start PG/PO feeds.\n"
}
] |
12,219 | 187,133 | Patient was admitted to Medicine, made n.p.o. and patient underwent a barium swallow . It showed irregular erosions of the esophageal wall, elevation of the left hemidiaphragm and abnormal position of the stomach. Patient then underwent esophagogastroduodenoscopy by the gastrointestinal service on which was significant for grade 2 esophagitis of the lower third of the esophagus and open pylorus and an extrinsic stenosis of the second part of the duodenum. The patient felt symptomatically better after several days of bowel rest. Patient was restarted on liquid diet, was on Protonix for his gastritis and subsequently developed nausea and vomiting once again and intolerance to any p.o. intake. At this point patient had a PICC line placed. Total parenteral nutrition was started. A second esophagogastroduodenoscopy with biopsies was performed. The esophagogastroduodenoscopy was significant for gastric inlet patch, gastritis of the stomach and extrinsic stenosis of the second part of the duodenum once again. The biopsies were negative for any malignancy. Surgery was consulted and once being cleared by cardiology due to his history of paroxysmal atrial fibrillation patient was taken to the operating room on for planned gastrojejunostomy. During rapid induction for intubation patient became hypotensive with systolic blood pressure in the 60s and the monitor showed an eight beat run of ventricular tachycardia. Patient was intubated, started on pressors and was taken to the Intensive Care Unit without undergoing any procedure. Patient in the Intensive Care Unit remained hemodynamically stable. He was weaned off pressors and extubated without incident. CKs were flat. Troponin Is were 1.9 and 1.8 respectively. There were no electrocardiographic changes post event. After spending several days in a closely monitored setting it was decided the patient would once again return to the operating room on . Patient was inducted without any incident. Patient on underwent a gastrojejunostomy, anal dilatation and a biopsy of intraoperative finding of a retroperitoneal mass which was compressing the duodenum. Patient tolerated this procedure well, was transferred to the post anesthesia care unit extubated and in stable condition. He was then transferred to the Surgical Intensive Care Unit for close monitoring and after spending one night patient was then transferred to the floor for the remainder of his recovery. Postoperatively cardiology-wise patient remained stable with no postoperative electrocardiogram changes. Postoperatively the patient has remained afebrile. He received a five day course of Levaquin. On postoperative day number one after being transferred to the floor patient received rapid atrial fibrillation with a stable blood pressure. He was treated with intravenous Lopressor and became rate controlled. Patient then converted spontaneously to sinus. On postoperative two the patient once again had an episode of rapid atrial fibrillation which was rate controlled and patient converted back to normal sinus. Patient has remained on beta blockade with adjustments as appropriate. Patient was restarted on his Coumadin on postoperative day number three and his current INR is 1.7. The patient received 5 mg of Coumadin for tonight and will be followed by Dr. as he has been doing in the past. Patient's respiratory status has remained stable. He has been weaned off oxygen with O2 saturations in the high 90 percents. Patient's nasogastric tube was discontinued on postoperative day number two and he has been advanced to a soft diet which he is tolerating. Patient's total parenteral nutrition was weaned and the PICC line was removed. Patient has been cleared by physical therapy for discharge to home and has been ambulating without problem. Patient's hematocrit has remained stable at 30. Patient's electrolyte balance has remained sable and kidney function has remained stable with his last BUN and creatinine being 33 and 1.0. Patient is stable and ready for discharge to home. The biopsy of the retroperitoneal mass pathology has returned result of poorly differentiated adenocarcinoma, signet cell features, positive for keratin and cytokeratin 7 and 20. This is the same staining properties as the mass biopsied from the bladder and is likely metastatic disease. Patient was seen by the oncology service and outpatient chemotherapy and will continue. Patient will follow up with Dr. in one week and will follow up with Dr. in one week for Coumadin adjustment and atrial fibrillation management. | Sinus rhythmConsider old septal infarctSince previous tracing, , ST depression absent. Lungs CTA per H.O. HR nsr 80-90..occassinal pvc..ekg done.. bp 160-200/90.. (aline in r femoral) to restart lopressor iv this eve.Was to start on Heparin..given 3,000u bolus..but gtt held per HO..was not anticoagulated on floor.. Volume status: 1800cc in OR for recusitation..IVF ns 150hr..u/o is good..? PAD=16-18 PCW=13,CVP=8.CO TD=7.1,FICK=7.9.IV LR at 100cc/h. Allergies: Succinylcholine..?malagnant hypertermia..Systems review: Respiratory: Arrived intubated and sedated on propofol..imv 12/700/100%/5peep..no spont respirations..suctioned for mod amt white secretions..propofol dc'd..pt placed on 10ps/5peep..spontrr ..abg good..extubated at 10am..2lnc..with good abgs.. cough..no sputum.Lungs clear. No other red or open areas noted.PAIN: Pt is on PCA Dilaudid 0.25mg/cc. PMHX: Bladder ca ..has had chemo up until PAT..on coumadin DepressionPt was initially admitted with N/V/dehydration..work-up reveled stenosis in duodenum..was to have gastro-jejunostomy today. Probable change in leadV2 positionOtherwise within normal limits Sinus arrhythmiaST junctional depression is nonspecificEarly precordial R transitionSince previous tracing, , no significant change Lungs clear and diminished at bases.GU: U/O=15-50cc/h. WEDGE HAS GONE FROM 7 TO 8 TO 9 AFTER (3) 1 LITER BOLUSES OF NS. IV Hydralizine given. Surgery cancelled, pt fluid resucitated, admitted to MICU on for monitoring, then transferred to 12 Reiesmann on .PMH: bladder CA s/p chemo, ?mets to rectum, PAF, HTN, depression, glaucoma,ALLERGIES: succinycholine--malignant hyperthermiaREVIEW OF SYSTEMS:NEURO:A+O x3, MAECV: SR 80-100, BP 120-140/60; is on IV Lopressor q6h, PA line placement this eve, IVF 75cc/hr.RESP: LS clear but dim at bases, Sat 94% on RAGI: Ngt in place to LWS, is putting out a fair amount of dark green drainage, replace NGT output with IVF cc/cc Q8hrs see MD order, BS +, TPN @ 85 cc/hGU: foley draining tea colored urineACCESS: right AC PICC double lumen, LAC #18.SKIN: warm/dry intactSocial: with lives wife, family and friends in visiting, asking appropriate ? Prominent R wave inlead V2. Sinus rhythmPossible old anteroseptal myocardial infarctionSince previous tracing, , no significant changeOtherwise normal ECG IV lopressor given and dose increased with minimal effect. Abd dsd D&I. MICU-NPNNEURO: Pt. 4 ICU nursing admit note: 81 y/o gentleman transfered from the OR d/t hypotension/8beat VT.Pt was being given anesthesia at this time..case cancelled. has been hypertensive most of noc with sbp's in the 150's-200's. HR=95-102 SR with no ectopy noted. He has had incisional pain relieved very well with the PCA.ACCESS: Two large bore IV's in Antecubitals-H.L.'s. Maintaining PCWP ~20 and CVP ~14. Compared to the previous tracing of there has been nodiagnostic interval change. SBP dropped to 80s 30min after Dilaudid started w/assoc drop in PCWP 15 and CVP to 10. Went to OR on for gastrojejunostomy; became hypotensive and had 8 beat run of VT. MICU/SICU NPN 0700-1900A&O x3. ICU note cont... Received 2.5L IVF in OR. SBP aline=81-135,SBP cuff=84-116. Gd UO. LR at 100cc//hr. rr 10-14 Cardiac: No cp..is being r/o..cks flat so far. UO EXCELLENT, TEA COLORED BUT I THINK THAT THIS IS D/T SM CLOTS I'VE SEEN IN THE TUBING. Skin warm and dry.NEURO: Pt alert and oriented x3. Pt says Dilaudid seems to be helping. ?if pt to go to OR on Monday.. Neuro: Alert orinetated MAE..quite conversant..disapointed surgery was cancelled..c/o not sleeping in "weeks"..? SURGERY THIS AM. ?try haldol..says ativan doesnt work..PT was also on parnait..antidepressent..has been on hold for 3weeks..? To OR 1015. ?contributing to insommnia. NGT draining bilious=200cc.SKIN: Abdomenal incision dsg clean,dry and intact. No heparin at this time.RESP: LS clear, POX>95%, denies SOB,GI: abdomen soft& distended, non-tender, NGT-LIWS draining clear green bile, denies nausea. gtt is off. IVF dc'd.incontinent of formed stool x1.GU: Foley drng adequate amt's of bloody urine with clots. Fent gtt still on at 50ucgs. ?need to follow cvp GI: No c/o pain..abdomen soft +bs..passing small amts semi formed brown stool..NG..to LIS..clear-green aspirates..NPO..on TPN. is A&Ox3, follows commands appropriately.CV: pt. "B"-REVIEW OF SYSTEMS.CVS: T102.2 to 99.5,Blood and urine cultures sent. Pt A&O at the time. MICU admit noteADMISSION NOTE:81 yo male transferred from 12 for invasive monitoring, evaluation of fluid volume status and repletion of vol if needed.HOSP Course: Pt admitted with N,V, and dysphagia on . TPN infusing as ordered. Sats mostly 92-94% on 3-4l nc. 'sPlan: PA line placement and assessment of fluid status, volume repletion if needed, OR for gastrojejunostomy monday Plan to titrate off. CSM all extremities good. No deficits noted.RESP: Sats drifted down to 89% when asleep. Sinus tachycardia. Started on Fent gtt @25ucgs after multiple IVBs until PCA could be obtained. Encouraged to c&db,also doing IS extremely well up to . Pt given LR IV boluses=1250cc during the night for low BP and u/o dip to 15cc.x1. Plan to continue to monitor fluid status overnight and contiune with pain controll efforts. Had break through pain intermittently. Pulses intact. Felt pt was dehydrated causing hypotension..sent to ICU for further care. Returned at 1300. Currently receiving 500cc LR IVB and BP is slowly rising. Non-specific ST-T wave abnormalities. NPN (NOC): PT HAS HAD A VERY STABLE NIGHT. Irrigated Q1-2 hr's to see if it clears.SKIN: lidocaine gel to penis for comfort. Dilaudid PCA started at 1830. ? ? yellow to amber slightly cloudy.GI: No bowel sounds. NGT PUT OUT 700 CC'S OF GREEN BILE OVERNIGHT. PA and Aline show good curves and flush well. ID: No temp..no antibiotics.. Social: Wife..2 daughters..all exhauster..wife wanting to stay overnite..explained she should get home for some rest..daughters agreed..they did leave for a few hours..Daughters will be staying with mother at her house tonoc.. Lines: double lumen PICC r arm..#18 Left antecube..r femoral line. | 11 | [
{
"category": "ECG",
"chartdate": "2174-05-25 00:00:00.000",
"description": "Report",
"row_id": 295569,
"text": "Sinus arrhythmia\nST junctional depression is nonspecific\nEarly precordial R transition\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-10 00:00:00.000",
"description": "Report",
"row_id": 295570,
"text": "Sinus tachycardia. Non-specific ST-T wave abnormalities. Prominent R wave in\nlead V2. Compared to the previous tracing of there has been no\ndiagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-31 00:00:00.000",
"description": "Report",
"row_id": 295567,
"text": "Sinus rhythm\nPossible old anteroseptal myocardial infarction\nSince previous tracing, , no significant change\nOtherwise normal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-27 00:00:00.000",
"description": "Report",
"row_id": 295568,
"text": "Sinus rhythm\nConsider old septal infarct\nSince previous tracing, , ST depression absent. Probable change in lead\nV2 position\nOtherwise within normal limits\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-31 00:00:00.000",
"description": "Report",
"row_id": 1422667,
"text": " \"B\"-REVIEW OF SYSTEMS.\n\nCVS: T102.2 to 99.5,Blood and urine cultures sent. HR=95-102 SR with no ectopy noted. SBP aline=81-135,SBP cuff=84-116. Pt given LR IV boluses=1250cc during the night for low BP and u/o dip to 15cc.x1. PAD=16-18 PCW=13,CVP=8.CO TD=7.1,FICK=7.9.IV LR at 100cc/h. Skin warm and dry.\n\nNEURO: Pt alert and oriented x3. No deficits noted.\n\nRESP: Sats drifted down to 89% when asleep. Encouraged to c&db,also doing IS extremely well up to . Sats mostly 92-94% on 3-4l nc. Lungs clear and diminished at bases.\n\nGU: U/O=15-50cc/h. yellow to amber slightly cloudy.\n\nGI: No bowel sounds. NGT draining bilious=200cc.\n\nSKIN: Abdomenal incision dsg clean,dry and intact. No other red or open areas noted.\n\nPAIN: Pt is on PCA Dilaudid 0.25mg/cc. He has had incisional pain relieved very well with the PCA.\n\nACCESS: Two large bore IV's in Antecubitals-H.L.'s. PA and Aline show good curves and flush well. CSM all extremities good. Pulses intact.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-28 00:00:00.000",
"description": "Report",
"row_id": 1422663,
"text": "MICU-NPN\n\nNEURO: Pt. is A&Ox3, follows commands appropriately.\nCV: pt. has been hypertensive most of noc with sbp's in the 150's-200's. IV lopressor given and dose increased with minimal effect. IV Hydralizine given. No heparin at this time.\nRESP: LS clear, POX>95%, denies SOB,\nGI: abdomen soft& distended, non-tender, NGT-LIWS draining clear green bile, denies nausea. TPN infusing as ordered. IVF dc'd.incontinent of formed stool x1.\nGU: Foley drng adequate amt's of bloody urine with clots. Irrigated Q1-2 hr's to see if it clears.\nSKIN: lidocaine gel to penis for comfort.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-29 00:00:00.000",
"description": "Report",
"row_id": 1422664,
"text": "MICU admit note\nADMISSION NOTE:\n81 yo male transferred from 12 for invasive monitoring, evaluation of fluid volume status and repletion of vol if needed.\n\nHOSP Course: Pt admitted with N,V, and dysphagia on . Went to OR on for gastrojejunostomy; became hypotensive and had 8 beat run of VT. Surgery cancelled, pt fluid resucitated, admitted to MICU on for monitoring, then transferred to 12 Reiesmann on .\n\nPMH: bladder CA s/p chemo, ?mets to rectum, PAF, HTN, depression, glaucoma,\n\nALLERGIES: succinycholine--malignant hyperthermia\n\nREVIEW OF SYSTEMS:\nNEURO:A+O x3, MAE\nCV: SR 80-100, BP 120-140/60; is on IV Lopressor q6h, PA line placement this eve, IVF 75cc/hr.\nRESP: LS clear but dim at bases, Sat 94% on RA\nGI: Ngt in place to LWS, is putting out a fair amount of dark green drainage, replace NGT output with IVF cc/cc Q8hrs see MD order, BS +, TPN @ 85 cc/h\nGU: foley draining tea colored urine\nACCESS: right AC PICC double lumen, LAC #18.\nSKIN: warm/dry intact\nSocial: with lives wife, family and friends in visiting, asking appropriate ?'s\n\nPlan: PA line placement and assessment of fluid status, volume repletion if needed, OR for gastrojejunostomy monday\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-30 00:00:00.000",
"description": "Report",
"row_id": 1422665,
"text": "NPN (NOC): PT HAS HAD A VERY STABLE NIGHT. WEDGE HAS GONE FROM 7 TO 8 TO 9 AFTER (3) 1 LITER BOLUSES OF NS. UO EXCELLENT, TEA COLORED BUT I THINK THAT THIS IS D/T SM CLOTS I'VE SEEN IN THE TUBING. NGT PUT OUT 700 CC'S OF GREEN BILE OVERNIGHT. ? SURGERY THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-30 00:00:00.000",
"description": "Report",
"row_id": 1422666,
"text": "MICU/SICU NPN 0700-1900\n\nA&O x3. Lungs CTA per H.O. To OR 1015. Returned at 1300. Awake and alert but in severe pain. Started on Fent gtt @25ucgs after multiple IVBs until PCA could be obtained. Had break through pain intermittently. Dilaudid PCA started at 1830. Fent gtt still on at 50ucgs. Plan to titrate off. Abd dsd D&I. LR at 100cc//hr. Received 2.5L IVF in OR. Maintaining PCWP ~20 and CVP ~14. Gd UO. SBP dropped to 80s 30min after Dilaudid started w/assoc drop in PCWP 15 and CVP to 10. Currently receiving 500cc LR IVB and BP is slowly rising. Pt A&O at the time. gtt is off. Pt says Dilaudid seems to be helping. Plan to continue to monitor fluid status overnight and contiune with pain controll efforts.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-27 00:00:00.000",
"description": "Report",
"row_id": 1422661,
"text": " 4 ICU nursing admit note:\n 81 y/o gentleman transfered from the OR d/t hypotension/8beat VT.\nPt was being given anesthesia at this time..case cancelled.\n PMHX: Bladder ca ..has had chemo up until \n PAT..on coumadin\n Depression\nPt was initially admitted with N/V/dehydration..work-up reveled stenosis in duodenum..was to have gastro-jejunostomy today. Felt pt was dehydrated causing hypotension..sent to ICU for further care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-27 00:00:00.000",
"description": "Report",
"row_id": 1422662,
"text": "ICU note cont...\n Allergies: Succinylcholine..?malagnant hypertermia..\nSystems review:\n Respiratory: Arrived intubated and sedated on propofol..imv 12/700/100%/5peep..no spont respirations..suctioned for mod amt white secretions..propofol dc'd..pt placed on 10ps/5peep..spontrr ..abg good..extubated at 10am..2lnc..with good abgs.. cough..no sputum.\nLungs clear. rr 10-14\n Cardiac: No cp..is being r/o..cks flat so far. HR nsr 80-90..occassinal pvc..ekg done.. bp 160-200/90.. (aline in r femoral) to restart lopressor iv this eve.Was to start on Heparin..given 3,000u bolus..but gtt held per HO..was not anticoagulated on floor..\n Volume status: 1800cc in OR for recusitation..IVF ns 150hr..u/o is good..??need to follow cvp\n GI: No c/o pain..abdomen soft +bs..passing small amts semi formed brown stool..NG..to LIS..clear-green aspirates..NPO..on TPN. ??if pt to go to OR on Monday..\n Neuro: Alert orinetated MAE..quite conversant..disapointed surgery was cancelled..c/o not sleeping in \"weeks\"..??try haldol..says ativan doesnt work..PT was also on parnait..antidepressent..has been on hold for 3weeks..??contributing to insommnia.\n ID: No temp..no antibiotics..\n Social: Wife..2 daughters..all exhauster..wife wanting to stay overnite..explained she should get home for some rest..daughters agreed..they did leave for a few hours..Daughters will be staying with mother at her house tonoc..\n Lines: double lumen PICC r arm..#18 Left antecube..r femoral line.\n\n"
}
] |
56,788 | 153,935 | **The patient underwent emergent bilateral EVD placement in the Emergency Department and was then admitted to Neurosurgery. Following successful placement, she was transferred to the ICU for close monitoring and Q1 neuro checks. A cerebral angio performed that evening confirmed the presence of . She was put on mannitol 25g Q6 for edema, which was weaned down on to 12.5mg Q6 and has subsequently been weaned off. The EVDs were kept patent with TPA flushing. **On her EVD's were raised to 20 and on her Left EVD was clamped and her Head CT was stable. Overnight on into she was febrile and became more lethargic. Her L EVD was subsequently opened on and a Head CT was done which showed unchanged IVH and slowly evolving subacute R basal ganglia and superior parietal lobe infarcts. **On she continued to be febrile and her L EVD was again clamped with her R continuing to be open at 20. On her exam began to improve as she was oriented to self and that she was in the hopsital. Her Left EVD was removed and her Right was rasied to 25. CSF was also sent for studies. **On patient's EVD was clamped for a trial. Patient's ICPs overnight ranged from 13-19. She was also being transitioned to Keprra for antiseizure coverage due to elevated LFTs. A speech and swallow evaluation was declined because of patient's lethargy. A PEG was placed on without complications and patient will remained NPO until . Her exam is stable, EVD was removed and CSF cultures were sent. **On patient was lethargic, arousable only with constant noxious stimuli. Patient making eye contact and spontaneous with RUE, but no commands or mouthing of words. Head CT showed more prominent ventricles, but no hydrocephalus. **She was then transferred to the Neurology Stroke Service on . Exam significant for abulia, tracking, left hemiplegia. MRI/MRA was repeated and showed Right intraventricular hemorrhage as on previous CT scans. Acute/subacute right periatrial white matter infarct as seen on the previous CT examination (). Signal changes in the right basal ganglia could be due to subacute/chronic hemorrhage. Increased signal in the right side of the midbrain probably due to subacute or chronic infarct in this location. MRA showed bilateral supraclinoid internal carotid artery flow signal narrowing indicative of occlusive disease. The middle cerebral arteries were not fully visualized. Similar findings were seen on the previous CTA examination. In the posterior circulation, basilar artery is well visualized but diminished flow signal is seen in both posterior cerebral arteries. **She was then weaned off of Keppra and EEG repeated showing no seizure activity. She remained afebrile after . Cultures only revealed yeast in urine, but blood and CSF were negative. Abdominal U/S negative despite elevated LFTs. Patient was anemic and sickle cell screen was negative. Platlets elevated, but hematology team not concerned and they trended downwards. LENIS negative for DVT on . **On , MS exam improved. She was vocalizing, following all commands with continued left hemiplegia. She was seen by speech and swallow and cleared to have thin liquids, ground solids with one to one monitoring. CXRAY should be repeated to check for silent aspiration. Labs in terms of transaminitis and thrombocytosis improving. She was afebrile for over 72 hours. **Family Meeting conducted and she will be discharged to rehab. **Patient will have outpatient follow up with Dr. , to consider vascular bypass and Dr. in stroke clinic. Neurosurgery followup should also be arranged as detailed below. | F/u Na, Osm -- intrathecal tPA (through EVD) q 12h. F/u Na, Osm -- intrathecal tPA (through EVD) q 12h. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 17. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 17. Chief complaint: ICH PMHx: DM2 Current medications: 1. Chief complaint: ICH PMHx: DM2 Current medications: 1. Dilantin level = pending -- start ASA 81mg qd once EVD drains are out -- fentanyl prn pain -- repeat head CT stable -- Dilantin 100mg q8h. Dilantin level = -- start ASA 81mg qd once EVD drains are out -- fentanyl prn pain -- repeat head CT stable Cardiovascular: --stable. F/u Na, Osm -- intrathecal tPA (through EVD) q 12h. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 17. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 17. Chief complaint: ICH PMHx: DM Current medications: 1. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 20. Febrile 102.1 - pancultured, LFTs ordered as per neurology. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807 7. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP < 160 Order date: @ 1713 5. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP < 160 Order date: @ 1713 5. Chief complaint: ICH PMHx: DM2 Current medications: 1. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 21. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 7. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 7. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807 7. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807 7. Chief complaint: ICH PMHx: DM Current medications: 1. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 17. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 0641 21. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 6. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 6. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608 6. Dilantin level = pending -- start ASA 81mg qd once EVD drains are out -- fentanyl prn pain -- repeat head CT stable -- Dilantin 100mg q8h. There is slight prominence of the right temporal seen as on the previous CT examination. Evolution of intraventricular hemorrhage, with interval removal of left frontal drain, and right frontal drain remains in place, with stable appearance of the ventricles. There is unchanged hyperdensity in the right basal ganglia and hemorrhage layering in the right occipital . The hypodensity in the right centrum semiovale related to subacute infarct is unchanged. Since theprevious tracing of sinus tachycardia and diffuse ST-T wave changes arenow present. There is a hypodense area in the corona radiata on the right, in similar pattern compared to prior CT scan, 2:18, likely encephalomalacia in this area, or edema. Stable hemorrhage layering in the right occipital . Additionally, there is evidence of restricted diffusion seen in the right periatrial white matter region indicative of acute/subacute infarct. interval change Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) FINDINGS: A right-sided ventricular drain is identified and terminates in the right frontal of the lateral ventricle, unchanged in position. The hypodense subacute infarct in the right centrum semiovale is essentially unchanged. Known subacute hypodense infarcts in the right basal ganglia and right superior parietal lobe appear unchanged. FINDINGS: There is an unchanged amount of layering hemorrhage in the right occipital . FINDINGS: There is an unchanged amount of layering hemorrhage in the right occipital . Stable left frontal lobe and right basal ganglia hemorrhage. Stable residual hemorrhage in the right lateral ventricle. Persistent intraventricular hemorrhage, left frontal lobe hemorrhage and right basal ganglia hyperdensity, unchanged. Persistent intraventricular hemorrhage, left frontal lobe hemorrhage and right basal ganglia hyperdensity, unchanged. Persistent intraventricular hemorrhage, left frontal lobe hemorrhage and right basal ganglia hyperdensity, unchanged. Unchanged intraventricular hemorrhage with bilateral frontal drains. Unchanged intraventricular hemorrhage with bilateral frontal drains. Known subacute hyperdense infarcts in the right basal ganglia and right superior parietal lobe are essentially unchanged. | 116 | [
{
"category": "Physician ",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 517014,
"text": "Chief Complaint: seizure\n HPI:\n 37 yo f w/ DM2 found to have IVH after suffering altered MS & SZ\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Nitroprusside - 3 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 03:00 AM\n Dilantin - 03:15 AM\n Other medications:\n Past medical history:\n Family / Social history:\n DM2\n no tobac/etoh/illicits\n Flowsheet Data as of 03:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 88 (88 - 97) bpm\n BP: 164/92(119) {162/92(119) - 164/97(121)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 14 (9 - 14) mmHg\n Total In:\n 311 mL\n PO:\n TF:\n IVF:\n 311 mL\n Blood products:\n Total out:\n 0 mL\n 629 mL\n Urine:\n 590 mL\n NG:\n Stool:\n Drains:\n 39 mL\n Balance:\n 0 mL\n -318 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 19 cmH2O\n Compliance: 35.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.58/26/469/24/4\n Ve: 12.8 L/min\n PaO2 / FiO2: 469\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils 3mm fixed.\n Head, Ears, Nose, Throat: No(t) Normocephalic, evdx2\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous\n movement, Tone: Not assessed, extensor posturing all extremities\n Labs / Radiology\n 354 K/uL\n 9.6 g/dL\n 193 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n WBC\n 12.3\n Hct\n 29.4\n Plt\n 354\n Cr\n 0.6\n TCO2\n 25\n Glucose\n 193\n Other labs: Ca++:8.5 mg/dL, Mg++:1.5 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n Assessment And Plan: 37 yo f w/ DM2 found to have IVH after suffering\n altered MS & SZ\n Neurologic: Larbe IVH, extensor posturing all extremities. pupils 3mm &\n nonreactive. Bil EVD placed in ER. Dilantin load in sicu, will check\n level and follow w/ 100mg tid. to angio in am. intrathecal tPA q12h.\n mannitol q6 (hold for Na>150, osm<320), icp (), decadron 4 q8.\n Cardiovascular: goal bp 100-140, nipride gtt, prn hydral, nimodipine 60\n q4.\n Pulmonary: intubated, hyperventilated abg resp alk w/ co2 26. will\n continue for now. CXR wnl. repeat in am.\n Gastrointestinal: OGT, npo.\n Renal: adequate uop, K 5.1, will recheck in am\n Hematology: hct 32.2, coags nl. no products given.\n Infectious Disease: kefzol 1 q8 while drains in place\n Endocrine: RISS\n Fluids: ns @ 50\n Electrolytes: K as above, o/w nl\n Nutrition: npo\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 517017,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: PLAN TO MONITOR RESP STATUS. PT VOMITING. PT UNRESPONSIVE\n WITH POSTURING.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517200,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Not sedated. Unresponsive this am. Arousable to stimuli by afternoon\n following commands, able to lift and hold right hand, give thumbs up\n and wiggle toes.\n RUE/RLE moving spontaneously/purposeful. LUE/LLE withdraws to painful\n stimuli. Agitated w/ exams HR up to 140-150\ns SBP up to 170\n Pupils equal @3mm. nonreactive this am, sluggish by afternoon.\n Bilat ventric drains in place @15 above the tragus. Draining serosang.\n Left draining more than right.\n ICP on left 18-20. ICP on the right .\n Received on nipride gtt to keep SBP less than 140.\n Husband at bedside.\n Action:\n Neuro exams Q1hr. Drains assessed and emptied Q1hr.\n Diagnostic angio this am.\n Nipride gtt changed to nicardipine SBP goal 100-140.\n Mannitol given per serum os.\n 50mcg fent given prior to 1800 neuro exam to keep less agitated. Pt\n able to move right side spontaneous lift arm up but follow no other\n commands.\n TPA instilled into Right drain @1700 by neurosurg resident \n .\n Response:\n No AVM\ns or aneurysm\ns seen on angio. Moyamoya disease noted by Dr.\n .\n +PP no hematoma at angio site in R femoral.\n SBP less than 140 on Nicardipine @2mcg.\n HR and SBP better controlled w/fent prior to exam however less\n responsive. Neurosurg resident aware.\n Waiting for pharmacy to send 2^nd syringe of TPA for left drain.\n Plan:\n Continue Q1hr Neuro exams . Monitor ICP\n Monitor drain output. Call neurosurg resident when TPA arrives.\n Titrate nicardipine gtt to keep SBP less than 140.\n Premedicate to keep Hr and SBP stable during neuro exams.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517030,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with significant spontaneous Intra Ventricular bleed, possible AVM\n per team.\n Bilateral Ventriculostomy drains placed in ED, Intubated and sedated.\n Pt with some spontaneous movement, non-purposeful, posturing only to\n painful stimuli when off sedation. No eye opening, pupils 2mm L&R and\n non reactive to light.\n Hypertensive to 190\ns and tachycardic at times to 130\n Action:\n Propofol now off.\n Nitroprusside drip started to maintain SBP 100-140mmHg.\n Ventric drains placed at 15cm above tragus. Tpa to be instilled by\n Neuro Surgery.\n Manitol and Dilantin.\n Hyperventilated on CMV 24/500/5/100%.\n Response:\n Unchanged neuro exam currently.\n Pt has vomited x3 despite having OGT in place to LCS, Neuro Surgery\n aware.\n Plan:\n Pt to neuro Angio today.\n Emotional support for family.\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517666,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n Alteplase\n Bisacodyl\n CefazoLIN\n Docusate Sodium\n Famotidine\n Fentanyl Citrate\n Heparin\n HydrALAzine\n Insulin\n Mannitol\n Metoprolol Tartrate\n Nimodipine\n NiCARdipine 1\n Phenytoin (Suspension)\n Sarna Lotion\n Senna 23.\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:30 PM\n ARTERIAL LINE - START 06:42 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:05 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:03 PM\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Metoprolol - 10:05 PM\n Fentanyl - 01:33 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37\nC (98.6\n HR: 103 (80 - 138) bpm\n BP: 131/66(87) {120/60(80) - 153/80(102)} mmHg\n RR: 21 (16 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 15 (8 - 18) mmHg\n Total In:\n 1,622 mL\n 250 mL\n PO:\n 120 mL\n 30 mL\n Tube feeding:\n IV Fluid:\n 1,502 mL\n 220 mL\n Blood products:\n Total out:\n 2,639 mL\n 360 mL\n Urine:\n 2,442 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 197 mL\n 40 mL\n Balance:\n -1,017 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), sinus tachycardia, labile HR/BP\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: drains secured, minimal dressing staining\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n purposeful R sided movements, withdraws to pain on left\n Labs / Radiology\n 395 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.3 %\n 11.4 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n Plt\n 354\n 266\n 321\n 395\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.4 mg/dL, Mg:2.5 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, questionably related to MoyaMoya.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off). F/u\n Na, Osm\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n -- Lopressor prn tachycardia\n Pulmonary:\n -- extubated , sats 90's on NC\n Gastrointestinal / Abdomen:\n -- Diet; per speech/swallow\n -- GI prophy famotidine\n -- Dobhoff tube\n Nutrition: Thin liquids, puree solids\n Renal: foley, good uop. Cr 0.5\n Hematology: hct 31.3 coags WNL\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley, L rad aline\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n 20 Gauge - 11:18 PM\n Arterial Line - 06:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517841,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n Alteplase\n Bisacodyl\n CefazoLIN\n Docusate Sodium\n Famotidine\n Fentanyl Citrate\n Heparin\n HydrALAzine\n Insulin\n Mannitol\n Metoprolol Tartrate\n Nimodipine\n NiCARdipine 1\n Phenytoin (Suspension)\n Sarna Lotion\n Senna 23.\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:30 PM\n ARTERIAL LINE - START 06:42 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:05 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:03 PM\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Metoprolol - 10:05 PM\n Fentanyl - 01:33 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37\nC (98.6\n HR: 103 (80 - 138) bpm\n BP: 131/66(87) {120/60(80) - 153/80(102)} mmHg\n RR: 21 (16 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 15 (8 - 18) mmHg\n Total In:\n 1,622 mL\n 250 mL\n PO:\n 120 mL\n 30 mL\n Tube feeding:\n IV Fluid:\n 1,502 mL\n 220 mL\n Blood products:\n Total out:\n 2,639 mL\n 360 mL\n Urine:\n 2,442 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 197 mL\n 40 mL\n Balance:\n -1,017 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), sinus tachycardia, labile HR/BP\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: drains secured, minimal dressing staining\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n purposeful R sided movements, withdraws to pain on left\n Labs / Radiology\n 395 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.3 %\n 11.4 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n Plt\n 354\n 266\n 321\n 395\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.4 mg/dL, Mg:2.5 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, questionably related to MoyaMoya. Physical exam wax\n and wane.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off). F/u\n Na, Osm\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n -- Lopressor 25 PO TID due to tachy to 160\n Pulmonary:\n -- extubated , sats 90's on NC\n Gastrointestinal / Abdomen:\n -- Diet; per speech/swallow\n -- GI prophy famotidine\n -- Dobhoff tube for adequate nutrition\n Nutrition: Thin liquids, puree solids\n Renal: foley, good uop. Cr 0.5\n Hematology: hct 31.3 coags WNL\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley, L rad aline\n Wounds: EVD x 2\n Imaging: CT head today\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n 20 Gauge - 11:18 PM\n Arterial Line - 06:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517902,
"text": "Pt is a 37 yo women with DM@ found to IVH after suffering altered MS &\n SZ. Pt found to have moyamoya disease.\n Sepsis without organ dysfunction\n Assessment:\n pt spiked to 102.1 overnight\n Action:\n pan cx, 2 sets of blood cx, urine, and csf , Tylenol given x2\n Response:\n currnt temp 99.9, cx pending.turned q 3 with neuro checks, mouth care,\n currently on cefazolin\n Plan:\n ? starting additional antibiotics, cont to monitor temp curve, check\n cx results\n Intracerebral hemorrhage (ICH)\n Assessment:\n pt flex withdraws to painful stimuli on all ext. left sluggish compared\n to right, inconsistently opeinng eyes to any stimulation, will draw\n right arm to sternum when rubbed. Perrla at 3mm, occasionally will\n mumbly out word such as\nouch\n ICP 5-17, right icp draining 1-5 cc/hr\n Action:\n q 3 hour neuro checks, nimodipine q4\n Response:\n pt more lethargic than prior night shift as also noted by earlier day\n shift, temp 102..5\n Plan:\n cont with q 3 neuro, check on results from csf\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517264,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ\n PMHx:\n DM2\n Current medications:\n Alteplase, CefazoLIN, Famotidine, Fentanyl Citrate, HydrALAzine,\n Mannitol, Nimodipine, NiCARdipine, Phenytoin, Potassium Chloride\n 24 Hour Events:\n ANGIOGRAPHY - At 08:15 AM - no evidence of aneurysm or\n active bleeding\n - mannitol continued\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:21 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Nicardipine - 2 mcg/Kg/min\n Mannitol - 12.5 grams/hour\n Other ICU medications:\n Fentanyl - 09:20 PM\n Famotidine (Pepcid) - 10:16 PM\n Hydralazine - 01:00 AM\n Dilantin - 01:01 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.3\nC (99.2\n HR: 103 (82 - 134) bpm\n BP: 101/51(68) {98/49(62) - 159/82(107)} mmHg\n RR: 25 (24 - 25) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 10 (10 - 22) mmHg\n Total In:\n 2,288 mL\n 880 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,288 mL\n 880 mL\n Blood products:\n Total out:\n 3,593 mL\n 1,108 mL\n Urine:\n 3,310 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 283 mL\n 78 mL\n Balance:\n -1,305 mL\n -228 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 380 (380 - 380) mL\n RR (Set): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 17 cmH2O\n Plateau: 14 cmH2O\n Compliance: 42.2 cmH2O/mL\n SPO2: 100%\n ABG: 7.48/31/209/23/1\n Ve: 7.4 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) PERRL, pupils sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n Weakness), (LUE: Weakness), (RLE: Weakness), (LLE: Weakness),\n spontaneously moves L side, follows commands R side\n Labs / Radiology\n 266 K/uL\n 9.1 g/dL\n 171 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.1 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.5 %\n 12.0 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n WBC\n 12.3\n 12.0\n Hct\n 29.4\n 27.5\n Plt\n 354\n 266\n Creatinine\n 0.6\n 0.5\n TCO2\n 25\n 22\n 24\n Glucose\n 193\n 171\n Other labs: PT / PTT / INR:13.1/23.2/1.1, Lactic Acid:3.9 mmol/L,\n Ca:8.7 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ.\n Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, ICP monitor,\n EVD in place, TPA q 12hrs, mannitol, propofol for sedation\n Cardiovascular: HD stable, nicardipine drip for SBP > 160\n Pulmonary: Cont ETT, (Ventilator mode: CMV). Try PSV and possibly\n extubate\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: NPO now. Will place doboff and start TF\n Renal: Foley, Adequate UO, monitor Na and serum osm with mannitol\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Ancef while EVD in place\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP),\n EVD x 2\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n Arterial Line - 12:08 PM\n 20 Gauge - 11:18 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517898,
"text": "SICU\n HPI:\n 37F found to have IVH after suffering altered MS & SZ - large IVH\n secodary to syndrome\n Chief complaint:\n altered mental status, seizure\n PMHx:\n DM2\n Current medications:\n Acetaminophen, Bisacodyl, CefazoLIN, Docusate, Famotidine, Fentanyl,\n Heparin, HydrALAzine, Insulin, Mannitol Metoprolol, Nimodipine,\n Phenytoin, Potassium Chloride, Sarna Lotion, Senna\n 24 Hour Events:\n - dobhoff placed, TF started\n BLOOD CULTURED - At 11:00 PM\n CSF CULTURE - At 11:00 PM\n URINE CULTURE - At 12:38 AM\n FEVER - 102.1\nF - 10:30 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:12 AM\n Famotidine (Pepcid) - 09:01 PM\n Heparin Sodium (Prophylaxis) - 09:01 PM\n Other medications:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.2\nC (98.9\n HR: 102 (85 - 133) bpm\n BP: 131/87(105) {116/59(79) - 196/193(195)} mmHg\n RR: 24 (20 - 29) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 18 (6 - 18) mmHg\n Total In:\n 1,540 mL\n 576 mL\n PO:\n 30 mL\n Tube feeding:\n 324 mL\n 288 mL\n IV Fluid:\n 886 mL\n 107 mL\n Blood products:\n Total out:\n 1,465 mL\n 241 mL\n Urine:\n 1,307 mL\n 220 mL\n NG:\n Stool:\n Drains:\n 158 mL\n 21 mL\n Balance:\n 75 mL\n 335 mL\n Respiratory support\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Drains in place\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness), inconsistently follows commands\n Labs / Radiology\n 461 K/uL\n 10.5 g/dL\n 153 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 113 mEq/L\n 146 mEq/L\n 32.2 %\n 13.9 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n 13.9\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n 32.2\n Plt\n 354\n 266\n 321\n 395\n 461\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n 0.7\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n 153\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.2 mg/dL, Mg:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 3 hr, Phenytoin - therapeutic, ICP monitor,\n f/u dilantin level 15.5\n mannitol weaned off\n repeat head CT\n Cardiovascular: keep SBP < 180\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid\n Pulmonary: room air, no issues\n Gastrointestinal / Abdomen: Dobhoff in place, TF to goal\n Nutrition: Tube feeding, Regular diet\n Renal: Foley, Adequate UO\n Hematology: Hct 32.2\n Endocrine: RISS\n Infectious Disease: Check cultures, Ancef 1g q8h while drains in place\n - temp spike to 102 overnight, f/u cultures\n Lines / Tubes / Drains: Foley, Dobhoff, Surgical drains (hemovac, JP)\n Wounds:\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 03:29 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n Arterial Line - 06:42 PM\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517253,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ\n Chief complaint:\n PMHx:\n DM2\n Current medications:\n Alteplase, CefazoLIN, Famotidine, Fentanyl Citrate, HydrALAzine,\n Mannitol, Nimodipine, NiCARdipine, Phenytoin, Potassium Chloride\n 24 Hour Events:\n ANGIOGRAPHY - At 08:15 AM - no evidence of aneurysm or\n active bleeding\n - mannitol continued\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:21 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Nicardipine - 2 mcg/Kg/min\n Mannitol - 12.5 grams/hour\n Other ICU medications:\n Fentanyl - 09:20 PM\n Famotidine (Pepcid) - 10:16 PM\n Hydralazine - 01:00 AM\n Dilantin - 01:01 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.3\nC (99.2\n HR: 103 (82 - 134) bpm\n BP: 101/51(68) {98/49(62) - 159/82(107)} mmHg\n RR: 25 (24 - 25) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n ICP: 10 (10 - 22) mmHg\n Total In:\n 2,288 mL\n 880 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,288 mL\n 880 mL\n Blood products:\n Total out:\n 3,593 mL\n 1,108 mL\n Urine:\n 3,310 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 283 mL\n 78 mL\n Balance:\n -1,305 mL\n -228 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 380 (380 - 380) mL\n RR (Set): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 17 cmH2O\n Plateau: 14 cmH2O\n Compliance: 42.2 cmH2O/mL\n SPO2: 100%\n ABG: 7.48/31/209/23/1\n Ve: 7.4 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) PERRL, pupils sluggish\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n Weakness), (LUE: Weakness), (RLE: Weakness), (LLE: Weakness),\n spontaneously moves L side, follows commands R side\n Labs / Radiology\n 266 K/uL\n 9.1 g/dL\n 171 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.1 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.5 %\n 12.0 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n WBC\n 12.3\n 12.0\n Hct\n 29.4\n 27.5\n Plt\n 354\n 266\n Creatinine\n 0.6\n 0.5\n TCO2\n 25\n 22\n 24\n Glucose\n 193\n 171\n Other labs: PT / PTT / INR:13.1/23.2/1.1, Lactic Acid:3.9 mmol/L,\n Ca:8.7 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ.\n Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, ICP monitor,\n EVD in place, TPA q 12hrs, mannitol, propofol for sedation\n Cardiovascular: HD stable, nicardipine drip for SBP > 160\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: NPO\n Renal: Foley, Adequate UO, monitor Na and serum osm with mannitol\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Ancef while EVD in place\n Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP),\n EVD x 2\n Wounds:\n Imaging: CXR today\n Fluids: NS, NS at 75\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n Arterial Line - 12:08 PM\n 20 Gauge - 11:18 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517372,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 517541,
"text": "/ Signed by on at 4:43 pm Affiliation:\n Asked by RN to provide counseling and support to the husband of\n this 37 yr old woman who is s/p head bleed. Pt is awake and at times\n wrest less in the bed, is following commands and communicating with her\n husband in their native language. Husband is professor who\n reports being at dinner with his wife this past evening. Pt\n began to complain of some pain in her neck, the couple became concerned\n as pt had recently been in PT for issues related to her neck. Husband\n describes pt's mental status diminishing during the taxi ride home, pt\n was brought to the ED. Today husband is thankful for the report that he\n received from the neurosurgeon re: pt's progress. Husband states that\n initial reports where grim and he has been in touch with his parents\n and the parents re: the possibility of a poor out come. Parents all\n reside in . Husband expressing guilt that perhaps he could have\n seen symptoms or been more attentive to the prior neck problems.\n knows this is not rational thinking and admits to feeling\n helpless. Husband has been at the bedside all weekend, \"I cannot go\n home, it is not a home without her\". Husband reports that many friends\n have visited here to bring him food. The couple do not have family in\n the area. Husband grateful for today's visit and for the concern and\n care of all of the staff. Will continue to follow pt's progress and to\n provide counseling and support to husband during this frightening time.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518130,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli, does not open eyes, does not follow\n commands, pupils equal and reactive, withdraws all extremities to\n nailbed pressure, localizes on the right, moves R extremities\n spontaneously, no apnic periods\n Vent drain x2, L drain clamped with ICP 12-15, R vent drain\n open at 20cm H2O, ICP 9-15, 5-10cc/hr of blood tinged CSF\n SBP 120-150, NSR-NST 80-120\ns, tmax 101.3\n Adequate u/o\n TF at goal\n Husband spent the night in the family waiting area again,\n appears to have some support from friends, encouraged to go home and\n sleep, but he is unable as it is just him and his wife and he does not\n want to be alone at home without her. Husband very appropriate with\n questions and care.\n Action:\n Neuro checks Q3hrs\n Monitor ICP\ns, keep L drain clamped, R drain open\n Lyte repletions prn\n Keep SBP <140\n Nimodipine as ordered\n Dilantin as ordered\n Tylenol given\n Emotional support provided to husband and pt\n Response:\n After pt turned and repositioned around 0500, L ICP 19-23,\n gave pt ample time to settle out, ICP remains elevated, MD from\n Neuro and SICU resident MD notified at approx 0530, will\n continue to monitor and team will be by to assess pt\n temp 98\n Neuro exam remains unchanged\n VSS\n Plan:\n Neuro exams Q3hrs\n Monitor drain outputs\n Monitor ICP\n Provide pt and family with emotional support\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517245,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt remains intubated on cmv. Neuro exam is improved pt opens eyes to\n stimulation. Follows commands. On right side. wiggles. Toes. And shows\n thumb on right hand and lifts right ar off bed left arm less\n consistentl with following commands. Moves spontaneously and lift and\n falls off the bed. Pt witdraws left leg to pain and slight movement of\n toes. Pupils equal and reactive to light sluggishly. Left eye reacts\n more sluggish than right. np of neurosurg team aware and\n in to evaluate pt. Tpa instilled into vent drains by np. Icp 11-18 and\n both are draining blood tinged csf. Icp waveform improved on left after\n transducer dressing changed. Propofol started and titrated from\n 10-40mcg/kg/min for sedation. Pt off sedation is gagging on ettube and\n hr up to 136 st and sbp up to 170\ns. pt appears comfortable on propofol\n drip. Propofol off for neuro exam. Nicardipine drip titrated for sbp\n less than 140. One dose of Hydralazine with good response.\n Action:\n continue with neuro exam. Husband updated by neurosurg team and sicu\n team.\n Response:\n neuro exam is improving. Propofol is effective in sedating pt and sbp\n less than 140 onb propofol and nicardipine.\n propofol titrated for sedation. Hydralazine given prior to bath and\n effective in controlling bp. Vent drains remain open and continue to\n drain bloody drainage.\n Plan:\n neuro q1, titrate propofol and nicardipine. Mannitol. Q6, send labs as\n ordered. Replete k.\n 1.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517591,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt. arouses to voice/stimulation. She inconsistently follows simple\n commands on right side. Withdrawal to noxious stimuli on left . pupils\n are equal and reactive. Left more briskly reactive throughout the day.\n Lethargy waxes and weans, when able to answer questions oriented x1-2.\n bilateral vent drains in place with blood tinged CSF. ICP ranging .\n Pt. tachy to 140\ns with stimulation.\n Action:\n Q1 hr neuro checks, Nicardipine gtt @2.5 for sbp<140, vent drain raised\n to 20 at tragus from 15, mannitol decreased to 12.5g qid x24 hrs. 5 mg\n IV lopressor given x1.\n Response:\n Neuro status essentially unchanged. Alertness waxes and weans. SBP\n fairly well controlled within parameters. HR decrease to 90\ns after IV\n lopressor.\n Plan:\n Continue q1 hr neuro checks, goal SBP<140- titrate Nicardipine PRN. CT\n scan tomorrow am. Monitor ICP and drain output.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518002,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with ICH. Ventricular drains in place, at 20cm above tragus, right\n drain draining small amounts of blood tinged CSF, left drain clamped.\n Pt only responding to painful stimuli, will withdraw/localize with\n right arm, withdraws only with left side. Pt has spontaneous\n non-purposeful movement to right leg. Pupils equal and reactive to\n light (3mm).\n Pt had episodes of apnea lasting up to 20 seconds, also had left sided\n ICP\ns into the mid 20\n Action:\n Pt to CT, chest X-Ray, Left ventricular drain opened to drainage.\n Response:\n CT stable per NSurg team, small amounts of blood tinged CSF from Left\n ventricular drain, ICP\ns within previous range. No further episodes of\n apnea.\n Plan:\n Continue with Q3hr neuro checks.\n Emotional support for pt\ns husband.\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 517070,
"text": "Chief Complaint: seizure\n HPI:\n 37 yo f w/ DM2 found to have IVH after suffering altered MS & SZ\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Nitroprusside - 3 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 03:00 AM\n Dilantin - 03:15 AM\n Past medical history:\n Family / Social history:\n DM2\n no tobac/etoh/illicits\n Flowsheet Data as of 03:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 88 (88 - 97) bpm\n BP: 164/92(119) {162/92(119) - 164/97(121)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n ICP: 14 (9 - 14) mmHg\n Total In:\n 311 mL\n PO:\n TF:\n IVF:\n 311 mL\n Blood products:\n Total out:\n 0 mL\n 629 mL\n Urine:\n 590 mL\n NG:\n Stool:\n Drains:\n 39 mL\n Balance:\n 0 mL\n -318 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 19 cmH2O\n Compliance: 35.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.58/26/469/24/4\n Ve: 12.8 L/min\n PaO2 / FiO2: 469\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils 3mm fixed.\n Head, Ears, Nose, Throat: No(t) Normocephalic, evdx2\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous\n movement, Tone: Not assessed, extensor posturing on right extremities.\n Now not moving left side.\n Labs / Radiology\n 354 K/uL\n 9.6 g/dL\n 193 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n WBC\n 12.3\n Hct\n 29.4\n Plt\n 354\n Cr\n 0.6\n TCO2\n 25\n Glucose\n 193\n Other labs: Ca++:8.5 mg/dL, Mg++:1.5 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n Assessment And Plan: 37 yo f w/ DM2 found to have IVH after suffering\n altered MS & SZ\n Neurologic: Larbe IVH, extensor posturing all extremities. pupils 3mm &\n nonreactive. Bil EVD placed in ER. Dilantin load in sicu, will check\n level and follow w/ 100mg tid. Check dilantin level today. to angio in\n am. intrathecal tPA q12h. mannitol q6 (hold for Na>150, osm<320), icp\n (), decadron 4 q8 per neurosurgeon.\n Cardiovascular: goal bp 100-140, nipride gtt, prn hydral, nimodipine 60\n q4.\n Pulmonary: intubated, hyperventilated abg resp alk w/ co2 26. will stop\n hyperventilation and move to low tidal volumes. CXR wnl. repeat in am.\n Gastrointestinal: OGT, npo.\n Renal: adequate uop, K 5.1, will recheck in am\n Hematology: hct 32.2, coags nl. no products given.\n Infectious Disease: kefzol 1 q8 while drains in place\n Endocrine: RISS\n Fluids: ns @ 50\n Electrolytes: K as above, o/w nl\n Nutrition: npo\n Billing diagnosis: Intracranial hemorhage\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Rehab Services",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 517736,
"text": "Consult received and appreciated, spoke with nsg and patient still has\n bilateral EVD\ns and is not appropriate for PT at this time. We will\n continue to follow and evaluate as appropriate.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518120,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115 10. HydrALAzine\n 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 2. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0641\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737 12. Metoprolol Tartrate 37.5 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ \n 4. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721 13. Nimodipine\n 60 mg PO Q4H Order date: @ 0119\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641 14. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @\n 1608\n 6. Docusate Sodium 100 mg PO BID Order date: @ 0737 15.\n Potassium Chloride IV Sliding Scale Order date: @ 0352\n 7. Famotidine 20 mg IV Q12H Order date: @ 2049 16. Sarna Lotion\n 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641 17. Senna 1 TAB PO/NG Order date: @ 0737\n 9. Heparin 5000 UNIT SC TID Order date: @ 0920 18. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:16 PM\n FEVER - 102.0\nF - 04:00 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:58 AM\n Famotidine (Pepcid) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 36.7\nC (98\n HR: 87 (78 - 120) bpm\n BP: 121/78(88) {111/69(78) - 152/95(109)} mmHg\n RR: 19 (13 - 24) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 10 (4 - 23) mmHg\n Total In:\n 2,076 mL\n 341 mL\n PO:\n Tube feeding:\n 1,202 mL\n 231 mL\n IV Fluid:\n 424 mL\n 50 mL\n Blood products:\n Total out:\n 1,159 mL\n 292 mL\n Urine:\n 1,050 mL\n 275 mL\n NG:\n Stool:\n Drains:\n 109 mL\n 17 mL\n Balance:\n 917 mL\n 49 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 471 K/uL\n 10.7 g/dL\n 199 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 112 mEq/L\n 146 mEq/L\n 33.1 %\n 12.9 K/uL\n [image002.jpg]\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n Plt\n 266\n 321\n 395\n 461\n 471\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.1 mg/dL, Mg:2.5 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, questionably related to MoyaMoya\n Neurologic: Neuro checks Q: hr, -- Large IVH, b/l EVD in place (L\n re-clamped but icps increasing 18-20 overnight), no longer\n following simple commands, rare eye opening to voice, mental status\n declined , following less commands. no eating.\n -- Dilantin 100mg q8h. Dilantin level = pending\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n -- repeat head CT stable\n -- Dilantin 100mg q8h. Dilantin level =\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n -- repeat head CT stable\n Cardiovascular: --stable.\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid for occ tachy\n -- Hydralazine prn SBP > 180\n Pulmonary: -- extubated , on room air now\n --apneic episodes am. none since\n --cxr neg\n Gastrointestinal / Abdomen: -- Passed speech/swallow, however\n inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n Nutrition: Tube feeding, -- tube feeds replete with fiber (goal\n 60cc/hr)\n Renal: Foley, Adequate UO, foley, good uop. Cr 0.6\n Hematology: hct stable coags WNL. recheck in am.\n Endocrine: RISS\n Infectious Disease: Ancef 1g q8h while drains in place\n - temp spike to 102 , f/u cultures (bld, urine, csf, UA neg, cxr\n neg) (likely neurogenic fever)\n -csf w/ 1+pmn\n -still intermittent temps Tm 102 (MN)\n -wbc 12.9<-13.9<-11.4\n Lines / Tubes / Drains: Foley, Dobhoff, EVDx2, piv\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), CVA, Seizure\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 11:18 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517576,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. Mannitol 25 g IV Q12H Order date: @ 0407\n 2. Alteplase *NF* 1 mg Intrathecal Q12H Duration: 3 Days\n Start: Order date: @ 0815\n 12. Metoprolol Tartrate 5 mg IV ONCE Duration: 1 Doses Order date:\n @ 0208\n 3. CefazoLIN 1 g IV Q8H Order date: @ 0119\n 13. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 14. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP < 160 Order\n date: @ 1713\n 5. Famotidine 20 mg IV Q12H Order date: @ 2049\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Fentanyl Citrate 25-100 mcg IV Q2H:PRN agitation Order date: \n @ 1710\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 17. Potassium Chloride PO Sliding Scale Duration: 24 Hours\n Hold for K > Order date: @ 0809\n 8. Heparin 5000 UNIT SC TID Order date: @ 0920\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. HydrALAzine 10 mg IV Q4H:PRN SBP > 160\n hold sbp < 100 Order date: @ 1713\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 10. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0641\n 24 Hour Events:\n Extubated uneventfully . Maintaining patent airway. Mannitol\n weaned this AM to .\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 04:35 PM\n Infusions:\n Nicardipine - 2 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 AM\n Hydralazine - 11:00 AM\n Famotidine (Pepcid) - 10:08 PM\n Heparin Sodium (Prophylaxis) - 10:42 PM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.8\n HR: 91 (91 - 117) bpm\n BP: 121/63(83) {101/51(68) - 143/73(94)} mmHg\n RR: 18 (18 - 30) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 13 (7 - 14) mmHg\n Total In:\n 2,463 mL\n 106 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,463 mL\n 106 mL\n Blood products:\n Total out:\n 4,075 mL\n 523 mL\n Urine:\n 3,825 mL\n 480 mL\n NG:\n Stool:\n Drains:\n 250 mL\n 43 mL\n Balance:\n -1,612 mL\n -417 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 384) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 0%\n RSBI: 65\n SPO2: 97%\n ABG: 7.48/31/96./23/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, disconjugate eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), b/l EVD\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), purposeful movements of RLE&RUE. Spontaneously moves\n left sided extremities\n Labs / Radiology\n 321 K/uL\n 9.7 g/dL\n 146 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.7 %\n 12.8 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n WBC\n 12.3\n 12.0\n 12.8\n Hct\n 29.4\n 27.5\n 29.7\n Plt\n 354\n 266\n 321\n Creatinine\n 0.6\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n Other labs: PT / PTT / INR:13.1/23.2/1.1, Lactic Acid:0.9 mmol/L,\n Ca:9.0 mg/dL, Mg:2.4 mg/dL, PO4:2.1 mg/dL\n Imaging: CT Head - Interval decrease in IVH, hydrocephalus and mass\n effect. Focal hypodensity in the right basal ganglia may represent a\n focal area of infarction. Questionable small amount of subarachnoid\n hemorrhage in the left frontoparietal region. The left lateral\n ventricle is smaller than the right in all portions including frontal\n body and temporal pole compatible with asymmetric drainage of the\n lateral ventricles. Close followup imaging is recommended.\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off)\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n Pulmonary:\n -- extubated \n Gastrointestinal / Abdomen:\n -- Sips, advance as tolerated\n -- GI prophy famotidine\n Dobhoff and tube feeds as too somnolent during the day to take adequate\n nutrition PO\n Nutrition: Sips, advance as tolerated\n Renal: f/c. adequate uop. Cr 0.5\n Hematology: hct stable @ 29.7. coags nl\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Code status:FULL\n Disposition:SICU\n Time spent: 35 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 517739,
"text": "Subjective: Per patient\ns husband, patient followed a low carbohydrate\n diet and had lost about 5 lbs over the past few months\n by exercising\n more - to help control her blood sugars.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 67.1 kg\n 64.3 kg ( 01:00 AM)\n 28.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 148%\n 51 kg\n 63.5 kg\n 105%\n Diagnosis: ICH\n PMHx: Type 2 DM\n Food allergies and intolerances: none\n Pertinent medications: Mannitol, nicardipine drip, RISS, Normal Saline\n @ 10mL/hr, ABx, Heparin, Pepcid, colace, senna, others noted\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 04:08 AM\n Glucose Finger Stick\n 209\n 10:00 AM\n BUN\n 11 mg/dL\n 04:08 AM\n Creatinine\n 0.5 mg/dL\n 04:08 AM\n Sodium\n 148 mEq/L\n 04:08 AM\n Potassium\n 3.7 mEq/L\n 04:08 AM\n Chloride\n 113 mEq/L\n 04:08 AM\n TCO2\n 22 mEq/L\n 04:08 AM\n PO2 (arterial)\n 96. mm Hg\n 12:22 PM\n PCO2 (arterial)\n 31 mm Hg\n 12:22 PM\n pH (arterial)\n 7.48 units\n 12:22 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 12:22 PM\n Albumin\n 4.1 g/dL\n 04:08 AM\n Calcium non-ionized\n 9.4 mg/dL\n 04:08 AM\n Phosphorus\n 2.8 mg/dL\n 04:08 AM\n Magnesium\n 2.5 mg/dL\n 04:08 AM\n Phenytoin (Dilantin)\n 15.9 ug/mL\n 04:08 AM\n WBC\n 11.4 K/uL\n 04:08 AM\n Hgb\n 10.4 g/dL\n 04:08 AM\n Hematocrit\n 31.3 %\n 04:08 AM\n Current diet order / nutrition support: Diet: pureed solids with thin\n liquids\n GI: abd soft, hypoactive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished\n Estimated Nutritional Needs\n Calories: 1275-1530 (25-30 cal/kg)\n Protein: 61-76 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 37 y.o. Female w/ DM2 found to have IVH after suffering altered MS &\n SZ, questionably related to MoyaMoya disease. Patient\ns neuro exam\n continues to wax and wane. Patient passed a swallow evaluation for\n pureed diet with thin liquids, and was able to eat small amounts\n yesterday. Today, patient is more lethargic and unsafe for po\n Recommend placing an NGT to start tube feeds to help patient meet her\n needs. Once patient is more awake and consistently taking po\n recommend cycling feeds overnight.\n Medical Nutrition Therapy Plan - Recommend the Following\n Diet per SLP recommendations.\n Recommend placing NGT and starting Boost Glucose Control @\n 10mL/hr and advance 10mL q4hrs to goal of 50mL/hr (1272kcals, 70g\n protein).\n Will follow patient\ns progress and neuro status and make\n cycling recommendations as needed.\n Continue with sliding scale insulin for high finger stick\n blood sugars.\n Following - #\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518062,
"text": "SICU\n HPI:\n 37F found to have IVH after suffering altered MS & SZ - large IVH\n secodary to syndrome\n Chief complaint:\n altered mental status, seizure\n PMHx:\n DM2\n Current medications:\n Acetaminophen, Bisacodyl, CefazoLIN, Docusate, Famotidine, Fentanyl,\n Heparin, HydrALAzine, Insulin, Mannitol Metoprolol, Nimodipine,\n Phenytoin, Potassium Chloride, Sarna Lotion, Senna\n 24 Hour Events:\n - dobhoff placed, TF started\n BLOOD CULTURED - At 11:00 PM\n CSF CULTURE - At 11:00 PM\n URINE CULTURE - At 12:38 AM\n FEVER - 102.1\nF - 10:30 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:12 AM\n Famotidine (Pepcid) - 09:01 PM\n Heparin Sodium (Prophylaxis) - 09:01 PM\n Other medications:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.2\nC (98.9\n HR: 102 (85 - 133) bpm\n BP: 131/87(105) {116/59(79) - 196/193(195)} mmHg\n RR: 24 (20 - 29) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 18 (6 - 18) mmHg\n Total In:\n 1,540 mL\n 576 mL\n PO:\n 30 mL\n Tube feeding:\n 324 mL\n 288 mL\n IV Fluid:\n 886 mL\n 107 mL\n Blood products:\n Total out:\n 1,465 mL\n 241 mL\n Urine:\n 1,307 mL\n 220 mL\n NG:\n Stool:\n Drains:\n 158 mL\n 21 mL\n Balance:\n 75 mL\n 335 mL\n Respiratory support\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Drains in place\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness), inconsistently follows commands\n Labs / Radiology\n 461 K/uL\n 10.5 g/dL\n 153 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 113 mEq/L\n 146 mEq/L\n 32.2 %\n 13.9 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n 13.9\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n 32.2\n Plt\n 354\n 266\n 321\n 395\n 461\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n 0.7\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n 153\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.2 mg/dL, Mg:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 3 hr, Phenytoin - therapeutic, ICP monitor,\n f/u dilantin level 15.5\n mannitol weaned off\n repeat head CT\n Cardiovascular: keep SBP < 180\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid\n Pulmonary: room air, no issues\n Gastrointestinal / Abdomen: Dobhoff in place, TF to goal\n Nutrition: Tube feeding, Regular diet\n Renal: Foley, Adequate UO\n Hematology: Hct 32.2\n Endocrine: RISS\n Infectious Disease: Check cultures, Ancef 1g q8h while drains in place\n - temp spike to 102 overnight, f/u cultures\n Lines / Tubes / Drains: Foley, Dobhoff, Surgical drains (hemovac, JP)\n Wounds:\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 03:29 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n Arterial Line - 06:42 PM\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 517182,
"text": "Day of mechanical ventilation: 1\n ETT:\n Position:21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Pt still hyperventilated (PaCO2\n 30) on lung protective settings. To\n IR for angiogram with results still pending. Received TPA this PM. Tmax\n 101.4. Continue with current vent settings while continuing to monitor\n IVH and neuro status.\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 517229,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Keep PaC02 35-40\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: Unresponsive at this time. Cont to monitor resps\n status.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Last ABG resp alkalosis. Decreased RR. Will cont to monitor\n ABG\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517184,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with significant spontaneous Intra Ventricular bleed, possible AVM\n per team.\n Bilateral Ventriculostomy drains placed in ED, Intubated and sedated.\n Pt with some spontaneous movement, non-purposeful, posturing only to\n painful stimuli when off sedation. No eye opening, pupils 2mm L&R and\n non reactive to light.\n Hypertensive to 190\ns and tachycardic at times to 130\n Action:\n Propofol now off.\n Nitroprusside drip started to maintain SBP 100-140mmHg.\n Ventric drains placed at 15cm above tragus. Tpa to be instilled by\n Neuro Surgery.\n Manitol and Dilantin.\n Hyperventilated on CMV 24/500/5/100%.\n Response:\n Unchanged neuro exam currently.\n Pt has vomited x3 despite having OGT in place to LCS, Neuro Surgery\n aware.\n Plan:\n Pt to neuro Angio today.\n Emotional support for family.\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517428,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. Mannitol 25 g IV Q12H Order date: @ 0407\n 2. Alteplase *NF* 1 mg Intrathecal Q12H Duration: 3 Days\n Start: Order date: @ 0815\n 12. Metoprolol Tartrate 5 mg IV ONCE Duration: 1 Doses Order date:\n @ 0208\n 3. CefazoLIN 1 g IV Q8H Order date: @ 0119\n 13. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 14. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP < 160 Order\n date: @ 1713\n 5. Famotidine 20 mg IV Q12H Order date: @ 2049\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Fentanyl Citrate 25-100 mcg IV Q2H:PRN agitation Order date: \n @ 1710\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 17. Potassium Chloride PO Sliding Scale Duration: 24 Hours\n Hold for K > Order date: @ 0809\n 8. Heparin 5000 UNIT SC TID Order date: @ 0920\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. HydrALAzine 10 mg IV Q4H:PRN SBP > 160\n hold sbp < 100 Order date: @ 1713\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 10. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0641\n 24 Hour Events:\n Extubated uneventfully . Maintaining patent airway. Mannitol\n weaned this AM to .\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 04:35 PM\n Infusions:\n Nicardipine - 2 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 AM\n Hydralazine - 11:00 AM\n Famotidine (Pepcid) - 10:08 PM\n Heparin Sodium (Prophylaxis) - 10:42 PM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.8\n HR: 91 (91 - 117) bpm\n BP: 121/63(83) {101/51(68) - 143/73(94)} mmHg\n RR: 18 (18 - 30) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 13 (7 - 14) mmHg\n Total In:\n 2,463 mL\n 106 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,463 mL\n 106 mL\n Blood products:\n Total out:\n 4,075 mL\n 523 mL\n Urine:\n 3,825 mL\n 480 mL\n NG:\n Stool:\n Drains:\n 250 mL\n 43 mL\n Balance:\n -1,612 mL\n -417 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 384) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 0%\n RSBI: 65\n SPO2: 97%\n ABG: 7.48/31/96./23/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, disconjugate eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), b/l EVD\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), purposeful movements of RLE&RUE. Spontaneously moves\n left sided extremities\n Labs / Radiology\n 321 K/uL\n 9.7 g/dL\n 146 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.7 %\n 12.8 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n WBC\n 12.3\n 12.0\n 12.8\n Hct\n 29.4\n 27.5\n 29.7\n Plt\n 354\n 266\n 321\n Creatinine\n 0.6\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n Other labs: PT / PTT / INR:13.1/23.2/1.1, Lactic Acid:0.9 mmol/L,\n Ca:9.0 mg/dL, Mg:2.4 mg/dL, PO4:2.1 mg/dL\n Imaging: CT Head - Interval decrease in IVH, hydrocephalus and mass\n effect. Focal hypodensity in the right basal ganglia may represent a\n focal area of infarction. Questionable small amount of subarachnoid\n hemorrhage in the left frontoparietal region. The left lateral\n ventricle is smaller than the right in all portions including frontal\n body and temporal pole compatible with asymmetric drainage of the\n lateral ventricles. Close followup imaging is recommended.\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off)\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n Pulmonary:\n -- extubated \n Gastrointestinal / Abdomen:\n -- Sips, advance as tolerated\n -- GI prophy famotidine\n Nutrition: Sips, advance as tolerated\n Renal: f/c. adequate uop. Cr 0.5\n Hematology: hct stable @ 29.7. coags nl\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517718,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n Alteplase\n Bisacodyl\n CefazoLIN\n Docusate Sodium\n Famotidine\n Fentanyl Citrate\n Heparin\n HydrALAzine\n Insulin\n Mannitol\n Metoprolol Tartrate\n Nimodipine\n NiCARdipine 1\n Phenytoin (Suspension)\n Sarna Lotion\n Senna 23.\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:30 PM\n ARTERIAL LINE - START 06:42 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:05 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:03 PM\n Heparin Sodium (Prophylaxis) - 09:03 PM\n Metoprolol - 10:05 PM\n Fentanyl - 01:33 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37\nC (98.6\n HR: 103 (80 - 138) bpm\n BP: 131/66(87) {120/60(80) - 153/80(102)} mmHg\n RR: 21 (16 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 15 (8 - 18) mmHg\n Total In:\n 1,622 mL\n 250 mL\n PO:\n 120 mL\n 30 mL\n Tube feeding:\n IV Fluid:\n 1,502 mL\n 220 mL\n Blood products:\n Total out:\n 2,639 mL\n 360 mL\n Urine:\n 2,442 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 197 mL\n 40 mL\n Balance:\n -1,017 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), sinus tachycardia, labile HR/BP\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: drains secured, minimal dressing staining\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n purposeful R sided movements, withdraws to pain on left\n Labs / Radiology\n 395 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.3 %\n 11.4 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n Plt\n 354\n 266\n 321\n 395\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.4 mg/dL, Mg:2.5 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, questionably related to MoyaMoya. Physical exam wax\n and wane.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off). F/u\n Na, Osm\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n -- Lopressor 25 PO TID due to tachy to 160\n Pulmonary:\n -- extubated , sats 90's on NC\n Gastrointestinal / Abdomen:\n -- Diet; per speech/swallow\n -- GI prophy famotidine\n -- Dobhoff tube for adequate nutrition\n Nutrition: Thin liquids, puree solids\n Renal: foley, good uop. Cr 0.5\n Hematology: hct 31.3 coags WNL\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley, L rad aline\n Wounds: EVD x 2\n Imaging: CT head today\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n 20 Gauge - 11:18 PM\n Arterial Line - 06:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Rehab Services",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Generic Note",
"row_id": 517723,
"text": "TITLE:\n Rehab Services: Occupational Therapy\n Consult received and appreciated spoke with RN and pt with increased\n lethargy and only one drain that is able to be clamped. Will hold off\n on evaluation and eval as able.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517688,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt neuro status waxes and wanes thru shift, pt will flex withdraw with\n all exts although left side has a delayed response, pt has purposeful\n movement on right with bringing hand to face to scratch nose, pt will\n instantly squeeze with right hand so it is difficult to tell if she is\n doing this to command, also spontaneously moves right leg, did speak\n with very soft voice on 2 to 3 occassions with one word response,\n perrla at 3mm and brisk, icp 8-15, 1 to 8 cc output from drains, pt hr\n and abp labile with frequent trends to the 120-130\ns = HR and systolic\n abp low 140\ns with high in the 150\ns with or without stimulation.\n Action:\n neuro\ns q1, nicardipine gtt cont at 2.5 mcg, pt given Lopressor 5 mg iv\n x2 over shift, pt also given fent 25mcg ? pain at 130am after\n contacting Dr. ., cont on mannitol\n Response:\n pt hr and abp systolic seemed better controlled after 2^nd dosing of\n Lopressor, no sign deficit noted in exam after fent dosing, 3^rd dosing\n of iv Lopressor 5mg given at 530am, neuro status cont to wax and wane,\n pt has spont movement on right side, withdraws to nail bed on left with\n delayed response\n Plan:\n cont with q 1 neuro, wean nicardipine gtt if standing Lopressor\n started, ? time for head ct scan\n Coping: husband exhausted, was able to sleep for short period of time\n last night in waiting room. ? family support available, friends in last\n night.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517818,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt. very lethargic today. Rarely arousible to voice, mostly to noxious\n stimuli. spontaneous movement and localizes pain at times on the right.\n ICP continues to be <20, averaging . Bilateral vent drains with\n blood tinged drainage. BP\nS 130\ns-150\ns/60\ns-70\ns, HR 90\ns-130\n Action:\n CT scan today in am. Left vent drain clamped .Nicardipine drip weaned\n off for new SBP parameters<180. neuro checks changed to q3 from q1.\n Doboff placed s/t lethargy and poor po intake. TF started @ 20 cc, for\n goal of 50 cc/hr. Dr. up to assess pt. and informed ragarding\n concerns of increasing lethargy.\n Response:\n Tolerating vent clamp with ICP\n WNL. BP\ns below 180\ns off\n nicardipine. Tolerating TF.\n Plan:\n CT scan in am. Neuro checks q3. SBP<180. Dr. okay with current\n neuro status given good CT and ICP\ns, but ok to scan tonight if neuro\n exam worsens.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517411,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt doing well extubated. On room air o2 sat is 100%. Breath sounds are\n clear and diminished in the bases. Pt with strong cough. Neuro pt opens\n eyes to stimulation. States name is . The month is and\n the year is .. pt follows commands on right side. She is able to\n open mouth and stick out tongue. Withdraws to stimuli on the left.\n Bothl eft arm and leg are stiff. Pt continues on Mannitol q 6hrs.\n Nicardipine is titrated to keep sbp less than 140. Currently it is on\n 2.0mcg/kg/min. Ventricular drains remain at 15 above the tragus. TPA\n instilled in both drains by neurosurg. Both drains continue to drain\n bloody csf. Icp remain .\n Action:\n continue with q1 neuro exams. Titrate nicardipine for sbp less than\n 140. q6hr osmo and na. mannitol q6.\n Response:\n neuro exam is unchanged. Nicardipine effective in maintaining sbp\n less than 140. hr up to 120\ns- with stimulation of neuro exam.\n Doing well extubated. Breathing appears comfortable.\n Plan:\n neuro exams q1. tpa q12 by neuro to ventricular drains. Keep sbp\n less thsn 140.\n"
},
{
"category": "Rehab Services",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 517493,
"text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 37 y/o female with NIDDM\nadmitted on after developing sudden onset pain and\nvomiting and becoming unresponsive. Pt with GCS of 5 on arrival\nto ED, found to have extensive IVH on head CT. Emergent bilateral\nEVDs were placed upon arrival . A cerebral angiogram\nperformed on was notable for a Moyamoya pattern with\nintracranial stenosis of bilateral ICAs, more significant on the\nleft, with collaterals present. No evidence of AVM or aneurysm.\nPt was extubated and we were consulted to evaluate for oral\nand pharyngeal dysphagia. She was initially NPO but has been\nadvanced to sips.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the SICU.\nCognition, language, speech, voice:\nPt was awake but with reduced alertness, noted to keep her eyes\nclosed unless cued to open them. However, pt remained fully awake\nand participatory for ~15 minutes. Pt was initially non-verbal,\nbut was able to verbally produce her name. She was also oriented\nto name and hospital with multiple choice (giving verbal\nresponses), but reported month as with a list of 2 choices.\nNo spontaneous speech was produced and she was echolalic at\ntimes, repeating all requests and commands. She followed ~25% of\nbasic one step commands. Speech was without dysarthria, but with\nreduced volume.\nTeeth: full set in good condition\nSecretions: wfl in the oral cavity\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Unable to formally assess lingual strength or ROM, but\nfunctional for POs given.\nSWALLOWING ASSESSMENT:\nThe pt was seen with oral swabs, ice chips, thin liquids (tsp,\ncup), purees, ground solids and soft solids. Pt responded\nappropriately to all boluses with timely mastication and oral\ntransit. A mild coating of oral residue remained after ground and\nsoft solids. Pt without overt coughing, throat clearing or\nchanges in vocal quality and she denied the sensation of\naspiration or residue with yes/no questions. O2 SATs remained\nstable. Laryngeal elevation was timely and wfl to palpation.\nSUMMARY / IMPRESSION:\nMs. thin liquids and soft solids well without\nany overt signs of aspiration. While her eyes remained closed,\nshe could safely take POs with minimal cuing. She willingly\naccepted POs and I feel it is reasonable to hold off on placing\nan NG tube until we see if she can take in enough by mouth. Her\nMS may still fluctuate and she may require supplemental feedings,\nbut there is a good chance we can avoid a tube if she can stay as\nawake as she currently is. As such, suggest a PO diet of thin\nliquids and pureed solids to try to maximize intake.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5.\nRECOMMENDATIONS:\n1. Suggest a PO diet of thin liquids and pureed solids.\n2. Strict 1:1 supervision, feeding her only when most awake and\nalert.\n3. Suggest holding off on placing NG tube to see if she can take\nin enough by mouth. If her MS fluctuates, agree with placing the\ntube for supplemental tube feeds as recommended by nutrition.\n4. Meds crushed with puree.\n5. TID oral care.\n6. We will f/u later in the week to ensure she is tolerating and\nadvance her as able.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 9:10-9:25\nTotal time: 45 minutes\n [BUTTON Input] (not implemented)_____\n 09:40\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517956,
"text": "SICU\n HPI:\n 37F found to have IVH after suffering altered MS & SZ - large IVH\n secodary to syndrome\n Chief complaint:\n altered mental status, seizure\n PMHx:\n DM2\n Current medications:\n Acetaminophen, Bisacodyl, CefazoLIN, Docusate, Famotidine, Fentanyl,\n Heparin, HydrALAzine, Insulin, Mannitol Metoprolol, Nimodipine,\n Phenytoin, Potassium Chloride, Sarna Lotion, Senna\n 24 Hour Events:\n - dobhoff placed, TF started\n BLOOD CULTURED - At 11:00 PM\n CSF CULTURE - At 11:00 PM\n URINE CULTURE - At 12:38 AM\n FEVER - 102.1\nF - 10:30 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:12 AM\n Famotidine (Pepcid) - 09:01 PM\n Heparin Sodium (Prophylaxis) - 09:01 PM\n Other medications:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.2\nC (98.9\n HR: 102 (85 - 133) bpm\n BP: 131/87(105) {116/59(79) - 196/193(195)} mmHg\n RR: 24 (20 - 29) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 18 (6 - 18) mmHg\n Total In:\n 1,540 mL\n 576 mL\n PO:\n 30 mL\n Tube feeding:\n 324 mL\n 288 mL\n IV Fluid:\n 886 mL\n 107 mL\n Blood products:\n Total out:\n 1,465 mL\n 241 mL\n Urine:\n 1,307 mL\n 220 mL\n NG:\n Stool:\n Drains:\n 158 mL\n 21 mL\n Balance:\n 75 mL\n 335 mL\n Respiratory support\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Drains in place\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness), inconsistently follows commands\n Labs / Radiology\n 461 K/uL\n 10.5 g/dL\n 153 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 113 mEq/L\n 146 mEq/L\n 32.2 %\n 13.9 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n WBC\n 12.3\n 12.0\n 12.8\n 11.4\n 13.9\n Hct\n 29.4\n 27.5\n 29.7\n 31.3\n 32.2\n Plt\n 354\n 266\n 321\n 395\n 461\n Creatinine\n 0.6\n 0.5\n 0.5\n 0.5\n 0.7\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n 142\n 153\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.2 mg/dL, Mg:2.5 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 3 hr, Phenytoin - therapeutic, ICP monitor,\n f/u dilantin level 15.5\n mannitol weaned off\n repeat head CT\n Cardiovascular: keep SBP < 180\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid\n Pulmonary: room air, no issues\n Gastrointestinal / Abdomen: Dobhoff in place, TF to goal\n Nutrition: Tube feeding, Regular diet\n Renal: Foley, Adequate UO\n Hematology: Hct 32.2\n Endocrine: RISS\n Infectious Disease: Check cultures, Ancef 1g q8h while drains in place\n - temp spike to 102 overnight, f/u cultures\n Lines / Tubes / Drains: Foley, Dobhoff, Surgical drains (hemovac, JP)\n Wounds:\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 03:29 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 16 Gauge - 04:15 AM\n Arterial Line - 06:42 PM\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2132-12-29 00:00:00.000",
"description": "Intensivist Note",
"row_id": 517483,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. Mannitol 25 g IV Q12H Order date: @ 0407\n 2. Alteplase *NF* 1 mg Intrathecal Q12H Duration: 3 Days\n Start: Order date: @ 0815\n 12. Metoprolol Tartrate 5 mg IV ONCE Duration: 1 Doses Order date:\n @ 0208\n 3. CefazoLIN 1 g IV Q8H Order date: @ 0119\n 13. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 14. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP < 160 Order\n date: @ 1713\n 5. Famotidine 20 mg IV Q12H Order date: @ 2049\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Fentanyl Citrate 25-100 mcg IV Q2H:PRN agitation Order date: \n @ 1710\n 16. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 17. Potassium Chloride PO Sliding Scale Duration: 24 Hours\n Hold for K > Order date: @ 0809\n 8. Heparin 5000 UNIT SC TID Order date: @ 0920\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. HydrALAzine 10 mg IV Q4H:PRN SBP > 160\n hold sbp < 100 Order date: @ 1713\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 10. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0641\n 24 Hour Events:\n Extubated uneventfully . Maintaining patent airway. Mannitol\n weaned this AM to .\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 04:35 PM\n Infusions:\n Nicardipine - 2 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 AM\n Hydralazine - 11:00 AM\n Famotidine (Pepcid) - 10:08 PM\n Heparin Sodium (Prophylaxis) - 10:42 PM\n Other medications:\n Flowsheet Data as of 04:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.7\nC (99.8\n HR: 91 (91 - 117) bpm\n BP: 121/63(83) {101/51(68) - 143/73(94)} mmHg\n RR: 18 (18 - 30) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n ICP: 13 (7 - 14) mmHg\n Total In:\n 2,463 mL\n 106 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,463 mL\n 106 mL\n Blood products:\n Total out:\n 4,075 mL\n 523 mL\n Urine:\n 3,825 mL\n 480 mL\n NG:\n Stool:\n Drains:\n 250 mL\n 43 mL\n Balance:\n -1,612 mL\n -417 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 384) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 0%\n RSBI: 65\n SPO2: 97%\n ABG: 7.48/31/96./23/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, disconjugate eyes\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), b/l EVD\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), purposeful movements of RLE&RUE. Spontaneously moves\n left sided extremities\n Labs / Radiology\n 321 K/uL\n 9.7 g/dL\n 146 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.7 %\n 12.8 K/uL\n [image002.jpg]\n 01:12 AM\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n WBC\n 12.3\n 12.0\n 12.8\n Hct\n 29.4\n 27.5\n 29.7\n Plt\n 354\n 266\n 321\n Creatinine\n 0.6\n 0.5\n 0.5\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 193\n 171\n 146\n Other labs: PT / PTT / INR:13.1/23.2/1.1, Lactic Acid:0.9 mmol/L,\n Ca:9.0 mg/dL, Mg:2.4 mg/dL, PO4:2.1 mg/dL\n Imaging: CT Head - Interval decrease in IVH, hydrocephalus and mass\n effect. Focal hypodensity in the right basal ganglia may represent a\n focal area of infarction. Questionable small amount of subarachnoid\n hemorrhage in the left frontoparietal region. The left lateral\n ventricle is smaller than the right in all portions including frontal\n body and temporal pole compatible with asymmetric drainage of the\n lateral ventricles. Close followup imaging is recommended.\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ.\n Neurologic:\n -- Large IVH, b/l EVD in place, following simple commands, opening eyes\n to voice\n -- Dilantin 100mg q8h. Dilatin level = 15.2\n -- mannitol 25g (weaning protocol: 12.5g , off)\n -- intrathecal tPA (through EVD) q 12h.\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n Cardiovascular:\n -- goal bp < 140\n -- nicardipine drip\n -- nimodipine 60mg po q4\n -- hydralazine prn\n Pulmonary:\n -- extubated \n Gastrointestinal / Abdomen:\n -- Sips, advance as tolerated\n -- GI prophy famotidine\n Dobhoff and tube feeds as too somnolent during the day to take adequate\n nutrition PO\n Nutrition: Sips, advance as tolerated\n Renal: f/c. adequate uop. Cr 0.5\n Hematology: hct stable @ 29.7. coags nl\n Endocrine: RISS\n ID: Ancef 1g q8h while drains in place\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: H2B\n VAP bundle: n/a\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517394,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Sedated on propofol. Arousable to stimuli when shut off.\n Following commands on the right, giving thumbs up and wiggles toes.\n Left withdraws to painful stimuli.\n Pupils 3mm sluggish, by afternoon right brisk, left\n sluggish.\n On nicardipine gtt. SBP 110\ns-130\ns. HR sr-st 90-110\ns. No\n ectopy seen.\n Received on Cpap sats 98-100% Lscta.\n Bilat ventic drains @ 15 above the tragus. Draining\n serosang. ICP on the right trending down from 14 this am to 3 by\n afternoon. ICP on the left .\n Action:\n Propofol weaned off after Ct scan. Placed on Cpap 5/5. RSBI\n 65 then extubated.\n Q1hr neuro exams\n TPA instilled into drains this am by Neurosurg team.\n Mannitol given per serum os. Dilantin up as ordered.\n Bedside swallow eval done. Able to move tongue side to side,\n up and down. Chews on ice able to swallow pudding. Needs enc to open\n mouth wider and open eyes. Took dilantin suspension from a syringe\n without diff. No coughing noted. Nimodipine given in pudding.\n Nicardipine titrated to keep SBP less than 140.\n HOB elevated greater than 30 degrees.\n Response:\n RR 20\ns. ABG\ns wnl. Sats 98-100% on RA. LS remain clear.\n Ct scan shows ischemic infarct in right caudate, improvement\n in blood volume. Dr informed Pt\ns husband.\n Neuro exams wax/wane. At times arousable to stimuli others\n arousable to pain. LUE/LLE remains unchanged. Pt spoke clearly at 1700\n neuro exam. Opened eyes and looked toward this rn. Stated name, denied\n pain, stated she was good. Stated month was . Unable to\n reproduce this at 1800 however can still whisper her name and slightly\n nod head to simple questions. Dr on unit at that time and made\n aware.\n Plan:\n Continue Q1hr neuro exams.\n Give meds in pudding.\n Titrate gtt to keep SBP less than 140.\n Continue Mannitol & dilantin as ordered.\n Provide emotional support to family\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519820,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0759\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109\n 14. Metoprolol Tartrate 100 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0807\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 15. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 16. Nystatin Oral Suspension 5 mL PO QID Order date: @ 1616\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 17. Phenytoin Sodium (IV) 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 0804\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 18. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 19. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 20. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109\n 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 22. Senna 1 TAB PO/NG :PRN constipation Order date: @ 0642\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. IV access request: PICC Place Indication: Hydration Urgency: Urgent\n Order date: @ 0845\n 24 Hour Events:\n FEVER - 102.1\nF - 06:00 PM\n dilantin bolused and standing dose increased. Right EVD clamped with\n fluctuating ICP. head CT ordered while EVD clamped to eval change in\n ventricular size which showed no significant change with plan to open\n EVD only if ICP sustained over 25. Febrile 102.1 - pancultured, LFTs\n ordered as per neurology.\n Allergies:\n Tetracycline\n Rash; itching;\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.8\nC (100\n HR: 80 (80 - 124) bpm\n BP: 92/59(62) {92/59(62) - 117/86(93)} mmHg\n RR: 23 (11 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 20 (7 - 23) mmHg\n Total In:\n 1,876 mL\n 339 mL\n PO:\n Tube feeding:\n 1,216 mL\n 279 mL\n IV Fluid:\n 300 mL\n Blood products:\n Total out:\n 1,083 mL\n 300 mL\n Urine:\n 1,052 mL\n 300 mL\n NG:\n Stool:\n Drains:\n 31 mL\n Balance:\n 793 mL\n 39 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), R EVD\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 553 K/uL\n 8.8 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 20 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.1 %\n 11.3 K/uL\n [image002.jpg]\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n 09:31 AM\n 02:25 AM\n 01:53 AM\n WBC\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n 13.0\n 11.7\n 11.3\n Hct\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n 30.8\n 29.8\n 27.1\n Plt\n 71\n \n Creatinine\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 24\n Glucose\n 146\n 142\n 153\n 199\n 54\n Other labs: PT / PTT / INR:12.3/27.9/1.0, ALT / AST:106/81, Alk-Phos /\n T bili:61/0.1, Lactic Acid:0.9 mmol/L, Albumin:3.3 g/dL, Ca:9.0 mg/dL,\n Mg:2.4 mg/dL, PO4:4.2 mg/dL\n Imaging: CT Head - Evolution of IVH, with interval removal of left\n frontal drain, and right frontal drain remains in place, with stable\n appearance of the ventricles. Evolving infarct at the right basilar\n ganglia. Hypodensity in right periventricular region is unchanged.\n Head CT - overall unchanged from prior imaging with persistent\n IVH, R basal ganglia hemorrhage, L frontal lobe hemorrhage, mild\n dilatation of temporal horns overall unchanged. (prelim)\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ.\n Neurologic:\n -- R EVD clamped (pressures fluctuate up to low 20's); L EVD d/c'd \n -- mental status - inconsistently follows commands\n -- seizure prophy: dilantin 150mg tid (level 16)\n f/u EEG\n -- may need shunt placement\n discuss timing with neurosurgery\n -- start ASA 81mg qd once EVD drain is out\n -- tylenol prn pain/fever\n -- EEG - results pending\n Cardiovascular:\n -- tachycardic\n -- Lopressor increased to 100mg TID\n -- Nimodipine 60mg po q4\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room air\n Gastrointestinal / Abdomen:\n -- no PO intake at this time due to neuro status\n -- tube feeds via dobhoff @ goal\n -- bowel regimen: senna, colace, bisacodyl\n -- ALT (106)/AST (81) elevated (similar to yesterday), Tbili and\n AlkPhos wnl\n PEG placement coord with n- shunt\n LFTs not impressive\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.4\n -- UCX : negative\n Hematology:\n -- hct 27.1\n Endocrine:\n -- DM. Pt with elevated BS despite large insulin doses. Consider\n restarting metformin or adding long acting insulin. ]\n ID:\n -- Ancef 1g q8h while drain in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). CSF cx pending (gram stain negative)\n -- WBC 11.3\n T/L/D: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: n/a\n VAP bundle: nystatin oral suspension QID\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519643,
"text": "HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n unresponsive\n PMHx:\n Dm2\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient does not follow commands does not open eyes to voice when\n moving open eyes twice pupils brisk 3mm no movement on left does\n withdraw on right to nailbed pressure ICP increased over 20 clamped 25\n above tragus lungs clear no O2 abd soft + bowel sounds + flatus no BM\n foley patent draining clear yellow urine t max 100.3. Husband at\n bedside\n Action:\n Stat head CT ordered by neuro surgery for increased ICP drain to remain\n clamped.\n Response:\n Patient neuro status remains unchanged repeat head CT per neurosurgery\n showing no changes from previous also call neurosurgery if patient ICP\n goes > 25 sustained.\n Plan:\n ? transfer to floor continue to monitor neuro q3 and let team know of\n any changes provide comfort and support as needed.\n"
},
{
"category": "Rehab Services",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Swallowing Follow Up",
"row_id": 519779,
"text": "TITLE:\nSWALLOWING FOLLOW UP\nWe returned to f/u on thi 37 year old woman who experienced the\nacute onset nausea,vomiting, LOC, and seizure-like activity on\n. She was found to have diffuse intraventricular\nhemorrhage and bilateral - like vascular changes; EVDs\nwere placed, and dilantin was started. She had decreased MS on\n and was sent for another head CT showing persistent\nintraventricular hemorrhage, left frontal lobe hemorrhage and\nright basal ganglia hyperdensity, unchanged.\nWe have been following her for possible advancement to POs, but\nher MS continues to be preventative of attempting anything PO. As\nsuch, we will sign off for now. Please reconsult when pt's MS\nwould allow us to trial POs and we would be happy to return.\n_________________________________\n , MS, CCC-SLP\nPager#\nTotal Time: 15 minutes\n 02:36 PM\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519589,
"text": "HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n unresponsive\n PMHx:\n Dm2\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient does not follow commands does not open eyes to voice when\n moving open eyes twice pupils brisk 3mm no movement on left does\n withdraw on right to nailbed pressure ICP increased over 20 clamped 25\n above tragus lungs clear no O2 abd soft + bowel sounds + flatus no BM\n foley patent draining clear yellow urine t max 100.3. Husband at\n bedside\n Action:\n Stat head CT ordered by neuro surgery for increased ICP drain to remain\n clamped.\n Response:\n Patient neuro status remains unchanged repeat head CT per neurosurgery\n showing no changes from previous also call neurosurgery if patient ICP\n goes > 25 sustained.\n Plan:\n ? transfer to floor continue to monitor neuro q3 and let team know of\n any changes provide comfort and support as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 519863,
"text": "This 37 year old woman experienced acute onset nausea, vomiting, LOC, and seizur\ne-like activity on . She was found to have diffuse intraventricular hemor\nrhage and bilateral - like vascular changes; EVDs were placed, and \ntin was started. She has been in the SICU and is neurologically stable for tran\nsfer to step-down.\nNeuro: Mental status waxes and wanes. She will intermittently open eyes sponta\nneously and follow some commands (opens mouth, sticks out tongue, squeezes hand)\n. She speaks occasionally (\nouch\n and says her name). Localizes pain with righ\nt upper extremity and moves other three on bed (right side > left side). PERRLA\n. Gag/cough impaired. Right ventricular drain in place and clamped (25 above \n). Head CT done as drain clamped for 24 hours (pending read).\nCV: HRRR, no ectopy noted. BP stable. +pp/csm. Trace pedal edema noted.\nResp: LSCTA. O2 sats wnl room air.\nGI: Abdomen soft/nt/nd. +bs. Doboff feeding tube in place. Tube feeds at goal\n (Boost with glucose control). RISS.\nGU: Foley draining adequate amounts cyu.\nSkin: WDI.\nSocial: Supportive husband. Sister MICU nurse .\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 67.1 kg\n Daily weight:\n 61.1 kg\n Allergies/Reactions:\n Tetracycline\n Rash; itching;\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:68\n Temperature:\n 98.4\n Arterial BP:\n S:141\n D:104\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 0% %\n 24h total in:\n 1,138 mL\n 24h total out:\n 990 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 01:53 AM\n Potassium:\n 4.6 mEq/L\n 01:53 AM\n Chloride:\n 104 mEq/L\n 01:53 AM\n CO2:\n 25 mEq/L\n 01:53 AM\n BUN:\n 20 mg/dL\n 01:53 AM\n Creatinine:\n 0.4 mg/dL\n 01:53 AM\n Glucose:\n 154 mg/dL\n 01:53 AM\n Hematocrit:\n 27.1 %\n 01:53 AM\n Finger Stick Glucose:\n 192\n 04:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: 18:00\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518683,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 16-20. CSF blood-tinged <10/hr. EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic.\n Action:\n MD , resident on-call for Neurosurgery aware of ICP 20 at short\n intervals throughout the shift.\n EVD remains at 25 above tragus. Continued at that height MD .\n MD s ICP 20 without self resolving.\n Response:\n Pt within desired parameters thru out shift.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Follow plan of care per Neurosurgery and SICU team.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519630,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0759\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109\n 14. Metoprolol Tartrate 100 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0807\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 15. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 16. Nystatin Oral Suspension 5 mL PO QID Order date: @ 1616\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 17. Phenytoin Sodium (IV) 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 0804\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 18. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 19. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 20. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109\n 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 22. Senna 1 TAB PO/NG :PRN constipation Order date: @ 0642\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. IV access request: PICC Place Indication: Hydration Urgency: Urgent\n Order date: @ 0845\n 24 Hour Events:\n FEVER - 102.1\nF - 06:00 PM\n dilantin bolused and standing dose increased. Right EVD clamped with\n fluctuating ICP. head CT ordered while EVD clamped to eval change in\n ventricular size which showed no significant change with plan to open\n EVD only if ICP sustained over 25. Febrile 102.1 - pancultured, LFTs\n ordered as per neurology.\n Allergies:\n Tetracycline\n Rash; itching;\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.8\nC (100\n HR: 80 (80 - 124) bpm\n BP: 92/59(62) {92/59(62) - 117/86(93)} mmHg\n RR: 23 (11 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 20 (7 - 23) mmHg\n Total In:\n 1,876 mL\n 339 mL\n PO:\n Tube feeding:\n 1,216 mL\n 279 mL\n IV Fluid:\n 300 mL\n Blood products:\n Total out:\n 1,083 mL\n 300 mL\n Urine:\n 1,052 mL\n 300 mL\n NG:\n Stool:\n Drains:\n 31 mL\n Balance:\n 793 mL\n 39 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), R EVD\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 553 K/uL\n 8.8 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 20 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.1 %\n 11.3 K/uL\n [image002.jpg]\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n 09:31 AM\n 02:25 AM\n 01:53 AM\n WBC\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n 13.0\n 11.7\n 11.3\n Hct\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n 30.8\n 29.8\n 27.1\n Plt\n 71\n \n Creatinine\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 24\n Glucose\n 146\n 142\n 153\n 199\n 54\n Other labs: PT / PTT / INR:12.3/27.9/1.0, ALT / AST:106/81, Alk-Phos /\n T bili:61/0.1, Lactic Acid:0.9 mmol/L, Albumin:3.3 g/dL, Ca:9.0 mg/dL,\n Mg:2.4 mg/dL, PO4:4.2 mg/dL\n Imaging: CT Head - Evolution of IVH, with interval removal of left\n frontal drain, and right frontal drain remains in place, with stable\n appearance of the ventricles. Evolving infarct at the right basilar\n ganglia. Hypodensity in right periventricular region is unchanged.\n Head CT - overall unchanged from prior imaging with persistent\n IVH, R basal ganglia hemorrhage, L frontal lobe hemorrhage, mild\n dilatation of temporal horns overall unchanged. (prelim)\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ.\n Neurologic:\n -- R EVD clamped (pressures fluctuate up to low 20's); L EVD d/c'd \n -- mental status - inconsistently follows commands\n -- seizure prophy: dilantin 150mg tid (level 16)\n -- start ASA 81mg qd once EVD drain is out\n -- tylenol prn pain/fever\n -- EEG - results pending\n Cardiovascular:\n -- tachycardic\n -- Lopressor increased to 100mg TID\n -- Nimodipine 60mg po q4\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room air\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- tube feeds via dobhoff @ goal\n -- bowel regimen: senna, colace, bisacodyl\n -- ALT (106)/AST (81) elevated (similar to yesterday), Tbili and\n AlkPhos wnl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.4\n -- UCX : negative\n Hematology:\n -- hct 27.1\n Endocrine:\n -- DM. Pt with elevated BS despite large insulin doses. Consider\n restarting metformin or adding long acting insulin.\n ID:\n -- Ancef 1g q8h while drain in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). CSF cx pending (gram stain negative)\n -- WBC 11.3\n T/L/D: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: n/a\n VAP bundle: nystatin oral suspension QID\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down\n Time spent: 35\n"
},
{
"category": "Rehab Services",
"chartdate": "2133-01-07 00:00:00.000",
"description": "Generic Note",
"row_id": 520113,
"text": "TITLE:\n History\n Attending M.D.: \n Referral Date: \n Reason for Referral: eval and treat\n Medical Dx / ICD - 9: 432; IVH\n Activity Orders: Cleared for EOB evaluation by ICU team\n HPI / Subjective Complaint: 37 year old female with sudden onset of\n neck pain and vomitting. Patient quickly became unresonsive with GCS 5\n at scene. Found to have extensive IVH s/p bilateral EVD placement. CTA\n later found Moyamoya pattern with intracranial stenosis of bilateral\n ICA's, left greater than right. EVD and medical management has been\n only interventions at this time.\n Past Medical / Surgical History: DMII\n Medications: alteplase, cefazolin, dextrose, famotidine, fentanyl,\n glucagon, heparin, hydraliazine, insulin, mannitol, metoprolol,\n nimodipine, nicardipine, phenytoin,\n Labs\n Hematocrit (serum): 29.0 ...\n Hemoglobin: 9.3 ... g/dl\n WBC: 11.0 ...\n Platelet Count: 526 ...\n Radiology\n Radiology: CT brain : EVD in place on right side. Decrease in amount\n of hemorrhage on left lateral ventricle, 3rd ventricle, and 4th\n ventricle\n CT head : stable\n Occupational History\n Occupational Profile: currently not working, husband reports that\n patient is a \"housewife\", enjoys / movies\n Performance Patterns: lives with husband, primarily remains home during\n the day, lives in on campus, patient husband is a\n professor at the \n Baseline Occupational Performance: independent ADL and IADL, negative\n driving\n Environmental History: elevator access at home, however will require\n some stair negotiation to access apartment\n Current Activities of Daily Living\n Self Feeding: (Dependent)\n Grooming: (max A)\n UE Bathing: (max A)\n LE Bathing: (Dependent)\n UE Dressing: (max A)\n LE Dressing: (Dependent)\n Toileting: (Dependent)\n Specify: seated at eob assessment. hand over hand assist with right ue\n required. unable to use left ue for adl. poor sitting balance creating\n fall risk for le adl performance\n Current Instrumental Activities of Daily Living\n Home Management: Dependent\n Money Management: Dependent\n Community Integration: Dependent\n Performance Skills\n Process Skills: patient initialy somnolent supine, eyes opening briefly\n to sternal rub\n sitting up at eob patient demonstrated:\n attempting to make eye contact but unable due to nystagmus\n following 1 step simple commands for 2-3 minutes 25% of the time\n eye closed through cognitive assessment except for 2-3 minutes\n visually tracking from right to midline, apparent left neglect noted\n able to imitate guestures x 2 with the right upper extremity\n Communication / Interactive Skills: attempting to verbally respond to\n questions but unable\n intermittently nods appropriately to yes/ no questions\n Motor Skills - Functional Transfers\n Rolling: (max A)\n Supine / Side-lying to Sit: (max A)\n Functional Transfers Clarification: assist of 2 to sit up at eob.\n attempts to use right upper extremity to maintain sitting balance.\n frequent lob's posteriorly. trunk tone/ control noted with challenges\n in all directions.\n Functional Balance: poor sitting, unable to stand\n Aerobic Capacity: Rest\n Rest HR: 100\n Rest BP: 118/82\n Rest RR: 24\n Rest O2 sat: 98 %\n Supplemental O2: re\n Aerobic Capacity: Activity\n Activity HR: 104\n Activity BP: 120/86\n Activity RR: 34\n Activity O2 sat: 98 %\n Supplemental O2: re\n Aerobic Capacity: Recovery\n Recovery HR: 100\n Recovery BP: 116/80\n Recovery O2 sat: 99 %\n Supplemental O2: re\n Range of Motion\n Range of Motion: bilateral ue intact\n Muscle Performance: strength, power, endurance\n Muscle Performance: 0/5 right ue\n move right upper extremity spontaneously against gravity\n Additional Performance Skills\n Motor Control: flaccid left ue\n Coordination: pulls at lines and scratches face with right ue\n Limiting Symptoms: absent withdrawal to noxious stimuli on the left\n side. diminished response on the right side. facial grimacing noted\n with noxious stim on the right le and ue\n Sensation: unable to formally assess light touch\n Integumentary: right EVD, right PICC, left PIV, foley, tele\n Team Communication: RN and PT regarding patient status\n Patient Education: patient and husband education on current status and\n role of OT\n Diagnosis\n Diagnosis 1: decreased adl\n Diagnosis 2: decreased mobility\n Diagnosis 3: decreased cognition\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: 37 year old female presenting with\n moyamoya disease now with all abilities and limitations above. Patient\n is currently functioning well below baseline and unable to discharge\n home. Long term prognosis unclear given nature of condition. Fair to\n poor potential to progress to prior level of function given nature of\n condition and current functional status. At this time recommending\n rehab discharge when medically stable to maximize ADL performance.\n Continue to follow with OT on an acute level to progress status and\n assist with long term goal setting.\n Goals: patient / family, objective, measurable\n Goal 1: follow 1 step commands 50% of time\n Goal 2: express need for toileting with communcation board\n Goal 3: max assist commode transfer\n Goal 4: mod assist for oral hygiene\n Time Frame (expected attainment): 1 week\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: f/u for adl train, cognitive retrain, pt education, d/c\n planning\n Frequency / Duration: 2-3x/wk\n Therapist Information\n Therapist's Name: \n Date: \n Time: 1430-1500\n Pager #: \n Noted added into chart by , OTR/L\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 519851,
"text": "This 37 year old woman experienced acute onset nausea, vomiting, LOC, and seizur\ne-like activity on . She was found to have diffuse intraventricular hemor\nrhage and bilateral - like vascular changes; EVDs were placed, and \ntin was started. She has been in the SICU and is neurologically stable for tran\nsfer to step-down.\nNeuro: Mental status waxes and wanes. She will intermittently open eyes sponta\nneously and follow some commands (opens mouth, sticks out tongue, squeezes hand)\n. She speaks occasionally (\nouch\n and says her name). Localizes pain with righ\nt upper extremity and moves other three on bed (right side > left side). PERRLA\n. Gag/cough impaired. Right ventricular drain in place and clamped (25 above \n). Head CT done as drain clamped for 24 hours (pending read).\nCV: HRRR, no ectopy noted. BP stable. +pp/csm. Trace pedal edema noted.\nResp: LSCTA. O2 sats wnl room air.\nGI: Abdomen soft/nt/nd. +bs. Doboff feeding tube in place. Tube feeds at goal\n (Boost with glucose control). RISS.\nGU: Foley draining adequate amounts cyu.\nSkin: WDI.\nSocial: Supportive husband. Sister MICU nurse .\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519698,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0759\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109\n 14. Metoprolol Tartrate 100 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0807\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 15. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 16. Nystatin Oral Suspension 5 mL PO QID Order date: @ 1616\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 17. Phenytoin Sodium (IV) 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 0804\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 18. Phenytoin (Suspension) 150 mg PO/NG Q8H Order date: @ 0807\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 19. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 20. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109\n 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 22. Senna 1 TAB PO/NG :PRN constipation Order date: @ 0642\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. IV access request: PICC Place Indication: Hydration Urgency: Urgent\n Order date: @ 0845\n 24 Hour Events:\n FEVER - 102.1\nF - 06:00 PM\n dilantin bolused and standing dose increased. Right EVD clamped with\n fluctuating ICP. head CT ordered while EVD clamped to eval change in\n ventricular size which showed no significant change with plan to open\n EVD only if ICP sustained over 25. Febrile 102.1 - pancultured, LFTs\n ordered as per neurology.\n Allergies:\n Tetracycline\n Rash; itching;\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.8\nC (100\n HR: 80 (80 - 124) bpm\n BP: 92/59(62) {92/59(62) - 117/86(93)} mmHg\n RR: 23 (11 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 20 (7 - 23) mmHg\n Total In:\n 1,876 mL\n 339 mL\n PO:\n Tube feeding:\n 1,216 mL\n 279 mL\n IV Fluid:\n 300 mL\n Blood products:\n Total out:\n 1,083 mL\n 300 mL\n Urine:\n 1,052 mL\n 300 mL\n NG:\n Stool:\n Drains:\n 31 mL\n Balance:\n 793 mL\n 39 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), R EVD\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 553 K/uL\n 8.8 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 20 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.1 %\n 11.3 K/uL\n [image002.jpg]\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n 09:31 AM\n 02:25 AM\n 01:53 AM\n WBC\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n 13.0\n 11.7\n 11.3\n Hct\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n 30.8\n 29.8\n 27.1\n Plt\n 71\n \n Creatinine\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n 0.4\n TCO2\n 24\n Glucose\n 146\n 142\n 153\n 199\n 54\n Other labs: PT / PTT / INR:12.3/27.9/1.0, ALT / AST:106/81, Alk-Phos /\n T bili:61/0.1, Lactic Acid:0.9 mmol/L, Albumin:3.3 g/dL, Ca:9.0 mg/dL,\n Mg:2.4 mg/dL, PO4:4.2 mg/dL\n Imaging: CT Head - Evolution of IVH, with interval removal of left\n frontal drain, and right frontal drain remains in place, with stable\n appearance of the ventricles. Evolving infarct at the right basilar\n ganglia. Hypodensity in right periventricular region is unchanged.\n Head CT - overall unchanged from prior imaging with persistent\n IVH, R basal ganglia hemorrhage, L frontal lobe hemorrhage, mild\n dilatation of temporal horns overall unchanged. (prelim)\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ.\n Neurologic:\n -- R EVD clamped (pressures fluctuate up to low 20's); L EVD d/c'd \n -- mental status - inconsistently follows commands\n -- seizure prophy: dilantin 150mg tid (level 16)\n f/u EEG\n Q shunt placement and timing\n -- start ASA 81mg qd once EVD drain is out\n -- tylenol prn pain/fever\n -- EEG - results pending\n Cardiovascular:\n -- tachycardic\n -- Lopressor increased to 100mg TID\n -- Nimodipine 60mg po q4\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room air\n Gastrointestinal / Abdomen:\n -- no PO intake at this time due to neuro status\n -- tube feeds via dobhoff @ goal\n -- bowel regimen: senna, colace, bisacodyl\n -- ALT (106)/AST (81) elevated (similar to yesterday), Tbili and\n AlkPhos wnl\n PEG placement coord with n- shunt\n LFTs not impressive\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.4\n -- UCX : negative\n Hematology:\n -- hct 27.1\n Endocrine:\n -- DM. Pt with elevated BS despite large insulin doses. Consider\n restarting metformin or adding long acting insulin. ]\n ID:\n -- Ancef 1g q8h while drain in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). CSF cx pending (gram stain negative)\n -- WBC 11.3\n T/L/D: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: n/a\n VAP bundle: nystatin oral suspension QID\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down\n Time spent: 35\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519114,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115 13. IV access\n request: PICC Place Indication: Hydration Urgency: Urgent Order date:\n @ 0845\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109 14. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 2207\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249 15. Metoprolol Tartrate 50 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0815\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737 16. Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order\n date: @ 0415\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721 17. Nimodipine\n 60 mg PO Q4H Order date: @ 0119\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641 18. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @\n 1608\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737 19.\n Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Famotidine 20 mg PO/NG Order date: @ 0807 20. Potassium\n Chloride IV Sliding Scale Order date: @ 0352\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @\n 2046\n 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109 22.\n Senna 1 TAB PO/NG Order date: @ 0737\n 11. Heparin 5000 UNIT SC TID Order date: @ 0920 23. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 24 Hour Events:\n FEVER - 101.4\nF - 08:00 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 01:12 AM\n Other medications:\n : Metformin\n Flowsheet Data as of 04:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.3\nC (100.9\n HR: 115 (86 - 131) bpm\n BP: 125/91(99) {96/61(21) - 142/92(99)} mmHg\n RR: 22 (20 - 31) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 6 (6 - 27) mmHg\n Total In:\n 1,755 mL\n 303 mL\n PO:\n Tube feeding:\n 1,235 mL\n 213 mL\n IV Fluid:\n 50 mL\n Blood products:\n Total out:\n 1,234 mL\n 216 mL\n Urine:\n 1,115 mL\n 190 mL\n NG:\n Stool:\n Drains:\n 119 mL\n 26 mL\n Balance:\n 521 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, ? MoyaMoya.\n Neurologic: -- Large IVH, R EVD open this AM due to elevated ICP O/N\n and worse exam will discuss with n- about plan to re-clamp drain\n and necessity to remain in ICU; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands & occ answers questions appropriately, eye opening to\n voice/spontaneous\n --weekly dilantin levels\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular: -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid, 5mg IV prn breakthrough\n -- Hydralazine prn SBP > 180\n Pulmonary: -- sats 90's on room air\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen: -- Passed speech/swallow, however\n inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition: -- tube feeds: replete with fiber (goal 60cc/hr\n Renal: -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology: -- hct 29.8. lab holiday today\n n LENIs negative for DVT\n n Labs tomorrow AM\n Endocrine: tightened RISS once TF @ goal (required 10-14U each\n fingerstick)\n Infectious Disease: -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n Lines / Tubes / Drains: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), CVA, Seizure\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 08:15 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519018,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115 13. IV access\n request: PICC Place Indication: Hydration Urgency: Urgent Order date:\n @ 0845\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109 14. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 2207\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249 15. Metoprolol Tartrate 50 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0815\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737 16. Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order\n date: @ 0415\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721 17. Nimodipine\n 60 mg PO Q4H Order date: @ 0119\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641 18. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @\n 1608\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737 19.\n Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Famotidine 20 mg PO/NG Order date: @ 0807 20. Potassium\n Chloride IV Sliding Scale Order date: @ 0352\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @\n 2046\n 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109 22.\n Senna 1 TAB PO/NG Order date: @ 0737\n 11. Heparin 5000 UNIT SC TID Order date: @ 0920 23. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 24 Hour Events:\n FEVER - 101.4\nF - 08:00 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 01:12 AM\n Other medications:\n : Metformin\n Flowsheet Data as of 04:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.3\nC (100.9\n HR: 115 (86 - 131) bpm\n BP: 125/91(99) {96/61(21) - 142/92(99)} mmHg\n RR: 22 (20 - 31) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 6 (6 - 27) mmHg\n Total In:\n 1,755 mL\n 303 mL\n PO:\n Tube feeding:\n 1,235 mL\n 213 mL\n IV Fluid:\n 50 mL\n Blood products:\n Total out:\n 1,234 mL\n 216 mL\n Urine:\n 1,115 mL\n 190 mL\n NG:\n Stool:\n Drains:\n 119 mL\n 26 mL\n Balance:\n 521 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, ? MoyaMoya.\n Neurologic: -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands & occ answers questions appropriately, eye opening to\n voice/spontaneous\n --weekly dilantin levels\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular: -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid, 5mg IV prn breakthrough\n -- Hydralazine prn SBP > 180\n Pulmonary: -- sats 90's on room air\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen: -- Passed speech/swallow, however\n inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition: -- tube feeds: replete with fiber (goal 60cc/hr\n Renal: -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology: -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: tightened RISS once TF @ goal (required 10-14U each\n fingerstick)\n Infectious Disease: -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n Lines / Tubes / Drains: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), CVA, Seizure\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 08:15 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518507,
"text": "Subjective: Patient is too lethargic to feed RN. Said\nhospital\n this a.m.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 67.1 kg\n 64.3 kg ( )\n 28.8\n Pertinent medications: RISS, ABx, Heparin, Senna, Colace, Famotidine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 215 mg/dL\n 04:02 AM\n Glucose Finger Stick\n 262\n 10:00 AM\n BUN\n 14 mg/dL\n 04:02 AM\n Creatinine\n 0.5 mg/dL\n 04:02 AM\n Sodium\n 142 mEq/L\n 04:02 AM\n Potassium\n 3.9 mEq/L\n 04:02 AM\n Chloride\n 106 mEq/L\n 04:02 AM\n TCO2\n 24 mEq/L\n 04:02 AM\n PO2 (arterial)\n 96. mm Hg\n 12:22 PM\n PCO2 (arterial)\n 31 mm Hg\n 12:22 PM\n pH (arterial)\n 7.48 units\n 12:22 PM\n pH (urine)\n 7.0 units\n 04:22 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 12:22 PM\n Albumin\n 4.1 g/dL\n 04:08 AM\n Calcium non-ionized\n 8.9 mg/dL\n 04:02 AM\n Phosphorus\n 3.2 mg/dL\n 04:02 AM\n Magnesium\n 2.4 mg/dL\n 04:02 AM\n Phenytoin (Dilantin)\n 11.9 ug/mL\n 04:02 AM\n WBC\n 11.9 K/uL\n 04:02 AM\n Hgb\n 10.6 g/dL\n 04:02 AM\n Hematocrit\n 33.7 %\n 04:02 AM\n Current diet order / nutrition support: Tube Feeds: Boost Glucose\n Control @ 50mL/hr (1272kcals, 70g protein)\n GI: abd soft, bowel sounds & flatus present\n Assessment of Nutritional Status\n 37 y.o. Female w/ DM2 found to have IVH after suffering altered MS &\n SZ, questionably related to MoyaMoya disease. Patient\ns neuro exam\n continues to wax and wane, but remains much more lethargic than she was\n a few days ago. Patient passed a swallow evaluation for pureed diet\n with thin liquids , but RN has not been giving her po\ns as she is\n too lethargic to tolerate safely. Tube Feeds are running at goal over\n 24hr, meeting 100% of estimated needs. Blood sugars remain elevated\n despite low carbohydrate/high fiber formula.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with tube feeds at goal.\n Will re-evaluate next week\n if mental status improves and\n she is able to take po\ns, will consider cycling tube feeds.\n Continue with RISS coverage.\n Following - #\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518607,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt more alert this morning- following some intermittent commands on the\n right side and opening eyes briefly but not tracking or focusing. Left\n side withdrawing to painful stimuli only but per report occasionally\n moved left hand spontaneously prior to shift change. Bilat EVD drains :\n left clamped, right open at 20 above the tragus draining bloodtinged\n csf. Access issues. No stool. Fevers continue.\n Action:\n Q 2-3 neuro checks (0rder for q 3 hours). ICP monitoring q 1 hour.\n Drain level increased to 25ccH20 above the tragus. PT worked with pt\n today. Tube feeds continue around the clock d/t mental status. Left\n EVD discontinued. PICC line placed. Colace and Senna as ordered.\n Tylenol given q 4 per prn order to keep temp down and csf sent for\n culture by neuro team. Nimodipine and Dilantin cont.\n Response:\n Neuro status waxes and wanes\nat times withdrawal only and no commands/\n at times a few simple commands and one word answers (orientated). ICP\n elevated to 20 with stimulation but self-limiting. Pt had two loose\n MD notified and collected for culture awaiting order for\n culture to r/o cdiff (continued fevers). PT dangled at bedside with PT\n but unable to help much- difficulty staying awake/ cannot hold body\n upright on own.\n Plan:\n Cont neuro checks q 3 hours. Cont to monitor icp and csf drainage.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519318,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n unresponsive\n PMHx:\n Dm2\n Current medications:\n Acetaminophen, Bisacodyl, CefazoLIN, Docusate Sodium, Famotidine,\n Heparin, HydrALAzine, Insulin, Metoprolol Tartrate, Nimodipine,\n Phenytoin Sodium, Potassium Phosphate, Potassium Chloride, Sarna\n Lotion, Senna\n 24 Hour Events:\n EEG - At 02:30 PM\n FEVER - 101.1\nF - 12:00 PM\n CT head - no significant change from previous\n Dilantin level low, rebolus 500 IV x 1\n Drain remains open\n EEG performed\n Post operative day:\n POD 9 s/p EVD placement\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.1\nC (98.8\n HR: 99 (91 - 126) bpm\n BP: 109/83(89) {90/63(69) - 118/88(94)} mmHg\n RR: 28 (21 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 13 (9 - 18) mmHg\n Total In:\n 1,876 mL\n 416 mL\n PO:\n Tube feeding:\n 1,221 mL\n 276 mL\n IV Fluid:\n 300 mL\n 50 mL\n Blood products:\n Total out:\n 1,337 mL\n 217 mL\n Urine:\n 1,210 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 127 mL\n 17 mL\n Balance:\n 539 mL\n 199 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness), inconsistent neuro exam, inconsistently\n follows commands\n Labs / Radiology\n 573 K/uL\n 9.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 21 mg/dL\n 103 mEq/L\n 139 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n 09:31 AM\n 02:25 AM\n WBC\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n 13.0\n 11.7\n Hct\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n 30.8\n 29.8\n Plt\n 71\n 73\n Creatinine\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 23\n 24\n Glucose\n 146\n 142\n 153\n 199\n 215\n 168\n 137\n Other labs: PT / PTT / INR:12.5/22.6/1.1, ALT / AST:61/58, Alk-Phos / T\n bili:70/0.1, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca:9.2 mg/dL,\n Mg:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, dilantin level 9.3, L drain removed,\n R drain open, f/u EEG\n Cardiovascular: Beta-blocker, -- Nimodipine 60mg po q4\n -- incr Lopressor to 75mg po tid\n Pulmonary: -- sats 90's on room air\n Gastrointestinal / Abdomen: -- dobhoff in place, TF @ goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct 29.8 stable\n Endocrine: RISS\n Infectious Disease: Check cultures, cont Ancef\n Lines / Tubes / Drains: PIV, EVD Right, foley, PICC\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 01:35 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518804,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n Acetaminophen\n Bisacodyl.\n CefazoLIN\n Docusate Sodium\n Famotidine\n Heparin\n HydrALAzine\n Insulin\n Metoprolol Tartrate\n Nimodipine\n Phenytoin (Suspension)\n Senna\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ICP CATHETER - STOP 12:03 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 106 (93 - 120) bpm\n BP: 104/68(76) {97/68(75) - 133/93(101)} mmHg\n RR: 23 (20 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 12 (4 - 21) mmHg\n Total In:\n 1,924 mL\n 490 mL\n PO:\n Tube feeding:\n 1,204 mL\n 280 mL\n IV Fluid:\n 400 mL\n 50 mL\n Blood products:\n Total out:\n 1,213 mL\n 351 mL\n Urine:\n 1,110 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 103 mL\n 31 mL\n Balance:\n 711 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), EVD secured in place/clean\n sites\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n intermittently following commands, moves right side spontaneously, left\n side withdraws to pain\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands, eye opening to voice/spontaneous\n -- Dilantin 100mg q8h, levels therapeutic\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular:\n -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology:\n -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n T/L/D: PIV, EVD Right, foley, needs PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 12:57 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518805,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n Acetaminophen\n Bisacodyl.\n CefazoLIN\n Docusate Sodium\n Famotidine\n Heparin\n HydrALAzine\n Insulin\n Metoprolol Tartrate\n Nimodipine\n Phenytoin (Suspension)\n Senna\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ICP CATHETER - STOP 12:03 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 106 (93 - 120) bpm\n BP: 104/68(76) {97/68(75) - 133/93(101)} mmHg\n RR: 23 (20 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 12 (4 - 21) mmHg\n Total In:\n 1,924 mL\n 490 mL\n PO:\n Tube feeding:\n 1,204 mL\n 280 mL\n IV Fluid:\n 400 mL\n 50 mL\n Blood products:\n Total out:\n 1,213 mL\n 351 mL\n Urine:\n 1,110 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 103 mL\n 31 mL\n Balance:\n 711 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), EVD secured in place/clean\n sites\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n intermittently following commands, moves right side spontaneously, left\n side withdraws to pain\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands, eye opening to voice/spontaneous\n -- Dilantin 100mg q8h, levels therapeutic\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular:\n -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology:\n -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n T/L/D: PIV, EVD Right, foley, needs PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 12:57 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518331,
"text": "Pt is a 37 yo women with DM@ found to IVH after suffering altered MS &\n SZ. Pt found to have moyamoya disease.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Bilateral EVDs in place. Left clamped and transduced. Right open at\n 20cm H20 above the tragus. Pt is not following commands. Moves all\n extremities to painful stimuli and right side spontaneously but not\n purposefully. Q 2 hour neuro checks. Goal sbp <140 and pt has been\n running 120-140. HR sr to st up to 130s at times with fevers and\n stimulation. UO adequate via foley cath. Blood glucose elevated to 270\n at 1000. Pts husband at bedside and very supportive. Not getting any\n rest himself however and very anxious of her status. Fever spikes to\n 102 continue.\n Action:\n ICPs transduced, right drain open and icps checked q 1 hour. Drainage\n documented. Neuro checks q 2 hours. Nimodipine and lopressor as\n ordered. Famotidine changed to po (via ngt). Insulin 8 units given and\n MD notified of elevated sugars. Pt to ultrasound to rule out dvts\n causing fevers. Pt to head CT immediately after ultrasound. Tylenol\n given via ngt.\n Response:\n Preliminary results per ultrasound tech no signs of dvt. Improvements\n in temps to 99-100 with Tylenol. HR improved following Tylenol as well.\n No changes in neuro exam. Pt opened eyes x 2 however still no commands.\n Blood glucose to be rechecked at 1600. Pt\ns husband went home to shower\n for an hour but came back d/t unable to stay at home without his wife.\n :\n Cont neuro checks. ? call out to step down. Ct results pending.\n Ultrasound final results pending. Emotional support for pt\ns husband.\n Cont to monitor temps and medicate with Tylenol as needed. Will email\n social work.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518332,
"text": "Pt is a 37 yo women with DM@ found to IVH after suffering altered MS &\n SZ. Pt found to have moyamoya disease.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Bilateral EVDs in place. Left clamped and transduced. Right open at\n 20cm H20 above the tragus. Pt is not following commands. Moves all\n extremities to painful stimuli and right side spontaneously but not\n purposefully. Q 2 hour neuro checks. Goal sbp <140 and pt has been\n running 120-140. HR sr to st up to 130s at times with fevers and\n stimulation. UO adequate via foley cath. Blood glucose elevated to 270\n at 1000. Pts husband at bedside and very supportive. Not getting any\n rest himself however and very anxious of her status. Fever spikes to\n 102 continue.\n Action:\n ICPs transduced, right drain open and icps checked q 1 hour. Drainage\n documented. Neuro checks q 2 hours. Nimodipine and lopressor as\n ordered. Famotidine changed to po (via ngt). Insulin 8 units given and\n MD notified of elevated sugars. Pt to ultrasound to rule out dvts\n causing fevers. Pt to head CT immediately after ultrasound. Tylenol\n given via ngt.\n Response:\n Preliminary results per ultrasound tech no signs of dvt. Improvements\n in temps to 99-100 with Tylenol. HR improved following Tylenol as well.\n No changes in neuro exam. Pt opened eyes x 2 however still no commands.\n Blood glucose to be rechecked at 1600. Pt\ns husband went home to shower\n for an hour but came back d/t unable to stay at home without his wife.\n :\n Cont neuro checks. ? call out to step down. Ct results pending.\n Ultrasound final results pending. Emotional support for pt\ns husband.\n Cont to monitor temps and medicate with Tylenol as needed. Will email\n social work.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518930,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 10-18 CSF blood-tinged EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic.\n Tmax 101.2\n Action:\n EVD remains at 25 above tragus. Clamped for 2hrs. ICP up to 30.\n Tylenol 650mg every four hours.\n Response:\n NP aware of ICP. Drain unclamped.\n No changes in Neuro.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Clamp trial in am.\n"
},
{
"category": "Nursing",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 517658,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt neuro status waxes and wanes thru shift, pt will flex withdraw with\n all exts although left side has a delayed response, pt has purposeful\n movement on right with bringing hand to face to scratch nose, pt will\n instantly squeeze with right hand so it is difficult to tell if she is\n doing this to command, also spontaneously moves right leg, did speak\n with very soft voice on 2 to 3 occassions with one word response,\n perrla at 3mm and brisk, icp 8-15, 1 to 8 cc output from drains, pt hr\n and abp labile with frequent trends to the 120-130\ns = HR and systolic\n abp low 140\ns with high in the 150\ns with or without stimulation.\n Action:\n neuro\ns q1, nicardipine gtt cont at 2.5 mcg, pt given Lopressor 5 mg iv\n x2 over shift, pt also given fent 25mcg ? pain at 130am after\n contacting Dr. .\n Response:\n pt hr and abp systolic seemed better controlled after 2^nd dosing of\n Lopressor, no sign deficit noted in exam after fent dosing, 3^rd dosing\n of iv Lopressor 5mg given at 530am\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 518582,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: IVH / 432\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 37 yo F admitted \n after episode of acute onset neck pain, nausea and vomiting followed by\n unresponsiveness with possible seizure activity. Head CT revealed\n intraventricular hemorrhage and bilateral EVD's were placed. Cerebral\n angiogram notable for moyamoya pattern with intracranial stenosis of B\n ICA's with collaterals present. Small R caudate infarct present.\n Extubated . L EVD discharged .\n Past Medical / Surgical History: NIDDM\n Medications: metoprolol, hydralazine, tylenol\n Radiology: CXR - No pneumothorax has developed. No pulmonary\n vascular congestion exists and no evidence of acute infiltrates or\n pleural effusions\n Labs:\n 33.7\n 10.6\n 515\n 11.9\n [image002.jpg]\n Other labs:\n Activity Orders: ok for EOB activity as tolerated per icu team\n Social / Occupational History: lives with husband, not employed\n Living Environment: lives in apt with elevator to \n and flight of stairs to 5th.\n Prior Functional Status / Activity Level: I pta, no DME, does not drive\n Objective Test\n Arousal / Attention / Cognition / Communication: minimally responsive\n in supine, increased arousal for several minutes at edge of bed.\n Followed approx 25% of simple commands and answered simple yes/no\n questions intermittently while at edge of bed. Not oriented, minimally\n verbal, aphonic. Maintained eyes closed except for several minutes at\n edge of bed.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 100\n 118/82\n 24\n 98% on RA\n Activity\n 104\n 120/86\n 34\n 98% on RA\n Recovery\n 100\n 116/80\n 99% on RA\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lungs cta, non-labored breathing, no cough noted\n Integumentary / Vascular: R EVD clamped temporarily, R brachial PICC, L\n PIV, foley, tele\n Sensory Integrity: unable to assess\n Pain / Limiting Symptoms: denies pain\n Posture: WNL\n Range of Motion\n Muscle Performance\n B LE's WNL, L ankle to neutral\n Moves RLE against gravity\n Motor Function: No active movement noted LUE/LE, volitional movement\n noted RUE/LE. Mildly increased tone L ankle, hyporeflexive LLE.\n Grimaces to pain on R side only. L-sided neglect.\n Sustained R-beating nystagmus. Unable to track, scans to R and to\n midline only.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total assist for rolling and to get to edge of bed.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Max A static sitting at edge of bed, R UE extension reactions\n with LOB. Standing balance not assessed.\n Education / Communication: Reviewed PT with patient and husband.\n Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired balance\n 4.\n Impaired cognition\n 5.\n L-sided neglect\n Clinical impression / Prognosis: 37 yo F with IVH a/w moyamoya disease\n p/w above impairments a/w non-progressive CNS disorder. She is limited\n by dense L hemiplegia and impaired cognition, significantly below her\n baseline level of function. Prognosis remains guarded given the nature\n of her underlying disease. Given her age and her prior level of\n function, she has fair rehab potential when she is medically stable.\n Long-term functional outcome remains unclear given her prognosis, PT\n will continue to follow to progress as able at acute level.\n Goals\n Time frame: 1 week\n 1.\n Max A rolling and supine-to-sit, assess transfers\n 2.\n Tolerate OOB >/= 2 hours/day\n 3.\n Min A static/dynamic sitting balance\n 4.\n Follows 75% simple commands\n 5.\n Attends to L side 25% of the time\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, balance, endurance, education, strengthening,\n d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518476,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 2. 500 mL NS Bolus 250 ml Over 20 mins Order date: @ 0232\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0526\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 13. Metoprolol Tartrate 37.5 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ \n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 14. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 8. Famotidine 20 mg PO/NG Order date: @ 0807\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 19. Senna 1 TAB PO/NG Order date: @ 0737\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 24 Hour Events:\n ULTRASOUND - At 09:15 AM\n BLE ultrasound to rule out dvt\n FEVER - 103.2\nF - 03:00 PM\n - febrile 103.2. Pancultured. Lethargic.\n - minimal UOP (15-20cc/hr). LR 250cc bolus with good response.\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 01:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.6\nC (103.2\n T current: 37.4\nC (99.3\n HR: 89 (89 - 124) bpm\n BP: 96/66(73) {96/66(73) - 147/104(112)} mmHg\n RR: 24 (20 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 11 (3 - 22) mmHg\n Total In:\n 2,028 mL\n 634 mL\n PO:\n Tube feeding:\n 1,205 mL\n 254 mL\n IV Fluid:\n 442 mL\n 300 mL\n Blood products:\n Total out:\n 1,478 mL\n 152 mL\n Urine:\n 1,350 mL\n 125 mL\n NG:\n Stool:\n Drains:\n 128 mL\n 27 mL\n Balance:\n 550 mL\n 482 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 515 K/uL\n 10.6 g/dL\n 199 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 112 mEq/L\n 146 mEq/L\n 33.7 %\n 11.9 K/uL\n [image002.jpg]\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n TCO2\n 22\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.1 mg/dL, Mg:2.5 mg/dL, PO4:2.6 mg/dL\n Imaging: LENIs - negative for DVT\n CT Head - Unchanged IVH with bilateral frontal drains. Persistent\n symmetric drainage of lateral ventricles, recommend close followup.\n Evolving subacute infarcts in the right basal ganglia and superior\n parietal lobe.\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, b/l EVD in place (right open, left clamped),\n -- no longer following simple commands, rare eye opening to voice,\n mental status declined , not eating.\n -- Dilantin 100mg q8h. Dilatin level 12. ? start keppra today per\n neurosurg\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn fever\n -- repeat head CT stable\n Cardiovascular:\n -- Nimodipine 60mg po q4\n -- Lopressor to 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- extubated , on room air now\n -- cxr neg for infiltrates/effusions\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal ATC\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative; : pending\n Hematology:\n -- hct 33.7\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- temp spike to 102 () and 103.2 (). F/u cultures (bld, urine,\n CSF neg, UA neg, cxr neg) (likely neurogenic fever)\n -- WBC 11.9 <- 12.9 <- 13.9\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519204,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt received this am with\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518263,
"text": "Pt is a 37 yo women with DM@ found to IVH after suffering altered MS &\n SZ. Pt found to have moyamoya disease.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Bilateral EVDs in place. Left clamped and transduced. Right open at\n 20cm H20 above the tragus. Pt is not following commands. Moves all\n extremities to painful stimuli and right side spontaneously but not\n purposefully. Q 2 hour neuro checks. Goal sbp <140 and pt has been\n running 120-140. HR sr to st up to 130s at times with fevers and\n stimulation. UO adequate via foley cath. Blood glucose elevated to 270\n at 1000. Pts husband at bedside and very supportive. Not getting any\n rest himself however and very anxious of her status. Fever spikes to\n 102 continue.\n Action:\n ICPs transduced, right drain open and icps checked q 1 hour. Drainage\n documented. Neuro checks q 2 hours. Nimodipine and lopressor as\n ordered. Famotidine changed to po (via ngt). Insulin 8 units given and\n MD notified of elevated sugars. Pt to ultrasound to rule out dvts\n causing fevers. Pt to head CT immediately after ultrasound. Tylenol\n given via ngt.\n Response:\n Preliminary results per ultrasound tech no signs of dvt. Improvements\n in temps to 99-100 with Tylenol. HR improved following Tylenol as well.\n No changes in neuro exam. Pt opened eyes x 2 however still no commands.\n Blood glucose to be rechecked at 1600.\n Plan:\n Cont neuro checks. ? call out to step down. Ct results pending.\n Ultrasound final results pending. Emotional support for pt\ns husband.\n Cont to monitor temps and medicate with Tylenol as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519311,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt\ns neurological wax and wanes throughout shift.\n Moves R side spontaneously and purposefully. L side sm. intermittent\n mvts. spontaneously.\n Delayed withdrawal to x4 extremities with nail bed pressure.\n Opening eyes occasionally and for sm periods of time to stimulation.\n PERRLA 4-5 mm, non-tracking.\n ICP 16-19. CSF blood-tinged <10/hr. EVD 25 above the tragus.\n SBP 110\ns-120\n Tmax 100.4.\n Labs WNL.\n Action:\n EVD remains at 25 above tragus.\n Tylenol 650mg x1 overnight.\n Response:\n Remains tachycardiac 90-110\n Currently afebrile.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Follow plan of care per Neurosurgery and SICU team.\n Continue to encourage husband to take breaks from hospital and continue\n to involve SW for additional support.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518673,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518679,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 16-20.\n Action:\n MD\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518681,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 16-20. CSF blood-tinged <10/hr. EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic.\n Action:\n MD , resident on-call for Neurosurgery aware of ICP 20 at short\n intervals throughout the shift.\n EVD remains at 25 above tragus. Continued at that height MD .\n MD s ICP 20 without self resolving.\n Response:\n Pt within desired parameters thru out shift.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n ? Advance drain accordingly.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518757,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n Acetaminophen\n Bisacodyl.\n CefazoLIN\n Docusate Sodium\n Famotidine\n Heparin\n HydrALAzine\n Insulin\n Metoprolol Tartrate\n Nimodipine\n Phenytoin (Suspension)\n Senna\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ICP CATHETER - STOP 12:03 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 106 (93 - 120) bpm\n BP: 104/68(76) {97/68(75) - 133/93(101)} mmHg\n RR: 23 (20 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 12 (4 - 21) mmHg\n Total In:\n 1,924 mL\n 490 mL\n PO:\n Tube feeding:\n 1,204 mL\n 280 mL\n IV Fluid:\n 400 mL\n 50 mL\n Blood products:\n Total out:\n 1,213 mL\n 351 mL\n Urine:\n 1,110 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 103 mL\n 31 mL\n Balance:\n 711 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), EVD secured in place/clean\n sites\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n intermittently following commands, moves right side spontaneously, left\n side withdraws to pain\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands, eye opening to voice/spontaneous\n -- Dilantin 100mg q8h, levels therapeutic\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular:\n -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology:\n -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n T/L/D: PIV, EVD Right, foley, needs PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 12:57 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n"
},
{
"category": "Rehab Services",
"chartdate": "2132-12-31 00:00:00.000",
"description": "Swallowing Follow Up",
"row_id": 517987,
"text": "TITLE:\nSWALLOWING FOLLOW UP\nI returned to f/u on this 37 y/o female with NIDDM\nadmitted on after developing sudden onset pain and\nvomiting and becoming unresponsive, found to have extensive IVH\non head CT s/p emergent bilateral EVDs were placed upon arrival.\nPt was seen by our service and was advanced to thin\nliquids and purred solids with recommendations to hold off on\nplacing a Dobbhoff to see if she could meet her nutritional needs\nvia POs alone.\nI returned to f/u, but RN reporting pt was less verbal with\nsignificant changes in MS, prompting a CT scan scheduled for this\nafternoon. Pt was not appropriate for POs at this time. We will\nf/u with CT results tomorrow and repeat evaluation as\nappropriate. Pt has been made NPO MS and has tube feeds\nrunning for nutrition.\nRECOMMENDATIONS:\n1. Agree with NPO status given change in MS.\n2. Continue tube feeds as you are doing.\n3. We will f/u Thurs/Fri to repeat the evaluation as appropriate\nbased on her MS.\n_____________________________\n , MS, CCC-SLP\nPager#\nTotal Time: 15 minutes\n 14:10\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519381,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n unresponsive\n PMHx:\n Dm2\n Current medications:\n Acetaminophen, Bisacodyl, CefazoLIN, Docusate Sodium, Famotidine,\n Heparin, HydrALAzine, Insulin, Metoprolol Tartrate, Nimodipine,\n Phenytoin Sodium, Potassium Phosphate, Potassium Chloride, Sarna\n Lotion, Senna\n 24 Hour Events:\n EEG - At 02:30 PM\n FEVER - 101.1\nF - 12:00 PM\n CT head - no significant change from previous\n Dilantin level low, rebolus 500 IV x 1\n Drain remains open\n EEG performed\n Post operative day:\n POD 9 s/p EVD placement\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.1\nC (98.8\n HR: 99 (91 - 126) bpm\n BP: 109/83(89) {90/63(69) - 118/88(94)} mmHg\n RR: 28 (21 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 13 (9 - 18) mmHg\n Total In:\n 1,876 mL\n 416 mL\n PO:\n Tube feeding:\n 1,221 mL\n 276 mL\n IV Fluid:\n 300 mL\n 50 mL\n Blood products:\n Total out:\n 1,337 mL\n 217 mL\n Urine:\n 1,210 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 127 mL\n 17 mL\n Balance:\n 539 mL\n 199 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness), inconsistent neuro exam, inconsistently\n follows commands\n Labs / Radiology\n 573 K/uL\n 9.5 g/dL\n 137 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 21 mg/dL\n 103 mEq/L\n 139 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n 09:31 AM\n 02:25 AM\n WBC\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n 13.0\n 11.7\n Hct\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n 30.8\n 29.8\n Plt\n 71\n 73\n Creatinine\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 23\n 24\n Glucose\n 146\n 142\n 153\n 199\n 215\n 168\n 137\n Other labs: PT / PTT / INR:12.5/22.6/1.1, ALT / AST:61/58, Alk-Phos / T\n bili:70/0.1, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca:9.2 mg/dL,\n Mg:2.6 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, dilantin level 9.3, Bolus heparin and\n increase dose. L drain removed, R drain open, f/u EEG\n Cardiovascular: Beta-blocker, -- Nimodipine 60mg po q4\n -- incr Lopressor to 100mg po tid\n Pulmonary: -- sats 90's on room air\n Gastrointestinal / Abdomen: -- dobhoff in place, TF @ goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct 29.8 stable\n Endocrine: RISS\n Infectious Disease: Check cultures, cont Ancef\n Lines / Tubes / Drains: PIV, EVD Right, foley, PICC\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 01:35 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518723,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n Acetaminophen\n Bisacodyl.\n CefazoLIN\n Docusate Sodium\n Famotidine\n Heparin\n HydrALAzine\n Insulin\n Metoprolol Tartrate\n Nimodipine\n Phenytoin (Suspension)\n Senna\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ICP CATHETER - STOP 12:03 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 106 (93 - 120) bpm\n BP: 104/68(76) {97/68(75) - 133/93(101)} mmHg\n RR: 23 (20 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 12 (4 - 21) mmHg\n Total In:\n 1,924 mL\n 490 mL\n PO:\n Tube feeding:\n 1,204 mL\n 280 mL\n IV Fluid:\n 400 mL\n 50 mL\n Blood products:\n Total out:\n 1,213 mL\n 351 mL\n Urine:\n 1,110 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 103 mL\n 31 mL\n Balance:\n 711 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), EVD secured in place/clean\n sites\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n intermittently following commands, moves right side spontaneously, left\n side withdraws to pain\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands, eye opening to voice/spontaneous\n -- Dilantin 100mg q8h, levels therapeutic\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Cardiovascular:\n -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology:\n -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n T/L/D: PIV, EVD Right, foley, needs PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 12:57 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518915,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n Acetaminophen\n Bisacodyl.\n CefazoLIN\n Docusate Sodium\n Famotidine\n Heparin\n HydrALAzine\n Insulin\n Metoprolol Tartrate\n Nimodipine\n Phenytoin (Suspension)\n Senna\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ICP CATHETER - STOP 12:03 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 106 (93 - 120) bpm\n BP: 104/68(76) {97/68(75) - 133/93(101)} mmHg\n RR: 23 (20 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 12 (4 - 21) mmHg\n Total In:\n 1,924 mL\n 490 mL\n PO:\n Tube feeding:\n 1,204 mL\n 280 mL\n IV Fluid:\n 400 mL\n 50 mL\n Blood products:\n Total out:\n 1,213 mL\n 351 mL\n Urine:\n 1,110 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 103 mL\n 31 mL\n Balance:\n 711 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), EVD secured in place/clean\n sites\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness),\n intermittently following commands, moves right side spontaneously, left\n side withdraws to pain\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, R EVD; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands, eye opening to voice/spontaneous\n -- Dilantin 100mg q8h, levels therapeutic\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular:\n -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- sats 90's on room\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology:\n -- hct 29.8\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n T/L/D: PIV, EVD Right, foley, needs PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 12:57 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518647,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115 10. HydrALAzine\n 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 2. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0641\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737 12. Metoprolol Tartrate 37.5 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ \n 4. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721 13. Nimodipine\n 60 mg PO Q4H Order date: @ 0119\n 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641 14. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @\n 1608\n 6. Docusate Sodium 100 mg PO BID Order date: @ 0737 15.\n Potassium Chloride IV Sliding Scale Order date: @ 0352\n 7. Famotidine 20 mg IV Q12H Order date: @ 2049 16. Sarna Lotion\n 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641 17. Senna 1 TAB PO/NG Order date: @ 0737\n 9. Heparin 5000 UNIT SC TID Order date: @ 0920 18. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:16 PM\n FEVER - 102.0\nF - 04:00 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:58 AM\n Famotidine (Pepcid) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 36.7\nC (98\n HR: 87 (78 - 120) bpm\n BP: 121/78(88) {111/69(78) - 152/95(109)} mmHg\n RR: 19 (13 - 24) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 10 (4 - 23) mmHg\n Total In:\n 2,076 mL\n 341 mL\n PO:\n Tube feeding:\n 1,202 mL\n 231 mL\n IV Fluid:\n 424 mL\n 50 mL\n Blood products:\n Total out:\n 1,159 mL\n 292 mL\n Urine:\n 1,050 mL\n 275 mL\n NG:\n Stool:\n Drains:\n 109 mL\n 17 mL\n Balance:\n 917 mL\n 49 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 471 K/uL\n 10.7 g/dL\n 199 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 112 mEq/L\n 146 mEq/L\n 33.1 %\n 12.9 K/uL\n [image002.jpg]\n 02:36 AM\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n Plt\n 266\n 321\n 395\n 461\n 471\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n TCO2\n 25\n 22\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.1 mg/dL, Mg:2.5 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, questionably related to MoyaMoya\n Neurologic: Neuro checks Q: hr, -- Large IVH, b/l EVD in place (L\n re-clamped but icps increasing 18-20 overnight), no longer\n following simple commands, rare eye opening to voice, mental status\n declined , following less commands. no eating.\n -- Dilantin 100mg q8h. Dilantin level = pending\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n -- repeat head CT stable\n -- Dilantin 100mg q8h. Dilantin level =\n -- start ASA 81mg qd once EVD drains are out\n -- fentanyl prn pain\n -- repeat head CT stable\n Cardiovascular: --stable.\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid for occ tachy\n -- Hydralazine prn SBP > 180\n Pulmonary: -- extubated , on room air now\n --apneic episodes am. none since\n --cxr neg\n Gastrointestinal / Abdomen: -- Passed speech/swallow, however\n inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n Nutrition: Tube feeding, -- tube feeds replete with fiber (goal\n 60cc/hr)\n Renal: Foley, Adequate UO, foley, good uop. Cr 0.6\n Hematology: hct stable coags WNL. recheck in am.\n Endocrine: RISS\n Infectious Disease: Ancef 1g q8h while drains in place\n - temp spike to 102 , f/u cultures (bld, urine, csf, UA neg, cxr\n neg) (likely neurogenic fever)\n -csf w/ 1+pmn\n -still intermittent temps Tm 102 (MN)\n -wbc 12.9<-13.9<-11.4\n Lines / Tubes / Drains: Foley, Dobhoff, EVDx2, piv\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), CVA, Seizure\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 11:18 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n 18 Gauge - 01:04 AM\n 20 Gauge - 07:55 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes. Patient seen on rounds .\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518648,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 2. 500 mL NS Bolus 250 ml Over 20 mins Order date: @ 0232\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0526\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 13. Metoprolol Tartrate 37.5 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ \n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 14. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 8. Famotidine 20 mg PO/NG Order date: @ 0807\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 19. Senna 1 TAB PO/NG Order date: @ 0737\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 24 Hour Events:\n ULTRASOUND - At 09:15 AM\n BLE ultrasound to rule out dvt\n FEVER - 103.2\nF - 03:00 PM\n - febrile 103.2. Pancultured. Lethargic.\n - minimal UOP (15-20cc/hr). LR 250cc bolus with good response.\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 01:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.6\nC (103.2\n T current: 37.4\nC (99.3\n HR: 89 (89 - 124) bpm\n BP: 96/66(73) {96/66(73) - 147/104(112)} mmHg\n RR: 24 (20 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 11 (3 - 22) mmHg\n Total In:\n 2,028 mL\n 634 mL\n PO:\n Tube feeding:\n 1,205 mL\n 254 mL\n IV Fluid:\n 442 mL\n 300 mL\n Blood products:\n Total out:\n 1,478 mL\n 152 mL\n Urine:\n 1,350 mL\n 125 mL\n NG:\n Stool:\n Drains:\n 128 mL\n 27 mL\n Balance:\n 550 mL\n 482 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 515 K/uL\n 10.6 g/dL\n 199 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 112 mEq/L\n 146 mEq/L\n 33.7 %\n 11.9 K/uL\n [image002.jpg]\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n TCO2\n 22\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.1 mg/dL, Mg:2.5 mg/dL, PO4:2.6 mg/dL\n Imaging: LENIs - negative for DVT\n CT Head - Unchanged IVH with bilateral frontal drains. Persistent\n symmetric drainage of lateral ventricles, recommend close followup.\n Evolving subacute infarcts in the right basal ganglia and superior\n parietal lobe.\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, b/l EVD in place (right open, left clamped),\n -- no longer following simple commands, rare eye opening to voice,\n mental status declined , not eating.\n -- Dilantin 100mg q8h. Dilatin level 12. ? start keppra today per\n neurosurg\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn fever\n -- repeat head CT stable\n Cardiovascular:\n -- Nimodipine 60mg po q4\n -- Lopressor to 50mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- extubated , on room air now\n -- cxr neg for infiltrates/effusions\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal ATC\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative; : pending\n Hematology:\n -- hct 33.7\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- temp spike to 102 () and 103.2 (). F/u cultures (bld, urine,\n CSF neg, UA neg, cxr neg) (likely neurogenic fever)\n -- WBC 11.9 <- 12.9 <- 13.9\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 32 minutes.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518116,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli, does not open eyes, does not follow\n commands, pupils equal and recative, withdraws all extremities to\n nailbed pressure, localizes on the right\n Vent drain x2, L drain clamped with ICP 12-15, R vent drain\n open at 20cm H2O, ICP 9-15, 5-10cc/hr of blood tinged CSF\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519035,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt\ns neurological wax and wanes throughout shift.\n Moves R side spontaneously and purposefully. L side sm. intermittent\n mvts. spontaneously.\n Opening eyes occasionally and for brief moments to stimulation. PERRLA\n 4-5 mm, non-tracking.\n ICP 16-20. CSF blood-tinged <10/hr. EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic up to 130\n Tmax 101.4.\n Action:\n SICU MD made aware of tachycardia and temp spike.\n X1 5mg IVP Lopressor as ordered.\n No cultures ordered.\n EVD remains at 25 above tragus.\n Tylenol 650mg every four hours.\n Response:\n Remains tachycardiac 90-110\n Currently 99.8 PO.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Follow plan of care per Neurosurgery and SICU team.\n Continue to encourage husband to take breaks from hospital and continue\n to involve SW for additional support.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 519181,
"text": "SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM2\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115 13. IV access\n request: PICC Place Indication: Hydration Urgency: Urgent Order date:\n @ 0845\n 2. IV access: PICC, heparin dependent Location: Right Basilic, Date\n inserted: Order date: @ 1109 14. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 2207\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249 15. Metoprolol Tartrate 50 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ 0815\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737 16. Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order\n date: @ 0415\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721 17. Nimodipine\n 60 mg PO Q4H Order date: @ 0119\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641 18. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @\n 1608\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737 19.\n Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 8. Famotidine 20 mg PO/NG Order date: @ 0807 20. Potassium\n Chloride IV Sliding Scale Order date: @ 0352\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641 21. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @\n 2046\n 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1109 22.\n Senna 1 TAB PO/NG Order date: @ 0737\n 11. Heparin 5000 UNIT SC TID Order date: @ 0920 23. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 12. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 24 Hour Events:\n FEVER - 101.4\nF - 08:00 PM\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 01:12 AM\n Other medications:\n : Metformin\n Flowsheet Data as of 04:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.3\nC (100.9\n HR: 115 (86 - 131) bpm\n BP: 125/91(99) {96/61(21) - 142/92(99)} mmHg\n RR: 22 (20 - 31) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 61.1 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 6 (6 - 27) mmHg\n Total In:\n 1,755 mL\n 303 mL\n PO:\n Tube feeding:\n 1,235 mL\n 213 mL\n IV Fluid:\n 50 mL\n Blood products:\n Total out:\n 1,234 mL\n 216 mL\n Urine:\n 1,115 mL\n 190 mL\n NG:\n Stool:\n Drains:\n 119 mL\n 26 mL\n Balance:\n 521 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 215 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29.8 %\n 11.7 K/uL\n [image002.jpg]\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n 03:51 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n 11.7\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n 29.8\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n 535\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n 0.5\n TCO2\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n 215\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:8.9 mg/dL, Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 37F w/DM2 found to have IVH after suffering\n altered MS & SZ, ? MoyaMoya.\n Neurologic: -- Large IVH, R EVD open this AM due to elevated ICP O/N\n and worse exam will discuss with n- about plan to re-clamp drain\n and necessity to remain in ICU; L drain d/c'd \n -- mental status - waxes and wanes, occassionally following simple\n commands & occ answers questions appropriately, eye opening to\n voice/spontaneous\n --weekly dilantin levels\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain/fever\n Daily fever curve to 103. likely neurogenic. No infectious source\n Cardiovascular: -- tachy but stable BP\n -- Nimodipine 60mg po q4\n -- Lopressor 50mg po tid, 5mg IV prn breakthrough\n -- Hydralazine prn SBP > 180\n Pulmonary: -- sats 90's on room air\n -- sputum gram stain neg. micro\n Gastrointestinal / Abdomen: -- Passed speech/swallow, however\n inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition: -- tube feeds: replete with fiber (goal 60cc/hr\n Renal: -- foley, good uop. Cr 0.5\n -- UCX : negative\n Hematology: -- hct 29.8. lab holiday today\n n LENIs negative for DVT\n n Labs tomorrow AM\n Endocrine: tightened RISS once TF @ goal (required 10-14U each\n fingerstick)\n Infectious Disease: -- Ancef 1g q8h while drains in place\n -- F/u cultures (bld, urine, CSF neg, UA neg, cxr neg) (likely\n neurogenic fever). csf cx pending\n -- WBC 11.7\n Lines / Tubes / Drains: PIV, EVD Right, foley, PICC\n Wounds: EVD x 1\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), CVA, Seizure\n ICU Care\n Nutrition:\n Boost Glucose Control (Full) - 08:15 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 01:00 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518965,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 10-18 CSF blood-tinged EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic.\n Tmax 101.2\n Action:\n EVD remains at 25 above tragus. Clamped for 2hrs. ICP up to 30.\n Tylenol 650mg every four hours.\n Response:\n NP aware of ICP. Drain unclamped.\n No changes in Neuro.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Clamp trial in am.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519548,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt. with bilateral IVH and new evolving right basal ganglia stroke.\n Received with EVD open @ 25cm above tragus. Neuro exam waxing and\n . At best exam, pt. AFEBRILE, spontaneously opening eyes,\n conversing (in whisper) with husband appropriately, and following\n commands with right extremities; pt. moves left hand spontaneously but\n not to command. No movement of LLE noted, but sensation intact. At\n worst exam, pt. unresponsive with no eye opening, withdrawing right and\n left upper extremity slightly with intermittent delay. ICP stable this\n a.m. as documented. HR tachy at times up to 120\ns. Febrile as\n documented.\n Action:\n Neuro exams Q2-3hrs. Nimodipine Q4hrs. EVD clamped this a.m. at\n approximately 0930. CSF, blood, and urine cultured due to temp.\n Dilantin bolus given for subtherapeutic level.\n Response:\n ICP was stable throughout the day. On rare occasion (3-4 times this\n afternoon), transient spike noted up to 22-24. However, since pt.\n turned at 1800, after settling/re-leveling, ICP has been 22-30, with\n occasional dip under 20. Neurosurg. Team aware of all above findings.\n Present exam: pt. not opening eyes, but responding to pain with\n right/left upper extremities. Cough/gag remain intact.\nOuch\n noted\n when turned, but no further speech.\n Plan:\n At 1900, if ICP remains >20 will discuss with neurosurg, then likely\n open drain. Continue to monitor and treat as indicated. Follow\n culture data, monitor HR and effects of all meds.\n"
},
{
"category": "Physician ",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 518417,
"text": "TITLE:\n SICU\n HPI:\n 37F w/ DM2 found to have IVH after suffering altered MS & SZ.\n Chief complaint:\n ICH\n PMHx:\n DM\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0115\n 11. HydrALAzine 10 mg IV Q4H:PRN SBP > 180\n hold sbp < 100 Order date: @ \n 2. 500 mL NS Bolus 250 ml Over 20 mins Order date: @ 0232\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0526\n 3. Acetaminophen 325-650 mg PO/NG Q4H:PRN pain / fever Order date:\n @ 2249\n 13. Metoprolol Tartrate 37.5 mg PO/NG TID\n hold sbp<100, hr<60 Order date: @ \n 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 0737\n 14. Nimodipine 60 mg PO Q4H Order date: @ 0119\n 5. CefazoLIN 1 g IV Q8H\n keep while EVD's are in place Order date: @ 0721\n 15. Phenytoin (Suspension) 100 mg PO/NG Q8H Order date: @ 1608\n 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 0641\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0442\n 7. Docusate Sodium 100 mg PO BID Order date: @ 0737\n 17. Potassium Chloride IV Sliding Scale Order date: @ 0352\n 8. Famotidine 20 mg PO/NG Order date: @ 0807\n 18. Sarna Lotion 1 Appl TP QID:PRN pruritis Order date: @ 2046\n 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 0641\n 19. Senna 1 TAB PO/NG Order date: @ 0737\n 10. Heparin 5000 UNIT SC TID Order date: @ 0920\n 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0115\n 24 Hour Events:\n ULTRASOUND - At 09:15 AM\n BLE ultrasound to rule out dvt\n FEVER - 103.2\nF - 03:00 PM\n - febrile 103.2. Pancultured. Lethargic.\n - minimal UOP (15-20cc/hr). LR 250cc bolus with good response.\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 01:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.6\nC (103.2\n T current: 37.4\nC (99.3\n HR: 89 (89 - 124) bpm\n BP: 96/66(73) {96/66(73) - 147/104(112)} mmHg\n RR: 24 (20 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 64.3 kg (admission): 67.1 kg\n Height: 60 Inch\n ICP: 11 (3 - 22) mmHg\n Total In:\n 2,028 mL\n 634 mL\n PO:\n Tube feeding:\n 1,205 mL\n 254 mL\n IV Fluid:\n 442 mL\n 300 mL\n Blood products:\n Total out:\n 1,478 mL\n 152 mL\n Urine:\n 1,350 mL\n 125 mL\n NG:\n Stool:\n Drains:\n 128 mL\n 27 mL\n Balance:\n 550 mL\n 482 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, lethargic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 515 K/uL\n 10.6 g/dL\n 199 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 112 mEq/L\n 146 mEq/L\n 33.7 %\n 11.9 K/uL\n [image002.jpg]\n 07:30 AM\n 02:28 AM\n 02:39 AM\n 09:41 AM\n 12:22 PM\n 02:24 AM\n 04:08 AM\n 03:09 AM\n 03:04 AM\n 04:02 AM\n WBC\n 12.0\n 12.8\n 11.4\n 13.9\n 12.9\n 11.9\n Hct\n 27.5\n 29.7\n 31.3\n 32.2\n 33.1\n 33.7\n Plt\n 266\n 321\n 395\n 461\n 471\n 515\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.7\n 0.6\n TCO2\n 22\n 24\n 23\n 24\n Glucose\n 171\n 146\n 142\n 153\n 199\n Other labs: PT / PTT / INR:12.6/23.9/1.1, Lactic Acid:0.9 mmol/L,\n Albumin:4.1 g/dL, Ca:9.1 mg/dL, Mg:2.5 mg/dL, PO4:2.6 mg/dL\n Imaging: LENIs - negative for DVT\n CT Head - Unchanged IVH with bilateral frontal drains. Persistent\n symmetric drainage of lateral ventricles, recommend close followup.\n Evolving subacute infarcts in the right basal ganglia and superior\n parietal lobe.\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, INTRACEREBRAL HEMORRHAGE (ICH)\n ASSESSMENT: 37F w/DM2 found to have IVH after suffering altered MS &\n SZ, ? MoyaMoya.\n Neurologic:\n -- Large IVH, b/l EVD in place (right open, left clamped),\n -- no longer following simple commands, rare eye opening to voice,\n mental status declined , not eating.\n -- Dilantin 100mg q8h. Dilatin level pending\n -- start ASA 81mg qd once EVD drains are out\n -- tylenol prn pain\n -- repeat head CT stable\n Cardiovascular:\n -- Nimodipine 60mg po q4\n -- Lopressor 37.5mg po tid\n -- Hydralazine prn SBP > 180\n Pulmonary:\n -- extubated , on room air now\n -- cxr neg for infiltrates/effusions\n Gastrointestinal / Abdomen:\n -- Passed speech/swallow, however inadequate po intake\n -- dobhoff in place, TF @ goal\n -- GI prophy famotidine\n -- bowel regimen: senna, colace, bisacodyl\n Nutrition:\n -- tube feeds: replete with fiber (goal 60cc/hr)\n Renal:\n -- foley, good uop. Cr 0.5\n -- UCX : negative; : pending\n Hematology:\n -- hct 33.7\n -- LENIs negative for DVT\n Endocrine: RISS\n ID:\n -- Ancef 1g q8h while drains in place\n -- temp spike to 102 () and 103.2 (). F/u cultures (bld, urine,\n CSF neg, UA neg, cxr neg) (likely neurogenic fever)\n -- WBC 11.9 <- 12.9 <- 13.9\n T/L/D: PIV, EVDx2, foley\n Wounds: EVD x 2\n Imaging:\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: intraventricular hemorrhage\n Prophylaxis:\n DVT: boots, SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: step down vs. SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518418,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli, does not open eyes, does not follow\n commands, pupils equal and reactive, withdraws all extremities to\n nailbed pressure, localizes on the right, moves R extremities\n spontaneously, no apnic periods\n Vent drain x2, L drain clamped with ICP 12-15, R vent drain\n open at 20cm H2O, ICP 11-19, 5-10cc/hr of blood tinged CSF\n SBP 110-150, NSR-NST 80-120\ns, tmax 101\n U/O dipped to 20\ns x 2 hrs, clear yellow urine\n Tol TF at goal\n Husband spent the night in family waiting area again, able\n sleep well, emotional support provided, updated by RN\n Action:\n Neuro checks Q3hrs\n Monitor ICP\ns, keep L drain clamped, R drain open\n Lyte repletions prn\n Keep SBP <140\n Nimodipine as ordered\n Dilantin as ordered\n Cefazolin as ordered\n 250cc fluid bolus x1 for low u/o\n Tylenol given\n Emotional support provided to husband and pt\n Response:\n No change in neuro exams\n Current temp 99.2\n VSS\n U/O approx 40cc/hr\n Plan:\n Neuro exams Q3hrs\n Monitor drain outputs\n Monitor ICP\n Provide pt and family with emotional support\n"
},
{
"category": "Rehab Services",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Deferred Swallow Follow Up",
"row_id": 518561,
"text": "TITLE:\nSWALLOW FOLLOW UP:\nHISTORY:\nThank you for consulting on this 37 y/o female with NIDDM\nadmitted on after developing sudden onset pain and\nvomiting and becoming unresponsive. Pt with GCS of 5 on arrival\nto ED, found to have extensive IVH on head CT. Emergent bilateral\nEVDs were placed upon arrival . A cerebral angiogram\nperformed on was notable for a Moyamoya pattern with\nintracranial stenosis of bilateral ICAs, more significant on the\nleft, with collaterals present. No evidence of AVM or aneurysm.\nPt was extubated . MD note on , pt then noted with\nsignificant decline in MS, and no longer following simple\ncommands. Head CT on revealed unchanged IVH with bilateral\nfrontal drains and evolving subacute infarcts in the R BG and\nsuperior parietal lobe. CXR on was without evidence of PNA.\nPt has been followed by our department during this admission and\nwas initially evaluated at bedside on and was noted to be\nlethargic, but recommended for a diet of pureed solids and thin\nliquids. Attempted swallow f/u on , but deferred \nsignificant decline in MS. Pt was then made NPO and placed on\ntube feeds. We return today to re-assess swallow function and\ndetermine if pt's MS has improved enough to re-trial PO.\nREASON FOR DEFERRAL:\n RN, pt still with poor MS to feed. Please keep pt\nNPO over the weekend with alternative means of nutrition. We\nwill f/u next week.\nRECOMMENDATIONS:\n1.) NPO including no oral meds or ice chips\n2.) Alternative means for all nutrition/medication\n3.) Please continue to consult with Nutrition to assist with tube\nfeeding management\n4.) We will f/u early next week\nThese recommendations were shared with the patient, nurse and\nmedical team.\n______________________________________\n , B.A., SLP/s\nPager #\n____________________________________\n , M.S., CCC-SLP\nPager #\nTotal time: 30 minutes\n"
},
{
"category": "Rehab Services",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Deferred Swallow Follow Up",
"row_id": 518562,
"text": "TITLE:\nSWALLOW FOLLOW UP:\nHISTORY:\nThank you for consulting on this 37 y/o female with NIDDM\nadmitted on after developing sudden onset pain and\nvomiting and becoming unresponsive. Pt with GCS of 5 on arrival\nto ED, found to have extensive IVH on head CT. Emergent bilateral\nEVDs were placed upon arrival . A cerebral angiogram\nperformed on was notable for a Moyamoya pattern with\nintracranial stenosis of bilateral ICAs, more significant on the\nleft, with collaterals present. No evidence of AVM or aneurysm.\nPt was extubated . MD note on , pt then noted with\nsignificant decline in MS, and no longer following simple\ncommands. Head CT on revealed unchanged IVH with bilateral\nfrontal drains and evolving subacute infarcts in the R BG and\nsuperior parietal lobe. CXR on was without evidence of PNA.\nPt has been followed by our department during this admission and\nwas initially evaluated at bedside on and was noted to be\nlethargic, but recommended for a diet of pureed solids and thin\nliquids. Attempted swallow f/u on , but deferred \nsignificant decline in MS. Pt was then made NPO and placed on\ntube feeds. We return today to re-assess swallow function and\ndetermine if pt's MS has improved enough to re-trial PO.\nREASON FOR DEFERRAL:\n RN, pt still with poor MS to feed. Please keep pt\nNPO over the weekend with alternative means of nutrition. We\nwill f/u next week.\nRECOMMENDATIONS:\n1.) NPO including no oral meds or ice chips\n2.) Alternative means for all nutrition/medication\n3.) Please continue to consult with Nutrition to assist with tube\nfeeding management\n4.) We will f/u early next week\nThese recommendations were shared with the patient, nurse and\nmedical team.\n______________________________________\n , B.A., SLP/s\nPager #\n____________________________________\n , M.S., CCC-SLP\nPager #\nTotal time: 30 minutes\n ------ Protected Section ------\n The above note was reviewed and I agree with the deferral and treatment\n plan based on the pt\ns MS at the time if the attempted evaluation.\n , MS, CCC-SLP\n ------ Protected Section Addendum Entered By: , M.S.,\n CCC-SLP on: 15:29 ------\n 15:29\n"
},
{
"category": "Social Work",
"chartdate": "2133-01-02 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 518568,
"text": "Met with pt's husband today to assess coping and offer support. Husband\n is able to focus on the positive things that are happening for the pt.\n ie: PT is working with the pt today, pt's is now afebrile and abit more\n alert. Husband states that he has been able to leave the hospital for\n short periods of time to go home to shower and to eat. Feels that he is\n coping better and understands that healing and progress will require\n time. Husband reports feeling good about the repore he has with the\n Attending and the RN's , states communication has been very good. Will\n continue to follow pt's progress and provide support and counseling to\n husband.\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 519238,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt received this am with Ventricular drain open 25 @ tragus\n Neuro exam Q3 hrs Waxes and Wanes\n Pt unresponsive and occasionally opens eyes to deep stimuli\n not following commands\n From previous reports pt very mobile on Right side but less\n mobile this am\n During rounds with Neuro team ? possible SZ activity MD\n because he feels that she should be more alert\n Dilantin level 6.2 this am\n HR Tachy this am to as high as 130\n T-max 101.4\n Action:\n CT Scan done\n EEG\n Dilantin load given\n Lopressor increased\n Tylenol 1GM for temp\n Response:\n + response in HR from Lopressor and Tylenol\n PT moving right side more and spontaneously opening eyes\n with decreased temp and HR\n + occasionally sounds when repositioned\n Plan:\n Cont with Q3 neuro checks\n F/U EEG\n Monitor for s/s of infection\n ? possible stepdown\n Supportive care to husband\n"
},
{
"category": "Nursing",
"chartdate": "2133-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518707,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No changes in neurological assessment.\n Moves R side spontaneously. L side to painful stimuli.\n Not opening eyes. PERRLA 4mm, non-tracking.\n Moaning at times with turning and repositioning.\n ICP 16-20. CSF blood-tinged <10/hr. EVD 25 above the tragus.\n SBP 110\ns-120\n Tachycardic.\n Tmax 100.5. WBC 11.7\n Action:\n MD , resident on-call for Neurosurgery aware of ICP 20 at short\n intervals throughout the shift.\n EVD remains at 25 above tragus. Continued at that height MD .\n MD ICP 20 without self resolving.\n Tylenol 650mg every four hours.\n Response:\n Pt within desired parameters thru out shift.\n Plan:\n Continue to monitor ICP and CSF output.\n Q3 neuro checks as ordered.\n Follow plan of care per Neurosurgery and SICU team.\n"
},
{
"category": "ECG",
"chartdate": "2132-12-30 00:00:00.000",
"description": "Report",
"row_id": 229137,
"text": "Sinus tachycardia. Delayed R wave progression. Diffuse ST-T wave abnormalities.\nFindings are non-specific. Clinical correlation is suggested. Since the\nprevious tracing of sinus tachycardia and diffuse ST-T wave changes are\nnow present.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-12-26 00:00:00.000",
"description": "Report",
"row_id": 229138,
"text": "Baseline artifact. Sinus rhythm. RSR' pattern, normal variant. No previous\ntracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122115,
"text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with fever after recent PEG. Also history of intracranial\n hemorrhage. Please do as portable.\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old woman with fever after recent PICC placement. Rule\n out pneumonia.\n\n COMPARISON: Portable chest radiograph .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: The right PICC line tip is not clearly visualized. PEG tube is\n noted in the left upper quadrant. There is free air under the right\n hemidiaphragm likely secondary to PEG placement. Cardiac, mediastinal and\n hilar contours are normal. Both lungs volumes are low with no focal\n consolidation, pleural effusion or pneumothorax.\n\n IMPRESSION:\n 1. Right PICC line tip is not clearly visualized. Recommend lateral films or\n oblique views for better evaluation of PICC tip placement.\n 2. Free air under right hemidiaphragm likely secondary to PEG placement.\n\n Dr. was notified of the results at 13:48 on . IV\n nurse was also notified of the results at 13:50 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-14 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1122915,
"text": " 3:41 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PROLONGED BEST REST. PLEASE ASSESS FOR DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman s/p stroke with resultant immobility. Now with leg pain, R>L\n REASON FOR THIS EXAMINATION:\n Please assess for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old woman post stroke. Now with leg pain. Assess for\n DVT.\n\n FINDINGS: Normal flow, compressibility and augmentation are seen on\n -scale and Doppler imaging of the left common femoral vein, left\n superficial femoral vein and left popliteal vein. Patent flow is seen in the\n deep calf veins of the left lower limb on color imaging.\n\n There is normal flow, compressibility and augmentation on -scale and\n Doppler imaging of the right common femoral vein, right superficial femoral\n vein, right popliteal vein. There is patent flow in the deep calf veins of\n the right lower limb on color imaging.\n\n IMPRESSION:\n 1. No evidence of deep venous thrombosis in the right lower limb or left\n lower limb.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1122281,
"text": " 8:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with \n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SAT 10:15 AM\n No change since prior exam in left frontal and right basal ganglia hemorrhage,\n with blood layering in the occipital of the right lateral ventricle. No\n new areas of bleeding, or new ventriculomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old woman with moyamoya. Evaluate interval change.\n\n COMPARISON: Multiple prior exams, most recently .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There has been no interval change in high-density material within\n the right basal ganglia, with hemorrhagic products layering dependently in the\n occipital of right lateral ventricle. There has been no interval\n ventriculomegaly.\n\n Adjacent to bilateral frontal bone burr holes, ventriculostomy catheter tracts\n extend towards the frontal horns of both lateral ventricles, with a small\n amount of high-density material within the tracts. This is also unchanged.\n Overall, there is no new intracranial hemorrhage, edema, shift of normally\n midline structures, or major vascular territorial infarct. The -white\n matter differentiation is preserved. The basilar cisterns are symmetric. The\n mastoid air cells and paranasal sinuses are well aerated.\n\n IMPRESSION:\n 1. Stable appearance of right ventricular hemorrhage, with blood products\n layering dependently in the occipital of the right lateral ventricle. No\n new hemorrhage.\n 2. Stable ventricular size.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1122282,
"text": ", J. NSURG FA11 8:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with \n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No change since prior exam in left frontal and right basal ganglia hemorrhage,\n with blood layering in the occipital of the right lateral ventricle. No\n new areas of bleeding, or new ventriculomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1121382,
"text": " 9:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with mental status change with EVD\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 10:38 AM\n Ventricules stable. Interval removal of left frontal drain. Evolving\n hemmorhage at right BG, and intraventricular hemmorhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 37-year-old woman with mental status change with EVD. Question of\n interval change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: CT head.\n\n FINDINGS: There is evolution of the intraventricular hemorrhage layering in\n the lateral ventricles, more on the right, with slight interval decrease in\n size compared to recent CT. There is a hypodense area in the corona radiata\n on the right, in similar pattern compared to prior CT scan, 2:18, likely\n encephalomalacia in this area, or edema. Interval removal of left drain, with\n right drain remaining in place. There is a hemorrhagic track seen at the site\n of the prior left drain, unchanged compared to before. There is no evidence\n of new hemorrhage.\n\n The ventricles have similar appearance in size and shape compared to recent CT\n with right lateral ventricle persistently larger containing more residual\n hemorrhage compared to the left.\n\n There are multiple periventricular supratentorial white matter hypodensities\n reflecting sequela of chronic microvascular ischemic changes. There is\n evolution in the hyperdense infarct in the right basal ganglia. Visualized\n portion of paranasal sinuses and mastoid air cells is clear.\n\n IMPRESSION:\n 1. Evolution of intraventricular hemorrhage, with interval removal of left\n frontal drain, and right frontal drain remains in place, with stable\n appearance of the ventricles.\n 2. Evolving infarct at the right basilar ganglia. Hypodensity in right\n periventricular region is unchanged.\n\n\n (Over)\n\n 9:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-11 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1122381,
"text": " 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Gallstones or inflammation?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with stroke, fevers of unknown origin, concern for biliary\n tract disease\n REASON FOR THIS EXAMINATION:\n Gallstones or inflammation?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 9:38 AM\n Normal right upper quadrant ultrasound without evidence of gallstones or\n intra- or extra-hepatic biliary ductal dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old female with stroke and fevers of unknown origin.\n Concern for biliary tract disease. Evaluate for gallstones or inflammation.\n\n COMPARISON: Abdominal radiograph of .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates normal echotexture\n without focal mass lesion. There is no intra- or extra-hepatic biliary ductal\n dilatation and the common bile duct measures 1.2 mm. The main portal vein is\n patent with hepatopetal flow. The gallbladder is unremarkable without stones,\n pericholecystic fluid, distention, or wall thickening. Visualized portion of\n the pancreas is unremarkable. The aorta is normal caliber throughout. The\n right kidney is unremarkable.\n\n IMPRESSION: Normal right upper quadrant ultrasound without evidence of\n cholecystitis or intra- or extra-hepatic biliary ductal dilatation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-11 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1122382,
"text": ", NMED FA11 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Gallstones or inflammation?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with stroke, fevers of unknown origin, concern for biliary\n tract disease\n REASON FOR THIS EXAMINATION:\n Gallstones or inflammation?\n ______________________________________________________________________________\n PFI REPORT\n Normal right upper quadrant ultrasound without evidence of gallstones or\n intra- or extra-hepatic biliary ductal dilatation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1122139,
"text": " 10:13 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for dvt / prolonged bedrest\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with prolonged bedrest - low grade temps\n REASON FOR THIS EXAMINATION:\n eval for dvt / prolonged bedrest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 37-year-old female with prolonged bed rest. Evaluate for deep\n vein thrombosis.\n\n COMPARISON: Bilateral leg ultrasound .\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, superficial femoral, popliteal and tibial veins. There is\n normal flow, compression and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120774,
"text": " 11:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with apnea\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:32 P.M., .\n\n HISTORY: Apnea.\n\n IMPRESSION: AP chest compared to :\n\n Feeding tube ends in the region of the pylorus. Lungs are low in volume but\n clear. Heart size normal. No pleural abnormality or evidence of central\n adenopathy. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1121114,
"text": " 11:14 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check PICC tip right basilic 46cm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with new line placement\n REASON FOR THIS EXAMINATION:\n please check PICC tip right basilic 46cm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a new PICC line has been\n inserted over the right upper extremity. The tip of the line projects over\n the right atrium, the line should be pulled back by approximately 4-5 cm. No\n evidence of complications. Unchanged course and position of the Dobbhoff\n catheter. Unchanged normal appearance of the lung parenchyma and the cardiac\n silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-26 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1120076,
"text": " 10:29 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with sudden vom and unresponsive\n REASON FOR THIS EXAMINATION:\n r/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n I-\n ______________________________________________________________________________\n WET READ: DLrc FRI 11:55 PM\n AVM is not excluded as cause. No evidence of aneursym. Marked narrowing of\n the right ICa and MCA raise possibilities of vasculitides and and as\n source of large extensive intraventricular hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE HEAD\n\n CLINICAL INFORMATION: Patient with sudden loss of responsiveness and\n intracranial hemorrhage.\n\n TECHNIQUE: Axial images of the head were obtained without contrast. Following\n this, using departmental protocol, CT angiography of the head was acquired.\n\n FINDINGS: CT head demonstrates hemorrhage involving the lateral third and the\n fourth ventricle. Hemorrhage is also seen extending through the foramen of\n Luschka bilaterally. There is prominence of the ventricles and temporal horns\n indicating hydrocephalus. There is obliteration of the sulci due to mild\n brain edema. The basal cisterns remain patent.\n\n CT ANGIOGRAPHY OF THE HEAD:\n\n The CT angiography of the head demonstrates normal flow in the distal cervical\n internal carotid arteries with marked narrowing of both supraclinoid internal\n carotid arteries with diminished flow in the both MCA trunks. Flow is\n visualized normally in the anterior cerebral arteries as well as somewhat\n diminished flow is seen in the posterior circulation. Vascular structures are\n attenuated and it is difficult to evaluate for an aneurysm. Extensive\n collateral vascular structures are seen in the region of basal ganglia\n bilaterally.\n\n The superior sagittal and transverse sinuses are patent. The vein of \n and straight sinus are also patent. The anterior portions of both internal\n cerebral veins are not well visualized, which could be secondary to blood\n within the third ventricle and focal mass effect.\n\n IMPRESSION:\n 1. Head CT shows intraventricular hemorrhage with dilated lateral ventricles\n due to hydrocephalus.\n 2. CT angiography of the head demonstrates attenuated internal carotid\n arteries and middle cerebral arteries with collateral lenticulostriate\n (Over)\n\n 10:29 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n arteries indicative of a moyamoya pattern which could be secondary to\n vasculitis. The arterial structures are quite attenuated for evaluation of\n aneurysm, although none is obviously present. Further evaluation with\n cerebral angiography is recommended. Although no obvious aneurysm or\n arteriovenous malformation is seen but the conventional angiography can\n provide better information of the arterial structures.\n\n At the time of reporting of this examination, a cerebral angiography has\n already been performed.\n\n COMMENT: This report is provided without the availability of 3D reformatted\n images.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1122222,
"text": " 5:13 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: acute infarction\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with \n REASON FOR THIS EXAMINATION:\n acute infarction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:13 PM\n Acute/subacute infarct in the right periatrial white matter as seen on the\n previous CT examination of . Intraventricular hemorrhage. MRA\n demonstrates supraclinoid occlusive disease bilaterally as on the previous\n angiographic study and CT angiographic studies.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with moyamoya disease, rule out acute stroke.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\n images of the brain were acquired. 3D time-of-flight MRA of the circle of\n obtained. Correlation was made with the multiple prior CT examinations\n including those of and and . Correlation was also\n made with the CT angiographic study of .\n\n FINDINGS: BRAIN MRI:\n There is a right-sided intraventricular hemorrhage identified which\n demonstrates restricted diffusion due to blood products. Additionally, there\n is evidence of restricted diffusion seen in the right periatrial white matter\n region indicative of acute/subacute infarct. This infarct was visualized on\n prior CT of . There is a small focus of hyperintensity on diffusion\n and T2 images within the right side of the mid brain, which could be due to a\n subacute infarct. The location is less consistent with wallerian\n degeneration. There are bifrontal diffusion abnormalities seen due to blood\n products and secondary to placement of the bifrontal ventricular drains.\n There is no midline shift identified. There is slight prominence of the right\n temporal seen as on the previous CT examination. There is no overall\n hydrocephalus.\n\n IMPRESSION: Right intraventricular hemorrhage as on the previous CT.\n Acute/subacute right periatrial white matter infarct as seen on the previous\n CT examination. Signal changes in the right basal ganglia could be due to\n subacute/chronic hemorrhage. Increased signal in the right side of the\n midbrain probably due to subacute or chronic infarct in this location. No\n other acute infarct seen. Other findings as above.\n\n MRA OF HEAD:\n Head MRA demonstrates bilateral supraclinoid internal carotid artery flow\n signal narrowing indicative of occlusive disease. The middle cerebral\n arteries are not fully visualized. Similar findings were seen on the previous\n (Over)\n\n 5:13 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: acute infarction\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CTA examination. In the posterior circulation, basilar artery is well\n visualized but diminished flow signal is seen in both posterior cerebral\n arteries.\n\n IMPRESSION: The MRA appearance has not significantly changed since the\n previous CTA examination. Diminished flow is seen in both middle cerebral\n arteries secondary to supraclinoid occlusive disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1122223,
"text": ", J. NSURG FA11 5:13 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: acute infarction\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with \n REASON FOR THIS EXAMINATION:\n acute infarction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Acute/subacute infarct in the right periatrial white matter as seen on the\n previous CT examination of . Intraventricular hemorrhage. MRA\n demonstrates supraclinoid occlusive disease bilaterally as on the previous\n angiographic study and CT angiographic studies.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120217,
"text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with ICH\n REASON FOR THIS EXAMINATION:\n eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube assessment.\n\n FINDINGS: Endotracheal tube is low, with tip terminating about 1.5 cm above\n the carina. Nasogastric tube continues to coil in the stomach. Heart size is\n normal, and lungs are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1122137,
"text": " 10:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 37 year old woman with IVH, s/p EVD removal, more lethargic\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with IVH, s/p EVD removal, more lethargic this am, ? hydro.\n REASON FOR THIS EXAMINATION:\n 37 year old woman with IVH, s/p EVD removal, more lethargic this am, ? hydro.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IVH, status post EVD removal, more lethargic this morning.\n\n COMPARISON: Multiple priors include the most recent CT head .\n\n TECHNIQUE: MDCT with contiguous axial images through the head were obtained\n without IV contrast.\n\n FINDINGS:\n There has been interval removal of the drainage catheter with post-surgical\n changes seen in the frontal lobe. There is stable residual hemorrhage in the\n left frontal lobe in the region of the prior left side ventriculostomy\n catheter.\n\n There is unchanged hyperdensity in the right basal ganglia and hemorrhage\n layering in the right occipital . Although the ventricles are larger then\n study from , and possibly mildly larger when compared to the\n prior CT of , there is no definite hydrocephalus. The\n hypodensity in the right centrum semiovale related to subacute infarct is\n unchanged. There are no new areas of hemorrhage, edema, mass effect, or acute\n infarct. There is no shift of normally midline structures.\n\n Visualized paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Status post removal of ventriculostomy catheter. The ventricles are\n possibly mildly enlarged when compared to prior study, without definitive\n hydrocephalus.\n\n 2. Unchanged left frontal lobe and right basal ganglia hemorrhage. Stable\n hemorrhage layering in the right occipital . No new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-09 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1122225,
"text": " 5:18 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: 37 year old woman with ? picc line crossing midline, please\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with ? picc line crossing midline, please perform oblique\n view for picc placement.\n REASON FOR THIS EXAMINATION:\n 37 year old woman with ? picc line crossing midline, please perform oblique\n view for picc placement.\n ______________________________________________________________________________\n WET READ: SHfd FRI 8:34 PM\n\n PRIOR FREE AIR NOT WELL SEEN. R PICC IN PROX SVC.\n WET READ VERSION #1 SHfd FRI 8:33 PM\n R PICC IN PROX SVC.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Evaluate PICC placement. One view.\n\n Comparison with the previous study done earlier the same day. Lungs appear\n clear. The heart and mediastinal structures are unchanged. A PICC line is\n again demonstrated on the right. Its tip is projected in the mid superior\n vena cava.\n\n IMPRESSION: Line placement as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120243,
"text": " 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman w/IVH s/p EVD placement\n REASON FOR THIS EXAMINATION:\n ?interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intraventricular hemorrhage, status post EVD placement.\n Please evaluate for interval change.\n\n COMPARISON: Cerebral angiogram from , head CT from , , and head CTA from .\n\n NON-CONTRAST HEAD CT: There has been interval decrease in the amount of\n hyperdense blood in the left lateral ventricle and third ventricle and fourth\n ventricle. There has been decrease in amount of hydrocephalus in the interval\n since . The suprasellar cistern is patent. The basal\n cisterns are slightly narrowed; however, visualized. This demonstrates\n improvement since , where the basal cisterns were obliterated.\n A focal area of hypodensity in the right basal ganglia (2:11) is noted. Linear\n hyperdensity in the sulci of the left frontoparietal region (2:17) may\n represent a component of subarachnoid hemorrhage. Bilateral ventricular\n shunts from a frontal approach are stable in place. There has been interval\n resolution of previously seen pneumocephalus. There is minimal subcutaneous\n gas (2:26). There is no sclerotic or lytic bony lesion to suggest malignancy.\n Minimal mucosal thickening in the posterior right ethmoid air cells are noted.\n\n IMPRESSION:\n\n 1. Interval decrease in intraventricular hyperdense hemorrhage and interval\n decrease in hydrocephalus and mass effect with interval visualization of the\n basal cisterns, which were obliterated on prior exam.\n\n 2. Focal hypodensity in the right basal ganglia may represent a focal area of\n infarction. This was not seen on prior exam. Clinical correlation is\n recommended.\n\n 3. Questionable small amount of subarachnoid hemorrhage in the left\n frontoparietal region, new since prior exam.\n\n 4. The left lateral ventricle is smaller than the right in all portions\n including frontal body and temporal pole compatible with asymmetric drainage\n of the lateral ventricles. Close followup imaging is recommended.\n (Over)\n\n 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120082,
"text": " 12:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change post-bolt\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with ICH\n REASON FOR THIS EXAMINATION:\n ? change post-bolt\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 37-year-old female with intracranial hemorrhage.\n Evaluate for change status post bolt.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: Comparison is made to recent examination from performed\n at 11 p.m. Note that the patient did receive recent contrast from CTA\n examination.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. Recent\n contrast administration was performed from concurrent CTA approximately one\n hour and a half prior.\n\n FINDINGS: Placement of bilateral frontal approach ventriculostomy catheters\n with tips terminating within the mid aspect of the frontal horns of the\n bilateral ventricles. There has been no significant interval change in\n extensive intraventricular hemorrhage with associated obstructive\n hydrocephalus with the third ventricle measuring up to 9 mm and the fourth\n ventricle measuring up to 19 mm. The basilar cisterns appear roughly similar\n in extent since prior examination. There are several small foci of\n pneumocephalus along site of ventriculostomy catheters. The grey-white matter\n differentiation remains preserved with no evidence of acute territorial\n infarction. No evidence of transtentorial herniation at this time. The\n visualized portions of the paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION: Interval placement of bifrontal ventriculostomy catheters with no\n significant interval change in extensive intraventricular hemorrhage and\n associated obstructive hydrocephalus.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120914,
"text": " 9:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman w/ IVH; change in neuro exam\n REASON FOR THIS EXAMINATION:\n please evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old female with intraventricular hemorrhage and moyamoya.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain.\n\n FINDINGS: There is an unchanged amount of intraventricular hemorrhage\n layering in the lateral, third, and fourth ventricles. Drains are again seen\n entering from the bilateral frontal regions, with surrounding hemorrhage and\n edema, and tips in the bodies of the right and left lateral ventricles. There\n are no new large areas of hemorrhage.\n\n Again noted is ventricular asymmetry, with the right lateral ventricle\n persistently larger in size and containing more residual hemorrhage. This may\n signify asymmetric ventricular drainage, and close followup is recommended.\n\n Multiple periventricular and supratentorial white matter hypodensities reflect\n sequelae of chronic microvascular disease. Known subacute hyperdense infarcts\n in the right basal ganglia and right superior parietal lobe are essentially\n unchanged.\n\n The paranasal sinuses and mastoid air cells are clear. There are no\n fractures. The orbits appear unremarkable.\n\n IMPRESSION:\n 1. Unchanged intraventricular hemorrhage with bilateral frontal drains.\n Persistent symmetric drainage of lateral ventricles, recommend close followup.\n 2. Evolving subacute infarcts in the right basal ganglia and superior\n parietal lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120976,
"text": " 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with fevers\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 37-year-old female patient with fevers, evaluate for infiltrates.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position is analyzed in direct comparison with the next preceding\n similar study of . Findings are unchanged. The previously described\n Dobhoff line remains in unchanged position. No pneumothorax has developed.\n No pulmonary vascular congestion exists and no evidence of acute infiltrates\n or pleural effusions as seen on AP single view examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-27 00:00:00.000",
"description": "ADD'L 2ND/3RD ORDER",
"row_id": 1120122,
"text": " 8:18 AM\n CAROT/CEREB Clip # \n Reason: r/o avm, vasculitis, etc\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100ML OPTI240;56ML OPTI320\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER EXT CAROTID BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with IVH\n REASON FOR THIS EXAMINATION:\n r/o avm, vasculitis, etc\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: This is a 37-year-old woman with intraventricular bleed.\n\n REASON FOR EXAM: Rule out AVM or vasculitis.\n\n PROCEDURE PERFORMED: Diagnostic cerebral angiogram.\n\n VESSESL SELECTED: Right internal carotid arteriogram, right external carotid\n arteriogram, left internal carotid arteriogram, left external carotid\n arteriogram, left vertebral arteriogram and right common femoral arteriogram.\n\n OPERATOR: Dr. .\n\n ASSISTANT: Dr. .\n\n ANESTHESIA: The procedure was done under moderate sedation provided by\n divided doses of 100 mcg of fentanyl and 2 mg of Versed during the total\n intraservice time of 1 hour 40 minutes during which the patient's hemodynamic\n parameters were continuously monitored and remained stable.\n\n DETAILS OF THE PROCEDURE: Informed consent was obtained from the patient's\n husband after explaining indication, benefit, risks and alternative\n management. The patient was brought into the neurointerventional suite and\n placed in supine position on biplane table. Preprocedure timeout documenting\n the nature of the procedure, patient identity and relevant blood workup was\n done using two independent verifiers. Both groins were prepped and draped in\n usual sterile fashion. After using local anesthetic into the right femoral\n area, the right common femoral artery was accessed using a micropuncture set.\n Using Seldinger technique, a 5 French vascular sheath was successfully placed\n into the right common femoral artery. Through the sheath and using 4 French\n Berenstein catheter with the aid of .03 angled wire, the above-mentioned\n vessels were selectively catheterized and arteriograms were obtained. AP,\n (Over)\n\n 8:18 AM\n CAROT/CEREB Clip # \n Reason: r/o avm, vasculitis, etc\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100ML OPTI240;56ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lateral and oblique projections were done where necessary. After reviewing\n the images, the catheter and wire was removed. Right common femoral\n arteriogram was done and did not demonstrate any extravasation or stenosis of\n the vessel. An attempt to close the site of the puncture with a 6 French\n Angio-Seal was unsuccessful as we were no able to pass the artery localizer.\n Pressure was held to the groin for a total of 30 minutes until hemostasis was\n obtained. The patient was sent to the ICU with post-procedure orders.\n\n FINDINGS:\n Right internal carotid arteriogram showed normal filling of the internal\n carotid along cervical, petrous and cavernous portion. There was severe\n degree of narrowing of the supraclinoid portion of the internal carotid artery\n and carotid bifurcation. Diminished flow also noticed in the middle cerebral\n artery and to a lesser extent into the anterior cerebral artery. Extensive\n collateralization of the lenticulostriate vessels was noted. This pattern is\n consistent with Moyamoya disease stage 3. There was no aneurysm or\n arteriovenous malformation noted. The posterior communicating artery appeared\n prominent suggestive of persistent fetal origin of the right PCA.\n\n Right external carotid arteriogram showed normal filling of the vessels and\n its branches with some collateralization from the middle meningeal artery\n through Ophthalmic artery to the intracranial circulation.\n\n Left internal carotid arteriogram showed normal filling of the internal\n carotid along cervical, petrous and cavernous portion. There is moderate to\n severe stenosis of the supraclinoid portion of the internal carotid artery ,\n carotid bifurcation and the M1 segment of the MCA. There is a mild degree of\n stenosis on the anterior cerebral artery noted with some cross filling through\n the ACOM to the contralateral ACA. There are also extensive vascular\n collaterals seen in the region of the basal ganglion. The presence of this\n pattern bilaterally is consistent with Moyamoya appearance which appears at a\n stage 2 on the left side. Posterior communicating artery also appears\n prominent. There was no aneurysm or arteriovenous malformation noted.\n\n Left external carotid arteriogram showed normal filling of the external\n carotid artery and its branches. There is no dural AV fistula. There are\n some collaterals through the middle meningeal artery filling retrogradely\n through the ophthalmic into the distal ICA and MCA ipsilaterally.\n\n Left vertebral arteriogram showed the vessel arises directly from the arch.\n There was a normal distal portion of the left vertebral artery. Basilar\n appears normal in course and both PICAS, superior cerebellar arteries and AICA\n were seen and appeared normal. Both PCAs were small and the distal portion of\n the basilar appeared narrow. This could be seen with the underlying vascular\n disease \"Moyamoya\" or due to filling of the PCA through fetal origin. There\n (Over)\n\n 8:18 AM\n CAROT/CEREB Clip # \n Reason: r/o avm, vasculitis, etc\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100ML OPTI240;56ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was no aneurysm or arteriovenous malformation noted.\n\n Right common femoral arteriogram showed normal filling of the vessels with no\n dissection, extravasation or stenosis.\n\n IMPRESSION: Diagnostic cerebral angiogram showed presence of bilateral\n intracranial stenosis in the distal internal carotid artery and middle\n cerebral artery and more pronounced on the right side with the presence of\n extensive collaterals in the lenticulostriate area and some external/internal\n carotid artery collaterals through the middle meningeal filling retrogradely\n through the ophthalmic. Those findings are indicative of appearance of\n moyamoya disease. There was no aneurysm, arteriovenous malformation or dural\n AV fistula noted. Recommend followup angiography once resorption of blood\n occurs to assess for presence of aneurysm or AVM. Those findings were\n discussed with the neurosurgery team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120542,
"text": " 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with IVH\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 37-year-old female with IVH, moyamoya disease.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain.\n\n FINDINGS: There has been interval decrease in the amount of blood seen\n layering in the lateral, third, and fourth ventricles Two drains are again\n seen entering from the bilateral frontal regions, right- tip in the frontal\n and left- tip medial to the margin of the body of the left lateral\n ventrcile. There is persistent hemorrhage in the dependent portions of the\n ventricles, as well as surrounding the courses of the ventricular drains in\n the bilateral frontal lobes. As previously noted, there may be a focal area\n of subarachnoid involvement. There are no new large areas of acute\n hemorrhage.\n\n Multiple supratentorial and periventricular white matter hypodensities\n reflect chronic microvascular disease. The hypodense, presumed lacunar\n infarct in the right basal ganglia is stable. A focal hypodensity in the\n right superior parietal lobe ( ) appears more prominent on this\n examination and may represent an evolving acute-subacute infarct. Reactive\n edema is also seen surrounding the drains as they traverse the frontal lobes.\n\n Again noted is some ventricular asymmetry, with the right lateral ventricle\n being larger than the right. This may be consistent with asymmetric drainage,\n given the persistently larger amount of hemorrhage in the right ventricle.\n Close followup is recommended.\n\n IMPRESSION:\n 1. Decrease in intraventricular hemorrhage. Possible asymmetric drainage of\n right and left lateral ventricles, recommend long-term follow-up. Evolving\n hemorrhage and edema surrounding the drains in the frontal lobes.\n 2. New hypodensities in the right basal ganglia and superior parietal lobe,\n new since and evolving since , likely represent acute\n infarcts.Can be confirmed with MR if necessary and if there is no\n contra-indication.\n\n This was discussed with by M.Ho on at 12:15 p.m.\n (Over)\n\n 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1121712,
"text": " 4:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman s/p IVH\n REASON FOR THIS EXAMINATION:\n please evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 37-year-old female with moyamoya, intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain.\n\n FINDINGS: There is an unchanged amount of layering hemorrhage in the right\n occipital . A right frontal drainage catheter terminates in the body of\n the right lateral ventricle. There is stable residual blood in the left\n frontal lobe, in the region of the prior left-sided ventriculostomy catheter.\n Again noted is slight asymmetry of the lateral ventricles, with the right\n ventricle persistently larger in size and containing more residual hemorrhage.\n This is suggestive of asymmetric ventricular drainage, and should be followed\n closely.\n\n Again noted is an area of hypodensity in the right centrum semiovale,\n representing a subacute infarct. A focal hyperdensity in the right basal\n ganglia is also unchanged. There are no new areas of hemorrhage, edema, mass\n effect, or large vascular territorial infarct. There is no significant\n midline shift, and the basilar cisterns are preserved.\n\n The paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Persistent hemorrhage in right lateral ventricle, with intraventricular\n shunt. Recommend close followup for asymmetric ventricular drainage.\n\n 2. Stable left frontal lobe and right basal ganglia hemorrhage.\n\n 3. Unchanged subacute infarct in right centrum semiovale.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120591,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: dobhoff palcement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with new dobhoff placement\n REASON FOR THIS EXAMINATION:\n dobhoff palcement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. A Dobbhoff catheter has\n been newly inserted. The catheter has a normal course, the position is\n correct. No evidence of complications, notably no pneumothorax. Unremarkable\n lung parenchyma. Normal size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120077,
"text": " 10:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with s/p intub\n REASON FOR THIS EXAMINATION:\n check tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 37-year-old female status post intubation. For tube\n placement.\n\n EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH.\n\n COMPARISONS: None available.\n\n FINDINGS: An endotracheal tube is seen with tip 1.8 cm above the level of the\n carina, which can be withdrawn by approximately 2 cm for more optimal\n positioning. A nasogastric tube is seen coursing below the diaphragm. The\n lungs are clear, without consolidation, pleural effusions or pneumothorax.\n Cardiomediastinal contours are normal with a normal heart size, accentuated by\n low lung volumes. Pulmonary vascularity is normal.\n\n IMPRESSION: ET tube 1.8 cm above the level of the carina and can be withdrawn\n by approximately 2 cm for more optimal positioning. Clear lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-01 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1120898,
"text": " 8:52 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PATIENT WITH CX NEG FEVERS ASSESS FOR DVT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with cx neg fevers. r/o DVT\n REASON FOR THIS EXAMINATION:\n DVT?\n ______________________________________________________________________________\n WET READ: 11:56 AM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever of unknown origin.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler imaging of the common femoral,\n superficial femoral, and popliteal veins are performed bilaterally. Normal\n compressibility, flow, waveform, and augmentation is demonstrated. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of lower extremity deep venous thrombosis\n bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1121576,
"text": " 8:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for change, eval for ventricular size\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with EVD in place\n REASON FOR THIS EXAMINATION:\n eval for change, eval for ventricular size\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 9:18 PM\n 1. No significant change when compared to prior exam. Persistent\n intraventricular hemorrhage, left frontal lobe hemorrhage and right basal\n ganglia hyperdensity, unchanged.\n 2. No significant change in configuration of ventricles.\n 3. No change in right centrum semiovale hypodensity.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n COMPARISON: .\n\n HISTORY: Evaluate for change in ventricular size.\n\n TECHNIQUE: MDCT axially acquired images through the brain were obtained. No\n IV contrast was administered. Coronal and sagittal reformats were not\n performed.\n\n FINDINGS: A right-sided ventricular drain is identified and terminates in the\n right frontal of the lateral ventricle, unchanged in position. Again\n identified is intraventricular hemorrhage layering along the right posterior\n of the lateral ventricle, similar in appearance. There is no significant\n change in the size and configuration of the ventricles. There is mild\n dilatation of the temporal horns, unchanged. Focal area of hypodensity in the\n right centrum semiovale (2, 18) is again identified and not significantly\n changed. Small amount of blood in the left frontal lobe along the previous\n tract of prior left-sided ventriculostomy catheter is again identified and not\n significantly changed. Small amount of hyperdensity along the right basal\n ganglia is also similar in appearance and unchanged. There are no new areas\n of hemorrhage identified. There is no shift of normally midline structures.\n The basilar cisterns are preserved. The visualized paranasal sinuses are\n clear.\n\n IMPRESSION:\n 1. No significant change when compared to prior exam. Persistent\n intraventricular hemorrhage, left frontal lobe hemorrhage and right basal\n ganglia hyperdensity, unchanged.\n 2. No significant change in configuration of ventricles.\n 3. No change in right centrum semiovale hypodensity.\n (Over)\n\n 8:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for change, eval for ventricular size\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1121577,
"text": ", J. NSURG SICU-A 8:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for change, eval for ventricular size\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with EVD in place\n REASON FOR THIS EXAMINATION:\n eval for change, eval for ventricular size\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No significant change when compared to prior exam. Persistent\n intraventricular hemorrhage, left frontal lobe hemorrhage and right basal\n ganglia hyperdensity, unchanged.\n 2. No significant change in configuration of ventricles.\n 3. No change in right centrum semiovale hypodensity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1121807,
"text": " 9:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 37 year old woman with sah, ventric clamped for 24 hours. pl\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with sah, ventric clamped for 24 hours. please evaluate for\n hydrocephalus.\n REASON FOR THIS EXAMINATION:\n 37 year old woman with sah, ventric clamped for 24 hours. please evaluate for\n hydrocephalus.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 37-year-old female with moyamoya, intracranial hemorrhage,\n ventricular drain clamped x 24 hours.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast contiguous axial images were obtained through the\n brain.\n\n FINDINGS: There is an unchanged amount of layering hemorrhage in the right\n occipital . The clamped right frontal drainage catheter is seen with tip\n in the body of the right lateral ventricle. There is no significant change in\n ventricular size to indicate hydrocephalus. Again noted is slight asymmetry\n of the lateral ventricles, right greater than left, suggestive of asymmetric\n drainage.\n\n There is stable residual blood in the left frontal lobe, in the region of a\n prior left-sided ventriculostomy catheter. Persistent hyperdensity is also\n present in the right basal ganglia. The hypodense subacute infarct in the\n right centrum semiovale is essentially unchanged. There are no new areas of\n hemorrhage, edema, mass effect, or infarct. There is no midline shift, and\n the basilar cisterns are preserved.\n\n The paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Stable residual hemorrhage in the right lateral ventricle. Clamped drain\n with no evidence of hydrocephalus.\n 2. Unchanged left frontal lobe and right basal ganglia hemorrhage.\n 3. Subacute infarct in the right centrum semiovale.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-07 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1121808,
"text": " 9:31 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: 37 year old woman with DHT, please evaluate placement.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with DHT, please evaluate placement. Pt going for head Ct,\n please perform while pt in radiology if possible.\n REASON FOR THIS EXAMINATION:\n 37 year old woman with DHT, please evaluate placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 37-year-old female with Dobbhoff tube placement.\n For evaluation of positioning.\n\n EXAMINATION: Single abdominal radiograph.\n\n COMPARISONS: None available.\n\n FINDINGS: A Dobbhoff tube is seen with tip in a post-pyloric position. Note\n is made of mildly gaseously distended loops of large bowel with a large bowel\n particularly within the transverse colon measuring up to 6.5 cm. without\n evidence of obstruction or ileus. No evidence of pneumoperitoneum.\n Visualized osseous structures are intact. No soft tissue calcifications.\n\n IMPRESSION:\n 1. Dobhoff tube in likely post-pyloric position.\n 2. No evidence of ileus or obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-12-31 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120795,
"text": " 2:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman w/IVH s/p EVD placement\n REASON FOR THIS EXAMINATION:\n ?interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 37-year-old female with moyamoya disease and IVH.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain.\n\n FINDINGS: There is an unchanged amount of intraventricular hemorrhage\n layering in the lateral, third, and fourth ventricles. Again seen are drains\n entering from the bilateral frontal regions, with surrounding hemorrhage and\n edema, and tips in the bodies of the right and left lateral ventricles. Foci\n of gas are seen in the nondependent regions of the lateral ventricles. There\n are no new large areas of hemorrhage.\n\n Multiple supratentorial and periventricular white matter hypodensities reflect\n sequelae of chronic microvascular disease. Known subacute hypodense infarcts\n in the right basal ganglia and right superior parietal lobe appear unchanged.\n\n Again noted is ventricular asymmetry, with the right lateral ventricle\n persistently larger in size and with more residual hemorrhage. This may\n signify asymmetric ventricular drainage, and close followup is recommended.\n\n The paranasal sinuses and mastoid air cells are clear. There are no\n fractures. The orbits appear unremarkable.\n\n IMPRESSION:\n 1. Unchanged intraventricular hemorrhage with bilateral frontal drains.\n Possible asymmetric drainage of lateral ventricles, recommend close followup.\n 2. Evolving subacute infarcts in the right basal ganglia and superior\n parietal lobe.\n\n"
}
] |
73,059 | 124,602 | On Admission: is an 81 year old female with a history of atrial fibrillation not on anticoagulation, ESRD (on dialysis) who presented as a transfer from Hospital for L MCA infarct. She was brought to Hospital where her exam was notable for aphasia and right-sided hemiparesis. She had a head CT scan performed which showed an acute/subacute left MCA distribution infarct. Neurology evaluated the patient and she received t-PA. She was transferred to -ICU for further care. On arrival she had ecchymoses/hematoma over her left chest at the site of pacemaker placement and right upper arm (prior bruise from fall). Compressive dressings were placed on both these sites. ICU course: (- ) | There isno pericardial effusion.IMPRESSION: Normal biventricular systolic function. IMPRESSION: Stable moderate right pleural effusion and retrocardiac opacity. Physiologic MR (within normal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets. No LA mass/thrombus (best excluded by TEE).RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Physiologic mitral regurgitation is seen (withinnormal limits). FINDINGS: As compared to the previous radiograph, the previously malpositioned nasogastric tube now shows a normal course and has its tip projecting over the stomach. A moderate left pleural effusion and retrocardiac opacity are unchanged. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). IMPRESSION: Moderate right pleural effusion. Cardiomegally and aortic arch calcifications are stable. Note is made of mild hyperostosis frontalis interna. Remote left PCA infarct is noted, with encephalomalacia in the left occipital lobe. The rhythm appears to beatrial fibrillation.Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cerebrovascular event/TIA.Height: (in) 60Weight (lb): 123BSA (m2): 1.52 m2BP (mm Hg): 128/57HR (bpm): 111Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Small left pleural effusion is again visualized and is unchanged. Minor ST-T wave abnormalities. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There is mild pulmonary artery systolic hypertension. Mild [1+] TR. Small left pleural effusion is unchanged. Probably mild persistent fluid overload. Old L PCA infarct. Aortic arch calcifications are noted. Aneurysmal interatrial septum.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). There is a left-sided effusion, atelectasis and possible pneumonia, unchanged. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The interatrial septum isaneurysmal. There is a minimal increase in diameter of the pulmonary vessels. Patent intracranial arteries. Patchy opacity in right mid zone also noted. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: The left MCA territory is hypodense, consistent with evolving infarction. There continues to be dense retrocardiac opacity likely due to a combination of volume loss and effusion, although an infiltrate cannot be excluded. The size of the cardiac silhouette is constant, there is blunting of the left costophrenic sinus, so that the presence of a small pleural effusion cannot be excluded. Transvenous pacemaker leads are in standard position. Sinus rhythm with probable ventricular premature beat followed by a ventricularpaced beat. No left atrial mass/thrombus seen (bestexcluded by transesophageal echocardiography). Right supraclavicular double-lumen catheter is in standard position. Right ventricular chamber size and free wallmotion are normal. There is a focal ulceration of the right common carotid artery at the site of origin (3:81). 11:06 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: please eval r/o embolic/thrombotic stroke, left MCA distribu MEDICAL CONDITION: History: 81F with stroke REASON FOR THIS EXAMINATION: please eval r/o embolic/thrombotic stroke, left MCA distribution infarct No contraindications for IV contrast WET READ: MJMgb TUE 11:44 AM NECT: No acute hemorrhage. (Over) 11:06 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: please eval r/o embolic/thrombotic stroke, left MCA distribu FINAL REPORT (Cont) 3. There is mild symmetric left ventricular hypertrophy with normalcavity size and global systolic function (LVEF>55%). Bilateral lens prostheses are noted. IMPRESSION: Evolving left MCA infarct. A tunneled right internal jugular dialysis catheter tip terminates in the right atrium. Old left PCA territorial infarct, with encephalomalacia. Normal mitralvalve supporting structures. T wave abnormalities. The ventricles and sulci are prominent, consistent with age-related atrophy. Moderate left pleural effusion and retrocardiac opacity are similar to the exam of 9:30 a.m. CTA HEAD AND NECK: The major branches of the anterior and posterior circulation are patent. This could be indicative of mild fluid overload. The paranasal sinuses are well aerated. Left MCA infarction. The ventricles and sulci are normal in size and morphology. Dual-chamber pacing leads project over the expected positions of the right atrium and right ventricle. CONCLUSION Dobhoff postioned in proximal stomach FINDINGS: A single portable semi-erect chest radiograph was obtained. FINDINGS: A single portable semi-erect chest radiograph was obtained. NECT HEAD: There is hypodensity involving the left MCA territory, consistent with acute infarction. Mild cardiomegaly is stable. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation. Cardiomegally is mild. Clinical correlation is suggested.TRACING #1 The right lung is relatively clear. Sinus rhythm with a single ventricular premature beatfollowed by an A-V paced beat. The aortic valve leaflets (3) appear structurally normalwith good leaflet excursion. Mastoid air cells and middle ear cavities are clear. The basal cisterns are patent. The basal cisterns are patent. COMPARISON: NECT of the head on . The right lung remains clear. Mild vascular congestion has improved. Prominent atherosclerotic calcifications are noted in the carotid siphons. This likely represents vasodilation w/ BBB breakdown early reperfusion of acute infarct and pooling of contrast from prior CTA. Focal ulceration at the origin of the right common carotid artery. The Dobbhoff has advanced below the left hemidiaphragm, but is probably within the proximal stomach and could be advanced a little further. INDICATION: Recent Dobbhoff placement. Hyperdensity in the region of the MCA bifurcation present on outside NECT is no longer present. No evidence of left atrialmass/thrombus although TTE cannot exclude this. The dual-lead pacemaker and right supraclavicular double-lumen catheter is again visualized. The thyroid gland is normal. Baseline artifact. If clinically indicated, a TEEwill better assess for LAA thrombus. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. | 12 | [
{
"category": "Echo",
"chartdate": "2106-06-09 00:00:00.000",
"description": "Report",
"row_id": 104657,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA.\nHeight: (in) 60\nWeight (lb): 123\nBSA (m2): 1.52 m2\nBP (mm Hg): 128/57\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV. Aneurysmal interatrial septum.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Beat-to-beat variability on LVEF due to irregular\nrhythm/premature beats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). The interatrial septum is\naneurysmal. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and global systolic function (LVEF>55%). There is considerable\nbeat-to-beat variability of the left ventricular ejection fraction due to an\nirregular rhythm/premature beats. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Physiologic mitral regurgitation is seen (within\nnormal limits). There is mild pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: Normal biventricular systolic function. No evidence of left atrial\nmass/thrombus although TTE cannot exclude this. If clinically indicated, a TEE\nwill better assess for LAA thrombus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241670,
"text": " 1:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Dobhoff placed, please assess for position\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with hemiparesis\n REASON FOR THIS EXAMINATION:\n Dobhoff placed, please assess for position\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Recent Dobbhoff placement. Assess for position.\n\n TECHNIQUE: Portable AP radiographs obtained.\n\n COMPARISON: timed at 7:59 a.m. Current radiograph after this\n date is timed at 13:07 a.m.\n\n REPORT: Right-sided dialysis catheter, dual chamber pacemaker are in\n unchanged position.\n\n The Dobbhoff has advanced below the left hemidiaphragm, but is probably within\n the proximal stomach and could be advanced a little further.\n\n There is a left-sided effusion, atelectasis and possible pneumonia, unchanged.\n Patchy opacity in right mid zone also noted. Probably mild persistent fluid\n overload.\n\n CONCLUSION\n\n Dobhoff postioned in proximal stomach\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241886,
"text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Stroke.\n\n Comparison is made with prior study, .\n\n Mild cardiomegaly is stable. Transvenous pacemaker leads are in standard\n position. Right supraclavicular double-lumen catheter is in standard\n position. NG tube tip is in the stomach. Small left pleural effusion is\n unchanged. Adjacent opacities, likely atelectases, have increased. There is\n no pneumothorax. Mild vascular congestion has improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1241611,
"text": " 4:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Hemorrhage, evolution of ischemic lesion, mass effect\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n Hemorrhage, evolution of ischemic lesion, mass effect\n CONTRAINDICATIONS for IV CONTRAST:\n already given, patient anuric, not yet dialysed.\n ______________________________________________________________________________\n WET READ: MLHh WED 5:32 AM\n New mild cortical edema and hyperdensity in L MCA distribution. This likely\n represents vasodilation w/ BBB breakdown early reperfusion of acute\n infarct and pooling of contrast from prior CTA.\n Old L PCA infarct.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female presenting with left MCA stroke symptoms on\n .\n\n COMPARISON: CTA head from at 11:06 and outside hospital CT head dated\n at 7:59.\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain and reconstructed at 5-mm intervals. 2-mm coronal and sagittal\n multiplanar reformats were also created.\n\n FINDINGS: There is extensive cytotoxic edema throughout the left MCA\n distribution, with sulcal effacement. Serpentine hyperdensity has developed\n throughout the gyri and centrally, with attenuation of 30-40 . Remote left\n PCA infarct is noted, with encephalomalacia in the left occipital lobe. The\n ventricles and sulci are normal in size and morphology.\n\n Note is made of mild hyperostosis frontalis interna. The paranasal sinuses\n are well aerated. Mastoid air cells and middle ear cavities are clear.\n Bilateral lens prostheses are noted.\n\n IMPRESSION:\n 1. Extensive cytotoxic edema and hyperdensity throughout the left MCA\n distribution, in an evolving territorial infarct. This likely represents\n abnormal parenchymal enhancement (related to the contrast given for the CTA,\n roughly 17 hours earlier), in the setting of blood-brain barrier breakdown in\n the acutely ischemic brain.\n 2. Old left PCA territorial infarct, with encephalomalacia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241748,
"text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with hemepariesis\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the previously\n malpositioned nasogastric tube now shows a normal course and has its tip\n projecting over the stomach.\n\n The other monitoring and support devices are constant and unremarkable. The\n lung volumes have slightly decreased. There is a minimal increase in diameter\n of the pulmonary vessels. This could be indicative of mild fluid overload.\n The size of the cardiac silhouette is constant, there is blunting of the left\n costophrenic sinus, so that the presence of a small pleural effusion cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241624,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulmonary edema in light of omission of HD\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with ESRD on HD, has not been diallysed since saturday\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema in light of omission of HD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with end-stage renal disease, on dialysis.\n\n COMPARISONS: .\n\n FINDINGS: A single portable semi-erect chest radiograph was obtained. A\n moderate left pleural effusion and retrocardiac opacity are unchanged. There\n is no pulmonary edema. The right lung remains clear. Dual-chamber pacing\n leads project over expected positions. A tunneled right internal jugular\n dialysis catheter tip terminates in the right atrium. Cardiomegally and\n aortic arch calcifications are stable.\n\n IMPRESSION: Stable moderate right pleural effusion and retrocardiac opacity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1241973,
"text": " 4:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleeding\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with L MCA s/p tPA\n REASON FOR THIS EXAMINATION:\n eval for bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left MCA stroke, treated with TPA. Evaluation for bleeding.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast.\n\n COMPARISON: NECT of the head on .\n\n FINDINGS: The left MCA territory is hypodense, consistent with evolving\n infarction. There is no evidence of hemorrhage. The ventricles and sulci are\n prominent, consistent with age-related atrophy. There is no shift of midline\n structures. The basal cisterns are patent. The visualized paranasal sinuses,\n mastoid air cells, and middle ear cavities are clear.\n\n IMPRESSION: Evolving left MCA infarct. No evidence of hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242059,
"text": " 1:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with NG tube placed\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: NG tube placement.\n\n FINDINGS: The NG tube tip is in the stomach. The dual-lead pacemaker and\n right supraclavicular double-lumen catheter is again visualized. Small left\n pleural effusion is again visualized and is unchanged. There continues to be\n dense retrocardiac opacity likely due to a combination of volume loss and\n effusion, although an infiltrate cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-08 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1241524,
"text": " 11:06 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: please eval r/o embolic/thrombotic stroke, left MCA distribu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 81F with stroke\n REASON FOR THIS EXAMINATION:\n please eval r/o embolic/thrombotic stroke, left MCA distribution infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJMgb TUE 11:44 AM\n NECT: No acute hemorrhage.\n\n CTA: Severe atherosclerosis. Patent intracranial arteries. No aneurysm.\n Possible ulceration at origin of right common carotid (awaiting 3D\n reconstructions for further evluation).\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for thrombotic stroke in the left MCA distribution.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequent rapid axial imaging was performed from the\n aortic arch through the brain during infusion of 70 cc of Omnipaque\n intravenous contrast material. Curved reformations, 3D reconstructions, and\n multiplanar maximum-intensity projection images were reviewed.\n\n COMPARISON: Outside NECT head .\n\n NECT HEAD: There is hypodensity involving the left MCA territory, consistent\n with acute infarction. Hyperdensity in the region of the MCA bifurcation\n present on outside NECT is no longer present. There is no evidence of\n hemorrhage The ventricles and sulci are prominent, consistent with\n age-related atrophy. The basal cisterns are patent. The visualized paranasal\n sinuses, mastoid air cells, and middle ear cavities are clear.\n\n CTA HEAD AND NECK: The major branches of the anterior and posterior\n circulation are patent. The left vertebral artery provides nearly all its\n flow to the PICA, with a small twig continuing to the basilar artery. There is\n no evidence of vertebral artery stenosis. There is bilateral atherosclerosis\n in the carotid bifurcations with mild stenosis. There are atheromatous\n changes in the left common carotid throughout its length. Prominent\n atherosclerotic calcifications are noted in the carotid siphons. There is no\n evidence of aneurysm formation.\n\n There is a focal ulceration of the right common carotid artery at the site of\n origin (3:81). The orbits and nasopharyngeal soft tissues are unremarkable.\n There is no cervical lymphadenopathy. The thyroid gland is normal. The lung\n apices are clear.\n\n IMPRESSION:\n 1. Left MCA infarction. No evidence of hemorrhage.\n 2. Focal ulceration at the origin of the right common carotid artery.\n (Over)\n\n 11:06 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: please eval r/o embolic/thrombotic stroke, left MCA distribu\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Extensive atherosclerosis involving the arotic arch, left common carotid\n artery, and carotid bifurcations.\n MJMgb\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241536,
"text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o acute process\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 81F with ? pneumonia vs aspiration\n REASON FOR THIS EXAMINATION:\n please eval r/o acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with pneumonia versus aspiration.\n\n COMPARISON: , 9:30 this morning from Hospital.\n\n FINDINGS: A single portable semi-erect chest radiograph was obtained.\n Moderate left pleural effusion and retrocardiac opacity are similar to the\n exam of 9:30 a.m. The right lung is relatively clear. Dual-chamber pacing\n leads project over the expected positions of the right atrium and right\n ventricle. A right internal jugular tunneled dialysis catheter tip is in the\n right atrium. Aortic arch calcifications are noted. Cardiomegally is mild.\n\n IMPRESSION: Moderate right pleural effusion. Retrocardiac opacity may\n represent pneumonia, atelectasis or other pulmonary process.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-08 00:00:00.000",
"description": "Report",
"row_id": 306028,
"text": "Sinus rhythm with probable ventricular premature beat followed by a ventricular\npaced beat. T wave abnormalities. Since the previous tracing no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-08 00:00:00.000",
"description": "Report",
"row_id": 306029,
"text": "Baseline artifact. Sinus rhythm with a single ventricular premature beat\nfollowed by an A-V paced beat. Minor ST-T wave abnormalities. No previous\ntracing available for comparison. Clinical correlation is suggested.\nTRACING #1\n\n"
}
] |
46,324 | 138,604 | ASSESSMENT AND PLAN: 47 year old with mild intermittent asthma who presents with fever, dyspnea who developed hypotension and respiratory failure now intubated and sedated. . # Shock: Given fever, bandemia and LL opacity, the thought was likely septic shock from pneumonia. However, on bedside ECHO seemed to have possible global cardiac dysfunction and given pulmonary edema, there may be some component of cardiac stunning/dysfunction. Also severe electrolyte abnormalities and acidosis contributing to cardiac dysfunction and hypotension. The patient was emperically started on Vanco/Cefepime/Levoflox (renally dosed) and was started on levophed as needed to maintain MAP <65. IVF was given to maintain a CVP <8 (particularly if patient has massive urine output but will otherwise be gentle given his ARF and volume overload). Blood and urine cultures remained negative, and viral aspirate was pending. Sputum was ordered but not yet registered as pending. Renal was consulted for potential HD. Electrolyte abnormalities were aggressively treated. The patient was aggressively fluid rescucitated. The patient was eventually started on dobutamine at maximum dose in addition to max dose levophed. Vasopressin was also started in addition to this. | Probable sinus tachycardia. When stable, recommend PA and lateral radiographs. AnterolateralST-T wave abnormalities. Low limb lead QRS voltage. Low limb lead QRS voltage. Low limb lead QRS voltage. Low limb lead QRS voltage. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Probable worsening edema. There is somewhat worsening of the pulmonary interstitial markings. Modest lateral lead T wavechanges. FINDINGS: The tip of the ET tube has been withdrawn and is now at the level of the clavicles, approximately 6.5 cm from the carina. Anterolateral lead ST-T wave changes are non-specific.Clinical correlation is suggested. FINDINGS: Mediastinal, hilar, and cardiac contours are unremarkable. There is worsening interstitial edema. AP CHEST RADIOGRAPH. Anterolateral lead ST-T wavechanges. Anterolateral lead ST-T wavechanges. IMPRESSION: Left lower lung consolidation obscuring left hemidiaphragm may represent combination of atelectasis/infectious process and effusion, though layering effusion alone is a possibility. Significant worsening in appearance of the lungs with extensive ground-glass opacity consistent with edema, likely noncardiogenic. Stable left lower lobe opacity. Stable left lower lobe opacity. IMPRESSION: Satisfactory ET tube position. COMPARISON: Radiographs of . A right-sided IJ line is in place, in satisfactory position in the mid SVC. Possible left lower lobe pneumonia and probable associated moderately large pleural effusion. FINDINGS: Extensive new ground-glass opacity is seen throughout the lungs, and in the setting of a normal heart size is suggestive of non-cardiogenic pulmonary edema. There may be a small left effusion, but no right-sided effusion. Findings are non-specific. Findings are non-specific. Findings are non-specific. tube placement, eval interval change FINAL REPORT INDICATION: Hypoxic respiratory failure, evaluate for tube placement. Since the previous tracing of the same date probably nosignificant change.TRACING #2 Evaluate intubation. IMPRESSION: 1. Homogeneous density in the left lower zone suggests the presence of either extensive pneumonia or effusion or a combination of both. An NG tube is in the stomach. 3:01 AM CHEST (PORTABLE AP) Clip # Reason: ? Satisfactory position of medical devices. IMPRESSION: The ET tube has backed out since the previous examination, now 6.5 cm above the carinal. Findings are non-specific and basline artifact makesassessment difficult. The NG tube is in the stomach. Satisfactory IJ line. Opacification noted in left lower lung obscuring the left hemidiaphragm may represent an infectious process with associated pleural effusion or possibly simply a layering effusion. Left basilar opacity is stable. There remains extensive opacification at the left base similar to the prior study. PORTABLE AP CHEST RADIOGRAPH COMPARISON: , at 21:45. COMPARISON: Comparison is made to chest radiograph performed . Since the previous tracing of the samedate no significant change.TRACING #3 COMPARISON: Chest radiograph at 2056. The right internal jugular central venous catheter, endotracheal and nasogastric tubes are in satisfactory position. 3. FINDINGS: The patient has been intubated with the tip of the ET tube 2.8 cm from the carina. 2. No previous tracing available forcomparison.TRACING #1 No pneumothorax identified. Since the previous tracing of the samedate no significant change.TRACING #4 No previous tracing available forcomparison. No pneumothorax is present. Increased in vascular engorgement/vascular congestion. REASON FOR THIS EXAMINATION: Please eval line placement FINAL REPORT INDICATION: Pneumonia and recent line placement, evaluate line. There is no pneumothorax. 9:44 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess intubation MEDICAL CONDITION: 47 year old man with respiratory failure, hypotension REASON FOR THIS EXAMINATION: assess intubation FINAL REPORT INDICATION: Respiratory failure. tube placement, eval interval change Admitting Diagnosis: PNEUMONIA;RENAL FAILURE MEDICAL CONDITION: 47 year old man with hypoxic respiratory failure REASON FOR THIS EXAMINATION: ? 8:48 PM CHEST (PORTABLE AP) Clip # Reason: eval for PNA MEDICAL CONDITION: 47 year old man with crackles, hypotensive REASON FOR THIS EXAMINATION: eval for PNA FINAL REPORT INDICATION: Crackles, hypotensive, please evaluate for pneumonia. | 9 | [
{
"category": "Radiology",
"chartdate": "2126-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188722,
"text": " 8:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with crackles, hypotensive\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crackles, hypotensive, please evaluate for pneumonia.\n\n COMPARISON: Comparison is made to chest radiograph performed .\n\n FINDINGS: Mediastinal, hilar, and cardiac contours are unremarkable.\n Opacification noted in left lower lung obscuring the left hemidiaphragm may\n represent an infectious process with associated pleural effusion or possibly\n simply a layering effusion. No pneumothorax identified.\n\n IMPRESSION: Left lower lung consolidation obscuring left hemidiaphragm may\n represent combination of atelectasis/infectious process and effusion, though\n layering effusion alone is a possibility. When stable, recommend PA and\n lateral radiographs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188733,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube placement, eval interval change\n Admitting Diagnosis: PNEUMONIA;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n ? tube placement, eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxic respiratory failure, evaluate for tube placement.\n\n COMPARISON: Radiographs of .\n\n FINDINGS: Extensive new ground-glass opacity is seen throughout the lungs,\n and in the setting of a normal heart size is suggestive of non-cardiogenic\n pulmonary edema. Homogeneous density in the left lower zone suggests the\n presence of either extensive pneumonia or effusion or a combination of both.\n The right internal jugular central venous catheter, endotracheal and\n nasogastric tubes are in satisfactory position.\n\n IMPRESSION:\n 1. Significant worsening in appearance of the lungs with extensive\n ground-glass opacity consistent with edema, likely noncardiogenic.\n 2. Possible left lower lobe pneumonia and probable associated moderately\n large pleural effusion.\n 3. Satisfactory position of medical devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188729,
"text": " 10:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with pna and recent line placement.\n REASON FOR THIS EXAMINATION:\n Please eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and recent line placement, evaluate line.\n\n PORTABLE AP CHEST RADIOGRAPH\n\n COMPARISON: , at 21:45.\n\n FINDINGS: The tip of the ET tube has been withdrawn and is now at the level\n of the clavicles, approximately 6.5 cm from the carina. The NG tube is in the\n stomach. A right-sided IJ line is in place, in satisfactory position in the\n mid SVC. There is no pneumothorax. Left basilar opacity is stable. There is\n worsening interstitial edema. There may be a small left effusion, but no\n right-sided effusion.\n\n IMPRESSION: The ET tube has backed out since the previous examination, now\n 6.5 cm above the carinal. Satisfactory IJ line. Stable left lower lobe\n opacity. Probable worsening edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188726,
"text": " 9:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with respiratory failure, hypotension\n REASON FOR THIS EXAMINATION:\n assess intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure. Evaluate intubation.\n\n AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph at 2056.\n\n FINDINGS: The patient has been intubated with the tip of the ET tube 2.8 cm\n from the carina. An NG tube is in the stomach. There remains extensive\n opacification at the left base similar to the prior study. There is somewhat\n worsening of the pulmonary interstitial markings. No pneumothorax is present.\n\n IMPRESSION: Satisfactory ET tube position. Stable left lower lobe opacity.\n Increased in vascular engorgement/vascular congestion.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-06 00:00:00.000",
"description": "Report",
"row_id": 174026,
"text": "Sinus tachycardia. Low limb lead QRS voltage. Anterolateral lead ST-T wave\nchanges. Findings are non-specific. Since the previous tracing of the same\ndate no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-06 00:00:00.000",
"description": "Report",
"row_id": 174027,
"text": "Sinus tachycardia. Low limb lead QRS voltage. Anterolateral lead ST-T wave\nchanges. Findings are non-specific. Since the previous tracing of the same\ndate no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-06 00:00:00.000",
"description": "Report",
"row_id": 174028,
"text": "Probable sinus tachycardia. Low limb lead QRS voltage. Anterolateral\nST-T wave abnormalities. Findings are non-specific and basline artifact makes\nassessment difficult. Since the previous tracing of the same date probably no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-06 00:00:00.000",
"description": "Report",
"row_id": 174029,
"text": "Sinus tachycardia. Anterolateral lead ST-T wave changes are non-specific.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-07 00:00:00.000",
"description": "Report",
"row_id": 174030,
"text": "Sinus tachycardia. Low limb lead QRS voltage. Modest lateral lead T wave\nchanges. Findings are non-specific. No previous tracing available for\ncomparison.\n\n"
}
] |
85,539 | 196,491 | ASSESSMENT: 55yo F with Hx of HTN and DM who experienced acute shortness of breath, likely a result of pulmonary edema hypertensive urgency. . # SOB/dialstolic CHF: Presentation and CXR are indicative of flash pulmonary edema in the setting of uncontrolled hypertension. Pt is on a relatively large dose of clonidine, so if missed a dose experienced rebound HTN. Labetolol drips and nitro drips were started in the ED. Pt was placed on BiPAP in the ED, and was able to be taken off of it easily upon arrival to the CCU. In the CCU, she responded briskly to Lasix. Her LOS fluid balance was -7.6L. Per patient, she did not carry a Dx of CHF. Echo showed grade II LV disastolic dysfunction. Cardiac enzymes were negative. . # HTN: Pressures well-controlled on nitro gtt. The goal antihypertensive regimen for this patient was long-acting meds to avoid rebound with missed doses. After trail and error, the pt's SBP was stable in the 110s-120s on metoprolol succinate 300mg daily, lisinopril 40mg daily, and amlodipine 10mg daily. HCTZ 25mg daily was added as this pt appears to have very salt-responsive HTN. According to previous PMD's office, pt had not had a workup for secondary causes of HTN. TSH/T4 were normal. Renal US showed no evidence of renal vascular disease. 24 hour urine for metanephrines and cortisol as well as serum renin and aldosterone were sent out to look for any other endocrinse causes of HTN. Pt is going to establish a new PMD here at who can f/u on these labs when the results are available. . # Type II DM: Home metforim was continued. . # Methadone maintenance: Home dose of 80mg was continued after it was verified with her counselor. She recieves her methadone d/c to take to her clinic. . # Depression: Home doses of sertraline and amitryptline continued. Social work consulted to talk to patient re: stressors at home. . # gastritis: Home pantoprozole continued. . #. Code: presumed full . | Mild (1+) mitral regurgitation is seen. There is mild symmetric left ventricularhypertrophy. Mild Q-T interval prolongation. Normal ascending aortadiameter. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Doppler parametersare most consistent with Grade II (moderate) left ventricular diastolicdysfunction. Low normal LVEF.Doppler parameters are most consistent with c/w Grade II (moderate) LVdiastolic dysfunction. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. ST-T wave abnormalities are less prominent.TRACING #2 No resting LVOT gradient.AORTA: Normal aortic diameter at the sinus level. The left ventricular cavity size is normal. Sinus rhythm at upper limits of normal rate. Normal LV cavity size. Since the previous tracingST-T wave abnormalities are less prominent.TRACING #3 BorderlinePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Normal aortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation. Hypertension.Height: (in) 66Weight (lb): 216BSA (m2): 2.07 m2BP (mm Hg): 147/93HR (bpm): 81Status: InpatientDate/Time: at 11:25Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Sinus rhythm. Sinus rhythm. Since the previous tracingof probably no significant change. Probable sinus tachycardia. ST-T wave abnormalities. Baseline artifact. The mitral valve leafletsare mildly thickened. There isborderline pulmonary artery systolic hypertension. No AS. ST-T waveabnormalities are new.TRACING #1 Overall leftventricular systolic function is low normal (LVEF 50-55%). Since the previous tracing the rate isslower. ST-T wave abnormalities.Since the previous tracing of the rate is faster. There is no pericardialeffusion. | 5 | [
{
"category": "Echo",
"chartdate": "2147-06-27 00:00:00.000",
"description": "Report",
"row_id": 99753,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Hypertension.\nHeight: (in) 66\nWeight (lb): 216\nBSA (m2): 2.07 m2\nBP (mm Hg): 147/93\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 11:25\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF.\nDoppler parameters are most consistent with c/w Grade II (moderate) LV\ndiastolic dysfunction. No resting LVOT gradient.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is low normal (LVEF 50-55%). Doppler parameters\nare most consistent with Grade II (moderate) left ventricular diastolic\ndysfunction. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. The mitral valve leaflets\nare mildly thickened. Mild (1+) mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-06-27 00:00:00.000",
"description": "Report",
"row_id": 285055,
"text": "Sinus rhythm. Mild Q-T interval prolongation. Since the previous tracing\nST-T wave abnormalities are less prominent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2147-06-27 00:00:00.000",
"description": "Report",
"row_id": 285056,
"text": "Sinus rhythm. ST-T wave abnormalities. Since the previous tracing the rate is\nslower. ST-T wave abnormalities are less prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-06-26 00:00:00.000",
"description": "Report",
"row_id": 285057,
"text": "Baseline artifact. Probable sinus tachycardia. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. ST-T wave\nabnormalities are new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2147-06-27 00:00:00.000",
"description": "Report",
"row_id": 285054,
"text": "Sinus rhythm at upper limits of normal rate. Since the previous tracing\nof probably no significant change.\n\n"
}
] |
20,747 | 192,314 | The patient, as noted above, was initially admitted to the Medical Intensive Care Unit. The first two weeks of the patient's approximately hospital stay were spent in the Intensive Care Unit. The patient was admitted to the Medical Intensive Care Unit on pressor support and started on ceftriaxone for presumed sepsis. The ensuing workup of the patient's fever included blood cultures that would later grow out methicillin-sensitive staphylococcus aureus, as would tissue samples from the patient's right lower extremity. Cerebrospinal fluid and joint fluid from the patient's right knee did not yield any cultured organisms. The Vascular Surgery and Infectious Disease services were consulted and followed the patient throughout the remainder of his hospital course. The patient's antibiotic regimen underwent several iterations following admission. The Medical Intensive Care Unit course was notable for the following events: : The patient ruled in for a myocardial infarction, with a maximum CK of 1284, and a maximum troponin of greater than 50. He was intubated for respiratory failure. The patient's creatinine also reached its zenith at 3.3. The patient underwent right lower extremity biopsy of his fascia, which was ultimately deemed to be necrotizing fascitis per pathology report. | min serosang drg. Doppler pulses noted. wheeze with gd. Vas deferens calcifications are seen. Resp CarePt. ceftaz and flagyl dc'd. lopressor on hold.troponin elevated, r/i for mi. PERRLA, +cough noted. edema noted throughout, part dependent.neuro: very sedate with min response to intervention, sxn'ing, turning etc. rhonchi, clearing somewhat with sxn. See carevue for titrations. CHEST, SINGLE AP PORTABLE: The left subclavian central line terminates within the mid-SVC. Wean vent as tolerated per MDS. The ET tube has migrated caudally, with the tip now less than 1 cm above the carina. Sutures to RT. IMPRESSION: 1) Bilateral pleural effusions with a small amount of dependent atelectasis. min brown, ob+aspirates. SINGLE-VIEW CHEST: There is moderate LV enlargement. ngt clamped. Sepsis. Rule out necrotizing fasciitis. There is a persistent right effusion. A left-sided CVC terminates within the mid SVC. Left hemidiaphragm is noted with visualized suggestive of left lower lobe consolidation. monitor for ischemia/chf. PERRLA. REASON FOR THIS EXAMINATION: ?consolidatin, ? Interval development of mild CHF with a small left pleural effusion. Left subclavian CV line is in proximal SVC. S/P CABG. follow cks. mb+. Became tachypnic, hypertensive, VT's decreased, decided to rest pt. Sternal wires are present, evidence of prior sternotomy. Chews on ET tube. Please check placement of ET tube. Please check placement of ET tube. 10:27 PM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: PT with asymmetric RLE swelling. TEMP MAX 99.3NEURO: MS04 WEANED OFF. ?extubation today pending on mental status.GI: Abd softly distended with +BS. CURRENT ABG'S 7.41,29,103,19,-4. extubate in the AM if pt tolerates ativan wean and diuresis. small bm in am.endo- cont. tachypneic, resp. BS HYPOACTIVE. Slight non purposeful movements noted in upper extremities.CV: B/P labile after given lasix and lopressor this AM. HAD LG BM. finally stabililzed with propofol gtt. SEE FLOW REGARDING BS TRENDS.SKIN: REMAINS EDEMATEOUS. NTG at 2.1 mcg/kg/mincurrently and tolerating well. sepsis, resp failuremicu npn (in ccu)o- id- afebrile, cont. K+ replacement given as ordered.GI: Pt. REMAINS ON NTG 1.94MCG/KG/MIN SBP 134-150/62-73.RESP: CPAP+PS10,40%,peep 5, VT 370-490. Was given MSO4 2mg IVP x two. EKG done. abgs done x2, ph 7.32 to 7.34. last abg- 79,32,7.34,18. sats 95-100. l/s coarse/dim with scat wheezes at times. ABG'S 7.39,30,105,19,-5. Temp 100 rectal. BROWN GUIAC +.GU: U/O 30-90CC/HR. Lip ulcers healing, oral care provided.ID: Temp max 100.6. Resp CarePt. ABG 7.50/32/112/26. aware gtt stopped and D5 infusion hung at 100cc/hr. CXR done this AM. ABD LGBUT SOFT WITH HYPOACTIVE BS. MYCOSTATIN APPLIED.NEURO: REMAINS ON PROPOFOL 25MCG. Receiving MDI's per resp. ACE WRAP REAPPLIED. FS checked q1-2hr. CLINDA,CEFTRIAXONE,GENTA. Suctioned Q2-3H for small amt of white thin secretions.GI/GU: TF at goal 60cc's with minimal residual. i+o remains pos.gi- cont. Replete K+. repos with skin care q3hrs. HAS BILAT PULSES BY DOPPLER. will need baracat prep.endo: bs 220-300, started on qid ss coverage.gu: uop 40-100cc/hr. BS COUSRE BILAT.GI: TF OFF FOR LP. BS: ess. DIURESED WELL.ID: T(MAX)101(PO)->99.8. Pt edematous generally. Abdomen soft, hypocative BS noted, NG connected to LIS. ON IV OXACILLIN & ACYCLOVIR & PO LEVOFLOX.ENDO: BS 309->228. NTG drip d'cd and isosorbide given per Dr. . Continues on oxacillin, levaquina and acyclovir.GI: Pt. On Oxacillin, clinda and ceftaz. Abd distended, more so than a couple days ago, soft, BS present. gen + edema. Wean on vent as tolerated, monitor ABGs. Update pt. Temp. Temp. Doppler pulses noted dp/pt bilaterally. scant serosang drg. spike to 101.3, reported to Dr. . ABGs sent, see carevue. See weaning per carevue. Resp. Pt repeated with CA and Mg today.ID: Pt low grade temp t-max 100.4, sputum cx sent to complete ON pan cx. Vanco dose x1 given as ordered. Coarse to clear breath sounds.GI/GU: Tf re-initiated at 1400. LP DONE IN ER . follow uop/volume status. Sinus rhythmPossible left atrial abnormalityLeft axis deviationPoor R wave progressionSince previous tracing, anterior T waves are now upright Sm sips given. Currently Ativan at 1mg/hr and MSO4@2mg/hr. to receive inhalers, RT aware. Re-orientation provided to pt. Follows commands.CV:Nitro gtt @ 9cc/hr=60mcg/min. MDIs given as ordered. Culture from leg + for staph aureus. FSBS Q1H. IV NTG initiated for B/P controlwith fair effect at .75mcg/kg/min. PERRLA. MS TEMP 105HYPOTENSIONDMCHFP. Able to wean them, see carevue for titrations. BP 121-152/44-68. abd soft, +bs. BS clear and shallow bilaterally.GI: Pt on TF, promote with fiber at goal of 70, minimal residual. FINAL REPORT INDICATION: Persistent erythema of the right lower extremity following debridement. There arepersistent small R waves in the inferolateral leads consistent with oldinferior wall myocardial infarction. Sinus rhythmLeft axis deviation - anterior fascicular blockNonspecific lateral ST-T abnormalitiesSince previous tracing, , wide complex today no longer present Sinus tachycardiaLeft axis deviation - consistent with left anterior fascicular blockPossible old anterior infarctNonspecific anterolateral ST-T abnormalities - possible ischemiaSince previous tracing, , no significant change FINAL REPORT INDICATION: Right lower extremity wound. Minimal bibasilar atelectasis and blunting of the right costophrenic angle. The distal third metatarsal appears ill-defined, with cortical interruption, suggestive of osteolysis of the distal third metatarsal. Allowing for this, patient is status post sternotomy. TECHNIQUE: Noncontrast head CT. RIGHT FOOT, 3 VIEWS: There is evidence of diffuse osteopenia. The left hemidiaphragm is again not visualized, suggestive of left lower lobe consolidation. Sinus rhythmPossible left atrial abnormalityAnterolateral ST-T changes may be due to myocardial ischemiaSince previous tracing, no significant change Sinus tachycardiaPossible left atrial abnormalityAnterolateral ST-T changes may be due to myocardial ischemiaLow QRS voltages in limb leadsSince previous tracing, precordial T wave changes noted consistent withischemia The tip is not optimally seen, though appears to overlie the mid SVC. FINDINGS: Son of the left upper extremity demonstrated a patent and compressible basilic vein. Old inferior myocardialinfarction. FINAL REPORT HISTORY: Respiratory failure. There is evidence of prior sinus surgery on the left as the ethmoid air cells are not present. Minimal blunting right costophrenic angle. | 74 | [
{
"category": "Radiology",
"chartdate": "2132-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759142,
"text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?consolidatin, ? atelectasis. intubated patient spiking new\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis and sepsis,\n intubated.\n REASON FOR THIS EXAMINATION:\n ?consolidatin, ? atelectasis. intubated patient spiking new fever.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Diabetes. Sepsis.\n\n CHEST, AP: Comparison is made to previous films from . Again noted\n is evidence of NG tube and ET tube, both of which are in good position. The\n heart is at upper limits of normal size. Hilar and mediastinal contours are\n unremarkable. Left hemidiaphragm is noted with visualized suggestive of left\n lower lobe consolidation. Also noted is linear atleectasis noted at the left\n base. No evidence of definite effusion or pneumothorax. Visualized osseous\n structures are unremarkable.\n\n IMPRESSION: Left lower lobe consolidation, consistent with early focus of\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758462,
"text": " 3:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with hypotension and fever\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension and fever, rule out pneumonia.\n\n COMPARISON: .\n\n AP CHEST: There are lower lung volumes on today's exam. Given the\n differences associated with this technique, the heart, mediastinal and hilar\n contours have not changed. The pulmonary vascularity is normal. There is no\n evidence of overt failure or pneumonia. The apparent prominence in the\n interstitium is likely due to crowding of vessels. There are no effusion.\n Sternal wires are present, evidence of prior sternotomy. Osseous structures\n are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary pathology.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758556,
"text": " 12:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with labored breathing. Please evaluate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n REASON FOR THIS EXAMINATION:\n Pt with labored breathing. Please evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 46 y/o male admitted with cellulitis, now with labored\n breathing.\n\n PORTABLE AP CHEST: Comparison is made to an exam of . There has been\n slight interval enlargement of the cardiac silhouette with increased\n engorgement and indistinctness of the pulmonary vasculature. There is a small\n left pleural effusion as well as obscuration of the left hemidiaphragm by a\n retrocardiac opacity. The soft tissues and osseous structures are unchanged.\n\n IMPRESSION:\n 1. Interval development of mild CHF with a small left pleural effusion.\n 2. New retrocardiac opacification, which may represent left lower lobe\n atelectasis versus an evolving pneumonic consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758573,
"text": " 3:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new L subclavian placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n REASON FOR THIS EXAMINATION:\n new L subclavian placement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Cellulitis. New left subclavian line placement.\n\n CHEST, SINGLE AP PORTABLE: The left subclavian central line terminates\n within the mid-SVC. There is no evidence for pneumothorax. The cardiac and\n mediastinal contours are unremarkable. There are small bilateral pleural\n effusions. There is no evidence for CHF.\n\n IMPRESSION: Appropriate positioning of left subclavian catheter without\n evidence for pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-30 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 758512,
"text": " 10:27 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: PT with asymmetric RLE swelling. Please eval for DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout\n REASON FOR THIS EXAMINATION:\n PT with asymmetric RLE swelling. Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cellulitis in right lower extremity with swelling in right lower\n extremity.\n\n RIGHT LOWER EXTREMITY VENOUS ULTRASOUND WITH DOPPLER AND COLOR FLOW ANALYSIS:\n The right femoral, superficial femoral, and popliteal veins show normal\n compressibility, color flow signal, and Doppler flow signal. There is no\n evidence of deep venous thrombosis in the right lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-01 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 758595,
"text": " 12:18 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval abd and right leg. ? acute abd process. ? right\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD s/p CABG, and s/p renal transplant now with gram +\n bacteremia and right leg pain. Need to eval abd for acute process but contrast\n difficult given renal function and sepsis. further please evaluate right leg\n for faschitis. patient cannot have MR given history of metal in eye\n REASON FOR THIS EXAMINATION:\n please eval abd and right leg. ? acute abd process. ? right leg fasciaitis\n ______________________________________________________________________________\n FINAL REPORT\n CT ABODMEN AND PELVIS WITHOUT IV OR ORAL CONTRAST, AT 0011\n\n INDICATION: Gram positive bacteremia and right leg pain.\n\n TECHNIQUE: Noncontrast CT images were obtained from the lung bases through\n pubic symphysis without oral or IV contrast.\n\n No prior CT of the abdomen available for comparison.\n\n CT ABDOMEN W/O IV CONTRAST: There are bilateral pleural effusions with\n associated dependent atelectasis. The liver shows diffuse fatty infiltration.\n The spleen, pancreas, and adrenal glands are normal in this noncontrast study.\n Diffuse vascular calcifications are seen along the aorta, celiac axis, iliac\n vessels, and splenic artery. The native kidneys are bright and there are\n multiple vascular calcifications in the native renal arteries.\n\n There is no free air within the abdomen. Some ascites is seen tracking around\n the liver and spleen. A small amount of ascites tracks down into the right\n paracolic gutter. There is no significant mesenteric or retroperitoneal\n adenopathy.\n\n CT PELVIS W/O IV CONTRAST: The large and small bowel are not opacified but are\n adequately visualized. The small bowel is mostly collapsed. Some air is seen\n within the transverse colon. There are no areas suspicious for bowel wall\n thickening. There are no focal areas of luminal dilatation. Some free fluid\n is present within the pelvis. Vas deferens calcifications are seen.\n\n Bone windows show no suspicious lytic or blastic lesions.\n\n IMPRESSION: 1) Bilateral pleural effusions with a small amount of dependent\n atelectasis. 2) Extensive vascular calcifications. 3) No intraabdominal\n abscess or collections of free air. There is, however, some free fluid within\n the pelvis and a trace amount of ascites around the liver and spleen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-01 00:00:00.000",
"description": "R CT LOWER LIMB W/O CONTRAST RIGHT",
"row_id": 758596,
"text": " 12:19 AM\n CT LOWER LIMB W/O CONTRAST RIGHT Clip # \n Reason: QUESTION LEG FASCIAITIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cellulitis. Rule out necrotizing fasciitis.\n\n TECHNIQUE: Axial scans from the just above the knee to the ankle mortise. No\n prior studies are available for comparison.\n\n FINDINGS: There is stranding of the subcutaneous tissues medially along most\n of the length of the lower leg. At the distal tibia and fibula, stranding\n also exists posteriorly and anteriorly. The stranding is confined to the\n subcutaneous tissues and does not extend into the deep muscles. The distal\n muscles demonstrate fatty atrophy. More proximally, the appearance of the\n muscles are normal. At the distal tibia and fibula there are more focal fluid\n densities located both medially and posteriorly, and these may represent\n developing subcutaneous abscesses. No air is seen throughout the region\n scanned. Note is made of extensive vascular calcifications. The visualized\n bones are well corticated, and show no evidence of focal demineralization, no\n areas of periosteal reaction and no cortical irregularities to suggest\n osteomyelitis.\n\n IMPRESSION:\n\n 1. Cellulitis along the length of the leg.\n\n 2. Possible developing subcutaneous abscesses distally over medial malleolus,\n located both medially and posteriorly.\n\n 3. No air to suggest necrotizing fasciitis.\n\n 3. Fatty atrophy of the distal calf muscles but no inflammation of the deep\n muscles of the lower leg.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758846,
"text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary edema. ? worsening effusion.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n\n REASON FOR THIS EXAMINATION:\n ? pulmonary edema. ? worsening effusion.\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Diabetes, CAD, admitted with cellulitis and pulmonary edema. Assess\n for worsening effusion.\n\n PORTABLE AP CHEST: Comparison is made to exam of .\n\n The ET tube has migrated caudally, with the tip now less than 1 cm above the\n carina. The NG tube and left-sided central venous catheter remain in\n satisfactory position. There is persistent cardiomegaly. The mediastinal and\n hilar contours are stable. There has been an interval increase in the size of\n the left pleural effusion. There is a persistent right effusion. The lungs\n are otherwise, unchanged. The soft tissues and osseous structures are stable.\n\n IMPRESSION:\n 1) Tip of ET tube too low with tip less than 1 cm above the carina.\n\n 2) Interval increase in the size of left pleural effusion with persistent\n small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758586,
"text": " 5:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PT is post-intubation. Please check placement of ET tube.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n REASON FOR THIS EXAMINATION:\n PT is post-intubation. Please check placement of ET tube.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of diabetes and cellulitis with intubation. To evaluate ETT.\n\n S/P CABG. ETT is 2 cm above carina. Left subclavian CV line is in proximal\n SVC. No pneumothorax. NGT is in stomach with distal end not included on\n film. The lungs are grossly clear apart from possible mild atelectasis in the\n left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758633,
"text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt s/p intubation for resp distress, finding of CHF. Please\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n REASON FOR THIS EXAMINATION:\n Pt s/p intubation for resp distress, finding of CHF. Please evaluate for\n improvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/p , CHF.\n\n COMPARISON: .\n\n SINGLE-VIEW CHEST: There is moderate LV enlargement. There are small\n bilateral pleural effusions. Upper zone redistribution is present. There is\n blurring of the vascular detail at both lung bases. There is a small amount\n of collapse/consolidation of the left lower lobe.\n\n The ET tube is was in appropriate position. The NG tube extends below the\n diaphragm. A left-sided CVC terminates within the mid SVC.\n\n IMPRESSION: Findings consistent with worsening CHF. Lines and tubes in\n appropriate position.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-01 00:00:00.000",
"description": "Report",
"row_id": 1534283,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ SEPSIS; RESP FX\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- HR- 80-100'S SR, NO VEA.\nBP- 109/54- 128/67- ABLE TO WEAN DOWN LEVO GTT FROM 15 MCG TO 2 MCG CURRENTLY. HEMODYNAMICS STABLE THIS SHIFT WITH WEANING OF PRESSOR.\n\n PT REMAINS ON VENTILATORY SUPPORT WITH MARGINAL ACID/BASE BALANCE AND LOW CO2.\nCURRENTLY ON 40%/700/16 A/C. DECREASED FROM A RATE OF 25 AT START OF SHIFT IN ATTEMPTS TO RAISE CO2>20.\n\nRANGES- PO2- 126-173\n CO2- 15- 20\n PH- 7.26- 7.33\n\nSUCTIONED FOR MINIMAL SPTUTUM WITH DIM BREATH SOUNDS AT BASE.\nONCE SEDATED, BREATHING IN SYNCH WITH VENT.\n\n PT REMAINS ON FLAGYL/VANCO/CEF.\nSURGERY PERFORMED BIOPSY AT 7P OF RT LEG.\nPT TO CT SCAN OF ABDOMEN AND RT LEG AT 12AM.\nPRELIM REPORT FOR CT SCAN- (-).\n\n PT OG TUBE CLAMPED.\nNO STOOL THIS SHIFT.\nBILOUS MATERIAL FROM OG- TR (+)-= STARTED ON PROTONIX.\n\nENDO- SUGARS TRENDING UP - 250-350'S- GIVEN 8 U REG SS AND INCREASED LENTE TO 9U. DISCUSSED INSULIN GTT- DEFERED AT THIS TIME.\n\n PT INITIALLY ON PROPOFOL GTT 55 MCG/KG WITH GOOD LEVEL OF SEDATION AND STABLE BP.\nORDERED TO SWITCH TO ATIVAN/MSO4 FOR RENAL CONSIDERATION.\nREQUIRING MUCH BOLUSES TO ACHIEVE LEVEL OF SEDATION.\nCURRENTLY ON 10 MSO4/4 ATIVAN GTT.\n\n WIFE IN TO VISIT, LEFT AT 11PM.\nAPPEARS TO UNDERSTAND SITUATION.\n\nA/ PT WITH SEVERE SEPSIS CONTINUES TO REQUIRE MECHANICAL VENTILATION TO COMPENSATE FOR ACIDOSIS.\n\n CONTINUE TO ATTEMPT TO KEEP CO2 > 20, PH > 7.30.\n ? INSULIN GTT TODAY.\n CONTINUE TO ATTEMPT TO WEAN OFF LEVO GTT - GOAL MAP> 60.\n CONTINUE ANTIBX AS ORDERED- AWAIT FINAL CT SCAN/BIOPSY RESULTS.\n SEDATION/COMFORT WHILE INTUBATED.\n KEEP FAMILY AWARE OF PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-01 00:00:00.000",
"description": "Report",
"row_id": 1534284,
"text": "Resp Care note 7p-7a\nPt remains on full vent support, well sedated. ABG's continue with metabolic acidosis, attempting to compensate with vent MD. PaCO2's continue in high teens->low 20's. Well Oxygenated. Would plan to wean rate to increase PaCO2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-01 00:00:00.000",
"description": "Report",
"row_id": 1534285,
"text": "ccu/micu nursing progress note\ns: sedated, orally intubated\no: pls see carevue flowsheet for complete vs/data/events\nid: afeb. wbc 22(20). ceftaz and flagyl dc'd. awaiting id approval for zosyn. cont on vanco, needs a trough before 4pm dose.\ncv: hr 80s sr, no vea. cont to req low dose levo to support sbp >90. lopressor on hold.\ntroponin elevated, r/i for mi. follow cks. mb+. no current evidence of ischemia.\nhct 27.5. 1st of 2u prbcs up at 2pm.\nresp: a/c 600 x14. 40%, 5peep. bs coarse at bases. scant secretions. last abg: 7.36/28/96/16/ -7.\ngi: abd soft, no bs appreciated. no stool today. ngt clamped. min brown, ob+aspirates. plan to start tf this afternoon.\nendo: bs 350-400, with anion gap this am. rec'd ns bolus, 1/2amp d50, iv insulin push and now a gtt. also getting freq k replacement. bs now <200 on insulin at 6u/hr. will cont to follow q1-2hrs.\ngu: uop 60-100cc/hr. cr 2.1. no diuresis. rec'ing d5ns w/ 40kcl at 100cc/hr, currently on hold as pt rec'ing bld products.\nskin: r leg with incision on posterior calf, approximated. benign. min serosang drg. dsd changed. leg with mild erythema. some mottling near arch area on bottom of foot. leg kept elevated, pitting edema. edema noted throughout, part dependent.\nneuro: very sedate with min response to intervention, sxn'ing, turning etc. ativan and mso4 titrated back per flowsheet.\nsocial: wife and present and updated by nursing and physicians.\n\na: hemodynamics and acidosis improving. bs stabilizing on insulin gtt.\n\np: wean levo as tol for sbp >90. follow volume status. transfuse this eve. monitor for ischemia/chf. follow bs, titrate insulin gtt per scale. begin tf, advance as tol, awaiting nutrition recommendation.\ncheck vanco trough at 4pm. follow hct and lytes post transfusion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-01 00:00:00.000",
"description": "Report",
"row_id": 1534286,
"text": "CCU NPN 3-11PM\nCV: remains on Levo, decreased to 1ug/min with BP 100-110/70, HR 80's NSR.\n\nResp: No changes made in vent, sats 100%. LS clear, suctions for scant white secretions.\n\nEndo: cont on SS reg ins, following BS q 1 hr, see careview for details. BS dropping added D10 and kept Reg ins gtt at 1U/hr.\n\nNeuro: sedated on MSO4 and Ativan gtt.\n\nSkin: dressing to R calf D&I.\n\nID: afebrile, started on Zosyn this eve.\n\nGI: started on Peptamin TF, FS at 100/hr with residual of 10cc after 4 hrs, increased to 20cc/hr at 9PM.\n\nsoc: wife in for few hours this eve, updated.\n\nA/P: able to wean Levo somewhat, BS droping, cont q 1 hr BS with adjustments, cont sedation, vent support, support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 1534287,
"text": "NURSING PROGRESS NOTES 7PM-7AM\n\nNEURO: Pt. remains sedated on Morphine and Ativan drips. Able to titrate MSO4 drip down to 6mg/hr, with pt. remaining sedated. See carevue for titrations. Half-way opens eyes with turns and moves arms spontaneously with turns. Does not follow commands. PERRLA, +cough noted. Grimaces and stiffens body when right leg touched or moved. Falls back to sleep when left alone. Care and procedures explained to pt. Emotional support given.\n\nRESP: Vent settings= AC rate 14, FIO2=40%, TV=600, +5 peep. No vent changes made this shift. ABGs done, and MDs aware of results, no further orders received. Lungs clear, suctioned for scant white secretions. O2 sats>98%.\n\nCV: Pt. remains in NSR without ectopy. Levophed titrated to maintain MAP>60 per Dr. and Dr. . See titrations per flow sheet. Currently Levo gtt off, with SBP>90 and MAP>65. Pt. has remained afebrile, skin warm and dry. Doppler dp/pt pedal pulses. Repeat HCT at 0130=32 and CK level reported to Dr. , no further orders received.\n\nGI: Pt. still receiving D10 at 50cc/hr. Blood sugars checked and insulin drip titrated as ordered, currently at 3u/hr. See carevue for blood sugars and insulin drip titrations. Peptamen infusing via NG. Initial residual check at 2400=90cc, rate kept at 20cc/hr. Residual re-checked at 0400 =20cc. Tube feed rate increased to 30cc/hr. Minimal bowel sounds noted, no BMs as of yet. Chemistry labs done at 2400, reported to Dr. , potssium 40meq given via NG as ordered.\n\nGU: Urine output >30cc/hr via foley catheter.\n\nSKIN: Right calf to knee, reddened, warm and swollen. Doppler pulses noted. Dressing on posterior calf dry and intact. Purplish area noted on arch of right foot. Right leg elevated on pillows. No skin breakdown noted on back or buttocks. Pt. turned q2h.\n\nSOCIAL: No contact with any family from as of yet. wife was in earlier, prior to assuming care of pt.\n\nPLAN: Wean sedation as tolerated, maintaining pt's comfort while on vent. Wean vent as tolerated per MDS. Monitor labs, replace electrolytes as ordered and monitor HCT. Monitor blood sugars and titrate insulin drip as needed. Monitor temps, WBC and give antibiotics as ordered. Continue to update family and provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 1534288,
"text": "GI: Blood sugar at 0400=209. Insulin drip not increased at tPROGRESS NOTE TIME ACTUAL = 2300 to 0700, not 7p-7a.his time by error. Blood sugar re-checked at 0600=221, Insulin drip increased from 1u/hr to 3u/hr at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 1534289,
"text": "GI: Blood sugar at 0400=209. Insulin drip not increased at tPROGRESS NOTE TIME ACTUAL = 2300 to 0700, not 7p-7a.his time by error. Blood sugar re-checked at 0600=221, Insulin drip increased from 1u/hr to 3u/hr at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-06 00:00:00.000",
"description": "Report",
"row_id": 1534302,
"text": "7a-7p Shift Nursing Note\n\nNeuro: Ativan DC'd at 12p and no MSO4 given since 10a. Pt. con't to be sedated. Attempts to open eyes with aggressive stimulation. Grimaces with turning. Chews on ET tube. PERRLA. Purposeful movement noted to bilat arms. Bilat. soft wrist restraint on.\n\nCV: ST throughout shift. HR110-120. SBP 145-180/65-90. Remains on lopressor and started on Valsartan for BP.\n\nPulm: No changes to vent. CPAP+PS 5 and peep 5. FiO2 40% TV 650-750. RR-. O2 sat 100% throughout shift. LS clear-course and dim to bases. Sxn small white thin secretions. If pt wakes up MICU team would like to extubate.\n\nGI: BS+X4. ABD. soft. BM X 2. TF off in anticipation of extubation. NG remains to Rt. nare. Insulin gtt con't, titrate according to order.\n\nGU: UOP yellow, clear, and WNL.\n\nSkin: Amputations of digits to hands and feet. Various fingers to bilat. hands with blackening. Sutures to RT. leg intact with scant amt of drainage. Dressing change done @ 1645.\n\nSoc: Wife has not been in to visit this shift.\n\nIV:TLC to Lt.SC and Rt.radial art line.\n\nStatus:full code\n\nPlan: Hold sedation to allow pt to wake. Monitor BS and titrate gtt as ordered, Maintain pain/comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 1534303,
"text": "Resp Care\nPt. on PSV 5/5/40% tolerating well. Became tachypnic, hypertensive, VT's decreased, decided to rest pt. overnight on . Vts 500-650mls, with MV varying from 10-15Lpm. Bs: coarse,occ. exp. wheeze with gd. response to bronchodilators, occ. rhonchi, clearing somewhat with sxn. Sxn'd thick brown plug x1, otherwise scant to moderate white. Plan is to extubate on days if pts. LOC is adequate\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 1534304,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Sedation off since 12pm. Pt blinking pt not opening his eyes. Pt biting on ETT and moving head. No spontaneous movement of extremities noted. Pt is not following commands. wife visiting last evening and commented that pt was not as bright as . Pt hasnot received morphine since 10am .\n\nCV: ST HR 109-116 w/o ectopy. Pt conts to receive lopressor 25mg and valssartan 80mg QD (rec'd first dose pm ). BP 164-180/80's of hypertension. Pt with total body fluid overload.\nHCT 34.2 K+3.0 await orders for repletion.\n\nPULM: Mechanically ventilated on CPAP and PS now 10 (5 )peep and 40%fi02. LS coarse. Early this am pt became tachycardic to 130's, RR 30, and Tv decreased. Pt bagged and sxn'd for tan plug, PS increased to 10 at this time with effect. ABG 7.50/32/112/26. RR currently 20 with sats 100%. ?extubation today pending on mental status.\n\nGI: Abd softly distended with +BS. Pt had BM x 1 soft brown stool. TF restarted at 9pm promote with fiber at goal rate 60cc/hr and stopped again at 5am for possible extubation.\n\nGU: Foley cath patent draining cyu in large amts u/o 125-150cc/hr. BUN 49 and Creat 1.3 -250 since mn and + LOS. Pt last rec'd lasix am .\n\nENDO: Pt conts on insulin gtt at 6u/hr. BS 94-173 overnight. FS checked q1-2hr. Per pt's wife please check BS using ear lobe.\n\nPROPH: hep sc.\n\nSKIN: RLE cellulitis dsg c/d/i. Buttocks intact. Pt with many areas of skin tares. Lip ulcers healing, oral care provided.\n\nID: Temp max 100.6. Pt conts on clinda and oxacillin for cellulitis. WBC trending up 30.1(27.9).\n\nLINES: L SCTLC and R radial a-line\n\nDISPO: Full Code\n\nSOCIAL: Pt with wife and two children. Wife visited last evening updated on plan of care.\n\nP: Monitor Bp/HR. Replete K+. ?extubation today pending pt's mental status. Cont PS wean as tolerated. Cont q1-2hr FS. TF off. Skin Care. Provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 1534305,
"text": "Addendum to Nursing Porgress Note:\nPt spontaneously opening his eyes at 6am but not following commands. FS 55 since TF off for possible extubation, H.O. aware gtt stopped and D5 infusion hung at 100cc/hr. K+ 3.0 pt ordered to receive 60meq KCL wa from pharmacy. CPNCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-10 00:00:00.000",
"description": "Report",
"row_id": 1534316,
"text": "NEURO: SEDATED ON PROPOFOL 25MCG/KG. OPENS EYES SPONTANEOUSLY & MAKES\n EYE CONTACT AT TIMES. COOPERATIVE WITH CARE, BUT DOES NOT\n FOLLOW COMMANDS. MOVES ARMS SLIGHTLY ON BED.\nRESP: ON VENT: .40 + IPS 10 & PEEP 5. RR 11-25. O2 SAT 96-100%. SX FOR\n MOD. AMTS. THICK YELLOW SPUTUM. BS CLEAR BUT DIMINISHED AT\n BASES. AM ABG-> 7.47/39/149/29.\nCARDIAC: HR 120->90'S (AFTER LOPRESSOR). SR, NO ECTOPY. BP 117-153/\n 53-69. IV NTG TITRATED TO KEEP SBP 120-150. PRESENTLY\n INFUSING AT 1.5MCG/KG.\nGI: TF: FS PROMOTE WITH FIBER INFUSING AT GOAL RATE 60CC/HR. MINIMAL\n TO 0 RESIDUALS. ABD. SL. DISTENDED. BS HYPOACTIVE. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 55-75CC/HR.\nID: T(MAX) 100.4(PO)-> 99.4(PO). CONT. TO RECEIVE IV VANCO, OXACILLIN,\n & ACYCLOVIR, & PO LEVOFLOXACIN.\nENDO: INSULIN GTT INFUSING AT 3U/HR. BS 122-157.\nAM LABS PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-10 00:00:00.000",
"description": "Report",
"row_id": 1534317,
"text": "Neuro: Propofol dc'd this am and pt awake and alert following commands consistently and appropriately this afternoon. Moving extremities and grasping writer's hand when pt asked to do so.\nTracking with eyes when staff in room.\n\nCV: HR and B/P elevated after dc of propofol. NTG at 2.1 mcg/kg/min\ncurrently and tolerating well. St with no ectopy. Received 40 mg lasix IV with excellent diuresis.\n\nResp: L/S diminshed in the left lower base and clear to coarse in the upper lobes. Suctioned for small amt of thick yellow sputum Q3-4H prn. Sats 100%. Ps to 5 and PEEP at 5. Plans to extubate this afternoon. See CareVue for ABG's.\n\nGI/GU: TF at 60cc/goal. Small BM. + bowel sounds. Foley patent and draining clear urine.\n\nEndo: Insulin gtt at 5 u/hr and FSBS within 100-160.\n\nInteg: Lesions on lips crusting over which is consistent with HSV.\nLP results pending for CSF results but doubtful if it is herpes encephalitis due to only 1 WBC. Groin area and uttocks red and appear worse than on . Nystatin powder applied prn with frequent positioning changes. Sutures and lesions on lower extremities are stable and unchanged. Doppler pedal pulses.\n\nPlan: Extubate this afternoon if stable, continue antibiotics,\npain control, monitor VS and titrate NTG prn, and support patient and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-05 00:00:00.000",
"description": "Report",
"row_id": 1534298,
"text": "Neuro: Ativan wean in progress. Pt will open eyes to command and blinks upon command when asked if in pain. Slight non purposeful movements noted in upper extremities.\n\nCV: B/P labile after given lasix and lopressor this AM. Transient periods of hypotension to systolic low of 84. Team aware. Diuresised well after 20 mg lasix IVP. NSR to ST with no ectopy noted. Pt recently R/I MI therefore goal is to maximize beta blocker dose and ?\ninitiate ace therapy.\n\nResp: PS 10 and 5 PEEP. Excellent TV 1 Liter. Coarse breath sounds with occasional exp wheeze. Receiving MDI's per resp. O2 sats maintained at 100%. RR 8-20. CXR done this AM. Suctioned Q2-3H for small amt of white thin secretions.\n\nGI/GU: TF at goal 60cc's with minimal residual. Hypoactive bowel sounds. Loose stool X 2. Rectal bag placed without success and removed. Foley patent and draining clear yellow urine.\n\nEndo: Regular insulin gtt at 6u/HR. See CareVue for FSBS.\n\nID: Triple antibiotic coverage continues. Max temp 99.9 Ax. WBC 27\nwhich is increased from 24 but clinically pt appears improved.\n\nInteg: remains with blackened areas on finger tips and anterior aspect of foot. Team relates erythema improved, however. Right leg ace off per vascular and DSD applied. Sutures intact with no drainage.\n\nPlan: Diuresis carefully, increase beta blocker as pt tolerates, continue insulin gtt and steriods until pt off vent, monitor FSBS, pain control, ? extubate in the AM if pt tolerates ativan wean and diuresis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-06 00:00:00.000",
"description": "Report",
"row_id": 1534299,
"text": "Resp Care\nPt. initially on CPAP/PSV, breathing only 5-6 bpm, with tidal volumes exceeding 1200cc. Occasionally had periods of apnea. PS level lowered to 5,no periods of apnea ensued. Vts 900-1200cc with minute ventilation 10-13 lpm. Abgs acceptable range. BS: ess. CTO, sxn'd x2 for scant amounts white.Also following for mdis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-06 00:00:00.000",
"description": "Report",
"row_id": 1534300,
"text": "NSG NOTE\n\nCV: HR'S 92-112. NSR-ST. NO VEA NOTED. STARTED ON LOPRESSOR 12.5MG WITH LITTLE EFFECT ON HR. STABLE BP'S WITH MAP'S > 60. HYPERTENSIVE 170/80'S WHEN AWAKE.\n\nRESP: INITIAL SETTINGS CPAP+PS 10,40%,PEEP5. VT > 1000 WITH PERIODS OF APNEA RR 5-8. PS DECREASED TO 5 WITH NO PERIODS OF APNEA NOTED. RR- VT 900-1200. ABG'S 7.39,30,105,19,-5. SUCTIONED FOR THICK YELLOW SECRETIONS IN SM AMT'S. BS COURES.\n\nGI: TF PROMOTE WITH FIBER @ GOAL 60CC. RESIDUALS LOW. + BS NO STOOL THIS SHIFT.\n\nGU: RECEIVED LASIX 20MG WITH ADEQUATE DIURESIS. 24/HR TOTAL NEG BY 600CC,BUT OVERALL LOS STILL +. LOWER EXT SEEM TO BE LESS EDAMATOUS.\n\nSKIN: SUTURES OF R LEG C&D. DSD APPLIED. LEGS ELEVATED.\nLIP ULCER CARE COMPLETED.\n\nLABS: K+ 3.7 RECEIVED 40MEQ KCL IV\n BS PER CAREVUE. INSULIN CURRENTLY ON 3U/HR\n\n\nID: ON TRIPLE ABX OXACILLIN,CEFTRIAXONE,CLINDA. TEMP MAX 99.3\n\nNEURO: MS04 WEANED OFF. OPENS EYES ON COMMAND,ALTHOUGH NO CONSISTENCY WITH FOLLOWING COMMANDS. CON'T ON ATIVAN GTT .25MG IV. HAS PRN MS04 IF NEEDED. RECEIVED MS04 X2 OVERNOC WITH FAIR CONTROL.PEARL.\n\nSOCIAL: WIFE IN ON EVES TO VISIT. AWARE OF CONDITION AND PROGRESS MADE.\n\nDISPOSITION: FULL CODE\n\nA: GUARDED STABLE\n\nP: AM LABS\n CON'T PER NSG JUDGEMENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-09 00:00:00.000",
"description": "Report",
"row_id": 1534313,
"text": "CCU NPN\n S/O: Neuro: Eyes open to voice and once this am pt turned toward the speaker. Does not track or follow commands. Moving LE's minimally. Grimaces with movement. Has cough and gag. Grimaces and Turns away from oral sxing. LP done this pm. Pt flat on left side post LP.\n? if pt in pain, with grimacing and with very sore looking oral lesions. Was given MSO4 2mg IVP x two. Appeared more comfortable after 2nd dose this pm.\n\n Respiratory: Found to be tachypneic to 30 with TV's 300 on PSV 5. Sx'd x one for tenacious white secretions of moderate amount. Placed back on PSV 10, with rr down to 17-22 and TV's 400-500.\nSats 99-100 on 40%.\n\n Cardiac: Hypertensive to 180's/ systolic this am, after Lopressor dose. Started on NTG drip which is now up to 1.94 mcg/kg/min, BP has been 150's, and now down to 130's after 2pm meds.\nHeart rate has been creeping up to low 100's. Temp 100 rectal. EKG done.\n GI: Tolerating Tube feeds well. Low aspirates, which are OB negative. No stool. Feedings off post LP while lying flat.\n\n Endo: Insulin drip up to 4u/hr this am where it has remained. BS 150, now 116-134.\n\n Skin: Circumoral lesions black and encrusted. Another ? Herpes lesion under left eye. Groin and perianal area reddened and yeast like. Nystatin powder applied. Right leg with multiple areas of mild erythema and new area of reddness on anterior shin. Anterior suture line is clean and dry, posterior suture line blackened ? due to old blood. Several small areas of ? necrotic areas. Heel area outlined is unchanged.\n Social: Wife called twice for update and was contact for LP consent by Dr. H.Y.\n\n A/P: Increasing BP and Heart rate, now on IV NTG. Lopressor to be increased.\n Assess for pain and give MSO4 as needed. Increase Propofol for comfort.\n Await LP results. Continue to monitor mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-09 00:00:00.000",
"description": "Report",
"row_id": 1534314,
"text": "RESP. CARE NOTE\nPt received on CPAP 5 PSV 5 and 40%. Pt became ^ tachypneic with RR 30's and did not settle despite sxn. pain med. PSV increased to 10 with Pt settling out to RR low 20's. Current settings PSV 10 peep 10 and 40%, see flowsheet for additional data. Cont to receive MDI's Q vent check. Sxn for tenacious pale yellow secretions. Pt opens eyes to voice but does not follow commands. Cont present vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-09 00:00:00.000",
"description": "Report",
"row_id": 1534315,
"text": "NSG NOTE 1500-1900\n\nCV: ST HR 104-111. NO VEA NOTED. REMAINS ON NTG 1.94MCG/KG/MIN SBP 134-150/62-73.\n\nRESP: CPAP+PS10,40%,peep 5, VT 370-490. SUCTIONED FOR THICK WHITE SECRETIONS. COPIOUS ORAL SECRETIONS. BS COUSRE BILAT.\n\nGI: TF OFF FOR LP. RESTARTED AT GOAL RATE OF 60CC. + BS. NO STOOL THIS SHIFT.\n\nGU: U/O ADEQUATE\n\nSKIN: R LEG SUTURE SITES C&D. LEG REMAINS EDEMATOUS. ELEVATED ON PILLOWS. GROIN AND BUTTOCKS WITH YEAST RASH. MYCOSTATIN APPLIED.\n\nNEURO: REMAINS ON PROPOFOL 25MCG. OPENS EYES OCCASSIONALY TO VOICE AND TO WIFE'S COMMANDS. NO MOVING EXT. NOT FOLLOWING COMMANDS\n\nLABS; AWAITING 1800 LYTES AND CBC. BS PER FLOW INSULIN GTTT AT 3/U/HR\n\nID: TEMP MAX 100.4 RECTAL. REMAINS ON VANCO,LEVO AND ACYCLOVAR IV FOR HSV COVERAGE.\n\nA: STABLE\n\nP: CON'T PER NSG JUDGEMENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-30 00:00:00.000",
"description": "Report",
"row_id": 1534279,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ FEVER/SEPSIS\n\nS- \" I FEEL BETTER...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT INITIALLY ON 15-20 MCG DOPA WITH MAPS NEARLY 60- HR- 100-130 ST ON DOPA GTT. GIVEN 1 LITER BOLUS OVER 1 HOUR- TOLERATED WELL AND BETTER BP- ABLE TO TITRATE DOWN DOPA TO PRESENT- 5 MCG/KG.\nBP CURRENTLY UP TO 110/ WITH MAPS- 70. SIGNIFICANTLY IMPROVED HEMODYNAMICS FROM EARLIER IN SHIFT. NO VEA.\nREPLETED MG/PHOS/CALCIUM.\n\n PT INITIALLY ON 6 L /100% NONREBREATHER WITH SATS LOW 90'S-\nABLE TO TITRATE BACK TO 70% NEB- SEE FLOWSHEET FOR ABG'S.\nLATEST ONE-- 128-28-7.39 98%.\nTOLERATED ONE LITER IVF BOLUS WITHOUT RESP ISSUES.\n\n PT 101.8- 99.4- REMAINS ON CEFTRIAXONE. URINE/LP/BLOOD AND RT KNEE TAP ALL PERFORMED ER- CCU.\nRT LEG REDDENED DOWN TO ANKLE.\nHO AWARE AND EXAMINED. NO CHANGE FROM EARLIER IN SHIFT.\n\n\nGU- UO IMPROVED WITH BETTER PERFUSION PRESSURE.\n160-200/HOUR THIS AM- EARLIER- ONLY 20-30CC/HOUR.\nI/O CURRENTLY (+) 1 LITER.\n\nGI- NPO . LARGE FORMED BM X 3- G (-), THIS SHIFT.\n\nENDO- STARTED ON INSULIN GTT- 1 U/HOUR.\nBS- 78-150- CURRENTLY OFF FOR BS<120.\n\n PT LETHARGIC, BUT ABLE TO ANSWER QUESTIONS AND EASILY AWAKENED.\nTHIS AM APPEARS SLIGHTLY MORE ALERT, LESS LETHARGIC.\nWIFE IN ALL EVE- LEFT FOR HOME- 12 AM.\n\nLINES- RT FEMORAL TRIPLE LUMEN IN PLACE. RT RADIAL ALINE IN PLACE.\nONE PERIPHERAL #18 RT LOWER ARM.\n\nA/ PT ADMITTED WITH SEPSIS/FEVER/HYPOTENSION CURRENTLY MAINTAINING O2 SATS, HEMODYNAMICS ON MUCH LESS O2/PRESSORS/\nRESPONDING WELL TO FLUID BOLUS/ANTIBX.\n\nCONTINUE TO CLOSELY WATCH- WATCH SPECIMEN RESULTS FOR ANY FINDINGS/\nCONTINUE ANTIBX AS ORDERED- CLOSELY WATCH LEG FOR ANY SIGN OF INCREASED REDNESS- DISCUSS ? NEED FOR LENI TODAY.\nWEAN OFF DOPA FOR MAP>60.\nWEAN DOWN O2 FOR SATS >93.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nINSULIN GTT PER SCALE AS NEEDED.\nLYTES REPLETION AS NEEDED.\nWATCH CLOSELY FOR RESP DISTRESS IN SETTING OF 4 LITERS IVF IN SINCE .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-30 00:00:00.000",
"description": "Report",
"row_id": 1534280,
"text": "s. C/O OF MOD TO SEVERE PAIN RT LE STATING THAT DEMEROL 50 MG IV Q 4 JUST TAKING THE EDGE OFF OF IT\nO. ID WBC 13.7 AFEBRILE BLD CX CAME BACK GRAM + COCCI PAIRS REPEAT BLD CX DONE PERIPHERAL AND ALINE, RT LEG +2 EDEMA ERYTHEMATOUS TO KNEE\nCARDIAC HR 90-100 NSR-ST WITHOUT ECTOPY BP 110/-120/ DOPA WEANED OFF GIVEN 1L NS BOLUS LYTES WNL CK 1167 MB INDEX 1.8 CK MB SENT 1700 SKIN COOL AND DRY PP DOPPLER\nNEURO A/OX3 MAE\nRESP 3LNP O2 SAT 96-100% LUNGS CTA\nGU FOLEY SEDIMENT YELLOW BUN 69 CR 3.1 U/O AROUND 60-100CC QHR\nENDO PLACED ON INSULIN GTT .5 U REG Q HR BS 100'S IV D5NS AT 100CC QHR X2 LITERS\nGI STARTED TO EAT SM AMT ABD SOFT DISTENDED BS+ SOFT BROWN STOOL LG OB NEG\nACCESS RT FEM TRIPLE, LT HAND 18G, RT HAND 20G\nSKIN UNCHANGED\nA.CELLULITIS PAIN\n+BLD CX\nDM\nPVD\nCAD\nP. BLD CX X 2 DONE\nMONITOR WBC, TEMP\nMEDICATE Q 4 HRS WITH DEMEROL 50MG IV PRN START NEUROTIN\nWEAN INSULIN GTT ONCE TAKING PO ADEQUATELY AND RESTART INSULIN DOSE\nTAKE FEM LINE OUT TONIGHT IF BP REMAINS STABLE OFF DOPA\nMONITOR CK'S\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-04 00:00:00.000",
"description": "Report",
"row_id": 1534296,
"text": "sepsis, resp failure\nmicu npn (in ccu)\no- id- afebrile, cont. on abx.\nneuro- responds to loud voice rarely and will rarely nod yes or no appropriately. occ. grimace and expression changes with any stimulation. not moving extremities (edematous). cont. on ativan/mso4.\ncv- hr up to 70-100s sr/st, no vea. bp 90s-127/, rarely in 80s and up with stimulation. k replaced, repeat 4.4.\nresp- changed to psv 10, 5peep at 40%, rr 8-14, tv 800s-1100. no sob noted. abgs done x2, ph 7.32 to 7.34. last abg- 79,32,7.34,18. sats 95-100. l/s coarse/dim with scat wheezes at times. u/o 16-55cc/hr. i+o remains pos.\ngi- cont. on goal t/f with low residuals. small bm in am.\nendo- cont. on insulin drip. bs 120s-189.\nskin- unchanged, remains on 1st step mattress. repos with skin care q3hrs. dsg changed to rll, incisions c+d x3, dsd and ace wrap on per surgery, leg elevated on pillow with heel free. heel with darkened areas, marked by ho. hands remain edatous with necrotic finger tips.\nsocial- wife in most day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-08 00:00:00.000",
"description": "Report",
"row_id": 1534310,
"text": "Nursing 7A-7P\n\nNeuro: Remains on propofol at 25 mcg/kg/min. Opening eyes spontaneously but not following commands or tracking with eyes.\nHead CT from negative per team. ? rationale for pt's sub optimal mental status.\n\nCV: HR and B/P improved on sedation. Lopressor increased to 75 mg po bid. Lasix now 20 mg tid with standing K orders. Fair amt of diuresis. See CareVue for objective data. NSR-ST with no ectopy.\n\nResp: L/S remain clear to coarse. CXR this am demonstrated ?LLL pneumonia. Pt spiked this am and pan cultured. Vanco and levoquin initiated for the latter findings. Suctioned Q2-3H for thick yellow\nsputum. Sputum Culture sent prior to new antibiotic therapy. Remains on 5PS and 5 PEEP. RR 20-28 on propofol with TV 320-580. Ph remains above 7.5 but po bicarb dc'd.\n\nGI/GU: TF at goal. Small BM. Abd appears to be less distended than . Foley patent. Bowel sounds present. Minimal residual from TF.\n\nEndo: Insulin gtt at 3 units an hour with FSBS less than 160.\n\nInteg: HSV culture done for lip ulcers which are not improving with frequent mouth care. Fungal skin redness noted in groin area. Miconazole powder ordered and applied to affected areas. Right leg elevated to keep foot off of bed and looks slightly less red. Sutures intact and no drainage noted. Hands less edematous elevated on pillows. Back/buttocks skin intact.\n\nPlan: Antibiotics as ordered,, await growth of cultures, maintain present therapy, maximize beta blockade and ace post MI, monitor hemodynamics, and continue to support wife and pt.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-08 00:00:00.000",
"description": "Report",
"row_id": 1534311,
"text": "Addendum:\nAcyclovir IV added to therapy for ? HSV on lips. Lasix on hold due to pt's alkalosis. Chem 7 pending. Wife updated on pt's status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-09 00:00:00.000",
"description": "Report",
"row_id": 1534312,
"text": "NURSING PROGRESS NOTE 7PM-7AM\n\nNEURO: Pt. remains sedated on Propofol, also in efforts to reduce heart rate and blood pressure. Opened eyes half-way this morning with turning. Otherwise does not open eyes spontaneously or to voice. Does not move extremities spontaneously. Withdraws extremities to painful stimuli. Titrated propofol for desired effect of BP, currently propofol drip at 25mcg/kg/min. Care and procedures explained to pt, re-orientation given to pt.\n\nRESP: Upon initial assessment, pt. tachypneic, resp. rate 28-30. O2 sats 100%, yet pt. appears uncomfortable. Propofol drip increased to 40mcg/kg/min without decrease in resp. rate noted. Reported to Dr. , psv on vent increased to 10 overnight, from 5. Resp. rate improved to <28, with tidal volumes 400-500ml. Will decreased psv to 5 morning of as ordered. Suctioned for thick white, occ. yellow thick secretions.\n\nCV: Pt. remains in NSR/ST without ectopy. Initially pt. with elevated SBP 160-180, despite propofol at 40mcg/kg/min. Decrease in SBP and heart rate noted after increase in psv on vent. Pt. with low-grade temp, temp. max 99 this shift. Antibiotics infused as ordered. Doppler pulses obtained dp/pt bilaterally. K+ replacement given as ordered.\n\nGI: Pt. tolerating tube feeds of Promote with fiber at goal rate of 60cc/hr with minimal residuals. Insulin drip has remained at 3u/hr throughout shift with blood sugars between 100-130. No BMs as of yet.\n\nGU: Urine output >100cc every two hours.\n\nSKIN: Faint red non-raised rash on chest unchanged compared to 24 hours ago. Right calf pink, with sutures intact. Scant amount sero-sanguinous drainage on posterior aspect of leg. No skin breakdown on back or buttocks. Buttocks slightly red, aloe vesta cream applied. Groin area, reddened, anti-fungal powder applied. Lip ulcers noted, culture re-sent for HSV.\n\nSOCIAL: wife and father in at beginning of shift. Questions answered, update given.\n\nPLAN: Wean propofol as tolerated, and wean vent this am as tolerated. Monitor neuro status. Administer antibiotics as ordered and monitor WBCs. Monitor blood sugars and titrate insulin as ordered. Continue to update family and provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-31 00:00:00.000",
"description": "Report",
"row_id": 1534281,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ SEPSIS; FUO\n\nS- \" I FEEL OK...NO FEVER?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- BP- 107/ 50- 162/70. DENIES CP.\nHR- 99-118 ST- NO VEA. RATE TRENDING UP SINCE 3 AM.\nNO FEVER, SIGN OF BLEEDING- I/O (+).\nHO AWARE- TO COME EXAMINE/PREROUND.\nPT DENIES PAIN, ASLEEP AND APPEARS COMFORTABLE.\nSTABLE BP OFF DOPA.\nREMAINS ON FLUIDS- 100CC/HOUR- SWITCHED FROM D5 TO NS.\n\nRESP- COMFORTABLE ON 3 L NP- O2 SATS REMAIN >97%.\nNO ISSUES CURRENTLY.\n\nGU- GOOD UO WITH BETTER PERFUSION PRESSURES.\n40-70CC VIA FOLEY CATHETER.\nI/O (+) 1300CC AS OF 12 AM.\nREMAINS ON HYDRATION FLUIDS.\n\nGI- MINIMAL PO INTAKE- LIX/SOFT SOLIDS. TAKING MEDS WITHOUT PROBLEM.\nSOME NAUSEA AFTER DEMEROL. MIMIMAL APPETITE.\nABD SOFT/(+) BOWEL SOUNDS.\n\nID- AFEBRILE- TO LOW GRADE TEMP- ADDED VANCO LAST EVE- REMAINS ON CEF.\nSURGICAL CONSULT TO EVAL RT LOWER LEG- REMAINS (+) REDDENED FROM KNEE TO ANKLE. PT TO ULTRASOUND AS WELL AT 11 PM FOR FURTHER EVAL TO R/O COMPARTMENT SYNDROME/CELLUITIS. (-) PER TEAM.\nCPK'S CONTINUE TO BE ELEVATED BUT MB (-).\n\nSKIN- SEE ABOVE.\n\nENDO- D/C INSULIN GTT- ADDED LENTE QHS AND REGULAR X 1 DOSE THIS AM.\n\n PT VERY ALERT AND ORIENTED- SLEPT WELL AFTER EVENING OF CONSULTS/ULTRASOUND. FAMILY IN TO VISIT AS WELL EARLIER IN EVE.\nRECIEVED 25 DEMEROL X 1 THEN ATIVAN FOR NAUSEA- 0.5 X 2 DOSES.\nREMAINS COMFORTABLE, ASLEEP- EASY TO AWAKEN.\n\nA/ PT S/P HYPOTENSION/HYPOXIA/FUO- CURRENTLY HEMODYNAMICALLY STABLE OFF PRESSORS/ON ANTIBX THERAPY.\n\nCONTINUE FEVER/SEPSIS W/U/ANTIBX AS ORDERED.\nHYDRATION FLUID UNTIL GOOD PO INTAKE.\nADD REGULAR INSULIN SCALE TO COVER BLOOD SUGARS.\nPAIN CONTROL/CLOSE OBSERVATION OF RT KNEE/LOWER EXTREMITY SWELLING.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE/PROGRESS.\nD/C ALINE/ADVANCE ACTIVITY AS TOLERATED IF REMAINS STABLE.\nENCOURAGE INCREASED PO INTAKE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-31 00:00:00.000",
"description": "Report",
"row_id": 1534282,
"text": "ccu/micu nursing progress note\npls see carevue flowsheet for complete vs/data/events\ns: i feel so nauseaus.\no: pt with worsening sepsis throughout day indicated by ^temp, hr and rr. by afternoon pt req central access, fluid bolused and pressures were started and by 5pm pt was intubated electively as his ms cont to decline. pt undergoing open biopsy at bedside by vascular surgery of r calf. will also require ct of leg and abd this eve to eval for infection source.\nros:\nid: t spike to 102.8 r at 1pm. wbc 19.1(13.7). flagyl added. vanco dose increased to 1gm q 12.\n\ncv: tachycardic, up to 150-160st in afternoon. no vea. bp stable at 120-140/ . rec'd a dose of iv lopressor with hr to 130s, bp droppped to 100/ . central access placed, cvp 12-16. ivf bolus began. by 3pm bp began to drop to the 80s/ . responded initially to more ns but then after intubation levo was req to support bp >90/ . now at 15mcg/min.\n\nresp: rr to 35-44, labored. basilar cxs. pt attempting to compensate for metabolic acidosis. ms began to decline and ph began to fall. electively intubated at 5pm. min secretions. has a big gagging issue. diff to ventilate intially with coughing and biting tube. finally stabililzed with propofol gtt. now adjusting settings. currently on a/c 700 x25, 40% and 5peep.\n\ngi: c/o nausea this am, some wretching. but only produced clear saliva type o/p. lrg soft, brn stool ob-. no c/o abd pain, abd soft, nontender. post intubation appeared to be gagging, passing air/belching. ngt placed. which has now drained about 100cc maroon ob+ o/p. pt npo. to undergo abd ct this eve. will need baracat prep.\nendo: bs 220-300, started on qid ss coverage.\n\ngu: uop 40-100cc/hr. cr 2.7 this am. ivf currently infusing at 200cc/hr.\n\nms: more lethargic as day progressed. no focal deficits. now sedated on propofol. will change over to mso4/ativan as appropriate.\n\nsocial: wife present this afternoon and consented for procedures, updated as to condition. will contact ss for support tomorrow.\n\na: sepsis, unstable req pressors and intubation. unclear etiology.\n\np: check abg/hct this eve. med for comfort/vent mgmnt. ct this eve of r leg and abd. adjust levo for bp, add ?dopa for further hypotension.\nsupport to wife.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-05 00:00:00.000",
"description": "Report",
"row_id": 1534297,
"text": "NSG NOTE\n\nCV: HR 94-107 NSR,ST NO VEA NOTED. BP STABLE.SBP 116-186/DBP 55-76. TRANSIENTLY DROPS WITH DEEP SLEEP,BUT MAP'S REMAIN > 60.\n\nRESP: CPAP,PS-10,40%,PEEP 5. TV 730-980. RR-20-22. ETT PULLED BACK,NOW AT 24 AT LIP. CURRENT ABG'S 7.41,29,103,19,-4. BS COURSE BILAT TO DIMINISHED AT THE BASES.SUCTIONED FOR THICK YELLOW SECRETIONS.\n\nGI: TF VIA NGT PROMOTE WITH FIBER AT GOAL OF 60CC/HR. LOW RESIDUALS <5CC. ABD LGBUT SOFT WITH HYPOACTIVE BS. HAD LG BM. BROWN GUIAC +.\n\nGU: U/O 30-90CC/HR. LOS + 15,885CC. BUN/CREAT ON 41,1.5\n\nENDO: REMAINS ON INSULIN GTT NOW AT 5U/HR. SEE FLOW REGARDING BS TRENDS.\n\nSKIN: REMAINS EDEMATEOUS. R LEG DSG DONE DSD TO SUTURE SITES WHICH ARE C&D. ACE WRAP REAPPLIED. LEG ELEVATED ON PILLOW. HAS BILAT PULSES BY DOPPLER. ULCERS ON LIPS. CARMEX APPLIED. HAS NECROTIC FINGERS ON BOTH R/L HANDS.\n\nNEURO: WILL OPEN EYES TO VERBAL/PAINFUL STIMULI. FOLLOWS COMMANDS INCONSISTENTLY. REMAISN ON ATIVAN TITRATED UP TO 1MG AND MS04 TITRATED UP TO 3MG.\n\nID; TEMP MAX 99.3-100 REMAINS ON TRIPLE ABX COVERAGE. CLINDA,CEFTRIAXONE,GENTA. WBC TODAY ELEVTAED 27.6\n\nLABS: AWAITING REMAINING AM LABS\n\nSOCIAL: WIFE IN LAST EVE. VERY PLEASANT. AWARE OF PT CONDITION. SHE ASKS APPROPRIATE QUESTIONS CONCERNING HIS CARE AND TREATMENTS.\n\nA: GUARDED/SEPSIS\n\nP: START TO DIURESIS PT NOW THAT BP IS MORE STABLE\n CON'T PER NSG JUDGEMENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-03 00:00:00.000",
"description": "Report",
"row_id": 1534294,
"text": "CCU NPN 3-11PM\nCV: BP 90-100/50, drifting down to high 80's sys, maintaining MAPS>60. HR 80's NSR. When stimulated BP rises above 100 sys. K+ 3.8.\n\nResp: remains vented, no changes made in settings, ABG 100/30/7.37. Suctioning q 3-4 hrs for scant white secretions. LS bronchial at bases bilaterally, otherwise clear. No spon RR above AC 14.\n\nGI: residuals <10cc, TF advanced to goal of 60cc/hr. Abd distended, more so than a couple days ago, soft, BS present. No stool. On colace.\n\nEndo: since TF at goal, IV D5W decreased to 10cc/hr KVO. BS were up to 250, reg ins gtt increased accordingly, BS decreasing, now at 148.\n\nSkin: Ace to R leg intact, no drainage noted.PT and DP pulses are dopplerable. Purplish areas on arch of R foot, heel and anterior aspect. Leg elevated on pillow. Vascular folowing.\n\nID: afebrile, actually a bit low, blankets applied. On Oxacillin, clinda and ceftaz. ID following.\n\nSoc: wife and 1 daughter in tonight, updated. Daughter becoming emotional, crying at bedside.\n\nA/P: remains critical, continue supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-04 00:00:00.000",
"description": "Report",
"row_id": 1534295,
"text": " \"B\" review of systems:\n\nCVS: T=97.5-97.8 p.o. HR=71-85 NSR no ectopy. SBP dropped to 78,map=55 and stayed in this range for about an hour. IV Levophed was restarted for a few hours at a low dose of 1.3 to .4mcg/min. Shut off at 5am. MAP>60 rest of night.\n\nRESP: Maintained on Vent: AC 14 TV 600 FIO2 40% peep 5, ABG's better this am, ph=7.4, plan to start weaning to psv today. Suctioned for small amts white thin sputum. Lung sounds Coarse, diminished at bases.\n\nSKIN: Rt leg ace wrapped-no staining noted. Pt had gone to OR yesterday to explore rt calf wounds as source of sepsis. Both legs up on pillow to keep heels off bed. Pulses present with doppler, feet warm. Both hands very edematous,elevated when possible on pillow. Scrotum also slightly edematous. No drainage or decubiti no back side.\n\nGU: U/o=30-60cc/h via foley catheter.\n\nGI: No stool, but scant staining rectally.+bowel sounds, abdomen soft. TF tolerated well at 60cc/h which is goal. Free H20 100cc/q8h.\n\nENDO: IV insulin drip weaned to 3u/hr due to decreasing BS after IV fluids were decreased. BS=133-123. k=3.4, IV KCL 40meq infusing and to get another 20meq KCL IV at 10am. IonCa+=1.1-Given 2grams Ca gluconate IV.\n\nSocial: Wife in to visit and is pleased with pt's care.\n\nPain: IV MSO4 drip at 2mg/hr, drip was weaned to 1mg/hr but pt was grimacing in pain frequently. IV Ativan drip at 0.5mg/hr.\n\nNEURO: Pt is alert, focuses, moves arms but not legs mostly. Doesn't follow commands well probably due to edema of extremities. Nods appropriately.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-08 00:00:00.000",
"description": "Report",
"row_id": 1534308,
"text": "NURSING PROGRESS NOTE 7PM-7AM\n\nNEURO: Pt. opens eyes spontaneously and with stimuli. PERRLA. Does not track with eyes, does not follow commands. Turns head from side to side and bites on ETT. Withdraws arms to nailbed pressure. No spontaneous movement of extremities noted. Taken for CT scan of head last evening at 2200 without incident. No reports yet from MDs. Care and procedures explained to pt., orientation given to pt. Propfol drip remains on for hr/bp control, currently at 25mcg/kg/min.\n\nRESP: Pt. remains on CPAP 40% with +5 peep and +5 psv. Tidal volumes 300-500ml with O2 sats >98% and resp. rate <28. ABGs sent, see carevue. Lung sounds clear, suctioned for small amount white secretions.\n\nCV: Pt. in NSR/ST without ectopy noted. Temp. max 99.6. NTG drip d'cd and isosorbide given per Dr. . SBP generally 140s. Antibiotics given as ordered. K+ replacement given as ordered for K+ of 3.3 last evening.\n\nGI: Promote with fiber continues at goal rate of 60cc/hr via NG with minimal residuals. Abdomen rounded, softly distended,smear brown stool noted. Blood sugars per carevue. Insulin drip currently at 2u/hr, see titrations per carevue.\n\nGU: Lasix 20mg given last evening as ordered, with good diuresis. Pt. currently with urine output 40-50cc/hr.\n\nSKIN: Right calf and foot remains pink with necrotic areas on foot marked. Doppler pulses noted dp/pt bilaterally. Sutures in right leg intact without drainage. No skin breakdown on back or buttocks. Faint red rash on lower chest/upper abdomen, non-raised. Pt. turned q2h on air mattress.\n\nSOCIAL: wife in last evening and spoke with Dr. , update given. No results yet on CT scan, so unable to give results to wife.\n\nPLAN: Monitor neuro status, await CT scan results. Monitor BP and administer anti-hypertensive meds as ordered. Wean on vent as tolerated, monitor ABGs. Administer antibiotics as ordered. Continue to update family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-08 00:00:00.000",
"description": "Report",
"row_id": 1534309,
"text": "Resp. Note\nPt remains on PSV. TV 400-500 with RR 20s on %. MDIs given as ordered. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-29 00:00:00.000",
"description": "Report",
"row_id": 1534277,
"text": "48 YR OLD ADMITTED TO ER C T 105 .HX IDDM ,SP RENAL TRANSPLANT .LAST NIGHT VOMITED,HAD HEADACHE ,FELT WORSE THIS AM HAD MENTAL STATUS CHANGES C SLURRED SPEECH.PULSE FLUTUATING 40 TO 140 .BP 60 SYS,SAT 83.PH 7.57/20/192/19.LACTATE 6.3.BS 154. SYSTOLIC.STABLIZING C 2L FLUID ANTIBX,STEROIDS,TYLENOL. SPEECH RESOLVED .BLOOD,URINE ,SENT. LP DONE IN ER .\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-29 00:00:00.000",
"description": "Report",
"row_id": 1534278,
"text": "S. I NEED MY HEAD UP SO I CAN BREATHE\nPMH\nSINUSITIS\nANGIOPLASTY\nKIDNEY TRANSPLANT \nRT FEM TIB BYPASS \nRT DISTAL REVISION \nQUADRUPLE BYPASS \nRT UPPER REVISION \nRT GREAT TOE AMPUTATION \nLT LEG EXPLORATORY \nLT GREAT TOE AMPUTATION \nLT FOOT TMA 4.20/99\nLT ARM BRACHIAL RADIAL BPG \nRMF AMPUTATION \nDM\nHTN\nCAD\nVASCULAR DISEASE\nNEUROPATHY\nKIDNEY DISEASE\nDIABETIC PERIPPHERAL RETINOPATHY\nALLERGIES\nE-MYCIN\nPROTAMINE\nSOCIAL LIVES WITH WIFE AND CHILDREN DENIES ETOH SMOKED 20 YR AGO IPPD YRS\nO. PT ARRIVED CCU 1800 HOB FLAT SECONDARY TO RECENT LP ON 100%NRB BS DIMINISHED THROUGHOUT O2 SAT 68-70 GIVEN AN ADDITIONAL 5LNP O2 SAT UP TO 85-98% CXR SHOWING EARLY FAILURE RECEIVED A TOTAL OF 4.8 LITERS NS IN EW ALINE PLACED RT RADIAL ABG PNDING\nNEURO DROWSY ORIENTED X3 FC MAE PUPILS OS 4 MM OD 2 MM RL SLUGGISH\nCARDIAC HR 100 ST WITHOUT ECTOPY BP 74/- 140/ STARTED ON DOPAMINE 3MCG /KG/ MIN SKIN COOL AND DRY RT LEG +2 EDEMA FOOT 1/3 UP CALF EDEMA ERYTHEMATOUS PAINFUL TO LIGHT TOUCH GREAT TOE AMP PP DOPPLER BOTH EXTREMITIES LT LEG METATARSAL AMP 5 DIGITS, RT HAND NO EDEMA DOPPLER ULNAR AND RADIAL PULSE AMP BABY AND MIDDLE FINGER, ON LEFT HAND INDEX FINGER TIP AND NAILBED ECCHYMOTIC ULCER MIDDLE FINGER NAILBED ULCER AND BABY FINGER TIP ULCERATED UNABLE TO DOPPLER RADIAL PULSE ON LT ABLE TO DOPPLER BRACHIAL SKIN WARM FISTULA IN LT ARM\nGI NPO ABD FIRM DISTENDED BS HYPO\nGU FOLEY CR 3.8 FISTULA IN THE LT ARM PUTTING OUT URINE\nID TEMP 101.8 RECTALLY PAN CX IN ER\nENDO 141\nA. MS TEMP 105\nHYPOTENSION\nDM\nCHF\nP. DOPAMINE TITRATE BP RESPONSE\nMONITOR RESP STATUS\nAWAIT CX START ANTIBX\nMONITOR RENAL STATUS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-12 00:00:00.000",
"description": "Report",
"row_id": 1534320,
"text": "NURSING PROGRESS NOTE 7PM-7AM\n\nNEURO: Pt. A&O x3. Pt. c/o \"I'm uncomfortable\". Pt c/o \"cannot get comfortable in bed and my right leg is cramping.\" MSO4 2mg given IV q3-4h as needed and repositioned in bed, right leg elevated on pillow. Pt. states \"it helps take the edge off\". Pt. with generalized weakness, does help with turning somewhat. Care and procedures explained to pt., emotional support given. Pt. states \"I'm ready to go home.\"\n\nRESP: Remains on 2lpm O2 via n/c with O2 sats 98-100%. Lungs diminished throughout. Strong productive cough noted, at times raising white, occ yellow sputum. Denies SOB.\n\nCV: Pt. remains in NSR without ectopy. Lopressor dose increased per Dr. . NTG titrated to keep SBP 120-150, currently at 15mcg/min. See weaning per carevue. Pt. with generalized edema. Doppler pedal dp/pt pulses. Temp. spike to 101.3, reported to Dr. . CXR done, 2 sets of blood cultures sent and urine culture sent. Awaiting sputum spec. for culture. Vanco dose x1 given as ordered. Temp@ 0400=100. Continues on oxacillin, levaquina and acyclovir.\n\nGI: Pt. states \"when's breakfast?\". Pt. tolerating sips of clear liquids without difficulty. Discussed with Dr. , potential for clear liquid diet in am. Tube feedings at goal rate of 70cc/hr. Pt. denies n/v. Pt. did have one loose brown stool, guiac negative. Blood sugars as noted per carevue and covered with sliding scale. Scheduled lente dose to be given this am.\n\nGU: Urine output~50cc/hr via foley catheter.\n\nSKIN: Pt's groin and bottom are very reddened, no breakdown noted. Aloe vesta cream and anti-fungal powder applied. Pt. turned q2h.\n\nSOCIAL: wife and daughter in at beginning of shift, very supportive. Questions answered.\n\nPLAN: Encourage deep breathing and coughing. Maintain BP control with NTG drip as needed. Await culture results, continue to give antibiotics as ordered. Monitor blood sugars and treat with sliding scale as ordered. Monitor skin for any breakdown, continue with protective cream, and powder. Maintain pt's comfort with pain med and repositioning. Update pt. and family on plan of care. Provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-12 00:00:00.000",
"description": "Report",
"row_id": 1534321,
"text": "CCU Nursing Progress Note\nNeuro: Pt A&O x3, pt weak, able to follow all commands. Pt has pain in LLE, and at 1700, OOB to cardiac Chair.\n\nCardiac: Pt in SR, HR 87-105 no ectopy, BP 128-157/56-80, goal BP 120-150 sys. Pt edematous, given 20 mg lasix good response.\n\nResp: Pt on 2L via NC, O2 sat 97-100%. Pt has a productive cough. BS clear and shallow bilaterally.\n\nGI: Pt on TF, promote with fiber at goal of 70, minimal residual. ABD soft distended. +BS, -BM. Pt on clear liquid diet. Tolerating well.\n\nGU: Pt has f/c with good urine output. Pt repeated with CA and Mg today.\n\nID: Pt low grade temp t-max 100.4, sputum cx sent to complete ON pan cx. Pt on oxycillin, levo, and acyclovir.\n\nEndo: BG >200, requiring new insulin scale, pt on Lente, BG q6 hours.\n\nSkin: Peri area red and excoriated, cream placed.\n\nAccess: PICC in L ac.\n\nPt to be called out tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-13 00:00:00.000",
"description": "Report",
"row_id": 1534322,
"text": "NEURO: A&O X3. PLEASANT & COOPERATIVE.\nRESP: O2->2L NP. RR 15-22. O2 SAT 94-100%. BS CLEAR DIMINISHED AT\n BASES.\nCARDIAC: HR 85-107 SR, NO ECTOPY. BP 121-152/44-68. K 3.8->TREATED\n WITH KCL 40MEQ PB X1.\nGI: TF: FS PROMOTE WITH FIBER INFUSING AT GOAL RATE 70CC/HR. TOL. WELL\n WITH NO RESIDUALS. ABD. SL. DISTENDED. +BS. LG LOOSE BROWN BM X1,\n G-.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 50-770CC/HR.\n LASIX 20MG VP X1. DIURESED WELL.\nID: T(MAX)101(PO)->99.8. TYLENOL X1. CONT. ON IV OXACILLIN & ACYCLOVIR\n & PO LEVOFLOX.\nENDO: BS 309->228. TX PER SLIDING SCALE.\nAM LABS PENDING.\nCALL OUT TO ANY MEDICAL FLOOR TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-03 00:00:00.000",
"description": "Report",
"row_id": 1534292,
"text": "NURSING PROGRESS NOTE 7PM-7AM\n\nNEURO: Pt. remains sedated on Ativan and Morphine drips. Able to wean them, see carevue for titrations. Currently Ativan at 1mg/hr and MSO4@2mg/hr. Pt. opens eyes with turning, moves arms towards ET tube, becomes slightly agitated with stimuli. Re-orientation provided to pt. Pt. settles and falls back to sleep when left alone. Care and procedures explained to pt. Emotional support given. Bilateral wrist restraints remain on pt. to prevent self-extubation.\n\nRESP: No vent changes made this shift. Lung sounds clear this am. Suctioned for scant white secretions. Current vent settings: AC rate 14, TV 600, FIO2@40%, with peep+5.\n\nCV: Remains in NSR without any ectopy. Has remained off Levophed since 2100, with SBP >100 and MAP >70. Has remained afebrile. IV fluids continue D5W@125ml/hr. Pedal pulses, dp/pt, able to obtain via doppler bilaterally. Antibiotics changed post-op and given as ordered.\n\nGI: Tube feedings remain off per MDs, post-op. NG connected to LIS, draining bilious brown drainage. Insulin drip continues, currently at 2u/hr. See carevue for blood sugars and insulin drip titrations. Abdomen soft, no BMs as of yet.\n\nGU: Urine output adequate with 40-50ml/hr.\n\nSKIN: Right leg remains wrapped with ace bandage. Small amount serosanguinous drainage noted on lower calf. Ace wrap intact, right leg kept elevated on pillow. No skin breakdown on back or buttocks noted.\n\nSOCIAL: Wife in post-op and called later in evening, update given.\n\nPLAN: Maintain comfort with MSO4 and Ativan. Maintain safety with restraints. Possible weaning of vent today? Monitor labs and replace electrolytes as ordered. Monitor blood sugars and titrate insulin drip as ordered. Possible resume tube feeds. Administer antibiotics as ordered and monitor pulses in legs. Update family, and provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-03 00:00:00.000",
"description": "Report",
"row_id": 1534293,
"text": "ccu/micu nursing progress note\ns/o: pls see carevue flow sheet for complete vs/data/events\nid: afeb. cont on oxacillin, clindamycin and ceftaz.\nneuro: remains sedated on mso4 and ativan. wakes easily but doesn't follow commands. moves upper extremities purposefully. req soft wrist restraints.\ncv: hr 70-80s sr. rec'ing kphos to replace k and phos. lopressor on hold. remains off levo with bp 90-120/60-70, occ >140/ with interventions/more awake.\nresp: no vent changes. sats >97%. sxn'd q3-4hrs for scant white thick secretions.\ngi: tf resumed at noon at 40cc/hr. abd soft, +bs. no stool.\nendo: bs 160-220. insulin gtt titrated up. will d/c ivf when tf at goal.\nskin: surgical incisions with sutures to r calf, well approximated. scant serosang drg. has gen erythema extending up past knee. some mottling on heel, base of foot and top of foot. gen + edema. wrapped with ace and leg elevated.\nplaced on 1st step mattress today.\ngu: uop 20-30cc/hr. no diuresis.\nsocial: wife present and updated by nursing.\na: cv stable. afeb.\np: advance tf to goal. follow bs, titrate insulin gtt. follow uop/volume status. skin care. med for comfort. support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 1534306,
"text": "Nursing 7A-7P\n\nNeuro: Awake with spontaneous eye opening but not following commands.\nMoves extremities with nailbed stimuli. All sedation remains off and pt receiving prn doses of MSO4.\n\nCV: Hypertensive this AM 180/90's. IV NTG initiated for B/P control\nwith fair effect at .75mcg/kg/min. HR remains ST 100-120 despite increase in lopressor. Team aware and called to address. ? related to pain vs CV status. Received 20 mg lasix IVP with diuresis of 2L.\nK-2.7 repleted with 60 meq KCL IV.\n\nResp: Not extubated today related to sub optimal mental status. If not improved by am, Ct scan of the head to be done. See Care Vue for ABG's and settings. Suctioned Q3-4 H for small amt of thick white secretions. Coarse to clear breath sounds.\n\nGI/GU: Tf re-initiated at 1400. D10 dc'd. FSBS Q1H. Insulin gtt currently at 6u/hr. + bowel sounds and moderate soft formed BM today.\nFoley patent and draining clear yellow urine. CR 1.3 Abd appears\ndistended. Team called and will evaluate.\n\nID: WBC 30. Max temp 100.4 Clinda and oxacillin continue.\nRight leg incision with sutures and no drainage. Erythema on right knee and previous CABG incision remains the same.\n\nInteg: New non raised red rash noted on abdomen this afternoon.\nLesions on fingers and right foot remain stable.\n\nPlan: Monitor CV status, continue with FSBS checks, diuresis with an evening dose of lasix and replete K as needed, extubate in AM if more alert and if not, CT Scan.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 1534307,
"text": "Addendum:\nPropofol added for sedation related to increase HR and B/P. IV NTG off and B/P 140/60 with HR of 104 on 20 mcg/kg/min of propofol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-11 00:00:00.000",
"description": "Report",
"row_id": 1534318,
"text": "CCU Nursing Progress Note\nNeuro: Pt is A&O x1-2, pt able to follow commands consistantly. Moves extremeties weakly, pupils were unequal at 2100 so pts neuro status assessed, pt stable.\n\nCardiac: Pt in ST HR 96-113, BP 130-157/51-71 with MAP's 80-102; goal BP sys 120-150. NTG changed to mcg/min, decreased to 60 mcg/min from 80 at 0600, pts BP con't to decrease <120.\n\nResp: Pts BS shallow, clear, and decreased in the bases bilaterally. Pt on .4% cool neb, O2 sat 99-100%, pt has productive cough, needs encouragement and pulm toilet. Am ABG 7.49, 41, 113.\n\nGI: Pt has NGT, receiving promote with fiber at goal rate of 60 cc/hr. minimal residuals. +BS, +BM guiac neg. abd soft distended.\n\nGU: Pt has f/c with good urine output. Pt received 10mg lasix (between units of blood).\n\nID: T-max 99.4, pt on levo, vanco, oxycillin, acyclovir. Herpes around oral pharynx.\n\nEndo: Pts BG increasing, insulin gtt currently at 10 u/hr. Q BG.\n\nSkin: Pts genitals and buttock incredibly red and excoriated. Pt edematous generally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 1534290,
"text": "CCU nursing progress note\nCV: Pt initially off Levo gtt but MAP dropped <60 and Levo was restarted. Titrated between .5-1mcg/min with MAP maintained >60. Levo currently at .5mcg. HR 70 SR. Na up to 148 today. Pt receiving IVF D5W @ 125cc/hr.\n\nRespiratory: Remains vented on AC 14x 600 FIO2 40% PEEP 5. Lung sounds - clear. Suctioned for mininal secretions. ABG 7.41/28/126 at 5pm.\n\nID:Afebrile. Right leg remains red, warm up to thigh. Purple area noted on bottom and top of foot - area extending slightly over course of day. Area marked. Pedal pulses dopplerable. Culture from leg + for staph aureus. Surgery planned for this evening.\n\nGI: Abdomen soft distented BS hypoactive. TF advanced from 30 to goal of 60cc/hr. Formula changed to Promote with fiber. Minimal residuals through most of day. TF stopped at 5:30. 150cc residual aspirated and discarded.\n\nNeuro: Pt opening eyes to noxious stimuli but does not follow commands. Ativan gtt cont at 2mg/hr. MSO4 decreased from 6mg to 2mg/hr with pt remaining adequately sedated.\n\nEndo: BS up to 200s on D10 gtt. Insulin increased to 6u/hr. IVF changed to d5W. Insulin now down to 4u/hr with BS at 6pm 122.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 1534291,
"text": "POST-OP NOTE\n\n\nPt. returned from OR via bed at . Pt intubated and sedated. Pt. connected to ventilator in room, connected to monitor. Lung sounds wheezy throughout, Dr. aware. Pt. to receive inhalers, RT aware. Pt. continues on D5W @125ml/hr, Levophed drip at.5mcg/min, with hr=75 and SBP>100 and MAP>70, insulin gtt @4u/hr, blood sugar upon return from OR=90. Re-started MSO4 and Ativan drips at previous rates. Abdomen soft, hypocative BS noted, NG connected to LIS. Foley draining yellow urine. Right leg wrapped in ace bandage from foot to thigh. Doppler pedal pulses obtained bilaterally, dp and pt. Labs and ABG sent as ordered. Wife in to visit, emotional support given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-11 00:00:00.000",
"description": "Report",
"row_id": 1534319,
"text": "7a-7p Shift Nursing Note\nPt rec'd 2uPRBC on night shift. H/H stable this shift. Labs drawn at 1800 and pending. Pt also started on Mg replacement protocal. CVL to Lt.SC DC'd this after noon. PICC placed to LT AC under fluro.\n\nNeuro: Alert & orient . Approp. conversation. Moves upper extremities purposefully. Follows commands.\n\nCV:Nitro gtt @ 9cc/hr=60mcg/min. Titrate to maintain SBP <150. HR 88-110. SR. No ectopy. SBP 125-150. A-line DC'd to Rt. radial this afternoon.\n\nPulm:Extubated yesterday. Currently on 2L/NC. RR 20-25 O2 Sats have been maintained >95%. LS diminished throughout. Productive cough with thick yellow phlegm.\n\nGI:ABD distended/soft. BS+X4. Sm sips given. Pt tolerates well. Promote with fiber at goal of 70cc/hr with minimal residuals. Insulin gtt DC'd today and started on Sliding scale and lente.\n\nGU:Pt has F/C. UOP WNL. Clear yellow.\n\nSkin: Redness to inner thigh, groin, and buttocks. Protective cream applied and pt repositioned q2hr.\n\nID:Remins on levo and oxicillin. Vanco needs to be renewed by MICU team. Dr. aware. Maintain low grade fever. Tmax99.8. CSF from came back negative. HSV to lips.\n\nSoc:Wife at bedside. Questions and concerns discussed.\n\nPlan:Maintain SBP<150, titrate Nitro as needed. Monitor BS as ordered. Con't to apply protective cream and turn q 2 hrs to prevent skin break down.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-06 00:00:00.000",
"description": "Report",
"row_id": 1534301,
"text": "RESPIRATORY CARE:\nPT REMAINS ON VENTILATOR WITH SETTINGS OF PSV 5/ PEEP 5/FIO2 40%/VT OF 800 TO 1.0/RR 10 TO 14. PT ON ALBUTEROL AND ATROVENT MDI'S WITH BREATH SOUNDS THAT ARE DECREASED IN BASES WITH MILD CRACKLES THROUGHOUT. ETT RETAPED AND MOVED TO LEFT SIDE. SEDATION IS BEING REMOVED AND HOPEFULLY PT WILL BE EXTUBATED SOON.\n"
},
{
"category": "ECG",
"chartdate": "2132-04-09 00:00:00.000",
"description": "Report",
"row_id": 123577,
"text": "Sinus rhythm\nPossible left atrial abnormality\nLeft axis deviation\nPoor R wave progression\nSince previous tracing, anterior T waves are now upright\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-08 00:00:00.000",
"description": "Report",
"row_id": 123578,
"text": "Sinus rhythm\nPossible left atrial abnormality\nAnterolateral ST-T changes may be due to myocardial ischemia\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 123579,
"text": "Sinus tachycardia\nPossible left atrial abnormality\nAnterolateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing, precordial T wave changes noted consistent with\nischemia\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-04 00:00:00.000",
"description": "Report",
"row_id": 123580,
"text": "Sinus rhythm\nMarked left axis deviation - left anterior fascicular block\nAnteroateral ST-T changes may be due to myocardial ischemia\nPoor R wave progression - probably due to left anterior fascicular block -\npossible old anteroseptal myocardial infarction\nSince previous tracing, , T wave abnormalities in V2 more marked -?\nchange in lead position\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-02 00:00:00.000",
"description": "Report",
"row_id": 123630,
"text": "Sinus rhythm\nLeft axis deviation - anterior fascicular block\nNonspecific lateral ST-T abnormalities\nSince previous tracing, , wide complex today no longer present\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-31 00:00:00.000",
"description": "Report",
"row_id": 123631,
"text": "Wide complex tachycardia. There are P waves before each QRS complex suggestive\nof atrial tachycardia with aberrancy or atrial flutter with 2:1 block. Compared\nto the previous tracing of wide complex tachycardia is new. There are\npersistent small R waves in the inferolateral leads consistent with old\ninferior wall myocardial infarction. There is loss of R waves with ST segment\nelevations in leads V1-V4 suggestive of myocardial injury pattern. There are\nmore prominent T wave inversions in the lateral leads compared to the previous\ntracing of . Clinical correlation is suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-29 00:00:00.000",
"description": "Report",
"row_id": 123632,
"text": "Sinus rhythm. Since earlier this date the rate has slowed, but no other changes\nhave occurred.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-29 00:00:00.000",
"description": "Report",
"row_id": 123633,
"text": "Sinus tachycardia. Marked left axis deviation. Old inferior myocardial\ninfarction. Non-specific ST-T wave abnormalities. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-05 00:00:00.000",
"description": "Report",
"row_id": 123629,
"text": "Sinus tachycardia\nLeft axis deviation - consistent with left anterior fascicular block\nPossible old anterior infarct\nNonspecific anterolateral ST-T abnormalities - possible ischemia\nSince previous tracing, , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759246,
"text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening secretions from ET tube, difficult to wean. ? infi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis and sepsis,\n intubated.\n REASON FOR THIS EXAMINATION:\n worsening secretions from ET tube, difficult to wean. ? infiltrates/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of sepsis.\n\n CHEST, AP: Comparison film dated . Again noted is evidence of NG tube\n and ET tube, both of which are in good position. The heart is at the upper\n limits of normal in size. The hilar and mediastinal contours are\n unremarkable. The left hemidiaphragm is again not visualized, suggestive of\n left lower lobe consolidation. No evidence of definite effusion or\n pneumothorax. The visualized osseous structures are unremarkable.\n\n IMPRESSION: Left lower lobe consolidation, consistent with early focus of\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-11 00:00:00.000",
"description": "CVL/PICC",
"row_id": 759469,
"text": " 2:37 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: i am requesting a PICC line under fluoro. pt evaluated by PI\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with mult medical problems including CAD, type I DM, s/p renal\n transplant, sepsis, cellulitis of RLE\n REASON FOR THIS EXAMINATION:\n i am requesting a PICC line under fluoro. pt evaluated by PICC nurse, felt not\n candidate for them due to poor access. pt currently with subclavian line from\n which we want to pull. pt needs long term IV abx (2 weeks) for cellulitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY/INDICATION: Patient with multiple medical problems and sepsis. Needs\n PICC line for antibiotics.\n\n RADIOLOGIST:\n\n Attending radiologist: Dr. .\n\n Interventional radiology fellow: Dr. .\n\n TECHNIQUE: Informed consent was obtained prior to the procedure. Dr. \n was present for the entire procedure.\n\n The left upper extremity was sterilely prepped and draped. As no superficial\n veins were visible, ultrasound was used to localized the left basilic vein,\n which was found to be patent. After local anesthesia with 1% Lidocaine, a 21\n gauge needle was used to access the vein under son guidance. Under\n fluoroscopic guidance, .018 guidewire was advanced into the superior vena\n cava. Over the wire, a 5 FR sheath and dilator system were placed. The PICC\n line was cut to length and placed over the wire for that its tip was in the\n superior vena cava. Sterile dressing was appled. The catheter was flushed.\n Post-procedure radiograph was obtained.\n\n MEDICATIONS: Local anesthesia with 1% Lidocaine.\n\n COMPLICATIONS: No complications were evident.\n\n FINDINGS: Son of the left upper extremity demonstrated a patent and\n compressible basilic vein. Post-procedure radiograph demonstrates the tip of\n the PICC line to be in the superior vena cava.\n\n IMPRESSION:\n\n 1. Successful placement of 49 cm, 5 FR dual lumen PICC line via the left\n basilic vein into the superior vena cava.\n\n (Over)\n\n 2:37 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: i am requesting a PICC line under fluoro. pt evaluated by PI\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759510,
"text": " 12:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with new temp spike. Please evaluate for new infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis and sepsis,\n intubated.\n REASON FOR THIS EXAMINATION:\n Pt with new temp spike. Please evaluate for new infiltrates on CXR.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New temperature spike. Question new infiltrates.\n\n CHEST, SINGLE SEMIUPRIGHT VIEW.\n\n Low inspiratory volumes. Allowing for this, patient is status post sternotomy.\n The heart is not enlarged. A left sided subclavian line is present (? PICC\n line). The tip is not optimally seen, though appears to overlie the mid SVC.\n An NG tube is also present, also not well seen due to underpenetration. The\n tip does appear to extend beneath the diaphragm, but is not visualized beyond\n this, likely due to underpenetration.\n\n Minimal bibasilar atelectasis and blunting of the right costophrenic angle. No\n CHF, frank consolidation or other evidence of effusion.\n\n IMPRESSION:\n\n Left lower lobe opacity, consistent with LLL collapse and/or consolidation,\n slightly improved compared with 5-15.\n\n Minimal blunting right costophrenic angle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 759117,
"text": " 9:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? stroke as cause of altered mental status. Patient s/p \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESRD s/p renal trasplant, type I DM, CAD, PVD, admitted\n for sepsis.\n REASON FOR THIS EXAMINATION:\n ? stroke as cause of altered mental status. Patient s/p sepsis and MI due to\n demand now has been off sedation but no mental status recovery and roaming eye\n movements.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status in patient with multiple medical problems.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There are no regions of hyperattenuation to suggest intracranial\n hemorrhage. There is no shift of normally midline structures or mass effect.\n The ventricles, cisterns, and sulci are normal without effacement. The\n attenuation of the brain parenchyma is normal. There is evidence of prior\n sinus surgery on the left as the ethmoid air cells are not present. There is\n a small amount of fluid in the sphenoid sinuses dependently. The mastoid air\n cells are clear. No osseous or soft tissue abnormalities are seen. A focal\n metallic density is noted in the medial left orbit of unknown etiology.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or territorial\n infarction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758939,
"text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p pull back on ETT, recheck ETT placement. ? worsening CH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM, CAD, gout, admitted with cellulitis\n\n REASON FOR THIS EXAMINATION:\n s/p pull back on ETT, recheck ETT placement. ? worsening CHF.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure. Endotracheal tube repositioning.\n\n COMPARISONS: One day prior.\n\n An endotracheal tube has been repositioned and is currently in satisfactory\n position. Central venous catheter and nasogastric tube remain in place. The\n cardiac and mediastinal contours are stable. There has been marked improved\n aeration in the left lower lobe. There are bilateral pleural effusions, right\n greater than left.\n\n IMPRESSION:\n 1. Interval repositioning of endotracheal tube, currently in satisfactory\n position.\n 2. Bilateral pleural effusions, right greater than left.\n 3. Improved aeration in left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-16 00:00:00.000",
"description": "R CT LOWER LIMB W/O CONTRAST RIGHT",
"row_id": 759835,
"text": " 10:25 AM\n CT LOWER LIMB W/O CONTRAST RIGHT; CT RECONSTRUCTION Clip # \n Reason: ? OSTEOMYELITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM-1, PVD, RLE cellulitis/fasciitis.Please note: pt had CT\n of RLE yesterday that did not extend to foot/3rd metatarsal. We would like\n view of 3rd metatarsal; given renal transplant, recent dye load, do not want to\n use contrast. Please page w/ questions, results.\n REASON FOR THIS EXAMINATION:\n NON-contrast study to rule out osteomyelitis in R foot and 3rd metatarsal.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Diabetes, peripheral vascular disease, right lower extremity\n cellulitis/fasciitis. Inflammation adjacent to the 3rd metatarsal head with\n abnormal findings on radiograph.\n\n TECHNIQUE: Helical axial images through the foot was obtained and\n reconstructed in the coronal and sagittal planes.\n\n CT RIGHT FOOT W/O CONTRAST; There is fragmentation, cortical irregularity and\n destruction of the head of the 3rd metatarsal. There is marked adjacent soft\n tissue inflammatory change. There is elevation of the dorsal cortex of the\n distal 3rd metatarsal. Deep to this, is relative lower soft tissue\n attenuation. There is no focal drainable fluid collection. No other areas or\n bone destruction are present. There is marked vascular calcification. As\n seen on the previous CT scans, there is marked soft tissue inflammatory change\n along the posterior and medial aspect of the ankle.\n\n IMPRESSION: Findings consistent with osteomyelitis at the distal 3rd\n metatarsal head, not crossing the joint. There is a suggestion of an evolving\n abscess on the dorsal soft tissues, but no focal drainable fluid collection.\n Extensive inflammatory soft tissue along the medial aspect of the ankle joint.\n The adjacent bone is within normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-14 00:00:00.000",
"description": "R CT LOWER LIMB W/ CONTRAST RIGHT",
"row_id": 759690,
"text": " 2:18 PM\n CT LOWER LIMB W/ CONTRAST RIGHT; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Evaluate for gas/fluid collection.\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM-1, CAD, PVD, admitted w/ MSSA in blood, RLE. Now w/\n worsening RLE pain and erythema. Please page w/ questions, results.\n REASON FOR THIS EXAMINATION:\n Evaluate for gas/fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent erythema of the right lower extremity following\n debridement. Evaluate for gas or abscess collection within the soft tissues.\n\n TECHNIQUE: Contiguous 2 mm axial CT slices through the tibia was performed\n and reconstructed in the coronal and sagittal planes. Imaging was performed\n after administration of 100 cc Optiray IV contrast.\n\n CT LOWER EXTREMITY: There is a surgical defect within the proximal, posterior\n aspect of the calf. This is new since the previous study of . No gas\n collection or abscess is seen within the soft tissues. There is extensive\n edema within the subcutaneous tissues at the level of the ankle joint, most\n marked along the medial aspect but not significantly changed from the prior\n study. The cortex of the tibia and fibula is normal, with no signs to suggest\n osteomyelitis. There is extensive vascular calcification. Surgical clips\n within the soft tissues are likely secondary to previous vascular\n intervention. The foot was not not imaged.\n\n IMPRESSION: No abscess or soft tissue gas. Stable inflammatory stranding\n along the medial aspect of the distal calf. No signs of osteomyelitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-14 00:00:00.000",
"description": "R FOOT AP,LAT & OBL RIGHT",
"row_id": 759687,
"text": " 2:07 PM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: Evaluate for subcutaneous gas, signs of fasciitis.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with DM-1, ESRD, PVD, here w/ MSSA sepsis from RLE wound.\n REASON FOR THIS EXAMINATION:\n Evaluate for subcutaneous gas, signs of fasciitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right lower extremity wound.\n\n RIGHT FOOT, 3 VIEWS: There is evidence of diffuse osteopenia. The distal\n portion of the right first toe has been removed surgically. No evidence of\n acute fracture or dislocation. The joint spaces are well preserved. The\n distal third metatarsal appears ill-defined, with cortical interruption,\n suggestive of osteolysis of the distal third metatarsal. Also noted is\n evidence of periosteal reaction within the third metatarsal. There is\n extensive vascular calcification noted.\n\n IMPRESSION: Findings suspicius for osteomyelitis of the distal 3rd\n metatarsal. Please correlate with patient's clinical history, as ddx includes\n changes relate to subacute fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-17 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 759951,
"text": " 2:26 PM\n ART EXT (REST ONLY) Clip # \n Reason: sufficient arterial flow for osteo healing\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with right MTP osteomyelitis, type I DM, CAD, s/p renal\n transplant.\n REASON FOR THIS EXAMINATION:\n sufficient arterial flow for osteo healing\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Osteomyelitis, assess lower extremity vascularity.\n\n FINDINGS: Doppler evaluation shows triphasic wave forms at the femoral levels\n only. All other wave forms are monophasic. The ABI measurements are\n inaccurate due to vessel non-compressibility. The volume recordings\n demonstrate some wave form widening and amplitude loss at the ankle and\n metatarsal levels bilaterally.\n\n IMPRESSION: Findings as stated above which indicate significant SFA/proximal\n popliteal artery disease bilaterally. There is also bilateral significant\n tibial disease.\n\n\n"
}
] |
14,038 | 103,987 | 81yo man with h/o CLL c/b malignant pleural effusion, primary resected melanoma, type II diabetes mellitus, and gout presented to ED after mechanical fall and found to have subdural hematoma. During his hospitalization the following issues were addressed: . #. Subdural hematoma: Hemorrhage occurred in the setting of mechanical fall. He was seen by neurosurgery who recommended keeping SBP <140 and loading with Dilantin. He was admitted to the MICU for frequent neuro checks, and remained there for one day. On day two, his Dilantin level was subtherapeutic, and he was reloaded. On day three he developed neurologic changes of increased lethargy and dysarthria. Findings were consistent with Dilantin toxicity. His AM dose was held on day four, and symptoms resolved. He was continued on Dilantin 100mg po TID. His head CT showed multiple lesions concerning for mets disease. It was unclear whether these lesions could be due to his CLL/PLL or due to his remote history of nonmetastic resected melanoma. He had a brain MR that showed a single parietal lesion concerning for mets. The other lesions were read as consistent with amyloid angiopathy. Neuro-oncology was consulted, and did recommend LP for staging, and that patient may benefit from XRT. . A repeat head CT on showed new midline shift and rebleed (unclear of duration) without herniation. Hence, an LP was held. Neurosurgery was consulted and patient was not a surgical candidate because of his comorbidities and the size of the lesion. In addition, his thrombocytopenia introduced a substantial bleeding risk if any drains were placed in his head. On , another head CT showed no interval changes in the midline shift, but worsening mass effect. Follow up CT on showed stable midline shift. . Throughout the hospitalization, he was transfused platelet products for counts <50 to minimize worsening of his intracranial hemorrhage. . #. CLL: The patient is followed by oncology attending Dr. at NEBH; but has been admitted to the BMT service at previously. He underwent leukopharesis three times prior to transfer to BMT for hyperleukocytosis. His last dose of Campath was at NEBH . He was transfused both PRBC and platelets without much increase. In the MICU, he was followed by the BMT fellow and BMT attending with the OMED resident/intern team following. He underwent leukophoresis several times here with reductions in his WBC to usually < 300K. . Because of his previously failed chemotherapy experiences, he was offered to be treated with the anti-CD52 antibody, Campath. While the family was advised about the significant risks (inlcuding worsening of his ascites and the mass effect in his brain) regarding the administration of this drug in the face of his multiple medical comorbidities, they still requested that this drug be given. . 4 doses of Campath were given from (with an initial test dose of 3mg).He experienced small WBC count decrements, but soon started to rebound. At this time, his WBC count consisted predominantly of prolymphocytes. A short wait period was done to assess his response to the campath. And in the face of continuing rises in his WBC count, the family requested to have another trial of campath. Hence, he continued to receive campath on and and . . # ID issues: - Bacteroides and Citrobacter in 2 different blood cultures - on Vanco and ceftaz/flagyl and caspo, ganciclovir - : switched to ceftaz - CMV VL on : started on Ganciclovir -> : VL 7670 - CMV VL on ->2050 - patient was cultured significant temperature spikes. . # Bilateral malignant pleural effusions. - Thoracentesis : 1.5L by IP service - CXR: : A moderate right and small left pleural effusion are stable. - CXR: : b/l layering pleural effusions and perihilar edema . # DIC: as per previous labs, pt. in chronic DIC. On pt developed persistent bleeding at site of phereis catheter. Transfused 3 u platelets, 2 u FFP, 2 u cryoprecipitate c improvement in clinical symptoms and improvement in DIC labs. Plat cnt up to 60 from 20 s/p transfusions. This likely accounts for his petechial rash. Throughout his hospitalization, patient was transfused to keep his fibrinogen >100 for suspected chronic DIC. . #. ARF: baseline creat 1.0; elevated on admission 2.1. allopurinol and held. creatinine improved daily. FeNA calculated < 1%; appeared dry on exam. Likely prerenal in etiology. Renal ultrasound obtained to r/o post renal etiology. baseline creatinine of 1. Unclear cause - possibly secondary to leukemic infiltration vs. previous TLS. Dry on physical exam; may represent some component of pre-renal azotemia. . - U Na - 28, U Cr - 124, FeNA = .21%; c/w prerenal azotemia - renal u/s showing no obstruction - Cr 2.9 on : decreased ganciclovir on ; decreased spironolactone on -> Cr 2.7 on . #. HTN: Dyazide and Cozaar held given relative hypotension. goal SBP <140 per neurosurgery recc's. . #. Skin: patient has rash lymphoma per oncology; also with diffuse petechiae. . #. TIIDM: maintained on sliding scale insulin with good control. . # End of life issues: The hematology team had several discussions with the family regarding the state of health of the patient. It was reiterated multiple times that he had multiorgan failure and that there was only a small chance that he could recover from his illness. It was reiterated that campath could worsen his condition and they accepted this risk. He continued to be a DNR/DNI during the last days of his life. In the AM of , the patient passed after worsening respiratory status for the last few days of his life. He had become more and more unresponsive and was increasing his O2 requirements over the last few days of his life. The daughter (proxy) was offered an autopsy, but refused. Medications on Admission: Meds on Admission: Allopurinol 60mg daily Dyazide 37.5/25 daily Cozaar 50mg daily Campath supplemental O2 previously on metformin; stopped during last hospitalization Discharge Medications: Patient passed away in hospital Discharge Disposition: Expired Discharge Diagnosis: CLL/PLL Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2138-1-5** | Stable tiny right subdural hemorrhage. IMPRESSION: New moderate-sized right pleural effusion, with underlying collapse and/or consolidation. IMPRESSION: Stable right subdural hematoma. Again demonstrated is a tiny right extra-axial fluid collection, unchanged since the prior exam, consistent with a small subdural hemorrhage. IMPRESSION: Slightly improved right subdural hematoma and associated mass effect, with lessened contralateral shift of normally midline structures. FINDINGS: There has been some slight improvement in both the size of these right subdural hematoma and associated mass effect. There is again seen a large right-sided pleural effusion likely layering and a left-sided pleural effusion which is moderated sized. Stable periventricular and subcortical white matter hypodensities are again noted, consistent with chronic microvascular angiopathy. There is a left retrocardiac opacity. There is prominence of the right pulmonary hilum, similar to that seen on previous exams. There is a moderately large right effusion extending into the minor fissure, new compared with , with underlying collapse and/or consolidation. Grayscale and Doppler son of the right axillary vein and right brachial veins were performed. The previously identified high-density lesions are subsiding indicating that these were most likely hemorrhages rather than amyloid angiopathy. IMPRESSION: Small subdural hematomas as described. There is again seen a right-sided central venous catheter with distal tip in the SVC, unchanged. The hematoma extends under the right temporal lobe, which is slightly elevated and medially displaced. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.MITRAL VALVE: Trivial MR.PERICARDIUM: Small pericardial effusion. The configuration of the hemorrhage along the right cerebral convexity surface is unchanged. FINDINGS: There is a new moderate sized mixed density subdural fluid collection on the right. IMPRESSION: New moderate right subdural fluid collection, with mass effect and midline shift. There is a right-sided IJ central venous catheter, with the distal tip in the SVC, unchanged. Note of posterior scalp skin staples that are unchanged. decreased BS on right. Unchanged appearance of multiple high attenuation lesions scattered within the brain concerning for metastasis. There still remains mass effect, as shown by compression of the right lateral ventricle and contralateral shift of the normally midline structures. Delayed anterior precordialR wave progression may be normal variant but cannot exclude prior anteriormyocardial infarction. TECHNIQUE: Axial non-contrast head CT. Findings consistent with amyloid angiopathy. Diffuse non-diagnostic repolarization abnormalities.Compared to the previous tracing of multiple abnormalities as notedpersist without major change. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 68Weight (lb): 175BSA (m2): 1.93 m2BP (mm Hg): 115/63Status: InpatientDate/Time: at 16:08Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Right ventricular chamber size and free wall motion are normal.Trivial mitral regurgitation is seen. This may represent an early small-bowel obstruction versus ileus. RIGHT UPPER EXTREMITY DVT STUDY: The study is limited due to bandage overlying the right IJ and the right subclavian vein. There is a small lipoma over the left frontal region. IMPRESSION: Stable right subdural hematoma with slight progression of mass effect and shift of midline structures. There is a decreasing moderate sized right pleural effusion. FINDINGS: As seen on , there is a large right-sided pleural effusion, and a small-to-moderate left pleural effusion. IMPRESSION: 1) Moderate right and a small left pleural effusions. The right pleural effusion has decreased in the interim, secondary to pleurocentesis. polyp vs retention is noted in the right maxillary sinus. IMPRESSION: Stable large right and moderate left pleural effusions. There are bilateral moderate-sized layering pleural effusions on the supine radiograph. A moderate right and small left pleural effusion are stable. Very small (approximately 1 mm) right extra-axial fluid collection, with associated mild edema of the right hemisphere, but without midline shift. FINDINGS: Again seen is right-sided IJ central venous catheter, extending to the lower SVC. There are bilateral moderate-sized layering pleural effusions, right greater than left. right hemisphere is slightly edematous but no frank midline shift. NSVT occured x's one w/ placement of Pharesis catheter in R IJ. The right subclavian catheter tip is in the mid SVC. There are bilateral small pleural effusions with bibasilar atelectasis. The cardiac silhouette is upper limits of normal in size and stable. IMPRESSION: Bilateral small pleural effusions. TECHNIQUE: Axial noncontrast head CT. There is a small left pleural effusion. Left pleural effusion has increased in the interim, now moderate. Pulmonary edema FINAL REPORT INDICATION: CLL, pleural effusions, with shortness of breath. There is right IJ central venous catheter with the tip in distal SVC. REASON FOR THIS EXAMINATION: Evaluate size of pleural effusions. The right lateral chest is excluded from the image. There is slightly more confluent areas of hazy opacification centrally in the perihilar regions, right greater than left, likely reflecting a component of perihilar edema. There is mild shift of the midline structures to the contralateral side that has worsened slightly. There is decreasing mild congestive heart failure. CHEST: A single portable upright view is compared to previous examination of . 9:04 PM CHEST (PA & LAT) Clip # Reason: Evaluate size of pleural effusions. ?plan for thoracentisis, and/or paracentisis. Rounded lucencies are noted in the left clavicle and scapula. SDH unchanged per 2nd CT scan. Persistent left basilar atelectasis. Additionally, there is a tiny, approximately millimeter sized extra- axial fluid collection along the right cerebral convexity, but without significant mass effect on the underlying cerebral cortex. | 26 | [
{
"category": "Echo",
"chartdate": "2137-12-04 00:00:00.000",
"description": "Report",
"row_id": 65888,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 175\nBSA (m2): 1.93 m2\nBP (mm Hg): 115/63\nStatus: Inpatient\nDate/Time: at 16:08\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Trivial MR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand systolic function (LVEF>55%). Regional left ventricular wall motion is\nnormal. Right ventricular chamber size and free wall motion are normal.\nTrivial mitral regurgitation is seen. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-11-24 00:00:00.000",
"description": "Report",
"row_id": 140164,
"text": "Sinus tachycardia\nAtrial premature complexes\nLow limb lead QRS voltages\nPoor R wave progression with late precordial QRS transition\nFindings are nonspecific but clinical correlation is suggested for possible\nchronic pulmonary disease\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2137-12-15 00:00:00.000",
"description": "Report",
"row_id": 140163,
"text": "Sinus rhythm. Low QRS voltage in the limb leads. Delayed anterior precordial\nR wave progression may be normal variant but cannot exclude prior anterior\nmyocardial infarction. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of multiple abnormalities as noted\npersist without major change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 894663,
"text": " 1:07 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: eval for brain mass\n Admitting Diagnosis: SUBDURAL BLEED\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with h/o CLL s/p fall with SDH with CT concerning for brain\n lesions\n REASON FOR THIS EXAMINATION:\n eval for brain mass\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: History of chronic lymphatic leukemia, status post fall\n with subdural hematoma on CT.\n\n MRI OF THE BRAIN WITH GADOLINIUM\n\n Exam compared to the patient's CT scan of .\n\n FINDINGS: There is some abnormal signal material surrounding the brain, most\n notably adjacent to the right hemisphere, but also present in the left\n occipital and left frontal regions consistent with subdural hemorrhage. There\n are multiple abnormal signal foci on the susceptibility sequence within the\n brain. These are various in size and in location. The pattern suggests\n amyloid angiopathy. There is no definite evidence of territorial infarction.\n There are multiple T2 high signal intensity foci consistent with microvascular\n angiopathy. There is one abnormal signal focus in the left parietal region,\n which corresponds to a somewhat permeative appearance on the patient's CT scan\n represent a possible infiltrative lesion such as malignancy. There is a small\n lipoma over the left frontal region.\n\n IMPRESSION: Small subdural hematomas as described. Findings consistent with\n amyloid angiopathy. Some of these appear to correspond to the areas of\n slightly increased intensity seen on the patient's CT scan. Possible lytic\n lesion in the left parietal region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 897412,
"text": " 8:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess interval changes.\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with subdural hematoma, mass effect and midline shift.\n REASON FOR THIS EXAMINATION:\n Assess interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known subdural hematoma, please evaluate for mass effect and\n midline shift.\n\n COMPARISON: .\n\n TECHNIQUE: Axial non-contrast head CT.\n\n FINDINGS: There has been some slight improvement in both the size of these\n right subdural hematoma and associated mass effect. The configuration of the\n hemorrhage along the right cerebral convexity surface is unchanged. There\n still remains mass effect, as shown by compression of the right lateral\n ventricle and contralateral shift of the normally midline structures. The\n basal cisternal spaces, however, have retained their normal configuration. The\n - white matter distinction is preserved. No new intracranial hemorrhages\n are identified. Mucosal thickening within the right maxillary sinus is stable\n and the other paranasal sinuses are clear. Note of posterior scalp skin\n staples that are unchanged.\n\n IMPRESSION: Slightly improved right subdural hematoma and associated mass\n effect, with lessened contralateral shift of normally midline structures.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 895927,
"text": " 8:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess changes\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with subdural\n REASON FOR THIS EXAMINATION:\n assess changes\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN, :\n\n INDICATION: Subdural hematoma. Evaluate for change.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n Comparison is made to the previous CT scan of .\n\n FINDINGS:\n\n There is no change in the size or configuration of the right-sided subdural\n hemorrhage. Denser blood products are layering posteriorly. The hematoma\n extends under the right temporal lobe, which is slightly elevated and medially\n displaced. However, the basal cisternal spaces retain their normal\n configuration. There is mild shift of midline structures to the left,\n unchanged since the previous day's examination. Brain parenchymal attenuation\n is also stable.\n\n IMPRESSION: Stable right subdural hematoma. Findings were reported by\n telephone to Dr. at 9:20 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 894541,
"text": " 4:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evidence of change in size in subdural\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with new subdural s/p fall, no change in neuro exam\n REASON FOR THIS EXAMINATION:\n evidence of change in size in subdural\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New subdural hemorrhage after fall, followup.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There has been no significant interval change\n since the prior examination. Again demonstrated is a tiny right extra-axial\n fluid collection, unchanged since the prior exam, consistent with a small\n subdural hemorrhage. There is no mass effect, shift of midline structures, or\n new intra- or extra-axial hemorrhage identified. Again seen are multiple\n round high-density lesions within the right frontal, right temporal/parietal\n lobes, and left cerebellar hemispheres. Stable periventricular and\n subcortical white matter hypodensities are again noted, consistent with\n chronic microvascular angiopathy. The ventricles and sulci are stable in\n configuration, and there is no evidence of hydrocephalus. Visualized paranasal\n sinuses and mastoid air cells are clear. Multiple skin staples are seen\n overlying the right occipital scalp.\n\n IMPRESSION: No interval change in the appearance of the brain. Stable tiny\n right subdural hemorrhage. Unchanged appearance of multiple high attenuation\n lesions scattered within the brain concerning for metastasis.\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895291,
"text": " 5:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o PNA and worsening SOB\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions. New fever and SOB.\n\n REASON FOR THIS EXAMINATION:\n r/o PNA and worsening SOB\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, performed on .\n\n HISTORY: 81-year-old man with CLL and pleural effusions. Now with new fever\n and shortness of breath. Evaluate for pneumonia.\n\n FINDINGS: Comparison is made to the previous study from , at\n 5:35 a.m.\n\n There is again seen a right-sided central venous catheter with distal tip in\n the SVC, unchanged. There is persistent large pleural effusion on the right\n side with opacification of the right lung base. A left retrocardiac opacity\n is also identified, which may be secondary to underlying infiltrate or fluid.\n The left CP angle has been cut off from the study. These findings are\n essentially unchanged since the previous study.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 895857,
"text": " 3:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for changes in subdural and for any acute intracrania\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with subdural and AMS\n REASON FOR THIS EXAMINATION:\n Assess for changes in subdural and for any acute intracranial path\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural and altered mental status. Assess for changes in\n subdural and any intracranial path.\n\n COMPARISON: .\n\n FINDINGS: There is a new moderate sized mixed density subdural fluid\n collection on the right. The lateral ventricle is completely compressed\n indicating mass effect from the subdural fluid collection as well as a 3 mm\n shift of the normally midline structures. The mixed intensity of the\n collection likely consists of blood and other fluid given the mixed densities.\n The previously identified high-density lesions are subsiding indicating that\n these were most likely hemorrhages rather than amyloid angiopathy.\n\n IMPRESSION: New moderate right subdural fluid collection, with mass effect\n and midline shift. Dr. and I discussed the urgency of these findings at\n 3:45 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 895292,
"text": " 5:35 PM\n PORTABLE ABDOMEN Clip # \n Reason: abd pain\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with abd pain\n REASON FOR THIS EXAMINATION:\n abd pain\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP abdomen performed on .\n\n HISTORY: 81-year-old man with abdominal pain.\n\n FINDINGS: There are no prior studies available for comparison.\n\n There are several air-filled loops of mildly distended small bowel within the\n mid abdomen. There is some air seen within the expected location of the\n ascending colon as well as in the rectum. Gas is also seen within a\n moderately distended stomach.\n\n IMPRESSION:\n\n There is a nonspecific bowel gas pattern. There is some mildly distended\n loops of air-filled small bowel within the abdomen. However, gas is seen\n within the rectum and small portions of the colon. This may represent an\n early small-bowel obstruction versus ileus. Followup films is recommended.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895246,
"text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new infiltrate\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions. New fever.\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 81-year-old man with CLL and pleural effusions. New fever, evaluate\n for pneumonia.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a right-sided IJ central venous catheter, with the distal tip in the\n SVC, unchanged. There is again seen a large right-sided pleural effusion\n likely layering and a left-sided pleural effusion which is moderated sized.\n These are unchanged from previous. There is no evidence for overt pulmonary\n edema. There is a left retrocardiac opacity. This finding is unchanged.\n Underlying pneumonia would be difficult to exclude given the retrocardiac\n opacity and the large pleural effusions.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-01 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 895284,
"text": " 3:54 PM\n UNILAT UP EXT VEINS US RIGHT PORT; ABDOMEN U.S. (COMPLETE STUDY) PORTClip # \n Reason: please assess for clot\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL on campath therapy p/w R upper ext. swelling,\n weakness. Please evaluate for clot in R upper extremity vasculature\n REASON FOR THIS EXAMINATION:\n please assess for clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old male with CLL and DIC presenting with right upper\n extremity swelling. The patient also has abdominal distention and also acute\n renal failure.\n\n RIGHT UPPER EXTREMITY DVT STUDY: The study is limited due to bandage\n overlying the right IJ and the right subclavian vein. Grayscale and Doppler\n son of the right axillary vein and right brachial veins were performed.\n There is normal flow, compressibility and augmentation of these vessels. No\n intraluminal thrombus was identified.\n\n ABDOMINAL ULTRASOUND: The study is very limited due to distended bowel\n including very distended and air-containing stomach. This limits the\n visualization of the intra-abdominal structures. There is a moderate-to-large\n amount of ascites around the liver and in the pelvis.\n\n RENAL ULTRASOUND: The right kidney measures 10.3 cm. The left kidney\n measures 10.3 cm. There are multiple simple cysts in the kidneys bilaterally.\n There is no evidence of hydronephrosis. The echogenicity of the kidneys is\n within normal limits.\n\n IMPRESSION:\n\n 1. No evidence of DVT in the right upper extremity.\n\n 2. No evidence of hydronephrosis.\n\n 3. Distended loops of bowel containing air.\n\n 4. Moderate-to-large amount of ascites around the liver and in the pelvis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894416,
"text": " 12:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumonia, effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL here with weakness. decreased BS on right.\n REASON FOR THIS EXAMINATION:\n ? pneumonia, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CLL with weakness, decreased breath sounds on right.\n\n CHEST, SINGLE AP VIEW.\n\n There is a moderately large right effusion extending into the minor fissure,\n new compared with , with underlying collapse and/or consolidation.\n There is prominence of the right pulmonary hilum, similar to that seen on\n previous exams. This could reflect either pulmonary lymphadenopathy or\n pulmonary hypertension. There is atelectasis at the left lung base, but no\n left effusion. No CHF. Suspect underlying hyperinflation.\n\n IMPRESSION: New moderate-sized right pleural effusion, with underlying\n collapse and/or consolidation. Atelectasis at left base. Prominent right\n hium -- see comment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 895142,
"text": " 9:04 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate size of pleural effusions.\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL here with weakness. decreased BS bilaterally.\n REASON FOR THIS EXAMINATION:\n Evaluate size of pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n DATE OF EXAM: .\n\n INDICATION: 81-year-old male with CLL, with new-onset weakness and decreased\n breath sounds in the lung bases bilaterally.\n\n FINDINGS: As seen on , there is a large right-sided pleural\n effusion, and a small-to-moderate left pleural effusion. The airspace within\n the right lung base and retrocardiac region cannot be evaluated due to\n underlying effusions, and therefore pneumonia is not excluded. The upper\n lungs are better aerated. The right IJ central venous catheter tip projects\n at the SVC/right atrial junction. There is no pneumothorax. The previously\n seen possible lucencies within the left clavicle and scapula are not included\n on this film. Osseous structures are otherwise unchanged.\n\n IMPRESSION: Stable large right and moderate left pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894582,
"text": " 2:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? etiology of slight desat\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions, s/p thoracentesis.\n\n REASON FOR THIS EXAMINATION:\n ? etiology of slight desat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old with CLL status post thoracentesis.\n\n COMPARISON: .\n\n AP PORTABLE CHEST RADIOGRAPH: Again seen is a double lumen central venous\n catheter with tip in the SVC. Cardiomediastinal silhouette is stable. There\n is decreasing mild congestive heart failure. There is a decreasing moderate\n sized right pleural effusion. Again seen is left lower lobe collapse and/or\n consolidation. There is a small left pleural effusion. Rounded lucencies are\n noted in the left clavicle and scapula.\n\n\n IMPRESSION:\n\n 1. Mild congestive heart failure somewhat improved compared to the last chest\n radiograph with moderate sized right pleural effusion and small left pleural\n effusion. Left lower lobe atelectasis and/or consolidation.\n\n 2. Rounded lucencies in the left clavicle and scapula. Clinically correlate\n and follow-up as necessary.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 894447,
"text": " 5:51 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval change from previous study\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with small right subdural, low platelets (15)\n REASON FOR THIS EXAMINATION:\n interval change from previous study\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right subdural seen on previous CT scan. Follow-up.\n\n TECHNIQUE: Noncontrast head CT, compared with the examination of the same day\n at 12:00 p.m.\n\n FINDINGS: There has been no significant interval change. The minimal right\n extra-axial collection has not changed in size. There is no midline shift.\n The multiple round high density lesions seen scattered throughout the brain\n are again identified, as are the multiple low density lesions in the white\n matter. These findings are most concerning for an underlying metastatic\n process, which can be better evaluated with an MRI. Other etiologies cannot\n be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 894414,
"text": " 11:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with fall, head injury\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe SUN 12:30 PM\n tiny (mm-sized) left subdural collection. right hemisphere is slightly\n edematous but no frank midline shift. several nodules throughout brain\n (largest 7mm) suggesting metastasis - history of underlying malignancy??\n\n no fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with fall and head injury. History of CLL.\n\n TECHNIQUE: Non-contrast head CT without priors for comparison.\n\n FINDINGS: Multiple small nodules are seen in the brain, the largest measuring\n 7 mm. One is in the left cerebellar peduncle, one in the inferior left\n frontal lobe, one in the left temporoparietal region, one in the right\n temporoparietal region, and one in the right frontal lobe adjacent to the\n cingulate gyrus. These nodules are all high in density, though not of the\n density to suggest bleed, however, the multiplicity suggests a metastatic\n process. Additionally, there is a tiny, approximately millimeter sized extra-\n axial fluid collection along the right cerebral convexity, but without\n significant mass effect on the underlying cerebral cortex. Multiple subtle\n low density lesions are seen scattered throughout the white matter of both\n cerebral hemispheres, and the right cerebral hemisphere appears slightly\n edematous compared to the left, with mild effacement of sulci, and narrowing\n of the lateral ventricle, though without midline shift. No intra- axial\n hemorrhage is identified. No acute major vascular territorial infarct is\n seen.\n\n Bony structures are intact. polyp vs retention is noted in the right maxillary\n sinus. The reminader of the sinuses are clear. There is calcification of the\n vertebral and basilar arteries and of the choroid plexus.\n\n IMPRESSION:\n\n 1. High density nodules and multiple ill-defined hypodensities scattered\n throughout the brain, suggestive of a metastatic process.\n\n 2. Very small (approximately 1 mm) right extra-axial fluid collection, with\n associated mild edema of the right hemisphere, but without midline shift.\n\n An MRI of the brain is recommended for further evaluation of these findings.\n\n Preliminary findings were relayed to the ED dashboard at 12:30 p.m., 25\n (Over)\n\n 11:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895561,
"text": "\n CHEST (PORTABLE AP) Clip # \n Reason: Pt s/p pleurocentesis evaluate for signs of pneumothorax\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions. New fever and SOB.\n\n REASON FOR THIS EXAMINATION:\n Pt s/p pleurocentesis evaluate for signs of pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with CLL and pleural effusions. No fever and shortness\n of breath. Status post pleurocentesis. Evaluate for pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: Right internal jugular central venous catheter is in\n unchanged position. Heart size is normal. Mediastinal and hilar contours are\n unchanged. The right lateral chest is excluded from the image. The right\n pleural effusion has decreased in the interim, secondary to pleurocentesis.\n No definite pneumothorax is visualized. Left pleural effusion has increased\n in the interim, now moderate.\n\n IMPRESSION: No evidence of pneumothorax, status post pleurocentesis.\n Increasing left effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 896235,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions now sob w/ blood products,\n sounds wet on exam. please assess for increasing chf, effusions\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old with CML and pleural effusions, now with shortness of\n breath.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: Cardiomediastinal silhouette is stable. A moderate right and small\n left pleural effusion are stable. Lung fields are clear. The right\n subclavian catheter tip is in the mid SVC. There is no pneumothorax.\n Persistent left basilar atelectasis.\n\n IMPRESSION:\n\n 1) Moderate right and a small left pleural effusions.\n\n 2) Persistent bibasilar atelectasis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 896760,
"text": " 3:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval changes\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions now sob w/ blood products,\n sounds wet on exam.\n REASON FOR THIS EXAMINATION:\n please assess for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Shortness of breath.\n\n The cardiac silhouette is upper limits of normal in size for technique. There\n are bilateral moderate-sized layering pleural effusions on the supine\n radiograph. There is slightly more confluent areas of hazy opacification\n centrally in the perihilar regions, right greater than left, likely reflecting\n a component of perihilar edema. Additionally, there is a suggestion of\n anasarca and probable ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 896110,
"text": " 12:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for fluid reaccumulation. Please take picture as upri\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions. s/p 1.5L drainage 3d ago with\n increasing O2 requirements.\n REASON FOR THIS EXAMINATION:\n Assess for fluid reaccumulation. Please take picture as upright as possible to\n look for fluid layering.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: CLL, pleural effusions, status post 1.5-liter drainage three days\n ago with increasing oxygen requirements.\n\n CHEST: A single portable upright view is compared to previous examination of\n . There are bilateral small pleural effusions with bibasilar\n atelectasis. The lungs are clear. The heart size is within normal limits.\n There is right IJ central venous catheter with the tip in distal SVC.\n\n IMPRESSION: Bilateral small pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 897524,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute worsening of SOB. ? Pulmonary edema\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions now sob.\n\n REASON FOR THIS EXAMINATION:\n acute worsening of SOB. ? Pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL, pleural effusions, with shortness of breath. Evaluate\n pulmonary edema.\n\n TECHNIQUE: Single portable AP view of the chest was compared with examination\n from four days ago.\n\n FINDINGS: Again seen is right-sided IJ central venous catheter, extending to\n the lower SVC. There is significant worsening of the pleural effusions, and\n allowing for the increased effusion, probably no significant change in the\n pulmonary parenchymal pattern. The cardiac silhouette is difficult to\n distinguish given the amount of effusion, but the visualized portions are\n probably unchanged.\n\n IMPRESSION: Significant increase in pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 896262,
"text": " 9:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess interval changes\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with subdural and AMS\n REASON FOR THIS EXAMINATION:\n Assess interval changes\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural with acute mental status, assess interval change.\n\n COMPARISON: Comparison to at 8:06 a.m.\n\n TECHNIQUE: Axial noncontrast head CT.\n\n FINDINGS: There is no significant change in the size or configuration of the\n right-sided subdural hemorrhage extending under the right temporal lobe.\n There is mild shift of the midline structures to the contralateral side that\n has worsened slightly. The basal cistern spaces; however, retain their normal\n configuration. The -white matter distinction is preserved.\n\n IMPRESSION: Stable right subdural hematoma with slight progression of mass\n effect and shift of midline structures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 897128,
"text": " 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates, effusions\n Admitting Diagnosis: SUBDURAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CLL and pleural effusions now sob.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrates, effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED .\n\n COMPARISON: .\n\n INDICATION: CLL.\n\n Central venous catheter remains in satisfactory position. The cardiac\n silhouette is upper limits of normal in size and stable. There are bilateral\n moderate-sized layering pleural effusions, right greater than left. Overall,\n both effusions appear slightly larger in the interval. There has been\n interval decrease in the degree of perihilar haziness attributed to improving\n pulmonary edema. There remains a suggestion of ascites and anasarca.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-11-25 00:00:00.000",
"description": "Report",
"row_id": 1445481,
"text": "CCU NURSING PROGRESS NOTE 1900-0700,\n\n81 y/o male w/ hx of CLL, last treated w/ chemo on . Admitted to ccu w/ worsening weakness and s/p fall at home this am. + head injury, 4 stables intact, Head ct + for 1mm SDH, repeat Head CT not significant for changes in SDH. WBC 815.7, rec's pharesis at NEB regulary.\n\nS/O: Pt a&o x's 3, denies pain.\nsee carevue\n\nNeuro: Neuro check done frequently. No MS changes. Multiple nodules seen on Head CT, suggestive of metastasis. SDH unchanged per 2nd CT scan. Received 400 mg of po dilantin in ew, w/ additional 600mg IV, for complete dilatan load of 1000mg. No sz activity noted.\n\nCV: hr nsr w/ occ pvc's. NSVT occured x's one w/ placement of Pharesis catheter in R IJ. NIBP stable see carevue.\n\nHeme: Plt ct UP to 50 s/p 12units of plts (2 6unit bags). HCT read at 22 in accurate w/ wbc ct up to 815.7, pharesis done this shift via RIJ, line ok to use per xray. Calcium repleated w/ pharesis run\npost pharesis wbc down to 517., post hct up to 30.\n\nlabs sent thi am.\n\nResp: ls diminished Right mid to lower lobe. Chest cxr sig for large plueral effusion on right. O2 sat's drop to 88 on O2 via nc WHILE SLEEPING. new home O2 requirment since d/c on friday.\n\nGI/GU: voiding via urinal, + BS, + ascites. abd NT to palp. diet NPO.\n\nskin: intact\nSocial family visited last nigt up dated on plan of care\n\na/P: Pt tolerated Pharesis w/ adrop in wbc, stable hct, Pharesis line placed w/o complication.\nMS stable, neuro exam unchanged. o2 sat drop w/ sleep at times.\n?plan for thoracentisis, and/or paracentisis. Follow plt ct/wbc count.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-11-25 00:00:00.000",
"description": "Report",
"row_id": 1445482,
"text": "correc hct not up to 30 post pharesis, hct remains 23\n"
}
] |
6,702 | 132,390 | Again, the patient was brought to the Medical Intensive Care Unit for further workup. He had an urgent endoscopy by the Gastrointestinal Service which showed diffuse erosive esophagitis, grade IV, in the mid to distal esophagus. Stomach had positive bile reflux. There was no sign of acute or recent bleed. It was recommended that the patient be started on Prilosec 40 mg p.o. b.i.d., that his anticoagulation be held, and that he be observed very closely. The patient received 2 units of fresh frozen plasma and 4 units of packed red blood cells prior to the procedure. On hospital day two the patient remained asymptomatic, although he had about 2 liters of melenas stool overnight. His hematocrit had fallen to 25 (down from 27.4). This had not appropriately increased since receiving his 4 units of blood. The patient was given vitamin K and an additional 2 units of packed red blood cells. It was decided to repeat the esophagogastroduodenoscopy which showed similar findings as the prior study without any evidence of new bleeds. The patient was bowel prepped and brought to colonoscopy on . Colonoscopy revealed diverticulosis of the sigmoid colon and a polyp in the cecum. There was no site of active or recent bleeding. The patient was continued to be watched very closely in the Intensive Care Unit. His hematocrit increased to 33.8, and by , increased to 35.8. There were no signs of continued bleeding. The patient ambulated without orthostasis or symptoms. Throughout his hospital stay, he had no shortness of breath or chest pain. Although, the exact source of his bleeding was still unknown, it was hypothesized that he either had bleeding from his esophagitis or a bleeding diverticula which has since stopped. The patient's diet was advanced, and he was tolerating a regular diet. | IMPRESSION: No significant abnormality. No pleural effusion. The abnormalities are non-specific. Heart size is normal. The right costophrenic angle is partly coned off the film. T waves are flattened with very slight ST segment elevation inleads V5-V6. No evidence for CHF. The lungs are clear. Since the previous tracing of the rate is morerapid. Atrial fibrillation. | 2 | [
{
"category": "ECG",
"chartdate": "2123-04-28 00:00:00.000",
"description": "Report",
"row_id": 142125,
"text": "Atrial fibrillation. Since the previous tracing of the rate is more\nrapid. T waves are flattened with very slight ST segment elevation in\nleads V5-V6. The abnormalities are non-specific.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-04-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 739360,
"text": " 9:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Profound GI bleed, replenishing fluids, please evaluate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o gastric adenomocarcinoma, Billroth II, CVA, GI bleed\n REASON FOR THIS EXAMINATION:\n Profound GI bleed, replenishing fluids, please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Partial gastrectomy with stroke and GI bleeding with third\n replacement.\n\n Heart size is normal. No evidence for CHF. The lungs are clear. The right\n costophrenic angle is partly coned off the film. No pleural effusion.\n\n IMPRESSION: No significant abnormality.\n\n\n"
}
] |
92,606 | 149,752 | 79 year old man with past medical history significant for ?SIADH, COPD, BPH s/p TURP () with indwelling foley catheter, ulcerative colitis, non-hodgkins lymphoma, presenting with severe hyponatremia. . #. Hyponatremia: Etiology consistent with SIADH. Chest x-ray, head CT, TSH, cortisol all within normal limits. Treated with IV fluid hydration, hypertonic saline, now on salt tabs and fluid restriction with improvement in sodium from 108 to 133. The patient's fluoxetine was discontinued. CT chest revealed unchanged prior 2 4mm lung nodules of RUL, an unchanged prior 3mm nodule or right major fissure. No evidence of lung mass. . #. Possible urinary tract infection: Urine culture on with > 100K e coli, culture from with only 4000 GNR, culture from pending. Was initially treated with cipro on admission, then changed to ceftriaxone on when sensitivities of cx from returned with e coli resistant to cipro. Plan to finish 7 day course of ceftriaxone/cefpodoxime through . . #. Diabetic foot ulcer on left heel, infected: Podiatry consulted, swab with MRSA, wound was debrided and treated with vancomycin for 7 days per podiatry recs.. No osteo on plain film. -Patient to f/u with podiatry in 1 week. . #. Transient Atrial fibrillation: Transient overnight - treated with IV lopressor and PO lopressor x 1, with spontaneous conversion to normal sinus rhythm. No further noted recurrent events. . #. Altered mental status/delusions: Patient is very appropriate, but had delusions of seeing firemen in his room in ICU. Treated with haldol as needed. Etiology likely multifactorial from acute illness, ICU course, severe sleep deprivation, hyponatremia etc. The patient's delirium substantially improved throughout his admission. . #. Leukocytosis: Patient with elevated WBC on admission to 21.9, although appeared hemoconcentrated on admission. . #. BPH: s/p TURP, on tamsulosin. Foley removed. If patient fails without foley, can replace or straight cath. . #. Depression: holding fluoxetine for now. . #.Hypertension: Restarted lisinopril. . #. COPD: Continue albuterol prn . #. Diabetes: Insulin sliding scale, aspirin . #. Peripheral Neuropathy: Continue neurontin . #. Osteoarthritis: continue lidocaine patch and percocet. | Chief Complaint: Hyponatremia HPI: 79M with COPD, h/o SIADH, s/p TURP recently p/w N/V/D/abd pain and found to have Na of 108 and WBC-22. Chief Complaint: Hyponatremia HPI: 79M with COPD, h/o SIADH, s/p TURP recently p/w N/V/D/abd pain and found to have Na of 108 and WBC-22. Hyponatremia (low sodium, hyposmolality) Assessment: Admitted with Na of 108 with possible etiologies of SIADH from SSRI, pain, recent surgery (TURP), pulmonary disease. Hyponatremia (low sodium, hyposmolality) Assessment: Admitted with Na of 108 with possible etiologies of SIADH from SSRI, pain, recent surgery (TURP), pulmonary disease. Hyponatremia: Appears euvolemic on exam but history suggestive of hypovolemia. Hyponatremia: Appears euvolemic on exam but history suggestive of hypovolemia. Hyponatremia (low sodium, hyposmolality) Assessment: Na+ 108. EXTREMITIES: 1+ edema b/l, 2+ dorsalis pedis. EXTREMITIES: 1+ edema b/l, 2+ dorsalis pedis. # Incr CE- likely demand ischemia in setting of recent tachycardia without EKG changes but concerning given elevation of MBI and trop with falling CK - cycle CE today . 1)HyponatremiaThis is with patient likely euvolemic with continued water intake in the setting of poor po intake and diarrhea noted above. - cont Cipro for UTI and f/u cultures - cont vancomycin until foot cultures are negative - f/u podiatry reccs - will d/c flagyl # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side effect of TURP. Urinary tract infection (UTI) Assessment: Pt has a foley since TURP on . For now, delusions/ hallucinations not c/w SSRI withdrawl #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN for BP control. HypoNatremia: stable now in the 120 range, will fluid restrci and start salt tabs, trend TUD to QID/ 2. Pt was found to have UTI with wbcs 22 and Na+ 108. adm to Micu for further treatment. Pt was found to have UTI with wbcs 22 and Na+ 108. adm to Micu for further treatment. Pt was found to have UTI with wbcs 22 and Na+ 108. adm to Micu for further treatment. Pt was found to have UTI with wbcs 22 and Na+ 108. adm to Micu for further treatment. Pt was found to have UTI with wbcs 22 and Na+ 108. adm to Micu for further treatment. Pt was found to have uti with wbcs 22 and Na+ 108. adm to Micu for further treatment. Urinary tract infection (UTI) Assessment: Pt has a foley since TURP on . Triponin 0.02, cpk 273, ckmb 15. will get EKG and possible heparin gtt this am. Podiatry consultation Remaining issues as per Housestaff note s ICU Care Nutrition: Glycemic Control: Lines: PICC Line - 08:00 AM Prophylaxis: DVT: sc hep Stress ulcer: PPI Code status: Full code Disposition : possible tc out of ICU if stable mental status Total time spent: 30 Hyponatremia (low sodium, hyposmolality) Assessment: Action: Response: Plan: Urinary tract infection (UTI) Assessment: Action: Response: Plan: Hyponatremia (low sodium, hyposmolality) Assessment: Pt with severe hyponatremia on adm 108. Hyponatremia (low sodium, hyposmolality) Assessment: Pt with severe hyponatremia on adm 108. ICU Care Nutrition: Glycemic Control: Lines: PICC Line - 08:00 AM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: VAP: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: DNR / DNI Disposition :ICU Total time spent: CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate minimal atelectatic change dependently. - cont ceftriaxone for UTI and f/u cultures - cont vancomycin until foot cultures are negative - f/u podiatry reccs # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side effect of TURP. Hypertonic saline now on hold, 1115 Na 120. Hypertonic saline now on hold, 1115 Na 120. CT PELVIS WITH INTRAVENOUS CONTRAST: There is diverticulosis of the colon, predominantly within the sigmoid, without evidence of diverticulitis. - cont Cipro for UTI and f/u cultures - cont vancomycin until foot cultures are negative - f/u podiatry reccs - will d/c flagyl # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side effect of TURP. Within the liver, a vague hypoattenuating lesion in the centralized aspect of segment IV B (2:21) is unchanged. Ill-defined hypoattenuating lesion within segment IV B of the liver is unchanged dating back to . For now, delusions/ hallucinations not c/w SSRI withdrawl #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN for BP control. Degenerative changes of the lumbosacral spine, with grade I anterolisthesis of L4 on L5, unchanged. Unsure of date, Movement: Purposeful, Tone: Normal Labs / Radiology 182 K/uL 10.6 g/dL 122 mg/dL 0.7 mg/dL 21 mEq/L 3.7 mEq/L 9 mg/dL 93 mEq/L 120 mEq/L 29.4 % 12.0 K/uL [image002.jpg] 04:36 AM 09:43 AM 02:13 PM 06:26 PM 10:46 PM 04:04 AM 11:17 AM 06:42 PM 04:59 AM WBC 15.0 12.8 12.0 Hct 31.0 28.7 29.4 Plt Cr 0.6 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 TropT 0.02 0.02 0.02 Glucose 110 175 99 148 86 178 112 122 Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB / Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1 mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL Assessment and Plan .H/O ALTERED MENTAL STATUS (NOT DELIRIUM) HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY) URINARY TRACT INFECTION (UTI) 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative colitis, presenting with abdominal pain, diarrhea, leukocytosis, and severe hyponatremia. | 51 | [
{
"category": "Physician ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 559926,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Confused overnight and got Haldol\n Na was stable about 120\n 3% shut off\n getting salt tabs. Nephrology following\n Fluid restricted 1.5L\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:48 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:37 AM\n Ceftazidime - 08:37 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (98.9\n HR: 73 (57 - 84) bpm\n BP: 145/66(85) {101/51(63) - 155/104(111)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,432 mL\n 730 mL\n PO:\n 1,330 mL\n 480 mL\n TF:\n IVF:\n 1,102 mL\n 250 mL\n Blood products:\n Total out:\n 2,145 mL\n 780 mL\n Urine:\n 2,145 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 287 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Gen: alert, sitting up in bed,\n CV: RR\n Chest: CTA\n Abd: Soft NT\n Ext: no edema\n Neuro: alert, conversant and approproate but has a fixed delusion about\n fireman in the room\n detailed. That said he can state weher he\n is.\n Labs / Radiology\n 10.6 g/dL\n 182 K/uL\n 217\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 93 mEq/L\n 120 mEq/L\n 29.4 %\n 12.0 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n WBC\n 15.0\n 12.8\n 12.0\n Hct\n 31.0\n 28.7\n 29.4\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n 178\n 112\n 122\n 217\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1\n mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points.\n 1. There is a combination of appropriate and inappropriate ADH release\n in this gentleman with Na down to 110 on admission without mental\n status change. He has had diarrhea and concerns regarding left foot\n ulcer. He is in pain in the back from falls sustained at home, all of\n which could have potentiated Na drop. He needs 3% NS and then fluid\n restriction with or without demeclocycline to keep SIADH component in\n check. He may also have a reset osmostat at baseline. His SSRI will be\n held and switched to another mood stabilizing . Podiatry\n consultation has been requested and head CT will be ordered to r/o\n intracranial pathology. He has agreed to PICC placement for short term\n he may leave ICU in next 24 hours if he remains coherent and\n hemodynamically stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 560116,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - STOP 11:02 AM\n Overnight agitation with delusions of water puring off the ceiling\n Afib at 130's overnight: converted with IV and po metoprolol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftazidime - 07:30 AM\n Vancomycin - 08:40 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:15 AM\n Haloperidol (Haldol) - 03:15 AM\n Other medications:\n Neurontin, eye drops, ASA, insulin SS, Lidocaine patch\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.2\n HR: 86 (68 - 135) bpm\n BP: 141/65(82) {112/59(76) - 156/94(152)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,189 mL\n 280 mL\n PO:\n 720 mL\n 30 mL\n TF:\n IVF:\n 469 mL\n 250 mL\n Blood products:\n Total out:\n 1,970 mL\n 1,240 mL\n Urine:\n 1,970 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -781 mL\n -960 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 12.5 g/dL\n 260 K/uL\n 193 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 92 mEq/L\n 125 mEq/L\n 35.5 %\n 15.7 K/uL\n [image002.jpg]\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n 12:00 PM\n 06:00 PM\n 03:50 AM\n WBC\n 12.8\n 12.0\n 15.7\n Hct\n 28.7\n 29.4\n 35.5\n Plt\n 158\n 182\n 260\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n Glucose\n 99\n 148\n 86\n 178\n 112\n 122\n \n 193\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:227/9/0.04, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.5\n mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n DELIRIUM / CONFUSION\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 1. HypoNatremia: stable now in the 120 range, will fluid restrci\n and start salt tabs, trend TUD to QID/\n 2. Delusions: DDx would be delirium from ICU itself, lack of\n sleep, brewing infection, or from acute withdrawl of SSRI. Changes due\n acute sodium changes seem less likely but always in the DDX and we will\n follow closely.\n Remaining issues as per Housestaff note s\n ICU Care\n Nutrition: fluid restrict\n Glycemic Control:\n Lines:\n 22 Gauge - 02:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559723,
"text": "TITLE:\n Chief Complaint: 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP,\n ulcerative colitis, presenting with abdominal pain, diarrhea,\n leukocytosis, and severe hyponatremia.\n 24 Hour Events:\n PICC LINE - START 08:00 AM\n - started on hypertonic saline\n - was hypotensive in a.m. to SBP 80s, pulse 60. Responded to 1L NS.\n Had three subsequent episodes of hypotension and was fluid responsive.\n However, urine osmoles still high and urine sodium low. Talked to\n renal and outcome of boluses and urine lytes was that patient was in\n fact likely hypovolemic, as his pressures finally improved and urine\n osmolality fell, with a concurrent rise in serum sodium, after adequate\n volume ressucitation.\n - podiatry: Multipodus boots, unlikely to be infected, cont vanc\n pending cx data, will staff in a.m.\n - stopped hypertonic saline in a.m. to slow correction rate per surgery\n - put patient in for ECHO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 66 (54 - 68) bpm\n BP: 138/63(80) {76/27(45) - 143/66(81)} mmHg\n RR: 17 (12 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,363 mL\n 1,107 mL\n PO:\n 800 mL\n 490 mL\n TF:\n IVF:\n 3,563 mL\n 617 mL\n Blood products:\n Total out:\n 772 mL\n 715 mL\n Urine:\n 772 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,591 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 158 K/uL\n 10.6 g/dL\n 86 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 96 mEq/L\n 119 mEq/L\n 28.7 %\n 12.8 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n WBC\n 15.0\n 12.8\n Hct\n 31.0\n 28.7\n Plt\n 205\n 158\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Patient\ns urine osmolality was initially high\n (500-600) with a low urine sodium of less than 20. We initially\n corrected his sodium with hypertonic sodium but also gave him NS\n boluses for hypotension, as he had risk factors for volume depletion at\n presentation (decreased po intake). Other potential etiologies of\n SIADH include pain, recent surgery (TURP), pulmonary disease, and his\n SSRI. Goal for correction in this pt is .5 Na/hr or 12 in 24 hrs.\n Cortisol and TSH also normal. Sodium corrected more rapidly in a.m. of\n after total correction of hypovolemia, with a subsequent fall\n in urine osmolality and a rise in urine sodium.\n - goal sodium over 24 hours <= 124\n - PICC placed for 3% hypertonic saline but holding for now given\n improvement already\n - Check Q 4hr lytes\n - NS as needed for hypovolemia\n - f/u renal reccs\n - Regular diet without fluid restrictions for now.\n # Diabetic foot ulcer/?Abdominal infection: Patient\ns leukocytosis\n most likely from urinary tract infection although also has diabetic\n foot ulcer. Patient also with history of Ulcerative colitis and\n diverticulosis, however CT abdomen was negative for diverticulitis.\n - cont Cipro for UTI and f/u cultures\n - cont vancomycin until foot cultures are negative\n - f/u podiatry reccs\n - will d/c flagyl\n # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side\n effect of TURP. No evidence of acute spinal stenosis on abdominal CT.\n - continue to evaluate for any evidence of LE weakness\n #. BPH: s/p TURP, on tamsulosin. Urology aware.\n #. Depression: holding fluoxetine given SIADH. Will need to\n investigate other possible antidepressants given then seems to be\n helping pt as well as risks of continuing it once Na has stabilized.\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560125,
"text": "Chief Complaint: hyponatremia\n 24 Hour Events:\n PICC LINE - STOP 11:02 AM\n \n - per renal, started salt tabs TID, fluid restrictions on diet. No\n further need for hypertonic saline\n - Pt pulled out PICC but has PIVs,\n - Urology wants to keep in foley. Thinks likely colonized with E coli\n seen on urine culture\n -Na: 11p 119-> 5a 120 -> 11a 123-> 5p 125\n - Throughout day, pt oriented x3 but has fixed delusion re fireman\n coming to his room last night. By 7p, having new hallucinations and\n delusions incl of water coming off ceiling. Gave .5 Haldol at 9p\n - MRSA contact precautions ordered for positive nasal swab\n ____________________________________\n \n -On tele at 12:30am, went into A fib (no known h/o a fib) when MD\n notified at 2:30, IV access re-established. Pt given 5 Metoprolol IV\n x4, Haldol .5 IV x2\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftazidime - 08:37 AM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:15 AM\n Haloperidol (Haldol) - 03:15 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, no SOB. Feeling well\n Flowsheet Data as of 08:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 92 (68 - 135) bpm\n BP: 145/70(90) {112/59(76) - 156/94(152)} mmHg\n RR: 24 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,189 mL\n 30 mL\n PO:\n 720 mL\n 30 mL\n TF:\n IVF:\n 469 mL\n 0 mL\n Blood products:\n Total out:\n 1,970 mL\n 1,240 mL\n Urine:\n 1,970 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -781 mL\n -1,210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Anxious\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, Tone:\n Normal\n Labs / Radiology\n 260 K/uL\n 12.5 g/dL\n 193 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 92 mEq/L\n 125 mEq/L\n 35.5 %\n 15.7 K/uL\n [image002.jpg]\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n 12:00 PM\n 06:00 PM\n 03:50 AM\n WBC\n 12.8\n 12.0\n 15.7\n Hct\n 28.7\n 29.4\n 35.5\n Plt\n 158\n 182\n 260\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n Glucose\n 99\n 148\n 86\n 178\n 112\n 122\n \n 193\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:227/9/0.04, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.5\n mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n DELIRIUM / CONFUSION\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Patient\ns urine osmolality was initially high\n (500-600) with a low urine sodium of less than 20. We initially\n corrected his sodium with hypertonic sodium but also gave him NS\n boluses for hypotension, as he had risk factors for volume depletion at\n presentation (decreased po intake). Other potential etiologies of\n SIADH include pain, recent surgery (TURP), pulmonary disease, and his\n SSRI. Goal for correction in this pt is .5 Na/hr or 12 in 24 hrs.\n Cortisol and TSH also normal. Sodium corrected more rapidly in a.m. of\n after total correction of hypovolemia, with a subsequent fall\n in urine osmolality and a rise in urine sodium. Now, pt likely close\n to baseline at 125.\n - cont salt tabs TID, fluid restrict\n - Check Na\n - f/u renal reccs\n # Diabetic foot ulcer/?Abdominal infection: Patient\ns leukocytosis\n most likely from urinary tract infection although also has diabetic\n foot ulcer. Patient also with history of Ulcerative colitis and\n diverticulosis, however CT abdomen was negative for diverticulitis.\n - d/c ceftriaxone for UTI as urology thinks e-coli in urine cultures\n is likely a contaminant\n - cont vancomycin until foot cultures are negative\n - f/u podiatry reccs\n .\n # A fib- Pt with episode of A fib o/n. Did not initially convert to 5\n metoprolol IV x4. ? Etiology. Possibly in setting of adrenergic surge\n and hallucinations. Broke without other tx this am although did get\n 12.5 PO metoprolol O/N. Needs to continue to be on tele. If has A fib\n again, consider PO betablocker and cards consult. Trop this am slightly\n up to 0.04 from 0.02 likely demand although EKGs overnight without\n any st-t changes. Recommend following CE on floor.\n .\n # Pt is oriented x3 during hallucinatory episodes but has\n exhibited signs of sundowning 2 nights in a row with delusions and\n hallucinations which pt maintains occurred in am. Also, unable to sleep\n in at least 2 nights. Haldol .5 mg IV x3 overnight did not help. Will\n consider Trazodone for sleep in future. Need to continue to monitor.\n Pt has corrected Na appropriately so unlikely AMS related to this.\n # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side\n effect of TURP. No evidence of acute spinal stenosis on abdominal CT.\n - continue to follow for any evidence of LE weakness\n #. BPH: s/p TURP, on tamsulosin. Urology aware.\n #. Depression: holding fluoxetine given SIADH. Will need to\n investigate other possible antidepressants given then seems to be\n helping pt as well as risks of continuing it once Na has stabilized.\n For now, delusions/ hallucinations not c/w SSRI withdrawl\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition: regular diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:35 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559449,
"text": " year old man with pmhx of SIADH, COPD, ulcerative colitis,\n non-hodgkins lymphoma, hypercholesterolemia, Htn, PBH, major\n depression, gastroesophageal reflux, second degree av block, spinal\n stenosis, anemia, syncope, DM, erectile dysfunction, venous stasis,\n peripheral neuropathy, ulcerative colitis, diverticulosis. Pt presented\n at the ew with 3 days hx of general weakness, nausea and diarrhea. Pt\n was found to have uti with wbc\ns 22 and Na+ 108. adm to Micu for\n further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 108.\n Action:\n Pt was given 1gm of sodium oral.\n Response:\n Plan:\n Pt will get a picc in the am and will start on sodium 3% iv.\n Urinary tract infection (UTI)\n Assessment:\n Pt has a foley since TURP on . wbc\ns 22. urine has many\n bacteria and blood cells.\n Action:\n Pt is on Flagyl and cipro.\n Response:\n Plan:\n Cont with antibiotics\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559692,
"text": "TITLE:\n Chief Complaint: 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP,\n ulcerative colitis, presenting with abdominal pain, diahrrea,\n leukocytosis, and severe hyponatremia.\n 24 Hour Events:\n PICC LINE - START 08:00 AM\n - started on hypertonic saline\n - was hypotensive in a.m. to SBP 80s, pulse 60. Responded to 1L NS.\n Had three subsequent episodes of hypotension and was fluid responsive.\n However, urine osmoles still high and urine sodium low. Talked to\n renal and outcome of boluses and urine lytes was that patient was in\n fact likely hypovolemic, as his pressures finally improved and urine\n osmolality fell, with a concurrent rise in serum sodium, after adequate\n volume ressucitation.\n - podiatry: Multipodus boots, unlikely to be infected, cont vanc\n pending cx data, will staff in a.m.\n - stopped hypertonic saline in a.m. to slow correction rate per surgery\n - put patient in for ECHO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 66 (54 - 68) bpm\n BP: 138/63(80) {76/27(45) - 143/66(81)} mmHg\n RR: 17 (12 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,363 mL\n 1,107 mL\n PO:\n 800 mL\n 490 mL\n TF:\n IVF:\n 3,563 mL\n 617 mL\n Blood products:\n Total out:\n 772 mL\n 715 mL\n Urine:\n 772 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,591 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 158 K/uL\n 10.6 g/dL\n 86 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 96 mEq/L\n 119 mEq/L\n 28.7 %\n 12.8 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n WBC\n 15.0\n 12.8\n Hct\n 31.0\n 28.7\n Plt\n 205\n 158\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diahrrea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Appears euvolemic on exam but history suggestive of\n hypovolemia. Also, U NA 20 low for SIADH and suggestive of loss from\n GI/ poor PO intake as etology. Etiologies of SIADH incl induced by\n pain, pulmonary disease, SSRI. Goal for correction in this pt is .5\n Na/hr or 12 in 24 hrs. Cortisol 31 on admission so unlikely adrenal\n insufficiency. TSH also normal. Other possible causes of SIADH that\n should be considered include pulmonary disease(CXR here looks good but\n CT in past has showed some chronic unchanged nodules) and intracranial\n abnormality incl SDH\n -PICC placed so able to give hypertonic saline and per renal will start\n 3% saline at 30cc/hr.\n -Check Q 4hr lytes.\n -rpt UNa\n -appreciate renal recs\n -check CT head today given possible confusion and h/o falls at home to\n r/o this as life-threatening cause of SIADH\n - Regular diet without fluid restrictions for now.\n # Leukocytosis: Source most likely from urinary tract infection\n although also has diabetic foot ulcer. Patient also with history of\n Ulcerative colitis and diverticulosis, however CT abdomen was negative\n for diverticulitis.\n - cont Cipro/ flagyl but also adding Vanco today for foot\n - f/u Urine and wound cultures\n # s/p fall with poor rectal tone- Per urology, rectal tone not a side\n effect of TURP. Will d/w radiology any possible lumbal spine\n abnormalities seen on CT abd done in ED. If any question of\n abnormalities, will consider MRI lumbar spine\n # Diabetic foot ulcer- Looks stage 3 here with some pus. Culture sent\n -f/u cx\n -Podiatry consulted\n -Vancomycin started to cover gram positive skin flora incl MRSA\n # Incr CE- likely demand ischemia in setting of recent tachycardia\n without EKG changes but concerning given elevation of MBI and trop with\n falling CK\n - cycle CE today\n #.BPH: s/p TURP, on tamsulosin. Will FYI urology today\n #. Depression: holding fluoxetine given SIADH. Will need to investigate\n other possible antidepressants given then seems to be helping pt as\n well as risks of continuing it once Na has stabilized.\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 560150,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - STOP 11:02 AM\n Overnight agitation with delusions of water pouring off the ceiling\n Afib at 130's overnight: converted with IV and po metoprolol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftazidime - 07:30 AM\n Vancomycin - 08:40 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:15 AM\n Haloperidol (Haldol) - 03:15 AM\n Other medications:\n Neurontin, eye drops, ASA, insulin SS, Lidocaine patch\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.2\n HR: 86 (68 - 135) bpm\n BP: 141/65(82) {112/59(76) - 156/94(152)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,189 mL\n 280 mL\n PO:\n 720 mL\n 30 mL\n TF:\n IVF:\n 469 mL\n 250 mL\n Blood products:\n Total out:\n 1,970 mL\n 1,240 mL\n Urine:\n 1,970 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -781 mL\n -960 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: sitting up in bed, eating bfast\n CV: rr\n Chest: CTA\n Abd: soft NT\n Ext: rigth hand is wrpapped with IV\n Neuro: conversant, knoiws it is his daughters , still some\n delusions about firemen but not upset by it\n Labs / Radiology\n 12.5 g/dL\n 260 K/uL\n 193 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 92 mEq/L\n 125 mEq/L\n 35.5 %\n 15.7 K/uL\n [image002.jpg]\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n 12:00 PM\n 06:00 PM\n 03:50 AM\n WBC\n 12.8\n 12.0\n 15.7\n Hct\n 28.7\n 29.4\n 35.5\n Plt\n 158\n 182\n 260\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n Glucose\n 99\n 148\n 86\n 178\n 112\n 122\n \n 193\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:227/9/0.04, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.5\n mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n DELIRIUM / CONFUSION\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 1. HypoNatremia: stable now in the 125 range, will fluid restrict\n and continue salt tabs, trend . Appreciate Nephrology input/\n 2. Parox Afib: 1^st episode last night in setting of agitation\n that resolved with bblockade\n this us eof po bblocker can be\n reconsidered if Afib not recurs in light of risk of exacerbating\n depression w bblockers\n 3. Delusions: DDx would be delirium from ICU itself, lack of\n sleep, agitated depression\n try low dose Zyprexa and reorientation\n 4. Podiatry: Vanco for MRSA foot infection\n 5. UTI: appreciate Urology consultation, chronic infection, d/c\n Ceftraixone\n Remaining issues as per Housestaff note s\n ICU Care\n Nutrition: fluid restrict\n Glycemic Control:\n Lines:\n 22 Gauge - 02:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and dtr\n status: DNR / DNI\n Disposition :Transfer to floor\n acute with likely psych\n consult in AM\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 560152,
"text": "79M w/ pmh SIADH, COPD, Ulcerative colitis, diverticulosis, spinal\n stenosis, DM, hypercholesterolemia, htn, depression, Non-Hodgkins\n lymphoma, presenting with weakness, nausea, and diahrrea for three\n days. He is also reporting abdominal cramps over the past month. He\n denies fevers and chills. He has been unable to hold in his diahhrea,\n and is usually unaware that he even had a bowel movement. Has had some\n falls at home which is causing more back pain. Patient has recent\n history or TURP on which has been complicated by hematuria. he also\n reports having a foley in place for 7 weeks. On presentation to ED\n vitals were 100.9, 170/90, 60's. 100% on 2L, 97% on RA. He had Sodium\n of 108, wbc 22 with 89% neutrophils. Lactate was 1.7. UA was\n consistent with urinary tract infection. Abdominal CT was negative for\n diverticulitis or other intraabdominal process. The patient was given\n cipro, flagyl, and 1 liter of NS.\n Atrial fibrillation (Afib)\n Assessment:\n Pt has no history of a-fib but on at 0100 he converted to a-fib\n with rate 100-130. NBP 100-110/60\ns. At the time the pt was confused,\n delirious and agitated.\n Action:\n Given a total of 20mg lopressor.\n Response:\n Converted back to SR at 0700. NBP\ns 130\ns-140\ns/60-90\n Plan:\n Telemetry, cardiology consult if converts back to a-fib, hold on\n anticoagulation for now.\n Delirium / confusion\n Assessment:\n Pt is alert and oriented X3 but is hallucinating and delusional. At\n times he gets agitated and will pull out IV\ns and other tubes. He has\n not slept in 48hrs or more and is more confused at night.\n Action:\n Pain meds and SSRI on hold although delusions/hallucinations not\n consistent with SSRI withdrawal. Given haldol with little effect.\n Response:\n No improvement in MS.\n :\n Possible cause is ICU psychosis so transfer to floor with -psych\n evaluation.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Admitted with Na of 108 with possible etiologies of SIADH from SSRI,\n pain, recent surgery (TURP), pulmonary disease.\n Action:\n Hyponatremia initially corrected with hypertonic saline but then\n required fluid boluses for hypovolemia. He is now on sodium tabs TID\n and a fluid restriction of 1.5L/day.\n Response:\n Na this am 125; goal was to correct Na slowly and keep it at his\n baseline which is the 120\n Plan:\n Goal Na is 120\ns, continue Na tabs, FR 1.5L\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 560154,
"text": "79M w/ pmh SIADH, COPD, Ulcerative colitis, diverticulosis, spinal\n stenosis, DM, hypercholesterolemia, htn, depression, Non-Hodgkins\n lymphoma, presenting with weakness, nausea, and diahrrea for three\n days. He is also reporting abdominal cramps over the past month. He\n denies fevers and chills. He has been unable to hold in his diahhrea,\n and is usually unaware that he even had a bowel movement. Has had some\n falls at home which is causing more back pain. Patient has recent\n history or TURP on which has been complicated by hematuria. he also\n reports having a foley in place for 7 weeks. On presentation to ED\n vitals were 100.9, 170/90, 60's. 100% on 2L, 97% on RA. He had Sodium\n of 108, wbc 22 with 89% neutrophils. Lactate was 1.7. UA was\n consistent with urinary tract infection. Abdominal CT was negative for\n diverticulitis or other intraabdominal process. The patient was given\n cipro, flagyl, and 1 liter of NS.\n Atrial fibrillation (Afib)\n Assessment:\n Pt has no history of a-fib but on at 0100 he converted to a-fib\n with rate 100-130. NBP 100-110/60\ns. At the time the pt was confused,\n delirious and agitated.\n Action:\n Given a total of 20mg lopressor.\n Response:\n Converted back to SR at 0700. NBP\ns 130\ns-140\ns/60-90\n Plan:\n Telemetry, cardiology consult if converts back to a-fib, hold on\n anticoagulation for now.\n Delirium / confusion\n Assessment:\n Pt is alert and oriented X3 but is hallucinating and delusional. At\n times he gets agitated and will pull out IV\ns and other tubes. He has\n not slept in 48hrs or more and is more confused at night.\n Action:\n Pain meds and SSRI on hold although delusions/hallucinations not\n consistent with SSRI withdrawal. Given haldol with little effect.\n Response:\n No improvement in MS.\n :\n Possible cause is ICU psychosis so transfer to floor with -psych\n evaluation.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Admitted with Na of 108 with possible etiologies of SIADH from SSRI,\n pain, recent surgery (TURP), pulmonary disease.\n Action:\n Hyponatremia initially corrected with hypertonic saline but then\n required fluid boluses for hypovolemia. He is now on sodium tabs TID\n and a fluid restriction of 1.5L/day.\n Response:\n Na this am 125; goal was to correct Na slowly and keep it at his\n baseline which is the 120\n Plan:\n Goal Na is 120\ns, continue Na tabs, FR 1.5L\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPONATREMIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 85 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, COPD\n CV-PMH: Hypertension\n Additional history: SIADH, Hypercholesterolemia, BPH, major depression,\n gastric reflux, second degree av block, spinal stenosis, syncope,\n diabetes mellitus, lymphoma, erectile dysfunction, venous stasis,\n peripheral neuropathy, ulcerative colitis, diverticulosis,\n non-hodgkin's lymphoma\n Surgery / Procedure and date: TURP \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:63\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 520 mL\n 24h total out:\n 1,400 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 03:50 AM\n Potassium:\n 4.0 mEq/L\n 03:50 AM\n Chloride:\n 92 mEq/L\n 03:50 AM\n CO2:\n 21 mEq/L\n 03:50 AM\n BUN:\n 11 mg/dL\n 03:50 AM\n Creatinine:\n 0.7 mg/dL\n 03:50 AM\n Glucose:\n 193 mg/dL\n 03:50 AM\n Hematocrit:\n 35.5 %\n 03:50 AM\n Finger Stick Glucose:\n 189\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Rm 411\n Transferred to: 12R\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559963,
"text": "79M w/ pmh significant for SIADH, COPD, NHL, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n Delirium / confusion\n Assessment:\n Pt is alert and oriented X3 but having hallucinations involving fire\n trucks, computers, and things moving in his room. At times he is\n agitated and paranoid but non combative and remains cooperative except\n for pulling his PICC line out. OOB to chair with a walker for a couple\n of hours but then he requested to go back to bed. His gait is unsteady\n and weak.\n Action:\n Cause of delusions unknown. ? hyponatremia vs withdrawal from prozac vs\n infection vs ICU psychosis. Attempts to communicate that others are\n not seeing what he is seeing only serve to make him more agitated.\n Pain meds and prozac on hold.\n Response:\n Hallucinations continue\n Plan:\n Prozac on hold for hyponatremia, on vanco for heel ulcer and ceftaz for\n UTI, salt tabs for hyponatremia, lidocaine patches for pain, hold po\n pain meds.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt has SIADH; 1100 sodium 123 from 120 at 0400.\n Action:\n Na tabs TID, fluid restriction of 1.5L/day,\n Response:\n Sodium is correcting slowly.\n Plan:\n Na tabs, FR 1.5L/day, Serial lytes q 6hrs, urine osmolality qd.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560026,
"text": "79M w/ PMH: SIADH, COPD, BPH s/p TURP, ulcerative colitis, who\n presented with abdominal pain, diarrhea, leukocytosis, and severe\n hyponatremia.\n #Delirium / confusion\n Assessment:\n Pt is confused, answering questions inappropriately\n Pt is calling out frequently\n Pt removed peripheral IV this evening and PICC yesterday AM\n Action:\n Pt frequently reassured of his safety\n Bed alarm on\n Quiet environment\n Response:\n Pt responds well to reassurance\n Plan:\n Monitory closely for safety\n Bed alarm\n Activity progression, OOB to chair as tolerated and ambulate PRN\n #Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Serum Na has gone from 120 to 123 to 125 to 127 over the last 24 hours\n Action:\n Free water restriction\n Sodium chloride tabs 1g TID\n Response:\n Hyponatremia slowly correcting\n Plan:\n Continue free water restriction\n Continue PO repeletion of sodium\n Continue to follow serum sodium q6n and urine lytes \n #Atrial fibrillation (Afib)\n Assessment:\n Around 0100 pt noted to have developed new onset AF with ventricular\n rate of 100\ns to 120\n Action:\n EKG obtained\n Metoprolol 5mg IV x2 and repeated to a total dose of 20mg\n 12.5mg metoprolol PO\n Pt was medicated with haloperidol IV 0.5mg x3 for agitation/confusion\n Response:\n Pt remains in AF with ventricular rate of 90\ns to 100\n Plan:\n Continue to monitor closely\n Continue to rate control with BB or CCB\n Consider cardiology consultation in AM regarding cardioversion/chemical\n cardioversion\n Consider anticoagulation in concert with cardiology consult\n"
},
{
"category": "Echo",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Report",
"row_id": 105350,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Hypotension.\nHeight: (in) 73\nWeight (lb): 200\nBSA (m2): 2.15 m2\nBP (mm Hg): 104/58\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 10:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening\nof mitral valve chordae. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Regional left ventricular\nwall motion is normal. Left ventricular systolic function is hyperdynamic\n(EF>75%). The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis moderately dilated. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. No\nmitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a small pericardial effusion. The effusion appears\ncircumferential. There are no echocardiographic signs of tamponade.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with hyperdynamic left\nventricular global and regional systolic function. Moderately dilated\nascending aorta. Moderate pulmonary hypertension. Very small circumferential\npericardial effusion.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 559524,
"text": "Chief Complaint: Hyponatremia\n HPI:\n 79M with COPD, h/o SIADH, s/p TURP recently p/w N/V/D/abd pain and\n found to have Na of 108 and WBC-22. Started on cipro and flagyl.\n 24 Hour Events:\n EKG - At 06:20 AM\n Pt decline placement of central line yesterday so hypertonic saline\n could not be started. He was given salt tabs. PICC line was placed\n this morning.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Flowsheet Data as of 09:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98\n HR: 62 (58 - 70) bpm\n BP: 125/59(75) {112/44(60) - 148/101(110)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 850 mL\n 185 mL\n Urine:\n 100 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: dry MM\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n occassional left base)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: mild diffuse\n Extremities: Right: Absent, Left: Absent, purulent drainage from lesion\n of left heel\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 205 K/uL\n 110 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 80 mEq/L\n 110 mEq/L\n 31.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:36 AM\n WBC\n 15.0\n Hct\n 31.0\n Plt\n 205\n Cr\n 0.6\n TropT\n 0.02\n Glucose\n 110\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:273/15/0.02, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Imaging: CT Abd: no acute process (prelim)\n ECG: Sinus with AVD\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n --Volume repletion with 500ccNS, following Urine Na.\n --Once volume replete based on urine na, use 3% saline to correct\n hyponatremia.\n --Renal consult appreciated.\n --D/C SSRIs\n --Serial serum lytes, urine lytes\n --Head CT for eval for SDH/SAH as cause of SIADH\n URINARY TRACT INFECTION (UTI)\n Covered by antibiotics below.\n Discuss with urology.\n Diabetic foot ulcer:\n -Plain films\n -Antibiotic coverage for GP and GN pathogens.\n -Podiatry consult.\n Back pain:\n --Given reports of stool incontinence, review CT spine and plan for\n lumbar spine MR.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559541,
"text": "Chief Complaint: Hyponatremia\n 24 Hour Events:\n EKG - At 06:20 AM\n Quiet night- pt slept well.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states mild abd pain relieved with percocet. No\n SOB or other pain at this time.\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98\n HR: 62 (58 - 70) bpm\n BP: 125/59(75) {112/44(60) - 148/101(110)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 850 mL\n 185 mL\n Urine:\n 100 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 205 K/uL\n 11.6 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 80 mEq/L\n 110 mEq/L\n 31.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:36 AM\n WBC\n 15.0\n Hct\n 31.0\n Plt\n 205\n Cr\n 0.6\n TropT\n 0.02\n Glucose\n 110\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:273/15/0.02, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diahrrea, leukocytosis, and\n severe hyponatremia.\n .\n #. Hyponatremia: Appears euvolemic on exam but history suggestive of\n hypovolemia. Also, U NA 20 low for SIADH and suggestive of loss from\n GI/ poor PO intake as etology. Etiologies of SIADH incl induced by\n pain, pulmonary disease, SSRI. Goal for correction in this pt is .5\n Na/hr or 12 in 24 hrs. Cortisol 31 on admission so unlikely adrenal\n insufficiency. TSH also normal. Other possible causes of SIADH that\n should be considered include pulmonary disease(CXR here looks good but\n CT in past has showed some chronic unchanged nodules) and intracranial\n abnormality incl SDH\n -PICC placed so able to give hypertonic saline and per renal will start\n 3% saline at 30cc/hr.\n -Check Q 4hr lytes.\n -rpt UNa\n -appreciate renal recs\n -check CT head today given possible confusion and h/o falls at home to\n r/o this as life-threatening cause of SIADH\n - Regular diet without fluid restrictions for now.\n .\n # Leukocytosis: Source most likely from urinary tract infection\n although also has diabetic foot ulcer. Patient also with history of\n Ulcerative colitis and diverticulosis, however CT abdomen was negative\n for diverticulitis.\n - cont Cipro/ flagyl but also adding Vanco today for foot\n - f/u Urine and wound cultures\n .\n # s/p fall with poor rectal tone- Per urology, rectal tone not a side\n effect of TURP. Will d/w radiology any possible lumbal spine\n abnormalities seen on CT abd done in ED. If any question of\n abnormalities, will consider MRI lumbar spine\n .\n # Diabetic foot ulcer- Looks stage 3 here with some pus. Culture sent\n -f/u cx\n -Podiatry consulted\n -Vancomycin started to cover gram positive skin flora incl MRSA\n .\n # Incr CE- likely demand ischemia in setting of recent tachycardia\n without EKG changes but concerning given elevation of MBI and trop with\n falling CK\n - cycle CE today\n .\n #.BPH: s/p TURP, on tamsulosin. Will FYI urology today\n .\n #. Depression: holding fluoxetine given SIADH. Will need to investigate\n other possible antidepressants given then seems to be helping pt as\n well as risks of continuing it once Na has stabilized.\n .\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n .\n #.COPD: Continue albuterol\n .\n #.Diabetes: Insulin sliding scale, aspirin\n .\n #.Peripheral Neuropathy: Continue neurontin\n .\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition: Regular diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:17 PM\n PICC placed today\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU while on hypertonic saline\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 559554,
"text": "Chief Complaint: Hyponatremia\n HPI:\n 79M with COPD, h/o SIADH, s/p TURP recently p/w N/V/D/abd pain and\n found to have Na of 108 and WBC-22. Started on cipro and flagyl.\n 24 Hour Events:\n EKG - At 06:20 AM\n Pt decline placement of central line yesterday so hypertonic saline\n could not be started. He was given salt tabs. PICC line was placed\n this morning.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Flowsheet Data as of 09:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98\n HR: 62 (58 - 70) bpm\n BP: 125/59(75) {112/44(60) - 148/101(110)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 850 mL\n 185 mL\n Urine:\n 100 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: dry MM\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n occassional left base)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: mild diffuse\n Extremities: Right: Absent, Left: Absent, purulent drainage from lesion\n of left heel\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 205 K/uL\n 110 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 80 mEq/L\n 110 mEq/L\n 31.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:36 AM\n WBC\n 15.0\n Hct\n 31.0\n Plt\n 205\n Cr\n 0.6\n TropT\n 0.02\n Glucose\n 110\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:273/15/0.02, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Imaging: CT Abd: no acute process (prelim)\n ECG: Sinus with AVD\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n --Volume repletion with 500ccNS, following Urine Na.\n --Once volume replete based on urine na, use 3% saline to correct\n hyponatremia.\n --Renal consult appreciated.\n --D/C SSRIs\n --Serial serum lytes, urine lytes\n --Head CT for eval for SDH/SAH as cause of SIADH\n URINARY TRACT INFECTION (UTI)\n Covered by antibiotics below.\n Discuss with urology.\n Diabetic foot ulcer:\n -Plain films\n -Antibiotic coverage for GP and GN pathogens.\n -Podiatry consult.\n Back pain:\n --Given reports of stool incontinence, review CT spine and plan for\n lumbar spine MR.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points. There is a combination of appropriate and\n inappropriate ADH release in this gentleman with Na down to 110 on\n admission without mental status change. He has had diarrhea and\n concerns regarding left foot ulcer. He is in pain in the back from\n falls sustained at home, all of which could have potentiated Na drop.\n He needs 3% NS and then fluid restriction with or without\n demeclocycline to keep SIADH component in check. He may also have a\n reset osmostat at baseline. His SSRI will be held and switched to\n another mood stabilizing . Podiatry consultation has been\n requested and head CT will be ordered to r/o intracranial pathology. He\n has agreed to PICC placement for short term he may leave ICU in next 24\n hours if he remains coherent and hemodynamically stable\n Total time: 30 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 02:09 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-20 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 559423,
"text": "Chief Complaint: weakness\n HPI:\n 79M w/ pmh SIADH, COPD, Ulcerative colitis, Non-Hodgkins lymphoma,\n presenting with weakness, nausea, and diahrrea for three days. He is\n also reporting abdominal cramps over the past month. He denies fevers\n and chills. He has been unable to hold in his diahhrea, and is usually\n unaware that he even had a bowel movement. Patient has recent history\n or TURP on which has been complicated by hematuria. he also reports\n having a foley in place for 7 weeks. On presentation to ED vitals were\n 100.9, 170/90, 60's. 100% on 2L, 97% on RA. He had Sodium of 108, wbc\n 22 with 89% neutrophils. Lactate was 1.7. UA was consistent with\n urinary tract infection. Abdominal CT was negative for diverticulitis\n or other intraabdominal process. The patient was given cipro, flagyl,\n and 1 liter of NS.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled every four (4) hours\n as needed for shortness of breath or wheezing or cough\n DORZOLAMIDE-TIMOLOL [COSOPT] - 2-0.5 % Drops - 1 gtt ou twice a\n day glaucoma\n FLUOXETINE - 40 mg Capsule - 1 Capsule(s) by mouth once a day for\n depression\n GABAPENTIN - 600 mg Tablet - Tablet(s) by mouth qd, and 1 qhs\n spinal stenosis\n HYDROCODONE-ACETAMINOPHEN - 7.5 mg-750 mg Tablet - 1 Tablet(s) by\n mouth q 8h as needed for pain\n LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,\n Medicated - apply once a day as needed for for 12 hours per day,\n up to 24hours for each leg, spinal stenosis\n LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day bp\n LORAZEPAM - 1 MG TABLET - TAKE ONE BY MOUTH THREE TIMES A DAY AS\n NEEDED FOR FOR ANXIETY\n OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)\n by mouth once a day gerd\n SALSALATE - 500 mg Tablet - Tablet(s) by mouth twice a day as\n needed for pain with food or milk for back pain, shoulder pain\n TAMSULOSIN - 0.4 mg Capsule, Sust. Release 24 hr - 2 Capsule(s)\n by mouth at bedtime to improve urinating\n XALATAN - 0.005% Drops - ONE GTT EACH EYE AT BEDTIME\n Medications - OTC\n ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1\n Tablet, Delayed Release (E.C.)(s) by mouth once a day prevention\n B COMPLEX VITAMINS [B COMPLEX] - (OTC) - Capsule - Capsule(s)\n by mouth\n HORSE CHESTNUT - (Prescribed by Other Provider) - 150 mg Capsule\n - 2 (Two) Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n SIADH\n HYPERCHOLESTEROLEMIA\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n HYPERTENSION\n BENIGN PROSTATIC HYPERTROPHY\n MAJOR DEPRESSION\n GASTROESOPHAGEAL REFLUX\n SECOND DEGREE ATRIOVENTRICULAR BLOCK\n SPINAL STENOSIS\n ANEMIA \n SYNCOPE\n DIABETES MELLITUS \n LYMPHOMA \n HEALTH MAINTENANCE\n ERECTILE DYSFUNCTION\n VENOUS STASIS\n PERIPHERAL NEUROPATHY \n ULCERATIVE COLITIS\n DIVERTICULOSIS\n NON-HODGKIN'S LYMPHOMA\n NC\n Occupation: retired truck driver, construction\n Drugs: denies\n Tobacco: quit , 60 pack years\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Orthopnea\n Respiratory: Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, Diarrhea\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Flowsheet Data as of 10:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 60 (60 - 70) bpm\n BP: 137/52(74) {131/52(74) - 137/65(83)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 750 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -750 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: awake, alert, NAD\n HEENT: No conjunctival pallor. No scleral icterus. EOMI. MMM. OP\n clear. Neck Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTcrackles at right base.\n ABDOMEN: NABS. Soft, NT, ND. No HSM. guaiac neg per ED.\n EXTREMITIES: 1+ edema b/l, 2+ dorsalis pedis.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. poor rectal tone.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 109 mEq/L\n [image002.jpg]\n Fluid analysis / Other labs: Na 109\n wbc 23, Neutrophil 89%\n Imaging: CT abdomen : diverticulosis without diverticulitis.\n ECG: EKG: sinus rhythm at rate 62, normal axis, no LVH, no ST or\n T-wave changes consistent with ischemia.\n Assessment and Plan\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diahrrea, leukocytosis, and\n severe hyponatremia.\n .\n #. Hyponatremia: Etiologies include SIADH induced by pain, pulmonary\n disease, meds, worsened by diahrrea with continuous water intake. will\n correct at .5meq/L/hr, with 3% saline @30cc/hr. will stop infusion once\n Na > 120.\n -central access\n -3% NS @30cc/hr\n -Na check q4h\n -Uosm\n -U lytes\n -serum osm\n -TSH\n -Cortisol\n .\n #. Leukocytosis: Source most likely from urinary tract infection.\n Patient also with history of Ulcerative colitis and diverticulosis,\n however CT abdomen was negative for diverticulitis. Will continue with\n cipro/flagyl\n -cipro\n -flagyl\n .\n #.BPH: s/p TURP, on tamsulosin\n .\n #. Depression: holding fluoxetine\n .\n #. Ulcerative Colitis: continue salsalate\n .\n #.Hypertension: Holding lisinopril per renal, will use hydralazine for\n BP control.\n .\n #.COPD: Continue albuterol\n .\n #.Diabetes: Insulin sliding scale, aspirin\n .\n #.Peripheral Neuropathy: Continue neurontin\n .\n #.Osteoarthritis: continue lidocaine patch and percocet\n .\n FEN: diabetic diet.\n .\n PPX:\n -DVT ppx with sub q heparin, pneumoboots\n -Bowel regimen, omeprazole\n -Pain management with percocet, lidocaine patch.\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT:\n .\n DISPOSITION:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 559426,
"text": "Chief Complaint: weakness\n HPI:\n 79M w/ pmh SIADH, COPD, Ulcerative colitis, Non-Hodgkins lymphoma,\n presenting with weakness, nausea, and diahrrea for three days. He is\n also reporting abdominal cramps over the past month. He denies fevers\n and chills. He has been unable to hold in his diahhrea, and is usually\n unaware that he even had a bowel movement. Patient has recent history\n or TURP on which has been complicated by hematuria. he also reports\n having a foley in place for 7 weeks. On presentation to ED vitals were\n 100.9, 170/90, 60's. 100% on 2L, 97% on RA. He had Sodium of 108, wbc\n 22 with 89% neutrophils. Lactate was 1.7. UA was consistent with\n urinary tract infection. Abdominal CT was negative for diverticulitis\n or other intraabdominal process. The patient was given cipro, flagyl,\n and 1 liter of NS.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled every four (4) hours\n as needed for shortness of breath or wheezing or cough\n DORZOLAMIDE-TIMOLOL [COSOPT] - 2-0.5 % Drops - 1 gtt ou twice a\n day glaucoma\n FLUOXETINE - 40 mg Capsule - 1 Capsule(s) by mouth once a day for\n depression\n GABAPENTIN - 600 mg Tablet - Tablet(s) by mouth qd, and 1 qhs\n spinal stenosis\n HYDROCODONE-ACETAMINOPHEN - 7.5 mg-750 mg Tablet - 1 Tablet(s) by\n mouth q 8h as needed for pain\n LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,\n Medicated - apply once a day as needed for for 12 hours per day,\n up to 24hours for each leg, spinal stenosis\n LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day bp\n LORAZEPAM - 1 MG TABLET - TAKE ONE BY MOUTH THREE TIMES A DAY AS\n NEEDED FOR FOR ANXIETY\n OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)\n by mouth once a day gerd\n SALSALATE - 500 mg Tablet - Tablet(s) by mouth twice a day as\n needed for pain with food or milk for back pain, shoulder pain\n TAMSULOSIN - 0.4 mg Capsule, Sust. Release 24 hr - 2 Capsule(s)\n by mouth at bedtime to improve urinating\n XALATAN - 0.005% Drops - ONE GTT EACH EYE AT BEDTIME\n Medications - OTC\n ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1\n Tablet, Delayed Release (E.C.)(s) by mouth once a day prevention\n B COMPLEX VITAMINS [B COMPLEX] - (OTC) - Capsule - Capsule(s)\n by mouth\n HORSE CHESTNUT - (Prescribed by Other Provider) - 150 mg Capsule\n - 2 (Two) Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n SIADH\n HYPERCHOLESTEROLEMIA\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n HYPERTENSION\n BENIGN PROSTATIC HYPERTROPHY\n MAJOR DEPRESSION\n GASTROESOPHAGEAL REFLUX\n SECOND DEGREE ATRIOVENTRICULAR BLOCK\n SPINAL STENOSIS\n ANEMIA \n SYNCOPE\n DIABETES MELLITUS \n LYMPHOMA \n HEALTH MAINTENANCE\n ERECTILE DYSFUNCTION\n VENOUS STASIS\n PERIPHERAL NEUROPATHY \n ULCERATIVE COLITIS\n DIVERTICULOSIS\n NON-HODGKIN'S LYMPHOMA\n NC\n Occupation: retired truck driver, construction\n Drugs: denies\n Tobacco: quit , 60 pack years\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Orthopnea\n Respiratory: Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, Diarrhea\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Flowsheet Data as of 10:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 60 (60 - 70) bpm\n BP: 137/52(74) {131/52(74) - 137/65(83)} mmHg\n RR: 18 (15 - 18) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 750 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -750 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: awake, alert, NAD\n HEENT: No conjunctival pallor. No scleral icterus. EOMI. MMM. OP\n clear. Neck Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTcrackles at right base.\n ABDOMEN: NABS. Soft, NT, ND. No HSM. guaiac neg per ED.\n EXTREMITIES: 1+ edema b/l, 2+ dorsalis pedis.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. poor rectal tone.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 109 mEq/L\n [image002.jpg]\n Fluid analysis / Other labs: Na 109\n wbc 23, Neutrophil 89%\n Imaging: CT abdomen : diverticulosis without diverticulitis.\n ECG: EKG: sinus rhythm at rate 62, normal axis, no LVH, no ST or\n T-wave changes consistent with ischemia.\n Assessment and Plan\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diahrrea, leukocytosis, and\n severe hyponatremia.\n .\n #. Hyponatremia: Etiologies include SIADH induced by pain, pulmonary\n disease, meds, worsened by diahrrea with continuous water intake. will\n correct at .5meq/L/hr, with 3% saline @30cc/hr. will stop infusion once\n Na > 120.\n -central access\n -3% NS @30cc/hr\n -Na check q4h\n -Uosm\n -U lytes\n -serum osm\n -TSH\n -Cortisol\n .\n #. Leukocytosis: Source most likely from urinary tract infection.\n Patient also with history of Ulcerative colitis and diverticulosis,\n however CT abdomen was negative for diverticulitis. Will continue with\n cipro/flagyl\n -cipro\n -flagyl\n .\n #.BPH: s/p TURP, on tamsulosin\n .\n #. Depression: holding fluoxetine\n .\n #. Ulcerative Colitis: continue salsalate\n .\n #.Hypertension: Holding lisinopril per renal, will use hydralazine for\n BP control.\n .\n #.COPD: Continue albuterol\n .\n #.Diabetes: Insulin sliding scale, aspirin\n .\n #.Peripheral Neuropathy: Continue neurontin\n .\n #.Osteoarthritis: continue lidocaine patch and percocet\n .\n FEN: diabetic diet.\n .\n PPX:\n -DVT ppx with sub q heparin, pneumoboots\n -Bowel regimen, omeprazole\n -Pain management with percocet, lidocaine patch.\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT:\n .\n DISPOSITION:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n I was physically present with the housestaff team for discussion of the\n history, physical, ROS, PMH as defined above on . I agree with\n the above findings and would add the following comments.\n Patient is a 79 yo male admitted with weakness, nausea and diarrhea.\n He did not stool incontinence in this setting over the past 3\n days\nsmall volume and lose stool. Given the above findings patient to\n the ED for further evaluation.\n There he was found to have severe hyponatremia and significant\n elevation in WBC count to >20 with U/A suggesting significant urinary\n tract infection.\n Given severe hyponatremia patient to ICU for further care.\n Here\n Patient altert, cooperative, altert\n Heart-Regular, no murmur\n Abd-Soft\nsuprapubic tenderness but no rebound\n Ext\n1+ Peripheral edema, 2+ pulses\n Neuro-A+O x3, Cn without deficit, motor UE/LE and decreased\n reflexes in LE bilaterally + symmetrically\n Rectal-Significant decrease in rectal tone\n Back-Tender in lower lumbar region\n LABS-\n WBC-21.9\n87% PMN\n Na-109\n Cl-73\n HCO3-22\n -Gluc-158\n Urine OSM-Pending\n Serum OSM-228\n 79 yo male admitted with weakness, altered mental status and severe\n hyponatremia. This finding is in the setting of significant evidence\n of urinary tract infection.\n 1)Hyponatremia\nThis is with patient likely euvolemic with continued\n water intake in the setting of poor po intake and diarrhea noted\n above. Renal consult obtained and advice appreciated.\n -Will check urine OSMS to guide saline choice\n -Salt tablets right now\n -If urine OSMS <300 will move to NS now\n -Would favor 3% Saline but patient with clearly competent refusal of\n CVL tonight despite clearly described risk of death/seizure if not\n managed appropriately\n -PICC in am\n 2)Urinary Tract Infection\n -Cipro/Flagyl to continue\n -Follow up Culture\n 3)Stool incontinence\nno other findings of cord compression but will\n need further imaging to define\n -MRI L-spine\n -Follow exam\n Addition issues to be managed as defined in the resident note as above\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 00:39 ------\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559514,
"text": "Chief Complaint: Hyponatremia\n 24 Hour Events:\n EKG - At 06:20 AM\n Quiet night- pt slept well.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt states mild abd pain relieved with percocet. No\n SOB or other pain at this time.\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98\n HR: 62 (58 - 70) bpm\n BP: 125/59(75) {112/44(60) - 148/101(110)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 850 mL\n 185 mL\n Urine:\n 100 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 205 K/uL\n 11.6 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 80 mEq/L\n 110 mEq/L\n 31.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:36 AM\n WBC\n 15.0\n Hct\n 31.0\n Plt\n 205\n Cr\n 0.6\n TropT\n 0.02\n Glucose\n 110\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:273/15/0.02, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diahrrea, leukocytosis, and\n severe hyponatremia.\n .\n #. Hyponatremia: Etiologies include SIADH induced by pain, pulmonary\n disease, meds, worsened by diahrrea with continuous water intake. will\n correct at .5meq/L/hr, with 3% saline @30cc/hr. will stop infusion once\n Na > 120.\n -central access\n -3% NS @30cc/hr\n -Na check q4h\n -Uosm\n -U lytes\n -serum osm\n -TSH\n -Cortisol\n .\n #. Leukocytosis: Source most likely from urinary tract infection.\n Patient also with history of Ulcerative colitis and diverticulosis,\n however CT abdomen was negative for diverticulitis. Will continue with\n cipro/flagyl\n -cipro\n -flagyl\n .\n #.BPH: s/p TURP, on tamsulosin\n .\n #. Depression: holding fluoxetine\n .\n #. Ulcerative Colitis: continue salsalate\n .\n #.Hypertension: Holding lisinopril per renal, will use hydralazine for\n BP control.\n .\n #.COPD: Continue albuterol\n .\n #.Diabetes: Insulin sliding scale, aspirin\n .\n #.Peripheral Neuropathy: Continue neurontin\n .\n #.Osteoarthritis: continue lidocaine patch and percocet\n .\n FEN: diabetic diet.\n .\n PPX:\n -DVT ppx with sub q heparin, pneumoboots\n -Bowel regimen, omeprazole\n -Pain management with percocet, lidocaine patch.\n .\n ACCESS: PIV's\n ICU Care\n Nutrition: Regular diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559862,
"text": ".H/O altered mental status (not Delirium)\n Assessment:\n Pt has been oriented x3 throughout the shift but at the same time very\n confused and hallucinating about the fire dept being here and pt\n believes he was trapped in his bed, in the basement and the fire dept\n did not respond to him. Pt does know where he is, the date and he\n remembers staff names. He does believe hat our team are firemen.\n Action:\n Attempts to tell pt that the fire dept has not been here have only\n agitated the pt. pt did receive haldol 0.5mg iv push. Much diversional\n discussion used.\n Response:\n Pt less anxious than earlier but still confused.\n Plan:\n Cont to attempt to keep pt oriented. Pt may be called out to the floor\n to prevent unit psychosis.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt was adm with Na+ of 108. last evening at 2330 119. this am pt is\n 120.\n Action:\n Pt was on hypertonic saline but this was stopped yesterday to prevent\n Na+ from correcting to quickly.\n Response:\n This am pt is 120.\n Plan:\n Renal will be in to set goals for Na+. pt may be called out to the\n floor.\n Urinary tract infection (UTI)\n Assessment:\n Pt has had a uti since adm.\n Action:\n Pt has been on cipro, vanco another ua was sent this am. Wbc\ns 12.\n Response:\n Pt is resistant to cipro and team is discussing the possibility of\n changing the antibiotics.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 559715,
"text": "Chief Complaint: hyponatremia\n HPI:\n 24 Hour Events:\n PICC LINE - START 08:00 AM\n Hypotension that responded to NS.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Psychiatric / Sleep: hallucinations\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 65 (54 - 68) bpm\n BP: 108/45(62) {76/27(45) - 143/72(81)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,363 mL\n 1,603 mL\n PO:\n 800 mL\n 730 mL\n TF:\n IVF:\n 3,563 mL\n 873 mL\n Blood products:\n Total out:\n 772 mL\n 915 mL\n Urine:\n 772 mL\n 915 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,591 mL\n 688 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, normal skin turgor\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 158 K/uL\n 86 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 96 mEq/L\n 119 mEq/L\n 28.7 %\n 12.8 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n WBC\n 15.0\n 12.8\n Hct\n 31.0\n 28.7\n Plt\n 205\n 158\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n --Continue serial sodium monitoring\n --Holding hypertonic saline now\n Diabetic foot:\n continue antibiotics pending culture\n Podiatry following.\n Mental status:\n Continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559483,
"text": " year old man with pmhx of SIADH, COPD, ulcerative colitis,\n non-hodgkins lymphoma, hypercholesterolemia, Htn, PBH, major\n depression, gastroesophageal reflux, second degree av block, spinal\n stenosis, anemia, syncope, DM, erectile dysfunction, venous stasis,\n peripheral neuropathy, ulcerative colitis, diverticulosis. Pt presented\n at the ew with 3 days hx of general weakness, nausea and diarrhea. Pt\n was found to have uti with wbc\ns 22 and Na+ 108. adm to Micu for\n further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 108.\n Action:\n Pt was given 1gm of sodium oral. Sodium 1gram repeated.\n Response:\n Na+ 110 this am after first gram of sodium.\n Plan:\n Pt will get a picc in the am and will start on sodium 3% iv.\n Urinary tract infection (UTI)\n Assessment:\n Pt has a foley since TURP on . wbc\ns 22. urine has many\n bacteria and blood cells.\n Action:\n Pt is on Flagyl and cipro.\n Response:\n Wbc\ns 15 this am.\n Plan:\n Cont with antibiotics.\n Triponin 0.02, cpk 273, ckmb 15. will get EKG and possible heparin gtt\n this am.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559673,
"text": "79 year old man with PMH of SIADH, COPD, ulcerative colitis,\n diverticulosis, Non-Hodgkins lymphoma, hypercholesterolemia, HTN, BPH,\n major depression, gastroesophageal reflux, second degree av block,\n spinal stenosis, anemia, syncope, DM, erectile dysfunction, venous\n stasis, peripheral neuropathy. Pt presented at the EW with 3 days hx of\n general weakness, nausea and diarrhea. Pt was found to have UTI with\n wbc\ns 22 and Na+ 108. adm to Micu for further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt with severe hyponatremia on adm 108.\n Action:\n Pt remains on the hypertonic saline 3% at 40cchr.\n Response:\n Last evening Na+ was 114, current Na+ 119.\n Plan:\n Cont the 3% saline iv.\n Urinary tract infection (UTI)\n Assessment:\n Pt adm with uti. Foley since TURP on . urine with many bacteria\n and blood cells. Today urine has few bacteria.\n Action:\n Pt remains on vanco, cipro, levoflox and cipro. Pt also received a\n total of 2L ns for borderline b/p and low urine output.\n Response:\n Pt has remained afebrile this shift. Urine output and b/p have both\n improved.\n Plan:\n Cont with antibiotics. Observe urine output.\n Pt medicated with percocet for several complains of abd pain, leg pain\n etc. ct of abd neg.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559662,
"text": "79 year old man with PMH of SIADH, COPD, ulcerative colitis,\n diverticulosis, Non-Hodgkins lymphoma, hypercholesterolemia, HTN, BPH,\n major depression, gastroesophageal reflux, second degree av block,\n spinal stenosis, anemia, syncope, DM, erectile dysfunction, venous\n stasis, peripheral neuropathy. Pt presented at the EW with 3 days hx of\n general weakness, nausea and diarrhea. Pt was found to have UTI with\n wbc\ns 22 and Na+ 108. adm to Micu for further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt with severe hyponatremia on adm 108.\n Action:\n Pt remains on the hypertonic saline 3% at 40cchr.\n Response:\n Last evening Na+ was 114, current labs pending.\n Plan:\n Cont the 3% saline iv.\n Urinary tract infection (UTI)\n Assessment:\n Pt adm with uti. Foley since TURP on . urine with many bacteria\n and blood cells.\n Action:\n Pt remains on vanco, cipro, levoflox and cipro. Pt also received a\n total of 2L ns for borderline b/p and low urine output.\n Response:\n Pt has remained afebrile this shift. Urine output and b/p have both\n improved.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559772,
"text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Awoke patient this morning, pt disoriented to place & time, easily\n reoriented however pt with visual hallucinations. ICU team aware and\n ordered Na levels q4h. Hypertonic saline now on hold, 1115 Na \n Na 118, will give sodium tab as ordered once available from pharmacy.\n Action:\n Serial Na, phos and potassium replete as ordered.\n Response:\n Pt lethargic and hallucinating\n Plan:\n Cont w/q4h Na+ and cont to monitor mental status.\n Urinary tract infection (UTI)\n Assessment:\n Urine w/sediment, appeared to have bladder spasms overnight and voiced\n concern over wetting the bed.\n Action:\n UCx and lytes sent as ordered\n Response:\n No apparent bladder spasms today.\n Plan:\n Cont w/antbx as ordered, monitor temp and cx results.\n .H/O altered mental status (not Delirium)\n Assessment:\n Confused and disoriented this morning, appeared to be reoriented\n easily, able to answer orientation questions but hallucinating, seeing\ncleaning machines\n and firemen moving things.\n Action:\n ICU team including Drs. and kept informed of mental\n status, continuing to check lytes, attempting to refrain from using\n percocet\n Response:\n Confused at times, easily reoriented but continues to hallucinate\n Plan:\n Cont to monitor mental status, check lytes, use Tylenol and simethicone\n for abd pains.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559658,
"text": "79 year old man with PMH of SIADH, COPD, ulcerative colitis,\n diverticulosis, Non-Hodgkins lymphoma, hypercholesterolemia, HTN, BPH,\n major depression, gastroesophageal reflux, second degree av block,\n spinal stenosis, anemia, syncope, DM, erectile dysfunction, venous\n stasis, peripheral neuropathy. Pt presented at the EW with 3 days hx of\n general weakness, nausea and diarrhea. Pt was found to have UTI with\n wbc\ns 22 and Na+ 108. adm to Micu for further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560019,
"text": "79M w/ PMH: SIADH, COPD, BPH s/p TURP, ulcerative colitis, who\n presented with abdominal pain, diarrhea, leukocytosis, and severe\n hyponatremia.\n #Delirium / confusion\n Assessment:\n Pt is confused, answering questions inappropriately\n Pt is calling out frequently\n Pt removed peripheral IV this evening and PICC yesterday AM\n Action:\n Pt frequently reassured of his safety\n Bed alarm on\n Quiet environment\n Response:\n Pt responds well to reassurance\n Plan:\n Monitory closely for safety\n Bed alarm\n Activity progression, OOB to chair as tolerated and ambulate PRN\n #Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n #Atrial fibrillation (Afib)\n Assessment:\n Around 0100 pt noted to have developed new onset AF with ventricular\n rate of 100\ns to 120\n Action:\n EKG obtained\n Metoprolol 5mg IV x2 and repeated to a total dose of 20mg\n 12.5mg metoprolol PO\n Pt was medicated with haloperidol IV 0.5mg x3 for agitation/confusion\n Response:\n Pt remains in AF with ventricular rate of 90\ns to 100\n Plan:\n Continue to monitor closely\n Continue to rate control with BB or CCB\n Consider cardiology consultation in AM regarding cardioversion/chemical\n cardioversion\n Consider anticoagulation in concert with cardiology consult\n"
},
{
"category": "Respiratory ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 559962,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient in bed on R/A alert , coop , treated with ventolin inhaler with\n spacer. Follows instructions very well , now on MRSA precaution.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559568,
"text": "79 year old man with PMH of SIADH, COPD, ulcerative colitis,\n diverticulosis, Non-Hodgkins lymphoma, hypercholesterolemia, HTN, BPH,\n major depression, gastroesophageal reflux, second degree av block,\n spinal stenosis, anemia, syncope, DM, erectile dysfunction, venous\n stasis, peripheral neuropathy. Pt presented at the EW with 3 days hx of\n general weakness, nausea and diarrhea. Pt was found to have UTI with\n wbc\ns 22 and Na+ 108. adm to Micu for further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt\ns Na+ level 110 this AM.\n Action:\n Pt given 3% hypertonic saline at 30cc per hour through R PICC line.\n PO\ns encouraged.\n Response:\n Pt\ns Na+ level up to 111.\n Plan:\n Continue 3% hypertonic saline at 30cc per hour as per .\n Urinary tract infection (UTI)\n Assessment:\n Pt\ns white count is 15. Afebrile this shift. Pt. is s/p TURP on\n and has indwelling Foley catheter. Pt. has blood around the\n urethral opening and in the urine.\n Action:\n Monitored pt\ns temperature and labs closely. Administered PO and IV\n antibiotics as per .\n Response:\n Pt. remains afebrile.\n Plan:\n Closely monitor pt\ns temperature and labs. Continue to administer\n antibiotics as ordered.\n Pain\n Assessment:\n Pt. has diabetic peripheral neuropathy, abdominal pain d/t ulcerative\n colitis, and neck/back pain from a fall and spinal stenosis. Pt. was\n seen by podiatry and dead skin was shaved from around his L heel wound,\n which caused some soreness. Pt. reports a pain level of anywhere from\n 0 to throughout the shift.\n Action:\n 5% Lidocaine patch applied to pt\ns lumbar area. Percocet given as\n needed throughout shift (see ).\n Response:\n Pt. reported relief after administration of the Percocet. However pt\n BP dropped to low 80\ns systolic over mid-30\ns diastolic shortly after\n administration of the pain medication. Fluid boluses were administered\n as per flow sheet to good effect. Pt\ns BP went back up to mid 120\n over mid 60\n Plan:\n Continue to assess patient for pain often. Order food that is least\n likely to upset his stomach. Administer pain medication as ordered,\n and monitor pain response and vitals.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559561,
"text": "79 year old man with PMH of SIADH, COPD, ulcerative colitis,\n diverticulosis, Non-Hodgkins lymphoma, hypercholesterolemia, HTN, BPH,\n major depression, gastroesophageal reflux, second degree av block,\n spinal stenosis, anemia, syncope, DM, erectile dysfunction, venous\n stasis, peripheral neuropathy. Pt presented at the EW with 3 days hx of\n general weakness, nausea and diarrhea. Pt was found to have UTI with\n wbc\ns 22 and Na+ 108. adm to Micu for further treatment.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt\ns Na+ level 110 this AM.\n Action:\n Pt given 3% hypertonic saline at 30cc per hour through R PICC line.\n PO\ns encouraged.\n Response:\n Pt\ns Na+ level up to 111.\n Plan:\n Continue 3% hypertonic saline at 30cc per hour as per .\n Urinary tract infection (UTI)\n Assessment:\n Pt\ns white count is 15. Afebrile this shift. Pt. is s/p TURP on\n and has indwelling Foley catheter. Pt. has blood around the\n urethral opening and in the urine.\n Action:\n Monitored pt\ns temperature and labs closely. Administered PO and IV\n antibiotics as per .\n Response:\n Pt. remains afebrile.\n Plan:\n Closely monitor pt\ns temperature and labs. Continue to administer\n antibiotics as ordered.\n Pain\n Assessment:\n Pt. has diabetic peripheral neuropathy, abdominal pain d/t ulcerative\n colitis, and neck/back pain from a fall and spinal stenosis. Pt. was\n seen by podiatry and dead skin was shaved from around his L heel wound,\n which caused some soreness. Pt. reports a pain level of anywhere from\n 0 to throughout the shift.\n Action:\n 5% Lidocaine patch applied to pt\ns lumbar area. Percocet given as\n needed throughout shift (see ).\n Response:\n Pt. reported relief after administration of the Percocet. However pt\n BP dropped to low 80\ns systolic over mid-30\ns diastolic shortly after\n administration of the pain medication. Fluid boluses were administered\n as per flow sheet to good effect. Pt\ns BP went back up to mid 120\n over mid 60\n Plan:\n Continue to assess patient for pain often. Order food that is least\n likely to upset his stomach. Administer pain medication as ordered,\n and monitor pain response and vitals.\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 559749,
"text": "Chief Complaint: hyponatremia\n HPI:\n 24 Hour Events:\n PICC LINE - START 08:00 AM\n Hypotension that responded to NS.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Psychiatric / Sleep: hallucinations\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 65 (54 - 68) bpm\n BP: 108/45(62) {76/27(45) - 143/72(81)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,363 mL\n 1,603 mL\n PO:\n 800 mL\n 730 mL\n TF:\n IVF:\n 3,563 mL\n 873 mL\n Blood products:\n Total out:\n 772 mL\n 915 mL\n Urine:\n 772 mL\n 915 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,591 mL\n 688 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, normal skin turgor\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 158 K/uL\n 86 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 96 mEq/L\n 119 mEq/L\n 28.7 %\n 12.8 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n WBC\n 15.0\n 12.8\n Hct\n 31.0\n 28.7\n Plt\n 205\n 158\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:7.3\n mg/dL, Mg++:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n --Continue serial sodium monitoring\n --Holding hypertonic saline now\n Diabetic foot:\n continue antibiotics pending culture\n Podiatry following.\n Mental status:\n Continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: Mr has had a slow rise in his\n sodium but intermittent bouts of hypotension that have responded to\n IVF\ns. There are concerns regarding possible hallucinations. We will\n make sure rate of correction sodium is slower and continue IV Vanco for\n now till cultures are negative. Appreciate podiatry input. He will\n transition out of ICU later today if there are no significant setbacks.\n Total time: =30 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 03:35 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 559925,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Confised overnight\n 3% shut off\n Fluid restricted\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:48 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:37 AM\n Ceftazidime - 08:37 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (98.9\n HR: 73 (57 - 84) bpm\n BP: 145/66(85) {101/51(63) - 155/104(111)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,432 mL\n 730 mL\n PO:\n 1,330 mL\n 480 mL\n TF:\n IVF:\n 1,102 mL\n 250 mL\n Blood products:\n Total out:\n 2,145 mL\n 780 mL\n Urine:\n 2,145 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 287 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 10.6 g/dL\n 182 K/uL\n 217\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 93 mEq/L\n 120 mEq/L\n 29.4 %\n 12.0 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n WBC\n 15.0\n 12.8\n 12.0\n Hct\n 31.0\n 28.7\n 29.4\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n 178\n 112\n 122\n 217\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1\n mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points. There is a combination of appropriate and\n inappropriate ADH release in this gentleman with Na down to 110 on\n admission without mental status change. He has had diarrhea and\n concerns regarding left foot ulcer. He is in pain in the back from\n falls sustained at home, all of which could have potentiated Na drop.\n He needs 3% NS and then fluid restriction with or without\n demeclocycline to keep SIADH component in check. He may also have a\n reset osmostat at baseline. His SSRI will be held and switched to\n another mood stabilizing . Podiatry consultation has been\n requested and head CT will be ordered to r/o intracranial pathology. He\n has agreed to PICC placement for short term he may leave ICU in next 24\n hours if he remains coherent and hemodynamically stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 559937,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Confused overnight and got Haldol\n Na was stable about 120\n 3% shut off\n getting salt tabs. Nephrology following\n Fluid restricted 1.5L\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:48 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:37 AM\n Ceftazidime - 08:37 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (98.9\n HR: 73 (57 - 84) bpm\n BP: 145/66(85) {101/51(63) - 155/104(111)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,432 mL\n 730 mL\n PO:\n 1,330 mL\n 480 mL\n TF:\n IVF:\n 1,102 mL\n 250 mL\n Blood products:\n Total out:\n 2,145 mL\n 780 mL\n Urine:\n 2,145 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 287 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Gen: alert, sitting up in bed,\n CV: RR\n Chest: CTA\n Abd: Soft NT\n Ext: no edema\n Neuro: alert, conversant and approproate but has a fixed delusion about\n fireman in the room\n detailed. That said he can state weher he\n is.\n Labs / Radiology\n 10.6 g/dL\n 182 K/uL\n 217\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 93 mEq/L\n 120 mEq/L\n 29.4 %\n 12.0 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n WBC\n 15.0\n 12.8\n 12.0\n Hct\n 31.0\n 28.7\n 29.4\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n 178\n 112\n 122\n 217\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1\n mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 1. HypoNatremia: stable now in the 120 range, will fluid restrci\n and start salt tabs, trend TUD to QID/\n 2. Delusions: DDx would be delirium from ICU itself, lack of\n sleep, brewing infection, or from acute withdrawl of SSRI. Changes due\n acute sodium changes seem less likely but always in the DDX and we will\n follow closely.\n 3. Podiatry consultation\n Remaining issues as per Housestaff note s\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Code status: Full code\n Disposition : possible tc out of ICU if stable mental status\n Total time spent: 30\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559996,
"text": "79M w/ PMH: SIADH, COPD, BPH s/p TURP, ulcerative colitis, who\n presented with abdominal pain, diarrhea, leukocytosis, and severe\n hyponatremia.\n #Delirium / confusion\n Assessment:\n Pt is confused, answering questions inappropriately\n Pt is calling out frequently\n Pt removed peripheral IV this evening and PICC yesterday AM\n Action:\n Pt frequently reassured of his safety\n Bed alarm on\n Quiet environment\n Response:\n Pt responds well to reassurance\n Plan:\n Monitory closely for safety\n Bed alarm\n Activity progression, OOB to chair as tolerated and ambulate PRN\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560102,
"text": "Chief Complaint: hyponatremia\n 24 Hour Events:\n PICC LINE - STOP 11:02 AM\n \n - per renal, started salt tabs TID, fluid restrictions on diet. No\n further need for hypertonic saline\n - Pt pulled out PICC but has PIVs,\n - Urology wants to keep in foley. Thinks likely colonized with E coli\n seen on urine culture\n -Na: 11p 119-> 5a 120 -> 11a 123-> 5p 125\n - Throughout day, pt oriented x3 but has fixed delusion re fireman\n coming to his room last night. By 7p, having new hallucinations and\n delusions incl of water coming off ceiling. Gave .5 Haldol at 9p\n - MRSA contact precautions ordered for positive nasal swab\n ____________________________________\n \n -On tele at 12:30am, went into A fib (no known h/o a fib) when MD\n notified at 2:30, IV access re-established. Pt given 5 Metoprolol IV\n x4, Haldol .5 IV x2\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftazidime - 08:37 AM\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:15 AM\n Haloperidol (Haldol) - 03:15 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, no SOB. Feeling well\n Flowsheet Data as of 08:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 92 (68 - 135) bpm\n BP: 145/70(90) {112/59(76) - 156/94(152)} mmHg\n RR: 24 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,189 mL\n 30 mL\n PO:\n 720 mL\n 30 mL\n TF:\n IVF:\n 469 mL\n 0 mL\n Blood products:\n Total out:\n 1,970 mL\n 1,240 mL\n Urine:\n 1,970 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -781 mL\n -1,210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, Anxious\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, Tone:\n Normal\n Labs / Radiology\n 260 K/uL\n 12.5 g/dL\n 193 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 92 mEq/L\n 125 mEq/L\n 35.5 %\n 15.7 K/uL\n [image002.jpg]\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n 12:00 PM\n 06:00 PM\n 03:50 AM\n WBC\n 12.8\n 12.0\n 15.7\n Hct\n 28.7\n 29.4\n 35.5\n Plt\n 158\n 182\n 260\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n Glucose\n 99\n 148\n 86\n 178\n 112\n 122\n \n 193\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:227/9/0.04, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.5\n mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n DELIRIUM / CONFUSION\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Patient\ns urine osmolality was initially high\n (500-600) with a low urine sodium of less than 20. We initially\n corrected his sodium with hypertonic sodium but also gave him NS\n boluses for hypotension, as he had risk factors for volume depletion at\n presentation (decreased po intake). Other potential etiologies of\n SIADH include pain, recent surgery (TURP), pulmonary disease, and his\n SSRI. Goal for correction in this pt is .5 Na/hr or 12 in 24 hrs.\n Cortisol and TSH also normal. Sodium corrected more rapidly in a.m. of\n after total correction of hypovolemia, with a subsequent fall\n in urine osmolality and a rise in urine sodium.\n - goal sodium over 24 hours <= 124\n - per renal: d/c hypertonic saline, give salt tabs TID, fluid restrict\n today\n - Check Q 6hr Na\n - appreciate renal reccs\n # Diabetic foot ulcer/?Abdominal infection: Patient\ns leukocytosis\n most likely from urinary tract infection although also has diabetic\n foot ulcer. Patient also with history of Ulcerative colitis and\n diverticulosis, however CT abdomen was negative for diverticulitis.\n - cont ceftriaxone for UTI and f/u cultures\n - cont vancomycin until foot cultures are negative\n - f/u podiatry reccs\n # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side\n effect of TURP. No evidence of acute spinal stenosis on abdominal CT.\n - continue to follow for any evidence of LE weakness\n #. BPH: s/p TURP, on tamsulosin. Urology aware.\n #. Depression: holding fluoxetine given SIADH. Will need to\n investigate other possible antidepressants given then seems to be\n helping pt as well as risks of continuing it once Na has stabilized.\n For now, delusions/ hallucinations not c/w SSRI withdrawl\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition: regular diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 02:35 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 560118,
"text": "Chief Complaint: hyponatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - STOP 11:02 AM\n Overnight agitation with delusions of water puring off the ceiling\n Afib at 130's overnight: converted with IV and po metoprolol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftazidime - 07:30 AM\n Vancomycin - 08:40 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:15 AM\n Haloperidol (Haldol) - 03:15 AM\n Other medications:\n Neurontin, eye drops, ASA, insulin SS, Lidocaine patch\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.2\nC (97.2\n HR: 86 (68 - 135) bpm\n BP: 141/65(82) {112/59(76) - 156/94(152)} mmHg\n RR: 18 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,189 mL\n 280 mL\n PO:\n 720 mL\n 30 mL\n TF:\n IVF:\n 469 mL\n 250 mL\n Blood products:\n Total out:\n 1,970 mL\n 1,240 mL\n Urine:\n 1,970 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -781 mL\n -960 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: sitting up in bed, eating bfast\n CV: rr\n Chest: CTA\n Abd: soft NT\n Ext: rigth hand is wrpapped with IV\n Neuro: conversant, knoiws it is his daughters , still some\n delusions about firemen but not upset by it\n Labs / Radiology\n 12.5 g/dL\n 260 K/uL\n 193 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 92 mEq/L\n 125 mEq/L\n 35.5 %\n 15.7 K/uL\n [image002.jpg]\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n 08:00 AM\n 12:00 PM\n 06:00 PM\n 03:50 AM\n WBC\n 12.8\n 12.0\n 15.7\n Hct\n 28.7\n 29.4\n 35.5\n Plt\n 158\n 182\n 260\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n Glucose\n 99\n 148\n 86\n 178\n 112\n 122\n \n 193\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:227/9/0.04, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.5\n mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n DELIRIUM / CONFUSION\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 1. HypoNatremia: stable now in the 125 range, will fluid restrict\n and continue salt tabs, trend \n 2. Parox Afib: 1^st episode last nightin setting of agitation\n resolved with bblockade\n this can be reconsidered if not recurs in\n Light of risk of depression\n 3. Delusions: DDx would be delirium from ICU itself, lack of\n sleep, agitated depression\n 4. Podiatry: Vanco for MRSA foot infection\n 5. UTI: appreciate Urology consultation, chronic infection, d/c\n Ceftraixone\n Remaining issues as per Housestaff note s\n ICU Care\n Nutrition: fluid restrict\n Glycemic Control:\n Lines:\n 22 Gauge - 02:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559902,
"text": "Chief Complaint: Hyponatremia\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:48 AM\n -Echocardiogram showed mild LVH w/hyperdynamic left ventricular global\n and regional systolic function. Moderate pulmonary HTN. Very small\n circumferential pericardial effusion\n -Repeat Na came back at 118 so wrote for salt tabs and no fluids, then\n went to 125 at next check (4 hrs later but result didn't come back till\n 4 hours afterward)\n -Had ? hallucinations in the AM and then clear delusions overnight\n (fire trucks and getting stuck in bed)\n -Got 0.5 haloperidol overnight for delusional thinking and some\n agitation/paranoia\n -switched abx coverage of UTI to ceftriaxone as resistant to\n ciprofloxacin\n -Should call and discuss d/c foley w/ urology in AM as resistant\n organism and long term placement\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt denies pain, SOB. Seems confused, talking about\n firemen outside his window.\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 75 (57 - 84) bpm\n BP: 137/54(74) {101/45(62) - 155/104(111)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,432 mL\n 240 mL\n PO:\n 1,330 mL\n 240 mL\n TF:\n IVF:\n 1,102 mL\n Blood products:\n Total out:\n 2,145 mL\n 620 mL\n Urine:\n 2,145 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 287 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : at bases bilat, faint)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2. Unsure of date, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 182 K/uL\n 10.6 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 93 mEq/L\n 120 mEq/L\n 29.4 %\n 12.0 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n WBC\n 15.0\n 12.8\n 12.0\n Hct\n 31.0\n 28.7\n 29.4\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n 178\n 112\n 122\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1\n mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Patient\ns urine osmolality was initially high\n (500-600) with a low urine sodium of less than 20. We initially\n corrected his sodium with hypertonic sodium but also gave him NS\n boluses for hypotension, as he had risk factors for volume depletion at\n presentation (decreased po intake). Other potential etiologies of\n SIADH include pain, recent surgery (TURP), pulmonary disease, and his\n SSRI. Goal for correction in this pt is .5 Na/hr or 12 in 24 hrs.\n Cortisol and TSH also normal. Sodium corrected more rapidly in a.m. of\n after total correction of hypovolemia, with a subsequent fall\n in urine osmolality and a rise in urine sodium.\n - goal sodium over 24 hours <= 124\n - PICC placed for 3% hypertonic saline but holding for now given\n improvement already\n - Check Q 4hr lytes\n - NS as needed for hypovolemia\n - f/u renal reccs\n - Regular diet without fluid restrictions for now.\n # Diabetic foot ulcer/?Abdominal infection: Patient\ns leukocytosis\n most likely from urinary tract infection although also has diabetic\n foot ulcer. Patient also with history of Ulcerative colitis and\n diverticulosis, however CT abdomen was negative for diverticulitis.\n - cont Cipro for UTI and f/u cultures\n - cont vancomycin until foot cultures are negative\n - f/u podiatry reccs\n - will d/c flagyl\n # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side\n effect of TURP. No evidence of acute spinal stenosis on abdominal CT.\n - continue to evaluate for any evidence of LE weakness\n #. BPH: s/p TURP, on tamsulosin. Urology aware.\n #. Depression: holding fluoxetine given SIADH. Will need to\n investigate other possible antidepressants given then seems to be\n helping pt as well as risks of continuing it once Na has stabilized.\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition: reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 559999,
"text": "Chief Complaint: Hyponatremia\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:48 AM\n -Echocardiogram showed mild LVH w/hyperdynamic left ventricular global\n and regional systolic function. Moderate pulmonary HTN. Very small\n circumferential pericardial effusion\n -Repeat Na came back at 118 so wrote for salt tabs and no fluids, then\n went to 125 at next check (4 hrs later but result didn't come back till\n 4 hours afterward)\n -Had ? hallucinations in the AM and then clear delusions overnight\n (fire trucks and getting stuck in bed)\n -Got 0.5 haloperidol overnight for delusional thinking and some\n agitation/paranoia\n -switched abx coverage of UTI to ceftriaxone as resistant to\n ciprofloxacin\n -Should call and discuss d/c foley w/ urology in AM as resistant\n organism and long term placement\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt denies pain, SOB. Seems confused, talking about\n firemen outside his window.\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 75 (57 - 84) bpm\n BP: 137/54(74) {101/45(62) - 155/104(111)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,432 mL\n 240 mL\n PO:\n 1,330 mL\n 240 mL\n TF:\n IVF:\n 1,102 mL\n Blood products:\n Total out:\n 2,145 mL\n 620 mL\n Urine:\n 2,145 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 287 mL\n -380 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : at bases bilat, faint)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2. Unsure of date, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 182 K/uL\n 10.6 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 93 mEq/L\n 120 mEq/L\n 29.4 %\n 12.0 K/uL\n [image002.jpg]\n 04:36 AM\n 09:43 AM\n 02:13 PM\n 06:26 PM\n 10:46 PM\n 04:04 AM\n 11:17 AM\n 06:42 PM\n 04:59 AM\n WBC\n 15.0\n 12.8\n 12.0\n Hct\n 31.0\n 28.7\n 29.4\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.02\n 0.02\n 0.02\n Glucose\n 110\n 175\n 99\n 148\n 86\n 178\n 112\n 122\n Other labs: PT / PTT / INR:13.3/32.5/1.1, CK / CKMB /\n Troponin-T:152/11/0.02, Lactic Acid:0.8 mmol/L, LDH:327 IU/L, Ca++:8.1\n mg/dL, Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n .H/O ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n URINARY TRACT INFECTION (UTI)\n 79M w/ pmh significant for SIADH, COPD, BPH s/p TURP, ulcerative\n colitis, presenting with abdominal pain, diarrhea, leukocytosis, and\n severe hyponatremia.\n #. Hyponatremia: Patient\ns urine osmolality was initially high\n (500-600) with a low urine sodium of less than 20. We initially\n corrected his sodium with hypertonic sodium but also gave him NS\n boluses for hypotension, as he had risk factors for volume depletion at\n presentation (decreased po intake). Other potential etiologies of\n SIADH include pain, recent surgery (TURP), pulmonary disease, and his\n SSRI. Goal for correction in this pt is .5 Na/hr or 12 in 24 hrs.\n Cortisol and TSH also normal. Sodium corrected more rapidly in a.m. of\n after total correction of hypovolemia, with a subsequent fall\n in urine osmolality and a rise in urine sodium.\n - goal sodium over 24 hours <= 124\n - per renal: d/c hypertonic saline, give salt tabs TID, fluid restrict\n today\n - Check Q 6hr Na\n - appreciate renal reccs\n # Diabetic foot ulcer/?Abdominal infection: Patient\ns leukocytosis\n most likely from urinary tract infection although also has diabetic\n foot ulcer. Patient also with history of Ulcerative colitis and\n diverticulosis, however CT abdomen was negative for diverticulitis.\n - cont ceftriaxone for UTI and f/u cultures\n - cont vancomycin until foot cultures are negative\n - f/u podiatry reccs\n # S/p fall with ?poor rectal tone: Per urology, rectal tone not a side\n effect of TURP. No evidence of acute spinal stenosis on abdominal CT.\n - continue to follow for any evidence of LE weakness\n #. BPH: s/p TURP, on tamsulosin. Urology aware.\n #. Depression: holding fluoxetine given SIADH. Will need to\n investigate other possible antidepressants given then seems to be\n helping pt as well as risks of continuing it once Na has stabilized.\n For now, delusions/ hallucinations not c/w SSRI withdrawl\n #.Hypertension: Holding lisinopril per renal, will use hydralazine PRN\n for BP control.\n #.COPD: Continue albuterol\n #.Diabetes: Insulin sliding scale, aspirin\n # Peripheral Neuropathy: Continue neurontin\n #.Osteoarthritis: continue lidocaine patch and percocet\n ICU Care\n Nutrition: reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560004,
"text": "79M w/ PMH: SIADH, COPD, BPH s/p TURP, ulcerative colitis, who\n presented with abdominal pain, diarrhea, leukocytosis, and severe\n hyponatremia.\n #Delirium / confusion\n Assessment:\n Pt is confused, answering questions inappropriately\n Pt is calling out frequently\n Pt removed peripheral IV this evening and PICC yesterday AM\n Action:\n Pt frequently reassured of his safety\n Bed alarm on\n Quiet environment\n Response:\n Pt responds well to reassurance\n Plan:\n Monitory closely for safety\n Bed alarm\n Activity progression, OOB to chair as tolerated and ambulate PRN\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559743,
"text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Awoke patient this morning, pt disoriented to place & time, easily\n reoriented however pt with visual hallucinations. ICU team aware and\n ordered Na levels q4h. Hypertonic saline now on hold, 1115 Na 120.\n Action:\n Serial Na, phos and potassium replete as ordered.\n Response:\n Pt lethargic and hallucinating\n Plan:\n Cont w/q4h Na+ and cont to monitor mental status.\n Urinary tract infection (UTI)\n Assessment:\n Urine w/sediment, appeared to have bladder spasms overnight and voiced\n concern over wetting the bed.\n Action:\n UCx and lytes sent as ordered\n Response:\n No apparent bladder spasms today.\n Plan:\n Cont w/antbx as ordered, monitor temp and cx results.\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 559741,
"text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Awoke patient this morning, pt disoriented to place & time, easily\n reoriented however pt with visual hallucinations. ICU team aware and\n ordered Na levels q4h. Hypertonic saline now on hold, 1115 Na 120.\n Action:\n Serial Na, phos and potassium replete as ordered.\n Response:\n Pt lethargic and hallucinating\n Plan:\n Cont w/q4h Na+ and cont to monitor mental status.\n Urinary tract infection (UTI)\n Assessment:\n Urine w/sediment, appeared to have bladder spasms overnight and voiced\n concern over wetting the bed.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560047,
"text": "79M w/ PMH: SIADH, COPD, BPH s/p TURP, ulcerative colitis, who\n presented with abdominal pain, diarrhea, leukocytosis, and severe\n hyponatremia.\n #Delirium / confusion\n Assessment:\n Pt is confused, answering questions inappropriately\n Pt is calling out frequently\n Pt removed peripheral IV this evening and PICC yesterday AM\n Action:\n Pt frequently reassured of his safety\n Bed alarm on\n Quiet environment\n Response:\n Pt responds well to reassurance\n Plan:\n Monitory closely for safety\n Bed alarm\n Activity progression, OOB to chair as tolerated and ambulate PRN\n #Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Serum Na has gone from 120 to 125 over the last 24 hours\n Action:\n Free water restriction\n Sodium chloride tabs 1g TID\n Response:\n Hyponatremia slowly correcting\n Plan:\n Continue free water restriction\n Continue PO repletion of sodium\n Continue to follow serum sodium q6n and urine lytes \n #Atrial fibrillation (Afib)\n Assessment:\n Around 0100 pt noted to have developed new onset AF with ventricular\n rate of 100\ns to 120\n Action:\n EKG obtained\n Metoprolol 5mg IV x2 and repeated to a total dose of 20mg\n 12.5mg metoprolol PO\n Pt was medicated with haloperidol IV 0.5mg x3 for agitation/confusion\n Response:\n Pt remains in AF with ventricular rate of 90\ns to 100\n Plan:\n Continue to monitor closely\n Continue to rate control with BB or CCB\n Consider cardiology consultation in AM regarding cardioversion/chemical\n cardioversion\n Consider anticoagulation in concert with cardiology consult\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1064874,
"text": " 8:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p Right 52cm Picc Placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Right 52cm Picc Placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:11 AM\n Picc line terminating in mid SVC. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with right 52 mm PICC line placement.\n\n PORTABLE AP CHEST RADIOGRAPH: Right-sided PICC line with tip terminating in\n mid to lower SVC. Lungs are clear. No pleural effusion. No pneumothorax.\n Heart size within normal limits. Tortuous aorta.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1065858,
"text": " 3:41 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evluate for a pulmonary etiology of SIADH.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with SIADH, please evlaute for pulmonary etiology of SIADH.\n REASON FOR THIS EXAMINATION:\n Please evluate for a pulmonary etiology of SIADH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with SIADH, please evaluate for pulmonary\n etiology.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE: Axial MDCT images of the chest were obtained with no IV contrast\n administration. Sagittal and coronal reformatted images were then obtained.\n\n CT OF THE CHEST WITH NO CONTRAST: No central pathologically enlarged nodes\n are noted. No pathologically enlarged axillary nodes are seen. Diffuse\n calcification of the aorta is unchanged. No pleural or pericardial effusion\n is seen. Two 4-mm nodules of the right upper lobe are unchanged since\n . 3-mm right major fissure node is also unchanged. No focal\n consolidation or pneumothorax is detected. Incidental note is made of\n aberrant right subclavian artery.\n\n The visualized part of the upper abdomen including the liver, spleen, adrenal\n glands, upper pole of the kidneys, and gallbladder appear unremarkable. A\n small hiatal hernia is also identified.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesion is identified.\n\n IMPRESSION:\n 1. No mass lesion is identified to explain the SIADH syndrome.\n 2. Unchanged two 4-mm nodules of the right upper lobe and the nodule of the\n right major fissure appear unchanged since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1064904,
"text": " 10:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for intracranial process.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with SIADH and fall at home.\n REASON FOR THIS EXAMINATION:\n Evaluate for intracranial process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:58 AM\n PFI: No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male status post fall.\n\n COMPARISON: None available.\n\n NON-CONTRAST HEAD CT: There is no evidence for hemorrhage, edema, mass\n effect, or acute large vascular territory infarction. There is no obvious\n suprasellar mass. Prominence of the ventricles and sulci is noted, but\n symmetric in appearance, suggesting a degree of age-related involutional\n change. There are periventricular white matter hypodensities, nonspecific,\n but likely the sequelae of small vessel ischemic disease. Small punctate foci\n of calcification are incidentally noted in the basal ganglia. The basilar\n cisterns appear normal. The -white differentiation is preserved. The\n visualized osseous structures are normal, with no fractures, or suspicious\n lytic or sclerotic lesions. The paranasal sinuses and mastoid air cells are\n normally pneumatized and clear.\n\n IMPRESSION: No acute intracranial process, including no hemorrhage, edema,\n mass effect or acute large vascular territory infarction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1064905,
"text": ", MED 10:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for intracranial process.\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with SIADH and fall at home.\n REASON FOR THIS EXAMINATION:\n Evaluate for intracranial process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-21 00:00:00.000",
"description": "L FOOT AP,LAT & OBL LEFT",
"row_id": 1064906,
"text": " 10:18 AM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: evaluate for bone changes\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with ulcer\n REASON FOR THIS EXAMINATION:\n evaluate for bone changes\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE LEFT FOOT FROM \n\n HISTORY: Ulcer, evaluate for bony changes.\n\n COMMENT: AP, lateral and oblique views of the left foot are provided.\n\n FINDINGS: No obvious soft tissue defect is seen. There is no evidence of\n bony erosion. Bony mineralization is normal. Vascular calcifications are\n noted. Os peroneum is noted. The PIP joints are in flexion on all views.\n\n IMPRESSION: No bony destruction to suggest osteomyelitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1064782,
"text": " 5:48 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with F/abd pain, cough\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH, .\n\n Comparison is made with a prior chest CT from .\n\n CLINICAL HISTORY: 79-year-old man with fever, abdominal pain, cough. Evaluate\n for pneumonia. The patient has also a history of lymphoma.\n\n FINDINGS: AP and lateral views of the chest are obtained. Lungs are clear\n bilaterally demonstrating no evidence of pneumonia or CHF. Cardiomediastinal\n silhouette is grossly normal. Osseous structures are intact. No free air is\n seen below the diaphragm.\n\n IMPRESSION: No acute intrathoracic process.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1064776,
"text": " 5:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? diverticulitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with F, weakness, WBC 21, LLQ ttp\n REASON FOR THIS EXAMINATION:\n ? diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl WED 6:34 PM\n diverticulosis, no diverticulitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with fever and weakness, left lower quadrant\n tenderness to palpation. Question diverticulitis.\n\n COMPARISON: CT torso, . Prior studies indicate that the\n patient has history of lymphoma.\n\n TECHNIQUE: MDCT-axial images were obtained from the lung bases through the\n pubic symphysis following administration of 130 ml of Optiray intravenous\n contrast. No oral contrast was adnministered. Multiplanar reformatted images\n were generated.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate minimal\n atelectatic change dependently. There is no pleural effusion or pericardial\n effusion.\n\n Within the liver, a vague hypoattenuating lesion in the centralized aspect of\n segment IV B (2:21) is unchanged. The gallbladder, spleen, and adrenals are\n unremarkable. The pancreas appears unremarkable aside from fat infiltration.\n Renal cysts are unchanged. There is no free fluid or free air within the\n abdomen. The stomach, duodenum, small bowel, and colon are normal in caliber.\n No enlarged mesenteric or retroperitoneal lymph nodes are identified.\n\n The abdominal aorta is normal in caliber with scattered atherosclerotic\n calcifications. The proximal celiac, superior mesenteric, and inferior\n mesenteric veins are patent.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: There is diverticulosis of the colon,\n predominantly within the sigmoid, without evidence of diverticulitis. There\n is a Foley catheter within the urinary bladder, which is partially\n decompressed. Air within the nondependent portion of the urinary bladder may\n be due to instrumentation. No enlarged pelvic or inguinal lymph nodes are\n identified. There is no free fluid within the pelvis.\n\n BONES AND SOFT TISSUES: Evaluation of bone windows demonstrates multilevel\n degenerative changes. Grade I anterolisthesis of L4 on L5 is unchanged. No\n lesions suspicious for metastases are identified. A small lipoma noted in the\n left hip musculature.\n\n (Over)\n\n 5:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? diverticulitis\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Diverticulosis. No evidence of diverticulitis.\n 2. Ill-defined hypoattenuating lesion within segment IV B of the liver is\n unchanged dating back to .\n 3. Degenerative changes of the lumbosacral spine, with grade I\n anterolisthesis of L4 on L5, unchanged.\n 4. Unchanged renal cysts.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1064875,
"text": ", MED 8:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p Right 52cm Picc Placement\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Right 52cm Picc Placement\n ______________________________________________________________________________\n PFI REPORT\n Picc line terminating in mid SVC. No PTX.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-24 00:00:00.000",
"description": "Report",
"row_id": 310016,
"text": "Artifact is present. Probable atrial fibrillation with a rapid ventricular\nresponse. Non-specific ST-T wave changes. Compared to the previous tracing\natrial fibrillation is new. If clinically indicated, a repeat tracing may\nfurther clarify the rhythm.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-20 00:00:00.000",
"description": "Report",
"row_id": 310017,
"text": "Normal sinus rhythm. Within normal limits. Moderate artifact makes\nmeasuring the P-R interval difficult but it seems to be slightly prolonged.\nCompared to the previous tracing of no diagnostic interval change.\n\n"
}
] |
11,516 | 193,566 | Patient was transferred to the for further evaluaiton and management. He was admitted to the Trauma/Surgical intensive care unit and made NPO. IV fluids were started. Appropriate laboratory studies were obtained. GI service was consulted for a possible EGD. Patient was started on protonix , and 2 large bore IVs were placed. Renal team was consulted for management of hemodialysis. Gastrin, calcium, PTH levels were sent. Overnight, patient remained hemodynamically stable and had no decrease in hematocrit with no evidence of acute bleeding. EGD was performed and showed a healing ulcer in the second part of the duodenum with previously applied clips, erythema and congestion in the antrum and stomach body compatible with mild gastropathy, erythema and congestion in the gastroesophageal junction and lower third of the esophagus compatible with esophagitis, erosions in the antrum and stomach body, successful hemostasis from previous clipping, and no bleeding in stomach or duodenum. Serial hematocrits continued to be stable. Patient was subsequently transferred to the floor on . He remained hemodynamically stable. He was dialyzed on home schedule and prn for fluid overload and hyperkalemia. However, on patient binged on excessive amounts of food against medical advice and had blood sugars in the critical range. Insulin was given and sugars gradually went down through the course of the evening and morning. Patient continued to be noncompliant with his diet and was instructed that we would monitor his sugars throughout the day on the 26th at which time he would be released late in the afternoon if they remained under control. However, the patient did not wish to stay and left against medical advice later that morning. He did have instructions to follow up with his gastroenterologist as well as endocrinologist for further management of his diabetes. | Pulses palp throughout, thready PT's.Pulm: BS CTAb; sats>95 on RA.GI: abd soft, non-tender. Intermittent nausea med w/ promethazine effectively; no emesis. Given 2 tylenol for HA with NTP.CVS HR 90's nsr without ectopy bp 154/-179/99 lopressor 15mg IV q 6hr and NTP " q 6. PELVIS CT WITH INTRAVENOUS CONTRAST: Diverticula are present in the sigmoid colon, without evidence of acute diverticulitis. Med for back/leg pain w/ MS 4mg q4-5h.CV: NSR, ST, no VEA. Sigmoid diverticulosis without evidence of acute diverticulitis. No contraindications for IV contrast FINAL REPORT HISTORY: Recurrent gastrointestinal bleeding and ulcers. PRN MS pain (fentanyl patch in place). REASON FOR THIS EXAMINATION: r/o gastrinoma.pt is ESRD on HD. 12:01 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: r/o gastrinoma.pt is ESRD on HD. PRN hydralazine to maintain SBP<170. BPS 130's-170's; med w/ hydralazine 10mg IV x 1for sustained >170 w/ drop to 130's. Maintain SBp<170, prn hydralazine. Med w/ ativan x 1 for anxiety/sleeplessness. Fibrinogen, INR wnl.endo: extremely labile BG after starting on lantus. RA sats < 95%.GI: abd soft, tender to palp over epigastrum. NPO.GU: voided x 1 clear amber urine.skeletal: skin grossly intact excepting perineal rash that is typical looking fungal/yeast: red, macular, dry w/ peeling edges. BG checks q h until eating and less labile. He was given hydralazine 10mg IV x2 for bp >170/. Consult GI re endoscopy today. BS active; no stool. SBP 130's-170's; hydralazine 10mg x 1 for sustained SBP>170. Pulses palp throughout.pulm: BS CTAb. NPO.GU: voids infrequently, clear yellow urine.skeletal: skin grossly intact; groin rash slowly improving.heme: q6h HCt stable, >33. No focal deficits.CV: NSR, ST, 80's-110. The bladder, prostate, and rectum appear unremarkable. TECHNIQUE: Axial multidetector CT images of the abdomen were obtained without contrast and then with 150 cc of intravenous Optiray in arterial, portal venous, and delayed phases. Med for nausea w/ promethazine. Lotrimin applied.heme: hct stable @33. Evaluate for gastrinoma. The gallbladder, spleen, adrenal glands, and kidneys appear unremarkable. There are no briskly enhancing lesions in the pancreas or in the gastrinoma triangle. DM, HTN, retinopathy, ESRD, GI bld s/p clip done at OSH, gastroparesis, chronic painp. Small bowel and colon appear normal in caliber without evidence of wall thickening. c/o considerable back pain, which is his norm; med w/ MS4 mg IV q2-4h. BG checks done q 1-2h. He also stated that the NTP gives him a HA did not want to take itO, Neuro a/ox3, mae, medicated with morphine 4mg IV q 2hrs with adequate relief. INR 1endo: labile BG, requiring insulin (humolog) q 6h.ID: Tmax 99.6 po; WBC 11. Followed by for DM. No emesis. Consult Derm re perineal rash. PNPNo major eventsneuro: AAO x 3; calm and cooperative. Strict NPO. No evidence of a gastrinoma. COMPARISON: No previous studies. skin w+d pp+resp lungs cta using 4lnp occas o2 sats >96%gi to have EGD done at BS no evidence of bld abd soft bs+ no stool pt npo taking ice chips occ.gu voided 100cc yellow clear urine to have HD renal consult doneendo consult done will get lantus after EGD and ss humaloga. Needs VAD needle changed today (IV team notified). There is no mesenteric or retroperitoneal lymphadenopathy. Hct stable around 33 checked q 4hr. He was given phenergan IV for nausea with good relief. There is no pelvic or inguinal lymphadenopathy. Admitting Diagnosis: GI BLEED;ANEMIA Field of view: 32 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 25yo M with recurrent GI bleeds / ulcers. ABDOMEN CT WITH AND WITHOUT CONTRAST: There are no abnormalities at the visualized lung bases. NPNneuro: AAO x 3; calm and cooperative. DFDkq No focal deficits. Arterial calcifications are noted, unusual for the patient's age. Q6h Hct. BONE WINDOWS: There are no suspicious lytic or sclerotic bone lesions. There are no focal liver lesions. Does not look infected. IMPRESSION: 1. Vas deferens calcifications are suggestive of diabetes. No stool. D5NS @ 50cc while NPO.P: CT pancreas today. follow suggestions for diabetic control guidelines, pt appears to need tighter control of bp, HD tommorrow, phenergan prn nausea, pain med as ordered pt is use to taking xanax regularly at home ordered for .5mg IV ativan prn, may benefit from pain consult, support pt and family, await EGD results check Hcts q 4hr Consult Renal for HD on Friday. There is no free fluid. There is no free fluid. Effective pain and anxiety management. States that he takes 2 vicodan at least every 3hrs often more and also fentanyl patch. Delayed images of the pelvis were also obtained. 2. HD scheduled for today s. c/o of pain "all over" esp in his neck, back, legs and abd. No meds.Social: Mom and sister are staying at Best Western at , and will call this am to check on plan.P: consult for DM management. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2190-04-02 00:00:00.000",
"description": "Report",
"row_id": 1413212,
"text": "NPN\nneuro: AAO x 3; calm and cooperative. No focal deficits. Med for back/leg pain w/ MS 4mg q4-5h.\n\nCV: NSR, ST, no VEA. SBP 130's-170's; hydralazine 10mg x 1 for sustained SBP>170. Pulses palp throughout.\n\npulm: BS CTAb. RA sats < 95%.\n\nGI: abd soft, tender to palp over epigastrum. Med for nausea w/ promethazine. No emesis. No stool. NPO.\n\nGU: voids infrequently, clear yellow urine.\n\nskeletal: skin grossly intact; groin rash slowly improving.\n\nheme: q6h HCt stable, >33. Fibrinogen, INR wnl.\n\nendo: extremely labile BG after starting on lantus. BG checks done q 1-2h. D5NS @ 50cc while NPO.\n\nP: CT pancreas today. Followed by for DM. BG checks q h until eating and less labile. Needs VAD needle changed today (IV team notified). PRN hydralazine to maintain SBP<170. PRN MS pain (fentanyl patch in place). HD scheduled for today\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-04-01 00:00:00.000",
"description": "Report",
"row_id": 1413210,
"text": "PNP\nNo major events\n\nneuro: AAO x 3; calm and cooperative. c/o considerable back pain, which is his norm; med w/ MS4 mg IV q2-4h. Med w/ ativan x 1 for anxiety/sleeplessness. No focal deficits.\n\nCV: NSR, ST, 80's-110. BPS 130's-170's; med w/ hydralazine 10mg IV x 1\nfor sustained >170 w/ drop to 130's. Pulses palp throughout, thready PT's.\n\nPulm: BS CTAb; sats>95 on RA.\n\nGI: abd soft, non-tender. Intermittent nausea med w/ promethazine effectively; no emesis. BS active; no stool. NPO.\n\nGU: voided x 1 clear amber urine.\n\nskeletal: skin grossly intact excepting perineal rash that is typical looking fungal/yeast: red, macular, dry w/ peeling edges. Does not look infected. Lotrimin applied.\n\n\nheme: hct stable @33. INR 1\n\nendo: labile BG, requiring insulin (humolog) q 6h.\n\nID: Tmax 99.6 po; WBC 11. No meds.\n\nSocial: Mom and sister are staying at Best Western at , and will call this am to check on plan.\n\nP: consult for DM management. Consult Derm re perineal rash. Consult GI re endoscopy today. Consult Renal for HD on Friday. Strict NPO. Effective pain and anxiety management. Q6h Hct. Maintain SBp<170, prn hydralazine.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-04-01 00:00:00.000",
"description": "Report",
"row_id": 1413211,
"text": "s. c/o of pain \"all over\" esp in his neck, back, legs and abd. Pain like the pain he has regularly. States that he takes 2 vicodan at least every 3hrs often more and also fentanyl patch. He also stated that the NTP gives him a HA did not want to take it\nO, Neuro a/ox3, mae, medicated with morphine 4mg IV q 2hrs with adequate relief. He was given phenergan IV for nausea with good relief. Given 2 tylenol for HA with NTP.\nCVS HR 90's nsr without ectopy bp 154/-179/99 lopressor 15mg IV q 6hr and NTP \" q 6. He was given hydralazine 10mg IV x2 for bp >170/. Hct stable around 33 checked q 4hr. skin w+d pp+\nresp lungs cta using 4lnp occas o2 sats >96%\ngi to have EGD done at BS no evidence of bld abd soft bs+ no stool pt npo taking ice chips occ.\ngu voided 100cc yellow clear urine to have HD renal consult done\nendo consult done will get lantus after EGD and ss humalog\na. DM, HTN, retinopathy, ESRD, GI bld s/p clip done at OSH, gastroparesis, chronic pain\np. follow suggestions for diabetic control guidelines, pt appears to need tighter control of bp, HD tommorrow, phenergan prn nausea, pain med as ordered pt is use to taking xanax regularly at home ordered for .5mg IV ativan prn, may benefit from pain consult, support pt and family, await EGD results check Hcts q 4hr\n"
},
{
"category": "Radiology",
"chartdate": "2190-04-02 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 902041,
"text": " 12:01 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o gastrinoma.pt is ESRD on HD.\n Admitting Diagnosis: GI BLEED;ANEMIA\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25yo M with recurrent GI bleeds / ulcers.\n REASON FOR THIS EXAMINATION:\n r/o gastrinoma.pt is ESRD on HD.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recurrent gastrointestinal bleeding and ulcers. Evaluate for\n gastrinoma.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial multidetector CT images of the abdomen were obtained without\n contrast and then with 150 cc of intravenous Optiray in arterial, portal\n venous, and delayed phases. Delayed images of the pelvis were also obtained.\n\n ABDOMEN CT WITH AND WITHOUT CONTRAST: There are no abnormalities at the\n visualized lung bases. There are no briskly enhancing lesions in the pancreas\n or in the gastrinoma triangle. There are no focal liver lesions. The\n gallbladder, spleen, adrenal glands, and kidneys appear unremarkable. Small\n bowel and colon appear normal in caliber without evidence of wall thickening.\n There is no mesenteric or retroperitoneal lymphadenopathy. There is no free\n fluid. Arterial calcifications are noted, unusual for the patient's age.\n\n PELVIS CT WITH INTRAVENOUS CONTRAST: Diverticula are present in the sigmoid\n colon, without evidence of acute diverticulitis. Vas deferens calcifications\n are suggestive of diabetes. The bladder, prostate, and rectum appear\n unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no\n free fluid.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic bone lesions.\n\n IMPRESSION:\n 1. No evidence of a gastrinoma.\n 2. Sigmoid diverticulosis without evidence of acute diverticulitis.\n DFDkq\n\n"
}
] |
9,508 | 103,334 | 63F s/p extensive ventral hernia repair. She tolerated the sugery well. Post-operatively, she had persistent,mild hypoxia post extubation. The Medical Service was immediately consulted for low oxygen saturation. She was placed on supplemental oxygen post-extubation and was eventually weaned off. On the day of discharge, her oxygen sat was 96% on room air. With respect to her wound, in continued to remained clean/dry/intact. There was some erythema post-operatively, which is now much improved with antibiotic treatment. She has been afebrile with stable vitals, eating well, ambulating, making good urine and stool. She will be discharged, in good condition, to home with a visiting nurse to be by to evaluate for possible home physical therapy services. | Changed to PCA dilaudid with good effect.HR remains 114-118 st. SBP 120's 130's.UO adequate.A&O X3.Pneumo boots on. abd firm and distended with absent bowel sounds on auscultation. BS clear, diminished at bases. The mitral valve appears structurallynormal with trivial mitral regurgitation. Hypoxia S/P ventral hernia repair.Height: (in) 62Weight (lb): 200BSA (m2): 1.91 m2BP (mm Hg): 110/60HR (bpm): 86Status: OutpatientDate/Time: at 10:02Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Compared to theprevious tracing of no change.TRACING #1 No AS.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. + 2 GENERALIZED EDEMA, + PULSES PT DENIES CHEST PAIN OR DIZZINESS. S/B Dr. who feels it is not a problem at this X. L&R JP drains with small amts serrosang drainage.Afeb. Bibasilar atelectasis is significant, but unchanged. PT DENIES SOB.GI/GU: ABD FIRM, DISTENDED. abd dsg c/d/i abd binder in place. ekg=st but without ischemic changes and ck result flat. NGT d/c'd. REMAINS ON DILAUDID PCA. Sinus tachycardiaNormal ECG except for rateSince previous tracing of , no significant change No flatus, stool.Initial abd surgical dsg D&I. Small amt old dry blood from at top of abd dsg. Left lower lobe atelectasis is unchanged. Given benedryl X1 with relief. Mildly dilated ascending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lung volumes are low and there is substantial bibasilar atelectasis. There is a small indentation on the right side of the trachea at the thoracic inlet more suggestive of an adjacent goiter or tortuous vessel. sbp91-105.gi: abd surgical drsg with amt of sanguinous drainage which is marked and has not increased in size since her transfer here. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. ngt in place via r nare and to intermittent suction with sm amt of bloody to bilious drainage noted. CONTRAST: 100 cc of IV Optiray was administered. Normal sinus rhythm. Abd distended. ABd distended. NGT TO LIWS DRAINING SMALL AMOUNT BILIOUS FLUID. Lungs CTA decreased @ bases. LUNGS CTA DECREASED @ BASES. The lung window images reveal moderate bibasilar consolidations, right greater than left. Theascending aorta is mildly dilated. ekg changes.neuro: pt a&o x3 and appropriate in her response. Cont antibioticsNPO. HYPOACTIVE BOWEL SOUNDS. Within normal limits. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded. )CV: TMAX 100.6. The heart is normal size, exaggerated by low lung volumes. HR 110-125 ST NO ECTOPY. Left lower lobe atelectasis is stable. Compared to theprevious tracing of no diagnostic change. No significant change from theprevious tracing.TRACING #2 lungs essentially clear on asucultation with bibasilar crackles. Cont to assess resp status. ABD INCISIONS WITH DSG C/D/I ABDOMINAL BINDER IN PLACE. will continue to follow resp status closely and encourage deep breathing and coughing.cv: pt has remained achycardica rate of 110's-120's but no intervention ordered. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.Right ventricular chamber size and free wall motion appear normal. Given tylenol X1 for HA OOB to chair with two assists. IMPRESSION: AP chest compared to : Nasogastric tube can be traced below the diaphragm in the midline approximately 17 cm, but the tip is indistinct. Non-specific ST-T wave abnormalities. Non-specific ST-T wave abnormalities. Nsg transfer note done. Left ventricular wall thickness, cavitysize, and systolic function appear normal (LVEF>55%). will follow fluid status closely and pt may need to be diuresed today.id: max temp=99.8 orally and pt to receive cefazolin 1 gm i v q 8 hrs.social: pt is a full code. PUPILS EQUAL/REACTIVE BILAT. Pneumothorax cannot be excluded. Q 1-2hrs.Wearing 4L NP. POsitive fld balance 4.3L. IMPRESSION: 1. pt also has 2 jp drains to bulb suction draining sanguinous drainage.abd binder in place.gu: foley cath in palce with adequte hourly uo but i&o ps 445cc's at present time. Lucency in the lower mediastinum could be due to esophageal distention or hiatus hernia. The airways appear patent. VSS, afebrile. On cefazolinFoley draining adequate amts urine.Husband in to visitA/P; Pt does cont to desaturate at X's despite OOB, IS, CDB- ? Given lasix at 1830.Remains NPO. BP STABE 110-130/50-60. Bibasilar consolidations, right greater than left. Tol good. Upper lungs are grossly clear. L and R jp drains draining serosang fluid. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.There is no aortic valve stenosis. Cardiac silhouette is partially obscured, but not appreciably enlarged. Assess NG tube placement. PATIENT/TEST INFORMATION:Indication: Left ventricular function. 4 ICU NPN 1100-1900Called out to floor. pmh significant for nephrolithiasis',cholecystectomy,longtime smker who quit in ',obesity,h/o diverticulosis with resection and subsequent colostomy with reversal,h/o ventral repairs in past and depression. Sinus tachycardia. Sinus tachycardia. PT STATES THAT PCA PROVIDES ADEQUATE PAIN CONTROL AND PT IS PAIN FREE AT REST. JP DRAINS DRAINING SMALL SANGUANOUS FLUID.PLAN: CONT PCA FOR PAIN MANAGEMENT, ENCOURAGE TO DEEP BREATHE/COUGH AND CONT TO USE IS, WEAN OXYGEN AS TOLERATED, CONT NPO STATUS, CONT DIURESIS KEEP I&OS NEGATIVE, WILL CONT TO MONITOR. Using I.S. PT ENCOURAGED TO DEEP BREATHE/COUGH AND USING INCENTIVE SPIROMETER. baseline. mg of 1.8 repleted with 3 gm iv mag and will follw electrolytes a s ordered and replete as needed. "O: A&O X3. has long standing hx of smoking but no hx of copd or asthma.cxr c/w vascular congestion and bil pleural effusions according to dr. and decision made not t odiures pt at present time. Positive BS. Micu/Sicu Nursing Note:See carevue for assessment details and labs.PT remains on Dilaudid PCA for pain management. | 14 | [
{
"category": "Echo",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Report",
"row_id": 61229,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypoxia S/P ventral hernia repair.\nHeight: (in) 62\nWeight (lb): 200\nBSA (m2): 1.91 m2\nBP (mm Hg): 110/60\nHR (bpm): 86\nStatus: Outpatient\nDate/Time: at 10:02\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function appear normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nRight ventricular chamber size and free wall motion appear normal. The\nascending aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThere is no aortic valve stenosis. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-16 00:00:00.000",
"description": "Report",
"row_id": 115851,
"text": "Normal sinus rhythm. Within normal limits. No significant change from the\nprevious tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-15 00:00:00.000",
"description": "Report",
"row_id": 115852,
"text": "Sinus tachycardia. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-11 00:00:00.000",
"description": "Report",
"row_id": 115853,
"text": "Sinus tachycardia. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-10 00:00:00.000",
"description": "Report",
"row_id": 115854,
"text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-11 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 882471,
"text": " 1:35 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: S/ \n Admitting Diagnosis: VENTRAL HERNIA/SDA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p abdominal surgery, now with persistent O2 requirement,\n sinus tach\n REASON FOR THIS EXAMINATION:\n please eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman status post abdominal surgery with persistent\n oxygen requirement. Evaluate for pulmonary embolism.\n\n TECHNIQUE: Contiguous axial CT images of the chest were obtained with\n multiplanar reconstructions.\n\n CONTRAST: 100 cc of IV Optiray was administered.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: The soft tissue window images\n reveal no significant axillary, mediastinal, or hilar lymphadenopathy. The\n heart, pericardium, and the great vessels are unremarkable. There are no\n filling defects within the pulmonary vasculature. There are no pleural or\n pericardial effusions.\n\n The lung window images reveal moderate bibasilar consolidations, right greater\n than left. The airways appear patent.\n\n In the imaged portion of the upper abdomen, the visualized portion of the\n spleen, liver appear unremarkable.\n\n There are no suspicious lytic or blastic lesions in the osseous structures.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the above findings.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Bibasilar consolidations, right greater than left.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-10-11 00:00:00.000",
"description": "Report",
"row_id": 1388020,
"text": "Micu/Sicu Nursing Note:\n\nSee carevue for assessment details and labs.\n\nPT remains on Dilaudid PCA for pain management. VSS, afebrile. Remains on 4 L NC sats 90-14% desats to 88-89% with activity, quickly rebounds with rest/deep breathing. PT encouraged to cough/deep breathe and use IS q 2 hours while awake. Lungs CTA decreased @ bases. Remains NPO tolerated small ice chips and meds. L and R jp drains draining serosang fluid. abd dsg c/d/i abd binder in place. Pt to be transferred to 11 when bed available. Will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-10-10 00:00:00.000",
"description": "Report",
"row_id": 1388016,
"text": "admission note s/p or\nbriefly this is a 63 yo lady with nkda. pmh significant for nephrolithiasis',cholecystectomy,longtime smker who quit in ',obesity,h/o diverticulosis with resection and subsequent colostomy with reversal,h/o ventral repairs in past and depression. went to or for ventral hernia repair,extensive lysis fo adhesions,placement of mesh for abdominal wall reconstruction,closure of abdominal wall skin defect.transfered from pacu to micu for close monitoring in setting of mild hypoxia,tachycardia and ? ekg changes.\n\nneuro: pt a&o x3 and appropriate in her response. neurologically . pt has mso4 pca with dose of 1.5 mg , 6 minute lockout and 15mg/hr limit.pain well controlled and will continue to encourage pt to use pca for pain management.\n\nresp: on 02 at 4l/m nc with o2 sats> 92%. has long standing hx of smoking but no hx of copd or asthma.cxr c/w vascular congestion and bil pleural effusions according to dr. and decision made not t odiures pt at present time. lungs essentially clear on asucultation with bibasilar crackles. will continue to follow resp status closely and encourage deep breathing and coughing.\n\ncv: pt has remained achycardica rate of 110's-120's but no intervention ordered. ekg=st but without ischemic changes and ck result flat. mg of 1.8 repleted with 3 gm iv mag and will follw electrolytes a s ordered and replete as needed. sbp91-105.\n\ngi: abd surgical drsg with amt of sanguinous drainage which is marked and has not increased in size since her transfer here. abd firm and distended with absent bowel sounds on auscultation. ngt in place via r nare and to intermittent suction with sm amt of bloody to bilious drainage noted. pt tolerating ice chips but to remain npo at present time. pt also has 2 jp drains to bulb suction draining sanguinous drainage.abd binder in place.\n\ngu: foley cath in palce with adequte hourly uo but i&o ps 445cc's at present time. will follow fluid status closely and pt may need to be diuresed today.\n\nid: max temp=99.8 orally and pt to receive cefazolin 1 gm i v q 8 hrs.\n\nsocial: pt is a full code. no phone contact from her husband . pt may be transfered to medical floor today.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-10-10 00:00:00.000",
"description": "Report",
"row_id": 1388017,
"text": " 4 ICU NPN 1100-1900\nCalled out to floor. Nsg transfer note done. Please update prior to transfer.\nO2 weaned to 2l NP. This afternoon desaturating to ~88% despite OOB, IS. O2 increased to 4L NP. POsitive fld balance 4.3L. Given lasix at 1830.\nRemains NPO. ABd distended. hearing BS at 1830. No flatus, stool.\nInitial abd surgical dsg D&I. Small amt old dry blood from at top of abd dsg. Abd biner on throughout the day. L&R abd JP drains draining small amts serosang blood.\nOOB to chair at 1745. Took few steps in room.\nC/O itching with PCA morphine sulfate. Given benedryl X1 with relief. Changed to PCA dilaudid with good effect.\nHR remains 114-118 st. SBP 120's 130's.\nUO adequate.\nA&O X3.\nPneumo boots on.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-10-11 00:00:00.000",
"description": "Report",
"row_id": 1388018,
"text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT ALERT, ORIENTED X 3. PUPILS EQUAL/REACTIVE BILAT. MAE. TRANSFERS FROM BED TO CHAIR WITH 2 PERSON ASSISTANCE. PT C/O OF SHARP ABDOMINAL/INCISIONAL PAIN WITH ACTIVITY/MOVEMENT. REMAINS ON DILAUDID PCA. PT STATES THAT PCA PROVIDES ADEQUATE PAIN CONTROL AND PT IS PAIN FREE AT REST. INSTRUCTED TO USED PCA BEFORE ACTIVITY (TURNS, OOB, ETC.)\n\nCV: TMAX 100.6. BP STABE 110-130/50-60. HR 110-125 ST NO ECTOPY. + 2 GENERALIZED EDEMA, + PULSES PT DENIES CHEST PAIN OR DIZZINESS. PT DIURESED WELL TO LASIX 20 MG IVP GIVEN ON DAYSHIFT. PT I&O -1350 FOR 24 HOURS.\n\nPULM: PT REMAINS ON 4 L NC. SATS 90-94%. LUNGS CTA DECREASED @ BASES. PT ENCOURAGED TO DEEP BREATHE/COUGH AND USING INCENTIVE SPIROMETER. PT DENIES SOB.\n\nGI/GU: ABD FIRM, DISTENDED. HYPOACTIVE BOWEL SOUNDS. PT REMAINS NPO TOLERATING SMALL AMOUNTS OF ICE CHIPS. NGT TO LIWS DRAINING SMALL AMOUNT BILIOUS FLUID. FOLEY DRAINING YELLOW/CLEAR URINE. ABD INCISIONS WITH DSG C/D/I ABDOMINAL BINDER IN PLACE. JP DRAINS DRAINING SMALL SANGUANOUS FLUID.\n\nPLAN: CONT PCA FOR PAIN MANAGEMENT, ENCOURAGE TO DEEP BREATHE/COUGH AND CONT TO USE IS, WEAN OXYGEN AS TOLERATED, CONT NPO STATUS, CONT DIURESIS KEEP I&OS NEGATIVE, WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-10-11 00:00:00.000",
"description": "Report",
"row_id": 1388019,
"text": " 4 ICU NPN 0700-1900\n\nS: \"I wish I was feeling better two days after my operation.\"\nO: A&O X3. Using PCA dilaudid for pain management. Given tylenol X1 for HA OOB to chair with two assists. Tol good. Using I.S. Q 1-2hrs.\nWearing 4L NP. Sats 91-95%. Occas desat to high 80's with activity. BS clear, diminished at bases. Chest CT scan done to R/O PE. results pnd.\nHr 94-97 SR this afternoon. SBP 96-125. On maint IVF\nNPO except meds, ice chips. NGT d/c'd. Abd distended. Positive BS. No flatus, stool. C/O L abd more painful then R. Sl more reddened. S/B Dr. who feels it is not a problem at this X. L&R JP drains with small amts serrosang drainage.\nAfeb. On cefazolin\nFoley draining adequate amts urine.\nHusband in to visit\nA/P; Pt does cont to desaturate at X's despite OOB, IS, CDB- ? baseline. Cont to assess resp status. Encourage T,C,DB, IS, increase activity.\nPCA dilaudid for pain management- assess\nFollow WBC, temp. Cont antibiotics\nNPO.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882197,
"text": " 6:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for CHF\n Admitting Diagnosis: VENTRAL HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with bibasilar rales\n REASON FOR THIS EXAMINATION:\n Evaluate for CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:03 P.M. ON :\n\n HISTORY: Bibasilar rales.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lung volumes are low and there is substantial bibasilar atelectasis. Upper\n lungs are grossly clear. The heart is normal size, exaggerated by low lung\n volumes. Widening of the superior mediastinum could be due to goiter, dilated\n vessels, mediastinal fat, or any combination thereof. There is a small\n indentation on the right side of the trachea at the thoracic inlet more\n suggestive of an adjacent goiter or tortuous vessel.\n\n Stomach is severely distended with air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882395,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval last fiends\n Admitting Diagnosis: VENTRAL HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman post op from ventral hernia repair now w/ NG tube, assess\n placement. thank you\n REASON FOR THIS EXAMINATION:\n eval last fiends\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:41 A.M. \n\n HISTORY: Ventral hernia repair. Assess NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Nasogastric tube can be traced below the diaphragm in the midline\n approximately 17 cm, but the tip is indistinct. There is no appreciable\n gastric distension in the abdomen. Lucency in the lower mediastinum could be\n due to esophageal distention or hiatus hernia. Lung volumes remain quite low.\n Left lower lobe atelectasis is stable. Cardiac silhouette is partially\n obscured, but not appreciably enlarged. There may be small pleural effusions\n but no appreciable pleural collection or indication of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882220,
"text": " 10:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess NG tube placement please\n Admitting Diagnosis: VENTRAL HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman post op from ventral hernia repair now w/ NG tube, assess\n placement. thank you\n REASON FOR THIS EXAMINATION:\n assess NG tube placement please\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:31 P.M. ON \n\n HISTORY: Assess NG tube placement.\n\n IMPRESSION: AP chest compared to 7:03 p.m.:\n\n Nasogastric tube ends in the midline of the upper abdomen, presumably in the\n stomach since gastric distension has improved since previous study. Left\n lower lobe atelectasis is unchanged. Skin folds of the right scapula project\n over the right lower chest. Pneumothorax cannot be excluded. Bibasilar\n atelectasis is significant, but unchanged. The heart is normal size.\n\n\n"
}
] |
12,752 | 107,086 | There is moderate pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is a trivial/physiologic pericardial effusion.Conclusions:The left atrium is normal in size. There is mildregional left ventricular systolic dysfunction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. The left ventricular cavity size is normal.Overall left ventricular systolic function appears mildy depressed withprobable distal septal hypokinesis. Mild(1+) mitral regurgitation is seen. IMPRESSION: Stable hemorrhagic regions compared with the prior study. CONCLUSION: Possible slight progression of left posterior frontal hemorrhage, as noted above. IMPRESSION: Findings consistent with slight left heart failure. Patchy opacity is noted in the right lower lung zone and in the left lung base. There is moderate pulmonary artery systolichypertension. The left ventricular cavity size isnormal. Another small focus of hemorrhage is identified at the level of the lateral ventricles within the parietal lobe just above the sylvian fissure within the peripheral parenchyma on the left. At least trace aorticregurgitation is seen. The right posterior parietal parasagittal hemorrhage is unchanged in extent. Moderate (2+)aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Thereis now slight ST segment depression in lead aVL with T wave inversion. The aortic valve leaflets are mildly thickened.Moderate (2+) aortic regurgitation is seen. This appears slightly worsened in the right lung in the interval. Right ventricularconduction delay. These finding suggest left ventricular decompensation with early pulmonary edema. The pulmonary vessels remain slightly indistinct. There is associated blunting of the costophrenic angles suggesting small bilateral effusions. There is bibasilar minimal dependent atelectasis. Valvular heart disease.Status: InpatientDate/Time: at 15:18Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Left ventricular wall thicknesses are normal. CT UPPER CHEST WITH CONTRAST: A soft tissue mass with central hypodensity and peripherally enhancing rim is seen surrounding the head of the left clavicle and extending inferiorly to surround the left sterno-clavicular joint. IMPRESSION: Mild upper zone redistribution with no pulmonary edema. TECHNIQUE: Non-contrast head CT scanning was obtained. The heart again shows moderate left ventricular enlargement. Mild (1+) mitralregurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition.Conclusions:Limited study because patient was uncooperative. Prior anterolateral myocardial infarction. Additionally, there is a new geographic region of hypodensity posterior to the posterior of the left ventricle, corresponding with a PCA distribution. Joint effusion with enhancing margins (and suggestion of tiny focus of air within) at left sternoclavicular joint. Left atrial enlargement. Nomasses or vegetations are seen on the aortic valve. NONCONTRAST CT HEAD COMPARED WITH FINDINGS: Again seen are multiple hyperdensities involving the right occipital lobe and left parietal lobes, as seen on the prior exam. Endocarditis.Status: InpatientDate/Time: at 15:25Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. Remains on Oxacillin 2gm q4hr; seen by ID; gent d/c'd 2nd to rising creat, trough level obtained (pending), but not peak.Lines: 2 periph IVs, # 18 and #20 in RLA.Skin: L steranclavicular dressing intact. CONTINUES ON GENT AND OXACILLIN. WORSENING BUN/CRE NOW @73/3.4.ID: CONTINUES ON GENT AND OXACILLIN. PT HAS R SIDED PARLYSIS RECENT STROKE. MICU NPN 7P-7ANEURO: REMAINS ON MSO4 GTT @1MG/HR. Code Status: Remains DNI/DNI. MEDICATED THEN UNRESPONSIVE. MSO4 gtt at 1.0 mg/hr. RIGHT HEMIPARESIS. MINIMAL RESPONSE NOW, WITHDRAWS TO NAILBED PRESSURE. ABD SOFT WITH HYPOACTIVE BS. PT BECOMING MORE AWAKE, GRIMACING WHEN MOVED, W/ /RATE.CV: HR 71-93; BP 93-100/37-50, TMAX 99.3, AXILLARY. Rule out infarction. RESPONDS TO NAILBED PRESSURE BY WITHDRAWING.CARDIAC: HR 71-80 SR WITH NO ECTOPY. BP 80-130/37-63 HAD BEEN ON NTG GTT BUT THAT WAS D/C'D. D5W INFUSING. PERIPHERAL EDEMA PRESENT. Sinus rhythm. Sinus rhythm. Sinus rhythm. LS CLEAR, W/ SLIGHT CRACKLES IN LLL. Priolateral myocardial infarction Compared to the previous tracing of multifocal pacemaker sites are recorded. Grimaces when turned with increase HR and BP. OF NEW SAH. WENT TO OR FOR DRNG OF ABSCESS. See previous note re: status. OGT inserted - Xray done for confirmation. BREATHING PATTERN HAS BECOME MORE LABORED UPON TITRATION OF MORPHINE.GI/GU: +BS, NO BM, NPO. 2.1L OUTPUT FROM LASIX THEN OUTPUT DROPPED OFF. + periph pulses, extrems warm, +edema in hands bilat.Resp: Decreased to 4L n/p from 100% NRB maintaining 02sats at 97%. MS ANOTHER CT TODAY WHICH SHOWED EXTENSION ON INFARCTS AND ? LOPRESSOR HELD. Prominent Q waves in leads I and aVLsuggesting prior lateral myocardial infarction. CXR obtained and awaiting . Bloods sent as ordered.Remains DNR/DNI. RECEIVING D5W 50/HR. In addition, there is new T wave inversion inleads II, III, aVF and V4-V6 consistent with acute inferolateral ischemicprocess. CXR SHOWED CHF AND GIVEN LASIX PRIOR TO TRANSFER TO MICU.RECEIVED IN MICU AT CHANGE OF SHIFT ON 100% NRB AND CONFUSED. RR=. Above note on WRONG patient! Continue to monitor neuro status, VS. Support family. PERL. Groans when touched, turned, etc. Otherwise, no change.TRACING #1 Compared to the previous tracing of the rate has slowedand atrial ectopy has abated. Prominent lateral Q waves suggesting priorlateral myocardial infarction. PALPABLE PULSES THROUGHOUT.RESP: NON-REBREATHER 6L, 100%O2, O2 SAT'S~95%. BP 91-121/38-56. SATS 97-99%.GI/GU: ABD SOFT WITH +BS, NO STOOL. R leg moves w/ tactile stim; R arm - no movement. Clinical correlation is suggested.TRACING #1 Remains on MS04 gtt at 1mg/hr for comfort.Cardiac: HR=60-70's, NSR no ectopy. Left axis deviation. Left axis deviation. Left axis deviation. 3p-7p note WILL CONTINUE WITH CURRENT POC, DNR/DNI AND UTILIZING SMALL AMOUNT MSO4 FOR PAIN, CONTINUING ABX, BLOOD DRAWS. Moves L arm/leg spont and to tactile stim. Otherwise, no change.TRACING #2 PULSES PALPABLE. Sinus rhythm and multiple atrial pacemaker sites. PT STARTED ON VANC/GENT FOR ?ENDOCARDITIS AND POSSIBLE SEPTIC EMBOLI. LSC WITH RR 12-35. ****ONLT TO BE CHANGED BY SURGERY****ACCESS: 2 PIV'S.SOCIAL: MADE CMO WITH CONTINUED USE OF ABX. | 23 | [
{
"category": "Radiology",
"chartdate": "2167-02-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 787045,
"text": " 5:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with history of hemmorhagic strokes, bactermia, MRSA\n endocarditis\n REASON FOR THIS EXAMINATION:\n status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of hemorrhagic stroke and bacteremia with MR save.\n\n NONCONTRAST CT HEAD COMPARED WITH \n\n FINDINGS: Again seen are multiple hyperdensities involving the right occipital\n lobe and left parietal lobes, as seen on the prior exam. There is increased\n prominence of hypodensity deep to the left parietal lesion, which may\n represent progression of infarction. Additionally, there is a new geographic\n region of hypodensity posterior to the posterior of the left ventricle,\n corresponding with a PCA distribution. Additionally, in a region inferior to\n this, there is a hypodensity of the inferior occipital lobe on the left, which\n may represent a area of prior infarct as well. This lesion was not evident on\n the prior study either. There is no evidence of new intra or extra-axial\n hemorrhage. There is no shift of midline structures or mass effect. The sulci,\n cisterns, and ventricles are unremarkable. The visualized paranasal sinuses\n are clear. Mastoid air cells are clear. Osseous structures are unremarkable.\n\n IMPRESSION: Stable hemorrhagic regions compared with the prior study. There\n are new areas of hypodensity within the left occipital lobe corresponding to a\n left PCA distribution These findings were discussed with the house staff at\n the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-22 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 786605,
"text": " 11:47 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: right sided facial droop with right weakness\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with minimal pmh\n REASON FOR THIS EXAMINATION:\n right sided facial droop with right weakness\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR MON 3:13 AM\n 2 small foci of intraparenchymal hemorrhage at grey-white matter junction\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Right sided facial droop with right weakness in a patient with\n septic emboli.\n\n There is no prior study for comparison.\n\n TECHNIQUE: Axial images of the head prior to and following the administration\n of IV contrast were performed.\n\n FINDINGS: A 1.7 by 1.6 cm focus of parenchymal hemorrhage is seen along the\n falx cerebri on the right, located posteriorly at the vertex within the\n parietal lobe. Another small focus of hemorrhage is identified at the level of\n the lateral ventricles within the parietal lobe just above the sylvian fissure\n within the peripheral parenchyma on the left. It measures approximately 1.1 cm\n in length. No mass effect or shift of normally midline structures. No extra-\n axial or subarachnoid hemorrhage. Ventricles and sulci are normal in\n size/appearance and are symmetrical. No minor or major vascular territorial\n infarctions.\n\n Bone windows demonstrate no suspicious lytic or sclerotic lesions. The imaged\n portions of the paranasal sinuses and the mastoids are well aerated.\n\n IMPRESSION: 2 intraparenchymal foci of hemorrhage seen at the grey and white\n matter junction, one posteriorly along the falx at the vertex and the other\n within the left mid parietal lobe. This finding is likely consistent with the\n patient's known history of septic emboli but other causes cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-22 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 786606,
"text": " 11:47 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for infected soft tissue in L upper chest wall\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with wbc 23, septic emboli, soft tissue mass on chest/over\n streno-clavicular joint\n REASON FOR THIS EXAMINATION:\n assess for infected soft tissue in L upper chest wall\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR MON 2:56 AM\n Left sternoclavicular abscess measuring 7.1 x 5.6 cm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 81 y/o male with high white count and septic emboli with soft\n tissue mass over left sternoclavicular joint. Assess for abscess.\n\n TECHNIQUE: Localized images of the upper chest and lower neck, specifically\n localized to the sternoclavicular joint were performed following contrast\n administration.\n\n CT UPPER CHEST WITH CONTRAST: A soft tissue mass with central hypodensity and\n peripherally enhancing rim is seen surrounding the head of the left clavicle\n and extending inferiorly to surround the left sterno-clavicular joint. At the\n level of the clavicular joint, the mass extends over 7.1 x 5.6 cm. There is\n suggestion of a tiny focus of air within the mass. No underlying bone\n destruction is seen secondary to this soft tissue mass. The mass is seen to\n compress the left lobe of the thyroid with no appreciable compromise to the\n trachea. Incidental note is made of multiple small mediastinal lymph nodes in\n the prevascular space, the largest of which are approximately 1 cm in short\n axis dimension. Within the imaged portions of the lungs, no septic emboli are\n seen. There is bibasilar minimal dependent atelectasis. The imaged portions of\n the heart and great vessels show mild cardiac enlargement, but no other\n definite abnormalities. No axillary lymph nodes are seen. No enlarged lower\n neck lymph nodes are seen.\n\n IMPRESSION:\n\n 1. Joint effusion with enhancing margins (and suggestion of tiny focus of air\n within) at left sternoclavicular joint. Given patient's history, findings\n likely represent an abscess\n\n 2. Incidental note of multiple lymph nodes in the prevascular space, some of\n which are borderline enlarged.\n\n\n (Over)\n\n 11:47 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for infected soft tissue in L upper chest wall\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786600,
"text": " 10:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assessfor infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with evidence of septic emboli\n REASON FOR THIS EXAMINATION:\n assessfor infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST:\n\n INDICATION: 81 y/o male with evidence of septic emboli.\n\n There is no prior study for comparison.\n\n FINDINGS: The heart is slightly enlarged. There is mild upper zone vascular\n redistribution. Mediastinal and hilar contours are unremarkable. A vague ill-\n defined opacity at the left base is seen. There are no pleural effusions. No\n pneumothorax. Soft tissue and osseous structures appear unremarkable.\n\n IMPRESSION: Mild upper zone redistribution with no pulmonary edema.\n Atelectasis versus infiltrate in left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786717,
"text": " 9:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pneumothorax or hemothorax.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p I&D of neck abscess underneath the clavicular head.\n REASON FOR THIS EXAMINATION:\n Please assess for pneumothorax or hemothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P incision and drainage of neck abscess beneath the clavicular\n head.\n\n CHEST, PORTABLE AP: Comparison made to prior film of . The heart\n size is enlarged. Upper zone redistribution is noted in the pulmonary\n vasculature. An area of increased opacity is seen in the left retrocardiac\n region, which likely represents atelectasis.\n\n IMPRESSION: Findings consistent with slight left heart failure. This has\n worsened in the interval.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 786726,
"text": " 5:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O STROKES.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with 2 hemorrhagic strokes and worsening neuro exam\n REASON FOR THIS EXAMINATION:\n r/o enlargement of bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Two prior hemorrhagic strokes and worsening neurological\n examination. Assess for increased hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scanning was obtained.\n\n FINDINGS: There may be slight increase in the size of the left posterior\n frontal hemorrhage, compared to the prior day's study. The right posterior\n parietal parasagittal hemorrhage is unchanged in extent. There is also\n suggestion that a new area of hemorrhage, possibly subarachnoid in locale, has\n developed within the extreme right parietal vertex region. This hyperdensity\n is curvilinear in configuration, measuring about 12mm in length. There is no\n new mass effect or shift of normally midline structures. Allowing for motion\n artifacts, no definite new area of ischemia in the brain has become visible.\n No new overt extracranial pathology is seen.\n\n CONCLUSION: Possible slight progression of left posterior frontal hemorrhage,\n as noted above. ? of new high right cerebral vertex subarachnoid hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786778,
"text": " 4:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: with respiratory decompensation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p I&D of neck abscess underneath the clavicular head.\n REASON FOR THIS EXAMINATION:\n with respiratory decompensation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: S/P incision and drainage of neck abscess. Respiratory\n decompensation.\n\n FINDINGS: A single AP semi-upright view. Comparison study dated .\n The heart again shows moderate left ventricular enlargement. There is now\n evidence of upper zone redistribution and blurring of vascular detail in both\n lungs. Some illdefined infiltrate is noted at both bases. These finding\n suggest left ventricular decompensation with early pulmonary edema. There is\n associated blunting of the costophrenic angles suggesting small bilateral\n effusions. These findings have worsened since the previous day. There is no\n evidence of any pneumothorax.\n\n IMPRESSION: Worsening left heart failure with early pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786916,
"text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: OGT placement/lungs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p I&D of neck abscess underneath the clavicular head.\n\n REASON FOR THIS EXAMINATION:\n OGT placement/lungs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post OG tube placement.\n\n A single semi-upright portable radiograph of the chest is compared with the\n previous exam dated . An OG tube has its tip below the left\n hemidiaphragm. There has been interval improvement in the visualized portions\n of the lungs with resolving CHF. The pulmonary vessels remain slightly\n indistinct. There is persistent consolidation at the left in the retrocardiac\n region.\n\n IMPRESSION: OGT tip below left hemidiaphragm. Improving CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786967,
"text": " 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: TACHYPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p MSSA endocarditis; CVA now with tachypnea\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate; effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MSSA endocarditis. Now with tachypnea.\n\n CHEST X-RAY, PORTABLE AP: Comparison study dated . The\n cardiomediastinal silhouette is unchanged. The patient is somewhat rotated.\n Patchy opacity is noted in the right lower lung zone and in the left lung\n base. This appears slightly worsened in the right lung in the interval.\n\n IMPRESSION:\n 1) Persistent left basilar opacity and worsened right lower lung zone patchy\n opacity, indicating worsening infiltrates. A developing pneumonia should be\n considered.\n\n"
},
{
"category": "Echo",
"chartdate": "2167-02-24 00:00:00.000",
"description": "Report",
"row_id": 74679,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Endocarditis.\nStatus: Inpatient\nDate/Time: at 15:25\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Moderate (2+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Physiologic\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nOverall left ventricular systolic function appears mildy depressed with\nprobable distal septal hypokinesis. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets are mildly thickened.\nModerate (2+) aortic regurgitation is seen. No abscess seen (cannot exclude).\nThe mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a trivial pericardial effusion.\n\nThere is a mobile echo dense mass seen on the ventricular side of the anterior\nmitral leaflet which may represent a vegetation (versus a ruptured chorda).\n\nCompared to the prior study fo , the echo dense mass may have been\npresent in the prior study but images were suboptimal.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-02-23 00:00:00.000",
"description": "Report",
"row_id": 74680,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 15:18\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nAORTIC VALVE: No masses or vegetations are seen on the aortic valve. Trace\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition.\n\nConclusions:\nLimited study because patient was uncooperative. The images are poor. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). No\nmasses or vegetations are seen on the aortic valve. At least trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2167-02-28 00:00:00.000",
"description": "Report",
"row_id": 167470,
"text": "Sinus rhythm. Left atrial enlargement. Left axis deviation. Right ventricular\nconduction delay. Prior anterolateral myocardial infarction. Compared to the\nprevious tracing of the rate is increased, the T waves are no longer\ninverted in leads II, III and aVF and may represent pseudonormalization. There\nis now slight ST segment depression in lead aVL with T wave inversion. In\naddition, the T waves are now upright in leads V4-V6. Rule out active ischemic\nprocess. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-02-25 00:00:00.000",
"description": "Report",
"row_id": 167471,
"text": "Sinus rhythm. Compared to the previous tracing of the rate has slowed\nand atrial ectopy has abated. In addition, there is new T wave inversion in\nleads II, III, aVF and V4-V6 consistent with acute inferolateral ischemic\nprocess. Rule out infarction. Followup and clinical correlation are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-02-24 00:00:00.000",
"description": "Report",
"row_id": 167472,
"text": "Sinus rhythm and multiple atrial pacemaker sites. Left axis deviation. Prio\nlateral myocardial infarction Compared to the previous tracing of \nmultifocal pacemaker sites are recorded. Otherwise, no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-02-22 00:00:00.000",
"description": "Report",
"row_id": 167473,
"text": "Sinus rhythm. Left axis deviation. Prominent Q waves in leads I and aVL\nsuggesting prior lateral myocardial infarction. No previous tracing available\nfor comparison. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-02-23 00:00:00.000",
"description": "Report",
"row_id": 167474,
"text": "Sinus rhythm. Left axis deviation. Prominent lateral Q waves suggesting prior\nlateral myocardial infarction. Compared to the previous tracing of the\nrate is increased. Otherwise, no change.\nTRACING #2\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-25 00:00:00.000",
"description": "Report",
"row_id": 1429310,
"text": "1500-1900\n\nFamily at bedside until 1800. Phone # of unit given to several family members. (physician) wants to be called if there is any change\nin pt's condition. Assessment remains unchanged-pt with intermittent periods of apnea lasting 10-20 seconds with adequate sats and returns to spontaneous breathing without any intervention. MSO4 gtt at 1.0 mg/hr. Grimaces when turned with increase HR and BP. Maintenance fluids patent at 50 cc's an hour. Bloods sent as ordered.\nRemains DNR/DNI. See previous note re: status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-26 00:00:00.000",
"description": "Report",
"row_id": 1429311,
"text": "MICU NPN 7P-7A\nNEURO: REMAINS ON MSO4 GTT @1MG/HR. INITIALLY ONLY AROUSED TO PAIN WITH EYES OPEN BUT NOW AROUSABLE TO STIMULI. PERL @2MM AND BRISK. DOES NOT FOLLOW COMMANDS. RIGHT HEMIPARESIS. NONPURPOSEFUL MOVEMENT OF LEFT ARM/LEG. MOAN/GRIMACES WITH CARE, BUT COMFORTABLE AT REST. PT DOES NOT ATTEMPT TO SPEAK. RESPONDS TO NAILBED PRESSURE BY WITHDRAWING.\n\nCARDIAC: HR 71-80 SR WITH NO ECTOPY. K+ MAG WNL THIS MORNING. BP 91-121/38-56. PEDAL PULSES PRESENT. PERIPHERAL EDEMA PRESENT. HAS NOT RECEIVED LOPRESSOR. D5W CONTINUES AT 50CC/HR. HCT 35.9 UP FROM 33.7 YESTERDAY.\n\nRESP: REMAINS ON 100% NRB WITH 12L FLOW. SATS >98% WITH RR 10-15. LSC WITH FEW CRACKLES IN LEFT BASE. NO COUGH/CONG/SOB NOTED.\n\nGI/GU: NPO AS UNABLE TO PLACE OGT/NGT. D5W INFUSING. ABD SOFT WITH HYPOACTIVE BS. NO STOOL. U/O 13-40CC/HR YELLOW AND CLEAR/SEDIMENT. WORSENING BUN/CRE NOW @73/3.4.\n\nID: CONTINUES ON GENT AND OXACILLIN. TMAX 101.6 PR GIVEN 650MG TYLENOL WITH DESIRED EFFECT. WBC 19.4 UP FROM 18.7 YESTERDAY.\n\nSKIN: DSD TO LEFT STERNALCLAVICULAR JOINT INTACT.\n\nACCESS: 2 PIV'S.\n\nSOCIAL/DISPO: DR SPOKE WITH SON LAST EVENING. WILL CONTINUE WITH CURRENT POC, DNR/DNI AND UTILIZING SMALL AMOUNT MSO4 FOR PAIN, CONTINUING ABX, BLOOD DRAWS. SON WOULD LIKE TO BE CALLED WITH ANY SIGNIFICANT CHANGES IN PT'S CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-26 00:00:00.000",
"description": "Report",
"row_id": 1429312,
"text": "Code Status: Remains DNI/DNI. Pt is NOT as noted previously.\n\nNeuro: Remains unresponsive to verbal stim, opens eyes, but not focusing, not following commands. Pupils 2mm/brisk, but minimal rxn. Groans when touched, turned, etc. Pt speaks only Romanian, and son reports that he is more alert that yesterday. Moves L arm/leg spont and to tactile stim. R leg moves w/ tactile stim; R arm - no movement. Remains on MS04 gtt at 1mg/hr for comfort.\n\nCardiac: HR=60-70's, NSR no ectopy. BP=90-100's/40's. + periph pulses, extrems warm, +edema in hands bilat.\n\nResp: Decreased to 4L n/p from 100% NRB maintaining 02sats at 97%. Lungs clear bilat. RR=. No cough. No gag reflex, even when OGT inserted.\n\nGI: Abd soft, hypo BS, no BM. OGT inserted - Xray done for confirmation. Will start Promote w/ fiber at 20cc/hr (goal=50cc/hr) when OGT placement confirmed.\n\nGU: foley cath, clear dark yellow urine, about 30cc/hr.\n\nAntibx: T=100.4 to 99.6 axillary. Remains on Oxacillin 2gm q4hr; seen by ID; gent d/c'd 2nd to rising creat, trough level obtained (pending), but not peak.\n\nLines: 2 periph IVs, # 18 and #20 in RLA.\n\nSkin: L steranclavicular dressing intact. Not seen by CT surgeons at this writing - dressing to be chaned by that team.\n\nPlan: Pt may transfer to floor today. Continue to monitor neuro status, VS. Support family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-25 00:00:00.000",
"description": "Report",
"row_id": 1429308,
"text": "MICU NPN 7P-7A\nPATIENT IS AN 81Y/O MALE ADMITTED TO OM FOR RIGHT HEMIPARESIS AND LEFT SHOULDER PAIN. SHOULDER PAIN BEGAN 1WK PTA AND ON DAY OF ADM PT FELL AND C/O RLE NUMBNESS AND WEAKNESS AND NOTED RIGHT FACIAL DROOP. PT STARTED ON VANC/GENT FOR ?ENDOCARDITIS AND POSSIBLE SEPTIC EMBOLI. HEAD CT SHOWED SEVERAL HEMMORHAGIC INFARCTS AND CHEST CT SHOWED ABSCESS AT LSC JOINT. WENT TO OR FOR DRNG OF ABSCESS. NEXT MORNING ^^TROPONIN. INITIAL TTE NEG BUT NEXT SHOWED ?MV VEGETATION. NOT SURGICAL CANDIDATE. MS ANOTHER CT TODAY WHICH SHOWED EXTENSION ON INFARCTS AND ? OF NEW SAH. ON PT NEEDING INCREASED O2 AND BECOMING MORE AGITATED. MEDICATED THEN UNRESPONSIVE. CXR SHOWED CHF AND GIVEN LASIX PRIOR TO TRANSFER TO MICU.\n\nRECEIVED IN MICU AT CHANGE OF SHIFT ON 100% NRB AND CONFUSED. FAMILY WITH SON AND WIFE, RESIDENT AND INTERN. PATIENT WAS ALREADY DNR/DNI AND SON WISHED TO MAKE PATIENT COMFORTABLE BUT TO CONTINUE ABX THERAPY.\n\nNEURO: PATIENT GIVEN A TOTAL OF 2MG ATIVAN BEFORE MSO4 GTT WAS STARTED. PT CURRENTLY ON 4MG/HR WITH GOOD EFFECT. MINIMAL RESPONSE NOW, WITHDRAWS TO NAILBED PRESSURE. PERL. COMFORTABLE.\n\nCARDIAC: HR 72-90 SR WITH NO ECTOPY. BP 80-130/37-63 HAD BEEN ON NTG GTT BUT THAT WAS D/C'D. LOPRESSOR HELD. PULSES PALPABLE. NO LABS DRAWN.\n\nRESP: ON 100% NRB. LSC WITH RR 12-35. SATS 97-99%.\n\nGI/GU: ABD SOFT WITH +BS, NO STOOL. NPO. 2.1L OUTPUT FROM LASIX THEN OUTPUT DROPPED OFF. URINE YELLOW AND CLEAR.\n\nID: TMAX 100.6 GIVEN 650MG TYLENOL PR WITH EFFECT. CONTINUES ON GENT AND OXACILLIN. STAPH AUREAS ENDOCARDITIS.\n\nSKIN: DSG TO NECK. ****ONLT TO BE CHANGED BY SURGERY****\n\nACCESS: 2 PIV'S.\n\nSOCIAL: MADE CMO WITH CONTINUED USE OF ABX. SON SPENT AT BEDSIDE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-25 00:00:00.000",
"description": "Report",
"row_id": 1429309,
"text": "NPN 07:00-15:00 MICU\n*PLEASE REFER TO CAREVIEW FOR ADDITIONAL PATIENT INFORMATION\n*DNR/DNI\n\nNEURO: RECEIVED PT ON , MORPHINE GTT 4MG/HR, OVERALL PT SEDATED, NO SIGNS OF PT EXPERIENCING PAIN. PT HAS R SIDED PARLYSIS RECENT STROKE. *THIS AM FAMILY DECIDED THAT THEY NO LONGER WANTED PT TO BE \"\", SON STATING THAT HE HAD A \"CHANGE OF MIND\",ALSO REQUESTING THAT I BRING DOWN THE MORPHINE B/C OF THE BECOMING DIMINISHED. UPON ROUNDS, TEAM SPOKE TO FAMILY ABOUT CONCERNS AND PLAN OF CARE. SINCE THAT TIME, MORPHINE GTT HAS BEEN DECREASED TO 2MG/HR. PT BECOMING MORE AWAKE, GRIMACING WHEN MOVED, W/ /RATE.\n\nCV: HR 71-93; BP 93-100/37-50, TMAX 99.3, AXILLARY. PALPABLE PULSES THROUGHOUT.\n\nRESP: NON-REBREATHER 6L, 100%O2, O2 SAT'S~95%. LS CLEAR, W/ SLIGHT CRACKLES IN LLL. BREATHING PATTERN HAS BECOME MORE LABORED UPON TITRATION OF MORPHINE.\n\nGI/GU: +BS, NO BM, NPO. RECEIVING D5W 50/HR. U/O WNL.\n\nACCESS: LLARM 18G (REDNESS), RLA 18G WNL\n*LABS TO BE DRAWN THIS AFTERNOON.\nSKIN: INTACT\nSOCIAL: FAMILY AT BEDSIDE ALL DAY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-26 00:00:00.000",
"description": "Report",
"row_id": 1429313,
"text": "3p-7p\nNo change from previous note.\nNGT placed for infusion of golytely inprep for procedure tomorrow. Mushroom cath in place. CXR obtained and awaiting .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-02-26 00:00:00.000",
"description": "Report",
"row_id": 1429314,
"text": "Above note on WRONG patient! 3p-7p note\n"
}
] |
|
12,541 | 169,826 | He was admitted to the Surgery Service and was taken to the operating room for splenectomy. There were no intraoperative complications. Postoperatively he has done well, his hematocrits have been stable. His pain is being controlled with prn Dilaudid and his home dose of Methadone 80 mg daily was resumed. He was given the recommended immunizations because of his splenectomy and was given instructions to follow up with Dr. next week. | CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The lung bases are clear. TECHNIQUE: MDCT axial images through the abdomen and pelvis without and with IV contrast. The arterial phase images (3:39) raise the possibility of a small focus of extravasation in the lower pole; the delayed phase demonstrates no pooling of contrast at this site, or elsewhere. There is a complex laceration, or series of discrete lacerations, involving its lower pole, reaching the surface of the spleen in several places, but not involving its hilum or those vessels (Grade II). PTT 18, INR 1.0.RESP: LS clear/diminished at bases bilaterally. The kidneys demonstrate symmetrical enhancement and excretion without evidence of hydronephrosis. The cardiac silhouette, mediastinal and hilar contours are within normal limits. The well-defined non-enhancing 3.5cm cystic (7 , pre-contrast) structure, at the medial aspect of the splenic dome (3:20), likely represents an acquired cyst, related to more remote trauma. There is a moderately large amount of complex fluid (up to 45HU) gathered around the spleen and in the low pelvis, as well as over the dome of the liver; no hepatic or other visceral injury is seen. WBC 9.4.GI: Abd softly distended and tender on palplation especially in splenic region. Free hyperdense fluid in the pelvis is seen. CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal vesicles, and sigmoid are unremarkable. Normal ECG. + Non productive cough. 2 units of PRBCs were given along with a NS bolus, pt had fair response to and BP up to 90's systolic following transfusion (no transudion reaction noted) 2130 Hct 22 and post transfusion=27, 2nd serial hct pending. The aorta is mildly tortuous. A tiny cortical density in the lower pole of the left kidney is noted, too small to characterize. Kayexalate given, no stool yet.GU: NO IVF ordered. The gallbladder is normal. There is an irregular linear hypodensity transversing the inferior pole of the spleen consistent with laceration. IMPRESSION: No evidence of acute cardiopulmonary process. Moderate amount of hyperdense fluid within the abdomen is seen. Vendynes/Heparin for DVT prophlaxis. origin as narcotic analgesia minimized due to hypotension. The right kidney demonstrates a simple cyst in the upper pole measuring 3.1 x 3.3 cm. FINDINGS: Portable AP view of the chest on upright position. No abx ordered at this time. The pancreas and adrenal glands are normal. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. According to Dr. (Trauma ), the pelvic blood is new from the OSH study (not scanned into PACS, and therefore, not available or review). Degenerative changes of the thoracic spine are noted. (Over) 12:27 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: bleed- IV contrast ONLY Field of view: 50 Contrast: OPTIRAY Amt: 130 FINAL REPORT (REVISED) (Cont) Findings were discussed with Dr. at the time of the dictation. No oral contrast was given which limits the evaluation for loops of bowel, however, no gross abnormality is identified. No evidence of pelvic or inguinal lymphadenopathy. The spleen demonstrates a 9.7 x 3.8 cm hypodense lesion in the lateral aspect consistent with subcapsular hematoma. The pulmonary vasculature is normal. 3.3 x 3.1 cm right renal cyst. Foley catheter placed, draining clear yellow urine at 30cc-60cc/hr.ENDO: Blood glucose 360 at midnight, down to 210 following coverage.SKIN: Multiple abrasions noted in RUE-pt reports they are work related and not from MVC?, no drainage or redness noted. Findings are consistent with spleen laceration, spleen hematoma and hemoperitoneum. No evidence of fracture. No evidence of active contrast extravasation. The liver is diffusely hypodense consistent with fatty infiltration. 3.7 x 2.8 cm hypodense lesion in the anterior aspect of the spleen could represent a cyst. There is no evidence of pneumothorax or pneumoperitoneum. Medicated with IV Dialudid for pain control -good effect per pt report as he states pain has decreased from " to " Noted to be slightly anxious at times which is secondary to his PTSD he says-responds well to in depth communication regarding POC (home meds ordered).CV: Upon arrival to unit NIBP was 80's/40's and down to 70's shortly thereafter. Coronal and sagittal reformatted views were displayed. Pleural effusion. No previous tracing available for comparison. Sinus rhythm. The costophrenic angles are clear. Fatty liver. Pt found to have 10 pt Hct drop (in 24 hrs) following admission to CC6 and was tx to TSICU for further monitoring.NEURO: PT A/OX3-lethargic at times, ? No prior studies are available for comparison. No prior studies are available for comparison. Skin intact elsewhere. There is no evidence of free air. NC 2L placed on pt while sleeping as sats drift off to low 90's, normally 96% RA.ID: Afeb, tmax 99.2. 12:27 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # Reason: bleed- IV contrast ONLY Field of view: 50 Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 57 year old man with L abd pain s/p MVC 4 days ago with splenic lac REASON FOR THIS EXAMINATION: bleed- IV contrast ONLY No contraindications for IV contrast FINAL REPORT (REVISED) INDICATION: 57-year-old man with lower abdominal pain status post MVC four days ago with apparently known splenic laceration. | 4 | [
{
"category": "Radiology",
"chartdate": "2184-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 964311,
"text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with abd pain s/p mvc 4 days ago\n REASON FOR THIS EXAMINATION:\n pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with abdominal pain, status post MVC four days\n ago. Pleural effusion.\n\n No prior studies are available for comparison.\n\n FINDINGS: Portable AP view of the chest on upright position. The cardiac\n silhouette, mediastinal and hilar contours are within normal limits. The\n aorta is mildly tortuous. There is no evidence of pneumothorax or\n pneumoperitoneum. The costophrenic angles are clear. The pulmonary\n vasculature is normal. Degenerative changes of the thoracic spine are noted.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-06-03 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 964323,
"text": " 12:27 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: bleed- IV contrast ONLY\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with L abd pain s/p MVC 4 days ago with splenic lac\n REASON FOR THIS EXAMINATION:\n bleed- IV contrast ONLY\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 57-year-old man with lower abdominal pain status post MVC four\n days ago with apparently known splenic laceration.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: MDCT axial images through the abdomen and pelvis without and with\n IV contrast. 3' delayed images were also obtained. Coronal and sagittal\n reformatted views were displayed.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The lung bases are clear. The\n liver is diffusely hypodense consistent with fatty infiltration. The\n gallbladder is normal. The spleen demonstrates a 9.7 x 3.8 cm hypodense\n lesion in the lateral aspect consistent with subcapsular hematoma. 3.7 x 2.8\n cm hypodense lesion in the anterior aspect of the spleen could represent a\n cyst. There is an irregular linear hypodensity transversing the inferior pole\n of the spleen consistent with laceration. Moderate amount of hyperdense fluid\n within the abdomen is seen. No evidence of active contrast extravasation.\n\n The pancreas and adrenal glands are normal. There is no evidence of free air.\n No oral contrast was given which limits the evaluation for loops of bowel,\n however, no gross abnormality is identified. The kidneys demonstrate\n symmetrical enhancement and excretion without evidence of hydronephrosis. The\n right kidney demonstrates a simple cyst in the upper pole measuring 3.1 x 3.3\n cm. A tiny cortical density in the lower pole of the left kidney is noted,\n too small to characterize.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal vesicles,\n and sigmoid are unremarkable. Free hyperdense fluid in the pelvis is seen. No\n evidence of pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. No\n evidence of fracture.\n\n IMPRESSION:\n 1. Findings are consistent with spleen laceration, spleen hematoma and\n hemoperitoneum.\n\n 2. Fatty liver.\n\n 3. 3.3 x 3.1 cm right renal cyst.\n\n (Over)\n\n 12:27 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: bleed- IV contrast ONLY\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n Findings were discussed with Dr. at the time of the dictation.\n\n NOTE ADDED IN ATTENDING REVIEW: As above, there is a large splenic\n subcapsular hematoma, indenting virtually the entire lateral margin of the\n spleen. There is a complex laceration, or series of discrete lacerations,\n involving its lower pole, reaching the surface of the spleen in several\n places, but not involving its hilum or those vessels (Grade II). The arterial\n phase images (3:39) raise the possibility of a small focus of extravasation in\n the lower pole; the delayed phase demonstrates no pooling of contrast at this\n site, or elsewhere. There is a moderately large amount of complex fluid (up to\n 45HU) gathered around the spleen and in the low pelvis, as well as over the\n dome of the liver; no hepatic or other visceral injury is seen. According to\n Dr. (Trauma ), the pelvic blood is new from the OSH study (not\n scanned into PACS, and therefore, not available or review). The well-defined\n non-enhancing 3.5cm cystic (7 , pre-contrast) structure, at the medial\n aspect of the splenic dome (3:20), likely represents an acquired cyst,\n related to more remote trauma.\n\n (This note was e-mailed to Dr. and , 1330h, .)\n\n"
},
{
"category": "ECG",
"chartdate": "2184-06-03 00:00:00.000",
"description": "Report",
"row_id": 286709,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-06-04 00:00:00.000",
"description": "Report",
"row_id": 1426176,
"text": "NPN 2315-0700\n57 y/o male returns to with increased \"colicky abd pain\" after d/c home x 4days ago following MVC with grade 1 splenic lac. Pt found to have 10 pt Hct drop (in 24 hrs) following admission to CC6 and was tx to TSICU for further monitoring.\n\nNEURO: PT A/OX3-lethargic at times, ? origin as narcotic analgesia minimized due to hypotension. Pt follows all command sappropriately, MAEs with good strength. PERRLA 2-3mm and briskly react. Medicated with IV Dialudid for pain control -good effect per pt report as he states pain has decreased from \" to \" Noted to be slightly anxious at times which is secondary to his PTSD he says-responds well to in depth communication regarding POC (home meds ordered).\n\nCV: Upon arrival to unit NIBP was 80's/40's and down to 70's shortly thereafter. 2 units of PRBCs were given along with a NS bolus, pt had fair response to and BP up to 90's systolic following transfusion (no transudion reaction noted) 2130 Hct 22 and post transfusion=27, 2nd serial hct pending. Next due at 0930. Vendynes/Heparin for DVT prophlaxis. PTT 18, INR 1.0.\n\nRESP: LS clear/diminished at bases bilaterally. + Non productive cough. NC 2L placed on pt while sleeping as sats drift off to low 90's, normally 96% RA.\n\nID: Afeb, tmax 99.2. No abx ordered at this time. WBC 9.4.\n\nGI: Abd softly distended and tender on palplation especially in splenic region. Kayexalate given, no stool yet.\n\nGU: NO IVF ordered. Pt received (1)500cc NS bolus along with 750cc NS with blood transusion. K+ 5.7 and pt was given Insulin per RISS, sodium bicarb in 1L of D50 and Kayexalate, repeat K+ pending, other lytes WNl. Foley catheter placed, draining clear yellow urine at 30cc-60cc/hr.\n\nENDO: Blood glucose 360 at midnight, down to 210 following coverage.\n\nSKIN: Multiple abrasions noted in RUE-pt reports they are work related and not from MVC?, no drainage or redness noted. Skin intact elsewhere. (2) PIVs intact.\n\nSOCIAL: No calls from family overnight, pt reports he has 3 grown children that live nearby. Per pt report he lives with wife, however in chart it is noted pt lives in boarding house.\n\nPOC: Follow Hcts Q4 (next 0930)\n SW consult\n pain management\n ? OR\n\nPOC:\n\n\n\n\n"
}
] |
66,320 | 152,752 | 48 y/o F presents for elective angiogram for coiling of L MCA aneruysm. She was taken to angiogram on 1.25 without any complications. Patient was coiled successfully and then transferred to the ICU for recovery and monitoring. She was also placed on a heparin gtt. On , heparin gtt was discontinued at 7am, groin incision was intact and patient was nonfocal. She was discharge home after voiding, eating, and ambulating appropriately. | PREOPERATIVE DIAGNOSIS: Left internal carotid artery aneurysm. IMPRESSION: underwent cerebral angiography and coil embolization of a left internal carotid artery aneurysm at the bifurcation, that was uneventful. A right common femoral artery arteriogram was done and a 6 French Angio-Seal was used for closure of the right common femoral artery puncture site. PROCEDURE PERFORMED: Right common carotid artery arteriogram, left internal carotid artery arteriogram, right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site, coil embolization of left internal carotid artery bifurcation aneurysm with Cashmere coil and Target coils. FINDINGS: The patient is status post coiling of a left supraclinoid ICA/proximal MCA aneurysm at the M1 segment, with extensive streak artifacts from the aneurysm coil pack (2:11) limiting evaluation. INDICATION: The patient had presented with an unruptured large left internal carotid artery aneurysm. Access was gained to the right common femoral artery using a Seldinger technique and a 6 French vascular sheath was placed. Left internal carotid artery arteriogram status post embolization shows that the aneurysm is completely obliterated. We now catheterized the aneurysm with an SL-10 microcatheter and Synchro wire. Please note that this contrast-enhanced CT study is limited for evaluation of subtle subarachnoid hemorrhage. Left internal carotid artery arteriogram shows filling of the left internal carotid artery in the cervical, petrous, cavernous and supraclinoid portion. FINDINGS: Right common carotid artery arteriogram shows that the right (Over) 12:30 PM CAROT/CEREB Clip # Reason: Stent assisted coiling of aneurysmAnesthesia has been booked Contrast: OPTIRAY Amt: 301 FINAL REPORT (Cont) external carotid artery and its branches fill well. This revealed a 1.3 x 0.6 cm bilobed aneurysm of the internal carotid artery bifurcation, with a narrow neck. There is a 1.3 x 0.6 cm aneurysm in the left internal carotid artery bifurcation. Left subclavian artery arteriogram shows that there is a diminutive left vertebral artery and the left vertebral artery arteriogram shows that this vertebral artery predominantly ends in the PICA. Left vertebral artery arteriogram. Minimal intravenous contrast seen within the cerebral vessels secondary to the recent angiogram. The above-mentioned vessels were catheterized and AP, lateral filming was done. The right internal carotid artery fills well along the cervical, petrous, cavernous and supraclinoid portion. Right common femoral artery arteriogram shows widely patent right common femoral artery. 12:30 PM CAROT/CEREB Clip # Reason: Stent assisted coiling of aneurysmAnesthesia has been booked Contrast: OPTIRAY Amt: 301 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT * * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL UNILAT * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY * **************************************************************************** MEDICAL CONDITION: 48 year old woman with known aneurysm REASON FOR THIS EXAMINATION: Stent assisted coiling of aneurysmAnesthesia has been booked for 1pm FINAL REPORT DATE OF SERVICE: . DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IMPRESSION: Status post left aneurysm coiling, without evidence of intracranial hemorrhage or major vascular territorial infarction. We placed a Cashmere coil measuring 7 mm in diameter, followed by Target coils, and the aneurysm was seen to be completely obliterated. Following this, both groins were prepped and draped in a sterile fashion. IV sedation was given. 6:25 PM CT HEAD W/O CONTRAST Clip # Reason: eval for stroke and or bleed / pt s/p coiling of aneurysm Admitting Diagnosis: BRAIN ANEURYSM /SDA MEDICAL CONDITION: 48 year old woman with s/p coiling of mca aneurysm REASON FOR THIS EXAMINATION: eval for stroke and or bleed / pt s/p coiling of aneurysm No contraindications for IV contrast WET READ: 2:25 AM Status post left MCA aneurysm coiling, without evidence of intracranial hemorrhage or major vascular territorial infarction. | 2 | [
{
"category": "Radiology",
"chartdate": "2113-01-25 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1225291,
"text": " 12:30 PM\n CAROT/CEREB Clip # \n Reason: Stent assisted coiling of aneurysmAnesthesia has been booked\n Contrast: OPTIRAY Amt: 301\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL UNILAT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with known aneurysm\n REASON FOR THIS EXAMINATION:\n Stent assisted coiling of aneurysmAnesthesia has been booked for 1pm\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Left internal carotid artery aneurysm.\n\n INDICATION: The patient had presented with an unruptured large left internal\n carotid artery aneurysm. I elected to coil this, given the fact that she had\n a strong family history and was relatively young.\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, left internal\n carotid artery arteriogram, right common femoral artery arteriogram and\n Angio-Seal closure of right common femoral artery puncture site, coil\n embolization of left internal carotid artery bifurcation aneurysm with \n Cashmere coil and Target coils. Left vertebral artery arteriogram.\n\n ATTENDING:\n ASSISTANT: .\n\n DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV\n sedation was given. Following this, both groins were prepped and draped in a\n sterile fashion. Access was gained to the right common femoral artery using a\n Seldinger technique and a 6 French vascular sheath was placed. The\n above-mentioned vessels were catheterized and AP, lateral filming was done.\n This revealed a 1.3 x 0.6 cm bilobed aneurysm of the internal carotid artery\n bifurcation, with a narrow neck. We now catheterized the aneurysm with an\n SL-10 microcatheter and Synchro wire. We placed a Cashmere coil measuring 7\n mm in diameter, followed by Target coils, and the aneurysm was seen to be\n completely obliterated.\n\n A right common femoral artery arteriogram was done and a 6 French Angio-Seal\n was used for closure of the right common femoral artery puncture site.\n\n FINDINGS: Right common carotid artery arteriogram shows that the right\n (Over)\n\n 12:30 PM\n CAROT/CEREB Clip # \n Reason: Stent assisted coiling of aneurysmAnesthesia has been booked\n Contrast: OPTIRAY Amt: 301\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n external carotid artery and its branches fill well. The right internal\n carotid artery fills well along the cervical, petrous, cavernous and\n supraclinoid portion. Both anterior and middle cerebral arteries are seen\n well.\n\n Left internal carotid artery arteriogram shows filling of the left internal\n carotid artery in the cervical, petrous, cavernous and supraclinoid portion.\n There is a 1.3 x 0.6 cm aneurysm in the left internal carotid artery\n bifurcation. Left internal carotid artery arteriogram status post\n embolization shows that the aneurysm is completely obliterated.\n\n Left subclavian artery arteriogram shows that there is a diminutive left\n vertebral artery and the left vertebral artery arteriogram shows that this\n vertebral artery predominantly ends in the PICA.\n\n Right common femoral artery arteriogram shows widely patent right common\n femoral artery.\n\n IMPRESSION: underwent cerebral angiography and coil\n embolization of a left internal carotid artery aneurysm at the bifurcation,\n that was uneventful.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-01-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1225347,
"text": " 6:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke and or bleed / pt s/p coiling of aneurysm\n Admitting Diagnosis: BRAIN ANEURYSM /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with s/p coiling of mca aneurysm\n REASON FOR THIS EXAMINATION:\n eval for stroke and or bleed / pt s/p coiling of aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:25 AM\n Status post left MCA aneurysm coiling, without evidence of intracranial\n hemorrhage or major vascular territorial infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman with MCA aneurysm, status post coiling, to rule\n out hemorrhage versus stroke.\n\n COMPARISON: Reference MRI from an outside hospital .\n\n TECHNIQUE: MDCT images were acquired through the head without intravenous\n contrast. Sagittal and coronal reformats were generated and reviewed.\n\n FINDINGS: The patient is status post coiling of a left supraclinoid\n ICA/proximal MCA aneurysm at the M1 segment, with extensive streak artifacts\n from the aneurysm coil pack (2:11) limiting evaluation. Minimal intravenous\n contrast seen within the cerebral vessels secondary to the recent angiogram.\n No intracranial hemorrhage, edema, masses or mass effect is seen. -white\n matter differentiation is preserved. The ventricles and sulci are normal in\n caliber and configuration. The basal cisterns are normal. Please note that\n this contrast-enhanced CT study is limited for evaluation of subtle\n subarachnoid hemorrhage. The imaged paranasal sinuses and mastoid air cells\n are clear.\n\n IMPRESSION: Status post left aneurysm coiling, without evidence of\n intracranial hemorrhage or major vascular territorial infarction.\n\n"
}
] |
29,739 | 148,970 | The patient is an 88 year old woman with history of hypertension, osteoporosis who is presenting with acute on subacute mental status change and found to be markedly hypertensive. Likely etiology hypertensive encephalopathy. Blood pressure brought downwith labetolol drip and then patient transtitioned to home medications with improvement in blood pressures and mental status. . Altered Mental status: Etiology not clearly understood as basic chemistries, UA, CXR, CT head, and LP all normal and negative for sign of infection. There were no clear medication exposures nor new sedating meds. Hypertensive encephalopathy may have contributed as well as constipation (many days since last BM). She was administered ativan in the emergency department and became very sedated for the next 24 hours. TSH and B12 were checked and were normal. She slowly awakened and became aggitated and required restraints (posy vest and mittens). She was given an agressive bowel regimen and restarted on home quinipril and atenolol. Microbiology remained negative. Quinipril was increased to 20 mg daily. She improved without further intervention. . Hypertensive Urgency: Felt to be hypertensive urgency vs emergency given altered mental status although not clear if this was cause of confusion. She ruled out MI with negative enzymes x 3. She was on a labetolol drip which was titrated off in favor of her home BP med, quinipril. She was started on 10mg quinipril and titrated to 20 mg with improvement in BP. Her atenolol was subsequently restarted as well. . Right Wrist Pain - New pain and erythema in right wrist. No clear etiology for new symtoms. Chostrocalcinosis on wrist x-ray. Started on ibuprofen and PPI for treatment of presumptive psuedogout. Note uric acid level normal. CRP and ESR mildly elevated. Pain and erythema improved at discharge. . | There is diffuse osteopenia, as before. IVF AT KVO.GI: PT HAS BEEN NPO D/T LOC. Sinus rhythmConsider biatrial abnormalityRight bundle branch blockRightward axisPrecordial leds ST-T wave changes may be in part primaryClinical correlation is suggestedSince previous tracing of the same date, probably no significant change Visualized paranasal sinuses are normally-aerated. Moderate ventricular and sulcal prominence is unchanged since prior exam, consistent with age-related atrophy. EYE WIPED CLEAN AND HO NOTIFIED.GI:PT HAS BEEN NPO EXCEPT FOR SOME SIPS OF WATER. Baseline artifactSinus bradycardiaRight bundle branch block ST-T wave changes - may be in part primaryClinical correlation is suggestedSince previous tracing of , sinus bradycardia present, axis lessrightward and ST-T wave changes less prominent TECHNIQUE: Non-contrast head CT. Atrial ectopy is absent. PT W/U FOR SEPSIS. The present study is limited by the marked rotatory thoracic kypho-dextroscoliosis, as well as patient rotation to her right. Allowing for background osteopenia, doubt clinically significant lytic or sclerotic lesion. PT HAS PMH OF HTN AND OSTEOPOROSIS. ORAL CAVITY VERY DRY.CV: PT IN NSR WITH OCC PVC'S NOTED. BP MOSTLY HYPERTENSIVE. NURSING PROGRESS NOTE:NEURO: PT CONT TO BE VERY CONFUSED. Right bundle-branch block.Technically limited study. PT'S LEFT EYE WITH GREENISH DRAINAGE. SINCE NEW CATH INSERTED URINE IS SLIGHTLY PINK TINGED.SKIN: NO BREAKS NOTED. There is probable LV enlargement, with atherosclerotic change involving the thoracic aorta, but no pulmonary vascular congestion, pleural effusion, or other evidence of CHF. FINDINGS: Single bedside AP examination labeled "semi-upright at 1400" is compared with two views dated . NO STOOL OVERNIGHT.GU: PT PULLED OUT FOLEY CATH AND A NEW ONE HAS BEEN REPLACED. COMPARISON: Head CT from . Otherwise, no diagnosticinterim change. Chondrocalcinosis. Vascular calcification is unchanged. Right atrial enlargement. IMPRESSION: No acute intracranial process. IMPRESSION: Limited study, with no acute process. PT BECAME AGITATED AND RECEIVED 1MG OF ATIVAN. PT IV OF D51/2 NS AT 80/HR FINISHED. Please note that early septic arthritis or soft tissue infection might not be apparent radiographically. ONLY MEDICATION IS HEPARIN SC. MOUTH SWABS PROVIDED. Severe osteoarthritis. No significant events during the day.CVS;HR 70-90 NSR no ectopy,NBP 125-155/60-80 no antihypertensives till this time,may consider home meds later,To maintain SBP 150-160.Pedal pulses are easily palpable.D5.45 NS 80 ml/hr is onflow for total of 1000 ml.NEURO;Pt was letahrgic and sleepy till afternoon and morte alert as the day progresses,able to follow commands at times otherwise oriented to self not aware of place and time.Able to move all extrimities,upper extrimities are restarined for safety.RESP;Received with NC 3L weaned off to room air LS are clear,O2 sats are maintained 100% .Breathing efforts are normal.GI;Abdomen soft positive bowel sounds,NPO till wakes up.no bowel movement at this shift.GU;urine output remains on lower side 15-20 ml/hr,Informed MD no orders at this time.Skin;WNLSocial;Daughter at bedside most of the day and son visited and updated.Plan;To call out later if more awake.monitor SBP 160,? PALPABLE PULSES IN LOWER EXTREMETIES. There is advanced osteoarthritis, with marked narrowing of the radiocarpal joint and of multiple intercarpal joints, as well as marked narrowing and spurring about the first CMC joint. Of note, there is chondrocalcinosis about the wrist, seen over the lunatotriquetral region, along the expected course of the triangular fibro- cartilage, and along the volar and ? Allowing for this, no definite acute airspace process is identified. NO BP MEDS AT THIS TIME. Sinus rhythm. AFEBRILE. BP 120'S TO 170'S. IMPRESSION: 1. ABD SOFT WITH POS BOWEL SOUNDS, NO STOOL OVERNIGHT.GU: PT WITH FOLEY CATH DRAINING 10CC/HR OF CLOUDY URINE.SKIN: PT WITH SOME BRUISES ON ARMS AND SLIGHT LOWER EXTREMETY EDEMA. ORIENTED X 1 TO NAME. PT ABLE TO TAKE SIPS OF CLEAR LIQS WITHOUT DIFF. No acute fracture or dislocation is identified. ABD SOFT WITH POS BOWEL SOUNDS. NURSING PROGRESS NOTE:THIS IS AN 88 YO FEMALE WHO PRESENTED TO ED WITH CC OF ALTERED MENTAL STATUS. SHE HAD A RECENT MECHANICAL FALL 1-2 WEEKS AGO SUSTAINING HEAD LACERATION BUT DENIES LOC. PEARL..RESP: LUNG SOUNDS CLEAR THROUGHOUT. PEARL. There is moderately severe to severe diffuse osteopenia. GRADUALLY PT ABLE TO TALK BUT WAS CONFUSED. PT HAS BEEN WITHOUT SLEEP ALL SHIFT. PT REMAINS FULL CODE. HAS SOME BRUISING ON ARMS.ACCESS: PT PULLED OUT PIV ON THE LEFT A NEW # 18 PLACED ON THE RIGHT.SOCIAL: DAUGHTER CALLED AND UPDATED OVERNIGHT, WILL BE BACK IN THE AM. No findings specific for osteomyelitis. PT THEN SENT TO MICU 7 FOR FURTHER W/U.ALLERGIES: SULFA.CODE STATUS: FULL CODEPRECAUTIONS: RISK FOR FALL.REVIEW OF SYSTEMS:NEURO: PT TO VOICE AND WILL OPEN EYES TO COMMAND. BP IN THE 200'S AND WAS BRIEFLY STARTED ON LABETOLOL DRIP. worsening over past 2 wks REASON FOR THIS EXAMINATION: eval for bleed No contraindications for IV contrast FINAL REPORT HISTORY: 88-year-old female with altered mental status, worsening over the past two weeks. PT PLACED ON BEDPAN BUT UNABLE TO GO. AT FIRST UNABLE TO FORM WORDS ONLY INCOMPREHENSIBLE SOUNDS. The ddx includes CPPD arthritis, hemochomratosis, and hyperparathyroidism. FINDINGS: There is no intracranial hemorrhage, mass, mass effect or evidence of infarction. BY MORNING PT WAKING UP MORE AND BECOMING VERY RESTLESS AND ATTEMPTING TO GET OOB.RESP: LUNG SOUNDS CLEAR THROUGHOUT. Could pain and erythema in this indivdual be due to CPPD pseudogout? NO BREAKDOWN ON BACK SIDE.ACCESS: PT HAS ONE PIV IN LEFT ARM.SOCIAL: PT LIVES IN SETTING, HCP IS HER SON. O2 SAT'S IN MID TO HIGH 90'S ON ROOM AIR.CV: PT IS IN NSR TO ST WITH HR IN THE 70'S TO LOW 100'S. No radiopaque foreign body is identified. restart home medsobserve MS Changes.Update with family. PT LIVES ALONE AND PRESENTS WITH INCREASING CONFUSION NOTED BY HER NURESE AT HER SENIOR CITIZEN LIVING CENTER. HISTORY: 88-year-old woman with change in mental status and hypoxia; evaluate for infiltrate. | 10 | [
{
"category": "Radiology",
"chartdate": "2128-11-23 00:00:00.000",
"description": "R WRIST(3 + VIEWS) RIGHT",
"row_id": 993329,
"text": " 11:27 AM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: r/o joint infection and trauma\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with new right wrist pain and erythema\n REASON FOR THIS EXAMINATION:\n r/o joint infection and trauma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New right wrist pain, erythema, rule out joint infection.\n\n RIGHT WRIST, THREE VIEWS.\n\n There is moderately severe to severe diffuse osteopenia. There is advanced\n osteoarthritis, with marked narrowing of the radiocarpal joint and of multiple\n intercarpal joints, as well as marked narrowing and spurring about the first\n CMC joint. Of note, there is chondrocalcinosis about the wrist, seen over the\n lunatotriquetral region, along the expected course of the triangular fibro-\n cartilage, and along the volar and ? dorsal aspects of the wrist.\n\n No acute fracture or dislocation is identified. No erosions are seen.\n Allowing for background osteopenia, doubt clinically significant lytic or\n sclerotic lesion. No radiopaque foreign body is identified.\n\n IMPRESSION:\n\n 1. Severe osteoarthritis.\n 2. Chondrocalcinosis. The ddx includes CPPD arthritis, hemochomratosis, and\n hyperparathyroidism. Could pain and erythema in this indivdual be due to CPPD\n pseudogout?\n 3. No findings specific for osteomyelitis. Please note that early septic\n arthritis or soft tissue infection might not be apparent radiographically.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 992887,
"text": " 1:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with change in MS, hypoxic\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED .\n\n HISTORY: 88-year-old woman with change in mental status and hypoxia; evaluate\n for infiltrate.\n\n FINDINGS: Single bedside AP examination labeled \"semi-upright at 1400\" is\n compared with two views dated . The present study is limited by the\n marked rotatory thoracic kypho-dextroscoliosis, as well as patient rotation to\n her right. Allowing for this, no definite acute airspace process is\n identified. There is probable LV enlargement, with atherosclerotic change\n involving the thoracic aorta, but no pulmonary vascular congestion, pleural\n effusion, or other evidence of CHF. There is diffuse osteopenia, as before.\n\n IMPRESSION: Limited study, with no acute process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-11-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 992874,
"text": " 12:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with AMS. worsening over past 2 wks\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88-year-old female with altered mental status, worsening over the\n past two weeks.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass, mass effect or\n evidence of infarction. Moderate ventricular and sulcal prominence is\n unchanged since prior exam, consistent with age-related atrophy. Visualized\n paranasal sinuses are normally-aerated. There is no fracture. Vascular\n calcification is unchanged.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-11-19 00:00:00.000",
"description": "Report",
"row_id": 1646876,
"text": "Nsg.progress notes:\nsee flow sheet for specific:\n\n88 yr old female admitted from ED c/o altered MS,had h/o fall few weeks ago followed by some confusion admitted to hospital and discharged on .had acute mental status changes overnight,brought in ED Ct head negative LP done pending,all sepsis work ups done from ED.received 1 mg of ativan last dose at 1430 from ED.\n\nNeuro: Patient drowsy, opens eyes to call did follow some commands upon arrival then started agitating,PERL.Denies pain.MAE.\n\nCV : NSRE,HR in 80's no ectopy noted.pt came with labetelol gtt at 0.5mcg/kg/min on admiossion to ICU sbp 159,so labetelol stoped goal sbp ~180 around,confirmed from Dr..IVf kvo NS started,PIV infilterated new one inserted.++PP.EKG done and seen by Dr..\n\nResp: NC with 4 L O2,Ls clear.\n\nGI: Abd soft,+BS .\n\nGU: foley cath patent with yellow clear urine.\n\nSocial: visited by pt's son,waiting for iCu doctor to give information.\n\nPlan: cont moniotoring,neuro checks,SBP controll goal ~180. support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-11-21 00:00:00.000",
"description": "Report",
"row_id": 1646879,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT CONT TO BE VERY CONFUSED. ORIENTED X 1 TO NAME. AGITATED AT TIMES BECAUSE SHE WANTS TO HAVE ARMS FREE. PT WITH BILATERAL SOFT WRIST RESTRAINTS AND THEN HAS HAD MITTS ADDED FOR EXTRA PROTECTION OF LINES AND TUBES. PT HAS BEEN WITHOUT SLEEP ALL SHIFT. PEARL..\n\nRESP: LUNG SOUNDS CLEAR THROUGHOUT. O2 SAT'S IN MID TO HIGH 90'S ON ROOM AIR.\n\nCV: PT IS IN NSR TO ST WITH HR IN THE 70'S TO LOW 100'S. BP MOSTLY HYPERTENSIVE. NO BP MEDS AT THIS TIME. PT IV OF D51/2 NS AT 80/HR FINISHED. PT ABLE TO TAKE SIPS OF CLEAR LIQS WITHOUT DIFF. PT'S LEFT EYE WITH GREENISH DRAINAGE. EYE WIPED CLEAN AND HO NOTIFIED.\n\nGI:PT HAS BEEN NPO EXCEPT FOR SOME SIPS OF WATER. ABD SOFT WITH POS BOWEL SOUNDS. PT PLACED ON BEDPAN BUT UNABLE TO GO. NO STOOL OVERNIGHT.\n\nGU: PT PULLED OUT FOLEY CATH AND A NEW ONE HAS BEEN REPLACED. PT PASSING MOD AMT'S OF CLEAR YELLOW URINE. SINCE NEW CATH INSERTED URINE IS SLIGHTLY PINK TINGED.\n\nSKIN: NO BREAKS NOTED. HAS SOME BRUISING ON ARMS.\n\nACCESS: PT PULLED OUT PIV ON THE LEFT A NEW # 18 PLACED ON THE RIGHT.\n\nSOCIAL: DAUGHTER CALLED AND UPDATED OVERNIGHT, WILL BE BACK IN THE AM. PT REMAINS FULL CODE. IF PT IS CALLED OUT TO THE FLOOR WILL NEED A SITTER AS PT IS CONSTANTLY TRYING TO CLIMB OOB AND PULLING AT TUBES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-11-20 00:00:00.000",
"description": "Report",
"row_id": 1646877,
"text": "NURSING PROGRESS NOTE:\nTHIS IS AN 88 YO FEMALE WHO PRESENTED TO ED WITH CC OF ALTERED MENTAL STATUS. PT LIVES ALONE AND PRESENTS WITH INCREASING CONFUSION NOTED BY HER NURESE AT HER SENIOR CITIZEN LIVING CENTER. SHE HAD A RECENT MECHANICAL FALL 1-2 WEEKS AGO SUSTAINING HEAD LACERATION BUT DENIES LOC. PT HAS PMH OF HTN AND OSTEOPOROSIS. PT BECAME AGITATED AND RECEIVED 1MG OF ATIVAN. BP IN THE 200'S AND WAS BRIEFLY STARTED ON LABETOLOL DRIP. PT W/U FOR SEPSIS. PT THEN SENT TO MICU 7 FOR FURTHER W/U.\n\nALLERGIES: SULFA.\n\nCODE STATUS: FULL CODE\n\nPRECAUTIONS: RISK FOR FALL.\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT TO VOICE AND WILL OPEN EYES TO COMMAND. AT FIRST UNABLE TO FORM WORDS ONLY INCOMPREHENSIBLE SOUNDS. GRADUALLY PT ABLE TO TALK BUT WAS CONFUSED. BUT WAS ABLE TO TELL HER NAME AND THE NAME OF HER CHILDREN. DID NOT KNOW DATE OR WHERE SHE WAS. PT ABLE TO MOVE ALL EXTREMETIES WITH GOOD STRENGTH. PEARL. BY MORNING PT WAKING UP MORE AND BECOMING VERY RESTLESS AND ATTEMPTING TO GET OOB.\n\nRESP: LUNG SOUNDS CLEAR THROUGHOUT. O2 SAT'S ON 4LNC 100%. PT CHANGED OVER TO FACE TENT TO PROVIDE SOME MOISTURE. ORAL CAVITY VERY DRY.\n\nCV: PT IN NSR WITH OCC PVC'S NOTED. BP 120'S TO 170'S. AFEBRILE. ONLY MEDICATION IS HEPARIN SC. IVF AT KVO.\n\n\nGI: PT HAS BEEN NPO D/T LOC. MOUTH SWABS PROVIDED. ABD SOFT WITH POS BOWEL SOUNDS, NO STOOL OVERNIGHT.\n\nGU: PT WITH FOLEY CATH DRAINING 10CC/HR OF CLOUDY URINE.\n\nSKIN: PT WITH SOME BRUISES ON ARMS AND SLIGHT LOWER EXTREMETY EDEMA. PALPABLE PULSES IN LOWER EXTREMETIES. NO BREAKDOWN ON BACK SIDE.\n\nACCESS: PT HAS ONE PIV IN LEFT ARM.\n\nSOCIAL: PT LIVES IN SETTING, HCP IS HER SON. PT IS FULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-11-20 00:00:00.000",
"description": "Report",
"row_id": 1646878,
"text": "No significant events during the day.\n\nCVS;HR 70-90 NSR no ectopy,NBP 125-155/60-80 no antihypertensives till this time,may consider home meds later,To maintain SBP 150-160.Pedal pulses are easily palpable.D5.45 NS 80 ml/hr is onflow for total of 1000 ml.\n\nNEURO;Pt was letahrgic and sleepy till afternoon and morte alert as the day progresses,able to follow commands at times otherwise oriented to self not aware of place and time.Able to move all extrimities,upper extrimities are restarined for safety.\n\nRESP;Received with NC 3L weaned off to room air LS are clear,O2 sats are maintained 100% .Breathing efforts are normal.\n\nGI;Abdomen soft positive bowel sounds,NPO till wakes up.no bowel movement at this shift.\n\nGU;urine output remains on lower side 15-20 ml/hr,Informed MD no orders at this time.\n\nSkin;WNL\n\nSocial;Daughter at bedside most of the day and son visited and updated.\n\nPlan;To call out later if more awake.\nmonitor SBP 160,? restart home meds\nobserve MS Changes.\nUpdate with family.\n"
},
{
"category": "ECG",
"chartdate": "2128-11-24 00:00:00.000",
"description": "Report",
"row_id": 205551,
"text": "Baseline artifact\nSinus bradycardia\nRight bundle branch block ST-T wave changes - may be in part primary\nClinical correlation is suggested\nSince previous tracing of , sinus bradycardia present, axis less\nrightward and ST-T wave changes less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2128-11-19 00:00:00.000",
"description": "Report",
"row_id": 205552,
"text": "Sinus rhythm\nConsider biatrial abnormality\nRight bundle branch block\nRightward axis\nPrecordial leds ST-T wave changes may be in part primary\nClinical correlation is suggested\nSince previous tracing of the same date, probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2128-11-19 00:00:00.000",
"description": "Report",
"row_id": 205553,
"text": "Sinus rhythm. Right atrial enlargement. Right bundle-branch block.\nTechnically limited study. Compared to the prior tracing of the rate\nhas increased. Atrial ectopy is absent. Otherwise, no diagnostic\ninterim change.\n\n"
}
] |
4,842 | 127,065 | 86 M w/ Parkinson's disease a/w R intertroch fx, s/p repair, course c/b whiteout of L lung. . # Pulmonology: 1) Ecoli PNA-Initially started on Vancomycin/Pip-Tazo, narrowed to Ceftriaxone based on sensitivities from BAL. He was extubated on . Repeat CXRs showed initially worsening then some improvement. Patient should be re-evaluated by physician and CXR before dc'ing ceftriaxone. Scheduled for 14 day course to end on . 2) Left Pleural effusions-likely benign, no leukocytosis, no worsening hypoxia, no fever. Decision was madee not to tap. Patient with improvement with diuresis. Will need continued diuresis, Is and Os, daily weights on discharge. continue Albuterol inhalers. Continue weaning O2. . # Right intertrochanteric fracture: s/p right CM nail for right IT fracture on . Ortho follow up as scheduled. Patient is WBAT. Will need ongoing PT upon discharge. Continued Calcium, Vitamin D, Calcitonin . # Unwitnessed fall: Past h/o recurrent seizures. No evidence of MI by cardiac biomarkers. No valvular disease by TTE in . Likely mechanical fall given Parkinson's. . # Parkinson's disease: Continued Carbidopa/Levodopa . # HTN: Continued atenolol . # Urinary: Patient with scrotal edema and indwelling foley. Will need to have urinary voiding trial after scrotal swelling decreased. . # Depression: Continued mirtazapine . # FEN: Speech and swallow evaluation done while patient had NG tube in place showed aspiration with thin liquids. Per discussion with entire team, attending, fellow patient and his daughter decision was again made to continue eating soft foods, with water as only thin liquid and give vanilla ensure. Patient refused long term NG tube or J- or G-tube. Repleted lytes PRN. . PPX: DVT ppx with heparin in house. transitioned to lovenox on transfer (could consider coumadin), will need readdressed with ortho. PPI, bowel regimen. . Code: Documented DNR/DNI by all notes in chart. (DNI reversed for OR, now reinstated). No pressors, no central lines. Discussed with HCP. . Communication: Kozol, daughter, is HCP at (H); (M); (W) Medications on Admission: Morphine Sulfate IR 15-30 mg PO Q4-6H:PRN Atenolol 12.5 mg PO DAILY Pantoprazole 40 mg IV Q24H Carbidopa-Levodopa (25-100) 1 TAB PO QID Calcium Carbonate 500 mg PO TID Calcitonin Salmon 200 UNIT IN DAILY Senna 1 TAB PO BID:PRN CeftriaXONE 1 gm IV Q24H Docusate Sodium 100 mg PO BID Heparin 5000 UNIT SC TID Timolol Maleate 0.5% 1 DROP BOTH EYES Vitamin D 400 UNIT PO DAILY Mirtazapine 45 mg PO HS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation TID (3 times a day). 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous once a day: Could consider transition to coumadin. For DVT ppx s/p ORIF of right hip. . 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): Barrett's esophagus. 13. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic (2 times a day). 14. Ceftriaxone 1 g Recon Soln Sig: One (1) Intravenous once a day for 10 days: To have clinical picture reassessed at end of 14 days of treatment (). Discharge Disposition: Extended Care Facility: for the Aged - MACU Discharge Diagnosis: Primary ORIF for right hip fracture. E. coli pneumonia left pleural effusions parkinsons recurrent esophageal strictures requiring dilation . Secondary hypertension Depression Discharge Condition: Stable. Still with subacute medical needs. Known aspiration risk, but goals of care dictate modified diet as treatment. Discharge Instructions: Please follow up with your PCP, . at Rehab. . You were admitted with a right hip fracture. You were diagnosed with a left lung pneumonia and left pleural effusion. . If you have infection surrounding the wound, increased pain in the right hip or anything else of concern please go to the emergency department for evaluation. . If you have fever, chills, or difficulty breathing please return to the hospital. Please seek medical attention for anything of concern. Followup Instructions: Please follow up with a medical doctor (ie your PCP) before discontinuing the ceftriaxone for your pneumonia. . Please follow up with Dr. on at 8:40am, located on of the center. Please have them address duration of dvt prophylaxis. Provider: XRAY (SCC 2) Phone: Date/Time: 8:40 Provider: , MD Phone: Date/Time: 9:00 | There is stable appearance to calcification within a slightly tortuous thoracic aorta and a probable area of scarring within the peripheral left lower lobe. Moderately distended mid-to-distal esophagus, with smoothly tapered narrowing, but no holdup of contrast. Nasogastric tube tip terminates in the proximal stomach, but the sideport is above the GE junction level. Endotracheal tube remains in standard position and there has been decreased distention of the endotracheal tube cuff. The left lower lobe atelectasis is unchanged as well as the left pleural effusion, at least moderate in size, layering. Please note sensitivity for fractures is reduced. IMPRESSION: Linear right intertrochanteric fracture. Limited evaluation of the lower esophagus demonstrates a moderately dilated esophagus which tapers to a smooth narrowing. Osseous scoliotic changes of the spine are unchanged. S-shaped scoliosis of the thoracolumbar spine persists. Left lower lobe atelectasis is without change, and there is a persistent layering left pleural effusion. The NG tube was removed in the meantime interval. FINDINGS: This evaluation is limited secondary to patient motion. Laryngeal elevation and epiglottic deflection were moderately reduced, although this could be partially due to nasogastric tube in place. FINAL REPORT STUDY: CT of the C-spine without contrast. Again seen is an intratrochanteric fracture line. Marked diffuse global atrophy with predominance within the frontal lobes is unchanged in appearance compared to the previous examination. TECHNIQUE: Non-contrast head CT. Broad right side spinal curvature with associated compression deformities are unchanged. FINDINGS: Examination is limited by patient motion, specifically the posterior fossa and the region involving the nasal bones. The right lung remains clear and the endotracheal tube is approximately 3.5 cm from the carina. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: ORIF RT.HIP FX. Multilevel degenerative changes unchanged compared to . Mild canal stenosis is noted at the C6-C7 level. At the levels mentioned above there is again, marked disc space narrowing, facet joint degeneration and neural foraminal narrowing. SINGLE SUPINE AP CHEST RADIOGRAPH: The lungs are clear. An intramedullary nail with single distal screw and trochanteric fixation rod has been placed. Cardiac, mediastinal and hilar contours are normal. Moderate-to-severe oropharyngeal dysfunction with penetration and aspiration of thick and thin liquids. COMPARISON: at 1:38 a.m. TWO SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPHS: Previous left lung opacification (possible left lower lobe collapse) has resolved and the left lung has returned to its appearance of . The right lung is unremarkable. The small left pleural effusion likely still persists. pneumonitis/pna REASON FOR THIS EXAMINATION: Please assess proper location of NGT. INDICATION: Nasogastric tube placement. There was moderate-to-severe impairment of bolus formation, and limited bolus control. Coronal and sagittal reconstructions were then obtained. The assessment of the sacrum is markedly limited by overlying bowel contents. There has been improvement to areas of left upper lobe and lingular collapse; however, there is increased involvement of left lower lobe atelectasis with obscuration of the left hemidiaphragm. pt now diuresing after lasix.skin: pt has dsg on right lateral leg and hip. Pt will be DNI after extubation.GU - low u/o since admission. 2nd unit of blood ended at 1745 40mg ivp lasix given b/t units pt diuresing well. Phos=2.1 this am; repleted w/ 2 packets of Neutra-Phos via NGT. cont on Abx therapy.Endo: RISSID: ? Sinus bradycardia with 1st degree A-V block.Inferior infarct - age undeterminedLow QRS voltages in limb leadsSince previous tracing, no significant change cv:hr99-65 nsr frequent pvc's sbp 150-101/46-67gi: pos bowel sounds. ortho/ in room and states that ok if leaks "reinforce it" they'll take down initial dsg in am.pt scrotum is eccymotic and swollen, right hip eccymotic right inner thigh is eccymotic.id: bronch washing pos for ecoli pt on vanco, zosyn. Lung sounds clear to diminished on R. SUctined for thick tan sputum. Respiratory Care NotePt returned from OR and was placed on AC as noted. Nursing NOtePt is DNR. Nursing Progress NotePlease see carvue for specific:Pt arrived approx from PACU after aborted OR procedure for ORIF of right hip. respiratory carePt received from PACU at the begining of the shift.vent settings weaned to PSV 5/5,60%, tolerating well with acceptable Vt's and RR.RSBI this am was 34.8.Breath sounds very diminished on lt side, clear on the Rt side.Suctioned for moderate amount of thick yellow secretions frequently.Plan to go to OR for Hip surgery today? pt is to be a DNI once extubated.neuro: pt opens eyes and nods yes and no to questions. lower dsg d&i, dsg on hip is moderate amount of s/s drainage. Post op pt with HR 80-120, NSR to sinus tach with frequent PVC's. Per discussion with pt's daughter and MD ..Pt is DNR his DNI was reversed for OR. medicating with fentanyl 25-50 mics prior to turning ..pt less uncooperative,integumentary: r hip dressing is intact. Pt with quick response in SBP to fluid but shortly after bolus' finished pt would become hypotensive again. Pt trnf to MICU for furterh mmgt current assesment is as follows:Neuro: Pt arrived from intubated and sedated on 25mcgs of prop. Bronchoscopy done - pt suctioned for moderate amts thick, tan secretions during procedure. Lungs clear to coarse on right still diminished on left MD aware. need for c/s mult abx.Plan: Cont to monitor resp status. Fentanyl 25-50mcg with relief.CV - pre-op in NSR no ectopy. K=3.8 this am; repleted w/ 40 mEq KCL via NGT. abg= 7.41/36/140/24. Pt intubated for OR only. MEdicate for pain prn. Oral temps lower than ax temps.SKin - R elbow with contusion. Anticipate c/o to floor today. BS essentially clear, but diminished in bases especially L base. resp to do risbi in am and plan to extubate when pt is ready. PT cool - temp only 96-98 ax. An NGT is seen below the right hemidiaphragm with the tip probably in the gastric antrum. to OR intubated pre precedure turned on left side and sats dropped became hypoxic sats 60% pcxr complete white out of left lung. | 26 | [
{
"category": "Radiology",
"chartdate": "2108-05-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958621,
"text": " 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change.\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia, s/p bronch\n REASON FOR THIS EXAMINATION:\n please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with hypoxia, status post bronchoscopy. Evaluate\n for interval change.\n\n Comparison is made to prior radiographs dated and .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n There has been interval development of a dense left upper lobe air bronchogram\n containing consolidation worrisome for aspiration pneumonitis/pneumonia.\n There has been improvement to areas of left upper lobe and lingular collapse;\n however, there is increased involvement of left lower lobe atelectasis with\n obscuration of the left hemidiaphragm. The right lung remains clear and the\n endotracheal tube is approximately 3.5 cm from the carina. The balloon cuff\n does appear slightly overinflated. Osseous scoliotic changes of the spine are\n unchanged.\n\n The small left pleural effusion likely still persists.\n\n IMPRESSION:\n 1. Rapidly developing dense left upper lung opacity likely represents\n aspiration.\n 2. Improvement to left upper and lingular collapse but increased left lower\n lobe atelectasis.\n 3. Apparent overdistention of endotracheal tube balloon cuff.\n\n Findings discussed with physician caring for patient on date of exam at 3 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-28 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 959037,
"text": " 1:25 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess for aspiration\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with s/p hip fx and aspiration\n REASON FOR THIS EXAMINATION:\n assess for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n VIDEO OROPHARYNGEAL SWALLOW:\n\n INDICATION: 86-year-old male with Parkinson's, dysphagia, known esophageal\n stricture. Recent hip fracture. Please assess for aspiration.\n\n FINDINGS: Study was performed in conjunction with the speech pathologist who\n administered small amounts of barium of various consistencies.\n\n There was moderate-to-severe impairment of bolus formation, and limited bolus\n control. There was retention in the valleculae and piriform sinuses,\n particularly with thicker consistencies, and there was spontaneous spillage as\n well as penetration and aspiration with thick and thin liquids. There was no\n spontaneous cough. Directed cough was weak. Laryngeal elevation and\n epiglottic deflection were moderately reduced, although this could be\n partially due to nasogastric tube in place.\n\n Limited evaluation of the lower esophagus demonstrates a moderately dilated\n esophagus which tapers to a smooth narrowing. There is no significant holdup\n of contrast within the esophagus.\n\n IMPRESSION:\n\n 1. Moderate-to-severe oropharyngeal dysfunction with penetration and\n aspiration of thick and thin liquids.\n\n 2. Moderately distended mid-to-distal esophagus, with smoothly tapered\n narrowing, but no holdup of contrast.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 959302,
"text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess change\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia and LLL collapse, improved hypoxia now,\n effusion.\n REASON FOR THIS EXAMINATION:\n assess change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up patient with known left lower lobe\n collapse.\n\n COMPARISON: Chest radiograph from .\n\n The NG tube was removed in the meantime interval. The left lower lobe\n atelectasis is unchanged as well as the left pleural effusion, at least\n moderate in size, layering. The foreign bodies are again demonstrated, most\n likely in the stomach. The right lung is unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 959082,
"text": " 6:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for reinflation\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia and LLL collapse, improved hypoxia now.\n\n REASON FOR THIS EXAMINATION:\n please assess for reinflation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD, preop for CABG.\n\n COMPARISON: at 1:38 a.m.\n\n TWO SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPHS: Previous left lung opacification\n (possible left lower lobe collapse) has resolved and the left lung has\n returned to its appearance of . Diffuse airspace opacity within the\n left lung may represent pneumonia or re-expansion edema. Moderate- to- large\n left effusion has developed in the past two days. Retrocardiac opacity may be\n atelectasis or airspace consolidation. The right lung remains clear, without\n pleural effusion. No pneumothorax. Cardiac, mediastinal and hilar contours\n are normal.\n\n The metallic objects projecting over the left upper abdomen are in relatively\n unchanged position, likely dental fillings.\n\n IMPRESSION: Improvement in left lung opacification. Persistent moderate left\n pleural effusion and left-sided opacity may reflect pneumonia versus re-\n expansion edema. The right lung remains clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-23 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 958313,
"text": " 10:14 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: pna, trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with fall, probable hip fx\n REASON FOR THIS EXAMINATION:\n pna, trauma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with fall, probable hip fracture. Evaluate for\n pneumonia or intrathoracic trauma.\n\n Comparison is made to prior radiograph dated .\n\n SINGLE SUPINE AP CHEST RADIOGRAPH:\n\n The lungs are clear. Cardiomediastinal silhouette, hilar contours, and\n pleural surfaces appear unremarkable. There is stable appearance to\n calcification within a slightly tortuous thoracic aorta and a probable area of\n scarring within the peripheral left lower lobe. There is no evidence of a\n pneumothorax, pulmonary edema, or acute osseous fracture. S-shaped scoliosis\n of the thoracolumbar spine persists.\n\n IMPRESSION:\n\n 1. No acute cardiopulmonary process identified and no evidence of acute\n fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-23 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 958312,
"text": " 10:14 AM\n HIP UNILAT MIN 2 VIEWS LEFT; PELVIS (AP ONLY) Clip # \n Reason: fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with fall w/ R hip pain\n REASON FOR THIS EXAMINATION:\n fracture?\n ______________________________________________________________________________\n WET READ: YMf WED 11:21 AM\n Right intertrochanteric fracture with varus angulation of the distal fracture\n fragment.\n ______________________________________________________________________________\n FINAL REPORT\n AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT HIP, TWO VIEWS OF THE LEFT HIP.\n\n FINDINGS: There is a linear intertrochanteric right femoral fracture, with\n approximately 50% varus angulation of the distal fracture fragment. No other\n fracture is identified. Degenerative changes with osteophytes and subchondral\n cyst formation is seen about hip joints bilaterally. There is no focal lucent\n or sclerotic lesion. There are vascular calcifications. The assessment of\n the sacrum is markedly limited by overlying bowel contents. Surgical clips\n are redemonstrated within the pelvis.\n\n IMPRESSION: Linear right intertrochanteric fracture.\n\n Findings were communicated to the EU via CCC at 11:15 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958944,
"text": " 1:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for placement of NGT in stomach before feeding is r\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man getting feeds through NGT, pulled out NG and replaced\n tonight.\n REASON FOR THIS EXAMINATION:\n pls eval for placement of NGT in stomach before feeding is resumed.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:30 A.M. ON \n\n HISTORY: Nasogastric tube for feeding.\n\n IMPRESSION: AP chest compared to through 29:\n\n Left upper lobe pneumonia is obscured by new complete collapse of the left\n lung accompanied by at least a small volume of pleural effusion secondary to\n pulmonary processes.\n\n Two 4-mm wide metallic opacities projecting over the upper stomach have\n migrated inferiorly along the course of the esophagus from positions in the\n upper chest from and 29. These look like dental fillings.\n\n Nasogastric tube tip projects over the upper duodenum. No pneumothorax. Dr.\n was paged to report these findings at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958739,
"text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia, s/p bronch with evolving LUL aspiration\n pneumonitis/pna\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY WITH INDICATION OF LEFT UPPER LOBE\n ASPIRATION PNEUMONITIS.\n\n Endotracheal tube remains in standard position and there has been decreased\n distention of the endotracheal tube cuff. Cardiac and mediastinal contours\n are stable in appearance. Airspace opacity in left upper and midlung appears\n less dense compared to the previous study. Left lower lobe atelectasis is\n without change, and there is a persistent layering left pleural effusion.\n Right lung is clear.\n\n Small radiodensity measuring 2 mm overlying the left retrocardiac region is of\n uncertain etiology but could potentially be external to the patient.\n Attention to this area on followup radiograph would be helpful to exclude an\n aspirated foreign body.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-25 00:00:00.000",
"description": "RO HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.",
"row_id": 958697,
"text": " 6:18 PM\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RT.HIP FX. CHECK HARDWARE PLACEMENT\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: Open reduction and internal fixation of right\n intratrochanteric hip fracture.\n\n Four views of the right hip were acquired intraoperatively.\n\n Again seen is an intratrochanteric fracture line. An intramedullary nail with\n single distal screw and trochanteric fixation rod has been placed. Alignment\n appears satisfactory. Please refer to the operative note for additional\n information.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-23 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 958307,
"text": " 9:44 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with unwitnessed fall, nonverbal\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj WED 11:04 AM\n Limited assessment secondary to patient motion. No gross malalignment or\n acute fracture identified.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the C-spine without contrast.\n\n INDICATION: 86-year-old male with fall. Assess for fracture.\n\n COMPARISONS: .\n\n TECHNIQUE: Helical scanning of the cervical spine without IV contrast was\n performed. Coronal and sagittal reconstructions were then obtained.\n\n FINDINGS: This evaluation is limited secondary to patient motion. Please\n note sensitivity for fractures is reduced. There are multilevel degenerative\n changes, most severe at the C4-5, C5-6 and C6-7 levels. There is mild\n retrolisthesis of C4 in relation to C5. Otherwise, there is no other\n malalignment. At the levels mentioned above there is again, marked disc space\n narrowing, facet joint degeneration and neural foraminal narrowing. Moderate\n central canal stenosis is present at the C5-6 level. Mild canal stenosis is\n noted at the C6-C7 level. Narrowing of the central canal at these levels is\n secondary to posterior spondylytic ridges. There are no prevertebral soft\n tissue swelling. Overall, there is no malalignment or fracture discerned.\n\n IMPRESSION:\n\n 1. Study limited secondary to patient motion and thus is insensitive for the\n detection of small fractures. No definitive fracture is detected.\n\n 2. No malalignment.\n\n 3. Multilevel degenerative changes unchanged compared to .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958796,
"text": " 12:26 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess proper location of NGT. THanks\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia, s/p bronch with evolving LUL aspiration and\n now with NG tube placement. pneumonitis/pna\n\n REASON FOR THIS EXAMINATION:\n Please assess proper location of NGT. THanks\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 12:46\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Nasogastric tube placement.\n\n Nasogastric tube tip terminates in the proximal stomach, but the sideport is\n above the GE junction level. With the exception of nasogastric tube\n placement, there has not been a substantial change in the appearance of the\n chest since a recent study of earlier the same day allowing for positional\n differences of the patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-24 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 958546,
"text": " 3:48 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: DROP IN STATS\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Drop in sats.\n\n COMPARISON: .\n\n FINDINGS: Portable chest radiograph demonstrates acute partial collapse of\n the left lung that mostly involves upper lobe and lingula with associated\n volume loss and mediastinal shift. The patient has been intubated with the\n ETT in the mid trachea. The right lung is grossly clear. Broad right side\n spinal curvature with associated compression deformities are unchanged.\n\n IMPRESSION: Partial collapse of the left lung involving mostly upper lobe and\n lingula.\n\n , nurse caring for the patient and I discussed the case, as the\n physicians caring for the patient were occupied performing bronchoscopy for\n this patient.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 958306,
"text": " 9:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with unwitnessed fall, nonverbal\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj WED 10:46 AM\n Ltd assessment of posterior fossa and nasal bones secondary to patient motion.\n No intracranial hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head.\n\n INDICATION: 86-year-old male with unwitnessed fall. Nonverbal. Assess for\n intracranial hemorrhage.\n\n COMPARISONS: Comparison is made to the previous CT head from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Examination is limited by patient motion, specifically the\n posterior fossa and the region involving the nasal bones. There is no\n evidence of hemorrhage, shift of normally midline structures or major vascular\n territorial infarct. Marked diffuse global atrophy with predominance within\n the frontal lobes is unchanged in appearance compared to the previous\n examination. The -white matter differentiation is preserved. The soft\n tissues and osseous structures as well as the visualized portions of the\n paranasal sinuses and mastoid air cells appear unremarkable.\n\n IMPRESSION: No evidence of acute intracranial pathology, specifically no\n evidence of acute intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958863,
"text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia, s/p bronch with evolving LUL aspiration\n pneumonitis/pna\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 04:34\n\n INDICATION: Hypoxia.\n\n COMPARISON: at 12:46.\n\n Patient was uncooperative for this study and findings in the left upper lobe\n are largely obscured by patient's drooping head. The visualized left lung\n field appears stable and the right lung remains free of consolidation. An NGT\n is seen below the right hemidiaphragm with the tip probably in the gastric\n antrum. No evidence of worsening fluid status.\n\n IMPRESSION: Limited film - accounted for that, no significant interval\n change; more distal location of NGT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-05-27 00:00:00.000",
"description": "SCROTAL U.S.",
"row_id": 958906,
"text": " 1:35 PM\n SCROTAL U.S. Clip # \n Reason: ECCHYMOSIS R/O TORSION, MASS, EVALUATE FOR FLUID COLLECTION\n Admitting Diagnosis: HIP FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p right hip repair now with scrotal ecchymosis\n REASON FOR THIS EXAMINATION:\n r/o torsion, mass, evaluate for fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right hip repair with scrotal ecchymosis, rule out\n torsion.\n\n COMPARISON: None.\n\n FINDINGS: -scale and color Doppler son of the scrotum demonstrates\n scrotal swelling up to 1.3 cm, but no evidence for organized fluid collection\n or hematoma. The echotexture of both right and left testicles is normal,\n measuring 2.7 x 1.8 x 1.9 cm and 2.8 x 1.8 x 1.8 cm respectively. Blood flow\n is diminished, but symmetric bilaterally.\n\n IMPRESSION: Marked scrotal swelling, but no abscess or evidence for torsion.\n Follow-up imaging can be performed if pain persists.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-26 00:00:00.000",
"description": "Report",
"row_id": 1325206,
"text": "Respiratory Care: Pt remains intubated and vented. Suctioned minimal secretions. Successfully weaned to PSV 5/5 40% with good abg's. Morning RSBI = 34. Plan is to extubate in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-26 00:00:00.000",
"description": "Report",
"row_id": 1325207,
"text": "Resp. Care Note\nPt received intubated and vented on PSV settings as charted on resp flowsheet. RSBI 34 today, extubated in afternoon. Currently on 40% face tent. Plan is not to re-intubate but will do NIV if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-26 00:00:00.000",
"description": "Report",
"row_id": 1325208,
"text": "nursing progress notes\n86 yr old male resident at rehab w/ hx of anemia, arrhymias htn, parkinson's disease multiple aspirations depression, esophagos w/ mult. dilations, hep c, ca, and prostate ca. fell at night while tring to get oob at the rehab broke his right hip. on to . to OR intubated pre precedure turned on left side and sats dropped became hypoxic sats 60% pcxr complete white out of left lung. pt bronched for multyple mucus plugs, sats up to 100% bronch washing pos for ecoli. to micu for further care. to or on pinned right hip. extubated this afternoon at 1500, noted tooth in back of throat this rn retreived tooth, looks like it was from front teeth, ? when tooth fell out. NOTE: right front tooth loose, be careful w/ oral care. He is tolerating well on 40% cool aerosol face tent w/ sats of 98%.\n\nReview of systems:\n\nneuro: pt opens eyes to name, follows simple commands: wiggle toes, put your hand up. nods to simple questions \"do you have pain?\" pt lip smacks and rubs his head against the pillow at times. he can be very rigged and grab onto things, he is restrained for safety (d/t foley cath and aline) perl 3mm brisk, + gag reflex.\n\nResp: no sob noted rr 12-20 ls clear w/ diminished left base. sats on 40% face tent 99% pt has weak cough.\n\ncv: tele sr 60s-80s w/ pacs and pvcs. sbp 120/50s hrt sounds distant. pedal pulses +3 w/ post tibs +2. k+ this am 3.3 replaced w/ k phos 30mmols in 500cc, ca 7.8 repleated w/ 2gms of ca glucanate. recheck lytes tonight. hct this am 27 rechecked at 1000 25.2 per ortho 2 units of prbc to be given. 2nd unit of blood ended at 1745 40mg ivp lasix given b/t units pt diuresing well. access #16 in left ac.\n\ngi: abd soft bs+ ngt placed this afternoon for meds and tube feeding until monday when swallow eval to be preformed. pt has had 3 loose stools guiaic neg. pt on probalance at 10cc/hr goal of 40cc/hr per micu team.\n\ngu: foley draining dark yellow urine 20-50cc/hr. pt now diuresing after lasix.\n\nskin: pt has dsg on right lateral leg and hip. lower dsg d&i, dsg on hip is moderate amount of s/s drainage. ortho/ in room and states that ok if leaks \"reinforce it\" they'll take down initial dsg in am.\npt scrotum is eccymotic and swollen, right hip eccymotic right inner thigh is eccymotic.\n\nid: bronch washing pos for ecoli pt on vanco, zosyn. urine neg\n\npain: pt can receive fentanyl 25-50mcq/ivp q 2hrs prn for pain he has had 5 doses this shift (w/ every turn) pt does better w/ 50mcq ivp than 25mcq.\n\ncode: pt now dnr/dni no pressors\n\nsocial: daughter and son in law in to visit and have been updated.\n\nPlan:\n\nmonitor resp status. suction when needed\ncbc and lytes at 1900\ncont to administer fentanyl for pain/ before turning pt.\nincrease tube feeding to goal of 40cc/hr\nc/o in am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-27 00:00:00.000",
"description": "Report",
"row_id": 1325209,
"text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report. Pls refer to carevue for specific assessment data/vitals. Pt's HCT this am = 34.2, which is up from 25.2 after 2 units PRBCs. K=3.8 this am; repleted w/ 40 mEq KCL via NGT. Phos=2.1 this am; repleted w/ 2 packets of Neutra-Phos via NGT. Anticipate c/o to floor today. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-25 00:00:00.000",
"description": "Report",
"row_id": 1325204,
"text": "Nursing NOte\nPt is DNR. Pt intubated for OR only.\n\n Events - Bronchoscopy this am - much improved from yesterday per Pulmonary fellow. NO specimens sent from bronch today.\nto OR 1615 for nail placement in R hip. Returned to MICU about 1745.\n\nNeuro - intubated, nods to questions, follows commands consistently, moving all limbs. Nods yes to pain and reports pain in R arm and R hip. Fentanyl 25-50mcg with relief.\n\nCV - pre-op in NSR no ectopy. BP 90-140 sys, MAP > 55. Post op pt with HR 80-120, NSR to sinus tach with frequent PVC's. LYtes pending.\n\nREsp - pt intubated, on 5cm PEEP, on PSV pre-op, now on AC, but will probably be ready for PSV soon. Lung sounds clear to diminished on R. SUctined for thick tan sputum. pt has strong cough. Pt will be DNI after extubation.\n\nGU - low u/o since admission. Improved output with fluids and higher BP.\n\nGI - Pt's daughter refused to allow a gastric tube to be placed. SO pt is not receiving enteral meds. Pt had a small soft brown stool guiac neg pre op and stooled in OR.\n\nHeme - post op HCt pnd.\n\nID Pt on vanco and ZOsyn. PT cool - temp only 96-98 ax. Oral temps lower than ax temps.\n\nSKin - R elbow with contusion. R hip with two incisions dressed with gauze and transparent dressings team to change primary dressing.\n\nSOcial - pt's daughter and son have called today for updates.\n\nA: Post op pt with ectopy and more labile HR. fentanyl relieves pain. Vented on AC, will change to PSV soon.\n\nP: Extubate as soon as possible. Enteral meds as soon as possible. Orient pt prn. MEdicate for pain prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-26 00:00:00.000",
"description": "Report",
"row_id": 1325205,
"text": "cv:hr99-65 nsr frequent pvc's sbp 150-101/46-67\n\ngi: pos bowel sounds. npo. pt has recived no po meds, gstric tube not inserted per wishes of daughter who is proxy.several small bm's soft brown.\n\ngu: foley draining small amounts clear yellow urine. uo decreased to 35 cc total for 2 hours ...tx with 500 cclr bolus with adequate response uo ~ 30 cc/hr\n\nresp:abg with a pO 2 of 62 so peep increased to 10. abdg improved on .50/600/14/10..pO2=116 so pt switched to CPAP w PS peep=8/PS=5 pt did well . abg= 7.41/36/140/24. resp to do risbi in am and plan to extubate when pt is ready. pt is to be a DNI once extubated.\n\nneuro: pt opens eyes and nods yes and no to questions. pt resists turning, grabs hands of people trying to care for him and squeezes. resists care and turning and mouth care etc. medicating with fentanyl 25-50 mics prior to turning ..pt less uncooperative,\n\nintegumentary: r hip dressing is intact. mod amount of sanguinous dressing. there is a dsd lower on the r hip which is also dry and intact. knees are mottled.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-25 00:00:00.000",
"description": "Report",
"row_id": 1325200,
"text": "Nursing Progress Note\nPlease see carvue for specific:\nPt arrived approx from PACU after aborted OR procedure for ORIF of right hip. Pt with acute desat and P02 of 30. CXR in OR complete left sided white out. Pt then bronched for copious amts of secretions. Pt trnf to MICU for furterh mmgt current assesment is as follows:\nNeuro: Pt arrived from intubated and sedated on 25mcgs of prop. Prop stopped hypotensive events and pt remains off all sedation. Pt is arouseable to voice. Follows commands and nods appropriately to simple questions.\nCV: Upon arrival SBP in mid 90's. Pt became quickly hypotensive and received mult fluid bolus's over noc to maintain MAP of 50-55 per MICU resident MD . Pt with quick response in SBP to fluid but shortly after bolus' finished pt would become hypotensive again. Pt received approx 3 literso of fluid over noc Pt with SBP now in mid 80's to low 100's but is holding MAP 50-55. Per discussion with pt's daughter and MD ..Pt is DNR his DNI was reversed for OR. Pt's daughter and HCP does not wish for anything invasive for pt. No central line no pressoers no CPR and no shock. Pt is currently DNR.\nResp: Pt current settings as follows A/C TV 600X14 with 8 peep. See carvue for ABG's. Lungs clear to coarse on right still diminished on left MD aware. Sats remain 96-100%.\nGI/GU: Pt currently NPO. Unable to receive PO Meds intubation. daughter did not want us to place OGT/NGT in pt. Abd soft + BS\nFoley patent drng initially amber cloudy urine. Urine now more yellow in appearance and u/o increaseing after mult fluid bolus's.\nID: Pt cont with low grade temps. cont on Abx therapy.\nEndo: RISS\nID: ? need for c/s mult abx.\nPlan: Cont to monitor resp status. cont to monitor hemodynamics. cont to monitor for s/s of CHR to volume overload. cont with current plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-25 00:00:00.000",
"description": "Report",
"row_id": 1325201,
"text": "respiratory care\nPt received from PACU at the begining of the shift.vent settings weaned to PSV 5/5,60%, tolerating well with acceptable Vt's and RR.RSBI this am was 34.8.Breath sounds very diminished on lt side, clear on the Rt side.Suctioned for moderate amount of thick yellow secretions frequently.Plan to go to OR for Hip surgery today??\nWill cont to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-25 00:00:00.000",
"description": "Report",
"row_id": 1325202,
"text": "Respiratory Care Note\nPt returned from OR and was placed on AC as noted. Plan to wean to PSV as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-05-25 00:00:00.000",
"description": "Report",
"row_id": 1325203,
"text": "Respiratory Care Note\nPt received on PSV 5/5 as noted. BS essentially clear, but diminished in bases especially L base. Bronchoscopy done - pt suctioned for moderate amts thick, tan secretions during procedure. Airways are much improved since yesterday. FiO2 weaned from 60% to 50% after bronch. No SBT done - pt scheduled for OR for R hip repair. Pt taken to OR at 4pm. Plan to wean toward extubation once pt is back from OR.\n"
},
{
"category": "ECG",
"chartdate": "2108-05-23 00:00:00.000",
"description": "Report",
"row_id": 280316,
"text": "Sinus bradycardia with 1st degree A-V block.\nInferior infarct - age undetermined\nLow QRS voltages in limb leads\nSince previous tracing, no significant change\n\n"
}
] |
15,842 | 115,483 | The patient was admitted for cardiac catheterization. The patient underwent cardiac catheterization on . The left main revealed mild distal disease, LAD had a proximal 95% stenosis, was heavily calcified with serial 80% mid and distal stenoses, left circumflex had a proximal 90% stenosis at the bifurcation of the left circumflex and OM1 with a questionable occluded proximal marginal midvessel 80% left circumflex disease. The RCA had serial diffuse 50-60% stenosis with midvessel 80% stenosis. He had a balloon pump placed in the Catheterization Laboratory and Dr. was consulted. He had carotid ultrasounds done which revealed no evidence of stenosis. On , the patient underwent a CABG times three with LIMA to the LAD, reverse saphenous vein graft to OM, reverse saphenous vein graft to RPDA. The cross clamp time was 54 minutes. Total bypass time 80 minutes. He was transferred to the CSIU on Neo, milrinone, and propofol. He was extubated on postoperative night and he was still on his milrinone and Neo. He also had his pacemaker interrogated and the atrial lead was not working appropriately. He will have this dealt with as an outpatient. He went back into his chronic atrial fibrillation. He was slowly improving. On postoperative day number two, he had acute hypoxia and Pulmonary was consulted. They recommended inhaled steroids. Following this consult, he had hemoptysis. He had an urgent intubation and had large clots removed from his airway. He had hypotension at this time as well. He was re-Swanned. His cardiac index was stable. This hemoptysis resolved eventually and he remained sedated and had a slow milrinone wean for the next couple of days. He was extubated again on postoperative day number five and required aggressive respiratory therapy. He had his chest tubes discontinued on postoperative day number six. His milrinone was discontinued as well. He was on levofloxacin for his secretions. He slowly improved, weaning off his 02 requirement. On postoperative day number nine, he was transferred to the floor in stable condition. He continued to improve and was diuresed. He was also started on nutritional supplements and he continued to improve. On postoperative day number 13, he was discharged to rehabilitation in stable condition. | The left retrocardiac opacity has nearly resolved. The aorta is tortuous and the pulmonary vascularity is within normal limits. Pulmonary artery catheter has been advanced and now terminates in right main pulmonary artery. There is persistent vascular engorgement indicating CHF, unchanged from the most recent exam. The cardiomediastinal silhouette is stable, status post median sternotomy. Mild (1+)aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) aorticregurgitation is seen.5. There ismoderate pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Overall left ventricular systolicfunction is severely depressed.AORTA: The aortic root is moderately dilated.AORTIC VALVE: The aortic valve leaflets are moderately thickened. Mediastinal and left chest tube in situ. There is moderate pulmonaryartery systolic hypertension.7. Persistent left retrocardiac opacities noted, which probably represent atelectasis rather than pneumonia. There is stable mild cardiac enlargement. There is interval decrease in left pleural effusion, now only small effusion present. Moderate (2+)mitral regurgitation is seen.TRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. FINDINGS: There is cardiomegaly and prominence of the ascending aorta. There are two left- sided chest tubes which remain unchanged. The aortic root is moderately dilated.4. There are persistent small bilateral pleural effusions and there are minor atelectatic changes in both lung bases. Preoperative assessment.Height: (in) 69Weight (lb): 180BSA (m2): 1.98 m2BP (mm Hg): 145/93Status: InpatientDate/Time: at 14:32Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.LEFT VENTRICLE: The left ventricular cavity size is normal. IMPRESSION: Persistent small to moderate bilateral pleural effusions with adjacent atelectatic changes. FINDINGS: Pulmonary artery catheter enters via the right internal jugular, the tip is poorly seen. Moderate [2+] tricuspid regurgitation is seen. Pulmonary vascularity is considered within normal limits for technique. Cardiac and mediastinal contours demonstrate stable cardiac enlargement and tortuosity of the thoracic aorta. Mediastinal drains and left sided chest tube in unchanged position. CXR taken with lg L effussion..MT dc'd and L pleural left in but with min dng. neo to off and becoming somewhat hypertensive->ntg added. hypo bsp. HYPO BSP. HYPO BSP. RECHECK ABG. 1 U PC W/ MIN EFFECT. TITRATE NTG. CR 1.8.GI: ABD SOFT, NT,ND WITH +BS AND OCC BELCHING. CI dropped to 1.5-1.7..with SVO2-48-53...Milrinone bolused and restarted with ^ CI-2.2-2.7 with SVO2's-64-57. UNDERLYING NOW A-FIB. NEO WEAN TO OFF AND NOW REQUIRING LOW DOSE NTG. MAINTAIN MILRINONE/AMIODARONE. ofm to .60 w/ o2 4l n/c. Pt given alb/atr nebs as ordered Tol well AWARE->MIRINONE ADDED.RESP: ON VENT SETTINGS AS NOTED. POS PEADAL PULSES BILAT W/ DOPPLER.RESP~ON SIMV. GIVEN ZANTAC. Pre hct 29.4--post 28.8. AM CREAT~2.7. WILL CONT AMIODARONE PER EP. REMAINS ON NEO, AND LATER REQUIRING ADDITION OF MILRINONE. WILL USE 1.INCISIONS: PER CAREVUE. CSRU UPDATENEURO: LETHARGIC. Pt given 1u PRBC's slowly for vol. Started on Amio gtt for afib. GIVEN MS04 2 DOSES. ABG WNL. Cont with low uo.GI: Abd round soft, NT, ND with hypo BS. anticoagulate. csru updateNEURO; PT SEDATE ON PROPOFOL. CONT ON NEO. ABG-> MET ACIDOSIS, COMP W/ RESP ALK. Ca and Mg WNL. ABG'S~MET ACIDOSIS. ON NEO TITRATING TO MAINTAIN SBP~110-120.CO>2.5. CT PLACED AT CHANGE OF SHIFT W/ ~1100CC SEROSANG DNG UPON INSERT BUT SMALL AMTS THEREAFTER. REMAINS ON MILRINONE/AMIODARONE. PERL. RRT TREMULOUS UPPPER EXTREMS NOTED AT TIMES.CV: UNSTABLE W/ HYPOTENSION AT CHANGE OF SHIFT. TITRATE TO MAINTAIN SBP 110-120. Lungs- Bilat insp./exp wheezes noted through the shift. Restart meds. C/D.A: STABLE OFF GTTS.EXCEPT HEPARIN. Pt with runs VT- Swan dc'd...to be replaced.RESP: Lungs with I/E wheezes-very dim L..Neb treatments q 4 hrs by RT. anticoagulation began this am ->heparin at 800u/hr. AFEB. csru updatept alert. ON NEO FOR BP, ABLE TO TITRATE DOWN W/ V-PACED AT 88. uop marg w/ good responce to lasix later in shift. svo2 55-60.ci >2.3.lasix 40mg iv x1 and uop now adequate. INITIALLY AFIB W/ PVC, ABERRANCIES.AMIO DRIP AT 0.5MG/MIN. LUNGS COARSE.REQUIRING CPT FREQUENTLY->TOL WELL.. O2 SATS ~95% ON OFM .40.GI: ABD SOFT. Endo: Glu wnl. Neo weaned off. ?dc milrinone. BP's elevated, Ntg gtt on briefly. Lytes WNL. L radial aline positional.GI: + BS, abd soft. CONT W/ HEPARIN. diursis. CT's drng sml amt serous.Pulm: CPT, C+DB, expectorating thick wht. On ranitidine. EXTUBATED.PLAN: ?WEAN IABP AND D/C. Resp. REMAINS ON NEO AND MILRINONE.RESP: ABG AS NOTED. 4.3/2.13.CK neg.post cath fluids completed. Neo restarted. K,CA,MAG NL. Decrease Cr 1.9.GI: Abd soft, round NT,ND with +Bs, +belching. ABG's WNL. IV AMIODARONE DC'D. HEPARIN 500U .SITE C/D.R DP ABSENT,THER PULSES BY DOP .FELOW AWARE. NEURO~AWOKEN OFF PROPOFOL. Recurrent AF. Endo: Glu 110. PERL. Wt down .7kg, 10> preop. Epicardial pacer off. TX REGEMIN EFFECTIVE. dc cordis. ADEQUATE DIURESIS.A/P~EPISODES OF HEMODYNAMIC INSTABILITY. RRT X1 W/ 360J, TO NSR. CONT ON NITRO FOR HTN. STARTRED ON NORVASC. pulses R: D/D, L: 2+/2+. pt. pt. STARTED ON NITRO BRIEFLY EFFECTIVE. SVO2 60-72. titrating fio2. occas. K repleted. BS~EXP WHEEZING BILAT. C.O. USING INS . Wt 11>preop. IABP W/ GOOD ASSSIST/UNLOADING. Appears ready to extubate per resp parameters, but ?fluid overload.P: ?extubate. BUN/Cr stable 53/2.8. TOL WELL. ?source bloody from oropharynx.P: Cont current supports and efforts to diurese. AM PTT~25.9. am meds as orderd. CONT W/ HYDRALAZINE Q 6/HRS. ADEQUATE U/O.A/P~LABILE BP~ON NITRO. STERNAL DSG WITH SEROSANG DRAINAGE, CT DSG/ ACE WRAP C+D, IABP VIA RIGHT FEM AREA SOFT C+D, IABP 1:1 WITH GOOD AUGMENTATION. EXTREMELY LABILE SBP 58-140 REQUIRING NEO/NTG PRESENTLY ON 1 MCQ OF NEO. RESISTANT TO CPT.GI/GU: UOP QS. CCO SWAN DC'D. u/o 80-150cc/hr. HCT 30. Cont on amio gtt .5. CI > 2.4. Palp pedal pulses.Resp: Lungs coarse with upper airway wheezes..Rec nebs by RT. NPO. On/off NTG for HTN-Hydralazine 10mg started q6hrs. ID: Tmax 37.9, wbc 8.6, on levoflox. UNDERLYING AFIB W/ ABERRANCIES. GOOD ABG'S. NEURO~A+OX3. ETT ADVANCED 2 CM NP. CSRU Progress NoteS/O: Neuro: Sedated with propofol and occl MSO4. Wean NTG as tol-cont hydralazine. Remains on Amiodarone. Heme: Hct stable 28, plt at 87, INR 1.3. MAINTAINING SATS~96-97%.GI/GU~OGT LCS/OLD BLOODY DRAINAGE. | 41 | [
{
"category": "Radiology",
"chartdate": "2166-08-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 802717,
"text": " 10:05 AM\n CHEST (PA & LAT) Clip # \n Reason: ?infectious process\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x 3 with increasing white count\n REASON FOR THIS EXAMINATION:\n ?infectious process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Elevated white blood cell count status-post coronary\n artery bypass surgery.\n\n Comparison is made to previous study 4 days earlier.\n\n The patient is status-post median sternotomy and coronary artery bypass\n surgery. A permanent pacemaker remains in place with leads in the right atrium\n and right ventricle. The heart is enlarged but stable. The aorta is tortuous\n and the pulmonary vascularity is within normal limits. There are improving\n areas of atelectasis at both bases, as well as improving pleural effusions.\n There remains increased opacity in the right retrocardiac region which favors\n atelectasis as the most likely etiology. The left retrocardiac opacity has\n nearly resolved.\n\n IMPRESSION: Improving pleural effusions with small residual effusions\n remaining. Near resolution of left lower lobe atelectasis. Residual right\n retrocardiac opacity favors the diagnosis of atelectasis, but underlying\n infection cannot be excluded in this region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802329,
"text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n ?effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post coronary bypass surgery. Evaluate for pleural\n effusion.\n\n PORTABLE AP CHEST: Comparison is made to previous films from and\n .\n\n Patient is status post median sternotomy and coronary artery bypass surgery. A\n left sided chest tube remains in place, and there is no evidence of\n pneumothorax. The permanent pacemaker is unchanged in position. Cardiac and\n mediastinal contours demonstrate stable cardiac enlargement and tortuosity of\n the thoracic aorta. There are persistent small bilateral pleural effusions and\n there are minor atelectatic changes in both lung bases.\n\n IMPRESSION: Persistent small bilateral pleural effusions and bibasilar\n atelectatic changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801981,
"text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asess chf/infiltrates/effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n asess chf/infiltrates/effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to previous study of 2 days earlier.\n\n CLINICAL INDICATION: Status post coronary artery bypass surgery. Evaluate\n pleural effusion.\n\n The patient is status post median sternotomy and coronary artery bypass\n surgery. Left sided chest tubes remain in place. A Swan-Ganz catheter also\n remains in place, currently terminating in the right ventricular outflow tract\n region. Permanent pace maker leads remain in the atrium and right ventricle,\n and an endotracheal tube remains in satisfactory position. There is stable\n mild cardiac enlargement. The aorta is tortuous. Pulmonary vascularity is\n considered within normal limits for technique. There are persistent bilateral\n pleural effusions, somewhat difficult to compare due to differences in\n patient positioning, but likely unchanged. Bibasilar atelectatic changes are\n noted with slight improvement at the left base. No pneumothorax is\n identified.\n\n IMPRESSION: Persistent small to moderate bilateral pleural effusions with\n adjacent atelectatic changes. Slight improved aeration is noted at the left\n base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802232,
"text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check for chf\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n check for chf\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P CABG surgery. Check for chf.\n\n SINGLE AP SUPINE VIEW: Comparison study of .\n\n The heart again shows LV enlargement and evidence of the recent CABG surgery.\n The ET tube and NG line have been removed. The SG catheter tip is poorly\n displayed but is probably still in good position. The pulmonary vessels show\n upper zone prominence, but the patient is supine and it is difficult to\n evaluate for heart failure. The left chest tube remains in satisfactory\n position. There is again evidence of some pleural changes and basal\n atelectasis on the left side, consistent with the recent surgery. Some\n bibasilar loss of translucency is noted, but this is not significantly changed\n since the prior study.\n\n IMPRESSION: Stable post-operative changes. Upper zone redistribution is\n noted, but the appearances do not indicate worsening cardiac failure. Slight\n LV failure cannot be excluded.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801765,
"text": " 2:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx post chest tube pull\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x3 with IABP\n\n REASON FOR THIS EXAMINATION:\n r/o ptx post chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: S/P CABG surgery with intra-aortic balloon pump. R/O pneumothorax.\n Chest tube pulled.\n\n FINDINGS: A single AP semi-upright view. Comparison study taken 6 hours\n earlier on the same day. There is again evidence of marked cardiac\n enlargement, mainly left ventricular, associated with the recent CABG surgery,\n with sternal sutures, cardiovascular clips and skin staples noted. The aorta\n appears dilated and unfolded. There is a large left pleural effusion\n associated with collapse and consolidation of the left lower lobe behind the\n heart. The heart is displaced somewhat to the right. Slight upper zone\n redistribution is noted. The right side of the right hemithorax is not\n displayed on the present image. Right sided pacemaker is noted with dual\n chamber electrodes in unchanged and apparently satisfactory positions. A right\n IJ Swan-Ganz catheter is noted but its tip is not identifiable due to\n underpenetration.\n\n Marked left ventricular enlargement with worsening failure following the\n recent CABG procedure. A large left effusion and collapse of the left lower\n lobe are again noted. The tip of the Swan catheter is not identifiable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801802,
"text": " 10:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pa catheter placemnent\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x3 with IABP\n\n REASON FOR THIS EXAMINATION:\n pa catheter placemnent\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 81-year-old man status post CABG x 3, with IABP.\n\n Check PA catheter placement.\n\n Portable chest radiograph is compared to the study of .\n\n Since the previous study, a left chest tube has been placed, with the tip at\n the medial apex. There is a lucent line projecting in the medial aspect of\n the left lung, which could be artifactual, and it is unusual for a\n pneumothorax. Followup is recommended. Left lung base chest tube is\n unchanged. A right IJ Swan- Ganz catheter is in place, with the tip\n projecting at the pulmonary outflow tract. No pneumothorax is seen in the\n right lung. A right chest wall cardiac pacer is unchanged, with intact right\n atrial and right ventricular leads. Endotracheal tube is seen in proper\n position. There is a probable external pacer projecting over the left lower\n chest.\n\n The cardiomediastinal silhouette is stable, status post median sternotomy.\n There is interval decrease in left pleural effusion, now only small effusion\n present. There is no gross pulmonary edema. Right lung base aeration has\n improved. Persistent left retrocardiac opacities noted, which probably\n represent atelectasis rather than pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-05 00:00:00.000",
"description": "P CAROTID SERIES COMPLETE PORT",
"row_id": 801430,
"text": " 2:49 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: CAD, PREOP CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81 year old man with coronary artery disease, preoperative\n evaluation before CABG.\n\n COMPARISON: None available.\n\n TECHNIQUE AND FINDINGS: scale, color Doppler, and spectral Doppler\n examinations were performed bilaterally at the level of the cervical portions\n of the carotid and vertebral arteries.\n\n There is no major, significant plaque detected on either side. The waveforms,\n velocities and velocity ratios are normal bilaterally. There is antegrade flow\n in the bilateral vertebral arteries. The right external carotid artery is not\n visualized.\n\n CONCLUSION:\n 1. Right external carotid artery not visualized.\n 2. No evidence of significant stenosis in the bilateral internal or common\n carotid arteries otherwise.\n 3. Antegrade flow in the bilateral vertebral arteries.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801445,
"text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf, pna, ptx, masses\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with 3vd awaiting CABG\n REASON FOR THIS EXAMINATION:\n eval for chf, pna, ptx, masses\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with CABG.\n\n COMMENTS: Portable AP view of the chest was reviewed. No previous study is\n available for comparison.\n\n The tip of the IABP is identified at the level of carina. The tip of the Swan-\n Ganz catheter is identified in the right main PA. No pneumothorax is\n identified. Pacemaker is terminates in the right atrium and right ventricle.\n\n There is slight prominence of the pulmonary vasculature with cardiomegaly\n indicating very slight congestive heart failure.\n\n Note is made of prominence of the right infrahilar region, which is probably\n due to vasculature. Please obtain PA and lateral radiographs of the chest when\n the patient is recovered.\n\n IMPRESSION: Mild congestive heart failure with mild cardiomegaly. No\n pneumothorax. Note that the left costophrenic angle is not included in the\n radiograph.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801723,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x3 with IABP\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post CABG with IABP, r/o effusion.\n\n PORTABLE AP CHEST: Single AP portable semi-upright view. Comparison is made\n to previous films from .\n\n FINDINGS: Pulmonary artery catheter enters via the right internal jugular,\n the tip is poorly seen. The previously seen intra-aortic balloon pump is not\n visualized. Mediastinal drains and left sided chest tube in unchanged\n position. Interval increase in size of large left pleural effusions, layering\n posteriorly. The visualized portions of the cardiomediastinal silhouette\n appear unchanged. No CHF. Sternal wires and metallic skin staples. The\n visualized osseous structures are unchanged. Unchanged position of right\n sided pacemaker with dual electrodes.\n\n IMPRESSION: The intra-aortic balloon pump mentioned in the requisition is\n not seen. Other lines and tubes are unchanged and in satisfactory position.\n Increased size of large layering left pleural effusion with probable stable\n cardiomegaly and without CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801548,
"text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: immediate post-op\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x3 with IABP\n REASON FOR THIS EXAMINATION:\n immediate post-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CABG and intraaortic balloon placement.\n\n Status post CABG. Tip of intraaortic balloon is approximately 9 cm inferior\n to the superior margin of the aortic arch. Endotracheal tube is 5 cm above\n carina. Swan-Ganz catheter is in right main pulmonary artery. G-tube is in\n stomach. Mediastinal and left chest tube in situ. No pneumothorax. There is\n atelectasis in the left lower lobe and a left pleural effusion.\n\n IMPRESSION: No pneumothorax. No pleural effusion and left lower lobe\n atelectasis. Intraaortic balloon is 9 cm below aortic arch.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801773,
"text": " 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P L CHEST TUBE REMOVAL\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left chest tube removal.\n\n Comparison to study of 1 hour previously.\n\n FINDINGS: There is cardiomegaly and prominence of the ascending aorta.\n There are bilateral pleural effusions, left greater than right. There is\n stable collapse in the left lower lobe. There is persistent vascular\n engorgement indicating CHF, unchanged from the most recent exam. The left\n chest tube is not seen on the prior examination either but there remains no\n pneumothorax.\n\n IMPRESSION: Continued CHF and left lower lobe collapse. No pneumothorax\n seen. Aortic prominence probably related to techinque. Recommend continued\n followup.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801818,
"text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABGx3\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P CABG, evaluate for effusion.\n\n TECHNIQUE: Portable chest x-ray performed at 7:47 A.M.\n\n Comparison with prior study from .\n\n FINDINGS: Again seen is a dual chamber pacemaker with the leads in unchanged\n position. There is an ETT with the tip well above the carina. There is a\n right IJ sheath with the tip in the superior vena cava. There are two left-\n sided chest tubes which remain unchanged. There are epicardial wires. There\n is a median sternotomy and there are skin staples overlying the midline. The\n aorta is unfolded. The heart size is stable. There are bibasilar atelectases\n and small bilateral effusions, left slightly greater than right. There is no\n pneumothorax. There is mild peribronchial cuffing which may be related to\n mild heart failure.\n\n IMPRESSION:\n 1) Small bilateral effusions, left slightly greater than right.\n\n 2) Mild heart failure.\n\n 3) Small bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801618,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p CABG x3 with IABP\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG with intra-aortic balloon pump, rule out effusion.\n\n VIEWS: Single AP portable view. Comparison dated .\n\n FINDINGS: The intra-aortic balloon pump, mediastinal drain, and left-sided\n chest tube remain in stable and satisfactory position. Pulmonary artery\n catheter has been advanced and now terminates in right main pulmonary artery.\n ETT has been removed. The heart size, mediastinal contours, and pulmonary\n vasculature appear unchanged without congestive heart failure. Increase in\n size of layering left pleural effusion, with left lower lobe atelectasis or\n consolidation. No pneumothorax. S/P CABG with metallic skin staples, sternal\n wires, and mediastinal clips.\n\n IMPRESSION:\n\n Satisfactory position of lines and tubes. Increased size of layering left\n pleural effusion. Left lower lobe collapse or consolidation.\n\n"
},
{
"category": "Echo",
"chartdate": "2166-08-05 00:00:00.000",
"description": "Report",
"row_id": 73620,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 69\nWeight (lb): 180\nBSA (m2): 1.98 m2\nBP (mm Hg): 145/93\nStatus: Inpatient\nDate/Time: at 14:32\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. There is severe\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed.\n\nAORTA: The aortic root is moderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. The left ventricular cavity size is normal. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n3. The aortic root is moderately dilated.\n4. The aortic valve leaflets are moderately thickened. Mild (1+) aortic\nregurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension.\n7. Compared with the findings of the prior report (tape unavailable for\nreview) of , LV function has deteriorated.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2166-08-07 00:00:00.000",
"description": "Report",
"row_id": 169030,
"text": "Atrial fibrillation and intrinsic A-V conduction. Right bundle-branch block.\nIntermittent pacemaker artifact without capture. The latter recording is new\ncompared to the previous tracing of . Otherwise, no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2166-08-07 00:00:00.000",
"description": "Report",
"row_id": 169031,
"text": "Atrial fibrillation with a controlled ventricular response. Right bundle-branch\nblock. Compared to the previous tracing of ventricular paced rhythm is\nno longer recorded.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2166-08-06 00:00:00.000",
"description": "Report",
"row_id": 169032,
"text": "Ventricular paced rhythm. Since the previous tracing of no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-08-04 00:00:00.000",
"description": "Report",
"row_id": 169033,
"text": "Paced rhythm\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-09 00:00:00.000",
"description": "Report",
"row_id": 1468354,
"text": "RESPIRATORY CARE\nPT REMAINS ON MECHANICAL VENTILATION, WEANING FIO2 TO 40%.\nSUCTION X 1 BY RT FOR LARGE THICK BLOODY MUCUS PLUG. BILATERAL BREATH SOUNDS COARSE. MDI'S BEGUN AS ORDERED. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-09 00:00:00.000",
"description": "Report",
"row_id": 1468355,
"text": "CARDIAC~INITALLY V PACED @ 90 W/ EXTERNAL PACER. UNDERLYING RHYTHN SINUS IN 60'S. ATTEMPTED TO PT @ 84, TOL WELL FOR 15 MINS THEN DROP IN SBP AND NOTED THAT PTS OWN PERM PACER KICKING IN AND BEGAN HAVING INCREASED AMTS OF ECTOPY. PLACED BACK ON V-DEMAND OF 84. ISSUES RESOLVED. 10:00 EP IN TO INTERROGATE PACER. SEE FLOW SHEET FOR TRIAL RESULTS. UNABLE TO SUCCESSFULLY PT. UNDERLYING NOW A-FIB. @ 200J. UNSUCCESSFUL. SET PERM PACER @ VENT RATE OF 86. PT GIVEN AN ADDITIONAL AMIODARONE BOLUS AND AMIODARONE DRIP INCREASED TO 1 MG/MIN. TO CONTINUE TO INFUSE @ 1 MG/MIN FOR 12 HR THEN WILL DROP RATE TO .5 MG/MIN. EP TO RETURN IN AM AND INTERROGATE PACER AGAIN.\nCONT ON MILNIRONE @ 2.5UCG/KG/MIN. ON NEO TITRATING TO MAINTAIN SBP~110-120.CO>2.5. ELECTROLYTES REPLENISHED. POS PEADAL PULSES BILAT W/ DOPPLER.\n\nRESP~ON SIMV. ATTEMPTED WEAN OF FIO2 THIS AM FROM 50% TO 40%. TOL WELL WILL MAINTAIN FIO2 @ 40%. RATE OF 12. ABG'S~MET ACIDOSIS. BS~BILAT WHEEZING TO BEING COARSE BILAT TO CLEAR UPPER DIM IN BASES. COMBIVENT INHALERS.Q4 HRS. SX FOR MOD AMTS OF BLOODY SECRETIONS. MAINTAINING SATS @ 97%. NO FURTHER HEMOPTISIS NOTED FROM MOUTH.\n\nNEURO~REMAINS ON PROPOFOL @ 25 UCG/KG/MIN. PT COMFORTABLY SEDATED. GIVEN MS04 2 DOSES. PT HAVING BOUTS OF AGITATION AND REGIDITY. NOT APPEARING TO BE SEIZURES. PROPOFOL OFF @ 1500. PT AWOKE CALMLY. FOLLOWING COMMANDS, THOUGH VERY WEAK. FAMILY IN VISITING @ THE TIME.\n\nGI/GU~1200 OGT PLACED. INITALLY DRAINING MOD AMT OF DK BLOODY DRAINAGE. GIVEN ZANTAC. GIVEN LASIX 20 MG IV DIURESISING WELL. AM CREAT~2.7. REPEAT UNCHANGED. HYPOACTIVE BS.\n\nID~TO START LEVOQUIN 250 MG Q 24.\n\nA/P~LABILE BP. CONT ON NEO. TITRATE TO MAINTAIN SBP 110-120. V-PACED @ 86. WILL CONT AMIODARONE PER EP. TO ATTEMPT CARDIOVERSION IN AM. CONT TO MONITOR ABG'S WILL REST PT ON CURRENT SETTINGS THROUGHOUT THE NIGHT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-08 00:00:00.000",
"description": "Report",
"row_id": 1468352,
"text": "NPN:\n\nNeuro: Pt initially lethargic but oriented to place and . Later in the day with ^ confusion..Kept repeating Goddammit but unable to say what the problem was--denied pain. Could not state where he was.\nCV: 70-90's afib with occ paced beats and PVC's in afternoon. CI dropped to 1.5-1.7..with SVO2-48-53...Milrinone bolused and restarted with ^ CI-2.2-2.7 with SVO2's-64-57. Started on Amio gtt for afib. K5.2-5. Ca and Mg WNL. Pt on hep gtt at 800 with PTT 42.5. Pt given 1u PRBC's slowly for vol. Pre hct 29.4--post 28.8. Pt with runs VT- Swan dc'd...to be replaced.\nRESP: Lungs with I/E wheezes-very dim L..Neb treatments q 4 hrs by RT. O2 sats> 94% initially on 60%FT/4/nc-weaned to 40%ft and 3lnc. CXR taken with lg L effussion..MT dc'd and L pleural left in but with min dng. NTS for thick bloody secretions. At@ 18pm pt with bloody secretions orally..^ raspy coarse breathing with decresed sats...Not improving with ^ O2...Intubated by anesthesia after they removed lg bloody thick clots.\nGU: Pt with foley to gd-am cr 2.1...given 40 iv lasix at 10am--with little response. Foley irrigated and then changed to 16 fr. Cont with low uo.\nGI: Abd round soft, NT, ND with hypo BS. Tol sm amt ice chips.\nEndo: per protocol. 136-111.\nCOMFORT: Medicated with MS1-2 mg intermittently with effect.\nA: Pulmonary hemoptysis and decompensation requiring reintubation.\nP: Intubated-CT to be placed for pleural effussion, Echo done by anesthesia. Re swan. Restart meds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-09 00:00:00.000",
"description": "Report",
"row_id": 1468353,
"text": "csru update\nNEURO; PT SEDATE ON PROPOFOL. PERL. TREMULOUS UPPPER EXTREMS NOTED AT TIMES.\n\nCV: UNSTABLE W/ HYPOTENSION AT CHANGE OF SHIFT. DR AT BEDSIDE(CALCIUM CHLORIDE/EPI AND FLUIDS GUIVEN W/ GOOD EFFECT). CARDIAC ANESTHESIA IN FOR TEE->LG LT PLEURAL EFFUSION AND PT APPEARING DRY. INITIALLY AFIB W/ PVC, ABERRANCIES.AMIO DRIP AT 0.5MG/MIN. PT X 1 W/ 200J TO PERM PACED RHTHYM ->TO V PACED PER EPICARDIAL WIRES FOR INCREASED RATE. ON NEO FOR BP, ABLE TO TITRATE DOWN W/ V-PACED AT 88. CCO SWAN REFLOATED SVO2~60 W/ CI~2. 1 U PC W/ MIN EFFECT. CI DRIFTING TO 1.8. AWARE->MIRINONE ADDED.\n\nRESP: ON VENT SETTINGS AS NOTED. LUNGS COARSE INITIALLY BUT MUCH TOWARDS AM. SX FOR BLOODY SECRETIONS. ABG-> MET ACIDOSIS, COMP W/ RESP ALK. CT PLACED AT CHANGE OF SHIFT W/ ~1100CC SEROSANG DNG UPON INSERT BUT SMALL AMTS THEREAFTER. NO LEAK NOTED.\n\nGI: ABD LARGE SOFT. HYPO BSP. UNSUCCESSFUL ATTEMPT AT NGT/OGT THIS PM.\n\nGU: UOP LOW EARLY IN SHIFT. IMPROVING LATER AFTER FLUIDS AND PC.\n\nASSESS: BECOMING MORE SATBE. REMAINS ON NEO, AND LATER REQUIRING ADDITION OF MILRINONE. HEMO STBLE W/ SVO2 JUSST 60 AND CI~2.0.\n\nPLAN: MONITOR HEMOS CLOSELY. RECHECK ABG. ? FLUIDS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-14 00:00:00.000",
"description": "Report",
"row_id": 1468366,
"text": "NPN:\n\nNEURO: ALERT AND ORIENTED X2-3. MAE BUT DOES NOT MOVE R ARM MUCH UNLESS ASKED TO. SLEEPING WELL OVERNIGHT.\nCV: 60-70 AFIB WITH ?JUNC/VENT ESCAPE AND INTERNAL VPACED BEATS. ON PO AMIO, NORVASC AND IV HYDRALAZINE FOR HTN WITH BP IN GOOD CONTROL. PALP PEDAL PULSES. CORDIS DC'D ON HEPARIN^ AT MN TO 1000U/HR FOR PTT 31.6.\nRESP: LUNGS DIMINISHED AT BASES WITH OCC I/E WHEEZES WITH EXERTION. STRONG PROD COUGH BUT SWALLOWS FREQUENTLY. O2 SATS 97-98% ON 4L NC O2. ABG WNL. LEVOFLOX CHANGED TO PO.\nGU: FOLEY TO GD WITH UO> 40CC/HR. CR 1.8.\nGI: ABD SOFT, NT,ND WITH +BS AND OCC BELCHING. TOL SM AMTS CARDIAC DIET..TOL FLUIDS-DENIES N/V.\nENDO: GLUCOSES 94-100'S NO TREATMENT REQUIRED.\nACTIVITY: OOB TO CH UNTIL 22PM..DID WELL TRANSFERRING BACK TO BED. TURNED SIDE TO SIDE.\nCOMFORT: MEDICATED EARLIER WITH 2 PERC--SL LETHARGIC. WILL USE 1.\nINCISIONS: PER CAREVUE. C/D.\nA: STABLE OFF GTTS.EXCEPT HEPARIN. DELINED\nP: TRANSFER TO 2 FOR CONT CARDIAC REHAB, ? CHANGE HYDRAL TO PO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-07 00:00:00.000",
"description": "Report",
"row_id": 1468349,
"text": "Neuro: sleeping but arouses to voice - oriented to place and person reoriented to time. able to move all extremeties grasp equal bilat.\n\nActivity remains on bedrest due to iabp removal with rt leg straight. can sit up at 8pm.\n\nCV: epicardial paced at 94 this am to keep rhythm regular - iabp removed and ci stable pacer turned off and intrinsic rate afib with vpacing at 70. EP in to interrogate x2 then ch anged pacer to vvi rate 60. currently in afib 70-90 with rare paced beats. b/p stable with neo titrated up and down currently looking to maintain b/p 100-120. CI >2.4\n\nResp: lungs clear but diminished able to get him to cough only with chest PT - when asked to cough he just clears his throat. IS up to 250 - unable to wean oxygen sats would drift down. mt remain to suction no air leak - serosang drainage\n\nGI abd soft hypoactive bowel sounds tolerating clears\n\ngu foley to gravity output up and down team aware will cont to monitor - aware that Cr 1.8 this afternoon increased from 1.5\n\npain usually denied pain except when turned - morphine x1 this shift - has been sleeping unless arosed\n\nplan: cont to wean neo, monitor ci/co with milirone off, cont with chest pt and wean oxygen as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-08 00:00:00.000",
"description": "Report",
"row_id": 1468350,
"text": "Respiratory: Pt remains on F/T of 40% with 4lpn N/C. Alb tx ordered Q6 hrs prn. BS auscultated reveal bilateral wheezing which improve following HHN tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-08 00:00:00.000",
"description": "Report",
"row_id": 1468351,
"text": "csru update\npt alert. oriented. though inappropriate conversations at times. maew in bed. neo to off and becoming somewhat hypertensive->ntg added. anticoagulation began this am ->heparin at 800u/hr. no bolus given.\ncvp 5-8. 500cc ns fluid bolus given w/ min effect. svo2 55-60.ci >2.3.lasix 40mg iv x1 and uop now adequate. rr labored w/ any exertion. becoming increasingly wheezy as shift progressed. albuterol nebs w/ only little effect. ofm to .60 w/ o2 4l n/c. o2 sats mid 90's.\nabd lg,soft. hypo bsp. tol sips h20. uop marg w/ good responce to lasix later in shift. mso4 4g sq prn for pain w/ good effect.\nassess: marginal resp status.\nplan: aggressive pulm hygiene. check pcxr. anticoagulate. begin beta blockade.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-11 00:00:00.000",
"description": "Report",
"row_id": 1468359,
"text": "CSRU UPDATE\nNEURO: LETHARGIC. VOICE WEAK. ORIENTED TO PLACE. VERY WEAK.\n\nCV: VS/HEMOS AS PER FLOWSHEET. REMAINS ON MILRINONE/AMIODARONE. NEO WEAN TO OFF AND NOW REQUIRING LOW DOSE NTG. ARMS & LEGS QUITE EDEMATOUS. EXTREMS WARM,DIAPHORETIC AT TIMES. AFEB. SVO2 65-70 .CARDIAC INDEX 2- 2.8. REMAINS V PACED VIA EPICARDIAL WIRES, EPS IN->PT WILL REQUIRE NEW PERM A WIRE(PRESENT ONE BROKEN).\n\nRESP; EXTUBATED. CONGESTED COUGH OCCAS PRODUCTIVE THICK WHITE/BLOOD TINGE SPUTUM. LUNGS COARSE.REQUIRING CPT FREQUENTLY->TOL WELL.. O2 SATS ~95% ON OFM .40.\n\nGI: ABD SOFT. HYPO BSP. TUBE FEEDS TO START. REFUSING PO INTAKE AT PRESENT.\n\nGU: UOP BRISK. LASIX CONT.\n\nASSESS: MARGINAL RESP STATUS.\n\nPLAN: AGGRESSIVE PULM HYGIENE. MAINTAIN MILRINONE/AMIODARONE. TITRATE NTG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-12 00:00:00.000",
"description": "Report",
"row_id": 1468360,
"text": "RESP CARE: Pt recieved on 40% face tent. Lungs- Bilat insp./exp wheezes noted through the shift. Pt given alb/atr nebs as ordered Tol well\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-12 00:00:00.000",
"description": "Report",
"row_id": 1468361,
"text": "CSRU Update:\nNeuro: Awake and alert, oriented x 1. MAE, PEARL, follows commands.\n\nCV: On NTG overnight for BP control. Milrinone DC'd at 0630. Remains on Amiodarone. Cont to be V paced at 80. CT's drng sml amt serous.\n\nPulm: CPT, C+DB, expectorating thick wht. IS done w/ lots of encouragement.\n\nGI: Started Nepro TF's. No residuals, no stool.\n\nGU: Foley drng clr yellow urine.\n\nMisc: Skin intact.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-13 00:00:00.000",
"description": "Report",
"row_id": 1468363,
"text": "NPN:\n\nNeuro: Alert and oriented to ,place and self. Occ confused to date/time. Noted to be calling out at times,talking to self but pleasant and coop. MAE with equal strength.\nCV: Pt initially in Vpaced rhythm at 80, External pacer off@ 1am r/t burst afib/alarms and underlying rhythm 70-80's afib with occ int pacer beats. Remained HD stable with CI>2.5 and SVO2's > 65. On/off NTG for HTN-Hydralazine 10mg started q6hrs. Cont on amio gtt .5. Lytes WNL. K repleted. Palp pedal pulses.\nResp: Lungs coarse with upper airway wheezes..Rec nebs by RT. O2 sats> 95% on 4l nc O2. Pt with strong prod cough of thick clear to tan sputum. RR 20-28. ABG's WNL. L pleural CT to sxn without airleak-draining sm amt serous/sl sang dng.\nGU: Foley to gd with UO> 50/hr. Decrease Cr 1.9.\nGI: Abd soft, round NT,ND with +Bs, +belching. Denies N/V. Tol sm amts clears.\nEndo: Glucoses WNL-no treatment required.\nIncisions: Per carevue-C/D.\nComfort: Denies pain most of time-even with coughing.\nActivity: Turned side to side in bed.\nA: Underlying afib with stable HD and good uo.\nP: Cont to monitor..discuss afib/?conversion-change amio to po..EPS following. Possible change swan to TLCL for IV access. Wean NTG as tol-cont hydralazine. Watch BUN/Cr and discuss ? diursis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-13 00:00:00.000",
"description": "Report",
"row_id": 1468364,
"text": "NEURO~A+OX3. FC. MAE. MED W/ PERCOCET 1 TAB X1 FOR INCISIONAL DISCOMFORT. EFFECTIVE.\n\nCARDIAC~IN AFIB W BREAK THRU VENT PACED BEATS FROM INTERNAL PACER. EP IN TO INTERROGATE PACER. INTERNAL SET @ VVIR @ 60. EXTERNAL PACER WIRES DC'D. PT STARTED ON HEPARIN 800 UNITS. AM PTT~25.9. CCO SWAN DC'D. CONT ON NITRO FOR HTN. STARTRED ON NORVASC. CONT W/ HYDRALAZINE Q 6/HRS. IV AMIODARONE DC'D. NOW ON 400MG PO TID.\n\nRESP~ON 4 L NP. MAINTAINING SATS OF 95-97%. PRODUCTIVE COUGH. USING INS . BS~EXP WHEEZING BILAT. NEB TX'S PER RESP TX.\n\nGI/GU~TOL PO FOOD AND FLUIDS WELL. ADEQUATE U/O.\n\nA/P~LABILE BP~ON NITRO. WEAN TO OFF THIS PM. CONT W/ HEPARIN. OOB TO CHAIR THIS PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-13 00:00:00.000",
"description": "Report",
"row_id": 1468365,
"text": "1530-1900...Neuro: opens eyes spontanously, engages in approp , , follows command.\n\nPulm: Lungs diminished in bases, sats > 97% on 4l n/p. fair cough effort.\n\nCV: A fib with controlled VR with occasional paced beats. BP's elevated, Ntg gtt on briefly. Hydralazine 10mg IV at 1800 with effect.\nPalpable pedal pulses. L radial aline positional.\n\nGI: + BS, abd soft. Taking regular diet.\n\nGU: foley to CD, qs urine.\n\nPlan: continue pulm hygiene. OOB to chair. ? dc cordis. ? transfer to Far 2 tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-12 00:00:00.000",
"description": "Report",
"row_id": 1468362,
"text": "7a-3p\ncv: hr v-paced @ 80, no ectopy, sbp 120-190, map 64-109, ntg gtt increased up to 2.0 mcg/kg/min to keep map< 90, ntg now @ 1.0 mcg/kg/min, continues on amiodarone gtt @ 0.5 mg/min, milrinone gtt off since 0630 & ci > 2.0 all day(2.2-3.1)\n\nresp: on 50% ofm this am, now on 4 l np, bs + all lobes & course, coughing productively, mod amt thick green sputum, sats 93-98, rr 16-25, deep breathing/coughing encouraged\n\ngi: TF/ngt dc'd this am, dat tol well, no nausea or stool\n\ngu: foley cath patent, clear yellow urine, iv lasix dc'd this am\n\nneuro: awake, alert, oriented x 2, follows commands, moving all extremities, pt weak\n\nother: mediastinal ct's dc'd, L plueral ct in & draining sm amt serosang material, chest incision ota & clean & dry, family in & updated on pt's condition\n\nplan: continue to monitor hemodynamics, titrate ntg gtt as needed keeping map < 90/ > 60, encourage deep breathig & coughing\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-10 00:00:00.000",
"description": "Report",
"row_id": 1468356,
"text": "CSRU Progress Note\nS/O: Neuro: Sedated with propofol and occl MSO4. Grimaces to pain.\n CV: Vpaced with perm pacer at 85 with rare intrinsic beat, looks ventricular, ?underlying rhythm AF. Epicardial pacer off. Neo weaned off. CI 2.3-3 with SVO2 66%, PA 18. Amiodarone down to .5, milrinone at .25.\n Resp: No vent changes, pH 7.35 with BE -3. Lg amt thick bld-tinged sputum. Breathing above vent.\n Renal: Mild response to lasix 20, but UO 100/hr and I&O -500cc so far today. BUN/Cr stable 53/2.8. Wt down .7kg, 10> preop. K and Ca repleted.\n Heme: Hct stable 28, plt at 87, INR 1.3. Dk bloody secretions in oropharynx.\n ID: Tmax 37.9, wbc 8.6, on levoflox.\n GI: Sm amt dk blood from stomach, on ranitidine, no nutritional support.\n Endo: Glu 110.\n Skin: Coccyx slightly pink.\nA: Hemodynamically stable on milrinone, amiodarone and Vpacing. Renal failure appears to be stabilizing. ?source bloody from oropharynx.\nP: Cont current supports and efforts to diurese. Keep lightly sedated until ready for vent wean.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-10 00:00:00.000",
"description": "Report",
"row_id": 1468357,
"text": "NEURO~AWOKEN OFF PROPOFOL. RESPONDING APPROPRIATELY TO YES AND NO QUESTIONING. FC. MAE. CONT ON PROPOFOL @ 20 UCG/GK/MIN AND MSO4 2 MG X2 FOR DISCOMFORT/AGITAITON.\n\nCARDIAC~SP IN TO INTERROGATE PACER. PERM PACER A WIRE NOT FUNCTIONING.\n X1 W/ 360J, TO NSR. EXTERNAL PACER SET TO AVPACE @ 74.\nEPISODDE OF HYPERTENSION SBP ^ 160'S, MAP'S 90-102. GIVEN HYDRALAZINE 10 MG IV X 2 W LITTLE EFFECT. STARTED ON NITRO BRIEFLY EFFECTIVE. REBOUND HYPOTENSION NEO BRIEFLY CURRENTLY OFF ALL PRESSORS. MILNIRONE DECREASED TO 0.125 UCG/KG/MIN. CONT ON AMIODARONE @ .5MG/MIN.\n\nRESP~PLACED ON CPAP @ 1100. TOL WELL. GOOD ABG'S. LUNG SOUNDS CLEAR TO COARSE UPPER & SL DIMINISHED IN BASES. SX FOR SM AMTS OF THICK BLOODY SECRETIONS. MAINTAINING SATS~96-97%.\n\nGI/GU~OGT LCS/OLD BLOODY DRAINAGE. LASIX 20 MG IV. ADEQUATE DIURESIS.\n\nA/P~EPISODES OF HEMODYNAMIC INSTABILITY. TX REGEMIN EFFECTIVE. WILL REMAIN ON CPAP FOR TONIGHT AND WILL ATTEMPT EXTUBATION TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-11 00:00:00.000",
"description": "Report",
"row_id": 1468358,
"text": "CSRU Progress Note\nS/O: Neuro: Sedated with propofol, able to open eyes and nod head.\n CV: Vpaced at 80, underlying AF 70. Neo restarted. SVO2 74% with CI 3. Remains on IV amio and milrinone .125.Cont to vagal BP to 80 with cough.\n Resp: Large amt thick bld-tinged sputum, now whitish. Good abg on CPAP 5/5, RSBI 27, Vt 700.\n Renal: -1900cc for , -750cc so far today with uo 150-200/hr since lasix. Wt 11>preop. Arms and legs are very edematous.\n Heme: Hct stable, plt ct improving, on aspirin.\n ID: Afebrile, wbc 8, on IV levoflox.\n GI: Gastric drg now bilious, still dark bld in oropharynx. On ranitidine.\n Endo: Glu wnl.\n Skin: Coccyx slightly pink.\nA: Diuresing with excellent CI and SVO2, but requiring neo. Recurrent AF. Appears ready to extubate per resp parameters, but ?fluid overload.\nP: ?extubate. ?dc milrinone. If no extubate, begin tf and obtain firststep mattress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-06 00:00:00.000",
"description": "Report",
"row_id": 1468347,
"text": "S/P CABG X3\nO: CARDIAC: ARRIVED AV PACED 80- PT HAS OWN PACEMAKER SET @ 70. WHEN CHECKING UNDERLYING RYTHYM UNABLE TO A PACE- LEFT WITH INTRINSIC PACER @ 70 UNTIL SKIN LEAD PLACED @ 2100 AND PRESENTLY AV PACED. EXTREMELY LABILE SBP 58-140 REQUIRING NEO/NTG PRESENTLY ON 1 MCQ OF NEO. SVO2 40'S WITH HYPOTENSION,60'S AND 70'S WHEN AV PACED. CI>2 THROUGHOUT THE EVENING.MILRINONE TO CONTINUE OVERNIGHT @ .5 MCQ. STERNAL DSG WITH SEROSANG DRAINAGE, CT DSG/ ACE WRAP C+D, IABP VIA RIGHT FEM AREA SOFT C+D, IABP 1:1 WITH GOOD AUGMENTATION. BILATERAL PT ONLY,NP AWARE, FEET COOL TO TOUCH. CT DRAINAGE 250 ML. HCT 30. K,CA,MAG NL. FEBRILE RECIEVED TYLENOL PR- IF CONTINUED FEBRILE WITH A WBC ^ WILL PAN CULTURE IN AM NP .\n RESP: HYPOTENSION WITH COUGHING, VENT CHANGES PER FLOW, COURSE UPPER CLEARS WITH SUCTIONING THICK TAN SPUTUM MOD AMOUNT. ETT ADVANCED 2 CM NP. O2 SATS>99%, NO CHEST TUBE LEAK NOTED. LARGE AMOUNT OF BLOODY DRAINAGE FROM MOUTH NP DENIES TRAUMATIC PLACEMENT IN OR.\n NEURO: MOVED LEGS + HANDS NOT UPON COMMAND, AGITATED + CONTINUED PROPOFOL PRESENTLY @ 15MCQ, PT UNABLE TO FOLLOW COMMANDS. PERL.\n GI: OGT +PLACEMENT, ABSENT BOWEL SOUNDS, ABD OBESE SOFT,\n GU: ADEUATE UO\n ENDO: HAS NOT REQUIRED ANY SLIDING SCALE INSULIN\n ID: VANCO 1 GM @ 2100\n SOCIAL: SPOKE TO 2 NEPHEWS OVER THE PHONE\nA: LABILE SBP, DECREASED SVO2 WITH HYPOTENSION, FEBRILE.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-NEO, CT DRAINAGE, DSGS, PP, IABP + SITE, SVO2,CI, RESP STATUS- ATTEMPT TO WAKE + WEAN, NEURO STATUS- OFF PROPOFOL, I+O, LABS. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-07 00:00:00.000",
"description": "Report",
"row_id": 1468348,
"text": "CSRU UPDATE.\nNEURO: PROPOFOL OFF AT 2300. AWOKE. FOLLOWS COMMANDS. MAE IN BED. ORIENTED X1. SPEECH DIFF TO UNDERSTAND AT TIMES.ONLY MIN INTERACTIVE.\"GO TO HELL\" WHEN ASKING PT TO COUGH AND DB.\n\nCV: VS/HEMOS AS PER FLOWSHEET. AV PACED INITIALLY THEN INCREASED RATE W/ A-SENSING AND V-PACING ->NOW V PACED. UNDERLYING AFIB W/ ABERRANCIES. IABP 1:1, HAD ISSUES W/ GAS LEAKING REQUIRING CHANGE IN MACHINE (RESOLUTION OF PROBLEM). ONLY PT BILAT BY DOPPLER, AS PREVIOUS SHIFT. CI > 2.4. IABP W/ GOOD ASSSIST/UNLOADING. SVO2 60-72. REMAINS ON NEO AND MILRINONE.\n\nRESP: ABG AS NOTED. 22 20'S W/ TV 500S. ABLE TO LIFT HEAD OFF PILLOW AND FOLLING COMMMANDS-> WEAN TO EXTUBATION. O2 SATS MID 90'S. .50 OFM AND 4L N/C ADDED. LUNGS DIM. POOR COUGH EFFORT. RESISTANT TO CPT.\n\nGI/GU: UOP QS. NO NAUSEA.ABD SOFT.\n\nASSESS: STABLE PM. EXTUBATED.\n\nPLAN: ?WEAN IABP AND D/C. AGGRESSIVE PULM TOILET. MONITOR SVO2, WEAN MILRINONE AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-05 00:00:00.000",
"description": "Report",
"row_id": 1468344,
"text": "81 YR OLD ADMITTED FOR ELECTIVE CATH PRE ABD AORTIC ANEURYSM REPAIR FOUND TO HAVE 3VD ,FOR CABG TOMORROW .HYPOTENSIVE P PROCEDURE ,GOT FLUID,DOPAMINE ,IABP .\n\nPACED RHYTHM OCC OWN BEAT.DOPAMINE WEANED TO OFF, PT BECAME HYPERTENSIVE AS MEDS HAD BEEN HELD.MEDS RESUMED AND IV NITRO STARTED TO KEEP SYS BELOW 140 .PRESNTLY AT 1 MIC PER KG . HEPARIN 500U .SITE C/D.R DP ABSENT,THER PULSES BY DOP .FELOW AWARE. FEET COOL ,PALE .\nPA IN PLACE .CI 2,9\n\nSATS 97 4L BS CL\n\nPOS BS, E/D WELL ,NPO P MIDNOC ,NO INSULIN REQUIRED PER SLIDING SCALE\\\n\nGOOD URINE OUTPUT ,ON MUCOMIST\n\nALERT,ORIENTED ,COOPERATIVE\n\nCONTOL BP C IV NITRO\nREPORT CHANGE IN R FOOT\nPREOP 7 AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-06 00:00:00.000",
"description": "Report",
"row_id": 1468345,
"text": "CCU NPN 1900-0700\nS: \" I'm looking for the pictures I drew in the corner \"\nO: pt. Ox3 in eve, conversing with RN. becoming slightly confused during night. pt. stating that he felt confused at times. Still knows he is in hospital, date and name but saying non-sensical things.\nclose observation required. follows commands, MAE. did not give trazadone for sleep as ordered. pt. dozing for short periods.\n\nCV: HR 70 v-paced. occas. PVC. IABP 1:1. poor to no augmentation.\nMAP 82-110. nitro 1.5mcq to 1mcq/k/min.\nheparin at 600u/hr, PTT 37.4. increased to 700u/hr.\ndenies CP/SOB\nPAP 37-47/10-15. MVO2 59%. C.O. 4.3/2.13.\n\nCK neg.\n\npost cath fluids completed. u/o 80-150cc/hr. (-) 300cc at 12am and currently ~ 400cc neg.\n\nLS clear. sat 95-96% on 2lnc.\n\nGI: pt. passing gas PR. sips of water with meds.\nright groin: D/I. transparent dsg intact. pulses R: D/D, L: 2+/2+. feet cool.\n\nA/P: s/p cath showing 3VD now pre-op for CABG today.\n mild confusion over night.\nAM labs pnd at 0430. contin. NPO. am meds as orderd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-08-06 00:00:00.000",
"description": "Report",
"row_id": 1468346,
"text": "Resp. Note:\nPatient admitted to CSRU s/p CABG x3 , MVR, intubated with # 7.5 oett placed on 7200vent see carevue resp. flow sheet. BS coarse SX for bloody secretions, ABG'results resp. acidosis, correcting with increased RR. titrating fio2. RRT\n"
}
] |
49,407 | 183,964 | 55 yo F w/ RCC (dx ) with mets to lung and bone s/p L nephrectomy, XRT to R femur and tibia, cryodebridement and electrocautery ablation x2, IL-2 therapy c/b toxic encephalopathy and shock, who presented from OSH with hemoptysis s/p double lumen ET tube intubation for airway protection transferred to for further evaluation. . # Hemoptysis, likely due to endobronchial lesion. Patient with known RCC metatastatic to the lungs w/ prior bronch notable for endobronchial tumor of LUL as well as progression on CT (incr. precarinal lymph node, left hilar nodal mass, upper lobe anterior segment nodule, right lung apex nodule). Unable to perform a IR embolectomy due to difficult anatomy and no visible blush was seen on angiogram. She was intubated with double lumen tube and eventually ventilated with double ventilators (AC on right and PCV on left) with some recruitment (FiO2 decr to 50%). Flexible bronchoscopy on showed complete obstruction to level of Left main bronchus, but no active bleeding, w/ some blood tinged fluid suctioned throughout the day. On HD2, patient developed sepsis physiology (see below). IP performed rigid bronchoscopy on which showed purulent secretions (though cultures would not grow anything back), LUL that was completely occluded. She underwent debridment and electrocautery of LUL bronchus, which was opened, no active bleeding, but notable for old clots. Electrocautery applied to lingula w/o success. Her HCT remained overall stable 28 - 34. No further bleeding was noted. Upon ventilation, of Left lung s/p electrocatery and debridement, significant recruitment was achieved. After this procedure, she had no more hemoptysis the remainder of the hospitalization. # Hypoxic respiratory failure. Post. obstructive PNA/Volume overload/Hematemesis. On HD#1 was noted to have fevers, 103F Tmax with decreased UOP and hypotension. She was started on Vancomycin/Cefepime () for post obstructive PNA and Flagyl was added . With aggressvie volume resuscitation, UOP improved as did her pressures. Frank purulence was visualized on bronchoscopy as above. Although her bronchial washings grew commensal flora only (2 days on ABx), treatment was continued due to clinical presentation consistent w/ PNA. She will complete an 8 day course, initially on vanc/cefepime/flagyl for 6 days, then switched to levoquin/flagyl for 2 days. Pt. was extubated on with en episode of flash pulmonary edema. Did not tolerate BiPAP but responded well to IV lasix. At time of transfer to floor, LOS +2.2L. Pt. was on RA upon transfer to floor with minimal stridor on exam. On the floor, she continued to improve, with intermittent nebulizer treatments for wheezing on exam. She was started on a prednisone taper for laryngeal edema intubation. # Stridor. Noted grade III subglottic edema during ETT exchange on w/ IP. Received IV solumedrol in OR. On post extubated, was found to have signifiant stridor, received racemic epinephrine and additional dose of IV solumedrol. On changed to PO prednisone; she was sent out on a prednisone taper. # RCC. Discussed with Dr. , outpatient oncologist. Given recent events, pt reportedly did not quialify for drug trial initially suggested by her oncologist. However, an off label of a different study drug was suggested by Dr. , to be started once patient is able to return home (will be mailed to her) . # CKD: S/p nephrectomy. Baseline Cr seems to range 1.2-1.5. Improved with aggressive hydration to 1.0. . # Hypertension: pt developed significant hypertension on the floor, likely as a result of prednisone. She has a history of HTN, and has previously been on HCTZ, but did not tolerate this well so on admission had no HTN therapy. She was started on lisinopril and amlodipine, w/ close PCP f/u, given that her prednisone will be tapered and expect her HTN to come down from that alone. Pt instructed to get BP cuff and check daily, and educated about signs/symptoms of hypotension. . # Communication: Husband HCP - ; # Code: Full (confirmed) . ==== TRANSITIONAL ISSUES # Will need close monitoring of blood pressures, given she was quite high in house, but prednisone will be coming off | Known left mass and multiple pulmonary nodules are redemonstrated, partially obscured by pulmonary edema and newly appeared bibasal areas of atelectasis and pleural effusion. A 0.035 Benstson guidwire was advanced into the aorta. Known left lung mass and bilateral pulmonary nodules, less well seen. The unilateral left lung intubation device is in place. The known left mass and multiple pulmonary nodules are again seen. There is interval improvement of the atelectasis with currently better aerated left upper lung and central position of the mediastinum. Left IJ catheter extends to the cavoatrial junction or possibly the upper portion of the right atrium. Right lower lung opacity might reflect area of atelectasis. Known perihilar tumor on the left is partially seen, obscured by pleural effusion. New left IJ catheter tip is at the cavoatrial junction. The catheter and sheath were removed, hemostatsis was achieved with manual compression. IMPRESSION: Substantial new volume loss in the left lung status post placement of double-lumen endotracheal and orogastric tubes. Minimal interstitial edema is better seen in the right perihilar area. There is worsening in aeration of the remaining lung in the left upper hemithorax. The left internal jugular line tip is at the mid SVC level. There is interval progression of pulmonary edema. FINDINGS: The patient is intubated with a double-barrel endotracheal tube whose narrower limb terminates in the distal left main stem bronchus. A 0.018 microwire was advanced to the left of the midline under flouroscopic guidance. ET tube with tip in the left main bronchus is in unchanged position. There is a portion in the left upper lobe that is still aerated. Right lower lung opacity is unchanged. ANESTHESIA: Procedure performed under moderate sedation. Bilateral pleural effusions are noted, with no appreciable change in the left perihilar mass. FINAL REPORT HISTORY: Shortness breath. As compared to the prior study obtained at 8:42 p.m. on , there is minimal interval change on the current radiograph, but there is definitive interval increase in right pleural effusion and right lower lung opacity that might reflect aspiration or hemorrhage. Right lower lobe opacities are new or newly appeared, this could be due to hemorrhage, aspiration, or infection. Patient has taken a somewhat better inspiration with less coalescence of bilateral opacifications. Renegate Hi-Flow microcatheter was used in an attempt to selectively cannulate the right bronchial artery. Compensatory hyperinflation of the right lung is noted. Under palpatory guidance, right commmon femoral artery for punctured with a micropunture needle. Sinus rhythm with non-diagnostic repolarization abnormalities. Portable AP radiograph of the chest was reviewed in comparison to obtained at 02:58 a.m. (Over) 5:42 PM BRONCHIAL Clip # Reason: please embolize bronchial artery Admitting Diagnosis: HEMOPTYSIS Contrast: VISAPAQUE Amt: 150 FINAL REPORT (Cont) Small right pleural effusion. Portable AP radiograph of the chest was reviewed in comparison to . Portable AP radiograph of the chest was reviewed in comparison to . AP chest radiograph Additional interval improvement in the appearance of the left lung with substantial improvement of the left lung aeration is noted on the current study. Radiograph of the chest was reviewed. Right upper lobe opacities have worsened. There has been interval worsening of opacification of the left lung, consistent with worsening collapse. FINDINGS: In comparison with the study of , there are slightly lower lung volumes, but otherwise little change. There is substantial improvement of the left lung atelectasis. FINDINGS: In comparison with the study of , there is some improved level of inspiration with decrease in the bilateral opacifications. The patient was extubated. Patient now presents with hemoptysis, and potential embolization of the bronchial arteries. The left subclavian line tip is at the level of mid SVC. Right groin area was prepped and draped is usual sterile fashion. Left IJ line in the proximal Right atrium. A sterile dressing was applied. TECHNIQUE: Chest, AP supine portable. Lobular appearance of the left infrahilar area is consistent with known mass. The left bronchial artery was extremetely small in caliber, which prevented its effective cannulataion. REASON FOR THIS EXAMINATION: Pneumothorax or change in appearnace of left lung since IP procedure this morning FINAL REPORT REASON FOR EXAMINATION: Assessment of the patient after recent interventional pulmonary procedure. Compared to tracing #1 T waves are more flattenedin leads V4-V6. 1:39 PM CHEST (PORTABLE AP) Clip # Reason: {See Clinical Indication Field} MEDICAL CONDITION: History: 55F with hemotpysis, intubatedClinical Question: eval tube placement REASON FOR THIS EXAMINATION: {See Clinical Indication Field} FINAL REPORT CHEST RADIOGRAPH HISTORY: Hemoptysis status post intubation. An orogastric tube terminates in the stomach. 5:42 PM BRONCHIAL Clip # Reason: please embolize bronchial artery Admitting Diagnosis: HEMOPTYSIS Contrast: VISAPAQUE Amt: 150 ********************************* CPT Codes ******************************** * 1SR ORDER /BRACHIOCEPHALIC VISERAL SEL/SUPERSEL A-GRAM * **************************************************************************** MEDICAL CONDITION: 55 year old woman with RCC mets to lung and hemoptysis REASON FOR THIS EXAMINATION: please embolize bronchial artery FINAL REPORT INDICATION: Patient with history of RCC with metastatic disease to lungs and large left hilar mass. | 15 | [
{
"category": "Radiology",
"chartdate": "2119-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233237,
"text": " 7:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for effusion, pna\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with sob and stridor\n REASON FOR THIS EXAMINATION:\n eval for effusion, pna\n ______________________________________________________________________________\n WET READ: KKgc SAT 8:34 PM\n Mild pulmonary edema, stable since study done at 13:36 hours. Known left lung\n mass and bilateral pulmonary nodules, less well seen. Small right pleural\n effusion. Left IJ line in the proximal Right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness breath.\n\n FINDINGS: In comparison with the study of earlier in this date, there is\n little overall change. Patient has taken a somewhat better inspiration with\n less coalescence of bilateral opacifications. The known left mass and\n multiple pulmonary nodules are again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232755,
"text": " 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 55F with hemotpysis, intubatedClinical Question: eval tube placement\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Hemoptysis status post intubation.\n\n COMPARISONS: Earlier radiographs on the same day.\n\n TECHNIQUE: Chest, AP supine portable.\n\n FINDINGS: The patient is intubated with a double-barrel endotracheal tube\n whose narrower limb terminates in the distal left main stem bronchus. An\n orogastric tube terminates in the stomach. There is substantial increased\n volume loss in the left hemithorax with increased opacification suggesting\n atelectasis. Large left perihilar mass csn also be discerned. Compensatory\n hyperinflation of the right lung is noted. The right lung appears clear.\n There is no pneumothorax.\n\n IMPRESSION: Substantial new volume loss in the left lung status post\n placement of double-lumen endotracheal and orogastric tubes. Right lung\n remains clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233133,
"text": " 9:16 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Pneumothorax or change in appearnace of left lung since IP p\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with recent IP procedure to open up airway and cauterize\n tumor.\n REASON FOR THIS EXAMINATION:\n Pneumothorax or change in appearnace of left lung since IP procedure this\n morning\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Assessment of the patient after recent interventional\n pulmonary procedure.\n\n Portable AP radiograph of the chest was reviewed in comparison to obtained at 02:58 a.m.\n\n The ET tube tip is 5 cm above the carina. The left internal jugular line tip\n is at the mid SVC level. Heart size is unchanged in appearance. There is\n substantial improvement of the left lung atelectasis. Known perihilar tumor\n on the left is partially seen, obscured by pleural effusion. Right lower lung\n opacity is unchanged. No appreciable pneumothorax is present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232838,
"text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube migration\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoptysis s/p double lumen tube, R lung ventilation\n REASON FOR THIS EXAMINATION:\n eval for tube migration\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: History of hemoptysis, status post double lumen tube, Right\n ventilation.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube with tip in the left main bronchus is in unchanged position. NG tube\n tip is in the stomach. There has been interval worsening of opacification of\n the left lung, consistent with worsening collapse. There is a portion in the\n left upper lobe that is still aerated. Right upper lobe opacities have\n worsened. Right lower lobe opacities are new or newly appeared, this could be\n due to hemorrhage, aspiration, or infection. There is no evident\n pneumothorax. The cardiomediastinum is shifted towards the left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233268,
"text": " 1:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for progression, chf\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with RCC ca to lung\n REASON FOR THIS EXAMINATION:\n eval for progression, chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal cell carcinoma to the lung, to assess for progression.\n\n FINDINGS: In comparison with the study of , there is some improved level\n of inspiration with decrease in the bilateral opacifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233393,
"text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with RCC to the lungs, hemoptysis s/p cauderization of left\n bronchial mass\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastases to the lungs with hemoptysis and cauterization of left\n bronchial mass.\n\n FINDINGS: In comparison with the study of , there are slightly lower lung\n volumes, but otherwise little change. No definite focal area of consolidation\n or vascular congestion. Left IJ catheter extends to the cavoatrial junction\n or possibly the upper portion of the right atrium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233150,
"text": " 3:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoptysis, intubated\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient intubated after recent\n interventional pulmonary procedure.\n\n AP chest radiograph\n\n Additional interval improvement in the appearance of the left lung with\n substantial improvement of the left lung aeration is noted on the current\n study. Lobular appearance of the left infrahilar area is consistent with\n known mass. The left mid lung nodule is currently better visible due to\n improved lung aeration as well as multiple additional pulmonary nodules\n scattered throughout the lungs. Right basal opacity as well as bilateral\n pleural effusions have substantially improved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1232992,
"text": " 3:06 AM\n CHEST (PA & LAT) Clip # \n Reason: Interval change\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoptysis, intubated\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hemoptysis, intubated, followup for interval change.\n\n Radiograph of the chest was reviewed.\n\n As compared to the prior study obtained at 8:42 p.m. on , there\n is minimal interval change on the current radiograph, but there is definitive\n interval increase in right pleural effusion and right lower lung opacity that\n might reflect aspiration or hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1232851,
"text": " 6:14 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Placement of new LIJ CVL\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoptysis from endobronchial renal CA - dual lumen ETT\n REASON FOR THIS EXAMINATION:\n Placement of new LIJ CVL\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess new left IJ.\n\n Comparison is made with prior study performed three hours earlier.\n\n New left IJ catheter tip is at the cavoatrial junction. There is no evident\n pneumothorax. There is worsening in aeration of the remaining lung in the\n left upper hemithorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233215,
"text": " 1:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for lung collapse, effusion, pna\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with lung ca and sob\n REASON FOR THIS EXAMINATION:\n eval for lung collapse, effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with lung cancer and\n shortness of breath.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Left PICC line tip is at the cavoatrial junction. The patient was extubated.\n There is interval progression of pulmonary edema. Known left mass and\n multiple pulmonary nodules are redemonstrated, partially obscured by pulmonary\n edema and newly appeared bibasal areas of atelectasis and pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-12 00:00:00.000",
"description": "1SR ORDER THOR/BRACHIOCEPHALIC",
"row_id": 1232807,
"text": " 5:42 PM\n BRONCHIAL Clip # \n Reason: please embolize bronchial artery\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: VISAPAQUE Amt: 150\n ********************************* CPT Codes ********************************\n * 1SR ORDER /BRACHIOCEPHALIC VISERAL SEL/SUPERSEL A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with RCC mets to lung and hemoptysis\n REASON FOR THIS EXAMINATION:\n please embolize bronchial artery\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of RCC with metastatic disease to lungs and\n large left hilar mass. Patient now presents with hemoptysis, and potential\n embolization of the bronchial arteries.\n\n\n RADIOLOGISTS: Dr. (fellow), Dr. \n (Resident) were supervised by Dr. and Dr. , attending\n radiologist, throughout the entire procedure.\n\n ANESTHESIA: Procedure performed under moderate sedation.\n\n PROCEDURE:\n\n Prior to initiation of the procedure, potential risks, benefits and\n complications were explained to healthcare proxy, husband. Informed\n consent was subsequently obtained. Patient was brought the angiography suite\n and placed in supine position. Preprocedure timeout and huddle was performed\n per protocol. Right groin area was prepped and draped is usual sterile\n fashion. Under palpatory guidance, right commmon femoral artery for punctured\n with a micropunture needle. A 0.018 microwire was advanced to the left of the\n midline under flouroscopic guidance. The needle was exchanged for a\n micropuncture sheath. A 0.035 Benstson guidwire was advanced into the aorta.\n Several chatheters were used in an attempt to cannulate bronchial arteries. A\n 5 french Mikaelson catheter was used to successfully cannulate the origin of\n the bronchial artery, which immediately bifricated in left and right branches.\n Small amount of contrast was injected and there was no evidence of active\n contrast extravasation. Renegate Hi-Flow microcatheter was used in an\n attempt to selectively cannulate the right bronchial artery. However, due to\n the extreme angle at its origin, the attempt was unsuccessful. The left\n bronchial artery was extremetely small in caliber, which prevented its\n effective cannulataion. The catheter and sheath were removed, hemostatsis was\n achieved with manual compression. A sterile dressing was applied. The\n patient tolerated the procedure well, without immediate complications.\n\n IMPRESSION:\n\n Unsuccessful cannulation of bronchial arteries due to extreme angles at their\n origins. No evidence of active contrast extravasation.\n (Over)\n\n 5:42 PM\n BRONCHIAL Clip # \n Reason: please embolize bronchial artery\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1232978,
"text": " 8:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for pneumothorax\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with pulm mass and hemorrhage\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with pulmonary mass and\n hemorrhage, assess for pneumothorax.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The unilateral left lung intubation device is in place. The left subclavian\n line tip is at the level of mid SVC. There is interval improvement of the\n atelectasis with currently better aerated left upper lung and central position\n of the mediastinum. Bilateral pleural effusions are noted, with no\n appreciable change in the left perihilar mass. Multiple nodules are better\n appreciated on the cross-sectional imaging obtained on . Right\n lower lung opacity might reflect area of atelectasis. Minimal interstitial\n edema is better seen in the right perihilar area. There is no evidence of\n pneumothorax.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-04-17 00:00:00.000",
"description": "Report",
"row_id": 250315,
"text": "Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-04-13 00:00:00.000",
"description": "Report",
"row_id": 250316,
"text": "Normal sinus rhythm. Compared to tracing #1 T waves are more flattened\nin leads V4-V6. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-04-12 00:00:00.000",
"description": "Report",
"row_id": 250317,
"text": "Normal sinus rhythm. Normal tracing. Compared to the previous tracing\nof there is no significant change.\nTRACING #1\n\n"
}
] |
25,624 | 120,431 | 1. CARDIOVASCULAR: The patient finished her 18 hour course of Integrelin post cardiac catheterization and stenting. She was started on aspirin, Plavix, a beta blocker, and ACE inhibitor. She continued to do well without any events on telemetry. Her CKs and troponins trended down. She had no further episodes of any active ischemia. 2. PULMONARY: The patient was diuresed and quickly weaned off the ventilator and extubated without any problems. She was weaned off of her oxygen requirement and by the time of discharge was saturating 97% on room air with stable 02 sat on ambulation. 3. RENAL: She presented with acute renal failure with creatinine of 1.4 to 1.5. Her creatinine trended down to 0.6 to 0.7 by the time of discharge. 4. INFECTIOUS DISEASE: There was some concern about possible aspiration pneumonia; however, the patient remained afebrile with improving pulmonary status. She was not started on antibiotics and remained stable. 5. HEMATOLOGY: After catheterization, the patient had a drop in her hematocrit to the 30s. It remained stable throughout the rest of her hospital stay. | O2 weaned from Cool Neb to NP. Recieving Heparin SQ. Cont to give captopril and hold for SBP<90.Pulm: LS CTA, diminished @ bases. resp. currently neg. d/c foley today. CIs > 2.0. waking ~ 0400, c/o chest discomfort with above statement. 3:46 AM CHEST (PORTABLE AP) Clip # Reason: s/p intubation with transport. SBP 90s to 120s. Occasional strong but NP.GU/GI: Foley patent and draining CYU. K repleted overnight.RESP: LSCTA. And soft with (+) BSs. taken off ~ 0400 with sats remaining 92-95%. MAEs.CV:HR 90s to 100s. rare VEA. INTEGRILLIN 2MIC. Cont on coreg 3.125mg, started on captopril 12.5mg. tol. Probable sinus tachycardiaLeft bundle branch blockSince previous tracing of same date: sinus tachycardia present SR ST OCC PVCS .MAP 60S ,SYSTOLIC 90 TO 110. Cardiac and mediastinal contours are within normal limits. OOB and amb w/ PT around unit 2x, tol well.CV: Tele 80s-90s, rare PVC. even for . BP 99-110/40-50. NG tube placement. Palpable pulses distal with good CSM. AP CHEST: Comparison to prior study of . SBP 95-115. VSS. A/O x3.A/P: labs pnd 0500. ? Last 32. BP dropped transiently 1hr after captopril to 88/32, asymptomatic. status Anticipate AM start. R groin C/D/I, palp pulses. CCU NPN 7A-7PNeuro: Alert and oriented x 3, MAE. WET READ: CCqc TUE 4:10 AM ETT in good position; pulmonary edema FINAL REPORT *ABNORMAL! "SEE CAREVUE FOR ALL OBJECTIVE DATA AND VSO-MS:A/O/X/3. to . ST with rare PVCs. CDI at site. CI 2.7 .NO CO CP . The heart size, mediastinal and hilar contours remain within normal limits. ? Sinus rhythmLeft bundle branch blockSince previous tracing of : no significant change Denies dyspnea.GI/GU: +BS, abd soft, non-tender. sats 92-99% on 3lnc. 300cc.LS crackles right base. > 2.5L(-) for LOS. Sinus rhythmLeft bundle branch blockSince previous tracing of the same date: no significant change Taking POs w/o difficulty, no BM. Lasix 80mg IVP to meet fluid goal. Sinus rhythmLeft bundle branch blockConsider biatrial abnormalityNo previous tracing for comparison RFV sheath in place. REASON FOR THIS EXAMINATION: confirm ngt placement FINAL REPORT INDICATION: Cardiogenic shock. Denies SOB. CCU NPN 1900-0700S: " I feel like I have gas "O: pt. FINDINGS: An endotracheal tube is in satisfactory position approximately 2.3 cm above the level of the carina. IMPRESSION: 1) Satisfactory position of endotracheal tube. Cont to titrate cardiac meds as tol, c/o to floor. Passing flatus and taking POs well.ID: Low grade temps overnight.HEME: HCT with slow decline. PAD 11-13, R groin swan d/c this morning. PAD 10s to 15s. 2) New PA catheter terminates in distal main left pulmonary artery. IMPRESSION: 1) NG tube extends into stomach and off the film. There is a new PA catheter which has been placed from a lower extremity, and terminates in the distal left main pulmonary artery. MAPs 50s to 70s. Goal met. captopril 12.5.foley draining 50-100cc/hr. Given Tylenol and frequent position changes. An ET tube remains in unchanged position, 3 cm above the carina. Sats 95% on RA. Order to start BB but held at MN due to labile BPs. PAS 12 TO 14. EKG no changes. TECHNIQUE: PORTABLE AP CHEST Comparison: None. 2) Pulmonary edema. REASON FOR THIS EXAMINATION: s/p intubation with transport. 3) Moderate improvement in pulmonary edema. Incidental note is made of a prominent loop of bowel in the left upper quadrant. AM pending.A: 71 yo female s/p MI with stent to CxP: Anticipate RFV sheath removal todayContinue to follow fluid balancePossible echo today O2Sat > 95% throughout night. An NG tube has been placed, extending into the stomach and off of the film. There is perihilar fullness as well as diffuse interstitial and air space opacities, consistent with pulmonary edema. K ,MG REPLETED.ART SHEATH DC R FEM ,SWAN REAMAINS NO BLEEDING.PALP DISTAL PULSES .EXTUBATED 5PM SAT 100 ON 50 COOL MASKNPO AT PRESENT POS BSHUO 50 TO 200 CL URINE VIA FOLEY .ALERT,COOPERATIVE, FOLLOWS COMMANDS .STABLE POST PROCEDUREFOLLOW RESP STATUS POST EXTUBATIONMONITOR FOR BLEEDING Since the prior study, patchy perihilar lung opacities have decreased moderately. There are no new focal lung opacities. +130cc today.Social: Various members of pt's family in to visit today, updated by RN.A/P: Pt hemodynamically stable, OOB and amb w/ 1 assist. CCU Nursing Progress Note 1900-0700: s/p MIS-"Today is Tuesday. CLINICAL INDICATION: 71 year old female status-post intubation. Integrillin off at 8PM. No plans for continuous IV heparin. OOB to chair/ambulate. no SOB. Pt arrived from the cath lab via the er, unresponsive intubated in the with a #8 ETT 24 @ the lip. Cont emotional support for pt and family. Foley patent, draining cl yellow urine. Vfib arrest pt remains unresponsive on simv 600 12 100% 5 peep 5 P/S will cont. MEDICAL CONDITION: 71 year old woman with above. Occasional complaints of back discomfort d/t bed. The visualized osseous structures and soft tissues are unremarkable. HUO 35-110/hr, increasing this afternoon w/ increased PO intake. Sleeping throughout early morning. There are no pleural effusions. There are no pleural effusions. 8:50 AM CHEST (PORTABLE AP) Clip # Reason: confirm ngt placement MEDICAL CONDITION: 71 year old woman with cardiogenic shock s/p cath, stent, and intubation. | 11 | [
{
"category": "Radiology",
"chartdate": "2107-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 790304,
"text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation with transport.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with above.\n REASON FOR THIS EXAMINATION:\n s/p intubation with transport.\n ______________________________________________________________________________\n WET READ: CCqc TUE 4:10 AM\n ETT in good position; pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CLINICAL INDICATION: 71 year old female status-post intubation.\n\n TECHNIQUE: PORTABLE AP CHEST\n\n Comparison: None.\n\n FINDINGS: An endotracheal tube is in satisfactory position approximately 2.3\n cm above the level of the carina. Cardiac and mediastinal contours are within\n normal limits. There is perihilar fullness as well as diffuse interstitial and\n air space opacities, consistent with pulmonary edema. There are no pleural\n effusions. The visualized osseous structures and soft tissues are\n unremarkable. Incidental note is made of a prominent loop of bowel in the left\n upper quadrant.\n\n IMPRESSION:\n 1) Satisfactory position of endotracheal tube.\n 2) Pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 790318,
"text": " 8:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm ngt placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cardiogenic shock s/p cath, stent, and intubation.\n REASON FOR THIS EXAMINATION:\n confirm ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Cardiogenic shock. NG tube placement.\n\n AP CHEST: Comparison to prior study of .\n\n An NG tube has been placed, extending into the stomach and off of the film.\n An ET tube remains in unchanged position, 3 cm above the carina. There is a\n new PA catheter which has been placed from a lower extremity, and terminates\n in the distal left main pulmonary artery. The heart size, mediastinal and\n hilar contours remain within normal limits. Since the prior study, patchy\n perihilar lung opacities have decreased moderately. There are no new focal\n lung opacities. There are no pleural effusions.\n\n IMPRESSION:\n 1) NG tube extends into stomach and off the film.\n\n 2) New PA catheter terminates in distal main left pulmonary artery.\n\n 3) Moderate improvement in pulmonary edema.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-05-11 00:00:00.000",
"description": "Report",
"row_id": 1596349,
"text": "CCU Nursing Progress Note 1900-0700: s/p MI\nS-\"Today is Tuesday.\"\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND VS\nO-MS:A/O/X/3. Very pleasant and cooperative. Somewhat groggy on evenings, perking up later during the night. Sleeping throughout early morning. Occasional complaints of back discomfort d/t bed. Given Tylenol and frequent position changes. MAEs.\nCV:HR 90s to 100s. ST with rare PVCs. SBP 90s to 120s. MAPs 50s to 70s. Order to start BB but held at MN due to labile BPs. Anticipate AM start. RFV sheath in place. CDI at site. Palpable pulses distal with good CSM. PAD 10s to 15s. CIs > 2.0. Integrillin off at 8PM. No plans for continuous IV heparin. Recieving Heparin SQ. K repleted overnight.\nRESP: LSCTA. O2 weaned from Cool Neb to NP. O2Sat > 95% throughout night. Denies SOB. Occasional strong but NP.\nGU/GI: Foley patent and draining CYU. Lasix 80mg IVP to meet fluid goal. Goal met. > 2.5L(-) for LOS. And soft with (+) BSs. Passing flatus and taking POs well.\nID: Low grade temps overnight.\nHEME: HCT with slow decline. Last 32. AM pending.\nA: 71 yo female s/p MI with stent to Cx\nP: Anticipate RFV sheath removal today\nContinue to follow fluid balance\nPossible echo today\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-05-11 00:00:00.000",
"description": "Report",
"row_id": 1596350,
"text": "CCU NPN 7A-7P\nNeuro: Alert and oriented x 3, MAE. OOB and amb w/ PT around unit 2x, tol well.\n\nCV: Tele 80s-90s, rare PVC. PAD 11-13, R groin swan d/c this morning. R groin C/D/I, palp pulses. SBP 95-115. Cont on coreg 3.125mg, started on captopril 12.5mg. BP dropped transiently 1hr after captopril to 88/32, asymptomatic. Cont to give captopril and hold for SBP<90.\n\nPulm: LS CTA, diminished @ bases. Sats 95% on RA. Denies dyspnea.\n\nGI/GU: +BS, abd soft, non-tender. Taking POs w/o difficulty, no BM. Foley patent, draining cl yellow urine. HUO 35-110/hr, increasing this afternoon w/ increased PO intake. +130cc today.\n\nSocial: Various members of pt's family in to visit today, updated by RN.\n\nA/P: Pt hemodynamically stable, OOB and amb w/ 1 assist. Cont to titrate cardiac meds as tol, c/o to floor. Cont emotional support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-05-12 00:00:00.000",
"description": "Report",
"row_id": 1596351,
"text": "CCU NPN 1900-0700\nS: \" I feel like I have gas \"\nO: pt. waking ~ 0400, c/o chest discomfort with above statement. EKG no changes. VSS. no SOB. sat up in bed and burped with relief of pain.\nHR 90-100ST. rare VEA. BP 99-110/40-50. tol. captopril 12.5.\nfoley draining 50-100cc/hr. even for . currently neg. 300cc.\nLS crackles right base. sats 92-99% on 3lnc. taken off ~ 0400 with sats remaining 92-95%.(RA)\n\nslept well without aid. A/O x3.\nA/P: labs pnd 0500. ? d/c foley today. OOB to chair/ambulate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-05-10 00:00:00.000",
"description": "Report",
"row_id": 1596347,
"text": "Pt arrived from the cath lab via the er, unresponsive intubated in the with a #8 ETT 24 @ the lip. ? Vfib arrest pt remains unresponsive on simv 600 12 100% 5 peep 5 P/S will cont. to . resp. status\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-05-10 00:00:00.000",
"description": "Report",
"row_id": 1596348,
"text": "SR ST OCC PVCS .MAP 60S ,SYSTOLIC 90 TO 110. PAS 12 TO 14. CI 2.7 .NO CO CP . INTEGRILLIN 2MIC. K ,MG REPLETED.ART SHEATH DC R FEM ,SWAN REAMAINS NO BLEEDING.PALP DISTAL PULSES .\n\nEXTUBATED 5PM SAT 100 ON 50 COOL MASK\n\nNPO AT PRESENT POS BS\n\nHUO 50 TO 200 CL URINE VIA FOLEY .\n\nALERT,COOPERATIVE, FOLLOWS COMMANDS .\n\nSTABLE POST PROCEDURE\n\nFOLLOW RESP STATUS POST EXTUBATION\nMONITOR FOR BLEEDING\n"
},
{
"category": "ECG",
"chartdate": "2107-05-12 00:00:00.000",
"description": "Report",
"row_id": 178550,
"text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-10 00:00:00.000",
"description": "Report",
"row_id": 178551,
"text": "Probable sinus tachycardia\nLeft bundle branch block\nSince previous tracing of same date: sinus tachycardia present\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-10 00:00:00.000",
"description": "Report",
"row_id": 178552,
"text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of the same date: no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-10 00:00:00.000",
"description": "Report",
"row_id": 178553,
"text": "Sinus rhythm\nLeft bundle branch block\nConsider biatrial abnormality\nNo previous tracing for comparison\n\n"
}
] |
45,557 | 133,095 | The following hospital course as follows during his ICU course: The patient was admitted to the trauma surgery intensive care unit for monitoring. Plastic surgery saw the patient and recommended: - head of bed elevation - sinus precautions (no drinking through straw, sneeze with mouth open, no swimming) - recommend Unasyn X 1 week - clear liquid diet only; would not advance given occlusion - repair recommendations to be made following discussion at conference Orthopedic surgery saw the patient and recommended: - J collar for 6 weeks - Follow up in weeks for possible C2 fixation with ENT saw the patient on hospital day one for muffled voice and posterior and pharyngeal edema. Recommended: - Decadron 10mg IV q8 x 3 doses for uvular edema - Airway watch - Humidified O2 at all times | Calcified lymphadenopathy remains. Hypodensity within the anterior limb of the right internal capsule and right insular region are unchanged, likely representing chronic lacunes. There are two nondisplaced fracture of the right zygomatic arch and a nondisplaced fracture of the lateral left orbit. FINDINGS: The right PICC ends in the mid SVC. Known type 2 dens fracture, which remains nondisplaced. Known type 2 dens fracture, which remains nondisplaced. Known type 2 dens fracture, which remains nondisplaced. There is mucosal opacification of the ethmoid and right frontal sinus. Partially imaged nondisplaced type 2 dens fracture. At the level of C6-C7, there is loss of intervertebral disc height. Unchanged moderate tortuosity of the thoracic aorta. Acute nondisplaced fracture involving the posterior spinous process of C5. Acute nondisplaced fracture involving the posterior spinous process of C5. Acute nondisplaced fracture involving the posterior spinous process of C5. Paratracheal right-sided calcifications. There is facet arthrosis and uncovertebral hypertrophy which results in moderate bilateral neural foraminal narrowing. Second opinion CT for a maxillofacial CT. EXAMINATION: Non-contrast head CT. IMPRESSION: AP chest compared to : ET tube is in standard placement and a nasogastric tube passes below the diaphragm and out of view. This results in moderate bilateral neural foraminal narrowing. At the level of C5-C6, there is loss of intervertebral disc height. At the level of C4-C5, there is loss of intervertebral disc height. There is uncovertebral hypertrophy and facet arthrosis. There is facet arthrosis and uncovertebral hypertrophy. Likely chronic right basal ganglia lacunar infarcts. Likely chronic right basal ganglia lacunar infarcts. There is right greater than left preseptal soft tissue swelling without postseptal involvement. There is a hypodensity in the anterior limb of the right internal capsule as well as in the right subinsular region, likely chronic lacunar infarcts. At the level of C3-C4, there is facet arthrosis and uncovertebral hypertrophy, left greater than right that results in moderate neural foraminal narrowing. A C2 nondisplaced type 2 dens fracture is partially imaged. Right maxillary sinus fractures extend to the right alveolar ridge. Right PICC ending in the mid SVC. This results in moderate neural foraminal narrowing. Likely chronic internal capsule and subinsular lacunar infarcts. There is blood and mucosal opacification redemonstrated within the maxillary sinus and the nasopharynx.There is mild scarring in the right lung apex. The cardiac and mediastinal contours are unchanged. There is atherosclerotic calcification involving the vertebral arteries. There is a posterior disc osteophyte complex. CT has limited sensitivity for evaluation of the intrathecal contents. FINDINGS: As compared to the previous radiograph, the patient has been extubated. Borderline size of the cardiac silhouette is unchanged as compared to the previous examination. Thoracic aorta is generally large and tortuous but not focally dilated. Also noted is a moderate amount of blood and air in the retropharynx which causes narrowing of the oropharyngeal wall. Known extensive facial bone fractures are redemonstrated. Coronal and sagittal reformats were acquired. Also noted is significant uncovertebral joint hypertrophy of C5 and C6 left facet joints. There is nopericardial effusion.IMPRESSION: Grossly preserved biventricular systolic function. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Minimal pneumoperitoneum in the setting of recent gastrostomy tube placement. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:There is mild symmetric left ventricular hypertrophy with normal cavity size.There is mild regional left ventricular systolic dysfunction with probablemild inferolateral hypokinesis. Mild mitral regurgitation. Premature atrial contractions and ventricularpremature beats are absent. Mild (1+) MR.TRICUSPID VALVE: Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Right bundle-branch block with left anterior fascicular block.Non-specific ST-T wave changes. Mild mitralregurgitation. No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen.AORTA: Mildy dilated aortic root.AORTIC VALVE: Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild right basilar bronchiectasis. Trace aorticregurgitation is seen. Minimal pneumoperitoneum is explained by recent gastrostomy tube placement. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild regional LVsystolic dysfunction. Modest ST-T wave changes which are throughout. The cardiomediastinal silhouette shows a tortuous aorta. The aortic root is mildly dilated at the sinus level. Unchanged mild cardiomegaly. IMPRESSION: AP chest compared to : New ET tube in standard placement. There is mild subsegmental atelectasis. The visualized intracranial structures appear normal. There is a small amount of secretion above the endotracheal tube cuff. Left axis deviation.Non-specific ST-T wave changes. Left axis deviation.Non-specific ST-T wave changes. Mild cardiomegaly is unchanged. There is nopericardial effusion.IMPRESSION: Suboptimal image quality due to body habitus. Mild (1+) MR.PERICARDIUM: No pericardial effusion.Conclusions:There is mild symmetric left ventricular hypertrophy with normal cavity sizeand global systolic function (LVEF>55%). The right ventricleis not well seen. Possible atrial flutter with moderate ventricular response. The remainder of the mediastinal contours are normal. There is multilevel facet degenerative change and mild neural foraminal narrowing. FINDINGS: The left lung base is excluded on this radiograph. There is left ventricular hypertrophy known from recent cardiac echo. The hilar contours and pleural surfaces are normal. Limited study.Compared with the prior study (images reviewed) of , LV functionappears normal on both studies. Sinus tachycardia with atrial and ventricular ectopy. Sinus tachycardia with atrial and ventricular ectopy. Thoracic aorta generally large but not focally aneurysmal. Theestimated pulmonary artery systolic pressure is normal. PATIENT/TEST INFORMATION:Indication: Syncope.Height: (in) 69Weight (lb): 170BSA (m2): 1.93 m2BP (mm Hg): 131/69HR (bpm): 100Status: InpatientDate/Time: at 10:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. PE REASON FOR THIS EXAMINATION: eval for PE, other acute process No contraindications for IV contrast WET READ: JBRe 2:52 AM 1. Note is also made of right lower lobe mild bronchiectasis (3:63). A lower right paratracheal calcified node as well as a right lower lobe calcified pulmonary nodules are indicative of prior granulomatous exposure. TECHNIQUE: MDCT helical acquisition was performed through the chest before and after the uneventful administration of IV contrast. | 25 | [
{
"category": "Radiology",
"chartdate": "2130-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171923,
"text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate/effusion\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o resp failure, please eval for infiltrate/effusion\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated. There is no evidence of complications, notably no pneumothorax.\n Borderline size of the cardiac silhouette is unchanged as compared to the\n previous examination. Unchanged moderate tortuosity of the thoracic aorta.\n No pleural effusions. No focal parenchymal opacities suggesting pneumonia.\n Paratracheal right-sided calcifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171632,
"text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate/effusion\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o PEA arrest/desaturation, please eval for\n infiltrat/effusion\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with history of pulseless\n electrical activity and desaturation.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6 cm above the carina. The NG tube tip passes below the\n diaphragm terminating in the stomach. Cardiomediastinal silhouette is stable.\n The upper lungs are essentially clear, but slight progression of bibasilar\n opacities is noted that most likely represents atelectasis, but attention to\n this area should be paid especially on the left to exclude the possibility of\n developing infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-29 00:00:00.000",
"description": "L TIB/FIB (AP & LAT) LEFT",
"row_id": 1171192,
"text": " 10:03 AM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: Please eval for fracture\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o trauma to tib/fib, please eval for fracture\n REASON FOR THIS EXAMINATION:\n Please eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT TIB-FIB, \n\n CLINICAL INFORMATION: Trauma, evaluate for fracture.\n\n FINDINGS:\n\n Two views of the left tibia and fibula demonstrate no fracture or\n malalignment. Mild soft tissue edema. Vascular calcifications. Mild\n degenerative changes at the knee joint.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1172349,
"text": " 5:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p fall, ?syncopy\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:31 PM\n PFI:\n 1. No acute intracranial process, but no evidence of acute hemorrhage.\n 2. Known facial bone fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is an 86-year-old male status post fall.\n Questionable syncopal episode. Evaluate for intracranial hemorrhage.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: Comparison is made to multiple prior examinations, including\n and .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered. Coronal and sagittal reformations are\n provided for review.\n\n FINDINGS:\n\n Since the prior examination, there has been significant improvement in the\n right frontotemporal parietal scalp hematoma. Otherwise, there is little\n significant change since . There is no evidence of acute intracranial\n hemorrhage, edema, masses, mass effect, or acute territorial infarction. The\n -white matter differentiation is preserved. The ventricles and sulci are\n stable in size and configuration, demonstrating prominence, particularly of\n the bifrontal extra-axial spaces, most compatible with atrophic change.\n Hypodensity within the anterior limb of the right internal capsule and right\n insular region are unchanged, likely representing chronic lacunes.\n\n Known extensive facial bone fractures are redemonstrated. There is hematoma\n within the bilateral maxillary and sphenoid sinuses and within the nasal\n cavity. Known fractures include the right posterior and inferior orbital\n wall, bilateral maxillary sinuses, pterygoid processes, and the nasal bones.\n There is mucosal opacification of the ethmoid and right frontal sinus. There\n is extensive atherosclerotic calcification involving the internal carotid\n arteries and the vertebral arteries. The mastoid air cells remain well\n aerated.\n\n IMPRESSION:\n 1. No acute intracranial process, with no evidence of intracranial\n hemorrhage.\n (Over)\n\n 5:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Known facial bone fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1172350,
"text": ", M. CC6A 5:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p fall, ?syncopy\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No acute intracranial process, but no evidence of acute hemorrhage.\n 2. Known facial bone fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-05 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1172351,
"text": " 5:41 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for movement of dens fx\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p fall, ?syncopy\n REASON FOR THIS EXAMINATION:\n please eval for movement of dens fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:28 PM\n 1. Known type 2 dens fracture, which remains nondisplaced.\n 2. Acute nondisplaced fracture involving the posterior spinous process of C5.\n 3. Multilevel degenerative changes of the cervical spine as detailed above,\n resulting in anterolisthesis of C4 on C5.\n 4. Known facial bone fractures and hemorrhage within the paranasal sinuses\n and nasopharynx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is an 86-year-old male status post fall.\n Questionable syncopal episode. Evaluate for movement and dens fracture.\n\n EXAMINATION: CT of the cervical spine without intravenous contrast.\n\n COMPARISONS: Comparison is made to CT of the neck from and reference\n CT from .\n\n TECHNIQUE: Helically acquired axial images were obtained through the cervical\n spine. No intravenous contrast was administered. Coronal and sagittal\n reformations are provided for review.\n\n FINDINGS:\n\n The atlantoaxial and atlanto-occipital relationships are maintained. There is\n no prevertebral soft tissue abnormality.\n\n Redemonstrated is an obliquely oriented fracture extending across the dens\n compatible with a type 2 dens fracture. There is no associated displacement.\n In addition, since the prior examination, there has been interval development\n of an obliquely oriented fracture through the posterior spinous process of C5.\n Gross alignment is maintained. There are multilevel degenerative changes of\n the cervical spine as outlined below:\n\n At the level of C2-C3, there is facet arthrosis and uncovertebral hypertrophy,\n left greater than right that results in mild neural foraminal narrowing.\n There is no significant central canal stenosis.\n\n At the level of C3-C4, there is facet arthrosis and uncovertebral hypertrophy,\n left greater than right that results in moderate neural foraminal narrowing.\n There is no significant central canal stenosis.\n\n At the level of C4-C5, there is loss of intervertebral disc height. There is\n (Over)\n\n 5:41 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for movement of dens fx\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n grade 1 anterolisthesis of C4 on C5 vertebral body. There is uncovertebral\n hypertrophy and facet arthrosis. This results in moderate neural foraminal\n narrowing. There is no significant central canal stenosis.\n\n At the level of C5-C6, there is loss of intervertebral disc height. There is\n facet arthrosis and uncovertebral hypertrophy. There is a posterior disc\n osteophyte complex. This results in moderate bilateral neural foraminal\n narrowing. There is no significant central canal stenosis.\n\n At the level of C6-C7, there is loss of intervertebral disc height. There is\n facet arthrosis and uncovertebral hypertrophy which results in moderate\n bilateral neural foraminal narrowing. There is no significant central canal\n stenosis.\n\n Known extensive facial bone fractures are better outlined on the previously\n noted dedicated CT of the facial bones. The visualized inferior brain is\n unremarkable. The lung apices demonstrate mild apical scarring and are\n otherwise clear. There is atherosclerotic calcification involving the\n vertebral arteries. Secretions are demonstrated within the posterior aspect\n of the trachea. Visualized aspects of the mastoids remain well aerated.\n There is blood and mucosal opacification redemonstrated within the maxillary\n sinus and the nasopharynx.There is mild scarring in the right lung apex.\n\n CT has limited sensitivity for evaluation of the intrathecal contents. The\n visualized outline of the thecal sac appears unremarkable.\n\n IMPRESSION:\n 1. Known type 2 dens fracture, which remains nondisplaced.\n 2. Acute nondisplaced fracture involving the posterior spinous process of C5.\n 3. Multilevel degenerative changes of the cervical spine as detailed above,\n resulting in anterolisthesis of C4 on C5.\n 4. Known facial bone fractures and hematoma within the paranasal sinuses and\n nasopharynx.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-05 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1172352,
"text": ", M. CC6A 5:41 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for movement of dens fx\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p fall, ?syncopy\n REASON FOR THIS EXAMINATION:\n please eval for movement of dens fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Known type 2 dens fracture, which remains nondisplaced.\n 2. Acute nondisplaced fracture involving the posterior spinous process of C5.\n 3. Multilevel degenerative changes of the cervical spine as detailed above,\n resulting in anterolisthesis of C4 on C5.\n 4. Known facial bone fractures and hemorrhage within the paranasal sinuses\n and nasopharynx.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1172928,
"text": " 9:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 53cm\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with new picc\n REASON FOR THIS EXAMINATION:\n r picc 53cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC placement, assess position.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right PICC ends in the mid SVC. Increased opacification of the\n right lower lung is suspicious for pneumonia. The remainder of the lungs are\n clear. The cardiac and mediastinal contours are unchanged. There are no\n pleural abnormalities.\n\n IMPRESSION:\n 1. Right PICC ending in the mid SVC.\n 2. Increased right lower lung opacity, suspicious for pneumonia.\n\n These findings were reported to at 12:15 p.m. via\n telephone on the day of the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171744,
"text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with s/p PEA arrest\n REASON FOR THIS EXAMINATION:\n please eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M. ON \n\n HISTORY: 86-year-old man with PEA arrest.\n\n IMPRESSION: AP chest compared to :\n\n ET tube is in standard placement and a nasogastric tube passes below the\n diaphragm and out of view. Lungs are low in volume but clear. There is no\n pneumothorax or appreciable pleural effusion. Heart is top normal size.\n Thoracic aorta is generally large and tortuous but not focally dilated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-28 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1171093,
"text": " 3:54 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; OUTSIDE FILMS READ ONLYClip # \n Reason: Second opinion for CT maxillofacial done at \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man status post fall. Second opinion CT for a\n maxillofacial CT.\n\n TECHNIQUE: MDCT images were acquired through the face without IV contrast.\n Bone kernel reconstructions and multiplanar reformations were obtained and\n reviewed at an outside hospital.\n\n FINDINGS:\n\n There are multiple comminuted fractures of both maxillary sinuses (medial,\n lateral and inferior walls), the right lateral orbital wall, the bilateral\n lateral and medial pterygoid and the bilateral nasal bones. Right maxillary\n sinus fractures extend to the right alveolar ridge. There are two nondisplaced\n fracture of the right zygomatic arch and a nondisplaced fracture of the\n lateral left orbit. There is significant soft tissue swelling of the adjacent\n face with high-density material filling the nasal cavities, maxillary sinus\n and tracking down into the oropharynx. The mandible is intact with no\n fractures noted. There is right greater than left preseptal soft tissue\n swelling without postseptal involvement. A C2 nondisplaced type 2 dens\n fracture is partially imaged. Also noted is significant uncovertebral joint\n hypertrophy of C5 and C6 left facet joints. Also noted is a moderate amount\n of blood and air in the retropharynx which causes narrowing of the\n oropharyngeal wall.\n\n IMPRESSION:\n\n 1. Fractures of the nasal bones, bilateral maxilla, right zygomaticotemporal\n arch, bilateral lateral orbital walls, and bilateral pterygoid plates suggest\n Le Fort type III on the right and a Le Fort type II fracture on the left.\n\n 2. Partially imaged nondisplaced type 2 dens fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172736,
"text": " 7:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with AMS and elevated white count\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n WET READ: NATg 9:11 PM\n Increased miliary opacities in right lower lobe and loss of medial diaphragm\n may represent developing infection. Calcified lymphadenopathy remains.\n Cardiomediastinal contour is stable.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: AMS, respiratory failure.\n\n Comparison film .\n\n Since this time some faint opacities can be seen within the right lower lobe\n which may represent early evidence of a right lower lobe pneumonia. No other\n changes are seen. No failure is present.\n\n IMPRESSION:\n Probable early right lower lobe pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1171311,
"text": " 1:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P HYPOXEMIC ARREST. ? ICH\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with fall 2d ago, now s/p hypoxemic arrest with ROSC\n REASON FOR THIS EXAMINATION:\n eval for ICH,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBRe 4:14 AM\n PFI:\n 1. No acute intracranial process. Likely chronic right basal ganglia lacunar\n infarcts.\n 2. Known facial bone fractures\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with fall two days ago, now with hypoxic arrest.\n Please assess for intracranial hemorrhage.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n FINDINGS:\n No acute intracranial hemorrhage, cerebral edema, mass effect or large acute\n territorial infarction. There is a hypodensity in the anterior limb of the\n right internal capsule as well as in the right subinsular region, likely\n chronic lacunar infarcts. These lesions are also seen on an outside hospital\n facial bone CT; however, this study is limited for assessment of brain\n parenchyma.\n\n Predominantly frontal lobe involutional changes. Large right\n frontotemporoparietal subgaleal hematoma. Re-demonstrated are multiple facial\n bone fractures including right posterior and inferior orbital floor, bilateral\n maxillary sinus wall, pterygoid process fractures with hemorrhage in the\n maxillary sinuses, nasal cavity and sphenoid sinuses. The mastoid air cells\n are clear and well aerated.\n\n IMPRESSION:\n 1. No acute intracranial process. Likely chronic internal capsule and\n subinsular lacunar infarcts.\n 2. Known facial bone fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1171312,
"text": ", M. TSICU 1:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P HYPOXEMIC ARREST. ? ICH\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with fall 2d ago, now s/p hypoxemic arrest with ROSC\n REASON FOR THIS EXAMINATION:\n eval for ICH,\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No acute intracranial process. Likely chronic right basal ganglia lacunar\n infarcts.\n 2. Known facial bone fractures\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-30 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1171313,
"text": " 1:17 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CARDIAC ARREST. ? PE\n Admitting Diagnosis: S/P FALL\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with cardiac arrest, ? PE\n REASON FOR THIS EXAMINATION:\n eval for PE, other acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe 2:52 AM\n 1. No PE. No acute cardiothoracic process.\n 2. Bibasilar atelectasis\n 3. Enlarged right pulmonary artery.\n 4. Mild right basilar bronchiectasis.\n 5. Subglottic and proximal tracheal secretions with risk for aspiration.\n 6. Liver cyst.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with cardiac arrest. Evaluate for PE or other\n acute process.\n\n COMPARISON: Chest radiograph performed one hour earlier in ICU.\n\n TECHNIQUE: MDCT helical acquisition was performed through the chest before\n and after the uneventful administration of IV contrast. Multiplanar\n reformations, as well as 5- and 2.5-mm collimation images were reviewed.\n\n CTA CHEST WITH IV CONTRAST: Pulmonary arterial opacification is adequate, and\n there is no evidence of pulmonary embolus. There is a small amount of\n secretion above the endotracheal tube cuff. There is no focal consolidation.\n Note is also made of right lower lobe mild bronchiectasis (3:63). There is\n mild subsegmental atelectasis. There is no evidence of pulmonary edema.\n\n The right pulmonary artery is enlarged to 3.0 cm. There is left ventricular\n hypertrophy known from recent cardiac echo. There is no supraclavicular or\n axillary lymphadenopathy. A lower right paratracheal calcified node as well\n as a right lower lobe calcified pulmonary nodules are indicative of prior\n granulomatous exposure.\n\n A segment liver cyst is seen (3:102) but the partially\n imaged upper abdomen and osseous structures are otherwise unremarkable.\n\n IMPRESSION:\n\n 1. No pulmonary embolus.\n 2. Bilateral subsegmental lower lobe atelectasis.\n (Over)\n\n 1:17 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CARDIAC ARREST. ? PE\n Admitting Diagnosis: S/P FALL\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-28 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1171129,
"text": " 9:04 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for worsening edema, non-contrast\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o facial/C-spine trauma, with evidence of\n retropharyngeal hematoma on previous CT, with increasing edema in oropharynx.\n Please eval for worsening obstruction\n REASON FOR THIS EXAMINATION:\n please eval for worsening edema, non-contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg WED 9:39 PM\n Type II dens fx. Facial fractures better appreciated on OSH images.\n Regarding question of retropharyngeal hematoma, none is evident. There are\n secretions within the oro- and -pharynx. The vasculature of the neck and\n intracranial contents are unremarkable.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 86-year-old male with question of retropharyngeal\n hematoma with increasing difficulty breathing.\n\n COMPARISON: Outside films performed same day.\n\n TECHNIQUE: Axial images were acquired of the neck following the\n administration of intravenous contrast. These were reformatted in the coronal\n and sagittal planes.\n\n FINDINGS: No retropharyngeal hematoma is evident. Secretions with mottled\n gas and liquid are layered in the nasopharynx, and oropharynx. Evaluation of\n the floor of the mouth is limited by streak artifact from dental hardware.\n The vasculature of the neck is normal in appearance. The visualized\n intracranial structures appear normal.\n\n BONE WINDOWS: There is a type II fracture of the dens, which is nondisplaced.\n There is multilevel disc space narrowing of the cervical vertebral bodies with\n anterolisthesis of C4 on 5. There is multilevel facet degenerative change and\n mild neural foraminal narrowing. Facial fractures are redemonstrated, better\n appreciated on outside hospital studies, which include fractures through the\n anterior and lateral walls of the maxillary sinuses bilaterally as well as\n nasal bone fractures. Air-fluid levels are seen in the maxillary sinuses\n bilaterally and in the sphenoid sinuses. The mastoid air cells are clear.\n\n The lung apices are clear. There is atherosclerotic calcification of the\n aortic arch.\n\n IMPRESSION: No retropharyngeal hematoma is seen. Mottled secretions layering\n within the nasal and oropharynx are present.\n\n These findings were discussed with Dr. , trauma ICU resident, at\n approximately 9:30 p.m.\n (Over)\n\n 9:04 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for worsening edema, non-contrast\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171309,
"text": " 12:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n please eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:44 A.M. ON :\n\n HISTORY: 86-year-old man, hypoxic respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n New ET tube in standard placement. Lungs clear. Heart size normal. Thoracic\n aorta generally large but not focally aneurysmal. Stomach is newly distended\n with gas. No pleural abnormality.\n\n Granulomatous calcifications project over the paratracheal mediastinal\n stations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-11 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1173145,
"text": " 2:04 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess for aspiration\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with fall and cervical spine fx, now w/ dysphagia\n REASON FOR THIS EXAMINATION:\n assess for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dysphagia.\n\n SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video fluoroscopy was\n performed in conjunction with the speech and swallow division. Multiple\n consistencies of barium were administered. Barium passed freely through the\n oropharynx without evidence of obstruction. There was penetration of honey\n and puree consistencies. There was aspiration of nectar.\n\n IMPRESSION: Aspiration of nectar and penetration of honey and puree. For\n details, please refer to speech and swallow note in OMR.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-01-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173437,
"text": " 9:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 47 cm Picc placed in left basilic vein, need Picc tip placem\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc placed in left basilic vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC placement, assess position.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The left lung base is excluded on this radiograph. The left PICC\n ends near the superior cavoatrial junction. Right basilar atelectasis or\n pneumonia has increased. Mild cardiomegaly is unchanged. The thoracic aorta\n is tortuous. The remainder of the mediastinal contours are normal. There are\n no pleural abnormalities. Minimal pneumoperitoneum is explained by recent\n gastrostomy tube placement. Borderline dilated gas-filled loops of colon are\n seen.\n\n IMPRESSION:\n\n 1. Increased right basilar atelectasis or pneumonia.\n\n 2. Unchanged mild cardiomegaly.\n\n 3. Minimal pneumoperitoneum in the setting of recent gastrostomy tube\n placement.\n\n These findings were reported to at 1:20 p.m. via telephone\n on the day of the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1171062,
"text": " 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx, aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with multiple injuries\n REASON FOR THIS EXAMINATION:\n eval ptx, aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with multiple injuries. Evaluate for\n pneumothorax.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and clear. The cardiomediastinal silhouette shows\n a tortuous aorta. The hilar contours and pleural surfaces are normal. No\n pleural effusions or pneumothoraces are noted. No definite displaced rib\n fractures are seen.\n\n IMPRESSION:\n\n No acute intrathoracic process. No definite fractured ribs are noted,\n although if this is a clinical concern then consider dedicated rib radiographs\n for further evaluation.\n\n"
},
{
"category": "Echo",
"chartdate": "2129-12-29 00:00:00.000",
"description": "Report",
"row_id": 61607,
"text": "PATIENT/TEST INFORMATION:\nIndication: Syncope.\nHeight: (in) 69\nWeight (lb): 170\nBSA (m2): 1.93 m2\nBP (mm Hg): 131/69\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 10:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Beat-to-beat variability on LVEF due to irregular\nrhythm/premature beats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with probable\nmild inferolateral hypokinesis. There is considerable beat-to-beat variability\nof the left ventricular ejection fraction due to an irregular rhythm/premature\nbeats. The aortic root is mildly dilated at the sinus level. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality due to body habitus. Left ventricular\nsystolic function is difficult to assess due to irregular rhythm and\nsuboptimal image quality. The inferolateral wall may be mildly hypokinetic.\nOther focal wall motion abnormalities cannot be excluded. The right ventricle\nis not well seen. Mild mitral regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2129-12-30 00:00:00.000",
"description": "Report",
"row_id": 61640,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Interval change, s/p cardiac arrest.\nHeight: (in) 69\nWeight (lb): 165\nBSA (m2): 1.91 m2\nBP (mm Hg): 96/55\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 16:11\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npt is intubated on vent, with neck brace on.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Due to suboptimal technical quality,\na focal wall motion abnormality cannot be fully excluded. Right ventricular\nchamber size and free wall motion are normal. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Grossly preserved biventricular systolic function. Mild mitral\nregurgitation. Limited study.\n\nCompared with the prior study (images reviewed) of , LV function\nappears normal on both studies.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-29 00:00:00.000",
"description": "Report",
"row_id": 114083,
"text": "Sinus tachycardia with atrial and ventricular ectopy. Left axis deviation.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthere is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-28 00:00:00.000",
"description": "Report",
"row_id": 114084,
"text": "Sinus tachycardia with atrial and ventricular ectopy. Left axis deviation.\nNon-specific ST-T wave changes. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2130-01-05 00:00:00.000",
"description": "Report",
"row_id": 114081,
"text": "Possible atrial flutter with moderate ventricular response. Borderline\nleft axis deviation. Modest ST-T wave changes which are throughout. Compared\nto the previous tracing of probable atrial flutter is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2129-12-30 00:00:00.000",
"description": "Report",
"row_id": 114082,
"text": "Sinus rhythm. Right bundle-branch block with left anterior fascicular block.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthe ventricular rate is slower. Premature atrial contractions and ventricular\npremature beats are absent. Lateral T waves are now upright. Right\nbundle-branch block is new.\n\n"
}
] |
77,101 | 119,691 | 70F with PAF, tachy/brady syndrome presents with symptomatic bradycardia with sinus pauses of up to 4 seconds. . # BRADYCARDIA ?????? symptomatic with sick sinus syndrome: Patient with PAF on diltiazem and flecanide & previously known tachy-brady syndrome with symptomatic sinus pauses presents with dizziness and is found to have intermittent sinus arrest with pauses up to 4 seconds. She was planned for a pacemaker placement later this week. Initially her junctional escape was proven to be reliable and she did not require a temporary pacing wire. However, she then developed very frequent pauses up to 5 seconds in duration with symptomatic bradycardia. She was treated with dopamine which improved her heart rate to the 50s with symptom resolution. She had a pacemaker placed the next day without complication. Of note, her TSH was elevated at 6.1, but her free T4 was normal. She should have a repeat TSH in a 4-6 weeks. . # DIZZINESS / VERTIGO / LIGHTHEADEDNESS: bradycardia, now resolved. . # FEN: Patient received cardiac healthy diet. She tolerated POs well. . # CODE STATUS: Full code | Mild (1+) mitral regurgitation is seen. Pt cont to c/o mild HA at top of head and currently cont to c/o nausea additional zofran given. Pt cont to c/o mild HA at top of head and currently cont to c/o nausea additional zofran given. Pt cont to c/o mild HA at top of head and currently cont to c/o nausea additional zofran given Plan: Moderate tricuspid regurgitation. Moderate [2+] tricuspid regurgitation is seen. - pacemaker placement - restart diltiazem, flecanide - hold coumadin s/p placement - follow up CXR - abx x3 days - follow EP recs DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH) KNOWLEDGE DEFICIT ICU Care Nutrition: NPO p MN Glycemic Control: Lines: 18 Gauge - 01:00 PM Prophylaxis: DVT: SQH Stress ulcer: none VAP: none Comments: Communication: Comments: Patient Code status: Full code Disposition: To floor today PROPHYLAXIS: -DVT ppx with SQH -Bowel regimen . There is a trivial/physiologic pericardial effusion. - pacemaker placement - restart diltiazem, flecanide - hold coumadin s/p placement - follow up CXR - abx x3 days DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH) KNOWLEDGE DEFICIT ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 01:00 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Bradycardia Assessment: Action: Response: Plan: Dizziness / vertigo / lightheadedness (LH) Assessment: Action: Response: Plan: Diltiazem and Flecanide on hold. Mild mitral regurgitation. Diltazem & Flecanide restarted. At that time nbp noted to be 130/55 with map of 77, dopamine gtt off for a few moments with gtt back on at 3mcg and nbp 109/50 Plan: cont to assess nausea and c/o HA At that time nbp noted to be 130/55 with map of 77, dopamine gtt off for a few moments with gtt back on at 3mcg and nbp 109/50 Plan: cont to assess nausea and c/o HA ------ Protected Section ------ Consents for procedure in chart Pt would like family updated post-op ------ Protected Section Addendum Entered By: , RN on: 05:59 ------ Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is a trivial/physiologic pericardial effusion. Moderate tricuspid regurgitation. Moderate tricuspid regurgitation. Bradycardia Assessment: HR upon admission to CCU 33-36 with nbp 113/50 Action: On monitor, ekg done, minimal po fluid at this time r/t ? Bradycardia Assessment: HR upon admission to CCU 33-36 with nbp 113/50 Action: On monitor, ekg done, minimal po fluid at this time r/t ? Moderate [2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Diltiazem and Flecanide on hold. I would add the following remarks: History recent lightheaded w/o recent change meds. Mild mitral regurgitation. Mild mitral regurgitation. Permanent PM tomorrow for SSS (tachy-brady) with profound bradycardia. Permanent PM tomorrow for SSS (tachy-brady) with profound bradycardia. Diltazem & Flecanide restarted. PROPHYLAXIS: -DVT ppx with SQH -Bowel regimen . PROPHYLAXIS: -DVT ppx with SQH -Bowel regimen . Subtle ST-T wave flattening in lead V6consistent with myocardial ischemia. # Rhythm: Given duration of pauses and symptoms meets criteria for permanent pacer implantation. # Rhythm: Given duration of pauses and symptoms meets criteria for permanent pacer implantation. Mildly dilated right ventricle with normal function. Mildly dilated right ventricle with normal function. Denies dizziness. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: s/p cath at without CAD -PACING/ICD: PLANNED as per HPI 3. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: s/p cath at without CAD -PACING/ICD: PLANNED as per HPI 3. Consider dopamin if BP drops, or if signs of organ hypoperfusion (elevated Cr, decreased urine output) 4. Consider dopamin if BP drops, or if signs of organ hypoperfusion (elevated Cr, decreased urine output) 4. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. Dsg is C&D. DISPO: CCU ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:47 AM Prophylaxis: DVT: SQ UF Heparin(Systemic anticoagulation: None) Stress ulcer: Not indicated VAP: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Full code Disposition: ICU COMM: patient . COMM: patient . Plan: Monitor closely- atropine 1mg @ bedside- on monitor w/ pacer pads in place- cont dopamine gtt ? | 27 | [
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "CCU Fellow addendum",
"row_id": 611987,
"text": "TITLE: CCU Fellow Addendum\n Patient seen and discussed with CCU housestaff. For details, see CCU\n resident H&P. Briefly, the patient is a 70 year old woman, patient of\n Dr. and Dr. , with PMH of AF, with episodes of sinus\n arrest and tachy/brady syndrome who was originally scheduled for PPM\n placement on Monday, but who began to develop symptoms of\n lightheadedness at home while resting and came into the ED where she\n was found to have sinus bradycardia at 35-40, with episodes of sinus\n arrest with junctional escape rhythm in the 30s. Blood pressure in the\n ED was stable in the 130-140s systolic, although she did complain of LH\n with the longer pauses of seconds. She was admitted to the CCU for\n close observation, and after discussion with EP, plan will be to hold\n off on temp wire or chronotropic agents for now, and proceed with PPM\n tomorrow as scheduled. The patient continues to have episodes of\n bradycardia, although she is asymptomatic currently. Will continue\n close observation today, NPO for likely PPM tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 611989,
"text": "Chief Complaint: dizziness\n HPI:\n 70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours.\n .\n This morning she presented to the ED and was noted to have sinus pauses\n up to 3 seconds, intermittently in a junctional escape at a rate of 30\n maintaining adequate pressures. In the ED, initial vitals were 123/46\n with HR 40. She received only Aspirin, zofran and 1L of NS in the ED\n prior to admission to the CCU. Temporary pacing wire was not placed in\n the ED.\n .\n She stopped taking amiodarone in after developing\n transaminitis. Her last dose of coumadin was on in anticipation\n of the elective procedure scheduled for this week.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth 1x week on Tues\n DILTIAZEM HCL - - 120 mg XR DAILY\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] 40MG DAILY\n ESTRADIOL [VAGIFEM] - 25 mcg Tablet - 3x /week\n FEXOFENADINE [] - 180 mg\n FLECAINIDE - 100 mg Tablet - \n MEDROXYPROGESTERONE - - 5 mg 4x /year\n SERTRALINE - - 100 mg Tablet daily\n SIMVASTATIN - - 20 mg Tablet - daily\n WARFARIN - 2.5 daily, holding since \n ZOLPIDEM - 5 mg Tablet - daily\n ASPIRIN - 325 mg Tablet - daily\n CALCIUM with Vit D\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p cath at without CAD\n -PACING/ICD: PLANNED as per HPI\n 3. OTHER PAST MEDICAL HISTORY:\n - Paroxysmal atrial fibrillation S/p prior DCCV\n - Hyperlipidemia\n - Mild asthma\n - GERD\n - s/p right laparoscopic oophrectomy\n - pulmonary nodules\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death.\n Mother: died of esophageal carcinoma in her 90s\n Father: died of pancreatic carcinoma in his 70s\n Occupation: retired teacher\n Drugs: none\n Tobacco: none\n Alcohol: occ socially\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Flowsheet Data as of 07:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 46 (46 - 46) bpm\n BP: 113/50(64) {113/50(64) - 113/50(64)} mmHg\n RR: 19 (19 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 9 mL\n PO:\n TF:\n IVF:\n 9 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -166 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: The left atrium is normal in size. The right atrium is\n moderately dilated. The estimated right atrial pressure is 0-10mmHg.\n Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). There is no left ventricular\n outflow obstruction at rest or with Valsalva. The right ventricular\n cavity is mildly dilated with normal free wall contractility. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. No aortic regurgitation is seen. The mitral valve\n leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There\n is mild pulmonary artery systolic hypertension. There is a\n trivial/physiologic pericardial effusion.\n .\n IMPRESSION: Normal left ventricular systolic function without outflow\n obstruction. Mild mitral regurgitation. Mildly dilated right ventricle\n with normal function. Moderate tricuspid regurgitation.\n .\n CATH WITH REPORTEDLY NO CAD at \n Microbiology: none\n ECG: sinus bradycardia in 30s with intermittent sinus arrest and\n subsequent junctional escape. PR~200, longer than prior. Prolonged QT.\n Normal Axis. No STT changes concerning for ischemia.\n Assessment and Plan\n BRADYCARDIA\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n 70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds.\n .\n # Rhythm: Given duration of pauses and symptoms meets criteria for\n permanent pacer implantation. At this time, her junctional escape has\n proven to be reliable and she does not require a temporary pacing wire.\n - atropine at bedside, pacing pads in place, hold all nodal blocking\n agents at this time\n - d/w with EP regarding timing of placement of permanent pacer.\n INR=1.4. Nothing to suggest ongoing infection.\n .\n FEN: NPO for possible procedure today\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with SQH\n -Bowel regimen\n .\n CODE: full, confirmed\n .\n COMM: patient\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM p Rounds:\n - no plan to resume diltiazem or flecanide until after the PPM\n placement\n - PPM placement Monday\n - will condider dopamine if renal fxn declines or MAPs persistently\n under 55.\n - NPO p MN\n ------ Protected Section Addendum Entered By: , MD\n on: 11:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612049,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Tachy/brady syndrome\n Assessment:\n Tele: junctional rhythm w/ occ sinus beats- HR 30\ns w/ up to 5 sec\n pauses noted- c/o lightheadedness & nausea w/ each episode.\n Action:\n Pacer pads in place- new # 18 PIV placed L arm- CCU team & EP in to\n evaluate patient- dopamine gtt started\n & is presently infusing @ 3mcq/kg/min via R PIV.\n Response:\n HR increased 50\ns- no further pauses or c/o lightheadedness & nausea-\n hemodynamically stable- voiding qs.\n Plan:\n Monitor closely- atropine 1mg @ bedside- on monitor w/ pacer pads\n in place- con\nt dopamine gtt\n ? central line if dopamine requirement\n increases- NPO after 12am for insertion of PPM tomorrow.\n Addendum: HR 50\ns on dopamine gtt @ 3mcq/kg/min- 1L NS @ 150cc/hr X1\n ordered & hung @ 1900- urinary output good- (-) 800cc @ present.\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612143,
"text": "70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours.\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 612157,
"text": "Chief Complaint: 70F with PAF on diltiazem and flecanide, tachy/brady\n syndrome p/w dizziness. Found to have symptomatic sinus pauses up to 4\n seconds and bradycardia with HR in 30 BPM in EW.\n 24 Hour Events:\n No events\n .\n Cont on DA\n History obtained from Patient\n Allergies:\n History obtained from PatientCodeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from prior note except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.2\n HR: 52 (34 - 61) bpm\n BP: 117/44(63) {91/42(56) - 131/63(77)} mmHg\n RR: 13 (4 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 62 Inch\n Total In:\n 2,078 mL\n 551 mL\n PO:\n 1,080 mL\n 130 mL\n TF:\n IVF:\n 998 mL\n 421 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,575 mL\n Urine:\n 2,725 mL\n 1,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -647 mL\n -1,024 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 372 K/uL\n 10.8 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 17 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.3 %\n 10.6 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 10.6\n Hct\n 33.3\n Plt\n 372\n Cr\n 0.9\n Glucose\n 96\n Other labs: PT / PTT / INR:16.1/35.3/1.4, Ca++:9.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.8 mg/dL\n CXR:\n UPRIGHT AP VIEW OF THE CHEST: The lungs are clear without focal\n opacity. The\n cardiomediastinal silhouette, hilar contours, and pulmonary vasculature\n are\n not significantly changed from prior. There is no overt pulmonary edema\n or\n evidence of CHF. There is no pleural effusion or pneumothorax. There is\n slight elevation of the left hemidiaphragm.\n IMPRESSION: No acute intrathoracic abnormality.\n ECG: Sinus bradycardia with atrial premature beats and\n junctional beats.\n Assessment and Plan\n BRADYCARDIA\n symptomatic with sick sinus syndrome.\n - pacemaker placement\n - restart diltiazem, flecanide\n - hold coumadin s/p placement\n - follow up CXR\n - abx x3 days\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 612158,
"text": "Chief Complaint: 70F with PAF on diltiazem and flecanide, tachy/brady\n syndrome p/w dizziness. Found to have symptomatic sinus pauses up to 4\n seconds and bradycardia with HR in 30 BPM in EW.\n 24 Hour Events:\n No events\n .\n Cont on DA\n History obtained from Patient\n Allergies:\n History obtained from PatientCodeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from prior note except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.2\n HR: 52 (34 - 61) bpm\n BP: 117/44(63) {91/42(56) - 131/63(77)} mmHg\n RR: 13 (4 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 62 Inch\n Total In:\n 2,078 mL\n 551 mL\n PO:\n 1,080 mL\n 130 mL\n TF:\n IVF:\n 998 mL\n 421 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,575 mL\n Urine:\n 2,725 mL\n 1,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -647 mL\n -1,024 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 372 K/uL\n 10.8 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 17 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.3 %\n 10.6 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 10.6\n Hct\n 33.3\n Plt\n 372\n Cr\n 0.9\n Glucose\n 96\n Other labs: PT / PTT / INR:16.1/35.3/1.4, Ca++:9.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.8 mg/dL\n CXR:\n UPRIGHT AP VIEW OF THE CHEST: The lungs are clear without focal\n opacity. The\n cardiomediastinal silhouette, hilar contours, and pulmonary vasculature\n are\n not significantly changed from prior. There is no overt pulmonary edema\n or\n evidence of CHF. There is no pleural effusion or pneumothorax. There is\n slight elevation of the left hemidiaphragm.\n IMPRESSION: No acute intrathoracic abnormality.\n ECG: Sinus bradycardia with atrial premature beats and\n junctional beats.\n Assessment and Plan\n 70F with PAF, tachy/brady syndrome presents with symptomatic\n bradycardia with sinus pauses of up to 4 seconds.\n BRADYCARDIA\n symptomatic with sick sinus syndrome.\n - pacemaker placement\n - restart diltiazem, flecanide\n - hold coumadin s/p placement\n - follow up CXR\n - abx x3 days\n - follow EP recs\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition: NPO p MN\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: none\n VAP: none\n Comments:\n Communication: Comments: Patient\n Code status: Full code\n Disposition: To floor today\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 612162,
"text": "Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612141,
"text": "Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612142,
"text": "Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 612165,
"text": "70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours\n Bradycardia\n Assessment:\n Tele this am sinus brady 40\ns-60\n Dopamine 3mcgs/kg/min.\n Denies dizziness.\n OOB to commode.\n Diltiazem and Flecanide on hold.\n Action:\n To EP lab for PPM.\n Diltazem & Flecanide restarted.\n Maintained on bed rest post procedure.\n Sling to L arm.\n Post procedure instructions reviewed.\n Response:\n AVPaced at 60.\n Dsg is C&D.\n Plan:\n PA & lateral xray in am.\n Bedrest until am.\n ? transfer to 3 if bed available.\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612081,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Bradycardia\n Assessment:\n pt has hx of paf, hr 40-50\ns JR which seems to fluctuate back to sr as\n p waves are seen on ekg, pt scheduled for pacemaker placement this am\n Action:\n dopamine gtt titrated to 3.5 mcg to maintain map >60, ns at 150cc/hr x\n 1 L, npo after mn for procedure\n Response:\n map 60-70 since increase in dopamine gtt rate to 3.5 mcg, ivf to kvo\n team aware. Pt is 1000 cc negative at 5am, hr sr rate of 50\n Plan:\n cont with dopa to maintain map >60, monitor fluid balance\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n no c/o dizziness of vertigo during eves, pt did have c/o mild HA\n Action:\n Tylenol ordered for HA and given,\n Response:\n pt c/o nausea at 440 am, order for zofran obtained and 4mg iv given at\n 445 am. Pt cont to c/o mild HA at top of head and currently cont to c/o\n nausea additional zofran given. At that time nbp noted to be 130/55\n with map of 77, dopamine gtt off for a few moments with gtt back on at\n 3mcg and nbp 109/50\n Plan:\n cont to assess nausea and c/o HA\n ------ Protected Section ------\n Consents for procedure in chart\n Pt would like family updated post-op\n ------ Protected Section Addendum Entered By: , RN\n on: 05:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612078,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Bradycardia\n Assessment:\n pt has hx of paf, hr 40-50\ns JR which seems to fluctuate back to sr as\n p waves are seen on ekg, pt scheduled for pacemaker placement this am\n Action:\n dopamine gtt titrated to 3.5 mcg to maintain map >60, ns at 150cc/hr x\n 1 L, npo after mn for procedure\n Response:\n map 60-70 since increase in dopamine gtt rate to 3.5 mcg, ivf to kvo\n team aware. Pt is 1000 cc negative at 5am, hr sr rate of 50\n Plan:\n cont with dopa to maintain map >60, monitor fluid balance\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n no c/o dizziness of vertigo during eves, pt did have c/o mild HA\n Action:\n Tylenol ordered for HA and given,\n Response:\n pt c/o nausea at 440 am, order for zofran obtained and 4mg iv given at\n 445 am. Pt cont to c/o mild HA at top of head and currently cont to c/o\n nausea additional zofran given. At that time nbp noted to be 130/55\n with map of 77, dopamine gtt off for a few moments with gtt back on at\n 3mcg and nbp 109/50\n Plan:\n cont to assess nausea and c/o HA\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612076,
"text": "Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612077,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Bradycardia\n Assessment:\n pt has hx of paf, hr 40-50\ns JR which seems to fluctuate back to sr as\n p waves are seen on ekg, pt scheduled for pacemaker placement this am\n Action:\n dopamine gtt titrated to 3.5 mcg to maintain map >60, ns at 150cc/hr x\n 1 L, npo after mn for procedure\n Response:\n map 60-70 since increase in dopamine gtt rate to 3.5 mcg, ivf to kvo\n team aware. Pt is 1000 cc negative at 5am, hr sr rate of 50\n Plan:\n cont with dopa to maintain map >60, monitor fluid balance\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n no c/o dizziness of vertigo during eves, pt did have c/o mild HA\n Action:\n Tylenol ordered for HA and given,\n Response:\n pt c/o nausea at 440 am, order for zofran obtained and 4mg iv given at\n 445 am. Pt cont to c/o mild HA at top of head and currently cont to c/o\n nausea additional zofran given\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612021,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612023,
"text": "70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds- admitted to CCU for further monitoring.\n .\n Tachy/brady syndrome\n Assessment:\n Tele: junctional rhythm w/ occ sinus beats- HR 30\ns w/ up to 5 sec\n pauses noted- c/o lightheadedness & nausea w/ each episode.\n Action:\n Pacer pads in place- new # 18 PIV placed L arm- CCU team & EP in to\n evaluate patient- dopamine gtt started\n & is presently infusing @ 3mcq/kg/min via R PIV.\n Response:\n HR increased 50\ns- no further pauses or c/o lightheadedness & nausea-\n hemodynamically stable- voiding qs.\n Plan:\n Monitor closely- atropine 1mg @ bedside- on monitor w/ pacer pads\n in place- con\nt dopamine gtt\n ? central line if dopamine requirement\n increases- NPO after 12am for insertion of PPM tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "EP note",
"row_id": 612012,
"text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: 70 yo F with a history of PAF\n currently managed with diltiazem and flecanide & tachy-brady syndrome\n for which she was scheduled to have an elective permanent pacemaker\n implantation this week presented to the ED with worsening dizziness. A\n holter monitor (report not in our system) showed sinus pauses up to 4\n seconds during daylight hours. In the ED and was noted to have sinus\n bradycadria at a rate of 30 bpm, with junctional escape. Temporary\n pacing wire was not placed in the ED as patient is hemodynamically\n stable. Notably, sh stopped taking amiodarone in after\n developing transaminitis. Her last dose of coumadin was on in\n anticipation of the elective procedure scheduled for this week. Other\n medical history is significant for hypelipidemia.\n Medications\n Changed\n HOME MEDICATIONS:\n ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth 1x week on Tues\n DILTIAZEM HCL - - 120 mg XR DAILY\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] 40MG DAILY\n ESTRADIOL [VAGIFEM] - 25 mcg Tablet - 3x /week\n FEXOFENADINE [] - 180 mg\n FLECAINIDE - 100 mg Tablet - \n MEDROXYPROGESTERONE - - 5 mg 4x /year\n SERTRALINE - - 100 mg Tablet daily\n SIMVASTATIN - - 20 mg Tablet - daily\n WARFARIN - 2.5 daily, holding since \n ZOLPIDEM - 5 mg Tablet - daily\n ASPIRIN - 325 mg Tablet - daily\n CALCIUM with Vit D\n CURRENT MEDICATIONS:\n Heparin 5000 UNIT SC TID\n Alendronate Sodium 70 mg PO QTUES\n Pantoprazole 40 mg daily\n Fexofenadine 60 mg \n Sertraline 100 mg daily\n Simvastatin 20 mg daily\n Aspirin 325 mg daily\n Physical Exam\n General appearance: A&O x3\n No acute distress\n BP: 94 / 61 mmHg\n HR: 34 bpm\n RR: 16 insp/min\n Tmax C last 24 hours: 37.2 C\n Tmax F last 24 hours: 98.9 F\n T current C: 37.2 C\n T current F: 98.9 F\n Previous day:\n Output: 0 mL\n Fluid balance: 0 mL\n Today:\n Intake: 45 mL\n Output: 175 mL\n Fluid balance: -130 mL\n HEENT: (Conjunctiva and lids: Anicteric), (Oral mucosa: Moist),\n (Jugular veins: Not elevated)\n Cardiovascular: (Auscultation: Slow RRR, no murmurs)\n Respiratory: (Auscultation: CTA)\n Abdomen: (Palpation: Soft, non-tender)\n Neurological: (Orientation: A&O x3), (Motor / Sensory: No gross motor\n deficit)\n Tests\n ECG: (Date: ), Slow sinus rhythm with nodal escape\n Assessment and Plan\n BRADYCARDIA\n 1. Permanent PM tomorrow for SSS (tachy-brady) with profound\n bradycardia.\n 2. Hold Coumadin\n 3. Consider dopamin if BP drops, or if signs of organ hypoperfusion\n (elevated Cr, decreased urine output)\n 4. NPO midnight\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "EP note",
"row_id": 612016,
"text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: 70 yo F with a history of PAF\n currently managed with diltiazem and flecanide & tachy-brady syndrome\n for which she was scheduled to have an elective permanent pacemaker\n implantation this week presented to the ED with worsening dizziness. A\n holter monitor (report not in our system) showed sinus pauses up to 4\n seconds during daylight hours. In the ED and was noted to have sinus\n bradycadria at a rate of 30 bpm, with junctional escape. Temporary\n pacing wire was not placed in the ED as patient is hemodynamically\n stable. Notably, sh stopped taking amiodarone in after\n developing transaminitis. Her last dose of coumadin was on in\n anticipation of the elective procedure scheduled for this week. Other\n medical history is significant for hypelipidemia.\n Medications\n Changed\n HOME MEDICATIONS:\n ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth 1x week on Tues\n DILTIAZEM HCL - - 120 mg XR DAILY\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] 40MG DAILY\n ESTRADIOL [VAGIFEM] - 25 mcg Tablet - 3x /week\n FEXOFENADINE [] - 180 mg\n FLECAINIDE - 100 mg Tablet - \n MEDROXYPROGESTERONE - - 5 mg 4x /year\n SERTRALINE - - 100 mg Tablet daily\n SIMVASTATIN - - 20 mg Tablet - daily\n WARFARIN - 2.5 daily, holding since \n ZOLPIDEM - 5 mg Tablet - daily\n ASPIRIN - 325 mg Tablet - daily\n CALCIUM with Vit D\n CURRENT MEDICATIONS:\n Heparin 5000 UNIT SC TID\n Alendronate Sodium 70 mg PO QTUES\n Pantoprazole 40 mg daily\n Fexofenadine 60 mg \n Sertraline 100 mg daily\n Simvastatin 20 mg daily\n Aspirin 325 mg daily\n Physical Exam\n General appearance: A&O x3\n No acute distress\n BP: 94 / 61 mmHg\n HR: 34 bpm\n RR: 16 insp/min\n Tmax C last 24 hours: 37.2 C\n Tmax F last 24 hours: 98.9 F\n T current C: 37.2 C\n T current F: 98.9 F\n Previous day:\n Output: 0 mL\n Fluid balance: 0 mL\n Today:\n Intake: 45 mL\n Output: 175 mL\n Fluid balance: -130 mL\n HEENT: (Conjunctiva and lids: Anicteric), (Oral mucosa: Moist),\n (Jugular veins: Not elevated)\n Cardiovascular: (Auscultation: Slow RRR, no murmurs)\n Respiratory: (Auscultation: CTA)\n Abdomen: (Palpation: Soft, non-tender)\n Neurological: (Orientation: A&O x3), (Motor / Sensory: No gross motor\n deficit)\n Tests\n ECG: (Date: ), Slow sinus rhythm with nodal escape\n Assessment and Plan\n BRADYCARDIA\n 1. Permanent PM tomorrow for SSS (tachy-brady) with profound\n bradycardia.\n 2. Hold Coumadin\n 3. Consider dopamin if BP drops, or if signs of organ hypoperfusion\n (elevated Cr, decreased urine output)\n 4. NPO midnight\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n recent lightheaded w/o recent change meds. last diltiazem last night\n Physical Examination\n bp , p low\n rr, jvp low\n pulses symmetric\n skin:pale, dry\n extr:l 1+ edema\n Medical Decision Making\n perm pacer tomorrow, hydrate, dopamine for now\n ------ Protected Section Addendum Entered By: \n on: 15:35 ------\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 611951,
"text": "Per pt. she had been having difficulty with dizziness over last 6\n months. Per pt had change in her heart medications and she feels this\n is the reason why she has had problems with her heart. Pt also states\n that she has been more forgetful and sometimes forgets whether she took\n her medications or not. Pt also reports that she is having problems\n with her memory and wonders if it is a result of change in medications\n and low HR.\n Bradycardia\n Assessment:\n HR upon admission to CCU 33-36 with nbp 113/50\n Action:\n On monitor, ekg done, minimal po fluid at this time r/t ? surgery\n today.\n Response:\n Hr is stable in low 30\ns nbp stable\n Plan:\n Resident is awaiting to hear from CCU team whether Pacemenaker will be\n placed today,\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n Pt reports being lightheaded at this time, stating she does not feel\n normal\n Action:\n Pt on bedrest, monitored while on commode\n Response:\n Pt continues to feel light headed , bed alarm on.\n Plan:\n Cont to assess and supervise if ambulating\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 611953,
"text": "Chief Complaint: dizziness\n HPI:\n 70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours.\n .\n This morning she presented to the ED and was noted to have sinus pauses\n up to 3 seconds, intermittently in a junctional escape at a rate of 30\n maintaining adequate pressures. In the ED, initial vitals were 123/46\n with HR 40. She received only Aspirin, zofran and 1L of NS in the ED\n prior to admission to the CCU. Temporary pacing wire was not placed in\n the ED.\n .\n She stopped taking amiodarone in after developing\n transaminitis. Her last dose of coumadin was on in anticipation\n of the elective procedure scheduled for this week.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth 1x week on Tues\n DILTIAZEM HCL - - 120 mg XR DAILY\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] 40MG DAILY\n ESTRADIOL [VAGIFEM] - 25 mcg Tablet - 3x /week\n FEXOFENADINE [] - 180 mg\n FLECAINIDE - 100 mg Tablet - \n MEDROXYPROGESTERONE - - 5 mg 4x /year\n SERTRALINE - - 100 mg Tablet daily\n SIMVASTATIN - - 20 mg Tablet - daily\n WARFARIN - 2.5 daily, holding since \n ZOLPIDEM - 5 mg Tablet - daily\n ASPIRIN - 325 mg Tablet - daily\n CALCIUM with Vit D\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p cath at without CAD\n -PACING/ICD: PLANNED as per HPI\n 3. OTHER PAST MEDICAL HISTORY:\n - Paroxysmal atrial fibrillation S/p prior DCCV\n - Hyperlipidemia\n - Mild asthma\n - GERD\n - s/p right laparoscopic oophrectomy\n - pulmonary nodules\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death.\n Mother: died of esophageal carcinoma in her 90s\n Father: died of pancreatic carcinoma in his 70s\n Occupation: retired teacher\n Drugs: none\n Tobacco: none\n Alcohol: occ socially\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Flowsheet Data as of 07:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 46 (46 - 46) bpm\n BP: 113/50(64) {113/50(64) - 113/50(64)} mmHg\n RR: 19 (19 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 9 mL\n PO:\n TF:\n IVF:\n 9 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -166 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: The left atrium is normal in size. The right atrium is\n moderately dilated. The estimated right atrial pressure is 0-10mmHg.\n Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). There is no left ventricular\n outflow obstruction at rest or with Valsalva. The right ventricular\n cavity is mildly dilated with normal free wall contractility. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. No aortic regurgitation is seen. The mitral valve\n leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There\n is mild pulmonary artery systolic hypertension. There is a\n trivial/physiologic pericardial effusion.\n .\n IMPRESSION: Normal left ventricular systolic function without outflow\n obstruction. Mild mitral regurgitation. Mildly dilated right ventricle\n with normal function. Moderate tricuspid regurgitation.\n .\n CATH WITH REPORTEDLY NO CAD at \n Microbiology: none\n ECG: sinus bradycardia in 30s with intermittent sinus arrest and\n subsequent junctional escape. PR~200, longer than prior. Prolonged QT.\n Normal Axis. No STT changes concerning for ischemia.\n Assessment and Plan\n BRADYCARDIA\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n 70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds.\n .\n # Rhythm: Given duration of pauses and symptoms meets criteria for\n permanent pacer implantation. At this time, her junctional escape has\n proven to be reliable and she does not require a temporary pacing wire.\n - atropine at bedside, pacing pads in place, hold all nodal blocking\n agents at this time\n - d/w with EP regarding timing of placement of permanent pacer.\n INR=1.4. Nothing to suggest ongoing infection.\n .\n FEN: NPO for possible procedure today\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with SQH\n -Bowel regimen\n .\n CODE: full, confirmed\n .\n COMM: patient\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 612048,
"text": "Per pt. she had been having difficulty with dizziness over last 6\n months. Per pt had change in her heart medications and she feels this\n is the reason why she has had problems with her heart. Pt also states\n that she has been more forgetful and sometimes forgets whether she took\n her medications or not. Pt also reports that she is having problems\n with her memory and wonders if it is a result of change in medications\n and low HR.\n Bradycardia\n Assessment:\n HR upon admission to CCU 33-36 with nbp 113/50\n Action:\n On monitor, ekg done, minimal po fluid at this time r/t ? surgery\n today.\n Response:\n Hr is stable in low 30\ns nbp stable\n Plan:\n Resident is awaiting to hear from CCU team whether Pacemenaker will be\n placed today,\n Dizziness / vertigo / lightheadedness (LH)\n Assessment:\n Pt reports being lightheaded at this time, stating she does not feel\n normal\n Action:\n Pt on bedrest, monitored while on commode\n Response:\n Pt continues to feel light headed , bed alarm on.\n Plan:\n Cont to assess and supervise if ambulating\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 612206,
"text": "70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours\n Bradycardia\n Assessment:\n Tele this am sinus brady 40\ns-60\n Dopamine 3mcgs/kg/min.\n Denies dizziness.\n OOB to commode.\n Diltiazem and Flecanide on hold.\n Action:\n To EP lab for PPM.\n Diltazem & Flecanide restarted.\n Maintained on bed rest post procedure.\n Sling to L arm.\n Post procedure instructions reviewed.\n Response:\n AVPaced at 60.\n Dsg is C&D.\n Plan:\n PA & lateral xray in am.\n Bedrest until am.\n ? transfer to 3 if bed available.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n BRADYCARDIA\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 58.1 kg\n Daily weight:\n 60.5 kg\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Precautions:\n PMH: Asthma\n CV-PMH: Arrhythmias, CAD\n Additional history: PT IS FOLLOWED BY DR. IN EPS AND DR \n FOR CARDIOLOGY. PT HAD PLANNED PACEMAKER PLACEMENT SCHEDULED FOR MONDAY\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:60\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,197 mL\n 24h total out:\n 2,125 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 04:23 AM\n Potassium:\n 4.3 mEq/L\n 04:23 AM\n Chloride:\n 105 mEq/L\n 04:23 AM\n CO2:\n 28 mEq/L\n 04:23 AM\n BUN:\n 17 mg/dL\n 04:23 AM\n Creatinine:\n 0.9 mg/dL\n 04:23 AM\n Glucose:\n 96 mg/dL\n 04:23 AM\n Hematocrit:\n 33.3 %\n 04:23 AM\n Valuables / Signature\n Patient valuables: glasses & cell phone\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer:\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 612118,
"text": "Chief Complaint: 70F with PAF on diltiazem and flecainide, tachy/brady\n syndrome p/w dizziness. Found to have symptomatic sinus pauses up to 4\n seconds and bradycardia with HR in 30 BPM in EW.\n 24 Hour Events:\n No events\n .\n Cont on DA\n History obtained from Patient\n Allergies:\n History obtained from PatientCodeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.2\n HR: 52 (34 - 61) bpm\n BP: 117/44(63) {91/42(56) - 131/63(77)} mmHg\n RR: 13 (4 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 62 Inch\n Total In:\n 2,078 mL\n 551 mL\n PO:\n 1,080 mL\n 130 mL\n TF:\n IVF:\n 998 mL\n 421 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,575 mL\n Urine:\n 2,725 mL\n 1,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -647 mL\n -1,024 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 372 K/uL\n 10.8 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 17 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.3 %\n 10.6 K/uL\n [image002.jpg]\n 04:23 AM\n WBC\n 10.6\n Hct\n 33.3\n Plt\n 372\n Cr\n 0.9\n Glucose\n 96\n Other labs: PT / PTT / INR:16.1/35.3/1.4, Ca++:9.1 mg/dL, Mg++:1.8\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n BRADYCARDIA\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 612035,
"text": "Chief Complaint: dizziness\n HPI:\n 70 yo F with a history of PAF currently managed with diltiazem and\n flecanide & tachy-brady syndrome for which she was scheduled to have an\n elective permanent pacemaker implantation this week presented to the ED\n with worsening dizziness. A holter monitor (report not in our system)\n showed sinus pauses up to 4 seconds during daylight hours.\n .\n This morning she presented to the ED and was noted to have sinus pauses\n up to 3 seconds, intermittently in a junctional escape at a rate of 30\n maintaining adequate pressures. In the ED, initial vitals were 123/46\n with HR 40. She received only Aspirin, zofran and 1L of NS in the ED\n prior to admission to the CCU. Temporary pacing wire was not placed in\n the ED.\n .\n She stopped taking amiodarone in after developing\n transaminitis. Her last dose of coumadin was on in anticipation\n of the elective procedure scheduled for this week.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth 1x week on Tues\n DILTIAZEM HCL - - 120 mg XR DAILY\n ESOMEPRAZOLE MAGNESIUM [NEXIUM] 40MG DAILY\n ESTRADIOL [VAGIFEM] - 25 mcg Tablet - 3x /week\n FEXOFENADINE [] - 180 mg\n FLECAINIDE - 100 mg Tablet - \n MEDROXYPROGESTERONE - - 5 mg 4x /year\n SERTRALINE - - 100 mg Tablet daily\n SIMVASTATIN - - 20 mg Tablet - daily\n WARFARIN - 2.5 daily, holding since \n ZOLPIDEM - 5 mg Tablet - daily\n ASPIRIN - 325 mg Tablet - daily\n CALCIUM with Vit D\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p cath at without CAD\n -PACING/ICD: PLANNED as per HPI\n 3. OTHER PAST MEDICAL HISTORY:\n - Paroxysmal atrial fibrillation S/p prior DCCV\n - Hyperlipidemia\n - Mild asthma\n - GERD\n - s/p right laparoscopic oophrectomy\n - pulmonary nodules\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death.\n Mother: died of esophageal carcinoma in her 90s\n Father: died of pancreatic carcinoma in his 70s\n Occupation: retired teacher\n Drugs: none\n Tobacco: none\n Alcohol: occ socially\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Flowsheet Data as of 07:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 46 (46 - 46) bpm\n BP: 113/50(64) {113/50(64) - 113/50(64)} mmHg\n RR: 19 (19 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 9 mL\n PO:\n TF:\n IVF:\n 9 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -166 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: The left atrium is normal in size. The right atrium is\n moderately dilated. The estimated right atrial pressure is 0-10mmHg.\n Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). There is no left ventricular\n outflow obstruction at rest or with Valsalva. The right ventricular\n cavity is mildly dilated with normal free wall contractility. The\n diameters of aorta at the sinus, ascending and arch levels are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. No aortic regurgitation is seen. The mitral valve\n leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\n mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There\n is mild pulmonary artery systolic hypertension. There is a\n trivial/physiologic pericardial effusion.\n .\n IMPRESSION: Normal left ventricular systolic function without outflow\n obstruction. Mild mitral regurgitation. Mildly dilated right ventricle\n with normal function. Moderate tricuspid regurgitation.\n .\n CATH WITH REPORTEDLY NO CAD at \n Microbiology: none\n ECG: sinus bradycardia in 30s with intermittent sinus arrest and\n subsequent junctional escape. PR~200, longer than prior. Prolonged QT.\n Normal Axis. No STT changes concerning for ischemia.\n Assessment and Plan\n BRADYCARDIA\n DIZZINESS / VERTIGO / LIGHTHEADEDNESS (LH)\n KNOWLEDGE DEFICIT\n 70 yo F with PAF on diltiazem and flecanide & previously known\n tachy-brady syndrome with symptomatic sinus pauses presents with\n dizziness and is found to have intermittent sinus arrest with pauses up\n to 3 seconds.\n .\n # Rhythm: Given duration of pauses and symptoms meets criteria for\n permanent pacer implantation. At this time, her junctional escape has\n proven to be reliable and she does not require a temporary pacing wire.\n - atropine at bedside, pacing pads in place, hold all nodal blocking\n agents at this time\n - d/w with EP regarding timing of placement of permanent pacer.\n INR=1.4. Nothing to suggest ongoing infection.\n .\n FEN: NPO for possible procedure today\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with SQH\n -Bowel regimen\n .\n CODE: full, confirmed\n .\n COMM: patient\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:47 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ADDENDUM p Rounds:\n - no plan to resume diltiazem or flecanide until after the PPM\n placement\n - PPM placement Monday\n - will condider dopamine if renal fxn declines or MAPs persistently\n under 55.\n - NPO p MN\n ------ Protected Section Addendum Entered By: , MD\n on: 11:41 ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). , .\n I would add the following remarks:\n Medical Decision Making\n see remarks in addendum to Dr \n ------ Protected Section Addendum Entered By: \n on: 17:31 ------\n"
},
{
"category": "ECG",
"chartdate": "2161-11-23 00:00:00.000",
"description": "Report",
"row_id": 297550,
"text": "Atrially paced rhythm at rate of 60. Subtle ST-T wave flattening in lead V6\nconsistent with myocardial ischemia. Compared to the previous tracing\nof sinus pauses with junctional escape have given way to atrially\npaced rhythm and overall ventricular rate has risen from 40-60.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Report",
"row_id": 297551,
"text": "Sinus bradycardia with atrial premature beats and junctional beats. No\nsignificant change compared with tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-22 00:00:00.000",
"description": "Report",
"row_id": 297552,
"text": "Sinus bradycardia with atrial premature beats and junctional beats. Compared\nto the previous tracing of the rate is slower with appearance of\njunctional beats.\nTRACING #1\n\n"
}
] |
14,394 | 142,343 | Pt is a 67M with h/o of multiple medical problems including VF arrest now w/ AICD, ischemic cardiomyopathy EF 25-30%, CAD s/p CABG and mechanical MVR, CVA w/ residual L weakness admitted for shortness of breath and fever due to probable CHF exacerbation vs. infection (UTI vs. endocarditis). In ED, the patient was noted to be tachy to 110s, O2 sat 91-94% RA w/ ambulation. Pt underwent CTA to evaluate for PE ->revealed severe CHF. No large PE, but limited by motion. Given lasix 40mg IV, w/ good response ~ 600cc out w/in the first hour. Then approximately 700cc overnight and became acutely hypotensive (systolic in the 80's). The pt was diaphoretic but mentating and was fluid resuscitated, which brought his pressure back up. On the patient underwent a transthoracic echocardiogram which showed an ejection fraction of 15% (which was decreased compared with his study at in ) and increased gradient to ~16mm across his mechanical mitral valve. On he underwent a transesophageal echo which showed partial thrombosis of the mechanical mitral prosthesis with severe inflow obstruction (MS). Severe stasis of the LA/LAA. Possible pacemaker lead infection. At this point in time a multiservice evaluation took place. Cardiology recommended patient's options to be thrombolysis of clot vs. valve replacement as soon as possible given developing thrombis shown on echo. Cardiac surgery evaluated patient for mechanical MV replacement and spoke with family regarding this. At this time the family wishes to proceed with a replacement. The patient underwent angio on in preparation for possible replacement surgery. Neurology consultation for anticoagulation recs: neuro feels pt is ok to be tx'ed with heparin and ok for thrombolysis procedure. Hematology felt that the patient was ok for heparin now (goal PTT 80-100), but long terms dosing is high risk. On he was taken to the operating room where he underwent a Redo MVR and CABG x 2. He was transferred to the CSRU in critical but stable condition on multiple pressors. An IABP was placed post operatively. On POD #1 he was seen by transplant/general surgery for concern of ischemia gut given high pressor requirement, and increasing lactic acidosis. He continued to be followed by ID for question of endocarditis, there was no evidence of infection intraoperatively or on microbiology and his antibiotics were discontinued. After much volume repletion his vasoactive were able to be weaned over several days. His IABP was removed on POD #2. He was extubated on POD #3. He had initally been started on amiodarone post operatively, but had heart block and the amiodarone was dc'd. He then had SVT which terminated with beta blockade. He was transferred to the floor on POD #6. He was followed for neurology throughout his postoperative course for a re-presentation/exacerbation of his previous CVA. On he had a carotid u/s which showed < 40%. He was ready for discharge to rehab on POD # 10. | Simple atheroma in aortic arch. Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA thrombus.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal ascending aortadiameter. Normal aortic archdiameter. Nl interventricular septal motion.AORTA: Normal aortic diameter at the sinus level. Non- specific mediastinal lymphadenopathy as detailed above. Right internal jugular vascular catheter sheath has been removed, and right PICC line has been placed, terminating at the junction of the superior vena cava and right atrium. Again seen is a left-sided AICD with its leads overlying the right atrium and floor of the right ventricle. IMPRESSION: Moderate hydrostatic edema from cardiac decompensation. There is mild dilatation of the right lateral ventricle due to surrounding volume loss. Normal descending aorta diameter.Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is a trace to miild MR seen along with the mobile leafletconsistent with its washing jet.9) There is no pericardial effusion.PostBypass:Mild RV global systolic dysfunction.Patient is on epinephrine, milrinone and levophed. The cardiac and mediastinal contours are stable given differences in positioning and technique. Mild spondylotic change is noted throughout the mid thoracic spine. There is stable left basilar pleural effusion, unchanged position of the right-sided PICC line with its tip at the cavoatrial junction, and stable position as well of the left-sided, dual chamber pacemaker and its leads. Right jugular sheath ends in the SVC, and right atrial pacer and right ventricular pacer defibrillator leads are in standard placements, unchanged. Noatrial septal defect is seen by 2D or color Doppler.3) Left ventricular wall thicknesses are normal. PROCEDURE AND FINDINGS: Using ultrasound, the right basilic vein was found to be patent and compressible. Overall left ventricular systolic function is severelydepressed with EF of 15 to 20%.5) There is mild to moderate global right ventricular free wall hypokinesis.There is mild TR with normal septal motions.6) There are simple atheroma in the aortic arch and descending thoracic aorta.7) The aortic valve leaflets (3) are mildly thickened with no stenosis orregurgitation.8) There is a bileaflet mechanical mitral valve with the preserved motion ofthe leaflet close to the aortic valve. There is a 1.0 cm echodense, cessile mass along postero-lateralannulus ( ) of the mitral valve prosthesis that may represent thrombus.Trivial mitral regurgitation is seen. Noaortic regurgitation is seen. Probable thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Ruleout myocardial infarction. generalized edema noted. Poor R wave progression - consider anterior wall myocardialinfarction of undetermined age. Poor R wave progression - consider anterior wall myocardialinfarction of undetermined age. Probable junctional rhythmPremature ventricular contractionsOld inferior infarctProbable old anterior infarctT wave changes are nonspecificLeft bundle branch blockSince previous tracing of , junctional rhythm and ventricular prematurecomplex are present ct's draining minimalneuro: levetiracetam restarted. Mitral regurgitation is present butcannot be quantified. right antecubital picc line placed.resp: lungs clear, diminished at times. Non-diagnostic inferiorQ waves are noted. ]TRICUSPID VALVE: Mild [1+] TR. Mild (1+) mitral regurgitation is seen.There is no pericardial effusion.Compared with the prior study (images reviewed) of the newly notedfindings include (1) LA/LAA severe SEC (2) likely partial thrombosis of theMVR with complete restriction of the posterior prothetic leaflet (3) possiblevegetations on the pacemaker leads. Trace aortic regurgitation is seen. Filamentous strands onthe aortic leaflets c/with Lambl's excresences (normal variant). Prior inferiormyocardial infarction. Sinus rhythm and occasional atrial and ventricular ectopy. Intraventricular conduction delay of left bundle-branchblock type. Moderate to severespontaneous echo contrast is present in the left atrial appendage (earlythrombus). Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Left ventricular wall thicknesses are normal. No VSD.RIGHT VENTRICLE: RV function depressed.AORTA: Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). A mass/thrombus associated with acatheter/pacing wire in the RA or RV.LEFT VENTRICLE: LV not well seen.RIGHT VENTRICLE: RV not well seen.AORTA: Normal ascending aorta diameter. Compared to the previous tracing of sinus tachycardiais absent.TRACING #2 Abnormal MVRleaflet/disc motion. The gradient noted across the mitralprosthesis is similar.IMPRESSION: Partial thrombosis of the mechanical mitral prosthesis with severeinflow obstruction (MS). Moderate to severe spontaneous echocontrast is seen in the body of the left atrium. Vasopressin gtts weaned off. changedto cpap/ps with acceptable abg. PULSES AS CHARTED ON CAREVUE.HEPARIN SQ TID.RESP-RESTED ON CMV OVERNOC AND PUT BACK ON CPAP/PS @ 0500. albuterol nebs given. sbp labile, on epi, levo, vasopressin. SVO2 58-62 MD at and aware, 1 L LR bolus given. + doppler PP. Perrla 2mm sluggish.CV: Received HR 95-100s ST w/ BBB. hydralizine added w/minimal effect. FIO2 and PEEP weaned as tolerated by ABG results. HYPOACTIVE BS. To go by FICK MD . last creatinine was 1.1. Received on epi 0.03mcg/kg/min,milrinone 0.5mcg/kg/min,vasopressin 3units/hr, levophed 0.15mcg/kg/min. EKG taken. Monitor resp. abd firm & distended. good diuresis after lasix. hst stable. amio d/c'd. IABP remains 1:1 with good augmentation. shift update:neuro: lethargic. cpt done. pt given fluid bolus today x 4 d/t low sov2 and low filling pressures. CI by thermodilution <2, by FICK >2, MD aware and MD at and aware, see carevue. pt given amio bolus and started on amio gtt at 1 mg/min. resp. sternal incision draining cant serosang, scant sang drainage around ct sites.feet cool, edematous, has pt and dp pulses by doppler. Minimal diurese with lasix. mdi's given by ?pt understanding & effectiveness. encouraged to cdb, cough weak. breath sounds clear, decreased at bases, ett suctioned for small to mod amts thick white secretions, vagal response to suctioning x 2 with sbp drop to 70s, recovered with trendelenburg. rhythum change noted->awire tracing done which confirmed junctional w/chb. Keep sedated overnoc. Faint BS. ogt to lcs, small amt faintly bilious drainage. last abg was 7.43/32/81/22/-1. AMIO GTT @ 0.5MG/HR.K+ REPLETED X1. carept. WBC=14.2 CONTINUES ON FLAGYL IV.CHEST TUBES DRG SCANT AMT S/S DRG.GI- ABD OBESE. OGT + placement. Pt in SR with occassional PVC's. Lacate trending down although still remains elvated -> last lacate was 2.4. general surgery team following.resp: LS coase - clear with suctioing. SXD MOD. wbc elvated althought coming donw. Lasix started with minimal diurese. Minimal serosanquinous drainage. t&r.cv/skin: junctional w/chb. | 47 | [
{
"category": "Radiology",
"chartdate": "2198-03-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 952214,
"text": " 12:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p IABP insertion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2\n\n REASON FOR THIS EXAMINATION:\n s/p IABP insertion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:33 A.M., \n\n HISTORY: Status post MVR redo. IABP.\n\n IMPRESSION: AP chest compared to through 8:\n\n Tip of the intraaortic balloon pump projects over the left main bronchus,\n standard placement. Left subclavian transvenous right atrial and right\n ventricular pacer defibrillator leads are in standard placements. Bilateral\n pleural and mediastinal drains are unchanged in position. There is no\n pneumothorax or more than minimal pleural effusion but there is mild widening\n of the superior mediastinum due to fluid accumulation or vascular engorgement.\n ET tube is in standard placement and a nasogastric tube ends in the stomach.\n No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953221,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2 and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n Right internal jugular vascular catheter sheath has been removed, and right\n PICC line has been placed, terminating at the junction of the superior vena\n cava and right atrium. An ICD is in standard position. Cardiac and\n mediastinal contours are stable. Lung volumes remain low. Perihilar haziness\n has improved consistent with improving edema, and bibasilar atelectasis shows\n slight improvement as well. Small residual left pleural effusion is noted,\n and there is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 953371,
"text": " 9:47 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion - please do when he comes down for carotid\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67M ischemic s/p mvr and cabg\n REASON FOR THIS EXAMINATION:\n evaluate effusion - please do when he comes down for carotid u/s thank you\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate known left-sided pleural effusion.\n\n COMPARISON: Prior chest radiograph from .\n\n TECHNIQUE AND FINDINGS: Portable frontal and lateral chest radiographs were\n obtained at the bedside with a grid, in upright position.\n\n Mild further improvement in basilar atelectasis, especially on the left, is\n noted as compared to yesterday. There is stable left basilar pleural\n effusion, unchanged position of the right-sided PICC line with its tip at the\n cavoatrial junction, and stable position as well of the left-sided, dual\n chamber pacemaker and its leads. The cardiomediastinal silhouette,\n mediastinal clips and sternotomy wires are unchanged. Lung volumes remain\n low.\n\n CONCLUSION: Mild ongoing improvement of left basilar atelectasis but stable\n left pleural effusion as compared to yesterday.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 952193,
"text": " 5:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Postoperative radiograph.\n\n There has been interval new median sternotomy and cardiovascular surgery.\n Endotracheal tube terminates about 5 cm above the carina, a Swan-Ganz catheter\n terminates in distal right pulmonary artery, nasogastric tube courses below\n the diaphragm, and mediastinal drains and bilateral chest tubes are present.\n There is no pneumothorax evident on this supine radiograph. Cardiac and\n mediastinal contours are slightly widened, likely due to a combination of\n postoperative change and mild volume overload. Perihilar haziness is present\n as well bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952678,
"text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx. please call pager w/results\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2 and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx. please call pager w/results\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:05 P.M., \n\n HISTORY: Status post MVR. Chest tube removed.\n\n IMPRESSION: AP chest compared to through 13:\n\n Pleural and mediastinal drains have been removed. Lung volumes remain low,\n and moderately severe pulmonary edema and left lower lobe atelectasis have\n both worsened. Post-operative cardiomediastinal silhouette is unremarkable\n and unchanged. Right jugular sheath ends in the SVC, and right atrial pacer\n and right ventricular pacer defibrillator leads are in standard placements,\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 952942,
"text": " 9:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o new CVA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p redo MVR/CABG, s/p CVA in past.\n REASON FOR THIS EXAMINATION:\n r/o new CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN\n\n HISTORY: Status post redo mitral valve replacement and coronary artery bypass\n procedure, status post prior CVA. Rule out new CVA.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: Non-contrast head CT scan, reported by Drs. , \n and as revealing \"no intracranial pathology or hemorrhage identified.\n Extensive encephalomalacia from prior ischemic events\".\n\n FINDINGS: Comparison with the prior CT scans re-demonstrates the large right\n middle cerebral artery territory infarct, moderately large left posterior\n cerebral artery territory infarct and a much smaller inferior division left\n middle cerebral artery infarct, all chronic appearing. Within the limits of\n CT scanning, there is no new infarct identified. There is also a probable\n small chronic left cerebellar hemispheric infarct seen on both studies. It\n should be noted that some of the posterior fossa images are of poor quality\n due to motion artifacts. There are no other interval changes appreciated at\n this time. There is re-demonstration of the left-sided calvarial burr holes.\n There are no other new abnormalities seen aside from a probable mixture of\n fluid and mucosal thickening within the left sphenoid air cell. This\n abnormality could indicate an inflammatory process; however, the patient was\n recently intubated, as determined by reference to the chest x-\n ray. Such a procedure could account for new sinus fluid or mucosal findings.\n\n CONCLUSION: No definite signs for new infarct.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-13 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 953369,
"text": " 9:27 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: CVA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p CABG hx of CVA\n REASON FOR THIS EXAMINATION:\n ? carotid disease\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque is identified.\n\n On the right, peak systolic velocities are 61, 50, and 97 in the ICA, CCA and\n ECA respectively. ICA to CCA ratio is 1.2. This is consistent with less than\n 40% stenosis.\n\n On the left, peak systolic velocities are 73, 57, and 98 in the ICA, CCA, and\n ECA respectively. This is consistent with less than 40% stenosis.\n\n There is antegrade flow in the right vertebral artery. The left vertebral\n artery is not visualized.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-08 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 952870,
"text": " 4:47 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Poor access on IV vanco\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p redo MVR/CABG with poor access\n\n REASON FOR THIS EXAMINATION:\n Poor access on IV vanco\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 67-year-old man status post mitral valve replacement and CABG\n with need for intravenous access for vancomycin.\n\n TECHNIQUE: PICC line placement.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: Using ultrasound, the right basilic vein was found to\n be patent and compressible. A pre-procedure timeout was performed to verify\n patient identity and the procedure to be performed. The right upper arm was\n prepped and draped in the usual sterile fashion. 5 mL of 1% lidocaine was\n applied for local anesthesia. Under direct ultrasound visualization, the\n right basilic vein was accessed using a 21-gauge needle, through which a 0.018\n guidewire was passed into the subclavian vein. Hard copy ultrasound images\n were obtained before and after venous access documentng vessel patency. The\n needle was exchanged for a 4.5- French micropuncture sheath, over which the\n 0.018 guidewire was advanced into the distal superior vena cava. Over the\n sheath and wire, a 43.0 cm length double- lumen 5-French PICC line was\n advanced into the superior vena cava under fluoroscopic guidance. The wire was\n removed, and the catheter flushed. The catheter was secured to the adjacent\n skin with a StatLock device. The patient tolerated the procedure well. There\n were no immediate complications.\n\n IMPRESSION: Successful placement of double-lumen PICC line, via the right\n basilic vein, terminating in the superior vena cava. Ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952323,
"text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CP processes\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2 and resolving sepsis\n\n REASON FOR THIS EXAMINATION:\n CP processes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Resolving sepsis.\n\n Endotracheal tube is about 6 cm above the carina and could be advanced\n approximately 1 cm for standard positioning. Other lines and tubes remain in\n standard position. Cardiac and mediastinal contours are stable. Interstitial\n edema has slightly improved with minimal residual perihilar haziness\n remaining. Left lower lobe atelectasis has slightly worsened, and there is a\n probable adjacent layering left pleural effusion. No pneumothorax is evident\n on this supine radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 951990,
"text": " 6:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: resolution of CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67M ischemic CMP, h/o VF arrest, here w/ probable CHF exacerbation, but also\n fever.\n REASON FOR THIS EXAMINATION:\n resolution of CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with ischemic cardiomyopathy, probable\n congestive heart failure, fever.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT CHEST: The view is lorditic. Again seen is a left-sided AICD\n with its leads overlying the right atrium and floor of the right ventricle.\n The patient is status median sternotomy. The cardiac and mediastinal contours\n are stable given differences in positioning and technique. There has been\n interval improvement in the pulmonary vascular congestion. The heart remains\n enlarged. No regions of consolidation are identified. There is mild left\n lower lobe atelectasis. No pleural effusions are seen on this AP study.\n\n IMPRESSION: Improvement in the previously seen pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952578,
"text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo male s/p redo MVR/cabg x2\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Status post redo of mitral valve replacement and bypass surgery\n with two grafts.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a similar study dated . During the interval, the patient has been extubated. Swan-Ganz\n catheter with right internal jugular sheath and previously existing permanent\n pacer with ICD device remain in unchanged position. The same holds for\n bilateral chest tubes. No evidence of pneumothorax. No new parenchymal\n infiltrates and the pulmonary vasculature appears unchanged. The left lower\n lobe atelectasis remains stable and has not progressed further.\n\n IMPRESSION: Satisfactory findings on followup examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-02-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 951030,
"text": " 6:12 PM\n CHEST (PA & LAT) Clip # \n Reason: ?pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with slight sob and hypoxia, pacer\n REASON FOR THIS EXAMINATION:\n ?pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 1814 HOURS.\n\n HISTORY: Shortness of breath and hypoxia.\n\n COMPARISON: None.\n\n FINDINGS: The patient is status post median sternotomy and CABG. A dual\n chamber pacemaker/AICD is in place. There is engorgement of the vascular\n pedicle with indistinctness of the pulmonary vasculature consistent with\n moderate hydrostatic edema from cardiac decompensation. There is a tortuous\n atherosclerotic aorta. The cardiac silhouette is enlarged with a left\n ventricular configuration. No definite pleural effusion or pneumothorax is\n evident. The visualized osseous structures are unremarkable.\n\n IMPRESSION: Moderate hydrostatic edema from cardiac decompensation. Repeat\n radiography following appropriate diuresis recommended to assess for\n underlying infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-02-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 951197,
"text": " 4:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o new SDH\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with weakness, history of CVAs complicated by SDH which\n required decompression by burr hole\n REASON FOR THIS EXAMINATION:\n r/o new SDH\n CONTRAINDICATIONS for IV CONTRAST:\n elevated Cr\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with weakness and known prior CVAs and subdural\n hematoma, status post burr hole decompression.\n\n No prior comparison exams are available.\n\n NON-CONTRAST HEAD CT.\n\n FINDINGS: There is diffuse encephalomalacia involving the right frontal,\n parietal, and temporal lobes as well as right basal ganglia consistent with\n prior large right MCA distribution infarct. Additional areas of\n encephalomalacia are identified within the left occipital lobe consistent with\n prior left PCA infarct. No new areas of hemorrhage, intracranial mass, shift\n of midline structures, hydrocephalus, or acute large vascular territory\n infarct is identified. There is mild dilatation of the right lateral\n ventricle due to surrounding volume loss. Burr holes are identified within\n the left frontal bone with no remaining subdural hematoma noted. Osseous\n structures and soft tissues are otherwise unremarkable. The visualized\n paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. No acute intracranial pathology or hemorrhage identified.\n 2. Extensive encephalomalacia from prior ischemic events.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-02-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 951127,
"text": " 10:33 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67M ischemic CMP, h/o VF arrest, here w/ probable CHF exacerbation, but also\n fever.\n REASON FOR THIS EXAMINATION:\n eval for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Ischemia. V fib arrest. Probable CHF.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Mild pulmonary edema has improved. Moderate cardiomegaly is longstanding.\n Transvenous right atrial pacer and right ventricular pacer defibrillator leads\n are in standard placements. No pleural effusion, pneumothorax, or mediastinal\n widening is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-02-22 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 951044,
"text": " 8:05 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, HYPOXIA AND POSITIVE D-DIMER; EVAL FOR PE\n Field of view: 38 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with sob, hypoxia and +d-dimer\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:37 PM\n Heart failure with tiny r pl eff, no pe in main/segmental branches,\n subsegmental branches not evaluable due to resp motion\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST WITH AND WITHOUT CONTRAST AT 21:09 HOURS\n\n HISTORY: Shortness breath, hypoxia, and nonnegative D-dimer.\n\n TECHNIQUE: Sterile transverse images were acquired sequentially through the\n chest before and after the uneventful administration of 90 mL of Optiray 350.\n Timing was optimized during contrast administration for pulmonary artery\n opacification. Multiple orthogonal reformatted images were generated.\n\n COMPARISON: Chest x-ray obtained earlier same day.\n\n FINDINGS: The pulmonary artery measures at upper limits of normal 28 mm in\n diameter. There is no main or segmental branch embolus identified.\n Respiratory motion limits evaluation of the subsegmental branches, although no\n secondary signs of PE are noted. The heart is enlarged. There is a\n mechanical prosthetic mitral valve. There is evidence of prior bypass\n surgery. Stents are evident in the left anterior descending, ramus\n intermedius, and left circumflex arteries. Pacemaker wires are indwelling.\n The pacemaker generator is in the soft tissues of the left anterior chest wall\n and result in significant streak artifact throughout the upper contrast,\n limiting the evaluation as well. There is a 12 mm precarinal lymph node, 12\n mm subcarinal lymph node, and 15 mm right hilar lymph node. There is no\n pneumomediastinum. The esophagus image is normally. There is a bovine arch.\n The aorta is unremarkable otherwise.\n\n The visualized subdiaphragmatic viscera is unremarkable.\n\n There is diffuse pulmonary edema predominantly in a central \"bat \"\n distribution with interlobular septal thickening as well. Respiratory motion\n again severely limits the evaluation of the lung parenchyma. A small right\n pleural effusion is evident.\n\n Mild spondylotic change is noted throughout the mid thoracic spine. No\n blastic or lytic lesions are evident. As previously noted sternotomy wires\n are seen through the sternum.\n\n IMPRESSION: Findings consistent with hydrostatic edema secondary to cardiac\n (Over)\n\n 8:05 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, HYPOXIA AND POSITIVE D-DIMER; EVAL FOR PE\n Field of view: 38 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n decompensation. Suboptimal evaluation for subsegmental distal pulmonary\n embolus. No main pulmonary or segmental artery embolus identified. Non-\n specific mediastinal lymphadenopathy as detailed above.\n\n"
},
{
"category": "Echo",
"chartdate": "2198-03-03 00:00:00.000",
"description": "Report",
"row_id": 84695,
"text": "PATIENT/TEST INFORMATION:\nIndication: Redomitral valve and CABG, post mechanicamitral valve and thrombs\nWeight (lb): 210\nBP (mm Hg): 120/60\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 11:21\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Original digital images no longer available. WJM\nLEFT ATRIUM: Mild LA enlargement. Moderate to severe spontaneous echo contrast\nin the body of the LA. Moderate to severe spontaneous echo contrast in the\nLAA. Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA thrombus.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast\nor thrombus in the body of the RA or RAA. A catheter or pacing wire is seen in\nthe RA and extending into the RV. A mass/thrombus associated with a\ncatheter/pacing wire in the RA or RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. No LV\naneurysm. Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. Moderate-severe regional left ventricular systolic\ndysfunction. Severely depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferoseptal - hypo; mid inferior - hypo; mid inferolateral - hypo; mid\nanterolateral - hypo; inferior apex - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis. Moderate global RV free\nwall hypokinesis. Nl interventricular septal motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Focal calcifications in ascending aorta. Normal aortic arch\ndiameter. Simple atheroma in aortic arch. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Abnormal MVR leaflet/disc motion. Increased MVR gradient. Mitral\nvalve mass. Severe valvular MS (MVA <1.0cm2). Mild (1+) MR. Prolonged (>250ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n1) The left atrium is mildly dilated. Moderate to severe spontaneous echo\ncontrast is seen in the body of the left atrium mainly originating from left\natrial appendage. The left atrial appendage emptying velocity is depressed\n(<0.2m/s). A left atrial appendage thrombus cannot be excluded.\n2) No spontaneous echo contrast or thrombus is seen in the body of the right\natrium or the right atrial appendage. A mass/thrombus associated with a\ncatheter/pacing wire is seen in the right atrium and/or right ventricle. No\natrial septal defect is seen by 2D or color Doppler.\n3) Left ventricular wall thicknesses are normal. The left ventricular cavity\nis moderately dilated. No left ventricular aneurysm is seen. Due to suboptimal\ntechnical quality (poor Midesophageal views because of mechanicalmitral\nvalve), a focal wall motion abnormality cannot be fully excluded.\n4) There is moderate to severe regional left ventricular systolic dysfunction\nin the RCA and circumflex territory. Mid anterior and anteroseptal wallmotions\nare preserved at rest. Overall left ventricular systolic function is severely\ndepressed with EF of 15 to 20%.\n5) There is mild to moderate global right ventricular free wall hypokinesis.\nThere is mild TR with normal septal motions.\n6) There are simple atheroma in the aortic arch and descending thoracic aorta.\n7) The aortic valve leaflets (3) are mildly thickened with no stenosis or\nregurgitation.\n8) There is a bileaflet mechanical mitral valve with the preserved motion of\nthe leaflet close to the aortic valve. The other leaflet is immobile with 8 to\n10mm mass (? Thrombus with no independent motion) and pannus sitting on the\nleft atrial aspect. The gradients are higher than expected for this type of\nprosthesis with a mean of 12mm of Hg. There is severe mitral stenosis (area\n<1.0cm2). There is a trace to miild MR seen along with the mobile leaflet\nconsistent with its washing jet.\n9) There is no pericardial effusion.\n\nPost_Bypass:\nMild RV global systolic dysfunction.\nPatient is on epinephrine, milrinone and levophed. His global LVEF is 25% to\n30%. The previously hypokinetic inferior and inferoseptal walls are moving a\nlittle bit better.\nThere is a bioprosthesis in the mitral position, well seated and functioning\nwell, residual mean gradient of 4mm of HG. There are no regurgitant lesions\nacross the mitral valve.\nNo other new valvular abnormalities.\nAscending aortic contour is well preserved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2198-02-28 00:00:00.000",
"description": "Report",
"row_id": 84696,
"text": "PATIENT/TEST INFORMATION:\nIndication: mitral prosthesis dysfunction. R/O endocarditis\nHeight: (in) 60\nWeight (lb): 138\nBSA (m2): 1.60 m2\nBP (mm Hg): 138/79\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 12:30\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement. Moderate to severe spontaneous echo\ncontrast in the body of the LA. Moderate to severe spontaneous echo contrast\nin the LAA. Probable thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV. A mass/thrombus associated with a\ncatheter/pacing wire in the RA or RV.\n\nLEFT VENTRICLE: LV not well seen.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal ascending aorta diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Filamentous strands on\nthe aortic leaflets c/with Lambl's excresences (normal variant). Trace AR.\n\nMITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Abnormal MVR\nleaflet/disc motion. Increased MVR gradient. Mitral valve mass. Cannot exclude\nMS. Trivial MR. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild to moderate [+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). The posterior pharynx was\nanesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg\nof IV glycopyrrolate was given as an antisialogogue prior to TEE probe\ninsertion. Echocardiographic results were reviewed by telephone with the MD\ncaring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. Moderate to severe spontaneous echo\ncontrast is seen in the body of the left atrium. Moderate to severe\nspontaneous echo contrast is present in the left atrial appendage (early\nthrombus). Multiple small, mobile echodensities associated with a\ncatheter/pacing wires are seen in the right atrium. These represent either\nbland fibrin strands or infectious vegetations (clinical correlation). The RA\npacing lead is abnormally thickened at the insertion site (0.5-0.7 cm) near\nthe right atrial appendage which is of unclear significance. The aortic valve\nleaflets are mildly thickened. Trace aortic regurgitation is seen. A bileaflet\nmechancical mitral prosthesis is present. Motion of the prosthetic mitral\nvalve leaflets/poppet is abnormal suggesting partial obstruction/thrombosis\n(posterior leaflet). The gradients are higher than expected for this type of\nprosthesis. There is a 1.0 cm echodense, cessile mass along postero-lateral\nannulus ( ) of the mitral valve prosthesis that may represent thrombus.\nTrivial mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of the newly noted\nfindings include (1) LA/LAA severe SEC (2) likely partial thrombosis of the\nMVR with complete restriction of the posterior prothetic leaflet (3) possible\nvegetations on the pacemaker leads. The gradient noted across the mitral\nprosthesis is similar.\n\nIMPRESSION: Partial thrombosis of the mechanical mitral prosthesis with severe\ninflow obstruction (MS). Severe stasis of the LA/LAA. Possible pacemaker lead\ninfection.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2198-02-26 00:00:00.000",
"description": "Report",
"row_id": 84697,
"text": "PATIENT/TEST INFORMATION:\nIndication: logged in error\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nlogged in error\n\nConclusions:\nAn echocardiographic test was logged to this patient in error. No test was\nrequested, no imaging was performed, and no was generated.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2198-02-23 00:00:00.000",
"description": "Report",
"row_id": 84698,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 195\nBSA (m2): 1.85 m2\nBP (mm Hg): 116/80\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 10:37\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe global\nLV hypokinesis. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mechanical mitral valve prosthesis (MVR). Thickened MVR\nleaflets.. Increased MVR gradient. MR present but cannot be quantified. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mild [1+] TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is severe global left ventricular hypokinesis. No masses or\nthrombi are seen in the left ventricle. There is no ventricular septal defect.\nRight ventricular systolic function appears depressed. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. A mechanical mitral valve prosthesis is present.\nThe prosthetic mitral valve leaflets are thickened. The gradients are higher\nthan expected for this type of prosthesis. Mitral regurgitation is present but\ncannot be quantified. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The pulmonary artery\nsystolic pressure could not be determined.\n\nIMPRESSION: Severely depressed LVEF. High gradient across mechanical MVR\nsuggestive of some degree of mechanical valvular obstruction. If clinically\nindicated,a TEE may better evaluate the integrity of the MVR.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2198-02-23 00:00:00.000",
"description": "Report",
"row_id": 225236,
"text": "Sinus rhythm. Intraventricular conduction delay of left bundle-branch\nblock type. Poor R wave progression - consider anterior wall myocardial\ninfarction of undetermined age. This could also be due to the intraventricular\nconduction delay. Compared to the previous tracing of sinus tachycardia\nis absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-02-22 00:00:00.000",
"description": "Report",
"row_id": 225237,
"text": "Sinus tachycardia. Intraventricular conduction delay. Non-diagnostic inferior\nQ waves are noted. Poor R wave progression - consider anterior wall myocardial\ninfarction of undetermined age. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2198-03-07 00:00:00.000",
"description": "Report",
"row_id": 225230,
"text": "Sinus rhythm\nLeft bundle branch block\nNonspecific ST-T wave changes\nSince pervious tracing, further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2198-03-04 00:00:00.000",
"description": "Report",
"row_id": 225231,
"text": "Probable junctional rhythm\nPremature ventricular contractions\nOld inferior infarct\nProbable old anterior infarct\nT wave changes are nonspecific\nLeft bundle branch block\nSince previous tracing of , junctional rhythm and ventricular premature\ncomplex are present\n\n"
},
{
"category": "ECG",
"chartdate": "2198-03-01 00:00:00.000",
"description": "Report",
"row_id": 225232,
"text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2198-02-27 00:00:00.000",
"description": "Report",
"row_id": 225233,
"text": "Sinus rhythm. Left bundle-branch block. Consider prior septal myocardial\ninfarction although this is non-diagnostic. Diffuse ST-T wave abnormalities\nwith prolonged QTc interval could be due to the intraventricular conduction\ndelay, but cannot exclude ischemia or possible drug/electrolyte/metabolic\neffect. Clinical correlation is suggested. Since the previous tracing earlier\nthis date no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-02-27 00:00:00.000",
"description": "Report",
"row_id": 225234,
"text": "Sinus rhythm. The tracing is marred by baseline artifact. Compared to the\nprevious tracing of no apparent diagnostic interim change. Repeat\ntracing of diagnostic quality is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-02-25 00:00:00.000",
"description": "Report",
"row_id": 225235,
"text": "Sinus rhythm and occasional atrial and ventricular ectopy. Prior inferior\nmyocardial infarction. Left bundle-branch block. Compared to the previous\ntracing of there are new T wave inversions in leads II, III and aVF.\nUpward coved ST segments in leads V1-V6 with biphasic to inverted T waves in\nthese leads consistent with active ischemic process of the antero-apex. Rule\nout myocardial infarction. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-08 00:00:00.000",
"description": "Report",
"row_id": 1450078,
"text": "0700-1900:\nneuro: primarily spanish speaking, understands conversational english. perrl. denies pain. appears oriented, period of confusion in late afternoon, asking for glasses repeatedly son at stating slightly confused. resolved on own, appropriate at present. keppra started po.\n\ncv: sr 80-90, pac's and pvc's noted. no svt noted. permanent pacer ddi @ 60, aicd. sbp stable, lopressor tid. generalized edema noted. dopplerable pedal pulses bilaterally. right antecubital picc line placed.\n\nresp: lungs clear, diminished at times. audible exp wheezes heard at times, albuterol/atrovent nebs given. o2 95-100% on 2l nc.\n\ngi/gu: abd softly distended, bs positive. tol po, good po intake. foley to gravity, good huo. cr 1.4.\n\nendo: fs qid, cover per riss.\n\nid: wbc 13, vancomycin started secondary to positive blood culture from trauma line.\n\nplan: pulmonary toilet, monitor rhythm. d/c trauma line.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-09 00:00:00.000",
"description": "Report",
"row_id": 1450079,
"text": "Neuro: Spanish speaking , understand minimal English; A&O x3, episodes of confusion x2 during the night, think he's at home and asking for his wife, easily reoriented & reassure; MAE's, following commands consistently; seizure disorder, started on keppra\n\nCV: Afebrile; SR/ST 90's-100's, occasional PVC's noted; SBP 100's, 90's when sleeping; palpable pulses x4; RIJ trauma line DC'd, tip culture sent; R brachial 2x lumen PICC patent; K repleted\n\nResp: Lung sound clear, dim @ bases, exp wheezes noted when anxious, resolved with reassurance & nebs; 2L NC sat 96%\n\nGI: Abd soft distended, bowel sound x4; tolerating clear liquid, crushed pills with apple sauce, no signs of aspiration\n\nGU: Foley draining clear yellow urine, + diuresis after lasix\n\nInteg: Intact, see carevue for detail assesment\n\nPain: Denies pain\n\nSocial: Family called & updated\n\nID: WBC 11, on vanco\n\nEndo: cover per CSRU protocol\n\nPlan: pulm toilet; monitor hemodynamics, resp status & labs; advanced diet as tolerated; inc activity as tol per cardiac rehab; CT head ; ?transfer to 2\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-07 00:00:00.000",
"description": "Report",
"row_id": 1450074,
"text": "csru nursing update\ncvs: initially , pt had episodes of svt, self limiting, treated with lopressor iv. frequent ectopies noted afterwards, then Awires not sensing well, with low sbp, no underlying rhythm noticed also on back up rate of 50. Vpaced on back up rate of 60, sbp better, ectopies still present but lesser. ntg weaned off, hydralazine held as sbp mostly borderline especially with Apacing. febrile up to 38.6F, tylenol PR with good result\n\nresp: nebs given , pt very wheezy esp with exertion (post chest PT). slowly relieved by nebs, but relieved when pt calmer and resting. productive cough, pt appears to be swallowing secretions. acapella also done well. cough improving and getting stronger, gag still impaired. abg good, weaning fio2, sao2 97-100%. ct's draining minimal\n\nneuro: levetiracetam restarted. Pupils unequal, pa aware, right s.3+/ left s.5-6sluggish, though no facial droop/assymetry noted, pt awake and obeys commands. spanish speaking, verbal response appropriated when interpreted, pt understands little english and also follows gestures\n\ngi/gu: brisk response to lasix, k+given with lasix dose. remained npo, insulin off, will start lantus this am\n\nskin: pressure areas intact, pt still with generalized edema\n\nsocial: daughter phoned early in the night, updated\n\na/p: unequal pupils -> neuro already following, cont to monitor\n cont pulm toilet\n ?EP referral-> rhythm issues\n advance activity as tolerated, ?swallow consult\n cont plan of care\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-07 00:00:00.000",
"description": "Report",
"row_id": 1450075,
"text": " 7a-7p\nneuro: a+o x1 (reoriented to time, able to state place if given options to choose from), primarily spanish speaking-understands simple english; left pupil 5mm>right pupil 3mm, left pupil nonreactive, right pupil brisk response, tongue deviates to left, smile unequal (left side of face non-responsive), pt unable to move left arm at all (possible new symptom?), minimal movement of left LE, neuro in to assess pt-suggesting ct to r/o bleed, pt currently unable to tolerate ct (especially with heart rhythm); total lift transfer to chair today x 2.5 hours, required to return pt to bed\n\ncv: received v paced 80 with frequent pvcs, found to have perfusing underlying rhythm of junctional 70s, pacer turned to vvi 60, a wires not sensing or capturing appropriately (when testing capture, pt went into svt more often) even with reversing polarity and max ma to 25 on v side, lopressor 5mg ivp given multiple times to slow svt with good result and vvi backup, pt's sbp stable with svt, occasional runs vt 4-9 beats with sbp stable, electrolytes wnl; ep interrogated internal pacer, internal pacer set to ddi 60 (not ddd because av conduction normal and prefer not to wear out battery of aicd if conduction wnl), po lopressor 25mg started->advanced to 37.5mg po tid when svt continued post aicd reprogramming to ddi 60; epicardial wires d/ced once aicd reset; ci 2.6 pre swan removal-trauma line left in place since no piv sites seen; chest tubes d/ced this am; afeb\n\nresp: expiratory wheeze bilat this am, improved with albuterol/atrovent nebs, now cta except immediately following movement (becomes wheezy), 1600 albuterol/atrovent nebs stopped early this pm for svt; flutter machine q 4h, is q4h 250-500ml, strong nonproductive cough\n\ngi: tolerating full liquid diet, fingersticks ssri, firm/distended abdomen, bowel sounds present, small brown smear bm this pm\n\ngu: foley to gravity draining clear yellow urine >30ml/hr, lasix 40mg iv q8 with good result, goal -2.5L today\n\nlabs: stable\n\nsocial: spoke with daughter this am-updated re pt condition, another daughter and granddaughter visited today, pt spoke with wife on phone\n\nassess: stable\n\nplan: pulmonary toilet, advance diet as tolerated, increase activity, lopressor 5mg iv q1h prn svt\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-08 00:00:00.000",
"description": "Report",
"row_id": 1450076,
"text": "Resp Care\nNebs given Q4 as ordered. BS coarse bilaterally and diminished at lung bases. Pt cough more effective today. Currently on 4 L NC. plan to maintain o2 therapy and nebs as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-08 00:00:00.000",
"description": "Report",
"row_id": 1450077,
"text": "csru nursing update\nNSR with multi ectopies, episode of svt x1 responded to lopressor 5mg iv. sbp 100-130mmhg, drops to 80s when asleep. all pulses palpable, afebrile. exp wheezes with exertion, nebs continued, relieved by rest. no signs of resp distress, productive congested cough, pt appears to swallow secretions. doing IS and acapella, IS up to ~500cc only despite much encouragement. speaks some english, cooperates with care. oriented per relatives, follows gestures as well. denies any pain, but appears to have a guarded cough. left sided weakness, able to grasp with left hand but cannot lift. Pupils remained unequal, neuro following already. no problems swallowing, taking fluids/tablets well. excessive diuresing with lasix 40 tid, creatinine already elevated. passing stools, bowel sounds present. pressure areas intact, daughter phoned during the night, pt's wife apparently received a call from pt himself -> explanation and reassurance provided\n\nplan: lopressor prn for svt, EP following also\n cont pulmonary toilet\n follow up Physical therapy, advance activity as tolerated\n advance diets as tolerated\n cont plan of care\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-06 00:00:00.000",
"description": "Report",
"row_id": 1450072,
"text": "shift update:\n\nneuro: lethargic. responds to voice. nodding appropriately. unclear how much english pt understands. anesthesia reports pt understood a good amt of english preop. unable to assess orientation d/t language barrier. daughter due in this evening to translate. denies pain. remains on bedrest. t&r.\n\ncv/skin: junctional w/chb. atrial rate faster than ventricular lopressor 2.5mg given x2 to slow atrial rate, rate slowed to 60. apaced at 70 after lopressor. self limited runs of svt w/rate>140. lopressor 5mg given & tolerated. rhythum change noted->awire tracing done which confirmed junctional w/chb. currently apaced at 88 per . started ntg gtt due to sbp>140, currently at 0.5mcg/kg/min. hydralizine added w/minimal effect. amio d/c'd. svo2 60->80 but does drop to 50's w/activity. ci>2. ct->h2o seal ?d/c tonight vs am. k+, ca & mgso4 repleted. +rp & pp bilat.\n\nresp: lungs w/expir wheezes & dim at bases. encouraged to cdb, cough weak. cpt done. nt suctioned x1 by rt. albuterol nebs given. mdi's given by ?pt understanding & effectiveness. sat's drop to high 80's w/activity. oft on & fio2 titrated from 70% to 100% at times.\n\ngi/gu: npo. abd firm & distended. attempted ice chips but pt coughing quickly after. team aware pt did not take am po meds. good diuresis after lasix. see flow sheet.\n\nendo: insulin gtt per protocol.\n\nid: tmax 101.1.\n\nsocial: family member into visit this am but did not understand much english. daughter/translator to visit this evening.\n\nplan: pain management. cont to monitor hemodynmics, labs, i&o. ntg for bp control. aggressive pulmonary toilet. insulin gtt per protocol. ?need for ngt. ?need for swallow study.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-07 00:00:00.000",
"description": "Report",
"row_id": 1450073,
"text": "Resp Care\nPt placed on 95% High flow neb. FiO2 weaned throughout shift and is now set at 40%. ABG WNL. BS coarse with expiratory wheezes bilaterally L>R, BS diminished at lung bases. Nebs given often for increased WOB and wheezing and shows some inprovement to BS and RR. Pt mostly has weak cough, but strong cough at times. Pt given acapella divice to promote secretion clearance. Plan to continue O2 support and neb therapy as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-05 00:00:00.000",
"description": "Report",
"row_id": 1450069,
"text": "Nursing Progress Note:\nNeuro: Pt lightly sedated on propofol gtt. Opens eyes to voice. Not tracking. Not following commands. Extremeties localizes to painful stimuli. Perl 3mm brisk. Coughs when suctioned.\n\nCV: IABP d/c'd this afternoon. Vasopressin gtts weaned off. SVO2 60-70's. CI >. Apaced early on shift, but pacer now on ademand @60. Pt in SR with occassional PVC's. K and Ca repleted. Maintain map >60 and SBP >90. PAD 20's CVP >10. Lasix started with minimal diurese. A and V wires sense and capture. Mediastinal CT's to wall suction. Minimal serosanquinous drainage. Pt on amio gtt. Low grade temp.\n\nResp: LCTA diminished bases. Sats 94% on CPAP 12/5, 50% RR in the high 20's. Metabolic acidosis. Suctioned for minimal thick, yellow secretions.\n\nGI/GU: Abdomen soft, nondistended. Faint BS. Replete w/ fiber @10cc/hr via OGT. No BM. Foley cath. Minimal diurese with lasix. Good UO. Clear, yellow urine.\n\nPain: Morphine\n\nID: Insulin gtt\n\nID: Flagyl\n\nPlan: Wean vent, attempt extubate tomorrow? Pulmonary hygiene. SBP >90 MAP >60. Advance TF. D/c milrinone at midnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-06 00:00:00.000",
"description": "Report",
"row_id": 1450070,
"text": "Respiratory Care: Pt remains intubated and on vent. Rested on AC mode overnight. Plan is to wean to extubate in am. Morning RSBI = 91.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-06 00:00:00.000",
"description": "Report",
"row_id": 1450071,
"text": "NEURO-SEDATED ON PROPOFOL @ 10MCG/KG/MIN. AROUSABLE TO STIMULI BUT EASILY FALLS BACK TO SLEEP AND UNABLE TO FOLLOW COMMANDS.NO SPONTANEOUS MOVEMENT SEEN.INCREASE IN HEMODYAMICS DIRECTLY RELATED TO STIMULI WITH RETURN TO BASELINE.\n\nCV- A-PACED @90 NO ECTOPY.A/V WIRES /CAPTURE.HEMODYNAMICS,CO/CI STABLE WITH NO DECREASE IN MV02 /CI WHEN MILRINONE DCD @2400. AMIO GTT @ 0.5MG/HR.K+ REPLETED X1. PULSES AS CHARTED ON CAREVUE.HEPARIN SQ TID.\n\nRESP-RESTED ON CMV OVERNOC AND PUT BACK ON CPAP/PS @ 0500. LSC. SXD MOD. AMT THICK YELLOW SPUTUM X3. WBC=14.2 CONTINUES ON FLAGYL IV.CHEST TUBES DRG SCANT AMT S/S DRG.\n\nGI- ABD OBESE. HYPOACTIVE BS. TUBE FEED DCD @ 0300 FOR AM EXTUBATION.\nNO BM. ON COLACE .\n\nGU-ADEQUATE HOURLY U/O WITH TREMENDOUS DIURESES FROM LASIX 40MG . BUN/CR WNL.\n\nLABS- K+ REPLETED X1. GLUCOSE AND INSULIN GTT ADJUSTED TO CSRU PROTOCOL.\n\nPAIN- EXHIBITS NO S/S OR PAIN.\n\nPLAN- WEAN VENT TO CPAP/PS AND WAKE TO EXTUBATE,FOLLOWED BY PULM HYGEINE Q2H. CONTINUE TO MONITOR HEMODYNAMICS,IF CO/CI/MV02 REMAIN\n STABLE DC SWAN??DIURESE WITH LASIX. MONITOR HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-05 00:00:00.000",
"description": "Report",
"row_id": 1450066,
"text": "Respiratory Care\nPt remains intubated on SIMV mode of ventilation. No ventilator changes made this shift. BS mostly clear bilaterally, suctioning for scant amounts of thick white secretions. No RSBI completed due to hemodynamic instablity. See CareVue for details and specifics.\nPlan: Wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-05 00:00:00.000",
"description": "Report",
"row_id": 1450067,
"text": "apaced at 90, no ectopy, underlying accelerated junctional rhythm. amiodarone decreased to .5 mg. sbp 85-100, epi remains off, levophed weaned off, vasopressin weaned to 2.4 units. iabp at 1:1, no problems with trigger, timing is not optimal, but as good as can be achieved. filling pressures, cco/ci, and svo2 all stable. milrinone decreased to .25 mcg. afebrile. adequate uo with moderate sustained response to lasix 20 mg x 2. k stable, ca and mg repleted, glucose rx per protocol, gtt weaned to off. breath sounds clear, decreased at bases, ett suctioned for small to mod amts thick white secretions, vagal response to suctioning x 2 with sbp drop to 70s, recovered with trendelenburg. no vent changes overnight, abgs acceptable, see flow sheet. abd still distended, but soft, no bowel sounds heard, no stool. ogt to lcs, small amt faintly bilious drainage. chest tubes to suction, small amts serosang drainage, no air leak, no bleeding at site. sternal incision dry and intact. right and left leg incisions dry, changed, ace wraps in place. feet cool, color better, dp and pt pulses present by doppler, left hand cooler than right, radial pulse by doppler, fingertips are dusky, unchanged for earlier note. skin on back, buttocks, heels intact. sedated with propofol, morphine x 2, no response to verbal or physical stimuli. pulpils 3mm.equal, brisk. family in to visit and called, updated, but do not seem to be aware of serious patient condition. plan to support hemdynamics, wean iabp and decannulate as tol, wake to assess neuro status if tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-05 00:00:00.000",
"description": "Report",
"row_id": 1450068,
"text": "resp. care\npt. continues on vent. changed to a/c due to overbreathing/not\nin synch with vent. tidal vols. decreased due to low pc02 and\nhigh peak a/w pressures. abg continues to pco2. changed\nto cpap/ps with acceptable abg. see flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-03 00:00:00.000",
"description": "Report",
"row_id": 1450060,
"text": "Respiratory Care\nPt recieved from or placed on simv/ps increased peep to 8cm, rate to 14 abg pending. plan to wean to fast track protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-03 00:00:00.000",
"description": "Report",
"row_id": 1450061,
"text": "Admission\nPt s/p redo mvr (tissue) and cabgx2, see admission h+p for details of OR events and PMH. Received on epi 0.03mcg/kg/min,milrinone 0.5mcg/kg/min,vasopressin 3units/hr, levophed 0.15mcg/kg/min. See carevue.\n\nNeuro: Pt sedated on propofol gtt at 20mcg/kg/min. Perrla 2mm sluggish.\n\nCV: Received HR 95-100s ST w/ BBB. EKG taken. SBP labile, levophed as high as 0.25mcg/kg/min, see carevue. SVO2 58-62 MD at and aware, 1 L LR bolus given. CI by thermodilution <2, by FICK >2, MD aware and MD at and aware, see carevue. To go by FICK MD . PA 35-40/20s. CVP 15-18. Skin cool to touch, +dopplerable pedal pulses. Poor IV access per anesthesia, cordis to groin, trauma line w/ pa line to RIJ.\n\nResp: LS clear diminished. ABG 7.30 PaO2 80s on IMV rate 12, MD aware and at , peep and rate increased, cxr done and reviewed by MD, no new orders. See carevue for abgs and vent settings, MD updated throughout shift re:abgs. Sats 93-100%. See carevue. MD aware of CT pleural not draining, MD to assess, no new orders.\n\n\nGI/GU: Abd soft, absent BS. OGT + placement. Foley draining clear yellow urine, see carevue.\n\nEndo: Insulin gtt per protocol.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. wean levo if necessary, leave milrinone,epi,and vasopressin at present settings. Keep sedated overnoc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-04 00:00:00.000",
"description": "Report",
"row_id": 1450062,
"text": "Respiratory Care\nPt remains intubated on SIMV mode of mechanical ventilation. FIO2 and PEEP weaned as tolerated by ABG results. ABG currently shows uncompensated metabolic acidosis. BS clear bilaterally, suctioning for scant amounts of thick white secretions. Balloon pump placed this shift and Pt remains hemodynamically unstable at this time, therefore RSBI not completed. See CareVue for details and specifics.\nPlan: Maintain vent support, wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-04 00:00:00.000",
"description": "Report",
"row_id": 1450063,
"text": "ekg nsr, rate 80s, few to many pvcs. sbp labile, on epi, levo, vasopressin. currently titrating epi to off, levo remains at .2 mcg, have been unable to wean, vasopressin at 2.4. milrinone continues at .5 mcg with acceptable cco/ci, svo2 low 60s, occ drops to high 50s , responds to fluid. hypotension at 2200 did not respond to fluids and increased vaspressors. dr. here, tee done which showed improved wall motion. decided to place iabp via l fem, placed without incident, pumped at 1:1, skin trigger, arterial trace is dampened, using right fem line pressures for pressor titration. iabp site bleeding. breath sounds clear, decreased at bases. vent settings per flow sheet, fio2 weaned to .5, peep from 8 to 5. ett suctioned for small amts thick white secretions. continues to have metabolic acidosis, has received total of 5 amps of bicarb. lactate is up to 7.5. glucose monitored per protocol, k and ca repleted. hct dropped to 23 from 30 after crystalloid load, 2 units of prbcs given. 2 med and 2 pleural cts, draining small amts serosang fluid, no air leak. abd initially soft, obese, became distended and firm. is now less distened and softer. no bowel sounds heard, scant clear drainage from ogt. by surgical consult, rectal stool spec was possibly trace guaic positive. sternal incision draining cant serosang, scant sang drainage around ct sites.feet cool, edematous, has pt and dp pulses by doppler. ace bandages on bilat. turned x1, skin on back and buttocks intact. sedated with propfol, morphine given x 1. unresponsive to verbal and physical stimuli. pupils equal, sluggishly reactive. plan to maintain hemodynamic stability, wean epi and levo as tolerated, wake if possible to assess neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-04 00:00:00.000",
"description": "Report",
"row_id": 1450064,
"text": "Respiratory Care\nPt remains on a/c settings with fio2 increased to .6 Plan to continue support as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-03-04 00:00:00.000",
"description": "Report",
"row_id": 1450065,
"text": "7am-7pm update\nneuro: pt remains on propofol gtt at 30 mcg/kg/min. no spontaneous movement noted. PERRL. morphine given for pain control\n\nCV: pt 1st degree av block VS accelarated junctional - at times appears to have P waves. HR in the 70's. pt A Paced at 90 for BP support. pt with frequent PVC's this am -> BP did not tolerate ectopy. pt given amio bolus and started on amio gtt at 1 mg/min. SBP 80-110's. MAP 50-70's. vasopressin gtt increased to 4.8 u/hr this am per team. levo gtt titrated to keep MAP > 60 and SBP > 90. levo gtt weaned down to 0.08 mcg/kg/min. pt given fluid bolus today x 4 d/t low sov2 and low filling pressures. pt responded well to fluid. milr gtt remains at 0.5 mcg/kg/min. epi gtt turned off this am per Dr . SVO2 58-66. sov2 down to 53 with turn side to side - recovered quickly. CI by fick > 2.0. bil feet and finger tips of left hand mottled. Dr aware. + doppler PP. + doppler radial and ulnar pulse in left arm. IABP remains 1:1 with good augmentation. good unloading. hst stable. Lacate trending down although still remains elvated -> last lacate was 2.4. general surgery team following.\n\nresp: LS coase - clear with suctioing. pt continues on imv. vent settings 60% IMV with 5 peep and 5 ips. last abg was 7.43/32/81/22/-1. pt suctioned of small amount of this white sputum. CT with no airleak noted. CT draining serousanginous fluid\n\ngi/gu: BS remain absent. ogt draining billious fluid. abd distended although soft. abd slighly mottled in color. foley draining 25-50 cc/hr of clear yellow urine. last creatinine was 1.1. LFT slightly elvated see flowsheet.\n\nendo: pt continues on insulin gtt. insulin gtt at 26-30 u/hr of insulin. see flowsheet. pt with high insulin requirements. bs 226-114 today\n\nid: pt afebrile. wbc elvated althought coming donw. pt continues on flagyl, vanco and levaquin\n\nsocial: 2 daughters called today and given updates. daughter updated by Dr this am\n\nplan: monitor CO/CI by fick, monitor hemodynamics, keep IABP 1:1, wean levo gtt as tolerated, pulm toleit, pain control, monitor lactate, monitor LFT's, monitor lytes/hct/bs, antiobiotics\n\n"
}
] |
42,694 | 127,447 | This is a 48 year old female with past medical history significant for multiple craniotomies presents with R facial pain and low grade temperatures. MRI revealed right temporal fluid collection with dural enhancement suspicious for empyema, possible osteomyelitis. She was admitted to the neurosurgery service for further management. She was taken to the OR emergently on for craniectomy and evacuation of right epidural empyema and a right epidural drain placement x2 . Post operatively, patient was nonfocal on examination. She had complaints of baseline decreased hearing in the right ear (since ) and impaired right visual field deficit (since )she was taken to the ICU for further monitoring. Infectious Disease was consulted and patient started on antibiotic triple therapy with vancomycin, cefepime and flagyl. A helmet was ordered to be worn at all times while the patient is out of bed to protect the craniectomy site.The ENT service was consulted while the patient was inhouse for the risk of mastoiditis as a source for infection and they agreed with the plan for IV antibiotics. Dr. would like to see the patient after her course of IV antibiotics is complete for formal audiogram and assesment for residual infection. On POD1 the subgaleal drains were removed and the patient was transferred to the regular floor. The patient recieved the . Vancomycin troughs were followed throughout her hospital stay and her dose was adjusted to maintain a goal vanco level of 15-20 as recommended by ID. On cefepime was discontinued as organism appeared to be gram stain positive.The vancomycin was increased to 1250 mg every 8 hours.A PICC line was placed in anticipation of long term home IV antibiotics. On ,The vancomycine was increased to 1500mg every 8 hours. physical therapy cleared the patient for home and occupational therapy cleared the patient to go home with occupational therapy. On , the patient Neurontin was increased per the patients request to her home dose of 1200 mg po TID. On , Infectious Disease saw the patient and recommended that the flagy be discontinued which is was. The vancomycin trough elevated (39.7)and not thought to be a true trough. This was reordered and was 22. The infectious disease recommendations were to change the Vancomycin dosing to 1250 mg TID with plan for trough level to be drawn prior to the 4th dose. The patient will call for an appointment for follow up with infectious disease on Monday. Lab work will be drawn at the patient home and faxed to the clinic which will include CBC with diff, chem 7, LFTs, BNP, vancomycin trough. Serum magnesium and potassium levels were low and repleated. The patient was found to have white pustules in her mouth all over the oral pharynx and was started started nystatin for thrush. There was 4 staples that were removed from the old drain sites. The patient complained of worsening decreased hearing on the right since the time of surgery. The ENT service was called to evaluate the patient prior to her disposition home. There was no formal audiogram testing available, but bedside evaluation was consistent with worsening sensory neural hearing loss on the right. The patient was initiated on a Prednisone taper over 12 days and recommedation for follow up in weeks for audiogram as outpatient was made. The patient will call for this appointment on Friday.The patient is documented to have type II diabetes meilitis but denies this diagnosis. She states that she has a blood glucose moniotr at home and feels capable and comfortable taking her blood sugar at home prior to meals and prior to bed. If her blood sugar is over 200 then she will call her primary care physician for . The patient will be dispo to home with occupational therapy, a home safety evaluation, and home infusion therapy. The exam on the day of discharge is outlined above. | Within these limitations, the intracranial carotids, vertebrobasilar and anterior, middle and posterior cerebral arteries demonstrate normal flow-related enhancement. Diffuse likely reactive edema and enhancement involving the right infratemporal and retromaxillary zygomatic fossa as well as the masticator space. Diffuse likely reactive edema and enhancement involving the right infratemporal and retromaxillary zygomatic fossa as well as the masticator space. Diffuse likely reactive edema and enhancement involving the right infratemporal and retromaxillary zygomatic fossa as well as the masticator space. Peripherally enhancing fluid collection along the right temporal bone flap with mild epirual fluid component and extensive dural thickening and enhancement. Peripherally enhancing fluid collection along the right temporal bone flap with mild epirual fluid component and extensive dural thickening and enhancement. There is partial fluid opacification of the right mastoid air cells and middle ear cavity. Peripherally enhancing fluid collection along the right temporal bone flap with mild epidural fluid component and extensive dural thickening and enhancement. As seen on previous CT, there is a peripherally enhancing fluid collection extending laterlly, posteriorly an partly medially along the right temporal bone graft. LEFT TEMPORAL BONE: Mastoid air cells are well-developed and aerated. Right facial and external auditory canal inflammation. Marked fascial thickening and edema are noted, with superior extension into the temporalis, and inferior extension into the external auditory canal and parotid. There is extensive edema and diffuse enhancement involving the entire right infratemporal and retromaxillary zygomatic fossa, extending into the right masticator space. There is extensive opacification of the right mastoid air cells. There is marked soft tissue edema and fat stranding along the right malar and frontal soft tissues. Mild bilateral mucosal thickening of the ethmoid air cells is also seen. 2D TOF of venous sinuses in unremakable. There has been progressive erosion of the mastoid septae, tegmen tympani, and petrous apex, without destruction of the ossicular chain or scutum. FINDINGS: Post-surgical changes are noted in the right middle cranial fossa, with fragmentation of the squamous portion of the temporal bone, as well as a surgical defect in the anterior mastoid. Assessment for intracranial involvement. There is increased breakdown of bony septae, and more prominent irregularity of the anterior mastoid air cells and petrous apex. The cerebral sulci, ventricles and extra-axial CSF-containing spaces have normal size and configuration. Mild mucosal thickening is noted in the ethmoid air cells. The brain parenchyma has normal -white matter differentiation. These findings raise the suspicion of temporal soft tissue abcess, bone flap osteomyelitis and extra-axial empyema. These findings raise the suspicion of temporal soft tissue abcess, bone flap osteomyelitis and extra-axial empyema. These findings raise the suspicion of temporal soft tissue abcess, bone flap osteomyelitis and extra-axial empyema. intracranial extension of abscess No contraindications for IV contrast PFI REPORT 1. Now reports increased right facial swelling and trismus. Image quality of intracranial TOF MRA is significantly reduced by motion artifact and susceptibility from previous clipping of the right M1 bifurcation and basilar tip aneurysms. Several tiny defects are noted at the level of the tegmen tympani, and frank dehiscence (with risk of CSF leak) cannot be excluded. Rim-enhancing fluid collection superficial to right masseter muscle, highly suspicious for abscess, which may be amenable to percutaneous drainage. The carotid canal, jugular (Over) 4:33 AM CT ORBITS, SELLA & IAC W/ CONTRAST; -59 DISTINCT PROCEDURAL SERVICEClip # Reason: please obtain temporal bone scan to eval mass FINAL REPORT (Cont) foramen, and sigmoid sinus plate appear intact. 0.3-mm true axial and true coronal intraconal reformats were generated through each temporal bone. Orbits and intraconal structures appear symmetric. Petrous apex is preserved. The skull base appears grossly intact. Internal auditory canal is normal in caliber. COMPARISON: MRI head dated and CT head dated TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo, diffusion with ADC map images as well as TOF MRA and MRV of the brain were obtained without contrast. The middle ear cavity is clear. FINDINGS: The patient is status post right temporoparietal craniectomy with right temporal bone flap. Status post right MCF craniectomies, complicated by chronic otomastoiditis. intracranial extension of abscess Contrast: MAGNEVIST Amt: 16 FINAL REPORT (Cont) brainstem, cerebellum and craniocervical junction. The adjacent dura demonstrates servere, up to 1 cm in diamter thickening and avid enhancement. Auditory ossicles are intact. Sinus rhythm. The internal auditory canal is normal. Poor R wave progression, probably a normal variant. intracranial extension of abscess No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): HBcb TUE 12:52 PM 1. Temporomandibular joints are normal. The tympanic membrane is normal. TECHNIQUE: Helical axial MDCT images were acquired through the temporal bones without intravenous contrast. COMPARISON: Multiple CT and MR examinations between and . The parenchymal and enhancement is unremarkable. At this level, the masseter is slightly thickened and irregular in appearance. Following IV administration of gadolinium, axial T1 and sagittal CT images were obtained. | 4 | [
{
"category": "Radiology",
"chartdate": "2110-12-07 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1216466,
"text": ", EU 10:05 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: ? intracranial extension of abscess\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with multiple past craniotomies and swelling of a right\n temporal flap w/ findings on CT concerning for intracranial involvement\n REASON FOR THIS EXAMINATION:\n ? intracranial extension of abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Peripherally enhancing fluid collection along the right temporal bone flap\n with mild epirual fluid component and extensive dural thickening and\n enhancement. These findings raise the suspicion of temporal soft tissue\n abcess, bone flap osteomyelitis and extra-axial empyema.\n\n 2. Diffuse likely reactive edema and enhancement involving the right\n infratemporal and retromaxillary zygomatic fossa as well as the masticator\n space.\n\n 3. No evidence of intra-axial involvement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-12-07 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1216444,
"text": " 4:33 AM\n CT ORBITS, SELLA & IAC W/ CONTRAST; -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: please obtain temporal bone scan to eval mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with h/o multiple craniotomies presenting with right temporal\n mass\n REASON FOR THIS EXAMINATION:\n please obtain temporal bone scan to eval mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh SUN 5:32 AM\n see other report\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female with multiple craniotomies for aneurysm\n clipping, complicated by Group B Strep meningitis, chronic mastoiditis/otitis\n media, and temporalis flap retraction. Now reports increased right facial\n swelling and trismus.\n\n COMPARISON: Multiple CT and MR examinations between and .\n\n TECHNIQUE: Helical axial MDCT images were acquired through the temporal bones\n without intravenous contrast. 2.5-mm axial images were generated through the\n entire field of view. 0.3-mm true axial and true coronal intraconal reformats\n were generated through each temporal bone.\n\n FINDINGS:\n Post-surgical changes are noted in the right middle cranial fossa, with\n fragmentation of the squamous portion of the temporal bone, as well as a\n surgical defect in the anterior mastoid. At this level, the masseter is\n slightly thickened and irregular in appearance. There is marked soft tissue\n edema and fat stranding along the right malar and frontal soft tissues. Just\n superficial to the masseter, and 2 cm deep to the skin surface in the right\n preauricular region, is a 3 x 0.5 cm crescentic fluid collection suspicious\n for abscess. Within the masseter muscle, multiple air-density foci are\n unchanged and likely postsurgical (300b:35). Marked fascial thickening and\n edema are noted, with superior extension into the temporalis, and inferior\n extension into the external auditory canal and parotid.\n\n Temporomandibular joints are normal. Mild mucosal thickening is noted in the\n ethmoid air cells. Orbits and intraconal structures appear symmetric.\n\n RIGHT TEMPORAL BONE: Severe edema results in narrowing of the external\n auditory canal. There is partial fluid opacification of the right mastoid air\n cells and middle ear cavity. Debris is also noted within the external\n auditory canal, along the tympanic membrane, and within the meso- and\n hypotympanum. There is increased breakdown of bony septae, and more prominent\n irregularity of the anterior mastoid air cells and petrous apex. Several tiny\n defects are noted at the level of the tegmen tympani, and frank dehiscence\n (with risk of CSF leak) cannot be excluded. Demineralization is also seen\n along the bony roof of the facial nerve canal. Note is made of a large\n peritubal air cell, with internal air-fluid level. The carotid canal, jugular\n (Over)\n\n 4:33 AM\n CT ORBITS, SELLA & IAC W/ CONTRAST; -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: please obtain temporal bone scan to eval mass\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n foramen, and sigmoid sinus plate appear intact. Cochlea, bony vestibule and\n semicircular canals are well-covered by bone. Internal auditory canal is\n normal in caliber. The skull base appears grossly intact.\n\n LEFT TEMPORAL BONE: Mastoid air cells are well-developed and aerated. The\n tympanic membrane is normal. Auditory ossicles are intact. The middle ear\n cavity is clear. Cochlea, bony vestibule, and semicircular canals are well\n covered by bone. The internal auditory canal is normal. Petrous apex is\n preserved.\n\n IMPRESSION:\n 1. Status post right MCF craniectomies, complicated by chronic\n otomastoiditis. There has been progressive erosion of the mastoid septae,\n tegmen tympani, and petrous apex, without destruction of the ossicular chain\n or scutum. Patient remains at risk for intracranial extension and/or CSF\n leak.\n 2. Right facial and external auditory canal inflammation. Rim-enhancing\n fluid collection superficial to right masseter muscle, highly suspicious for\n abscess, which may be amenable to percutaneous drainage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-12-07 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1216465,
"text": " 10:05 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: ? intracranial extension of abscess\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with multiple past craniotomies and swelling of a right\n temporal flap w/ findings on CT concerning for intracranial involvement\n REASON FOR THIS EXAMINATION:\n ? intracranial extension of abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): HBcb TUE 12:52 PM\n 1. Peripherally enhancing fluid collection along the right temporal bone flap\n with mild epirual fluid component and extensive dural thickening and\n enhancement. These findings raise the suspicion of temporal soft tissue\n abcess, bone flap osteomyelitis and extra-axial empyema.\n\n 2. Diffuse likely reactive edema and enhancement involving the right\n infratemporal and retromaxillary zygomatic fossa as well as the masticator\n space.\n\n 3. No evidence of intra-axial involvement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old woman with status post right parietotemporal\n craniotomy with infection of bone flap. Assessment for intracranial\n involvement.\n\n COMPARISON: MRI head dated and CT head dated \n\n TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo, diffusion with\n ADC map images as well as TOF MRA and MRV of the brain were obtained without\n contrast. Following IV administration of gadolinium, axial T1 and sagittal CT\n images were obtained.\n\n FINDINGS: The patient is status post right temporoparietal craniectomy with\n right temporal bone flap.\n There is extensive edema and diffuse enhancement involving the entire right\n infratemporal and retromaxillary zygomatic fossa, extending into the right\n masticator space. As seen on previous CT, there is a peripherally enhancing\n fluid collection extending laterlly, posteriorly an partly medially along the\n right temporal bone graft. The adjacent dura demonstrates servere, up to 1 cm\n in diamter thickening and avid enhancement. No leptomeningeal enhancement is\n identified.\n\n The cerebral sulci, ventricles and extra-axial CSF-containing spaces have\n normal size and configuration. There is no shift of the midline structures.\n The brain parenchyma has normal -white matter differentiation. There is\n no evidence of acute infarction, intracranial hemorrhage, mass effect or\n midline shift. No abnormality is noted with regard to basal ganglia,\n (Over)\n\n 10:05 AM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: ? intracranial extension of abscess\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n brainstem, cerebellum and craniocervical junction. The parenchymal and\n enhancement is unremarkable. There is extensive opacification of the right\n mastoid air cells. Mild bilateral mucosal thickening of the ethmoid air cells\n is also seen.\n\n Image quality of intracranial TOF MRA is significantly reduced by motion\n artifact and susceptibility from previous clipping of the right M1 bifurcation\n and basilar tip aneurysms. Thereby, the distal segment of the basilar artery\n as well as the bilateral P1 segments are not visualized. Within these\n limitations, the intracranial carotids, vertebrobasilar and anterior, middle\n and posterior cerebral arteries demonstrate normal flow-related enhancement.\n There is no evidence of occlusion further aneurysm or arteriovenous\n malformation.\n 2D TOF of venous sinuses in unremakable.\n\n IMPRESSION:\n 1. Peripherally enhancing fluid collection along the right temporal bone flap\n with mild epidural fluid component and extensive dural thickening and\n enhancement. These findings raise the suspicion of temporal soft tissue\n abcess, bone flap osteomyelitis and extra-axial empyema.\n\n 2. Diffuse likely reactive edema and enhancement involving the right\n infratemporal and retromaxillary zygomatic fossa as well as the masticator\n space.\n\n 3. No evidence of intra-axial involvement.\n\n"
},
{
"category": "ECG",
"chartdate": "2110-12-07 00:00:00.000",
"description": "Report",
"row_id": 308968,
"text": "Sinus rhythm. Poor R wave progression, probably a normal variant. Compared to\nthe previous tracing of there is no significant diagnostic change.\n\n"
}
] |
22,588 | 133,228 | As previously stated the patient was admitted and placed in the surgical Intensive Care Unit. The plan was to return on hospital day two for repeat angiography. On the morning of hospital day two, the patient was taken back to the angiography suite. At angiography initially a successful thrombolysis of the hepatic artery occlusion was performed. There was evidence of a short but significant hepatic artery stenosis. The stenosis was unable to be crossed with a balloon angioplasty catheter. During the procedure the recurrence of a partially obstructing thrombi in hepatic artery both up and down stream of the hepatic artery stenosis. TPA and Heparin infusions were restarted. On hospital day three the patient was again taken to angiography. A patent donor hepatic artery with a very slow flow across focal anastomotic stenosis was again observed. Also there was luminal irregularity following the anastomosis which was interpreted as greater on the previous day with a widely patent vessel beyond the anastomosis. On that evening the patient was taken to the O.R. for hepatic artery repair of the saphenous vein interposition graft. Postoperatively the patient was transferred back to the Surgical Intensive Care Unit intubated, was subsequently extubated without incident. Perioperative antibiotics consisted of Unasyn. On hospital day four this was the morning following the operation, the patient was taken back to angiography and a the saphenous vein graft was seen and there was noted to be patent anastomosis with swift flow however, there seemed to be a looped complex in the left hepatic artery with no flow past that area. The patient continued in the surgical Intensive Care Unit and an insulin drip was started for an elevated blood glucose control. The patient was hypotensive and not responding to fluid boluses and albumin so a Dobutamine drip was started. A Swann-Ganz catheter was inserted for hemodynamic monitoring. The was transfused four units on this day for hematocrit drop. He was also transfused three units of platelets. The Unasyn was discontinued, Vancomycin and Zosyn was started for antibiotics. The Cell-Cept, Prograf and Prednisone were restarted. On postop day one, the patient was hypertensive, a Nitroglycerin drip was started and then subsequently weaned off. The patient was transfused another two units of platelets. A heme consult for thrombocytopenia was obtained, the recommendations including stopping the Heparin. There was a question of whether the patient had Heparin induced thrombocytopenia. They also recommended switching the proton pump inhibitor as well as brought up the issues were thrombocytopenia is likely secondary to a consumptive process verses decreased thrombopoietin. The ultrasound showed patent hepatic artery on this day. On postop day two large amount of drainage was observed from the left groin wound. The patient was hypertensive and Zestril was restarted. The patient received an additional three units of packed red cells and two units of platelets. Repeat ultrasound showed patent hepatic artery and the patient remained in the surgical Intensive Care Unit. On hospital day seven, which is postop day three, the patient was transfused an additional two units of platelets for a platelet count of 77,000. A CT scan was obtained which showed right hepatic artery flow with no flow on the left, with a question of a change in the left lobe suggestive of infarction. On postop day four the Swann line was discontinued as well as the cortise line which had been inserted for resuscitation. The tips were sent for culture and central venous line was placed. The patient was transferred to the floor on this day and TPN was started. On postop day five the patient was on the floor and improving. It was noted at this time that there was scrotal ecchymosis present. The platelet count was followed and had initially risen to above 100,000 but was now trending down and was actually 78,000 on this day. Also noted on this day there was a left eye hematoma. On postop day six, the patient's platelets were noted to be 54,000 in the morning. Also of note this day the patient's Prograf was held secondary to a level of 15.6. Pain medication was changed to p.o. Dilaudid from intravenous medications at this time. The patient was transfused a unit of platelets on the evening of this day. On postop day seven, the antibiotics were discontinued. Ultrasound showed both of the right and left hepatic artery and the common duct was also evaluated and measured 2.5 mm. On hospital day 12, postop day eight, the patient had a new complaint of calf tenderness. An ultrasound was obtained which was negative for deep vein thrombosis. On this day the patient was transfused two additional units of platelets for a platelet count of 63,000. On postop day nine, a CT scan was repeated to evaluate the hepatic artery and again flow was seen both in the right and left hepatic arteries. On postop day 10 the patient's Plavix was restarted and the patient continued to improve with ambulation, was tolerating a regular diet, was feeling generally well. On postop day 11, which is hospital day 15, on the patient was noted to be doing quite well, had no complaints, was afebrile, was tolerating p.o.'s and had not required any additional platelet transfusions for two days and was discharged home with a plan to follow-up in clinic with Dr. as well as with Dr. . | There has been interval removal of a catheter and exchange for a right IJ central venous catheter which terminates in the distal superior vena cava. There is left basilar atelectasis associated with pleural effusion. Superselective hepatic arteriogram demonstrates a partially occluded common hepatic arterial lumen, with multiple filling defects most consistent with thrombus. The native hepatic artery is patent, and demonstrates a very slow flow into the donor hepatic artery across a tight focal stenosis. The microcatheter was connected to the pump injector and a supraselective AP arteriogram of the hepatic area was performed, showing a patent but stenosed HA. IMPRESSION:: Patent donor hepatic artery with a very slow flow across a focal anastomotic stenosis. Distal to this stenosis, the donor artery is looped and now demonstrates more prononced luminal irregularities. collection/effusion FINAL REPORT HISTORY: Hepatic artery thrombosis, recent bypass, patient has low hematocrit. There is a patent and tortuous splenic artery, and an arterial stump corresponding to the hepatic artery. Selective celiac arteriogram demonstrates a patent celiac axis, with unremarkable left gastric and splenic arteries. Successful thrombolysis of the hepatic artery (HA) occlusion and evidence of a short but significant HA stenosis. Right IJ central venous catheter terminate in the distal superior vena cava without pneumothorax. The final supraselective hepatic arteriogram obtained shows the appearance of new, recurrent, filling defects, partially obstructing the lumen in the hepatic artery, both just upstream and just downstream of the stenosis. Evaluate hepatic vasculature. There is a small fluid collection inferior to the falciform ligament, likely post- operative in nature; there is also an area of low attenuation along the porta hepatis, again likely post- operative fluid. IMPRESSION: 1) S/P hepatic artery revascularization with only a small amount of contrast seen passing through the region of the bypass and low attenuation geographic area in the left lobe of the liver concerning for evolving infarction. Reflux of contrast is present, opacifying the celiac trunk and splenic artery. Delayed images showed patency of the portal vein, as well as of its right and left branches. Again noted is a small amount of subhepatic fluid below the left lateral segment and posterior to the right lobe of the liver. CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: Bilateral small pleural effusions are present with associated bibasilar compressive atelectasis. There is a short but significant stenosis of the hepatic artery, approximately at or just beyond the stump of the hepatic artery seen yesterday. Single bilateral renal arteries are noted, with early bifurcation on the right. FINDINGS: There is a saphenous vein graft between the donor hepatic artery and the recipient right hepatic artery after resection of a segment of artery that had appeared looped previously and also included a takeoff of the left hepatic artery. VAc (R) fem dsg C/D/I. Providing Dilaudid 1 mg IVP PRN w/ fair effect.PLAN: Cont TPA and hep gtts. 1700 hct 34.9 plts 83 K (P), Dr. notified.GI: FSBS q6h covered by RISS. Cont w/ generalized 3+ edema. (L) femeral inc with staples sm->mod serous drainage. ho notified dr with decrease hct. PT IS + 3854 CC MN - 1800.RESP: LS CLEAR, DIMINISHED RIGHT BASE. dopa d/c'd. GI: Bowel sounds present, Abd dsg CDI. Pt acknoledged his understanding.GI/GU: NPO since 0005. CT. Tol procedure well. CVP 2-6, PA PRESSURES ~26/13, PCWP 8, C.O. unasyn 3gms iv q6hrs x4post op doses. Lateral abd inc w/ staples sm amount serous drainage middle, some ecchymosis along inc line. Pt using IS w/ RN and (I). focus post opdatea: returned from the or. iv 1/2ns at 75cc/hr.action: abd dsg changed x3 for lg amt of serosang ddrainage. + HYPO BS. DRESSING CHANGED BY DR. .GU: LOW U/O 12-35CC/HR. vanco and zosyn iv given. PLTS 94 POST TRANSFUSION. Tachypneic in am, RR 14-25, shallow->nl.GI/GU: NPO except meds. Addendum to transfer note:CV: A-line d/c. GU: Diuresing well after lasix. iv vanco and iv zosyn ordered and given. Groin dsg changed, DSD applied mod amt serous-sang drainage. ABG IN AM: 7.37, 36, 99, 22, 97. Pt better less tachypneic, able to use IS.CV: Tmax 100.0, HTN in am. C/V: Afebrile, BP 190/ 90's, started on Lisinopril QD and Lasix 20mg IV x one with good effect. DR. AND AWARE AND IN TO PT. cxr confirm placement. Ecchymosis(L) lateral of inc and scrotum. focus hemodynmicsdata: vss. RIGHT FEMORAL SITE WITH SHEATH, OOZING FROM SITE. co/ci svr = 4.8./2.4/1017. hct 36.0 plt= 80 pt 13.7 inr 1.3 abg 7.39-39-177-24. d51/2ns at 100cc/hr. pt has #7 rapid infusion line in l antecubital. iv unasyn d/c'd. FINAL REPORT INDICATION: Status post hepatic artery thrombosis. plts 97 and platelets x2 given. PLATELETS X2 FOR PLT 30 + 72. Pt using MSO4 q 1-1.5 hrs w/ good effect. on iv vanco and iv zosyn. prbc x3 given platelets x2 given. r groin line intact but removed by dr . calicium iv given.mso4 iv prn for pain with effect. HCT UOP TO 29.8 AFTER 2 UNITS. abg ok.action: hob elevated. Blood: Tranfused 1 unit PRBC, post HCT done and reported. monitor resp status. NSG UPDATE A:ROS:NEURO: A&O x3. NOW ON 3L/M WITH O2 SAT 98%.GI: ABDOMEN SOFTLY DISTENDED. coughs on command. DISCUSSED WITH SICU AND DR. UNALBE TO WEDGE SWAN THIS AM. dr updated during the nite regarding condition. + PPP RIGHT FOOT, + CSM'S. mso4 2mg q1-2hrs iv for pain control and effective. CONTINUE WITH Q 12 HOUR LFT'S. CONDITION UPDATE:D/A: T MAX 100.2NEURO: PT CHIEF C/O IS PAIN. RIGHT GROIN LINE/SHEATH D/C'D. right radial aline patent. albumin 25gms iv given. calicium repleted. 7.87, C.I. 4.04, SR 77, SVR 1271. CONDITION UPDATED: PT ALERT AND ORIENTED. | 32 | [
{
"category": "Radiology",
"chartdate": "2197-05-31 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 762632,
"text": " 10:26 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: Status post liver transplant with abnormal LFTs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with post OLT please do Doppler of liver evaluate for HAT,\n PVT, HVT.\n REASON FOR THIS EXAMINATION:\n Status post liver transplant with abnormal LFTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with abnormal LFTs. Evaluate hepatic\n vasculature.\n\n ABDOMINAL DOPPLER ULTRASOUND: The liver has a homogeneous echotexture and is\n without focal mass. The bile ducts appear normal, without dilation or abnormal\n echogenicity. There is normal hepatopetal flow within the portal vein. The\n portal vein has normal Doppler waveforms. Normal Doppler waveforms in\n direction of flow were also established in the hepatic veins. Reliable Doppler\n waveforms could not be obtained from the hepatic arteries. There is normal\n flow within the splenic vein. The common bile duct measures 3 ml at the porta\n hepatis and approximately 5 mm farther away from the liver. The right kidney\n measures 8.3 cm and the left kidney measures 9.5 cm. Both kidneys are free of\n focal mass, hydronephrosis or stones. The spleen is unremarkable.\n\n IMPRESSION: Inability to document normal arterial waveforms from the hepatic\n arteries. Cannot exclude hepatic artery thrombosis or stenosis. Will refer the\n patient to the for additional evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-05-31 00:00:00.000",
"description": "TRANSCATHETER INFUSION FOR LYSIS",
"row_id": 762658,
"text": " 2:41 PM\n HEPATIC Clip # \n Reason: This gentleman is 58 years old and 2 years status post liver\n Contrast: OPTIRAY Amt: 80\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION FOR LYS INITAL 2ND ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER INFUSION *\n * VISERAL SEL/SUPERSEL A-GRAM EA ADD'L VESSEL AFTER BASIC A- *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with status post OLT ? HAT.\n REASON FOR THIS EXAMINATION:\n This gentleman is 58 years old and 2 years status post liver transplant\n currently with abnormal LFTs and absent hepatic aretery signal by Doppler.\n Please do flush aortogram and selective HA arteriogram.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old man status post OLT (), with recent worsening of\n liver function tests and right upper quadrant discomfort. No hepatic artery\n could not be seen nor Dopplered on today's hepatic color Doppler ultrasound.\n\n RADIOLOGISTS: Drs. , and . Dr. \n (Attending Radiologist) was present and supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient and informed consent was\n obtained.The patient was placed supine on the angiography table. The right\n groin was prepped and draped in the usual sterile manner, and following the\n administration of 1% Lidocaine for local anesthesia, the right common femoral\n artery was accessed using a 19 gauge needle. An 0.035 Bentson guidewire was\n advanced into the abdominal aorta under fluoroscopic guidance, and the needle\n was exchanged for a 5 French angiographic sheath which was connected to\n continuous irrigation with heparinized saline. A 5 Fr SOS Omniflush catheter\n was then advanced into the proximal abdominal aorta and an AP aortogram was\n performed.\n The catheter was then exchanged for a 5 Fr C2 Glidecatheter which was used to\n select the celiac trunk, and a selective celiac angiogram was performed.\n Multiple attempts to farther advance the catheter into the hepatic artery were\n unsuccessful. The catheter was therefore exchanged for a 5 Fr SOS catheter\n over a wire, and this was used to select the celiac trunk. Again, multiple\n attempts to advance this catheter farther within the celiac artery were\n unsuccessful.\n The 5 Fr angiographic sheath was therefore exchanged for a long 6 Fr \n angiographic sheath to provide more catheter stability. The 5 Fr SOS catheter\n was placed again in the ostium of the celiac trunk. A 3 French microcatheter\n was then advanced coaxially through the SOS catheter over its 0.018 wire, and\n under fluoroscopic guidance this was advanced into the hepatic artery. With\n the catheter in that position, a superselective angiogram was performed.\n The catheter was then left in position, and an in situ infusion with TPA was\n started through the microcatheter at 1 mg per hour for 1 hour. This was then\n to be reduced to 0.5 mg per hour over night. Low dose Heparin infusion was\n also started simultaneously (200 units per hour) through the side arm of the\n sheath.\n (Over)\n\n 2:41 PM\n HEPATIC Clip # \n Reason: This gentleman is 58 years old and 2 years status post liver\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The angiographic sheath was sutured to the skin using 0-silk suture. The\n catheters were taped to the patient's thigh over an arm board, and secured in\n position.\n A follow-up arteriogram was scheduled for the following morning.\n\n FINDINGS: Global aortogram demonstrated mild atherosclerotic disease of the\n infrarenal abdominal aorta. There is a high aortic bifurcation (at lower\n endplate of L3). The celiac artery appear somewhat small but patent. Single\n bilateral renal arteries are noted, with early bifurcation on the right. There\n is a patent and tortuous splenic artery, and an arterial stump corresponding\n to the hepatic artery. No distal parenchymal hepatic branches could be\n visualized, and no obvious collateral circulation was present. A large right\n phrenic artery was opacified.\n\n Selective celiac arteriogram demonstrates a patent celiac axis, with\n unremarkable left gastric and splenic arteries. The common hepatic artery\n occludes abruptly, and no distal branches are visualized. On the portal venous\n phase, the portal vein and splenic vein appear widely patent.\n\n Superselective hepatic arteriogram demonstrates a partially occluded common\n hepatic arterial lumen, with multiple filling defects most consistent with\n thrombus. Reflux of contrast is present, opacifying the celiac trunk and\n splenic artery. No antegrade flow of contrast could be demonstrated, with no\n visualization of intrahepatic arterial branches.\n\n IMPRESSION:\n 1. Occluded hepatic artery proximally and patent portal vein.\n 2. Placement of a microcatheter in front of the stump of the hepatic artery\n occlusion for TPA infusion overnight.\n 3. Follow-up arterogram in the morning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-03 00:00:00.000",
"description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM",
"row_id": 762900,
"text": " 12:39 PM\n HEPATIC Clip # \n Reason: flow in hepatic artery s/p surgical revision your catheter i\n Contrast: OPTIRAY Amt: 70\n ********************************* CPT Codes ********************************\n * EA 1ST ORDER ABD/PEL/LOWER EXT VISERAL SEL/SUPERSEL A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 yo s/p liver txstenosis and clot in hepatic arterys/p attempted thrombolysis\n and angioplasty6/28 surgery\n REASON FOR THIS EXAMINATION:\n flow in hepatic artery s/p surgical revision your catheter is still in\n placeplease call pager number with questions and with the results. will\n also need instructions for removal of cath (if not done down at IR).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53 yr old patient who had developed a stenosis in the hepatic\n arterial anastomosis liver transplant. He had undergone thrombolysis and then\n surgical graft placement. On ultrasound there was suspicion of low flow in\n the graft.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. with\n Dr. being present and supervising throughout the procedure.\n\n There was still the indwelling catheter from the TPA lysis. It had not been\n connected to a flush post operatively. Under fluoroscopy a KUB was taken. It\n demonstrated the beaded tip of the Trocar catheter. It was gently retracted\n so that it would not come apart. Also the indwelling Cobra catheter was\n removed. The 7 French Balkan sheath was flushed. A SOS catheter was advanced\n over a glidewire. It was engaged in the celiac trunk and an arteriogram was\n performed in different projections and obliquities. Comparison was made with\n an arteriogram performed on .\n\n FINDINGS: There is a saphenous vein graft between the donor hepatic artery and\n the recipient right hepatic artery after resection of a segment of artery that\n had appeared looped previously and also included a takeoff of the left hepatic\n artery. There is a patent distal and middle anastomosis. Between the\n junction between the donor hepatic artery and the first saphenous segment is a\n caliber change, however, the saphenous segmental diameter is about equal to\n the one of the right hepatic artery. The donor hepatic artery has proximally\n a focal area of mld narrowing hich may be spasm or residual of prior clamping\n Flow is much swifter today than it had been on prior arteriograms. Of note is\n in the parenchymal phase filling of the portal vein with retrograde flow in\n this vessel without visualization of a clear arterial portal fistula. The\n filling of the portal vein had been already present on the preoperative\n images.\n\n IMPRESSION: Patent anastomoses with swift flow. No further filling of the left\n hepatic artery after bypass of a looped complex.\n\n\n\n (Over)\n\n 12:39 PM\n HEPATIC Clip # \n Reason: flow in hepatic artery s/p surgical revision your catheter i\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 763074,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cont to drop hct. ? collection/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis\n\n REASON FOR THIS EXAMINATION:\n cont to drop hct. ? collection/effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatic artery thrombosis, recent bypass, patient has low\n hematocrit. Evaluate for effusions.\n\n TECHNIQUE: Portable upright chest.\n\n Comparison study dated .\n\n FINDINGS: The right IJ swan ganz catheter is well positioned in a right\n interlobar branch. The heart is mildly enlarged, the aorta is unfolded. The\n pulmonary vessels are slightly prominent in the upper zones. There are\n bilateral pleural effusions, right greater than left. There are bibasilar\n patchy infiltrates and a density in the retrocardiac region consistent with\n left lower lobe collapse.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions, right greater than left.\n 2. Bibasilar pulmonary infiltrates, failure cannot be excluded in the present\n exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 763163,
"text": " 7:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow right sided pleural effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis . s/p hepatic artery\n angioplasty. persisant oozing from wounds\n REASON FOR THIS EXAMINATION:\n follow right sided pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P liver transplant with hepatic artery thrombosis. S/P hepatic\n artery angioplasty. Persistent right-sided pleural effusions. Check status.\n\n FINDINGS: A single AP upright view. Comparison study dated . There\n has been significant improvement in the appearances of the pulmonary\n vasculature with partial clearing of the bibasilar pulmonary infiltrates noted\n previously and with reduction in size of the related bilateral pleural\n effusions. There is again evidence of consolidation and collapse of the right\n lower lobe and right middle lobe. Only the right upper lobe remains aerated.\n On the left side there is partial collapse of the left lower lobe behind the\n heart. Residual posterior pleural effusions may be present. The right IJ\n pulmonary artery catheter tip is in good position in the right main pulmonary\n artery.\n\n IMPRESSION:\n\n Significant improvement in the previously demonstrated left heart failure.\n Residual small bilateral effusions may well be present. Consolidation and\n some collapse of the right lower lobe and right middle lobe and patchy\n atelectasis also noted in the left lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-06 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 763106,
"text": " 1:24 PM\n CT ABD W&W/O C; CT PELVIS ORTHO W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: fOLLOWUP PERIHEPATIC HEMATOMA\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man S/P OLTX WITH NEW REVASCULARIZATION OF HEPATIC ARTERY\n REASON FOR THIS EXAMINATION:\n fOLLOWUP PERIHEPATIC HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P liver transplant with pre-vasculization of hepatic artery.\n\n COMPARISON: Ultrasound and abdominal CT \n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis with multiphasic imaging through the\n liver including non-contrast images.\n\n CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: Bilateral small pleural\n effusions are present with associated bibasilar compressive atelectasis. In\n the right lower lobe anteriorly there is a non-specific patchy opacity. There\n is a small pericardial effusion. A pulmonary artery catheter is present.\n\n There is a mild amount of fluid around the liver. There is a heterogeneous\n low attenuation appearance to the left lobe of the liver with a geographic\n pattern and vessels traversing the center concerning for an evolving hepatic\n infarction. In following the hepatic artery only a small amount of contrast is\n seen entering the hepatic artery with some entering the right hepatic artery\n but no visualization of left hepatic artery and is difficult to follow within\n the hepatic artery parenchyma. There is a small fluid collection inferior to\n the falciform ligament, likely post- operative in nature; there is also an\n area of low attenuation along the porta hepatis, again likely post- operative\n fluid. The spleen appears normal. There is a small splenule inferior to the\n spleen. There is a mild amount of fluid tracking along the left anterior para\n renal space. There is also soft tissue density within the lesser sac which\n does not measure to be simple fluid. This is of uncertain etiology.\n\n CT OF THE PELVIS WITH CONTRAST: There is scattered fluid throughout the\n pelvis and free fluid in the deep pelvis consistent with the patient's history\n of recent surgery. The large and small bowel appear unremarkable. In the\n left groin is a 5.0 x 3.2 cm soft tissue well-circumscribed density consistent\n with a hematoma. There is no evidence of active extravasation of contrast.\n This is associated with adjacent soft tissue stranding.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n\n IMPRESSION: 1) S/P hepatic artery revascularization with only a small amount\n of contrast seen passing through the region of the bypass and low attenuation\n geographic area in the left lobe of the liver concerning for evolving\n infarction.\n 2) Free fluid in the abdominal cavity consistent with patient's history of\n (Over)\n\n 1:24 PM\n CT ABD W&W/O C; CT PELVIS ORTHO W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: fOLLOWUP PERIHEPATIC HEMATOMA\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n recent surgery.\n 3) Higher attenuation materials in the lesser sac without a well-defined\n wall, also likely related to recent surgery.\n 4) Small left groin hematoma.\n 5) Bibasilar atelectasis with associated bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-01 00:00:00.000",
"description": "EXTCHG/INF CATH",
"row_id": 762713,
"text": " 8:43 AM\n HEPATIC Clip # \n Reason: S/P FOLLOW UP\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * EXTCHG/INF CATH EXCHG INF CATH *\n * F/U STATUS INFUSION/EMBO IV CONSCIOUTIOUS SEDATION PRO *\n * NON-IONIC 30 CC NON-IONIC 30 CC *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: S/P liver transplantation in 8/00, now admitted since yesterday\n with an occluded hepatic artery. Arteriogram is requested for followup after\n 13 hours of TPA infusion through a microcatheter positioned just in front of\n the hepatic artery stump, and possible balloon angioplasty if indicated.\n\n RADIOLOGISTS: Dr. , Dr. , and Dr. . Dr. \n , the attending radiologist, was present for the entire procedure.\n\n PROCEDURE/TECHNIQUE: The patient was placed supine on the angiographic table\n and the existing right femoral catheters and sheath were prepped and draped\n sterilely. The TPA infusion through the microcatheter positioned in the proper\n hepatic artery (HA) stump was discontinued, as well as the heparin infusion\n through the sidearm of the sheath. The microcatheter was connected to\n the pump injector and a supraselective AP arteriogram of the hepatic area was\n performed, showing a patent but stenosed HA. Two additional arteriograms in\n different obliquities were performed with the microcatheter in the same\n position, so as to precise the anatomy of the HA.\n\n An 0.018 Golden Glidewire was then advanced through the microcatheter across\n the HA stenosis untill it reached the right HA. The microcatheter could be\n advanced over the wire passed that stenosis. It could not, however, be\n advanced passed the loop that was located between the HA stenosis and the\n bifurcation of the proper HA downstream.\n\n Multiple attempts to replace that microcatheter by a 3 mm x 2 cm balloon\n angioplasty catheter were attempted over the wire, but unsuccessfully. These\n attempts consisted of using several combinations of guidewires and\n microcatheters. Guidewires included the 0.018 Golden Glidewire, a 350 cm long\n 0.018 Agility guidewire, and an 0.018 SV5 guidewire. The 5 French coaxial\n catheter was also replaced by a 5 French Cobra C2 Glide catheter that was\n advanced through the existing 5.5 French sheath.\n\n A control hepatic arteriogram was performed with the microcatheter tip in the\n HA, showing recurrent, partially-obstructing filling defects in the HA\n upstream and downstream of the stenosis. The decision was then made to stop\n attempts at balloon angioplasty from the femoral approach and to leave a new 3\n French Tracker microcatheter selectively in the HA with continuous TPA\n infusion overnight.\n\n Future management could include either re-attempting to cross the HA stenosis\n with an angioplasty balloon catheter from a left brachial approach, or to\n (Over)\n\n 8:43 AM\n HEPATIC Clip # \n Reason: S/P FOLLOW UP\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n attempt open surgical repair of that HA stenosis.\n\n The microcatheter was again to TPA infusion at the same dose (0.5 mg per hour)\n until the next morning and the heparin infusion (200 units per hour) was\n restarted through the sidearm of the sheath. The catheters and sheaths were\n afixed to the skin with an 0 Prolene suture and sterile dressings. The patient\n was then transferred to the surgical ICU.\n\n CONTRAST/MEDICATIONS: 60 ml of nonionic contrast intraarterially. Lidocaine 1%\n for local anesthesia. For conscious sedation, a total of 2 mg of Versed and\n 125 micrograms of Fentanyl were injected in divided intravenous doses and\n under continuous hemodynamic monitoring.\n\n FINDINGS:\n The initial control hepatic arteriogram through the Tracker microcatheter\n showed patency of the HA, as well as its right and left branches and their\n intrahepatic branches. The flow is rapid. There is a short but significant\n stenosis of the hepatic artery, approximately at or just beyond the stump of\n the hepatic artery seen yesterday. Beyond that stenosis, the HA course is\n tortuous, with an almost 360 degree loop, before eventually dividing in its\n right and left branches. Delayed images showed patency of the portal vein, as\n well as of its right and left branches.\n\n The craniocaudal arteriogram and the 25 degree caudocranial/8 degree \n oblique arteriograms performed during the procedure confirmed the above\n findings and better show the arterial loop located between the HA stenosis and\n the bifurcation of the HA.\n\n The final supraselective hepatic arteriogram obtained shows the appearance of\n new, recurrent, filling defects, partially obstructing the lumen in the\n hepatic artery, both just upstream and just downstream of the stenosis. This\n arteriogram also shows slower flow than on the initial arteriograms.\n\n COMPLICATIONS: Failure to cross the hepatic artery stenosis, thereby\n precluding any attempt of balloon angioplasty of that lesion. Recurrence of\n partial thrombosis in the HA during the procedure, leading to prolongation of\n the TPA infusion. No major complication otherwise.\n\n CONCLUSION:\n\n 1. Successful thrombolysis of the hepatic artery (HA) occlusion and evidence\n of a short but significant HA stenosis.\n 2. Unsuccessful attempts at crossing the stenosis with a 3 mm balloon\n angioplasty catheter, despite successful crossing of the lesion with an 0.018\n wire and a 3 French microcatheter.\n 3. Recurrence during the procedure of partially obstructing thrombi in the\n (Over)\n\n 8:43 AM\n HEPATIC Clip # \n Reason: S/P FOLLOW UP\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hepatic artery up- and downstream of the HA stenosis.\n 4. TPA and heparin infusion restarted at the same dose overnight. Control\n hepatic arteriogram scheduled for tomorrow morning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-05-31 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 762647,
"text": " 1:10 PM\n US ABD LIMIT, SINGLE ORGAN; FOLLOW-UP,REQUEST BY RAD. Clip # \n Reason: LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for hepatic artery waveforms, history of liver\n transplant.\n\n LIMITED ULTRASOUND: Focused ultrasound was performed with intent to document\n normal hepatic artery waveforms. Normal hepatic artery waveforms cannot be\n identified.\n\n IMPRESSION: Inability to document hepatic artery waveforms by ultrasound.\n Recommend further evaluation with angiogram.\n\n These findings were telephoned to Dr. at the completion of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-04 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 762953,
"text": " 1:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess hepatic artery patency and r/o hematoma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with post OLT please do Doppler of liver to evaluate for HAT,\n PVT, HVT.\n REASON FOR THIS EXAMINATION:\n assess hepatic artery patency and r/o hematoma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess hepatic artery patency. Evaluate for abdominal hematomas.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n COMPARISON: Prior study from .\n\n FINDINGS: There is a small to moderate amount of free fluid in the\n perihepatic, right paracolic, and right pelvic regions. Arterial flow is\n demonstrated in the region of the hepatic artery at approximately the level of\n the porta hepatis, there is normal flow in the portal vein.\n\n IMPRESSION:\n 1. Patent hepatic artery.\n\n 2. Small to moderate amount of fluid in the right hemi-abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-02 00:00:00.000",
"description": "F/U STATUS INFUSION/EMBO",
"row_id": 762788,
"text": " 8:03 AM\n HEPATIC Clip # \n Reason: TPA CATH CHECK\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n RADIOLOGISTS: Drs. and (the attending radiologist) was present\n and supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient and informed consent was\n obtained.\n\n The existing microcatheter which had been placed in the common hepatic artery\n for in situ TPA infusion was connected to the injector pump, and a selected\n hepatic arteriogram was performed.\n\n Catheter was then flushed and reconnected to the TPA infusion. The native\n hepatic artery is patent, and demonstrates a very slow flow into the donor\n hepatic artery across a tight focal stenosis. Distal to this stenosis, the\n donor artery is looped and now demonstrates more prononced luminal\n irregularities. The portion of the donor artery from just proximal to the\n hepatic bifurcation, up to the distal intraheptic arterial branches is patent.\n .\n\n IMPRESSION:: Patent donor hepatic artery with a very slow flow across a focal\n anastomotic stenosis. Greater than on the previous day luminal irregularity in\n the centimeters following the anastomosis beyond which the vessel is widely\n patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 762948,
"text": " 12:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis\n\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hepatic artery thrombosis.\n\n PORTABLE CHEST: Comparison is made to film from one day earlier. The Swan-\n Ganz catheter remains in place, its tip in the right pulmonary artery. The\n patient has slightly less good inspiratory effort on the current film.\n Allowing for this, midline structures are without definite change, as is the\n appearance of the right lung, with hazy increased density inferiorly. There\n is some progression of patchy increased density in the left retrocardiac area,\n where air bronchograms are now better seen. More cephalad portions of each\n hemithorax remain grossly clear.\n\n IMPRESSION: Areas of increased density persist at both lung bases, with some\n progression in the left retrocardiac area. Findings may reflect pleural\n effusion with associated atelectasis. Superimposed pneumonia cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-12 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 763549,
"text": " 11:34 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n 200CC NON IONIC CONTRAST SUPPLY; LAB RECONSTRUCTIONS\n Reason: Please reasses flow in left hepatic artery; eval progression\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man S/P OLTX WITH NEW REVASCULARIZATION OF HEPATIC ARTERY\n REASON FOR THIS EXAMINATION:\n Please reasses flow in left hepatic artery; eval progression of necrosis; r/o\n collection or bileoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate patency of left hepatic artery, s/p liver transplant.\n\n TECHNIQUE: Nonionic contrast material was administered given the need for\n rapid bolus administration.\n\n Following rapid bolus administration (5 cc per second) of contrast material a\n helical CT scan is performed through the liver and images obtained during the\n precontrast, the bolus and the nonequilibrium phases. Delayed images were\n obtained of the abdomen and pelvis 3 minutes following administration.\n Multiple reformatted images were obtained thereafter.\n\n ABDOMEN WITH CONTRAST: A patent saphenous vein graft connects the common\n hepatic artery with the origins of the left and right hepatic arteries. The\n intrahepatic left and right hepatic arteries are widely patent perfusing both\n the left and right lobes of the liver. In addition, the portal and hepatic\n veins are patent in both lobes of the liver. Areas of under-perfusion are\n noted again in the left lateral segment of the liver suggesting possible\n sequelae of previous left hepatic artery occlusion. No intrahepatic bile\n ducts are noted to be dilated. The extrahepatic bile duct is unremarkable.\n The gallbladder has been removed. Again noted is a small amount of subhepatic\n fluid below the left lateral segment and posterior to the right lobe of the\n liver. This has not increased in amount when compared to the prior CT from\n . A small hematoma is noted inferior to segment 4 of the liver also not\n changed in size or appearance.\n\n The lung bases are visualized and are unremarkable. Varices are also noted\n along the lesser and greater curvature of the proximal stomach. The spleen is\n unremarkable. The head, body and tail of the pancreas are unremarkable. The\n left and right adrenal glands are unremarkable. The left and right kidneys\n are unremarkable.\n\n PELVIS WITH CONTRAST: A small amount of fluid surrounds the inferior aspect\n of the right lobe of the liver. The visualized large and small bowel is\n unremarkable. The ureters are well visualized throughout their course and\n shown to insert into the bladder. The bladder is unremarkable. The prostate\n gland is not enlarged. A small amount of free fluid is again present in the\n pelvis. The subcutaneous tissues are unremarkable. The bony structures are\n unremarkable. When compared to the prior study from there has been\n marked reduction in the extent of intra-abdominal and intrapelvic free fluid.\n\n (Over)\n\n 11:34 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n 200CC NON IONIC CONTRAST SUPPLY; LAB RECONSTRUCTIONS\n Reason: Please reasses flow in left hepatic artery; eval progression\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT RECONSTRUCTIONS: Multiplanar reformatted images were acquired as well as\n maximum intensity projection images which confirm patency of the left hepatic\n artery.\n\n IMPRESSION: Widely patent left hepatic artery with marked decrease in the\n amount of intra-abdominal and free pelvic fluid when compared with study from\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-10 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 763410,
"text": " 11:01 AM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: Please do Doppler of liver to evaluate for HAT, PVT, , \n ______________________________________________________________________________\n FINAL ADDENDUM\n Common duct measures 2.5 millimeters, not cemtimeters as reported above. This\n is NOT enlarged.\n\n\n 11:01 AM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: Please do Doppler of liver to evaluate for HAT, PVT, , \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p post OLT now s/p hepatic artery repair with LFT elevation.\n Please do Doppler of liver to evaluate for HAT, PVT, , also please evaluate\n biliary tree.\n REASON FOR THIS EXAMINATION:\n Please do Doppler of liver to evaluate for HAT, PVT, , also please evaluate\n biliary tree.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post orthotopic liver transplant with hepatic artery repair and\n liver function enzyme elevations.\n\n LIVER ULTRASOUND WITH COLOR AND DOPPLER WAVE FORMS\n\n The left, main, right anterior and right posterior portal veins are patent\n with appropriate hepatopetal flow. The main hepatic artery, right hepatic\n artery, and left hepatic artery are patent with normal pulsatile flow. The\n right and middle hepatic veins show normal color and Doppler flow. The left\n hepatic vein shows normal color flow. Strong Doppler signal could not be\n obtained possibly secondary to the imaged portion of the vein being very\n superior and adjacent to significant cardiac motion.\n\n The common duct measures 2.5 cm. There is a trace amount of free fluid seen.\n There is no intrahepatic ductal dilatation or focal fluid collections\n\n IMPRESSION:\n\n 1. Documented patency and appropriate direction of flow within the portal\n venous, hepatic venous, and hepatic arterial systems.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 763209,
"text": " 4:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line change over wire. check for position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis . s/p hepatic\n artery angioplasty. persisant oozing from wounds\n REASON FOR THIS EXAMINATION:\n line change over wire. check for position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line change over a wire.\n\n COMPARISON STUDY: .\n\n CHEST SINGLE VIEW: Heart is enlarged but stable in appearance. There has been\n interval removal of a catheter and exchange for a right IJ central venous\n catheter which terminates in the distal superior vena cava. There is no\n pneumothorax. Again seen is bilateral pleural effusions small on the left and\n moderate on the right. There has been improved aeration in the superior\n segment of the right lower lobe as well as the medial segment of the right\n middle lobe. However, there is persistent consolidation of the remaining\n middle and right lower lobes. There is some left basilar atelecasis present.\n\n IMPRESSION:\n 1. Right IJ central venous catheter terminate in the distal superior vena cava\n without pneumothorax.\n 2. Bilateral pleural effusions right moderate, left small. There is associated\n partial collapse of the right lower and right middle lobes. There has been\n improved aeration as discussed above. There is left basilar atelectasis\n associated with pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-11 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 763492,
"text": " 3:23 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BIL.LEG PAIN, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant, now pod 8 from revision of hepatic artery\n REASON FOR THIS EXAMINATION:\n ?dvt (bilat tenderness and pain)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, bilateral tenderness and pain of\n the lower extremities.\n\n TECHNIQUE: scale, color and Doppler son of the left and right\n common femoral, superficial femoral and popliteal veins were performed. There\n is normal flow, augmentation, compressibility and Doppler wave forms\n demonstrated. No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT within the bilateral lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 762817,
"text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: preop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatic artery thrombosis post liver transplant.\n\n Comparison is made to .\n\n PORTABLE CHEST RADIOGRAPH: The heart size is normal. The vessels are normal.\n The lung fields are clear. There is no pneumothorax. There are no\n effusions.\n\n IMPRESSION:\n 1) No CHF or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-03 00:00:00.000",
"description": "ABDOMEN U.S. (PORTABLE)",
"row_id": 762891,
"text": " 10:42 AM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: Prior hepatic artery thrombosis s/p interposition graft repa\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with post OLT please do Doppler of liver to evaluate for HAT,\n PVT, HVT.\n REASON FOR THIS EXAMINATION:\n Prior hepatic artery thrombosis s/p interposition graft repair.Please evaluate\n for arterial flow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hepatic artery thrombosis.\n\n PORTABLE RIGHT UPPER QUADRANT ULTRASOUND: The liver is visualized without\n evidence of focal abnormalities. There is normal flow within the portal veins.\n There is no hepatic artery flow that can be demonstrated. No evidence of\n significant ascites. Discussed with the resident.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 762923,
"text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement of swan, ? ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p OLY wiht hepatic artery thrombosis\n\n REASON FOR THIS EXAMINATION:\n ? placement of swan, ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swan placement.\n\n PORTABLE CHEST: Comparison is made to prior study from one day earlier. There\n is a new Swan-Ganz catheter in place, its tip in the right pulmonary artery.\n No pneumothorax is seen on the supine film. There is hazy increased density in\n both bases, which could reflect pleural fluid. There is no evidence of CHF or\n overt air space infiltrate. Midline structures are grossly unchanged.\n\n IMPRESSION: 1. Swan-Ganz catheter tip in right pulmonary artery; no evidence\n of pneumothorax.\n 2. Possible bilateral pleural effusions.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-02 00:00:00.000",
"description": "Report",
"row_id": 1557504,
"text": "NSG UPDATE A:\nROS:\nNEURO: A&O x3. MAE good strength. PERL 3mm/3mm brisk. Pt anxious and awaiting OR this evening.\nCV: SR 57-94 no ectopy. Afebrile. Good bilat DP/PT, warm nl color. VAc (R) fem dsg C/D/I. TPA gtt @ 0.5mg/h and heparin gtt 200cc/h infusing via (R)VAc.\nRESP: LS occ coarse clear w/ coughing. Pt declined IS, pt encourage to C&DB q1h r/t prolonged bedrest, immobility, and upcoming surgery. Pt acknoledged his understanding.\nGI/GU: NPO since 0005. BS pos. No BM. Voiding clear yellow urine, using urinal (I).\nSKIN: W/D/I. C/O low back pain from bedrest. Providing Dilaudid 1 mg IVP PRN w/ fair effect.\n\nPLAN: Cont TPA and hep gtts. Cont to monitor (R) fem venous access, bilat pedal pulses, and CSM. Monitor labs, hemodynamics. Monitor comfort level and provide PRN Dilaudid. Provide emotional support re upcoming surgery.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-03 00:00:00.000",
"description": "Report",
"row_id": 1557505,
"text": "focus post op\ndatea: returned from the or. extubated and opens eyes to verbal stimuli. coughs on command. o2 via face mask and on 10L . o2sat 93-99%. abd dsg clean and intact. l femoral dsg intact.pedal pulses on both feet. venodyne on r leg only. right radial aline patent. pt has #7 rapid infusion line in l antecubital. r groin line intact but removed by dr . labs drawn. hct 36.0 plt= 80 pt 13.7 inr 1.3 abg 7.39-39-177-24. d51/2ns at 100cc/hr. npo.\naction: vs q15-30mins. monitor resp status. npo. unasyn 3gms iv q6hrs x4post op doses. pt to have liver and gall bladder ultrasound today. monitor labs closely.\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-03 00:00:00.000",
"description": "Report",
"row_id": 1557506,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.0\n\nNEURO: A+OX3, MAE, PAIN TREATED WITH MORPHINE PRN WITH GOOD EFFECT ON PAIN, PT MORE DROWSY AND HYPOTENSIVE AFTER MORPHINE. VISITING WITH WIFE.\n\nCV: HR 70'S-120'S NSR/ST. ABP 90'S-135/60-80. PT REQUIRING MANY FLUID BOLUS'S FOR LOW U/O AND TACHYCARDIA. TOTAL OF 3500 CC NS GIVEN, IVF @ 100. PT IS + 8LITERS SINCE MN. RIGHT GROIN LINE/SHEATH D/C'D. + DISTAL PP'S, PRESSURE DRESSING INTACT, NO DRG, NO S+S OF HEMATOMA. HCT STABLE @ 34.\n\nRESP: LS CLEAR, NO SOB, NO COUGH. PT O2 SAT 98% ON 4 L/M NC. NOW ON 3L/M WITH O2 SAT 98%.\n\nGI: ABDOMEN SOFTLY DISTENDED. NPO EXCEPT MEDS. ABD DRESSING WITH MODERATE AMOUNTS OF SERO-SANG DRG. DRESSING CHANGED BY DR. .\n\nGU: LOW U/O 12-35CC/HR. BOLUS'S AS ABOVE.\n\nENDO: ELEVATED GLUCOSE LEVELS, MAX 298, SS INSULIN ORDERS WRITTEN BY TRANSPLANT TEAM, RECONFIMED WITH DR. . K+ ELEVATED TO 5.7, PLEASE SEE CAREVIEW FOR FURTHER LAB RESULTS.\n\nR: LOW GRADE TEMP, LABILE BP, TACHYCARDIC, LOW U/O.\n\nP: LABS TO BE DRAWN Q 6 HOURS, CLOSELY MONITOR I+O, PAIN LEVEL, VITALS AND FLUID STATUS. ? SWAN -VS- TLCL. CONTINUE WITH CLOSE MONITORING AND MANAGEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-01 00:00:00.000",
"description": "Report",
"row_id": 1557502,
"text": "NURSING ADMISSION NOTE\n THIS 53 YR OLD GENTLEMAN IS S/P LIVER TRANSPLANT 2 YEARS AGO. AFTER EXPERIENCING RUQ PAIN YESTERDAY (), PT WAS INVESTIGATED, LFT'S ELEVATED, UNABLE TO VISUALIZE HEPATIC ARTERY ON DOPPLER USS.\n PT ARRIVED FROM INTERVENTIONAL RADIOLOGY @ FOLLOWING HEPATIC ANGIOGRAM. VERY ANGRY INITIALLY ABOUT HIS HEALTH COURSE OVER THE LAST FEW YEARS \"I DONT WANT TO LIVE LIKE THIS\", TAKING OUT FRUSTRATIONS VERBALLY ON NURSES OF ICU AND IR, AND MD'S. STATES HE WILL SIGN HIMSELF OUT AMA ON FRIDAY. AS EVENING PROGRESSED, PT BECAME CALMER AND MUCH MORE APPROPRIATE, APOLOGIZING FOR HIS OFFENSIVE SPEECH, THOUGH HE REMAINED FRUSTRATED OVER HIS HEALTH STATUS, AND WAS ANTICIPATING A VISIT FROM DR . DR STOPPED IN THE ICU AND REVIEWED PT STATUS, DID NOT WAKE PT WHO WAS SLEEPING AT THE TIME.\n VITAL SIGNS HAVE BEEN STABLE, TEMP 97.3, HR NSR 68-80, SBP 150'S ON ADMISSION, BUT SETTLED 100-118 THROUGHOUT SHIFT. O2 SAT 96-98% ON ROOM AIR. HAS MICRO-SHEATH FEM-LINE IN RIGHT GROIN, PULSE+ @ RT FEM, PEDAL PULSES ALSO POSITIVE BILATERALLY.\n IV GTTS HEPARIN INFUSING @ 200U/H AND TPA @ 1MG/H ON ARRIVAL, DECREASED TO 0.5MG/H @ PER I.R. ORDER. COAGS @ 0000 WITHIN ACCEPTABEL RANGE, IR RESIDENT CALLED WITH RESULTS, NO CHANGES ORDERED TO ANTICOAGULANTS.\n PLAN: RETURN TO IR @ 0800 THIS AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-01 00:00:00.000",
"description": "Report",
"row_id": 1557503,
"text": "CONDITION UPDATE:\nD/A: T 97.3\n\nEVENTS: TO ANGIO FROM 0800-1330.\n\nNEURO: UPON ARRIVAL FROM ANGIO, PT VERY ANGRY, INAPPROPRIATE. BECAME MORE APPROPRIATE AND APOLOGETIC WITHIN AN HOUR. C/O OF BACK PAIN, TREATED WITH DILAUDID WITH GOOD EFFECT.\n\nCV: HR 60'S-80'S NSR, NBP ~ 116/78, WILL ELEVATE TO 180 WHEN ANGRY, DOES NOT SUSTAIN. RIGHT FEMORAL SITE WITH SHEATH, OOZING FROM SITE. + PPP RIGHT FOOT, + CSM'S. HEPARIN GTT @ 200U/HR AND TPA GTT @ 0.5MG/HR INFUSING AS ORDERED.\n\nRESP: LS CLEAR, NO COUGH, NO SOB. PT WHEN DRIFTING OFF TO SLEEP TAKING SHALLOW BREATHS, 2L/M O2 VIA NC APPLIED, O2 SATS 99%.\n\nGI: NPO X SIPS WITH MEDS. DR. REQUESTED PREDNISONE AND TACROLIMUS TO BE GIVEN UPON RETURN FROM ANGIO, BEFORE RETURNING FOR NEXT ANGIO. NO NAUSEA.\n\nGU: VOIDING SPONT VIA URINAL.\n\nR: LABILE MOOD, VSS, FEMORAL SITE OOZING WITH + PPP, BACK PAIN TREATED WITH DILAUDID WITH GOOD EFFECT.\n\nP: CONTINUE WITH HEPARIN AND TPA GTTS AS ORDERED. TO DRAW LABS @ 1500. TO RETURN TO ANGIO @~1600 FOR ? STENTING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-06 00:00:00.000",
"description": "Report",
"row_id": 1557512,
"text": "Nursing Note 7A-7P\nNeuro: Awake alert and oreinted pleasant and cooperative. PERLA follows commands well. C/V: Afebrile, BP 190/ 90's, started on Lisinopril QD and Lasix 20mg IV x one with good effect. SR no ectopy. Resp: O2 on at 3L NC Sat= 97-99%. Lung sounds clear. Productive cough, using IS on own. GU: Diuresing well after lasix. Foley patent draining clear yellow urine. GI: Bowel sounds present, Abd dsg CDI. Groin dsg changed, DSD applied mod amt serous-sang drainage. Pain: Med q 1 to 2 hours with 4 mg MSO4 with good effect. Transported to Radiology for Abd. CT. Tol procedure well. Blood: Tranfused 1 unit PRBC, post HCT done and reported. cont with decreased Plt. Social: Wife into visit twice, emotional support provided.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-07 00:00:00.000",
"description": "Report",
"row_id": 1557513,
"text": "NURSING UPDATE\n PLATELET LEVEL OF 77 TREATED WITH TRANSFUSION OF 5-PACK PLATELETS. PLTS 94 POST TRANSFUSION. 2ND 5-PACK PLATELETS TRANSFUSED, FOLLOW UP PLTS 109.\n SLEPT POORLY, REQUESTED MSO4 FREQUENTLY FOR INCISIONAL DISCOMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-07 00:00:00.000",
"description": "Report",
"row_id": 1557514,
"text": "Addendum to transfer note:\nCV: A-line d/c. Pressure held x5 min. No bleeding or hematoma. 1700 hct 34.9 plts 83 K (P), Dr. notified.\nGI: FSBS q6h covered by RISS. Tol clears and milk.\nSKIN: Using MSo4 2-4 mg q1-4 h with good effect. Lateral abd inc w/ staples sm amount serous drainage middle, some ecchymosis along inc line. (L) femeral inc with staples sm->mod serous drainage. Ecchymosis(L) lateral of inc and scrotum. Hematoma palpable (L) inner groin unchanged.\n\nPLAN : to transfer to F7 when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-05 00:00:00.000",
"description": "Report",
"row_id": 1557509,
"text": "CONDITION UPDATE\nD: PT ALERT AND ORIENTED. STILL WITH SIGNIFICANT AMTS OF PAIN REQUIRING FREQUENT PAIN MEDS AND REPOSITIONING. MORPHINE EFFECTIVE IN CONTROLLING PAIN FOR A SHORT AMT OF TIME. HCT DOWN TO 26.1 AND PLATELETS STILL LESS THAN 100. WOUNDS CONTINUE TO OOZE BLOODY DRAINAGE. DR. AND AWARE AND IN TO PT. PT COUGHING AND RAISING WHHITE SPUTUM. O2 SAT 3L NC. PT SPLINTING WITH COUGHING AND TURNING. URINE OUTPUT REMAINS ADEQUATE. ALINE 20 POINTS HIGHER TRACING WITH FLING AND BUBBLE TEST BY DR. . CO AND CI REMAIN UNCHANGED. UNALBE TO WEDGE SWAN THIS AM. PT SLEEPING IN SHORT NAPS.\nA: TRANSFUSED WITH 2 UNITS OF PC AND 2 UNITS OF PLATELETS. MEDICATE FOR PAIN AS NEEDED. MDS AWARE PT IS REQUIRING FREQUENT PAIN MEDICATION. SALINE NASEL SPRAY ORDERED FOR DRY NOSE.\nR: MORPHINE EFFECTIVE IN CONTROLLING PAIN FOR A SHORT AMT OF TIME. HCT UOP TO 29.8 AFTER 2 UNITS. CHECK PLATLETS AT 6AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-05 00:00:00.000",
"description": "Report",
"row_id": 1557510,
"text": "NSG UPDATE A:\nROS: please refer to flowsheet.\nNEURO: A&O x3, cooperative. Pt using MSO4 q 1-1.5 hrs w/ good effect. Pt better less tachypneic, able to use IS.\nCV: Tmax 100.0, HTN in am. BP lower r/t better pain control. Cont w/ generalized 3+ edema. Following hct and plts q6 hours.\nRESP: Pt declining CPT r/t inability to tol lying flat/side. Pt using IS w/ RN and (I). Tachypneic in am, RR 14-25, shallow->nl.\nGI/GU: NPO except meds. Denies N/V. No stool or flatus. /h. u/o > 100cc/h. Diuressed well after Lasix 20 mg x1.\nSKIN: Drainage from later upper abd inc decreasing. (L) fem inc cont w/ large amt drainage requiring dsg changes q 4 hr, Dr. aware.\n\nPLAN: Cont to monitor hemodynamics, comfort level and provide pain med, abd inc and (L) fem inc change PRN, pedal pulses, resp status enc/assist with IS, FSBS and tx per RISS, labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-06 00:00:00.000",
"description": "Report",
"row_id": 1557511,
"text": "focus hemodynmics\ndata: vss. bp elevated >180. cuff bp lower than aline. alert and oriented. hob elevated. abd incision intact with visable drainage on the dsg. dsg changed. l groin dsg draining large amt of sang drainage. dsg changed x4. ho asked to see wound due to increase bloody drainaage.hct 28 total of 3units of prbcs given. plts 97 and platelets x2 given. mso4 2mg q1-2hrs iv for pain control and effective. good u.o >50cc/hr. on iv vanco and iv zosyn. appears to be in better spirits tonite. ho notified dr with decrease hct. abg ok.\naction: hob elevated. mso4 iv prn for pain control. vanco and zosyn iv given. prbc x3 given platelets x2 given. calicium repleted. npo\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-04 00:00:00.000",
"description": "Report",
"row_id": 1557507,
"text": "focus hemodynmics\ndata: vs as flow sheet. bp low at the start of shift 80-90's. u.o =40's. swan ganz catheter inserted by dr . cxr confirm placement. hr 120's dopamine ordered by the dr but pulse increase to 160's. dopa d/c'd. co/ci svr = 4.8./2.4/1017. hct 28.2 total of 4units prbc given. plts28,25 and platelets given x2 repeat 62. blood sugars 231 and insulin gtt started and blood sugars checked q1hr and blood sugar at 0500 123 and insulin off. iv 1/2ns at 75cc/hr.\naction: abd dsg changed x3 for lg amt of serosang ddrainage. l femoral dsg changed for mod amt of bloody drainage. pedal pulses postive. iv vanco and iv zosyn ordered and given. iv unasyn d/c'd. albumin 25gms iv given. calicium iv given.mso4 iv prn for pain with effect. abd distended and slightly soft. dr updated during the nite regarding condition. wife updated.\nresponse: monitor closelly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-06-04 00:00:00.000",
"description": "Report",
"row_id": 1557508,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.2\n\nNEURO: PT CHIEF C/O IS PAIN. DISCUSSED WITH SICU AND DR. TEAM, MSO4 Q 1-2 HOURS WITH GOOD EFFECT. PT REMAINS EASILY ARROUSABLE, A+OX3, FOLLOWING BALL GAME DESPITE MULTIPLE DOSES OF MORPHINE. CURRENTLY PAIN LEVEL IS A \"6\" WHICH IS ACCEPTABLE PER PT.\n\nCV: HR 105-125, ST. WITH CHANGE IN POSITION OR DRESSING CHANGES HR INCREASES. ABP AND NBP PRESSURES DO NOT ALWAYS CORRELATE, BOTH TEAMS AWARE. HYPERTENSIVE MOST OF DAY. NITRO GTT STARTED AND SOON AFTER STOPPED PER TEAM. GOAL SBP ~160, MET IN EVENING WITH GOOD PAIN CONTROL. CVP 2-6, PA PRESSURES ~26/13, PCWP 8, C.O. 7.87, C.I. 4.04, SR 77, SVR 1271. PLATELETS X2 FOR PLT 30 + 72. 500CC NS BOLUS X1. PT IS + 3854 CC MN - 1800.\n\nRESP: LS CLEAR, DIMINISHED RIGHT BASE. O2 SAT ~ 98 % ON 3 L/M NC. ABG IN AM: 7.37, 36, 99, 22, 97. C+DB AND IS DONE, PT WITH POOR EFFORT DUE TO PAIN ISSUES.\n\nGI: NPO X MEDS WITH SIPS. ABDOMEN DISTENDED. + HYPO BS. ABD AND LEFT GROIN DRESSING DRAINING SEROSANG DRG, REQUIRING DSG TO BE CHANGED X3 THIS SHIFT. US DONE. TPN STARTED.\n\nGU: FOLEY-BSD WITH CLEAR AMBER URINE.\n\nENDO: GLUCOSE LEVEL WNL.\n\nSX: WIFE IN MOST OF DAY. UPDATED THROUGHOUT DAY.\n\nR: LOW GRADE TEMP, HYPERTENSIVE, LOW PLATLETS, INCISIONS DRAINING.\n\nP: CONTINUE WITH Q 4 HOUR HCT/PLATLETS/GLUCOSE. CONTINUE WITH Q 12 HOUR LFT'S. CONTINUE TO TREAT PAIN, FOLLOW U/O, HEMODYNAMIC MONITORING, FAMILY SUPPORT. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2197-06-02 00:00:00.000",
"description": "Report",
"row_id": 164156,
"text": "Sinus bradycardia\nDelayed precordial R wave progression\nLow QRS voltages in limb leads\nCompared with ECG of no change\n\n"
}
] |
40,310 | 157,609 | 41 year old gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p admission at from to ) who was transferred from following episode of altered mental status early on day of admission, , that led to intubation for airway protection. | Action: Started dexamethasone today as neuro onc recs Response: Mental status not intact, speech slurred, non sensical. - Treat supportively with ondansetron and dexamethasone - bolus 1L now then start maintenance fluids as not taking good PO - IV phos #. - Treat supportively with ondansetron and dexamethasone - bolus 1L now then start maintenance fluids as not taking good PO (D51/2NS @125) - IV phos #. - Treat supportively with ondansetron and dexamethasone - bolus 1L now then start maintenance fluids as not taking good PO (D51/2NS @125) - IV phos #. Started on dexamethasone, restarted on lovenox for DVT after discussion with Dr. . - restarted lovenox for anticoagulation #. - restarted lovenox for anticoagulation #. - restarted lovenox for anticoagulation #. Lansoprazole Oral Disintegrating Tab 19. Cont steroids Response: Decreased LOC, prob aggressive stage of lymphoma given LDH increase. SKIN INTEGRITY: drsg x1 after stooling. - Wound care recs applied ICU Care Nutrition: Will try to put in NG tube again, may need PEG later Glycemic Control: Lines: Indwelling Port (PortaCath) - 04:37 PM 20 Gauge - 08:04 AM Prophylaxis: DVT: Lovenox Stress ulcer: Lansoprazole VAP: Comments: Communication: Comments: (HCP): Primary ph , Secondary ph Code status: Full code Disposition: ICU for now Exam now c/w progressive incr ICP - we are hyperventilating, giving mannitol, checking stat CT. Prognosis is very poor. ECHO was performed and showed anteroseptal akinesis of left ventricle, which is new when compared to - Obtain and review admission EKG - Consider TEE to fully assess # Diffuse large B-cell lymphoma: Patient is reportedly in remission after hyper-CVAD, R-, HD methotrexate, and intrathecal methotrexate. resistant to oxacillin CSF PEP pending CSF HSV pending CT Head Relatively stable vasogenic edema in the temporal lobes as well as leptomeningeal hyperdensity and hyperdensity in the left temporal lobe. resistant to oxacillin CSF PEP pending CSF HSV pending CT Head Relatively stable vasogenic edema in the temporal lobes as well as leptomeningeal hyperdensity and hyperdensity in the left temporal lobe. Initial concern for intracerebral hemorrhage given Head CT report from , aniscoria, systemic anticoagulation with enoxaparin, and report of acute mental status changes. Initial concern for intracerebral hemorrhage given Head CT report from , aniscoria, systemic anticoagulation with enoxaparin, and report of acute mental status changes. Decubitus ulcer (Present At Admission) Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Problem - Description In Comments Assessment: Action: Response: Plan: Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) Assessment: Action: Response: Plan: - Will stop Lovenox given CMO status # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent pseudomonal infection. 7) Lower extremity paraparesis attributed to leptomeningeal involvement of his lymphoma, vincristine toxicity, and critical care myopathy. Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) Assessment: Presented w/ unequal pupils, no movement of lower extremities noted, moves upper extremities in non purposeful fashion and turns head side to side. ECHO was performed and showed anteroseptal akinesis of left ventricle, which is new -EKG here unchanged from 2 prior with exception of ?U waves - TEE to fully assess # Diffuse large B-cell lymphoma: Patient is reportedly in remission after hyper-CVAD, R-, HD methotrexate, and intrathecal methotrexate. - Treat supportively with ondansetron and dexamethasone - bolus 1L now then start maintenance fluids as not taking good PO #. Tachypneic to 30s and hypertensive and tachycardic despite treatment w/lopressor. 7) Lower extremity paraparesis attributed to leptomeningeal involvement of his lymphoma, vincristine toxicity, and critical care myopathy. Morphine gtt started and titrated up to comfort. Lymphoma (Cancer, Malignant Neoplasm, Lymphoid) Assessment: Pt code status CMO,continued on morphine drip ,titrated as needed for comfort. Respiratory failure, acute (not ARDS/) Assessment: Pt remained as intubated ,vented ,sedated with fentanyl 200mics and versed 2mg/hr. Appears to be without obvious infection at this time as drainage is serosanguinous. Lansoprazole Oral Disintegrating Tab 19. - restarted lovenox for anticoagulation #. - Appreciate neurology consult input - Appreciate neurosurgery consult input - Appreicate BMT input - Appreciate neuro/onc input - FU final LP results and heme/path - Hold on further dilaudid or nortriptyline at this time, though may continue to give citalopram to avoid withdrawal from SSRI - Continue Dexamethasone 4 mg IV Q6H per Dr. # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on CXR suggest possible healthcare associated pneumonia. FINAL REPORT CT OF THE HEAD WITHOUT CONTRAST HISTORY: Lymphoma with worsening mental status. PATIENT/TEST INFORMATION:Indication: pericardial effusion?Height: (in) 69Weight (lb): 174BSA (m2): 1.95 m2BP (mm Hg): 149/92Status: InpatientDate/Time: at 16:47Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. HEAD CT WITHOUT IV CONTRAST: The study is significantly limited by patient motion; however, even allowing for motion and streak artifact and increased noise, there are slightly rounded foci of mild hyperdensity in the right temporal lobe and anterior left temporal lobe (7:9). Appears to be without obvious infection at this time as drainage is serosanguinous. Appears to be without obvious infection at this time as drainage is serosanguinous. Appears to be without obvious infection at this time as drainage is serosanguinous. Appears to be without obvious infection at this time as drainage is serosanguinous. No echocardiographic signs oftamponade.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. MRA HEAD: Given the degree of patient motion, evaluation for aneurysm is grossly suboptimal. COMPARISONS: MRI of the brain dated and . | 90 | [
{
"category": "Nutrition",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 609810,
"text": "Objective\n Pertinent medications: MVI, celexa, senna, lansoprazole, vancomycin,\n dexamethasone\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:16 AM\n Glucose Finger Stick\n 99\n 12:00 AM\n BUN\n 8 mg/dL\n 01:16 AM\n Creatinine\n 0.4 mg/dL\n 01:16 AM\n Sodium\n 132 mEq/L\n 01:16 AM\n Potassium\n 5.3 mEq/L\n 08:14 AM\n Chloride\n 98 mEq/L\n 01:16 AM\n TCO2\n 26 mEq/L\n 01:16 AM\n PO2 (arterial)\n 67 mm Hg\n 01:10 PM\n PO2 (venous)\n 47 mm Hg\n 12:18 PM\n PCO2 (arterial)\n 25 mm Hg\n 01:10 PM\n PCO2 (venous)\n 33 mm Hg\n 12:18 PM\n pH (arterial)\n 7.51 units\n 01:10 PM\n pH (venous)\n 7.45 units\n 12:18 PM\n pH (urine)\n 6.0 units\n 02:24 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 01:10 PM\n CO2 (Calc) venous\n 24 mEq/L\n 12:18 PM\n Albumin\n 3.6 g/dL\n 11:25 PM\n Calcium non-ionized\n 8.5 mg/dL\n 01:16 AM\n Phosphorus\n 1.4 mg/dL\n 01:16 AM\n Magnesium\n 1.6 mg/dL\n 01:16 AM\n ALT\n 8 IU/L\n 04:25 AM\n Alkaline Phosphate\n 73 IU/L\n 04:25 AM\n AST\n 13 IU/L\n 04:25 AM\n Amylase\n 17 IU/L\n 04:25 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:25 AM\n WBC\n 6.9 K/uL\n 01:16 AM\n Hgb\n 12.0 g/dL\n 01:16 AM\n Hematocrit\n 33.8 %\n 01:16 AM\n Current diet order / nutrition support: Tube Feed: Replete with Fiber\n at 80mL/hr with 30mL free water flushes Q 4hrs (on hold)\n Assessment of Nutritional Status\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 609811,
"text": "Objective\n Pertinent medications: Dextrose 5% in\n normal saline at 125mL/hr, MVI,\n celexa, senna, lansoprazole, vancomycin, dexamethasone\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:16 AM\n Glucose Finger Stick\n 99\n 12:00 AM\n BUN\n 8 mg/dL\n 01:16 AM\n Creatinine\n 0.4 mg/dL\n 01:16 AM\n Sodium\n 132 mEq/L\n 01:16 AM\n Potassium\n 5.3 mEq/L\n 08:14 AM\n Chloride\n 98 mEq/L\n 01:16 AM\n TCO2\n 26 mEq/L\n 01:16 AM\n PO2 (arterial)\n 67 mm Hg\n 01:10 PM\n PO2 (venous)\n 47 mm Hg\n 12:18 PM\n PCO2 (arterial)\n 25 mm Hg\n 01:10 PM\n PCO2 (venous)\n 33 mm Hg\n 12:18 PM\n pH (arterial)\n 7.51 units\n 01:10 PM\n pH (venous)\n 7.45 units\n 12:18 PM\n pH (urine)\n 6.0 units\n 02:24 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 01:10 PM\n CO2 (Calc) venous\n 24 mEq/L\n 12:18 PM\n Albumin\n 3.6 g/dL\n 11:25 PM\n Calcium non-ionized\n 8.5 mg/dL\n 01:16 AM\n Phosphorus\n 1.4 mg/dL\n 01:16 AM\n Magnesium\n 1.6 mg/dL\n 01:16 AM\n ALT\n 8 IU/L\n 04:25 AM\n Alkaline Phosphate\n 73 IU/L\n 04:25 AM\n AST\n 13 IU/L\n 04:25 AM\n Amylase\n 17 IU/L\n 04:25 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:25 AM\n WBC\n 6.9 K/uL\n 01:16 AM\n Hgb\n 12.0 g/dL\n 01:16 AM\n Hematocrit\n 33.8 %\n 01:16 AM\n Current diet order / nutrition support: Tube Feed: Replete with Fiber\n at 80mL/hr with 30mL free water flushes Q 4hrs (on hold)\n Assessment of Nutritional Status\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 609812,
"text": "Objective\n Pertinent medications: Dextrose 5% in\n normal saline at 125mL/hr, MVI,\n celexa, senna, lansoprazole, vancomycin, dexamethasone\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:16 AM\n Glucose Finger Stick\n 99\n 12:00 AM\n BUN\n 8 mg/dL\n 01:16 AM\n Creatinine\n 0.4 mg/dL\n 01:16 AM\n Sodium\n 132 mEq/L\n 01:16 AM\n Potassium\n 5.3 mEq/L\n 08:14 AM\n Chloride\n 98 mEq/L\n 01:16 AM\n TCO2\n 26 mEq/L\n 01:16 AM\n PO2 (arterial)\n 67 mm Hg\n 01:10 PM\n PO2 (venous)\n 47 mm Hg\n 12:18 PM\n PCO2 (arterial)\n 25 mm Hg\n 01:10 PM\n PCO2 (venous)\n 33 mm Hg\n 12:18 PM\n pH (arterial)\n 7.51 units\n 01:10 PM\n pH (venous)\n 7.45 units\n 12:18 PM\n pH (urine)\n 6.0 units\n 02:24 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 01:10 PM\n CO2 (Calc) venous\n 24 mEq/L\n 12:18 PM\n Albumin\n 3.6 g/dL\n 11:25 PM\n Calcium non-ionized\n 8.5 mg/dL\n 01:16 AM\n Phosphorus\n 1.4 mg/dL\n 01:16 AM\n Magnesium\n 1.6 mg/dL\n 01:16 AM\n ALT\n 8 IU/L\n 04:25 AM\n Alkaline Phosphate\n 73 IU/L\n 04:25 AM\n AST\n 13 IU/L\n 04:25 AM\n Amylase\n 17 IU/L\n 04:25 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:25 AM\n WBC\n 6.9 K/uL\n 01:16 AM\n Hgb\n 12.0 g/dL\n 01:16 AM\n Hematocrit\n 33.8 %\n 01:16 AM\n Current diet order / nutrition support: Tube Feed: Replete with Fiber\n at 80mL/hr with 30mL free water flushes Q 4hrs (on hold)\n Assessment of Nutritional Status\n Specifics:\n Change in Mental status d/t ?CNS lymphoma & will possibly need whole\n brain XRT per progress notes. Patient self extubated on & tube\n feeds were at 20mL/hr but currently off since then. Patient is not\n taking po\ns & noted possible plan for PEG. Noted electrolyte imbalance\n likely d/t poor nutrition/?refeeding syndrome; being repleted. Suggest\n placing NGT & starting tube feeds. Tube feeds still ordered in POE.\n Patient with stage IV sacral decub; current tube feed order provides\n optimal protein. Consider MVI/Minerals, ZnSO4, Vitamin A & Vitamin C if\n he has not been on these previously.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Obtain NGT & start tube feeds at 10mL/hr, advance by 10mL Q\n 6hrs to goal 80L/hr of Replete with Fiber\n 2. Adjust free water flushes per hydration\n 3. Consider\n"
},
{
"category": "Nutrition",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 609813,
"text": "Objective\n Pertinent medications: Dextrose 5% in\n normal saline at 125mL/hr, MVI,\n celexa, senna, lansoprazole, vancomycin, dexamethasone\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:16 AM\n Glucose Finger Stick\n 99\n 12:00 AM\n BUN\n 8 mg/dL\n 01:16 AM\n Creatinine\n 0.4 mg/dL\n 01:16 AM\n Sodium\n 132 mEq/L\n 01:16 AM\n Potassium\n 5.3 mEq/L\n 08:14 AM\n Chloride\n 98 mEq/L\n 01:16 AM\n TCO2\n 26 mEq/L\n 01:16 AM\n PO2 (arterial)\n 67 mm Hg\n 01:10 PM\n PO2 (venous)\n 47 mm Hg\n 12:18 PM\n PCO2 (arterial)\n 25 mm Hg\n 01:10 PM\n PCO2 (venous)\n 33 mm Hg\n 12:18 PM\n pH (arterial)\n 7.51 units\n 01:10 PM\n pH (venous)\n 7.45 units\n 12:18 PM\n pH (urine)\n 6.0 units\n 02:24 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 01:10 PM\n CO2 (Calc) venous\n 24 mEq/L\n 12:18 PM\n Albumin\n 3.6 g/dL\n 11:25 PM\n Calcium non-ionized\n 8.5 mg/dL\n 01:16 AM\n Phosphorus\n 1.4 mg/dL\n 01:16 AM\n Magnesium\n 1.6 mg/dL\n 01:16 AM\n ALT\n 8 IU/L\n 04:25 AM\n Alkaline Phosphate\n 73 IU/L\n 04:25 AM\n AST\n 13 IU/L\n 04:25 AM\n Amylase\n 17 IU/L\n 04:25 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:25 AM\n WBC\n 6.9 K/uL\n 01:16 AM\n Hgb\n 12.0 g/dL\n 01:16 AM\n Hematocrit\n 33.8 %\n 01:16 AM\n Current diet order / nutrition support: Tube Feed: Replete with Fiber\n at 80mL/hr with 30mL free water flushes Q 4hrs (on hold)\n Assessment of Nutritional Status\n Specifics:\n Change in Mental status d/t ?CNS lymphoma & will possibly need whole\n brain XRT per progress notes. Patient self extubated on & tube\n feeds were at 20mL/hr but currently off since then. Patient is not\n taking po\ns & noted possible plan for PEG. Noted electrolyte imbalance\n likely d/t poor nutrition/?refeeding syndrome; being repleted. Suggest\n placing NGT & starting tube feeds. Tube feeds still ordered in POE.\n Patient with stage IV sacral decub; current tube feed order provides\n optimal protein. Consider MVI/Minerals, ZnSO4, Vitamin A & Vitamin C.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Obtain NGT & start tube feeds at 10mL/hr, advance by 10mL Q\n 6hrs to goal 80L/hr of Replete with Fiber\n 2. Adjust free water flushes per hydration\n 3. Consider MVI/Minerals daily, Vitamin C, ZnSO4 & Vitamin A\n 4. Continue to monitor labs closely & replete PRN\n 5. need PEG if plan for long-term nutrition support ie if\n within plan of care\n Will follow plan.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609832,
"text": "TITLE: Resident Progress Note\n Chief Complaint: AMS\n 24 Hour Events:\n - Stopped acyclovir yesterday\n - Venous gas: 7.45/33\n - Updated health care proxy\n - Not having good oral intake\n - Requiring continued electrolyte repletion\n - Urine output has picked up significantly over the past 8-12 hours\n FEVER - 101.2\nF - 06:00 AM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 08:18 PM\n Cefipime - 12:17 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 PM\n Enoxaparin (Lovenox) - 09:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.4\nC (101.2\n HR: 96 (93 - 112) bpm\n BP: 145/109(118) {132/80(99) - 166/116(127)} mmHg\n RR: 24 (17 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,542 mL\n 1,379 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,442 mL\n 1,379 mL\n Blood products:\n Total out:\n 2,730 mL\n 1,480 mL\n Urine:\n 2,730 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 812 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Gen: Not responsive to verbal or tactile stimuli, does not follow\n commands\n HEENT: pupils mildly dilated left, mildly reactive bilaterally\n CV: RRR nl s1 s2 no m\n Pulm: Faint rhonchi bilaterally\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 230 K/uL\n 12.0 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 33.8 %\n 6.9 K/uL\n [image002.jpg]\n From 1am\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n Plt\n 60\n 230\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L,\n Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:1.4 mg/dL\n LDH 796\n and blood cx pending\n urine cx final no growth\n urine cx pending\n CSF cx NGTD\n 8:45 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN CLUSTERS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Further incubation required to determine the presence or absence of\n commensal respiratory flora.\n STAPH AUREUS COAG +. MODERATE GROWTH.\n OF TWO COLONIAL MORPHOLOGIES.\n CXR\n The endotracheal tube is no longer visualized. This is a rotated\n film. There is bilateral lower lobe subsegmental atelectasis. The right\n Port-A-Cath is unchanged.\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Neuro-oncology feels that full brain XRT would be the next step, but\n primary team feels that he would not be able to tolerate this treatment\n without intubation and unclear the benefit of intubation at this point\n - Will hold off on XRT pending discussions with radiation oncology,\n BMt, and neuro-oncology teams\n - Continue high-dose Decadron\n - Will involve social worker regarding goals of care, family\n situation, etc\n - FU final LP results\n - Check tumor lysis labs\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, especially given LP results and increasing LDH.\n - Stat CT head now to assess for herniation vs increased ICP. Nausea\n and vomiting also likely due to increased ICP.\n - FU final LP results and heme/path\n - Continue Decadron as above\n - Have stopped acyclovir\n - Check EEG to rule out non-convulsive status epilepticus\n #. Increased urine output: Some concern for central diabetes insipidus\n given known increased intracranial pressure and increased urine output.\n - Stop D51/2NS at this time to minimize worsening cerebral edema\n - Check CT head as above\n - Check urine lytes, recheck serum lytes, osmolarity\n - Replete lytes as needed\n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH, now exubated and doing well.\n - F/u sputum ctx\n - Plan for 10 day course with Vancomycin/Cefepime, today is day 4 of 10\n #. Hiccups: Will try thorazine for hiccup prevention.\n #. Rash: Likely drug rash, possibly Vancomycin\n - Will monitor\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Restarted lovenox for anticoagulation\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: Will try to put in NG tube again, may need PEG later\n Glycemic Control:\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609519,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained as intubated ,vented ,sedated with fentanyl 200mics and\n versed 2mg/hr. pt very impulsive and agitated,very strong and quick\n with both hands for any activity, large thick yellowish ET /oral\n secretions. VSS,afebrile. Per report 2lumen Porta cath was not with\n retun blood, TPA instilled and need to redraw at 2130hrs.\n Action:\n On CPAP 5/5/40% .sats maintained 98-100%. TF @ 20cc/hr,off at 4am for\n possible extubation today if RSBI ,secretions , blood gas are ok.\n Continued with sedations,needed bolus before turn sometimes. At\n 2130hrs,porta cath TPA withdrawn and flushed with n/s 10cc, good blood\n return and line is patent too,all IV\ns switched to porta cath. PIV x . Foley to gravity,UO adequate.\n Response:\n VSS,afebrile ,sats 98-100% RSBI in the am\n Plan:\n Wean and possible extubation today. f/u with am blood gas and labs.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Having stage 2 decub in the coccyx, dressing clean and intact,not\n changed this shift,.\n Action:\n Change of position , dressing change daily, pt on air bed. TF for\n nutrition,on bowel regimen,no BM this shift. bilateral venodynes\n on,pillows for heels to keep off the bed.\n Response:\n Ongoing with skin care .\n Plan:\n Continue with skin care and f/u with wound recs. Keep skin dry .\n ------ Protected Section ------\n Correction: -versed gtt @ 3mg/hr ( not 2mg/hr )\n :- Pt having stage 4 decubitus on coccyx ( not stage\n 2)\n ------ Protected Section Addendum Entered By: , RN\n on: 07:02 ------\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609713,
"text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609801,
"text": "TITLE: Resident Progress Note\n Chief Complaint: AMS\n 24 Hour Events:\n - Stopped acyclovir\n - Venous gas: 7.45/33\n - Discussed with HCP\n - ?needs PEG if doesn't perk up to eat- will need to confirm with HCP\n - Need to call /onc first thing in AM\n - Required continued electrolyte repletion\n FEVER - 101.2\nF - 06:00 AM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 08:18 PM\n Cefipime - 12:17 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 PM\n Enoxaparin (Lovenox) - 09:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.4\nC (101.2\n HR: 96 (93 - 112) bpm\n BP: 145/109(118) {132/80(99) - 166/116(127)} mmHg\n RR: 24 (17 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,542 mL\n 1,379 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,442 mL\n 1,379 mL\n Blood products:\n Total out:\n 2,730 mL\n 1,480 mL\n Urine:\n 2,730 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 812 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Gen: grunts to his eyes being opened, otherwise sleeping and does not\n follow commands\n CV: RRR nl s1 s2 no m\n HEENT: pupils mildly dilated left, reactive\n Pulm: crackles at bases b/l\n Abd: +BS, soft NTND\n Ext: 1+ b/l LE edema\n Labs / Radiology\n 230 K/uL\n 12.0 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 33.8 %\n 6.9 K/uL\n [image002.jpg]\n From 1am\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n Plt\n 60\n 230\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L,\n Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:1.4 mg/dL\n and blood cx pending\n urine cx final no growth\n urine cx pending\n CSF cx NGTD\n 8:45 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN CLUSTERS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Further incubation required to determine the presence or absence of\n commensal respiratory flora.\n STAPH AUREUS COAG +. MODERATE GROWTH.\n OF TWO COLONIAL MORPHOLOGIES.\n CXR\n The endotracheal tube is no longer visualized. This is a rotated\n film. There is bilateral lower lobe subsegmental atelectasis. The right\n Port-A-Cath is unchanged.\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Continue Dexamethasone 4 mg IV Q6H per Dr. \n - d/c Acyclovir as per neuro did not suggest it and it seems this is\n lymphoma according to LP\n - send VBG\n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH\n - f/u sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 3 of 10\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate, Contact -Onc early Monday\n #. Rash: likely drug rash, possibly Vancomycin\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n - bolus 1L now then start maintenance fluids as not taking good PO\n (D51/2NS @125)\n - IV phos\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - restarted lovenox for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: ?need for PEG\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609802,
"text": "TITLE: Resident Progress Note\n Chief Complaint: AMS\n 24 Hour Events:\n - Stopped acyclovir\n - Venous gas: 7.45/33\n - Discussed with HCP\n - ?needs PEG if doesn't perk up to eat- will need to confirm with HCP\n - Need to call /onc first thing in AM\n - Required continued electrolyte repletion\n FEVER - 101.2\nF - 06:00 AM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 08:18 PM\n Cefipime - 12:17 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:07 PM\n Enoxaparin (Lovenox) - 09:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.4\nC (101.2\n HR: 96 (93 - 112) bpm\n BP: 145/109(118) {132/80(99) - 166/116(127)} mmHg\n RR: 24 (17 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,542 mL\n 1,379 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,442 mL\n 1,379 mL\n Blood products:\n Total out:\n 2,730 mL\n 1,480 mL\n Urine:\n 2,730 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 812 mL\n -101 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Gen: grunts to his eyes being opened, otherwise sleeping and does not\n follow commands\n CV: RRR nl s1 s2 no m\n HEENT: pupils mildly dilated left, reactive\n Pulm: crackles at bases b/l\n Abd: +BS, soft NTND\n Ext: 1+ b/l LE edema\n Labs / Radiology\n 230 K/uL\n 12.0 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 33.8 %\n 6.9 K/uL\n [image002.jpg]\n From 1am\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n Plt\n 60\n 230\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L,\n Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:1.4 mg/dL\n and blood cx pending\n urine cx final no growth\n urine cx pending\n CSF cx NGTD\n 8:45 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN CLUSTERS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n Further incubation required to determine the presence or absence of\n commensal respiratory flora.\n STAPH AUREUS COAG +. MODERATE GROWTH.\n OF TWO COLONIAL MORPHOLOGIES.\n CXR\n The endotracheal tube is no longer visualized. This is a rotated\n film. There is bilateral lower lobe subsegmental atelectasis. The right\n Port-A-Cath is unchanged.\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Continue Dexamethasone 4 mg IV Q6H per Dr. \n - d/c Acyclovir as per neuro did not suggest it and it seems this is\n lymphoma according to LP\n - send VBG\n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH\n - f/u sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 3 of 10\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate, Contact -Onc early Monday\n #. Rash: likely drug rash, possibly Vancomycin\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n - bolus 1L now then start maintenance fluids as not taking good PO\n (D51/2NS @125)\n - IV phos\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - restarted lovenox for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: ?need for PEG\n Glycemic Control:\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "General",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Generic Note",
"row_id": 609975,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as generated during\n multidisciplinary rounds this morning. Moaning overnight.\n 98.9 105 144/95\n Obtunded\n Chest w/o crackles or wheezes\n CV 2/6 SEM\n Abd\n soft\n Hct 39\n WBC 9.3\n LD 1094\n He has begun to decline rapidly\n tachypneic, agitated, apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal. We\n have discussed this with his proxy and will confirm with other\n caregivers.\n Time spent 45 min\n Critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609441,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609601,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n (s/p admission at from to ) who was\n transferred from following episode of altered\n mental status that led to intubation for airway protection.\n Patient had a head CT performed at which was\n reported as showing right temporal and parietal edema and small foci of\n hemorrhage, though the images were not sent with the patient upon\n transfer to . According to discharge paperwork from \n today, the patient originally presented to the hospital on \n with intractable nausea and vomiting of 5 days duration. While at , the patient had several abdominal films as well as an upper GI\n series which were reportedly unremarkable. Physicians were concerned\n that there was a central cause of nausea and attempted head imaging,\n which the patient initially refused. Late on night of ,\n patient was found to be minimally responsive with head turning to right\n and arms flexed to chest. As he had received nortriptyline, there was\n initial concern for a dystonic reaction and 50 mg IV diphenhydramine\n was pushed. There was no improvement in his mental status following\n that intervention and he was intubated for ariway protection and head\n CT was then performed with results as above. Transfer to was\n requested given patient's decline in mental status requiring\n intubation.\n Of note, patient was recently admitted to on \n with hypercalcemia and a pseudomonas infection of stage IV pressure\n ulcer. He completed antibiotic course of ceftazidime, daptomycin, and\n azithromycin.\n Unknown level of ambulation immediately prior to presentation to on ; however, at time of discharge from \n on , he could stand and walk about 10 feet. A recent\n neurology note from assessed his IP strength as being 1 on\n the right and 0 on the left. He was assessed as having \"residual severe\n paraparesis due to combination of deconditioning and vincristine toxic\n polyneuropathy, and question of critical illness\n polyneuropathy/myopathy.\"\n ALLERGIES:\n Vincristine (Peripheral Neurotoxicity)\n MEDICATIONS ON TRANSFER:\n 1) Metoprolol 12.5 mg PO BID\n 2) Furosemide 20 mg PO BID (on hold)\n 3) Nitroglycerin 0.3 mg SL PRN chest pain\n 4) Morphine 2 mg IV PRN chest pain\n 5) Citalopram 20 mg DAILY\n 6) Pregabalin 50 mg \n 7) Nortriptyline 25 mg QHS\n 8) Tizanidine 2 mg Q12H\n 9) Lorazepam PRN\n 10) Polyethylene glycol DAILY\n 11) Senna 8.6 mg two tabs \n 12) Docusate sodium 100 mg TID\n 13) Bisacodyl 10 mg oral DAILY\n 14) Lactulose 30 mL Q6H:PRN constipation\n 15) Acetaminophen 650 mg Q4H:PRN pain or fever\n 16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN nausea\n 17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia\n 18) Lovenox 90 mg Q12H (on hold)\n 19) Multivitamins DAILY\n 20) Clotrimazole 10 mg QID\n 21) Miconazole topical QID:PRN\n PAST MEDICAL HISTORY:\n FAMILY HISTORY:\n 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n 16) MRSA in sputum \n Non-contributory per prior records.\n SOCIAL HISTORY:\n Brother incarcerated in . Patient has a 19 yr old son in\n . Prior to his recent hospitalization, he was living in\n automobile. Discharged to on and currently living\n at Wood Mill Skilled Nursing Facility.\n Tobacco: 2.5 packs X 25 years\n EtOH: unknown\n IVDA/other illicit drug use: previously denied\n Assigned PCP:\n (but has not met her yet)\n Oncologist:\n \n Decubitus ulcer (Present At Admission)\n Assessment:\n Coccyx ulcer 4cm in diameter w/undermining present, old dressing\n w/serosang drainage, old aquacel AG dressing removed w/green hue, no\n odor present. Wound cleansed w/spray wound cleaner, aquacel AG dressing\n applied and covered w/DSD.\n Action:\n Daily coccyx dressing changed QD as prescribed. Turned and positioned\n at least q2hours.\n Response:\n Apparent discomfort w/dressing change, not medicated w/fentanyl as just\n self extubated. Discomfort appeared to disappate as soon as quick\n dressing change completed.\n Plan:\n Cont w/QD dressing changes as prescribed and turn and position at least\n q2hours.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Self extubated, speech garbled, appears to make attempt to open eyes\n occasionally to voice, does not respond to questions or commands.\n Resistant to any nursing care, attempts to grab and squeeze @ care\n providers and also appears to have pain with repositioning or sacral\n decub dressing changes. Discussed w/MD and does not want to mask neuron\n status w/narcotics at present. Appears to not have pain with left alone\n in bed. Moves arms well, mitt restraints on to help prevent further\n pulling of tubes however, unable to keep O2 on patient. O2 sats 100%.\n New rash noted over right side of face and upper chest, ICU MDs in to\n assess.\n Action:\n Started dexamethasone today as neuro onc recs\n Response:\n Mental status not intact, speech slurred, non sensical.\n Plan:\n Cont to follow, anticipate possible chemo once atypicals from LP\n identified. Monitor rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Copious thick yellow secretions this morning requiring suctioning q15\n minutes, secretions then changed to white and thin. Patient self\n extubated @ 1050, able to bring head to restrained wrist. Pt\n transiently on 2L NC w/O2 sats 100% and breathing 18-28bpm, ABG\n 7.5/25/65, O2 increased to 4L, however, unable to keep O2 on despite\n wrist restraints and mitts. LS: now CTA.\n Action:\n Self extubated, cough strong, productive.\n Response:\n O2 sats 100%, RR 18-26.\n Plan:\n Cont to monitor resp status.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609790,
"text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is much less active not taking po. Responds only to pain with OUCH.\n Increased ectopy, labs done early am. Clear to diminished ls.\n Hypoactive bs but has had 4 stools this shift. Lg vol urine output\n with approx 200-380 cc/hr. fever 100.6 to current 101.2 rectal. Ldh\n has bumped up this am . hypertensive to 165-110. only able to give\n metoprolol iv. Decreased skin turgor\n Action:\n Cont to turn and position . repleted k and phos, iv fluid running cont\n at 125 cc/hr d5/.5 ns. Tylenol 650 mg x2 rectally. Cont steroids\n Response:\n Decreased LOC, prob aggressive stage of lymphoma given LDH increase.\n Resp status stable. Fever is concerning as not really relieved be\n Tylenol. High urine output with fever and freq bowel movements leaves\n pt poss dehydrated. See turgor\n Plan:\n Poss increase iv fluids. need to increase iv metoprolol to tx htn.\n Poss for radiation today of brain. Needs nutrition and will poss get\n PEG soon. Would consider asking HCP to rethink goal and DNR status\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609502,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained as intubated ,vented ,sedated with fentanyl 200mics and\n versed 2mg/hr. pt very impulsive and agitated,very strong and quick\n with both hands for any activity, large thick yellowish ET /oral\n secretions. VSS,afebrile. Per report 2lumen Porta cath was not with\n retun blood, TPA instilled and need to redraw at 2130hrs.\n Action:\n On CPAP 5/5/40% .sats maintained 98-100%. TF @ 20cc/hr,off at 4am for\n possible extubation today if RSBI ,secretions , blood gas are ok.\n Continued with sedations,needed bolus before turn sometimes. At\n 2130hrs,porta cath TPA withdrawn and flushed with n/s 10cc, good blood\n return and line is patent too,all IV\ns switched to porta cath. PIV x . Foley to gravity,UO adequate.\n Response:\n VSS,afebrile ,sats 98-100% RSBI in the am\n Plan:\n Wean and possible extubation today. f/u with am blood gas and labs.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Having stage 2 decub in the coccyx, dressing clean and intact,not\n changed this shift,.\n Action:\n Change of position , dressing change daily, pt on air bed. TF for\n nutrition,on bowel regimen,no BM this shift. bilateral venodynes\n on,pillows for heels to keep off the bed.\n Response:\n Ongoing with skin care .\n Plan:\n Continue with skin care and f/u with wound recs. Keep skin dry .\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609689,
"text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits.\n Action:\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n Plan:\n ICU team to contact HCP re: for nutritional support.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609889,
"text": "PMH: burketts lymphoma, with thoracic, stomach, kidney and cns\n involvement.\n Admitted from , where he was admitted for n/v\n x5days.\n Unwitnessed ? seizure-transf. to their micu and intubated for airway\n protection.\n Ct showed there ? of right parietal hemmorage.\n Transferred here for further medical management.\n Pt. self extubated on .\n Tolerating np at 2L.\n Pt. has become more somnolent the last 48hrs.\n RESP: o2 sats continue at 100% on 2L np.\n Bil rhonchi throughout. Poor cough. Non-productive.\n NEURO: unresponsive. Noted to have hiccups periodically and\n Medicated 1x with thorazine im. With good effect.\n Head ct done for ? of increased cerebral edema.\n Ct showed increased lymphoma involvement.\n Pupils equal, but sluggish reaction.\n GI: remains npo. Incont. Of loose brown stool.\n Flexiseal ordered and placed. Still oozing around rectum.\n RENAL: autodiuresing most of the day. Has slowly slightly\n Late today. Urine lytes sent.\n Presently receiving ns 1L at 100cc/hr.\n ENDOC: lytes repleted. Last k+ 3.3. given 40meq kcl ivpb. Mg+ 1.7\nrepleted this am\n And pm with 2gm ivpb.\n Phos 1.7 and presently receiving 15mml. At 85cc/hr.\n CV: pt. more tachy this pm. Up to 140 ST. also noted to have increased\n Pvc\ns. unifocal. No vt noted.\n Has improved since lytes repleted.\n PT. UNDERWENT RADIATION TO COMPLETE BRAIN THIS PM.\n PLEASE LEAVE MARKS ON HEAD AND NECK.\n ID: cont. on antibiotics. No fever today. Blood cx\ns sent x1.\n ACCESS: double lumen portacath. Irrigate with heparin to maintain\n access.\n SKIN INTEGRITY: drsg x1 after stooling. Intact.\n SOCIAL: : (his proxy) has just arrived and is having a meeting\n with\n Dr. and ho\ns. awaiting oncologist.\n PLAN: DNR/DNI. ? OF RADIATION TOMORROW. ONCOLOGIST TO ADDRESS THIS\n ISSUE.\n 22PM CHECK LYTES.\n ? TRANSFER TO FLOOR TOMORROW.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 609701,
"text": "TITLE: Intensivist\n Weekend\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above by Dr. , including the assessment and plan. I would\n emphasize and add the following points:\n Events: self-extubated on rounds, post ABG 7.51/25/67. Subsequently\n self-d/c\nd NGT tube.\n Started on dexamethasone, restarted on lovenox for DVT after discussion\n with Dr. .\n Developed macular rash on face and chest.\n Tm 100.6 P100\ns BP 140/90s. Sat 100% on RA.\n I/O: 2.5L/2.4L\n Exam notable for sutured L eyelid, B/L pupils reactive. Verbal and\n withdrawal response to pain in all 4\n Lungs coarse b/l. Abd scaphoid and soft. Rash minimal, improved per\n report.\n Labs reviewed. Cultures reviewed; CSF and blood NGTD.\n Meds include Vanc, cefepime, acyclovir, dexamethasone, metoprolol,\n lovenox\n 41 y/o with acromegaly and high grade B cell lymphoma with likely CNS\n recurrence.\n Agree with plan for brain XRT tomorrow per neuro-onc; will d/c acylovir\n given CSF results and predominance of likely malignant cells with low\n suspicion of HSV.\n Resp status stable after extubation though mental status remains very\n poor\n will remain in ICU for now. Continue Vanc/Cefepime course for\n HAP. Repeat ABG today to confirm that PCO2 is stable.\n Needs nutritional support\n attempted placement of NGT yest\n unsuccessful d/t pt resistance; though hopefully mental status will\n improve with treatment would consider repeat attempt at NGT vs Gtube.\n Remainder of plan per ICU team.\n Pt is critically ill. CC time 35 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609702,
"text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 10:57 AM\n INVASIVE VENTILATION - STOP 10:57 AM\n PAN CULTURE - At 04:07 AM\n bc x2 urine cult no sputum obtained\n -BMT says defer to Dr. , but will likely need whole brain XRT and\n intrathecal chemo\n -Dr. : Start dexamethasone. Call -onc first thing monday AM\n because he needs whole brain irradiation (and onc won't do this\n over weekend). No MTX, as he had it in and likely has\n resistant disease.\n - self-extubated, ABG: 7.51/25/67/21\n - not taking PO: changed metoprolol to IV and he didn't get rest of PO\n meds\n - restarted lovenox but at 70 (was previously on 90 and we couldn't\n figure out why)\n -sputum Cx growing GPCs -> on precautions\n - rash started on chest, face (flat, red)\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 11:50 AM\n Vancomycin - 09:00 PM\n Acyclovir - 04:09 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:38 PM\n Other medications:\n Acetaminophen 4. Acyclovir 5. Artificial Tears 6. Bisacodyl 7. CefePIME\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Citalopram Hydrobromide 10. Dexamethasone 11. Dexamethasone 12.\n Enoxaparin Sodium 13. Fentanyl Citrate\n 14. Heparin Flush (10 units/ml) 15. Heparin Flush (100 units/ml) 16.\n 17. Lactulose 18. Lansoprazole Oral Disintegrating Tab\n 19. Magnesium Sulfate 20. Metoprolol Tartrate 21. Metoprolol Tartrate\n 22. Midazolam 23. Multivitamins\n 24. Neutra-Phos 25. Ondansetron 26. Polyethylene Glycol 27. Senna 28.\n Sodium Chloride 0.9% Flush\n 29. Vancomycin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 108 (90 - 117) bpm\n BP: 144/96(111) {122/75(91) - 156/106(118)} mmHg\n RR: 28 (12 - 31) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 71 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 2,554 mL\n 246 mL\n PO:\n 170 mL\n 75 mL\n TF:\n 80 mL\n IVF:\n 2,034 mL\n 171 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,300 mL\n 390 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 174 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 690 (690 - 690) mL\n PS : 5 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/25/67/23/0\n Ve: 8 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Gen: grunts to his eyes being opened, otherwise sleeping and does not\n follow commands\n CV: RRR nl s1 s2 no m\n HEENT: pupils mildly dilated left, reactive\n Pulm: crackles at bases b/l\n Abd: +BS, soft NTND\n Ext: 1+ b/l LE edema\n Labs / Radiology\n 260 K/uL\n 12.8 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 137 mEq/L\n 37.6 %\n 7.9 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n Plt\n 60\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n Other labs: PT / PTT / INR:15.4/32.4/1.4, Albumin:3.6 g/dL, LDH:681\n IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:1.4 mg/dL\n Imaging: CXR:\n Microbiology: blood 12/10, 13 pending\n urine pending\n CSF ctx NGTD, fungal pending\n sputum coag + staph\n urine negative\n UA 2:30am: neg UTI with 5 WBC, 30 protein, net nitrite, 5 RBC, +ketones\n PEP: Pnd\n b2micro: Pnd\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Continue Dexamethasone 4 mg IV Q6H per Dr. \n - d/c Acyclovir as per neuro did not suggest it and it seems this is\n lymphoma according to LP\n - send VBG\n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH\n - f/u sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 3 of 10\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate, Contact -Onc early Monday\n #. Rash: likely drug rash, possibly Vancomycin\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n - bolus 1L now then start maintenance fluids as not taking good PO\n - IV phos\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - restarted lovenox for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: ?PEG in near future, will readdress tomorrow as not taking\n good PO\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: discuss plan with HCP today\n status: Full code\n Disposition: ICU level care\n"
},
{
"category": "General",
"chartdate": "2144-12-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 609881,
"text": "Clinician: Attending\n Critical Care\n Through the day Mr. has been increasingly lethargic with incr UO\n resulting in neg fluid balance and progressive tachycardia. We have had\n multiple discussions with Rad Onc, BMT and the ICU team. It is clear\n his lymphoma has returned aggressively. BMT does not feel chemo would\n be of benefit and there is limited benefit to but at least some\n chance of a response. His mental status now does not permit discussion\n of goals of care so we have presented the situation to his proxy who\n wishes to proceed with . If that is possible without needing heavy\n sedation or intubation we will continue with WBI for 12 treatments. In\n the meantime we are supporting his vital functions with fluids but if\n he deteriorates we will not intubate or resuscitate as he has no\n medical chance then of recovery.\n Total time spent: 75 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609986,
"text": "TITLE: Resident Progress Note\n Chief Complaint: CNS Lymphoma\n 24 Hour Events:\n - /BMT: Feel that intrathecal chemotherapy not possible at this\n point, should try XRT\n - Rad/Onc: Reviewed him in neuro-onc conference. Want to try XRT\n without intubating him, plan 2 weeks of daily tx, M-F.\n - Went for XRT for mapping, tolerated well\n - Gave 1L NS at 5pm for tachycardia (HR 120's) and negative fluid\n balance, HR decreased to the 100-110's\n - HCP came in at 6pm today, discussed poor prognosis, plan of care\n - Made CPR not indicated\n - EEG ordered but not done\n - Couldn't get NG tube in\n - Had episode of tachypnea with hiccups at 10pm after attempt to place\n NGT, likely aspirated, no intervention. At 5am, started to desat to\n the 80's, requiring some suctioning but appeared very uncomfortable.\n Gave 2mg IV morphine and updated HCP about deterioration.\n BLOOD CULTURED - At 12:52 PM\n RADIATION THERAPY - At 05:39 PM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 07:49 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:49 PM\n Metoprolol - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.9\nC (98.4\n HR: 113 (85 - 126) bpm\n BP: 160/103(116) {136/84(103) - 160/112(122)} mmHg\n RR: 38 (20 - 43) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 4,293 mL\n 652 mL\n PO:\n TF:\n IVF:\n 4,293 mL\n 652 mL\n Blood products:\n Total out:\n 4,100 mL\n 920 mL\n Urine:\n 4,100 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 193 mL\n -268 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Gen: Not responsive to verbal or tactile stimuli, does not follow\n commands\n HEENT: pupils mildly dilated left, mildly reactive bilaterally, stable\n from yesterday\n CV: RRR nl s1 s2 no m\n Pulm: Rhonchi bilaterally, increased from yesterday\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n [image002.gif]\n 216 K/uL\n 13.7 g/dL\n 123 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 131 mEq/L\n 38.6 %\n 9.3 K/uL\n [image004.jpg] Bun 10, Crt 0.4\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n Plt\n \n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L, Ca\n 8.6 Mg 2.1 Phos 2.4\n LDH 1094\n Uric Acid 2.2\n , , blood cx pending\n urine cx final no growth\n urine cx final no growth\n CSF cx NGTD\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF PEP pending\n CSF HSV pending\n CT Head \n Relatively stable vasogenic edema in the temporal lobes as well as\n leptomeningeal hyperdensity and hyperdensity in the left temporal lobe.\n Question of increased hypodensity in the mid brain, recommend\n correlation with\n MRI to exclude the possibility of ischemia.\n CXR today in OMR\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Tachypnea and Hypoxia: Overnight has had persistent tachypnea and\n hypoxia, requiring face mask for oxygen delivery. Possibly related to\n aspiration event overnight, but unfortunately more likely related to\n systemic lymphoma as LDH increasing. Feel that this represents a\n significant downtown in his clinical course and XRT very unlikely to\n benefit him at this time. Feel that he was uncomfortable overnight and\n responded to morphine. Best course for the patient at this point is to\n become measures only.\n - Have discussed CMO with health care proxy, will be by this afternoon\n - Continue high-flow oxygen delivery in face tent form to make patient\n comfortable\n - Morphine prn for patient , need to transition to drip at\n some point today\n - Will stop antibiotics at this time, as not measures\n - Will give 1L NS now to prevent tachycardia and perhaps help patient\n feel better on some level\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Scheduled for course of XRT today but given clinical deterioration,\n unlikely to benefit him and would cause more distress than benefit.\n Will stop treatments\n - Continue high-dose Decadron for palliation\n - Health care proxy updated on poor prognosis and plan\n - FU final LP results\n - Tumor lysis labs negative at this time\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, especially given LP results and increasing LDH. Still not\n responsive except to noxious stimuli.\n - CT head yesterday not significantly changed from previous but need\n MRI to fully assess\n - FU final LP results and heme/path\n - Continue Decadron as above\n #. Increased urine output: Some concern for central diabetes insipidus\n given known increased intracranial pressure and increased urine\n output. Now urine output has tapered off and urine appears\n concentrated based on urine lytes.\n #. Hiccups: Unclear if thorazine had benefit yesterday but can continue\n for .\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given CMO status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for \n ICU Care\n Nutrition: None at this time, NG tube unable to be placed, will\n continue to hold\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: Lovenox to stop today for CMO status\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: DNR/DNI, CMO\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610065,
"text": "41 y/o M w/ \ns lymphoma w/ extensive CNS mets. Admitted on\n w/ MS changes. Both his head CT and MRI were consistent w/\n progression of his disease. Mr. self extubated on and did\n not require re-intubation, however over the last several days his MS\n has continued to decline even in the absence of any sedating meds. A\n family meeting was held w/ his HCP on as oncology and neuro-onc\n do not feel that chemo would be of any benefit and his prognosis is\n exceptionally poor. Rad onc suggested that whole body irradiation\n would likely provide little benefit but had a small potential to reduce\n his tumor load. Mr HCP has opted to go forward w/ radiation\n therapy however if he were to decompensate or require re-intubation we\n would not perform any aggressive resuscitative measures and shift focus\n to comfort. He is now DNR/DNI.\n He has begun to decline rapidly\n tachypneic, agitated, and apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n No change in mental status\n moaning, agitated and appears in\n discomfort. Tachypneic to 30\ns and hypertensive and tachycardic despite\n treatment w/lopressor. NT suctioned for moderate amnt of thick brown\n secretions. In early afternoon (after repositioning) extremely agitated\n and appears in distress, tachypneic to 40\ns, tachycardic to 150\n moaning/crying, desat to 60-70\ns , on assessment no LS @RT\n Action:\n Ativan /morphine given, repositioned back on his LT side (unable to\n reposition on his back sacral decub). NT suctioned again for brown\n thick secretion. Morphine gtt started and titrated up to comfort.\n Response:\n B/L rhonchorous. Able to tolerate lying on his LT side only. Sats up to\n 100%. Remains tachy to 140\ns. However appears more comfortable.\n Plan:\n Continue to monitor patient status, comfort is the goal. HCP and\n caregivers notified\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609598,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n (s/p admission at from to ) who was\n transferred from following episode of altered\n mental status that led to intubation for airway protection.\n Patient had a head CT performed at which was\n reported as showing right temporal and parietal edema and small foci of\n hemorrhage, though the images were not sent with the patient upon\n transfer to . According to discharge paperwork from \n today, the patient originally presented to the hospital on \n with intractable nausea and vomiting of 5 days duration. While at , the patient had several abdominal films as well as an upper GI\n series which were reportedly unremarkable. Physicians were concerned\n that there was a central cause of nausea and attempted head imaging,\n which the patient initially refused. Late on night of ,\n patient was found to be minimally responsive with head turning to right\n and arms flexed to chest. As he had received nortriptyline, there was\n initial concern for a dystonic reaction and 50 mg IV diphenhydramine\n was pushed. There was no improvement in his mental status following\n that intervention and he was intubated for ariway protection and head\n CT was then performed with results as above. Transfer to was\n requested given patient's decline in mental status requiring\n intubation.\n Of note, patient was recently admitted to on \n with hypercalcemia and a pseudomonas infection of stage IV pressure\n ulcer. He completed antibiotic course of ceftazidime, daptomycin, and\n azithromycin.\n Unknown level of ambulation immediately prior to presentation to on ; however, at time of discharge from \n on , he could stand and walk about 10 feet. A recent\n neurology note from assessed his IP strength as being 1 on\n the right and 0 on the left. He was assessed as having \"residual severe\n paraparesis due to combination of deconditioning and vincristine toxic\n polyneuropathy, and question of critical illness\n polyneuropathy/myopathy.\"\n ALLERGIES:\n Vincristine (Peripheral Neurotoxicity)\n MEDICATIONS ON TRANSFER:\n 1) Metoprolol 12.5 mg PO BID\n 2) Furosemide 20 mg PO BID (on hold)\n 3) Nitroglycerin 0.3 mg SL PRN chest pain\n 4) Morphine 2 mg IV PRN chest pain\n 5) Citalopram 20 mg DAILY\n 6) Pregabalin 50 mg \n 7) Nortriptyline 25 mg QHS\n 8) Tizanidine 2 mg Q12H\n 9) Lorazepam PRN\n 10) Polyethylene glycol DAILY\n 11) Senna 8.6 mg two tabs \n 12) Docusate sodium 100 mg TID\n 13) Bisacodyl 10 mg oral DAILY\n 14) Lactulose 30 mL Q6H:PRN constipation\n 15) Acetaminophen 650 mg Q4H:PRN pain or fever\n 16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN nausea\n 17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia\n 18) Lovenox 90 mg Q12H (on hold)\n 19) Multivitamins DAILY\n 20) Clotrimazole 10 mg QID\n 21) Miconazole topical QID:PRN\n PAST MEDICAL HISTORY:\n FAMILY HISTORY:\n 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n Non-contributory per prior records.\n SOCIAL HISTORY:\n Brother incarcerated in . Patient has a 19 yr old son in\n . Prior to his recent hospitalization, he was living in\n automobile. Discharged to on and currently living\n at Wood Mill Skilled Nursing Facility.\n Tobacco: 2.5 packs X 25 years\n EtOH: unknown\n IVDA/other illicit drug use: previously denied\n Assigned PCP:\n (but has not met her yet)\n Oncologist:\n \n Decubitus ulcer (Present At Admission)\n Assessment:\n Coccyx ulcer 4cm in diameter w/undermining present, old dressing\n w/serosang drainage, old aquacel AG dressing removed w/green hue, no\n odor present. Wound cleansed w/spray wound cleaner, aquacel AG dressing\n applied and covered w/DSD.\n Action:\n Daily coccyx dressing changed QD as prescribed. Turned and positioned\n at least q2hours.\n Response:\n Apparent discomfort w/dressing change, not medicated w/fentanyl as just\n self extubated. Discomfort appeared to disappate as soon as quick\n dressing change completed.\n Plan:\n Cont w/QD dressing changes as prescribed and turn and position at least\n q2hours.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Self extubated, speech garbled, appears to make attempt to open eyes\n occasionally to voice, does not respond to questions or commands.\n Resistant to any nursing care, attempts to grab and squeeze @ care\n providers and also appears to have pain with repositioning or sacral\n decub dressing changes. Discussed w/MD and does not want to mask neuron\n status w/narcotics at present. Appears to not have pain with left alone\n in bed. Moves arms well, mitt restraints on to help prevent further\n pulling of tubes however, unable to keep O2 on patient. O2 sats 100%.\n New rash noted over right side of face and upper chest, ICU MDs in to\n assess.\n Action:\n Started dexamethasone today as neuro onc recs\n Response:\n Mental status not intact, speech slurred, non sensical.\n Plan:\n Cont to follow, anticipate possible chemo once atypicals from LP\n identified.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Copious thick yellow secretions this morning requiring suctioning q15\n minutes, secretions then changed to white and thin. Patient self\n extubated @ 1050, able to bring head to restrained wrist. Pt\n transiently on 2L NC w/O2 sats 100% and breathing 18-28bpm, ABG\n 7.5/25/65, O2 increased to 4L, however, unable to keep O2 on despite\n wrist restraints and mitts. LS: now CTA.\n Action:\n Self extubated, cough strong, productive.\n Response:\n O2 sats 100%, RR 18-26.\n Plan:\n Cont to monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 609681,
"text": "TITLE: Intensivist\n Weekend\n Events: self-extubated on rounds, post ABG 7.51/25/67\n Self-d/c\nd NGT tube\n Started on dexamethasone, restarted on lovenox\n Developed rash on face and chest\n Tm 100.6 P100\ns BP 140/90s. Sat 100% on RA.\n I/O: 2.5L/2.4L\n Exam: notable for sutured L eye, R reactive\n Labs reviewed. Cultures reviewed; CSF and blood NGTD.\n Meds include Vanc, cefepime, acyclovir, dexamethasone, metoprolol,\n lovenox\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 609684,
"text": "TITLE: Intensivist\n Weekend\n Events: self-extubated on rounds, post ABG 7.51/25/67\n Self-d/c\nd NGT tube\n Started on dexamethasone, restarted on lovenox\n Developed rash on face and chest\n Tm 100.6 P100\ns BP 140/90s. Sat 100% on RA.\n I/O: 2.5L/2.4L\n Exam: notable for sutured L eyelid, B/L pupils reactive. Withdrawal to\n pain in all 4\ns, says\n Lungs coarse b/l. Abd scaphoid and soft. Rash face on\n Labs reviewed. Cultures reviewed; CSF and blood NGTD.\n Meds include Vanc, cefepime, acyclovir, dexamethasone, metoprolol,\n lovenox\n Agree with plan for XRT tomorrow per neuro-onc; will d/c acylovir given\n CSF results and predominance of likely malignant cells.\n Will d/c acyclovir given LP results. Needs nutritional support though\n unable to place NGT.\n Lovenox for DVT.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 609685,
"text": "TITLE: Intensivist\n Weekend\n Events: self-extubated on rounds, post ABG 7.51/25/67\n Self-d/c\nd NGT tube\n Started on dexamethasone, restarted on lovenox\n Developed rash on face and chest\n Tm 100.6 P100\ns BP 140/90s. Sat 100% on RA.\n I/O: 2.5L/2.4L\n Exam: notable for sutured L eyelid, B/L pupils reactive. Withdrawal to\n pain in all 4\ns, says\n Lungs coarse b/l. Abd scaphoid and soft. Rash face on\n Labs reviewed. Cultures reviewed; CSF and blood NGTD.\n Meds include Vanc, cefepime, acyclovir, dexamethasone, metoprolol,\n lovenox\n Agree with plan for XRT tomorrow per neuro-onc; will d/c acylovir given\n CSF results and predominance of likely malignant cells.\n Resp status stable after extubation though mental status remains very\n poor\n will remain in ICU for now.\n Needs nutritional support\n attempted placement of NGT yest\n unsuccessful d/t pt resistance. Will re-attempt vs discuss Gtube.\n Lovenox for DVT.\n Remainder of plan per ICU team.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609937,
"text": "TITLE: Resident Progress Note\n Chief Complaint: CNS Lymphoma\n 24 Hour Events:\n - /BMT: Feel that intrathecal chemotherapy not possible at this\n point, should try XRT\n - Rad/Onc: Reviewed him in neuro-onc conference. Want to try XRT\n without intubating him, plan 2 weeks of daily tx, M-F.\n - Went for XRT today for mapping, tolerated well\n - Gave 1L NS at 5pm for tachycardia (HR 120's) and negative fluid\n balance, HR decreased to the 100-110's\n - HCP came in at 6pm today, discussed poor prognosis, plan of care\n - Made CPR not indicated\n - EEG ordered but not done\n - Couldn't get NG tube in\n - Had episode of tachypnea with hiccups at 10pm after attempt to place\n NGT, likely aspirated, no intervention. at 5am, started to desat to\n the 80's, requiring some suctioning but appeared very uncomfortable.\n Gave 2mg IV morphine and updated HCP about deterioration.\n BLOOD CULTURED - At 12:52 PM\n RADIATION THERAPY - At 05:39 PM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 07:49 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:49 PM\n Metoprolol - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.9\nC (98.4\n HR: 113 (85 - 126) bpm\n BP: 160/103(116) {136/84(103) - 160/112(122)} mmHg\n RR: 38 (20 - 43) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 4,293 mL\n 652 mL\n PO:\n TF:\n IVF:\n 4,293 mL\n 652 mL\n Blood products:\n Total out:\n 4,100 mL\n 920 mL\n Urine:\n 4,100 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 193 mL\n -268 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 216 K/uL\n 13.7 g/dL\n 123 mg/dL\n 0.3 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 6 mg/dL\n 99 mEq/L\n 131 mEq/L\n 38.6 %\n 9.3 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n Plt\n \n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609939,
"text": "TITLE: Resident Progress Note\n Chief Complaint: CNS Lymphoma\n 24 Hour Events:\n - /BMT: Feel that intrathecal chemotherapy not possible at this\n point, should try XRT\n - Rad/Onc: Reviewed him in neuro-onc conference. Want to try XRT\n without intubating him, plan 2 weeks of daily tx, M-F.\n - Went for XRT today for mapping, tolerated well\n - Gave 1L NS at 5pm for tachycardia (HR 120's) and negative fluid\n balance, HR decreased to the 100-110's\n - HCP came in at 6pm today, discussed poor prognosis, plan of care\n - Made CPR not indicated\n - EEG ordered but not done\n - Couldn't get NG tube in\n - Had episode of tachypnea with hiccups at 10pm after attempt to place\n NGT, likely aspirated, no intervention. at 5am, started to desat to\n the 80's, requiring some suctioning but appeared very uncomfortable.\n Gave 2mg IV morphine and updated HCP about deterioration.\n BLOOD CULTURED - At 12:52 PM\n RADIATION THERAPY - At 05:39 PM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Acyclovir - 04:09 AM\n Vancomycin - 07:49 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:49 PM\n Metoprolol - 04:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.9\nC (98.4\n HR: 113 (85 - 126) bpm\n BP: 160/103(116) {136/84(103) - 160/112(122)} mmHg\n RR: 38 (20 - 43) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 4,293 mL\n 652 mL\n PO:\n TF:\n IVF:\n 4,293 mL\n 652 mL\n Blood products:\n Total out:\n 4,100 mL\n 920 mL\n Urine:\n 4,100 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 193 mL\n -268 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Gen: Not responsive to verbal or tactile stimuli, does not follow\n commands\n HEENT: pupils mildly dilated left, mildly reactive bilaterally\n CV: RRR nl s1 s2 no m\n Pulm: Faint rhonchi bilaterally\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n [image002.gif]\n 216 K/uL\n 13.7 g/dL\n 123 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 131 mEq/L\n 38.6 %\n 9.3 K/uL\n [image004.jpg] Bun 10, Crt 0.4\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n Plt\n \n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n Other labs: PT / PTT / INR:15.3/37.6/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Albumin:3.6 g/dL, LDH:796 IU/L, Ca\n 8.6 Mg 2.1 Phos 2.4\n LDH pending\n Uric Acid 2.2\n , , blood cx pending\n urine cx final no growth\n urine cx final no growth\n CSF cx NGTD\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF PEP pending\n CSF HSV pending\n CT Head \n Relatively stable vasogenic edema in the temporal lobes as well as\n leptomeningeal hyperdensity and hyperdensity in the left temporal lobe.\n Question of increased hypodensity in the mid brain, recommend\n correlation with\n MRI to exclude the possibility of ischemia.\n CXR today in OMR\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Tachypnea and Hypoxia: Overnight has had persistent tachypnea and\n hypoxia, requiring face mask for oxygen delivery. Likely related to\n aspiration event overnight, and possibly complicated by CNS disease.\n Also being treated for HAP and growing MRSA in sputum\n - Continue high-flow oxygen delivery in face tent form to make patient\n comfortable\n - Morphine prn for patient comfort\n - Continue Vanc/Cefepime, today is day 5 of 10\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Scheduled for course of XRT x 2weeks that started yesterday\n - Continue high-dose Decadron\n - Health care proxy updated on poor prognosis\n - FU final LP results\n - Tumor lysis labs negative at this time, will follow\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, especially given LP results and increasing LDH. Still not\n responsive except to noxious stimuli.\n - CT head yesterday not significantly changed from previous but need\n MRI to fully assess\n - FU final LP results and heme/path\n - Continue Decadron as above\n - Have stopped acyclovir\n - Check EEG to rule out non-convulsive status epilepticus\n #. Increased urine output: Some concern for central diabetes insipidus\n given known increased intracranial pressure and increased urine\n output. Now urine output has tapered off and urine appears\n concentrated based on urine lytes.\n - Continue IVF as needed for urine output\n - Check CT head as above\n - Replete lytes as needed\n #. Hiccups: Unclear if thorazine had benefit yesterday but can continue\n for comfort.\n #. Rash: Likely drug rash, possibly Vancomycin\n - Will monitor\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Restarted lovenox for anticoagulation\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: None at this time, NG tube unable to be placed\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610098,
"text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt code status CMO,continued on morphine drip ,titrated as needed for\n comfort. Moans sometimes. Looks comfortable and calm. Having lot of\n thick secretions back to throat. Sats maintained low 80-mid 90\n desats when needed NT suctions, blocking the airway with thick\n secretions. HR 120-130\ns. BP stable.\n Action:\n NT suction 3-4 times during the shift with large thick yellowish\n secretions. Continued on morphine gtt.\n Response:\n Comfortable.sats improved after suction. Moans sometimes ,especially\n when turn.\n Plan:\n Code status : CMO , to inform the family member,HCP and case\n management when Pt drops HR.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 609312,
"text": "Chief Complaint: Altered mental status\n HPI:\n *per OSH records as patient can provide limited history while intubated\n and sedated*\n 41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n (s/p admission at from to ) who was\n transferred from following episode of altered\n mental status early today that led to intubation for airway protection.\n Patient had a head CT performed at which was\n reported as showing right temporal and parietal edema and small foci of\n hemorrhage, though the images were not sent with the patient upon\n transfer to . According to discharge paperwork from \n today, the patient originally presented to the hospital on \n with intractable nausea and vomiting of 5 days duration. While at , the patient had several abdominal films as well as an upper GI\n series which were reportedly unremarkable. Physicians were concerned\n that there was a central cause of nausea and attempted head imaging,\n which the patient initially refused. Late on night of ,\n patient was found to be minimally responsive with head turning to right\n and arms flexed to chest. As he had received nortriptyline, there was\n initial concern for a dystonic reaction and 50 mg IV diphenhydramine\n was pushed. There was no improvement in his mental status following\n that intervention and he was intubated for ariway protection and head\n CT was then performed with results as above. Transfer to was\n requested given patient's decline in mental status requiring\n intubation.\n Of note, patient was recently admitted to on \n with hypercalcemia and a pseudomonas infection of stage IV pressure\n ulcer. He completed antibiotic course of ceftazidime, daptomycin, and\n azithromycin.\n Unknown level of ambulation immediately prior to presentation to on ; however, at time of discharge from \n on , he could stand and walk about 10 feet. A recent\n neurology note from assessed his IP strength as being 1 on\n the right and 0 on the left. He was assessed as having \"residual severe\n paraparesis due to combination of deconditioning and vincristine toxic\n polyneuropathy, and question of critical illness\n polyneuropathy/myopathy.\"\n REVIEW OF SYSTEMS:\n *extremely limited due to intubated and sedated status of patient*\n ALLERGIES:\n Vincristine (Peripheral Neurotoxicity)\n MEDICATIONS ON TRANSFER:\n 1) Metoprolol 12.5 mg PO BID\n 2) Furosemide 20 mg PO BID (on hold)\n 3) Nitroglycerin 0.3 mg SL PRN chest pain\n 4) Morphine 2 mg IV PRN chest pain\n 5) Citalopram 20 mg DAILY\n 6) Pregabalin 50 mg \n 7) Nortriptyline 25 mg QHS\n 8) Tizanidine 2 mg Q12H\n 9) Lorazepam PRN\n 10) Polyethylene glycol DAILY\n 11) Senna 8.6 mg two tabs \n 12) Docusate sodium 100 mg TID\n 13) Bisacodyl 10 mg oral DAILY\n 14) Lactulose 30 mL Q6H:PRN constipation\n 15) Acetaminophen 650 mg Q4H:PRN pain or fever\n 16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN nausea\n 17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia\n 18) Lovenox 90 mg Q12H (on hold)\n 19) Multivitamins DAILY\n 20) Clotrimazole 10 mg QID\n 21) Miconazole topical QID:PRN\n PAST MEDICAL HISTORY:\n FAMILY HISTORY:\n 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n Non-contributory per prior records.\n SOCIAL HISTORY:\n Brother incarcerated in . Patient has a 19 yr old son in\n . Prior to his recent hospitalization, he was living in\n automobile. Discharged to on and currently living\n at Wood Mill Skilled Nursing Facility.\n Tobacco: 2.5 packs X 25 years\n EtOH: unknown\n IVDA/other illicit drug use: previously denied\n Assigned PCP:\n (but has not met her yet)\n Oncologist:\n \n Endocrinologist:\n \n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.44/33/205//0\n Ve: 9.3 L/min\n PaO2 / FiO2: 410\n Physical Examination\n VS: T 97, HR 94, BP 155/96, RR 17, O2Sat 100% (AC Vt 600, FiO2 50%, f\n 16, PEEP 5)\n GEN: NAD, appears cachectic, intubated and sedated\n HEENT: Left pupil reactive 3 -> 2 mm, right pupil sluggish 4 mm, right\n eyelid surgical changes, generous tongue, oral mucosa dry, ET tube in\n place, generous chin, frontal bossing\n NECK: No , no JVP elevation\n PULM: Significant pectus carinum, CTAB anteriorly\n CARD: RR, nl S1, nl S2, no M/R/G\n ABD: Thin, BS+, epigastric scar, soft, non-distended, non-tympanitic\n EXT: Minimal BLE pitting, markedly enlarged hands and feet\n SKIN: No rashes, approximately 4 x 5 cm sacral ulcer without visible\n exudates, but with undermining of superficial skin\n NEURO: Sedated, was seen to be moving both upper extremities\n non-purposefully while briefly off sedation, muscle tone is normal\n bilaterally in upper and lower extremities\n Labs from :\n WBC 6.6, HCT 36.2, PLT 210\n INR 1.3\n Na 137, K 3.0, Cl 109, CO2 21, BUN 5, Cr 0.4, Glu 145\n Ca 7.6, Mg 1.6\n AST 15, ALT 9, Tbili 0.4, Ammonia 27\n Albumin 3.2\n Blood culture pending and neg x 2\n Stool c.diff negative\n CT HEAD from :\n \"IMPRESSION: I would question an evolving infarct in the right\n temporoparietal region. Possibly with a small amount of assoicated\n hemorrhage. Follow-up CT or MRI would be suggested.\"\n CT HEAD W/O CONTRAST @ :\n *Wet read*\n Study limited by motion (though 5 attempts made). However, impression\n of mildly increased density diffusely, interdigitating with sulci,\n especially near skull base. Given the concern for hemorrhage, and lack\n of IV contrast administration, this may represent subarachnoid\n hemorrhage.\n TEE from :\n Draft report has impression of + MR ventricle anteroseptal\n akinesis consistent with prior MI. No AS or AI. No TR or PR. LVEF\n estimated at 45%.\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status:\n Patient\ns mental status changes severe enough to warrant intubation for\n airway protection. Initial concern for intracerebral hemorrhage given\n Head CT report from , aniscoria, systemic\n anticoagulation with enoxaparin, and report of acute mental status\n changes. Possible etiologies of ICH would be an ischemic stroke with\n hemorrhagic conversion, spontaneous bleed in setting of systemic\n anticoagulation, or unrealized trauma. Initial glance at STAT head CT\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage.\n Additionally, this presentation could represent a recurrence of his\n lymphoma, which was formerly thought to be in remission. Must consider\n that observed behavior and resulting mental status changes at were consistent with a seizure. Is possible that\n patient's serotonergic medications of citalopram, nortriptyline, and\n dilaudid acted to create a serotonin syndrome that presented with\n patient turning head to right due to increased tone. On physical exam\n at this time, muscle tone is essentially normal and patient has no\n history of fevers or clonus at OSH. Must also consider that his\n presentation is related to meningitis or encephalitis, though no\n prodrome of illness aside from nausea and vomiting and no reported\n fevers. As for other infections, should screen with blood culture, UA\n (was seen to have RBCs and WBCs at OSH), and CXR. No elevation in\n livier enzymes and ammonia of 27 at , both of which are\n inconsistent with a hepatic encephalopathy.\n - Follow-up final read of STAT Head CT that was obtained shortly after\n arrival to hospital\n - MRI with and without contrast, MRA head, and MRV head to attemp to\n rule out missed stroke or new mass lesion\n - Attempt to liberate from sedation overnight to assess patient's\n underlying mental status\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Follow-up labs from admission to rule-out hypercalcemia as cause of\n altered mental status\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to aboid withdrawal from SSRI\n - Consider LP if MRI benign and any evidence of new fevers to suggest\n CNS infection\n - CXR, blood cultures, and UA to screen for additional sources of\n infection that can cause acute mental status changes\n #. Nausea and vomiting:\n Patient's original presenting complaint to was\n nausea and vomiting. Abdominal films and upper GI series have yet been\n unrevealing. Some concern that this may be attributed to increased ICH\n in setting of known pituitary macroadenoma or new recurrence of NCS\n lymphoma.\n - Treat supportively with ondansetron\n - Follow-up MRI\n #. Report of abnormal EKG:\n Copy of EKG was not sent with patient; however, reportedly had diffuse\n ST and T changes that were attributed to nausea and vomiting and\n resulting electrolyte abnormalities. Two sets of cardiac enzymes were\n reportedly negative at . ECHO was performed and\n showed anteroseptal akinesis of left ventricle, which is new when\n compared to\n - Obtain and review admission EKG\n - Consider TEE to fully assess\n # Diffuse large B-cell lymphoma:\n Patient is reportedly in remission after hyper-CVAD, R-, HD\n methotrexate, and intrathecal methotrexate. Possible his AMS is related\n to recurrence of his lymphoma.\n - Appreciate consultation from BMT service\n - Follow-up MRI\n - Consider LP to rule out recurrent CNS lymphoma if MRI unrevealing and\n no other etiologies established\n # Acromegaly and Pituitary Macroadenoma:\n Recent labs to check HPA showed normal TSH, LH, testosterone, and\n cortisol with slightly high FSH (14, ULN: 12) and high prolactin at 26\n (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n and will need to be rescheduled\n # Sacral decubitus ulcer:\n Reportedly a stage IV ulcer with recent pseudomonal infection. Appears\n to be without obvious infection at this time as drainage is\n serosanguinous.\n - Wound care consult\n - Potential surgery consult for further debridement pending full\n evaluation from wound care team\n # Constipation:\n - Standing polyethylene glycol and senna\n - PRN bisacodyl and lactulose\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines: 18 Gauge - 04:36 PM, Indwelling Port (PortaCath) -\n 04:37 PM, 20 Gauge - 06:33 PM\n Prophylaxis:\n - DVT ppx with pneumoboots while patient has contraindication to\n anticoagulation\n - Lansoprazole for stress ulcer prophylaxis\n - Bowel regimen with senna, polyethylene glycol, bisacodyl, lactulose\n - Pain management with acetaminophen\n Communication: (HCP): Primary ph , Secondary\n ph \n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "General",
"chartdate": "2144-12-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 609304,
"text": "Clinician: Attending\n CRITICAL CARE\n 40 yo with high grade lymphoma (possibly Burkitt's) transferred from\n OSH for abrupt change in MS> Intubated for resp protection. CT\n apparently showed bleed plus edema. Lymphoma apparently in remission\n although he did have CNS involvement at presentation. Exam now c/w\n progressive incr ICP - we are hyperventilating, giving mannitol,\n checking stat CT. Prognosis is very poor. Will assess with NSurg after\n CT read. Coags good. BP in appropriate range.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609359,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:30 PM\n INDWELLING PORT (PORTACATH) - START 04:37 PM\n MAGNETIC RESONANCE IMAGING - At 11:43 PM\n - changed to 5/5\n - for phos of 0.8 given potassiumphos 30 mmol, neutraphos 2 pkts\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 01:37 AM\n Other medications:\n . Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order date:\n @ 2348\n . Metoprolol Tartrate 12.5 mg PO/NG \n Please hold for SBP < 110 or HR < 55 Order date: @ 1814\n Acetaminophen mg PO/NG Q6H:PRN pain Order date: @ 1822\n Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ \n . Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: @\n 2333\n Multivitamins 1 TAB PO/NG DAILY Order date: @ 1814\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @ \n Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses Order date: @ 0052\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1822\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL \n . Citalopram Hydrobromide 20 mg PO/NG DAILY Order date: @ 1822\n . Polyethylene Glycol 17 g PO/NG DAILY\n Hold for loose stools Order date: @ 1822\n . Fentanyl Citrate 25-250 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ \n Propofol 5-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1818\n Senna 1 TAB PO/NG TID\n Please hold for loose stools. Order date: @ 2225\n . Lactulose 30 mL PO/NG Q6H:PRN constipation Order date: @ 1822\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 108 (80 - 108) bpm\n BP: 140/90(102) {128/90(99) - 155/108(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 88 mL\n 621 mL\n PO:\n TF:\n IVF:\n 88 mL\n 441 mL\n Blood products:\n Total out:\n 890 mL\n 260 mL\n Urine:\n 690 mL\n 260 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -802 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 676 (676 - 676) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 19 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.44/33/205/25/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 512\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 202 K/uL\n 11.4 g/dL\n 90 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 5 mg/dL\n 109 mEq/L\n 142 mEq/L\n 33.2 %\n 6.7 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n WBC\n 6.7\n Hct\n 33.2\n Plt\n 202\n Cr\n 0.4\n TCO2\n 23\n Glucose\n 90\n Other labs: PT / PTT / INR:15.9/31.5/1.4, ALT / AST:, Alk Phos / T\n Bili:72/0.3, Differential-Neuts:85.0 %, Lymph:9.2 %, Mono:4.2 %,\n Eos:1.4 %, Albumin:3.6 g/dL, LDH:489 IU/L, Ca++:8.0 mg/dL, Mg++:1.9\n mg/dL, PO4:0.8 mg/dL\n blood and urine ctx pending\n MRI: New\n abnormal hyperintensity on T2/FLAIR in right temporal lobe and anterior\n left\n temporal lobe compared to MR one month ago. DDx includes neoplasm\n such as lymphoma (apparent mild enhancement of right temporal focus\n relative\n to background brain parenchyma; though the short-interval change argues\n slightly against). Also consider acute hemorrhage (iso T1, hyper T2;\n though\n CT density of only ~ 44, and no corresponding abnormality on GRE argue\n against). Pituitary mass again seen. MRA/MRV: No vascular occlusion or\n sinus\n thrombosis. D/W Dr. (medicine resident) 11:45 p\n .\n CT head:\n Study limited by motion (though 5 attempts made). However, impression\n of\n mildly increased density diffusely, interdigitating with sulci,\n especially\n near skull base. Given the concern for hemorrhage, and lack of IV\n contrast\n administration, this may represent subarachnoid hemorrhage. MRI had\n already\n been ordered, but discussed with Dr. 9p .\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status: Patient\ns mental status changes severe\n enough to warrant intubation for airway protection. Initial concern for\n intracerebral hemorrhage given Head CT report from , aniscoria, systemic anticoagulation with enoxaparin, and\n report of acute mental status changes. Possible etiologies of ICH would\n be an ischemic stroke with hemorrhagic conversion, spontaneous bleed in\n setting of systemic anticoagulation, or unrealized trauma. STAT head\n CT here (limited by motion) was able to rule out massive hemorrhage\n causing herniation, though still possibility of small hermorrhage.\n Additionally, this presentation could represent a recurrence of his\n lymphoma, which was formerly thought to be in remission. Must consider\n that observed behavior and resulting mental status changes at were consistent with a seizure. Is possible that\n patient's serotonergic medications of citalopram, nortriptyline, and\n dilaudid acted to create a serotonin syndrome that presented with\n patient turning head to right due to increased tone. On physical exam\n at this time, muscle tone is essentially normal and patient has no\n history of fevers or clonus at OSH. Must also consider that his\n presentation is related to meningitis or encephalitis, though no\n prodrome of illness aside from nausea and vomiting and no reported\n fevers. As for other infections, should screen with blood culture, UA\n (was seen to have RBCs and WBCs at OSH), and CXR. No elevation in\n livier enzymes and ammonia of 27 at , both of which are\n inconsistent with a hepatic encephalopathy.\n MRI here with ?hemorrhage versus malignancy. In the settind of\n elevated LDH, this could be an indication of recurrent disease. Phos\n decreased dramatically which could have caused a metabolic\n encephaolpathy or precipitated a seizure.\n - Attempt to liberate from sedation overnight to assess patient's\n underlying mental status, then consider extubation if no neurosurg\n involvement\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - am labs after phos repletion\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to aboid withdrawal from SSRI\n - hodl LP for now\n - CXR, blood cultures, and UA to screen for additional sources of\n infection that can cause acute mental status changes\n #. Nausea and vomiting:\n Patient's original presenting complaint to was\n nausea and vomiting. Abdominal films and upper GI series have yet been\n unrevealing. Some concern that this may be attributed to increased ICH\n in setting of known pituitary macroadenoma or new recurrence of NCS\n lymphoma.\n - Treat supportively with ondansetron\n #. Report of abnormal EKG:\n Copy of EKG was not sent with patient; however, reportedly had diffuse\n ST and T changes that were attributed to nausea and vomiting and\n resulting electrolyte abnormalities. Two sets of cardiac enzymes were\n reportedly negative at . ECHO was performed and\n showed anteroseptal akinesis of left ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - Consider TEE to fully assess\n # Diffuse large B-cell lymphoma:\n Patient is reportedly in remission after hyper-CVAD, R-, HD\n methotrexate, and intrathecal methotrexate. Possible his AMS is related\n to recurrence of his lymphoma.\n - Appreciate consultation from BMT service- consult heme/onc this am\n - Consider LP to rule out recurrent CNS lymphoma however unclear if can\n do this in the setting of MRI changes\n # Acromegaly and Pituitary Macroadenoma:\n Recent labs to check HPA showed normal TSH, LH, testosterone, and\n cortisol with slightly high FSH (14, ULN: 12) and high prolactin at 26\n (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n and will need to be rescheduled\n # Sacral decubitus ulcer:\n Reportedly a stage IV ulcer with recent pseudomonal infection. Appears\n to be without obvious infection at this time as drainage is\n serosanguinous.\n - Wound care consult\n - Potential surgery consult for further debridement pending full\n evaluation from wound care team\n # Constipation:\n - Standing polyethylene glycol and senna\n - PRN bisacodyl and lactulose\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines: 18 Gauge - 04:36 PM, Indwelling Port (PortaCath) -\n 04:37 PM, 20 Gauge - 06:33 PM\n Prophylaxis:\n - DVT ppx with pneumoboots while patient has contraindication to\n anticoagulation\n - Lansoprazole for stress ulcer prophylaxis\n - Bowel regimen with senna, polyethylene glycol, bisacodyl, lactulose\n - Pain management with acetaminophen\n Communication: (HCP): Primary ph , Secondary\n ph \n Code status: Full code\n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:36 PM\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 06:33 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609362,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:30 PM\n INDWELLING PORT (PORTACATH) - START 04:37 PM\n MAGNETIC RESONANCE IMAGING - At 11:43 PM\n - changed to 5/5\n - for phos of 0.8 given potassiumphos 30 mmol, neutraphos 2 pkts\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 01:37 AM\n Other medications:\n . Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order date:\n @ 2348\n . Metoprolol Tartrate 12.5 mg PO/NG \n Please hold for SBP < 110 or HR < 55 Order date: @ 1814\n Acetaminophen mg PO/NG Q6H:PRN pain Order date: @ 1822\n Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ \n . Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: @\n 2333\n Multivitamins 1 TAB PO/NG DAILY Order date: @ 1814\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @ \n Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses Order date: @ 0052\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1822\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL \n . Citalopram Hydrobromide 20 mg PO/NG DAILY Order date: @ 1822\n . Polyethylene Glycol 17 g PO/NG DAILY\n Hold for loose stools Order date: @ 1822\n . Fentanyl Citrate 25-250 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ \n Propofol 5-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1818\n Senna 1 TAB PO/NG TID\n Please hold for loose stools. Order date: @ 2225\n . Lactulose 30 mL PO/NG Q6H:PRN constipation Order date: @ 1822\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 108 (80 - 108) bpm\n BP: 140/90(102) {128/90(99) - 155/108(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 88 mL\n 621 mL\n PO:\n TF:\n IVF:\n 88 mL\n 441 mL\n Blood products:\n Total out:\n 890 mL\n 260 mL\n Urine:\n 690 mL\n 260 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -802 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 676 (676 - 676) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 19 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.44/33/205/25/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 512\n Physical Examination\n Gen: NAD, withdraws arms to pain, follows commands by squeezing hands\n but not opening eyes, pectus excavatum, large jaw, and hands\n CV: RRR nl s1/s2 no m\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Neuro: PERRL but sluggish\n Labs / Radiology\n 202 K/uL\n 11.4 g/dL\n 90 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 5 mg/dL\n 109 mEq/L\n 142 mEq/L\n 33.2 %\n 6.7 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n WBC\n 6.7\n Hct\n 33.2\n Plt\n 202\n Cr\n 0.4\n TCO2\n 23\n Glucose\n 90\n Other labs: PT / PTT / INR:15.9/31.5/1.4, ALT / AST:, Alk Phos / T\n Bili:72/0.3, Differential-Neuts:85.0 %, Lymph:9.2 %, Mono:4.2 %,\n Eos:1.4 %, Albumin:3.6 g/dL, LDH:489 IU/L, Ca++:8.0 mg/dL, Mg++:1.9\n mg/dL, PO4:0.8 mg/dL\n blood and urine ctx pending\n MRI: New\n abnormal hyperintensity on T2/FLAIR in right temporal lobe and anterior\n left\n temporal lobe compared to MR one month ago. DDx includes neoplasm\n such as lymphoma (apparent mild enhancement of right temporal focus\n relative\n to background brain parenchyma; though the short-interval change argues\n slightly against). Also consider acute hemorrhage (iso T1, hyper T2;\n though\n CT density of only ~ 44, and no corresponding abnormality on GRE argue\n against). Pituitary mass again seen. MRA/MRV: No vascular occlusion or\n sinus\n thrombosis. D/W Dr. (medicine resident) 11:45 p\n .\n CT head:\n Study limited by motion (though 5 attempts made). However, impression\n of\n mildly increased density diffusely, interdigitating with sulci,\n especially\n near skull base. Given the concern for hemorrhage, and lack of IV\n contrast\n administration, this may represent subarachnoid hemorrhage. MRI had\n already\n been ordered, but discussed with Dr. 9p .\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status: Patient\ns mental status changes severe\n enough to warrant intubation for airway protection. Initial concern for\n intracerebral hemorrhage given Head CT report from , aniscoria, systemic anticoagulation with enoxaparin, and\n report of acute mental status changes. Possible etiologies of ICH would\n be an ischemic stroke with hemorrhagic conversion, spontaneous bleed in\n setting of systemic anticoagulation, or unrealized trauma. STAT head\n CT here (limited by motion) was able to rule out massive hemorrhage\n causing herniation, though still possibility of small hermorrhage.\n Additionally, this presentation could represent a recurrence of his\n lymphoma, which was formerly thought to be in remission. Must consider\n that observed behavior and resulting mental status changes at were consistent with a seizure. Is possible that\n patient's serotonergic medications of citalopram, nortriptyline, and\n dilaudid acted to create a serotonin syndrome that presented with\n patient turning head to right due to increased tone. On physical exam\n at this time, muscle tone is essentially normal and patient has no\n history of fevers or clonus at OSH. Must also consider that his\n presentation is related to meningitis or encephalitis, though no\n prodrome of illness aside from nausea and vomiting and no reported\n fevers. As for other infections, should screen with blood culture, UA\n (was seen to have RBCs and WBCs at OSH), and CXR. No elevation in\n livier enzymes and ammonia of 27 at , both of which are\n inconsistent with a hepatic encephalopathy.\n MRI here with ?hemorrhage versus malignancy. In the settind of\n elevated LDH, this could be an indication of recurrent disease. Phos\n decreased dramatically which could have caused a metabolic\n encephaolpathy or precipitated a seizure.\n - Attempt to liberate from sedation overnight to assess patient's\n underlying mental status, then consider extubation if no neurosurg\n involvement\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - am labs after phos repletion\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to aboid withdrawal from SSRI\n - hodl LP for now\n - CXR, blood cultures, and UA to screen for additional sources of\n infection that can cause acute mental status changes\n # hypophosphatemia: unclear etiology. Unknown why it would be due to\n decreased absorption. Also could be from increased losses. Unlikely\nhungry bone\n given normal calcium. Could contribute to MS changes at\n this low of a level.\n -check PTH\n -urine lyes\n -repeat levels later this am\n #. Nausea and vomiting:\n Patient's original presenting complaint to was\n nausea and vomiting. Abdominal films and upper GI series have yet been\n unrevealing. Some concern that this may be attributed to increased ICH\n in setting of known pituitary macroadenoma or new recurrence of NCS\n lymphoma.\n - Treat supportively with ondansetron\n #. Report of abnormal EKG:\n Copy of EKG was not sent with patient; however, reportedly had diffuse\n ST and T changes that were attributed to nausea and vomiting and\n resulting electrolyte abnormalities. Two sets of cardiac enzymes were\n reportedly negative at . ECHO was performed and\n showed anteroseptal akinesis of left ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - Consider TEE to fully assess\n # Diffuse large B-cell lymphoma:\n Patient is reportedly in remission after hyper-CVAD, R-, HD\n methotrexate, and intrathecal methotrexate. Possible his AMS is related\n to recurrence of his lymphoma.\n - Appreciate consultation from BMT service- consult heme/onc this am\n - Consider LP to rule out recurrent CNS lymphoma however unclear if can\n do this in the setting of MRI changes\n # Acromegaly and Pituitary Macroadenoma:\n Recent labs to check HPA showed normal TSH, LH, testosterone, and\n cortisol with slightly high FSH (14, ULN: 12) and high prolactin at 26\n (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n and will need to be rescheduled\n # Sacral decubitus ulcer:\n Reportedly a stage IV ulcer with recent pseudomonal infection. Appears\n to be without obvious infection at this time as drainage is\n serosanguinous.\n - Wound care consult\n - Potential surgery consult for further debridement pending full\n evaluation from wound care team\n # Constipation:\n - Standing polyethylene glycol and senna\n - PRN bisacodyl and lactulose\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines: 18 Gauge - 04:36 PM, Indwelling Port (PortaCath) -\n 04:37 PM, 20 Gauge - 06:33 PM\n Prophylaxis:\n - DVT ppx with pneumoboots while patient has contraindication to\n anticoagulation\n - Lansoprazole for stress ulcer prophylaxis\n - Bowel regimen with senna, polyethylene glycol, bisacodyl, lactulose\n - Pain management with acetaminophen\n Communication: (HCP): Primary ph , Secondary\n ph \n Code status: Full code\n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:36 PM\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 06:33 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Generic Note",
"row_id": 609372,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. This am he is responsive,\n following commands. Copious secretions\n 100.1 94 136/92\n Moving UE to command\n min movement of toes\n Chest\n pectus crackles bilat mid insp w/o wheezes\n Abd\n soft\n w/o edema\n WBC 6.7\n MR\n T2 hyperintensity bilat temporal lobes\n Awaiting formal read of MR scan but seems likely to be recurrent\n lymphoma in his CNS\n known leptomeningeal involvement on adm this\n summer. BMT to see him this am\n should have LP today. Now has low\n grade fever and wbc is above his baseline\n sending sputum but will\n cover broadly. We are leaving intubated until procedures accomplished.\n Time spent 45 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609375,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:30 PM\n INDWELLING PORT (PORTACATH) - START 04:37 PM\n MAGNETIC RESONANCE IMAGING - At 11:43 PM\n - changed to 5/5\n - for phos of 0.8 given potassiumphos 30 mmol, neutraphos 2 pkts\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 01:37 AM\n Other medications:\n . Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order date:\n @ 2348\n . Metoprolol Tartrate 12.5 mg PO/NG \n Please hold for SBP < 110 or HR < 55 Order date: @ 1814\n Acetaminophen mg PO/NG Q6H:PRN pain Order date: @ 1822\n Midazolam 0.5-10 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ \n . Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: @\n 2333\n Multivitamins 1 TAB PO/NG DAILY Order date: @ 1814\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @ \n Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses Order date: @ 0052\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1822\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL \n . Citalopram Hydrobromide 20 mg PO/NG DAILY Order date: @ 1822\n . Polyethylene Glycol 17 g PO/NG DAILY\n Hold for loose stools Order date: @ 1822\n . Fentanyl Citrate 25-250 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ \n Propofol 5-50 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1818\n Senna 1 TAB PO/NG TID\n Please hold for loose stools. Order date: @ 2225\n . Lactulose 30 mL PO/NG Q6H:PRN constipation Order date: @ 1822\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 108 (80 - 108) bpm\n BP: 140/90(102) {128/90(99) - 155/108(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 88 mL\n 621 mL\n PO:\n TF:\n IVF:\n 88 mL\n 441 mL\n Blood products:\n Total out:\n 890 mL\n 260 mL\n Urine:\n 690 mL\n 260 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -802 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 676 (676 - 676) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 19 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.44/33/205/25/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 512\n Physical Examination\n Gen: NAD, withdraws arms to pain, follows commands by squeezing hands\n but not opening eyes, pectus excavatum, large jaw, and hands\n CV: RRR nl s1/s2 no m\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Neuro: PERRL but sluggish\n Labs / Radiology\n 202 K/uL\n 11.4 g/dL\n 90 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 5 mg/dL\n 109 mEq/L\n 142 mEq/L\n 33.2 %\n 6.7 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n WBC\n 6.7\n Hct\n 33.2\n Plt\n 202\n Cr\n 0.4\n TCO2\n 23\n Glucose\n 90\n Other labs: PT / PTT / INR:15.9/31.5/1.4, ALT / AST:, Alk Phos / T\n Bili:72/0.3, Differential-Neuts:85.0 %, Lymph:9.2 %, Mono:4.2 %,\n Eos:1.4 %, Albumin:3.6 g/dL, LDH:489 IU/L, Ca++:8.0 mg/dL, Mg++:1.9\n mg/dL, PO4:0.8 mg/dL\n blood and urine ctx pending\n MRI: New\n abnormal hyperintensity on T2/FLAIR in right temporal lobe and anterior\n left\n temporal lobe compared to MR one month ago. DDx includes neoplasm\n such as lymphoma (apparent mild enhancement of right temporal focus\n relative\n to background brain parenchyma; though the short-interval change argues\n slightly against). Also consider acute hemorrhage (iso T1, hyper T2;\n though\n CT density of only ~ 44, and no corresponding abnormality on GRE argue\n against). Pituitary mass again seen. MRA/MRV: No vascular occlusion or\n sinus\n thrombosis. D/W Dr. (medicine resident) 11:45 p\n .\n CT head:\n Study limited by motion (though 5 attempts made). However, impression\n of\n mildly increased density diffusely, interdigitating with sulci,\n especially\n near skull base. Given the concern for hemorrhage, and lack of IV\n contrast\n administration, this may represent subarachnoid hemorrhage. MRI had\n already\n been ordered, but discussed with Dr. 9p .\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status: Patient\ns mental status changes severe\n enough to warrant intubation for airway protection. Initial concern for\n intracerebral hemorrhage given Head CT report from , aniscoria, systemic anticoagulation with enoxaparin, and\n report of acute mental status changes. Possible etiologies of ICH would\n be an ischemic stroke with hemorrhagic conversion, spontaneous bleed in\n setting of systemic anticoagulation, or unrealized trauma. STAT head\n CT here (limited by motion) was able to rule out massive hemorrhage\n causing herniation, though still possibility of small hermorrhage.\n Additionally, this presentation could represent a recurrence of his\n lymphoma, which was formerly thought to be in remission. Must consider\n that observed behavior and resulting mental status changes at were consistent with a seizure. Is possible that\n patient's serotonergic medications of citalopram, nortriptyline, and\n dilaudid acted to create a serotonin syndrome that presented with\n patient turning head to right due to increased tone. On physical exam\n at this time, muscle tone is essentially normal and patient has no\n history of fevers or clonus at OSH. Must also consider that his\n presentation is related to meningitis or encephalitis, though no\n prodrome of illness aside from nausea and vomiting and no reported\n fevers. As for other infections, should screen with blood culture, UA\n (was seen to have RBCs and WBCs at OSH), and CXR. No elevation in\n livier enzymes and ammonia of 27 at , both of which are\n inconsistent with a hepatic encephalopathy.\n MRI here with ?hemorrhage versus malignancy. In the settind of\n elevated LDH, this could be an indication of recurrent disease. Phos\n decreased dramatically which could have caused a metabolic\n encephaolpathy or precipitated a seizure.\n - Will keep patient intubated for now pending LP.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - am labs after phos repletion\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to aboid withdrawal from SSRI\n - hodl LP for now\n - blood cultures Uctx to screen for additional sources of infection\n that can cause acute mental status changes\n # Respiratory failure: sputum and consolidation on CXR suggest possible\n healthcare associated pneumonia\n - sent sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime pending ctx data\n # hypophosphatemia: unclear etiology. Unknown why it would be due to\n decreased absorption. Also could be from increased losses. Unlikely\nhungry bone\n given normal calcium. Could contribute to MS changes at\n this low of a level.\n -check PTH\n -urine lyes\n -repeat levels later this am\n #. Nausea and vomiting:\n Patient's original presenting complaint to was\n nausea and vomiting. Abdominal films and upper GI series have yet been\n unrevealing. Some concern that this may be attributed to increased ICH\n in setting of known pituitary macroadenoma or new recurrence of NCS\n lymphoma.\n - Treat supportively with ondansetron\n #. Report of abnormal EKG:\n Copy of EKG was not sent with patient; however, reportedly had diffuse\n ST and T changes that were attributed to nausea and vomiting and\n resulting electrolyte abnormalities. Two sets of cardiac enzymes were\n reportedly negative at . ECHO was performed and\n showed anteroseptal akinesis of left ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TEE to fully assess\n # Diffuse large B-cell lymphoma:\n Patient is reportedly in remission after hyper-CVAD, R-, HD\n methotrexate, and intrathecal methotrexate. Possible his AMS is related\n to recurrence of his lymphoma.\n - Appreciate consultation from BMT service- consult heme/onc this am\n - Consider LP to rule out recurrent CNS lymphoma however unclear if can\n do this in the setting of MRI changes\n # Acromegaly and Pituitary Macroadenoma:\n Recent labs to check HPA showed normal TSH, LH, testosterone, and\n cortisol with slightly high FSH (14, ULN: 12) and high prolactin at 26\n (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n and will need to be rescheduled\n # Sacral decubitus ulcer:\n Reportedly a stage IV ulcer with recent pseudomonal infection. Appears\n to be without obvious infection at this time as drainage is\n serosanguinous.\n - Wound care consult\n - Potential surgery consult for further debridement pending full\n evaluation from wound care team\n # Constipation:\n - Standing polyethylene glycol and senna\n - PRN bisacodyl and lactulose\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines: 18 Gauge - 04:36 PM, Indwelling Port (PortaCath) -\n 04:37 PM, 20 Gauge - 06:33 PM\n Prophylaxis:\n - DVT ppx with pneumoboots while patient has contraindication to\n anticoagulation\n - Lansoprazole for stress ulcer prophylaxis\n - Bowel regimen with senna, polyethylene glycol, bisacodyl, lactulose\n - Pain management with acetaminophen\n Communication: (HCP): Primary ph , Secondary\n ph \n Code status: Full code\n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: PICC today\n 18 Gauge - 04:36 PM\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 06:33 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609295,
"text": "See admission note.\n Neuro: neuro consult-into evaluate pt. taken off sedation, but still\n sleepy. Pupils were equal and #2 and sluggish on adm.\n Now right pupil is slightly larger and not reacting. Right eye is\n slightly larger and not reacting.\n Pt. flailing both arms, but no lower extremeity movements. Does respond\n to a sternal rub.\n Resp: on cmv at tv 600 50% 5 peep rate of 16-not overbreathing.\n Health care proxy notified and consent given for mri as well as filling\n in mri sheet. .\n Plan is for MRI and needs an ekg.\n Skin issues: pt. has a large tunneled decub. Stage 4. pt.on a -air\n bed.\n Ngt in place.\n Pt. has a single lumen porta cath.\n New periph iv placed.\n Pt. with ekg changes at -enzymes were neg.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609545,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n (s/p admission at from to ) who was\n transferred from following episode of altered\n mental status that led to intubation for airway protection.\n Patient had a head CT performed at which was\n reported as showing right temporal and parietal edema and small foci of\n hemorrhage, though the images were not sent with the patient upon\n transfer to . According to discharge paperwork from \n today, the patient originally presented to the hospital on \n with intractable nausea and vomiting of 5 days duration. While at , the patient had several abdominal films as well as an upper GI\n series which were reportedly unremarkable. Physicians were concerned\n that there was a central cause of nausea and attempted head imaging,\n which the patient initially refused. Late on night of ,\n patient was found to be minimally responsive with head turning to right\n and arms flexed to chest. As he had received nortriptyline, there was\n initial concern for a dystonic reaction and 50 mg IV diphenhydramine\n was pushed. There was no improvement in his mental status following\n that intervention and he was intubated for ariway protection and head\n CT was then performed with results as above. Transfer to was\n requested given patient's decline in mental status requiring\n intubation.\n Of note, patient was recently admitted to on \n with hypercalcemia and a pseudomonas infection of stage IV pressure\n ulcer. He completed antibiotic course of ceftazidime, daptomycin, and\n azithromycin.\n Unknown level of ambulation immediately prior to presentation to on ; however, at time of discharge from \n on , he could stand and walk about 10 feet. A recent\n neurology note from assessed his IP strength as being 1 on\n the right and 0 on the left. He was assessed as having \"residual severe\n paraparesis due to combination of deconditioning and vincristine toxic\n polyneuropathy, and question of critical illness\n polyneuropathy/myopathy.\"\n ALLERGIES:\n Vincristine (Peripheral Neurotoxicity)\n MEDICATIONS ON TRANSFER:\n 1) Metoprolol 12.5 mg PO BID\n 2) Furosemide 20 mg PO BID (on hold)\n 3) Nitroglycerin 0.3 mg SL PRN chest pain\n 4) Morphine 2 mg IV PRN chest pain\n 5) Citalopram 20 mg DAILY\n 6) Pregabalin 50 mg \n 7) Nortriptyline 25 mg QHS\n 8) Tizanidine 2 mg Q12H\n 9) Lorazepam PRN\n 10) Polyethylene glycol DAILY\n 11) Senna 8.6 mg two tabs \n 12) Docusate sodium 100 mg TID\n 13) Bisacodyl 10 mg oral DAILY\n 14) Lactulose 30 mL Q6H:PRN constipation\n 15) Acetaminophen 650 mg Q4H:PRN pain or fever\n 16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN nausea\n 17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia\n 18) Lovenox 90 mg Q12H (on hold)\n 19) Multivitamins DAILY\n 20) Clotrimazole 10 mg QID\n 21) Miconazole topical QID:PRN\n PAST MEDICAL HISTORY:\n FAMILY HISTORY:\n 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n Non-contributory per prior records.\n SOCIAL HISTORY:\n Brother incarcerated in . Patient has a 19 yr old son in\n . Prior to his recent hospitalization, he was living in\n automobile. Discharged to on and currently living\n at Wood Mill Skilled Nursing Facility.\n Tobacco: 2.5 packs X 25 years\n EtOH: unknown\n IVDA/other illicit drug use: previously denied\n Assigned PCP:\n (but has not met her yet)\n Oncologist:\n \n Decubitus ulcer (Present At Admission)\n Assessment:\n Coccyx ulcer 4cm in diameter w/undermining present, old dressing\n w/serosang drainage, old aquacel AG dressing removed w/green hue, no\n odor present. Wound cleansed w/spray wound cleaner, aquacel AG dressing\n applied and covered w/DSD.\n Action:\n Daily coccyx dressing changed QD as prescribed. Turned and positioned\n at least q2hours.\n Response:\n Apparent discomfort w/dressing change, not medicated w/fentanyl as just\n self extubated. Discomfort appeared to disappate as soon as quick\n dressing change completed.\n Plan:\n Cont w/QD dressing changes as prescribed and turn and position at least\n q2hours.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Copious thick yellow secretions this morning requiring suctioning q15\n minutes, secretions then changed to white and thin. Patient self\n extubated @ 1050, able to bring head to restrained wrist. Pt now on 2L\n NC w/O2 sats 100% and breathing 18-28bpm, LS: now CTA. Unable to leave\n hands unrestrained as while in room while turning patient he grabbed\n the NGT and self d/c\nd tube. Both wrists restrained to prevent further\n self harm.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 609548,
"text": "TITLE: Intensivist\n Weekend\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Events notable for starting on vanc / cefepime / acyclovir, LP with\n opening pressure 49, with concerning differential and glucose of 1.\n Echo with EF 45%, pericardial effusion sl. Larger but no s tamponade.\n Vomited with ?aspiration and copious - now increased secretions from\n ETT.\n Extubated himself on rounds, now on 2L NC.\n Meds notable for versed / fentanyl, vanc / cefepime, acyclovir.\n Tm100.1 BP 134/88 RR 10-22 Sat 99% PSV 5/5 /40%\n NC.\n I/O 1773/1145\n Moving b/l arms purposefully, sedated. Lungs ronchorous. RRR\n borderline tachy\n Abd soft +BS NT 1+ edema\n WBC 7.3/32.5/191 stable\n Chem-7 136/3.5/106/24/8/0.3\n CSF 300WBC diff 99 other and glucose 1.\n 41 y/o acromegaly and lymphoma, altered mental status now with\n suspected recurrent CNS lymphoma.\n Awaiting further plans for intervention from neuro-onc services re:\n XRT, chemo.\n Remained intubated d/t concern for altered mental status, increasing\n secretions, and continued vomiting (most likely related to neuro\n status). Appreciate input of consultants\n will d/w them whether there\n are any other interventions we can try to help improve his mental\n status\n starting dexamethasone today.\n Pt is critically ill. CC time 40 min.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609630,
"text": "41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is clearly speaking response words like ouch and Oh god\n Action:\n Response:\n Plan:\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609453,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Wound nurse consulted. Stage 4 ulcer with tunneling\n Action:\n Drsg . Aquacel placed in wound.\n With 4x4 and tan tape.\n Pt. appeared to have pain with drsg .\n Bolus of fent. Given.\n Response:\n More comfortable.\n Plan:\n Drsg be changed qd. Directions in med book.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt. slightly lighter today.\n Action:\n Neuro: pt. sqeezing hand to command. Opens mouth on command.\n Pearl. Doesn\nt open his eyes. Moves upper extremeties-very strong.\n No movement in lower limbs-not new.\n LP done this pm. Spinal fluid looked clear.\n Sent for cytology, cell ct. and micro.\n Bolused with fent and versed for procedure\n Response:\n Well sedated throughout.\n Plan:\n Pt. to lie flat for several hrs. to prevent headache\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. ready for extubation..\n Action:\n Resp: suctioned for thick tan secretions this am.\n Sent for cx. and gm stain.\n Presently on . overbreathing vent. Inspite of sedation.\n Suctioned q2hrs throughout the day. For thick yellow.\n Bs\ns clear with RUL r;honchi this pm.\n Given 1x dose of vancomycin and cefapime.\n Temp 100.1 this am, but afebrile the rest of the day.\n Gi: tf\nings instituted, but off at present post LP.\n + bs\ns. conts. On bowel regimine.\n Renal: adequate u/o\ns. creat 0.4\n Cv: Hemodynamically stable. Have noted rare pvc\n Cardiac echo done. Small pericardial effusion and mod MR.\n Access: iv nurse into access his portacath. It is a double lumen.\n No blood return.\n TPA (5cc) instilled in both ports.\n Endoc: given phos on nights. Repeat phos within nl. Range.\n Neuro: cont. on versed at 3mg/hr and fent 200mcqs.\n Social: girlfriend called and updated.\n Response:\n Tol. Sedation. stable\n Plan:\n Reassess in am re: extubation. Restart tf\nings at 20cc/hr this evening.\n Remove TPA at 21:30pm.\n If port continues not draw-may need picc line placement tomorrow.\n Check lytes if he continues to have ect.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609522,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - Vanc/cefepime started\n - Tube feeds started\n -requested head CT images from - they should be\n overnighting it. If not, call . Cultures faxed -\n NG x 4 days\n - Rad onc not excited about radiating brain b/c burkitt's so\n chemosensitive, said there is no emergent need for XRT and will await\n LP cytology before establishing plan and to r/o progressive CNS disease\n - Nsurg:Don't think we'll need brain biopsy, but if we do, call them\n back.\n - Neurology: EEG,\n - Neuro-onc: Rule out infection first, will follow\n - BMT: Concern for lymphoma recurrence vs infection vs bleed, agree\n with LP/rad-on consult, send CSF for heme/path review and flow\n cytology, consider covering HSV, will discuss radiation vs HD\n methotrexate\n - Did LP, opening pressure 49, send 4 tubes to lab but not full because\n didn't want to take off too much given high opening pressure\n - Started acyclovir\n - PICC not put in b/c has double lumen port and didn't realize it.\n Tried to unclog it with TPA\n SPUTUM CULTURE - At 09:16 AM\n TRANSTHORACIC ECHO - At 03:15 PM\n LUMBAR PUNCTURE - At 05:28 PM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 11:22 AM\n Vancomycin - 09:00 PM\n Acyclovir - 04:19 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 AM\n Fentanyl - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.8\nC (98.3\n HR: 108 (94 - 109) bpm\n BP: 137/96(106) {134/88(100) - 149/103(113)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n Total In:\n 1,773 mL\n 334 mL\n PO:\n TF:\n 99 mL\n 80 mL\n IVF:\n 1,364 mL\n 224 mL\n Blood products:\n Total out:\n 1,145 mL\n 370 mL\n Urine:\n 1,145 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 628 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 456 (353 - 840) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///24/\n Ve: 7.5 L/min\n Physical Examination\n Gen: NAD, withdraws arms to pain, follows commands by squeezing hands\n but not opening eyes, pectus excavatum, large jaw, and hands\n CV: RRR nl s1/s2 no m\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Neuro: PERRL but sluggish\n Labs / Radiology\n 191 K/uL\n 11.0 g/dL\n 81 mg/dL\n 0.3 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 106 mEq/L\n 136 mEq/L\n 32.5 %\n 7.3 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n WBC\n 6.7\n 6.5\n 7.3\n Hct\n 33.2\n 31.2\n 32.5\n Plt\n \n Cr\n 0.4\n 0.4\n 0.3\n TCO2\n 23\n Glucose\n 90\n 92\n 81\n Other labs: PT / PTT / INR:14.8/29.7/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Differential-Neuts:85.0 %, Lymph:9.2 %, Mono:4.2 %,\n Eos:1.4 %, Albumin:3.6 g/dL, LDH:574 IU/L, Ca++:7.8 mg/dL, Mg++:1.7\n mg/dL, PO4:1.4 mg/dL\n Blood cx pending\n Sputum\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN CLUSTERS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Pending):\nCSF:\n 5:15 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE\n Source: LP TUBE#3.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n This is a concentrated smear made by cytospin method, please refer to\n hematology for a quantitative white blood cell count..\n FLUID CULTURE (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST CULTURE (Preliminary):\n The sensitivity of an AFB smear on CSF is very low..\n If present, AFB may take 3-8 weeks to grow..\n Cryptococcal Ag negative CSF\nImmunophenotyping pending\n HSV pending\n CSF PEP pending\n Total protein 463\n Glucose 1\n LDH 1459\n Tube 1: WBC 183 RBC 13 Polys 2 Other 98\n Tube 4: WBC 300 RBC 4 Polys 1 Other 99\n TTE :\n The left atrium is mildly dilated. No atrial septal defect is seen by\n 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg.\n Left ventricular wall thicknesses are normal. The left ventricular\n cavity size is normal. There is probably mild global left ventricular\n hypokinesis (LVEF = 45-50 %). No masses or thrombi are seen in the left\n ventricle. There is no ventricular septal defect. Right ventricular\n chamber size is normal. with borderline normal free wall function. The\n aortic valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is a small\n pericardial effusion. There are no echocardiographic signs of\n tamponade. Compared with the prior study (images reviewed) of\n , the LVEF is less vigorous. The pericardial effusion is\n slightly larger but still with no evidence for overt tamponade.\n CXR in OMR today\n MRI/MRA final read:\n 1. Diffuse leptomeningeal enhancement and FLAIR hyperintensity\n involving the\n right greater than left temporal and parietal lobes, with more focal\n areas of\n parenchymal abnormality in the temporal lobe, also right greater than\n left.\n Differential diagnostic considerations primarily include recurrent\n lymphoma\n (especially given the patient's history of Burkitt's lymphoma) as well\n as a\n meningoencephalitis such as herpes encephalitis, although other viral\n or\n bacterial meningoencephalitides could also result in a similar\n appearance.\n 2. Areas of decreased diffusion corresponding to the leptomeningeal\n disease\n with additional foci involving the right thalamus and right\n hippocampus, which\n may represent acute infarcts, although they may be related to\n lymphomatous\n involvement versus infectious process given the findings above. Hypoxic\n injury would be a less likely differential consideration.\n 3. Suboptimal MRA and MRV given patient motion. There is no definite\n evidence of venous thrombosis, although the sigmoid sinuses and the\n visualized\n internal jugular veins are suboptimally evaluated.\n 4. No evidence of a hemodynamically significant stenosis on the MRA of\n the\n head, although irregularity at the anterior communicating artery raises\n the\n possibility of a small aneurysm. This was suboptimally evaluated given\n the\n degree of patient motion. At the time of followup imaging, the MRA\n sequence\n could be repeated.\n 5. Pituitary adenoma, not significantly changed since the prior\n examination\n when accounting for differences in technique, although dedicated\n imaging of\n the sella was not obtained today.\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH, most likely recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate heme/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n # Respiratory failure: Sputum and consolidation on CXR suggest possible\n healthcare associated pneumonia. Patient was intubated for airway\n protection at OSH\n - sent sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 2 of 10\n - plan for extubation today, if possible\n # Hypophosphatemia: Unclear etiology. Unknown why it would be due to\n decreased absorption. Also could be from increased losses. Unlikely\nhungry bone\n given normal calcium. Could contribute to MS changes at\n this low of a level.\n -check PTH\n -urine lytes\n -repeat levels later this am\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Some concern that this may be\n attributed to increased ICH in setting of known pituitary macroadenoma\n or new recurrence of NCS lymphoma.\n - Treat supportively with ondansetron\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TEE to fully assess\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate. Possible his AMS is related to recurrence of his\n lymphoma.\n - Appreciate consultation from BMT service\n - FU LP results\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n and will need to be rescheduled\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care consult\n - Potential surgery consult for further debridement pending full\n evaluation from wound care team\n ICU Care\n Nutrition: Started tube feeds yesterday\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: Lansoprazole\n VAP:\n Comments: Bowel regimen with senna, polyethylene glycol, bisacodyl,\n lactulose, Pain management with acetaminophen\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609543,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n (s/p admission at from to ) who was\n transferred from following episode of altered\n mental status that led to intubation for airway protection.\n Patient had a head CT performed at which was\n reported as showing right temporal and parietal edema and small foci of\n hemorrhage, though the images were not sent with the patient upon\n transfer to . According to discharge paperwork from \n today, the patient originally presented to the hospital on \n with intractable nausea and vomiting of 5 days duration. While at , the patient had several abdominal films as well as an upper GI\n series which were reportedly unremarkable. Physicians were concerned\n that there was a central cause of nausea and attempted head imaging,\n which the patient initially refused. Late on night of ,\n patient was found to be minimally responsive with head turning to right\n and arms flexed to chest. As he had received nortriptyline, there was\n initial concern for a dystonic reaction and 50 mg IV diphenhydramine\n was pushed. There was no improvement in his mental status following\n that intervention and he was intubated for ariway protection and head\n CT was then performed with results as above. Transfer to was\n requested given patient's decline in mental status requiring\n intubation.\n Of note, patient was recently admitted to on \n with hypercalcemia and a pseudomonas infection of stage IV pressure\n ulcer. He completed antibiotic course of ceftazidime, daptomycin, and\n azithromycin.\n Unknown level of ambulation immediately prior to presentation to on ; however, at time of discharge from \n on , he could stand and walk about 10 feet. A recent\n neurology note from assessed his IP strength as being 1 on\n the right and 0 on the left. He was assessed as having \"residual severe\n paraparesis due to combination of deconditioning and vincristine toxic\n polyneuropathy, and question of critical illness\n polyneuropathy/myopathy.\"\n ALLERGIES:\n Vincristine (Peripheral Neurotoxicity)\n MEDICATIONS ON TRANSFER:\n 1) Metoprolol 12.5 mg PO BID\n 2) Furosemide 20 mg PO BID (on hold)\n 3) Nitroglycerin 0.3 mg SL PRN chest pain\n 4) Morphine 2 mg IV PRN chest pain\n 5) Citalopram 20 mg DAILY\n 6) Pregabalin 50 mg \n 7) Nortriptyline 25 mg QHS\n 8) Tizanidine 2 mg Q12H\n 9) Lorazepam PRN\n 10) Polyethylene glycol DAILY\n 11) Senna 8.6 mg two tabs \n 12) Docusate sodium 100 mg TID\n 13) Bisacodyl 10 mg oral DAILY\n 14) Lactulose 30 mL Q6H:PRN constipation\n 15) Acetaminophen 650 mg Q4H:PRN pain or fever\n 16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN nausea\n 17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia\n 18) Lovenox 90 mg Q12H (on hold)\n 19) Multivitamins DAILY\n 20) Clotrimazole 10 mg QID\n 21) Miconazole topical QID:PRN\n PAST MEDICAL HISTORY:\n FAMILY HISTORY:\n 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n Non-contributory per prior records.\n SOCIAL HISTORY:\n Brother incarcerated in . Patient has a 19 yr old son in\n . Prior to his recent hospitalization, he was living in\n automobile. Discharged to on and currently living\n at Wood Mill Skilled Nursing Facility.\n Tobacco: 2.5 packs X 25 years\n EtOH: unknown\n IVDA/other illicit drug use: previously denied\n Assigned PCP:\n (but has not met her yet)\n Oncologist:\n \n Decubitus ulcer (Present At Admission)\n Assessment:\n Coccyx ulcer 4cm in diameter w/undermining present, old dressing\n w/serosang drainage, old aquacel AG dressing removed w/green hue, no\n odor present. Wound cleansed w/spray wound cleaner, aquacel AG dressing\n applied and covered w/DSD.\n Action:\n Daily coccyx dressing changed QD as prescribed. Turned and positioned\n at least q2hours.\n Response:\n Apparent discomfort w/dressing change, not medicated w/fentanyl as just\n self extubated. Discomfort appeared to disappate as soon as quick\n dressing change completed.\n Plan:\n Cont w/QD dressing changes as prescribed and turn and position at least\n q2hours.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Copious thick yellow secretions this morning.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609544,
"text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - Vanc/cefepime started yesterday for HAP\n - Tube feeds started\n -requested head CT images from - they should be\n overnighting records. If not, call . Culture\n data obtained - NG x 4 days\n - Rad onc said no emergent need for XRT and will await LP cytology\n before establishing plan and to r/o progressive CNS disease\n - Nsurg: Don't think we'll need brain biopsy, but if we do, call them\n back\n - Neurology: EEG, LP, acyclovir for HSV, and to contact oncology, and\n neuro-oncology\n - Neuro-onc: Rule out infection first, will follow\n - BMT: Concern for lymphoma recurrence vs infection vs bleed, agree\n with LP/rad-on consult, send CSF for heme/path review and flow\n cytology, consider covering HSV, will discuss radiation vs HD\n methotrexate\n - Did LP, opening pressure 49, sent 4 tubes to lab but not full because\n didn't want to take off too much given high opening pressure\n - Started acyclovir\n - PICC not put in b/c has double lumen port and didn't realize it.\n Tried to unclog it with TPA\n SPUTUM CULTURE - At 09:16 AM\n TRANSTHORACIC ECHO - At 03:15 PM\n LUMBAR PUNCTURE - At 05:28 PM\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 11:22 AM\n Vancomycin - 09:00 PM\n Acyclovir - 04:19 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 AM\n Fentanyl - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.8\nC (98.3\n HR: 108 (94 - 109) bpm\n BP: 137/96(106) {134/88(100) - 149/103(113)} mmHg\n RR: 12 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n Total In:\n 1,773 mL\n 334 mL\n PO:\n TF:\n 99 mL\n 80 mL\n IVF:\n 1,364 mL\n 224 mL\n Blood products:\n Total out:\n 1,145 mL\n 370 mL\n Urine:\n 1,145 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 628 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 456 (353 - 840) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///24/\n Ve: 7.5 L/min\n Physical Examination\n Gen: NAD, withdraws arms to pain, pectus carinum, large jaw, and hands\n CV: RRR nl s1/s2 no m\n Pulm: Ventilated coarse breath sounds bilaterally, otherwise clear\n Abd: +BS, soft NTND\n Neuro: PERRL but sluggish, right eye sutured on lateral aspect\n Labs / Radiology\n 191 K/uL\n 11.0 g/dL\n 81 mg/dL\n 0.3 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 106 mEq/L\n 136 mEq/L\n 32.5 %\n 7.3 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n WBC\n 6.7\n 6.5\n 7.3\n Hct\n 33.2\n 31.2\n 32.5\n Plt\n \n Cr\n 0.4\n 0.4\n 0.3\n TCO2\n 23\n Glucose\n 90\n 92\n 81\n Other labs: PT / PTT / INR:14.8/29.7/1.3, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Differential-Neuts:85.0 %, Lymph:9.2 %, Mono:4.2 %,\n Eos:1.4 %, Albumin:3.6 g/dL, LDH:574 IU/L, Ca++:7.8 mg/dL, Mg++:1.7\n mg/dL, PO4:1.4 mg/dL\n Blood cx pending\n Sputum\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN CLUSTERS.\n 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Pending):\nCSF:\n 5:15 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE\n Source: LP TUBE#3.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n This is a concentrated smear made by cytospin method, please refer to\n hematology for a quantitative white blood cell count..\n FLUID CULTURE (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST CULTURE (Preliminary):\n The sensitivity of an AFB smear on CSF is very low..\n If present, AFB may take 3-8 weeks to grow..\n Cryptococcal Ag negative CSF\nImmunophenotyping pending\n HSV pending\n CSF PEP pending\n Total protein 463\n Glucose 1\n LDH 1459\n Tube 1: WBC 183 RBC 13 Polys 2 Other 98\n Tube 4: WBC 300 RBC 4 Polys 1 Other 99\n TTE :\n The left atrium is mildly dilated. No atrial septal defect is seen by\n 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg.\n Left ventricular wall thicknesses are normal. The left ventricular\n cavity size is normal. There is probably mild global left ventricular\n hypokinesis (LVEF = 45-50 %). No masses or thrombi are seen in the left\n ventricle. There is no ventricular septal defect. Right ventricular\n chamber size is normal. with borderline normal free wall function. The\n aortic valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is a small\n pericardial effusion. There are no echocardiographic signs of\n tamponade. Compared with the prior study (images reviewed) of\n , the LVEF is less vigorous. The pericardial effusion is\n slightly larger but still with no evidence for overt tamponade.\n CXR in OMR today\n MRI/MRA final read:\n 1. Diffuse leptomeningeal enhancement and FLAIR hyperintensity\n involving the\n right greater than left temporal and parietal lobes, with more focal\n areas of\n parenchymal abnormality in the temporal lobe, also right greater than\n left.\n Differential diagnostic considerations primarily include recurrent\n lymphoma\n (especially given the patient's history of Burkitt's lymphoma) as well\n as a\n meningoencephalitis such as herpes encephalitis, although other viral\n or\n bacterial meningoencephalitides could also result in a similar\n appearance.\n 2. Areas of decreased diffusion corresponding to the leptomeningeal\n disease\n with additional foci involving the right thalamus and right\n hippocampus, which\n may represent acute infarcts, although they may be related to\n lymphomatous\n involvement versus infectious process given the findings above. Hypoxic\n injury would be a less likely differential consideration.\n 3. Suboptimal MRA and MRV given patient motion. There is no definite\n evidence of venous thrombosis, although the sigmoid sinuses and the\n visualized\n internal jugular veins are suboptimally evaluated.\n 4. No evidence of a hemodynamically significant stenosis on the MRA of\n the\n head, although irregularity at the anterior communicating artery raises\n the\n possibility of a small aneurysm. This was suboptimally evaluated given\n the\n degree of patient motion. At the time of followup imaging, the MRA\n sequence\n could be repeated.\n 5. Pituitary adenoma, not significantly changed since the prior\n examination\n when accounting for differences in technique, although dedicated\n imaging of\n the sella was not obtained today.\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Treat with IV Decadron 10mg x 1, then 4mg q6h\n # Respiratory failure: Sputum and consolidation on CXR suggest possible\n healthcare associated pneumonia. Patient was intubated for airway\n protection at OSH\n - sent sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 2 of 10\n - plan for extubation today, if possible after assessing if mental\n status improving with dexamethasone\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n - Check amylase and lipase\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Start heparin gtt now for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: Started tube feeds yesterday, now stopped pending extubation\n possibly today\n Glycemic Control: None indicated at this time, will initiate QID\n fingersticks if serum glucose elevated\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: pneumoboots, heparin gtt without bolus\n Stress ulcer: Lansoprazole\n VAP:\n Comments: Bowel regimen with senna, polyethylene glycol, bisacodyl,\n lactulose, Pain management with acetaminophen\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609714,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n who was transferred from following episode of\n altered mental status that led to intubation for airway\n protection. Head CT which was reported as showing right temporal and\n parietal edema and small foci of hemorrhage. Late on night of\n , patient was found to be minimally responsive with head\n turning to right and arms flexed to chest. As he had received\n nortriptyline, there was initial concern for a dystonic reaction and 50\n mg IV diphenhydramine was pushed. There was no improvement in his\n mental status following that intervention and he was intubated for\n ariway protection and head CT was then performed with results as above.\n Transfer to was requested given patient's decline in mental\n status requiring intubation.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609715,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n who was transferred from following episode of\n altered mental status that led to intubation for airway\n protection. Head CT which was reported as showing right temporal and\n parietal edema and small foci of hemorrhage. Late on night of\n , patient was found to be minimally responsive with head\n turning to right and arms flexed to chest. As he had received\n nortriptyline, there was initial concern for a dystonic reaction and 50\n mg IV diphenhydramine was pushed. There was no improvement in his\n mental status following that intervention and he was intubated for\n ariway protection and head CT was then performed with results as above.\n Transfer to was requested given patient's decline in mental\n status requiring intubation.\n PMHX:\n 1) diffuse B Cell lymphoma\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to \n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n 16) MRSA in sputum \n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609716,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n who was transferred from following episode of\n altered mental status that led to intubation for airway\n protection. Head CT which was reported as showing right temporal and\n parietal edema and small foci of hemorrhage. Late on night of\n , patient was found to be minimally responsive with head\n turning to right and arms flexed to chest. As he had received\n nortriptyline, there was initial concern for a dystonic reaction and 50\n mg IV diphenhydramine was pushed. There was no improvement in his\n mental status following that intervention and he was intubated for\n ariway protection and head CT was then performed with results as above.\n Transfer to was requested given patient's decline in mental\n status requiring intubation.\n PMHX:\n 1) diffuse large B Cell lymphoma w/CNS involvement\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to \n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n 16) MRSA in sputum \n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609720,
"text": "41 yo gentleman with h/o acromegaly and diffuse large B-cell lymphoma\n who was transferred from following episode of\n altered mental status that led to intubation for airway\n protection. Head CT which was reported as showing right temporal and\n parietal edema and small foci of hemorrhage. Late on night of\n , patient was found to be minimally responsive with head\n turning to right and arms flexed to chest. As he had received\n nortriptyline, there was initial concern for a dystonic reaction and 50\n mg IV diphenhydramine was pushed. There was no improvement in his\n mental status following that intervention and he was intubated for\n ariway protection and head CT was then performed with results as above.\n Transfer to was requested given patient's decline in mental\n status requiring intubation.\n PMHX:\n 1) diffuse large B Cell lymphoma w/CNS involvement\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to \n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n 16) MRSA in sputum \n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt responsive to painful stimuli, appears to say\nouch\n when moved,\n does not respond to name calling and does not appears to speak today as\n he did yesterday (though speech was slurred). Pupils 4mm bilat and\n sluggish. Low grade temp persisits. Hand mitts on to prevent patient\n from pulling lines and grabbing care givers. Cont on IV dexamethasone\n as ordered. Attempted to administer morning meds crushed and dissolved\n in water, appeared to swallow first 10cc and then appeared to pocket\n and needed suctioning to remove from mouth, would not swallow.\n Attempted jello as well and patient spit this out. Too lethargic to\n attempt further feeding as fear patient will aspirate. HCT to visit\n today, ICU team to discuss possibility of if patient not waking for\n nutritional support.\n Action:\n ICU team spoke w/HCP and informed of possible recurrent lymphoma and\n probable plan for brain XRT.\n Response:\n No improvement in mental status noted.\n Plan:\n Possible whole brain radiation tomorrow.\n Decubitus ulcer (Present At Admission)\n Assessment:\n No change in stage IV ulcer noted, skin surrounding ulcer macerated,\n skin barrier applied. Dressing changed w/aquacel AG as prescribed.\n Wound base appears pink, cleanse w/wound cleaner.\n Action:\n Turned and positioned q2hour. Discussed nutritional needs on rounds\n Response:\n No change in stage IV coccyx ulcer.\n Plan:\n Cont w/wound care as prescribed. ICU team to talk w/HCP re: for\n nutritional support.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609335,
"text": "Briefly this is a 41 y/o M w/ a PMH significant for acromegaly and\n diffuse large B-cell lymphoma, who was transferred from w/ mental status changes. On the night of he received\n nortriptyline and was found unresponsive the following morning with\n what has been described as decorticate posturing. Head CT @ OSH showed\n parietal edema and a question of small hemorrhagic foci, he was then\n transferred to for further work up. On admission his R pupil was\n noted to be larger and non reactive to light.\n Overnight STAT Head CT and MRI performed, CT showed no evidence of any\n acute process, the initial interpretation of his MRI was questionable\n for progression of his B-cell lymphoma. Since admission all vitals have\n remained stable, his pupils now appear to be equal and reactive however\n no movement has been observed in his lower extremities, he is unable to\n track or follow commands and only moves his upper extremities in a\n non-purposeful fashion.\n Events:\n Head CT and MRI performed\n Phos of .8 repleted w/ 30mmol Kphos and 2 packets\n neutral-phos\n Stage IV on coccyx packed wet to dry and softsorb applied,\n Wound Consult ordered for AM.\n EKG showed NSR\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 4 on coccyx w/ small-moderate amounts serosanguinous drainage, no\n odor, tunneling present. Wound base and surrounding tissue is pink -red\n Action:\n Wound packed w/ kerlex soaked in sterile water covered w/ softsorb,\n wound care consult ordered, turned q 2hrs\n Response:\n unchanged from above assessment\n Plan:\n Wound care consult this AM, then follow recs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear throughout, satting 100% on AC w/ 50% FI02, ABG is within\n normal limits, pt had been intubated @ OSH for airway protection\n Action:\n AM wake up performed, sedation paused for 1 hour, switched to PS5/5\n Response:\n No evidence of discomfort, tolerating PS 5/5, satting 100% w/ a RR 20\n Plan:\n Cont to monitor resp status and potentially extubate.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Presented w/ unequal pupils, no movement of lower extremities noted,\n moves upper extremities in non purposeful fashion and turns head side\n to side. Unable to track or follow commands\n Action:\n Monitored neuro status, heavily sedated for head CT and MRI as pt was\n constantly moving head/arms, sedation lighted after returning from\n imaging\n Response:\n Pupils now appear equal and reactive, otherwise clinical presentation\n unchanged from above assessment.\n Plan:\n Monitor neuro status closely, follow up with official interpretation of\n MRI/CT.\n"
},
{
"category": "Respiratory ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609326,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: unknown\n Procedure location: outside hospital\n Tube Type\n ETT:\n Position: 24 cm at lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n RSBI=50. Weaned to psv 5/5/40%.Reason for continuing current\n ventilatory support: Cannot protect airway, Underlying illness not\n resolved. Possible extubation today?\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT/MRI\n :00\n Non\n Results pending\n"
},
{
"category": "Respiratory ",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609498,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot manage secretions\n Pt remained on psv overnight. RSBI this am acceptable=24.Still with\n large amts of thick yellow sput. Strong cough noted.\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609655,
"text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 10:57 AM\n INVASIVE VENTILATION - STOP 10:57 AM\n PAN CULTURE - At 04:07 AM\n bc x2 urine cult no sputum obtained\n -BMT says defer to Dr. , but will likely need whole brain XRT and\n intrathecal chemo\n -Dr. : Start dexamethasone. Call -onc first thing monday AM\n because he needs whole brain irradiation (and onc won't do this\n over weekend). No MTX, as he had it in and likely has\n resistant disease.\n - self-extubated, ABG: 7.51/25/67/21\n - not taking PO: changed metoprolol to IV and he didn't get rest of PO\n meds\n - restarted lovenox but at 70 (was previously on 90 and we couldn't\n figure out why)\n -sputum Cx growing GPCs -> on precautions\n - rash started on chest, face (flat, red)\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 11:50 AM\n Vancomycin - 09:00 PM\n Acyclovir - 04:09 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:38 PM\n Other medications:\n Acetaminophen 4. Acyclovir 5. Artificial Tears 6. Bisacodyl 7. CefePIME\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Citalopram Hydrobromide 10. Dexamethasone 11. Dexamethasone 12.\n Enoxaparin Sodium 13. Fentanyl Citrate\n 14. Heparin Flush (10 units/ml) 15. Heparin Flush (100 units/ml) 16.\n 17. Lactulose 18. Lansoprazole Oral Disintegrating Tab\n 19. Magnesium Sulfate 20. Metoprolol Tartrate 21. Metoprolol Tartrate\n 22. Midazolam 23. Multivitamins\n 24. Neutra-Phos 25. Ondansetron 26. Polyethylene Glycol 27. Senna 28.\n Sodium Chloride 0.9% Flush\n 29. Vancomycin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 108 (90 - 117) bpm\n BP: 144/96(111) {122/75(91) - 156/106(118)} mmHg\n RR: 28 (12 - 31) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 71 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 2,554 mL\n 246 mL\n PO:\n 170 mL\n 75 mL\n TF:\n 80 mL\n IVF:\n 2,034 mL\n 171 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,300 mL\n 390 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 174 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 690 (690 - 690) mL\n PS : 5 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/25/67/23/0\n Ve: 8 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 260 K/uL\n 12.8 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 137 mEq/L\n 37.6 %\n 7.9 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n Plt\n 60\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n Other labs: PT / PTT / INR:15.4/32.4/1.4, Albumin:3.6 g/dL, LDH:681\n IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:1.4 mg/dL\n Imaging: CXR:\n Microbiology: blood 12/10, 13 pending\n urine pending\n CSF ctx NGTD, fungal pending\n sputum coag + staph\n urine negative\n UA 2:30am: neg UTI with 5 WBC, 30 protein, net nitrite, 5 RBC, +ketones\n PEP: Pnd\n b2micro: Pnd\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Continue Dexamethasone 4 mg IV Q6H per Dr. \n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH\n - f/u sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 3 of 10\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate, Contact -Onc early Monday\n #. Rash: likely drug rash, possibly Vancomycin\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - restarted lovenox for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610312,
"text": "TITLE: Resident Progress Note\n Chief Complaint: CNS Lymphoma\n 24 Hour Events:\n - Alerted organ bank to impending death\n - HCP requests measurement of waist for funeral planning\n - Friends and sister and her husband visited per social work\n note, twin brother on probation and trying to work out a visit\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 13 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.6\nC (96\n HR: 125 (116 - 125) bpm\n BP: 123/60(76) {104/48(66) - 129/83(90)} mmHg\n RR: 12 (5 - 16) insp/min\n SpO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 1,466 mL\n 142 mL\n PO:\n TF:\n IVF:\n 1,466 mL\n 142 mL\n Blood products:\n Total out:\n 1,052 mL\n 220 mL\n Urine:\n 1,052 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 414 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 88%\n ABG: ////\n Physical Examination\n Gen: Obtunded, Not responsive to verbal or tactile stimuli, does not\n follow commands, appears comfortably, slow breathing\n CV: RRR nl s1 s2 no m\n Pulm: Rhonchi bilaterally on anterior exam, increased from yesterday\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n NO LABS TODAY\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n Serum:\n Protein Electrophoresis\n HYPOGAMMAGLOBULINEMIA\n BASED ON IFE (SEE SEPARATE REPORT),\n NO MONOCLONAL IMMUNOGLOBULIN SEEN\n INTERPRETED BY , MD, PHD\n Beta-2 Microglobulin\n 2.1\n mg/L\n 0.8 - 2.2\n RESULTS FROM SAMPLES DRAWN PRIOR TO ARE IN OUTSIDE LAB SYSTEM\n Immunoglobulin G\n 572*\n mg/dL\n \n Immunoglobulin A\n 43*\n mg/dL\n 70 - 400\n Immunoglobulin M\n 23*\n mg/dL\n 40 - 230\n Immunofixation\n NO MONOCLONAL IMMUNOGLOBULIN SEEN\n NEGATIVE FOR BENCE- PROTEIN\n INTERPRETED BY , MD, PHD\n CSF PEP: OLIGOCLONAL BANDING IS PRESENT IN THE CSF NONE OF THESE BANDS\n HAS A CORRESPONDING\n BAND IN THE PATIENT'S SERUM\n CSF HSV negative\n No new imaging\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n and CMO secondary to metastatic disease to the brain.\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Now comfort measures only\n - All non-comfort medications stopped, no blood draws or imaging.\n - Health care proxy being updated regularly\n - FU final LP results\n #. Hiccups: Unclear if thorazine is having benefit but can continue for\n comfort.\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given CMO status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for comfort\n ICU Care\n Nutrition: None\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: None\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Comfort measures only. DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Respiratory ",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609316,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: unknown\n Procedure location: outside hospital\n Tube Type\n ETT:\n Position: 24 cm at lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT/MRI\n :00\n Non\n Results pending\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609317,
"text": "Briefly this is a 41 y/o M w/ a PMH significant for acromegaly and\n diffuse large B-cell lymphoma, who was transferred from w/ mental status changes. On the night of he received\n nortriptyline and was found unresponsive the following morning with\n what has been described as decorticate posturing. Head CT @ OSH showed\n parietal edema and a question of small hemorrhagic foci, he was then\n transferred to for further work up.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609318,
"text": "Briefly this is a 41 y/o M w/ a PMH significant for acromegaly and\n diffuse large B-cell lymphoma, who was transferred from w/ mental status changes. On the night of he received\n nortriptyline and was found unresponsive the following morning with\n what has been described as decorticate posturing. Head CT @ OSH showed\n parietal edema and a question of small hemorrhagic foci, he was then\n transferred to for further work up. On admission his R pupil was\n noted to be larger and non reactive to light.\n Overnight STAT Head CT and MRI performed, CT showed no evidence of any\n acute process, the initial interpretation of his MRI was questionable\n for progression of his B-cell lymphoma. Since admission all vitals have\n remained stable, his pupils now appear to be equal and reactive however\n no movement has been observed in his lower extremities, he is unable to\n track or follow commands and only moves his upper extremities in a\n non-purposeful fashion.\n Events:\n Head CT and MRI performed\n Phos of .8 repleted w/ 30mmol Kphos and 2 packets\n neutral-phos\n Stage IV on coccyx packed wet to dry and softsorb applied,\n Wound Consult ordered for AM.\n EKG showed NSR\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 4 on coccyx w/ small-moderate amounts serosanguinous drainage, no\n odor, tunneling present. Wound base and surrounding tissue is pink -red\n Action:\n Wound packed w/ kerlex soaked in sterile water covered w/ softsorb,\n wound care consult ordered, turned q 2hrs\n Response:\n unchanged from above assessment\n Plan:\n Wound care consult this AM, then follow recs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear throughout, satting 100% on AC w/ 50% FI02, ABG is within\n normal limits, pt had been intubated @ OSH for airway protection\n Action:\n AM wake up performed\n Response:\n Plan:\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Presented w/ unequal pupils, no movement of lower extremities noted,\n moves upper extremities in non purposeful fashion and turns head side\n to side. Unable to track or follow commands\n Action:\n Monitored neuro status, heavily sedated for head CT and MRI as pt was\n constantly moving head/arms, sedation lighted after returning from\n imaging\n Response:\n Pupils now appear equal and reactive, otherwise clinical presentation\n unchanged from above assessment.\n Plan:\n Monitor neuro status closely, follow up with official interpretation of\n MRI/CT.\n"
},
{
"category": "Nutrition",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 609393,
"text": "Subjective: Patient intubated and sedated, no family members present.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 74.5 kg\n 23.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 99%\n kg\n 109kg kg\n 68%\n Diagnosis: Acromegaly, Burkitts Lymphoma\n PMHx: 1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS involvement:\n - hospitalization from - \n - oringinally had Bell's Palsy, urinary retention, and LE weakness;\n transferred to with labs suggestive of tumor lysis syndrome\n - bone marrow biopsy demonstrated Burkitt-like high grade lymphoma\n - imaging showed lymphangitic spread to lung, stomach, ureters\n - severe scrotal swelling felt to be due to tumor involvement\n - LP demonstrated malignant cells.\n - first treated with hyper-CVAD systemically and intrathecal\n chemotherapy with MTX and cytarabine starting the first week of \n - then treated with R- alternating with HD MTX. Vincristine was\n stopped due to concern that it might be causing severe polyneuropathy\n - treatment complicated by mucositis and pancytopenia requiring\n neupogen\n - now in remission\n 2) Pituitary Macroadenoma\n 3) Acromegaly\n 4) h/o Respiratory Failure with ARDS requiring mechanical ventilation\n to -- did well with PSV, had large TV (700-800) and\n MV (>10)\n 5) h/o Mycoplasma hominis PNA treated with cipro and doxy\n 6) Sinus Tachycardia with PVCs -- had significant work-up with TSH,\n TTE. Felt to be physiologic given lymphoma, infection, acromegaly.\n 7) Lower extremity paraparesis attributed to leptomeningeal involvement\n of his lymphoma, vincristine toxicity, and critical care myopathy.\n - received IVIG for possible paraneoplastic syndrome, but stopped b/c\n of low IgA\n 8) h/o DVT , plan for at least 6 months of lovenox\n 9) Stage IV Sacral ulcer, required surgical debridements\n 10) h/o Bell's Palsy -- unclear if acromegaly or Burkitt's\n 11) Constipation requiring aggressive bowel regimen\n 12) Peripheral neuropathy\n 13) h/o keratitis and right corneal ulcer, Cx grew coag neg staph, s/p\n right lid approximation\n 14) h/o Diffuse Joint Pain thought to be from acromegaly, on methadone\n 15) h/o right tibial fracture\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl, versed, ABx, prevacid, multivitamin,\n senna, KPhos repletion, others noted\n Labs:\n Value\n Date\n Glucose\n 92 mg/dL\n 09:18 AM\n Glucose Finger Stick\n 99\n 12:00 AM\n BUN\n 7 mg/dL\n 09:18 AM\n Creatinine\n 0.4 mg/dL\n 09:18 AM\n Sodium\n 140 mEq/L\n 09:18 AM\n Potassium\n 3.9 mEq/L\n 09:18 AM\n Chloride\n 109 mEq/L\n 09:18 AM\n TCO2\n 23 mEq/L\n 09:18 AM\n PO2 (arterial)\n 205 mm Hg\n 07:22 PM\n PCO2 (arterial)\n 33 mm Hg\n 07:22 PM\n pH (arterial)\n 7.44 units\n 07:22 PM\n pH (urine)\n 6.5 units\n 11:11 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 07:22 PM\n Albumin\n 3.6 g/dL\n 11:25 PM\n Calcium non-ionized\n 7.4 mg/dL\n 09:18 AM\n Phosphorus\n 2.2 mg/dL\n 09:18 AM\n Magnesium\n 2.0 mg/dL\n 09:18 AM\n ALT\n 9 IU/L\n 11:25 PM\n Alkaline Phosphate\n 72 IU/L\n 11:25 PM\n AST\n 15 IU/L\n 11:25 PM\n Total Bilirubin\n 0.3 mg/dL\n 11:25 PM\n WBC\n 6.5 K/uL\n 09:18 AM\n Hgb\n 10.8 g/dL\n 09:18 AM\n Hematocrit\n 31.2 %\n 09:18 AM\n Current diet order / nutrition support: Diet: NPO\n GI: abd soft, bowel sounds present, NGT in place\n Assessment of Nutritional Status\n Malnourished\n Patient at risk due to: severe wt loss, recurrent cancer\n Estimated Nutritional Needs\n Calories: 1865-2385 (25-32 cal/kg)\n Protein: 97-112 (1.3-1.5 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate (NPO)\n Specifics:\n 41 y.o. Male with h/o acromegaly and diffuse large B-cell lymphoma\n originally presented to outside hospital with intractable N/V x5\n days; work up was negative. Patient then has an acute episode of AMS\n requiring intubation for airway protection. Patient was found to have\n right temporal and parietal edema and small foci of hemorrhage on head\n CT. Patient was transferred to , where MRI shows malignancy versus\n hemorrhage. Team suspects that patient has recurrent CNS lymphoma;\n patient to have LP today to diagnose. Team consulted for tube feeding\n recommendations while patient is intubated. Agree with tube feeds\n given patient\ns malnourished state. Of note, patient received tube\n feeds during last admission, but was weaned off and was taking a\n regular diet at time of discharge.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feed goal of Replete with Fiber @ 80mL/hr\n (1920kcals, 119g protein).\n Check residuals q4hrs, hold if greater than 200mL.\n \\Multivitamin / Mineral supplement: via tube feeds.\n At risk for refeeding syndrome - monitor K / PO4 / Magnesium\n and repeat as needed.\n Check chemistry 10 panel daily\n Following - #\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609672,
"text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 10:57 AM\n INVASIVE VENTILATION - STOP 10:57 AM\n PAN CULTURE - At 04:07 AM\n bc x2 urine cult no sputum obtained\n -BMT says defer to Dr. , but will likely need whole brain XRT and\n intrathecal chemo\n -Dr. : Start dexamethasone. Call -onc first thing monday AM\n because he needs whole brain irradiation (and onc won't do this\n over weekend). No MTX, as he had it in and likely has\n resistant disease.\n - self-extubated, ABG: 7.51/25/67/21\n - not taking PO: changed metoprolol to IV and he didn't get rest of PO\n meds\n - restarted lovenox but at 70 (was previously on 90 and we couldn't\n figure out why)\n -sputum Cx growing GPCs -> on precautions\n - rash started on chest, face (flat, red)\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 11:50 AM\n Vancomycin - 09:00 PM\n Acyclovir - 04:09 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:38 PM\n Other medications:\n Acetaminophen 4. Acyclovir 5. Artificial Tears 6. Bisacodyl 7. CefePIME\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse\n 9. Citalopram Hydrobromide 10. Dexamethasone 11. Dexamethasone 12.\n Enoxaparin Sodium 13. Fentanyl Citrate\n 14. Heparin Flush (10 units/ml) 15. Heparin Flush (100 units/ml) 16.\n 17. Lactulose 18. Lansoprazole Oral Disintegrating Tab\n 19. Magnesium Sulfate 20. Metoprolol Tartrate 21. Metoprolol Tartrate\n 22. Midazolam 23. Multivitamins\n 24. Neutra-Phos 25. Ondansetron 26. Polyethylene Glycol 27. Senna 28.\n Sodium Chloride 0.9% Flush\n 29. Vancomycin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 108 (90 - 117) bpm\n BP: 144/96(111) {122/75(91) - 156/106(118)} mmHg\n RR: 28 (12 - 31) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 71 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 2,554 mL\n 246 mL\n PO:\n 170 mL\n 75 mL\n TF:\n 80 mL\n IVF:\n 2,034 mL\n 171 mL\n Blood products:\n Total out:\n 2,380 mL\n 390 mL\n Urine:\n 2,300 mL\n 390 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 174 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 690 (690 - 690) mL\n PS : 5 cmH2O\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/25/67/23/0\n Ve: 8 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Gen: grunts to his eyes being opened, otherwise sleeping and does not\n follow commands\n CV: RRR nl s1 s2 no m\n HEENT: pupils mildly dilated left, reactive\n Pulm: crackles at bases b/l\n Abd: +BS, soft NTND\n Ext: 1+ b/l LE edema\n Labs / Radiology\n 260 K/uL\n 12.8 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 102 mEq/L\n 137 mEq/L\n 37.6 %\n 7.9 K/uL\n [image002.jpg]\n 07:22 PM\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n Plt\n 60\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n TCO2\n 23\n 21\n Glucose\n 90\n 92\n 81\n 95\n Other labs: PT / PTT / INR:15.4/32.4/1.4, Albumin:3.6 g/dL, LDH:681\n IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:1.4 mg/dL\n Imaging: CXR:\n Microbiology: blood 12/10, 13 pending\n urine pending\n CSF ctx NGTD, fungal pending\n sputum coag + staph\n urine negative\n UA 2:30am: neg UTI with 5 WBC, 30 protein, net nitrite, 5 RBC, +ketones\n PEP: Pnd\n b2micro: Pnd\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n .\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, also some concern for infection or hemorrhage. STAT head CT here\n (limited by motion) was able to rule out massive hemorrhage causing\n herniation, though still possibility of small hermorrhage. Could also\n be seizure. MRI here with ?hemorrhage versus malignancy. In the\n setting of elevated LDH and preliminary LP results, most likely\n recurrent lymphoma.\n - Appreciate neurology consult input\n - Appreciate neurosurgery consult input\n - Appreicate BMT input\n - Appreciate neuro/onc input\n - FU final LP results and heme/path\n - Hold on further dilaudid or nortriptyline at this time, though may\n continue to give citalopram to avoid withdrawal from SSRI\n - Continue Dexamethasone 4 mg IV Q6H per Dr. \n # Respiratory failure/Coag + Staph sputum: Sputum and consolidation on\n CXR suggest possible healthcare associated pneumonia. Patient was\n intubated for airway protection at OSH\n - f/u sputum ctx\n - plan for 10 day course with Vancomycin/Cefepime, today is day 3 of 10\n # Diffuse large B-cell lymphoma: Patient is reportedly in remission\n after hyper-CVAD, R-, HD methotrexate, and intrathecal\n methotrexate but LP suggests that he is having recurrence.\n - Appreciate multiple consulting services\n - FU LP results\n - need full brain XRT vs methotrexate, Contact -Onc early Monday\n #. Rash: likely drug rash, possibly Vancomycin\n #. Nausea and vomiting: Patient's original presenting complaint to was nausea and vomiting. Abdominal films and upper GI\n series have yet been unrevealing. Likely related to increased ICP\n given high opening LP pressure.\n - Treat supportively with ondansetron and dexamethasone\n - bolus 1L now then start maintenance fluids as not taking good PO\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - restarted lovenox for anticoagulation\n #. Report of abnormal EKG: Copy of EKG was not sent with patient;\n however, reportedly had diffuse ST and T changes that were attributed\n to nausea and vomiting and resulting electrolyte abnormalities. Two\n sets of cardiac enzymes were reportedly negative at . ECHO was performed and showed anteroseptal akinesis of left\n ventricle, which is new\n -EKG here unchanged from 2 prior with exception of ?U waves\n - TTE here without change from previous except dynamic LV\n # Acromegaly and Pituitary Macroadenoma: Recent labs to check HPA\n showed normal TSH, LH, testosterone, and cortisol with slightly high\n FSH (14, ULN: 12) and high prolactin at 26 (ULN: 15).\n - Will eventually need surgical resection that was to be set up on\n outpatient basis; though, appointment with neurosurgery was \n - Defer until malignancy workup/tx complete\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied\n ICU Care\n Nutrition: ?PEG\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level care\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610121,
"text": "Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt code status CMO,continued on morphine drip ,titrated as needed for\n comfort. Moans sometimes. Looks comfortable and calm. Having lot of\n thick secretions back to throat. Sats maintained low 80-mid 90\n desats when needed NT suctions, blocking the airway with thick\n secretions. HR 120-130\ns. BP stable.\n Action:\n NT suction 3-4 times during the shift with large thick yellowish\n secretions. Continued on morphine gtt.\n Response:\n Comfortable.sats improved after suction. Moans sometimes ,especially\n when turn.\n Plan:\n Code status : CMO , to inform the family member,HCP and case\n management when Pt drops HR.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609638,
"text": "41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n early today that led to intubation for airway protection.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt is clearly speaking response words like ouch and\nOh god\n. No other\n verbal exchange.Not following commands or opening eyes.PERL. gag and\n cough intact. Diminished LS rt lobes. febrile to 100.6 rectally at\n 0200, tachycardic 100-114 nsr with rare pvc\ns. took po liquids slowly\n with syringe. Refused soft food. Bm x 5 soft to liquid brown. Urine\n output decreased over this shift from 120 to 50 cc/hr. girl friend\n called and did put phone to his ear. He moaned but did not speak.\n Referred her to MD for request for info. Stated HCP has not been\n available.\n Action:\n Slow po intake with sips or syringe. Cont to orient pt. Tylenol given\n for fever/tachycardia. Crushed meds and placed in small vol water and\n used syringe to instill in mouth. Completed 1000 cc ns with no further\n order for fluid. Blood and urine cultured.\n Response:\n Pt rested comfortably, able to cough with minimal secretions. Did take\n po and seemed to want to drink. With ldh up and lp results team feels\n this is most likely reoccurance of lymphoma with cns involvement\n Plan:\n Awaiting official LP results and will eval. If pt should get RXT or\n chemo next. Cont to support nutrition, gi output and skin care\n Decubitus ulcer (Present At Admission)\n Assessment:\n Dressing off with second stool . pt c/o pain when doing dsg and once\n answered\n bottom\n when asked about pain.\n Action:\n Dsg changed x1 and reinforced x`1. serous drainage\n Response:\n Wound is stage 4 with pink tissue and mod amt yellow tissue\n Plan:\n Cont dsg change q d, freq turning,Pt will move self to side. Need to\n address nutrition status with minimal po fluid intake now and attempt\n to get pt to eat more calories\n"
},
{
"category": "General",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Generic Note",
"row_id": 609589,
"text": "TITLE: Respiratory Care\n Pt self-extubated this shift. No ill effects noted. Tolerating being\n off invasive ventilation. BS after extubation were clear.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610242,
"text": "41 y/o M w/ \ns lymphoma w/ extensive CNS mets. Admitted on\n w/ MS changes. Both his head CT and MRI were consistent w/\n progression of his disease. Mr. self extubated on and did\n not require re-intubation, however over the last several days his MS\n has continued to decline even in the absence of any sedating meds. A\n family meeting was held w/ his HCP on as oncology and neuro-onc\n do not feel that chemo would be of any benefit and his prognosis is\n exceptionally poor. If the patient were to decompensate or require\n re-intubation we would not perform any aggressive resuscitative\n measures and shift focus to comfort. He is now DNR/DNI.\n He has begun to decline rapidly\n tachypneic, agitated, and apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal.\n Comfort care\n Assessment:\n No change in mental status\n moaning, agitated and appears in\n discomfort when repositioned. RR 6-10 and tachycardic to 120\ns. NT\n suctioned for small amnt of thick brown secretions. On morphine gtt\n Action:\n Continue Morphine gtt and titrate to comfort.\n Response:\n Appears comfortable\n Plan:\n Continue to monitor patient status, comfort is the goal. HCP and\n caregivers notified\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609481,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained as intubated ,vented ,sedated with fentanyl 200mics and\n versed 2mg/hr. pt very impulsive and agitated,very strong and quick\n with both hands for any activity, large thick yellowish ET /oral\n secretions. VSS,afebrile. Per report 2lumen Porta cath was not with\n retun blood, TPA instilled and need to redraw at 2130hrs.\n Action:\n On CPAP 5/5/40% .sats maintained 98-100%. TF @ 20cc/hr,off at 4am for\n possible extubation today if RSBI ,secretions , blood gas are ok.\n Continued with sedations,needed bolus before turn sometimes. At\n 2130hrs,porta cath TPA withdrawn and flushed with n/s 10cc, good blood\n return and line is patent too,all IV\ns switched to porta cath. PIV x . Foley to gravity,UO adequate.\n Response:\n VSS,afebrile ,sats 98-100% RSBI in the am\n Plan:\n Wean and possible extubation today. f/u with am blood gas and labs.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Having stage 2 decub in the coccyx, dressing clean and intact,not\n changed this shift,.\n Action:\n Change of position , dressing change daily, pt on air bed. TF for\n nutrition,on bowel regimen,no BM this shift. bilateral venodynes\n on,pillows for heels to keep off the bed.\n Response:\n Ongoing with skin care .\n Plan:\n Continue with skin care and f/u with wound recs. Keep skin dry .\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610433,
"text": "Around 1630 patient became bradycardic to 20-30\n> VT-->VF-->arrest.\n HCP called when patient became bradycardic. Patient passed away at\n 1645PM.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610440,
"text": "HCP in at 1900\nspent time with deceased.\n"
},
{
"category": "General",
"chartdate": "2144-12-31 00:00:00.000",
"description": "ICU Event Note",
"row_id": 610414,
"text": "Clinician: Attending\n Critical Care\n Progressive decline through the day. We have increased morphine to\n ensure comfort. Discussion with proxy who is comfortable with\n decision to make comfort measures. Passed away peacefully\n VT-VF-asystole.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609909,
"text": "Briefly this is a 41 y/o M w/ Burketts lymphoma w/ extensive CNS mets.\n Admitted on w/ MS changes. Both his head CT and MRI were\n consistent w/ progression of his disease. Mr. self extubated on\n and did not require re-intubation, however over the last several\n days his MS has continued to decline even in the absence of any\n sedating meds. A family meeting was held w/ his HCP on as\n oncology and neuro-onc do not feel that chemo would be of any benefit\n and his prognosis is exceptionally poor. Rad onc suggested that whole\n body irradiation would likely provide little benefit but had a small\n potential to reduce his tumor load. Mr HCP has opted to go\n forward w/ radiation therapy however if he were to decompensate or\n require re-intubation we would not perform any aggressive rescusitative\n measures and shift focus to comfort. He is now DNR/DNI.\n Overnight placement of an NGT was unsuccessful and resulted in Mr.\n vomiting, he has become increasingly tachypnic w/ a RR of 40 -45\n up from 35and required NT suctioning for small-moderate amounts of\n thick tan secretions. He has remained tachy w/ a ventricular rate in\n the 120\ns despite fluids and lopressor. Lytes were repleted w/ 2 gm\n Mag, 40meq Kcl, and 30mmol Kphos.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n Pt w/ known burketts lymphoma w/ extensive CNS involvement, PEARL,\n withdraws to painful stimuli and moans incomprehensible sounds when\n turned. Head CT and MRI have demonstrated worsening progression of his\n disease.\n Action:\n Attempted to place NGT, administered abx as ordered, repleted K,phos,\n and mag, NT suctioned x2 for thick tan secretions\n Response:\n NGT was unsuccessful and resulted in pt vomitting, morning lytes\n pendind\n Plan:\n Cont to monitor resp status, abx as ordered and replete lytes as\n necessary. Team will notify HCP if pt begins to develop resp distress\n or decompensates, with the intent to focus on comfort should this\n occur.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610018,
"text": "Briefly this is a 41 y/o M w/ Burketts lymphoma w/ extensive CNS mets.\n Admitted on w/ MS changes. Both his head CT and MRI were\n consistent w/ progression of his disease. Mr. self extubated on\n and did not require re-intubation, however over the last several\n days his MS has continued to decline even in the absence of any\n sedating meds. A family meeting was held w/ his HCP on as\n oncology and neuro-onc do not feel that chemo would be of any benefit\n and his prognosis is exceptionally poor. Rad onc suggested that whole\n body irradiation would likely provide little benefit but had a small\n potential to reduce his tumor load. Mr HCP has opted to go\n forward w/ radiation therapy however if he were to decompensate or\n require re-intubation we would not perform any aggressive rescusitative\n measures and shift focus to comfort. He is now DNR/DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610019,
"text": "Briefly this is a 41 y/o M w/ \ns lymphoma w/ extensive CNS\n mets. Admitted on w/ MS changes. Both his head CT and MRI were\n consistent w/ progression of his disease. Mr. self extubated on\n and did not require re-intubation, however over the last several\n days his MS has continued to decline even in the absence of any\n sedating meds. A family meeting was held w/ his HCP on as\n oncology and neuro-onc do not feel that chemo would be of any benefit\n and his prognosis is exceptionally poor. Rad onc suggested that whole\n body irradiation would likely provide little benefit but had a small\n potential to reduce his tumor load. Mr HCP has opted to go\n forward w/ radiation therapy however if he were to decompensate or\n require re-intubation we would not perform any aggressive resuscitative\n measures and shift focus to comfort. He is now DNR/DNI.\n He has begun to decline rapidly\n tachypneic, agitated, and apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal.\n Lymphoma (Cancer, Malignant Neoplasm, Lymphoid)\n Assessment:\n No change in mental status\n moaning, agitated and appears in\n discomfort. Tachypneic to 30\ns and hypertensive and tachycardic despite\n treatment w/lopressor. NT suctioned for moderate amnt of thick brown\n secretions. In early afternoon (after repositioning) extremely agitated\n and appears in distress, tachypneic to 40\ns, tachycardic to 150\n moaning/crying, desat to 60-70\ns , on assessment no LS @RT\n Action:\n Ativan /morphine given, repositioned back on his LT side (unable to\n reposition on his back sacral decub). NT suctioned again for brown\n thick secretion. Morphine gtt started and titrated up to comfort.\n Response:\n B/L rhonchorous. Able to tolerate lying on his LT side only. Sats up to\n 100%. Remains tachy to 140\ns. However appears more comfortable.\n Plan:\n Continue to monitor patient status, comfort is the goal. HCP and\n caregivers notified\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610286,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Received pt on morphine @ 10 mg/hr appearing comfortable, unresponsive\n and opening eyes to stimulation. RR 6-10, breathing shallowly. Sp02\n 94-96% on 6 L NC and 100% bucket mask. Lungs rhonchus but without\n secretions when NT suctioned. Urine amber with UO 30-50 cc/hr. Skin\n warm, ST 120\ns with frequent PVC\ns. SBP 100-120. Afebrile. Flexiseal\n draining brown loose stool.\n Action:\n Morphine gtt to comfort. 02 off. Bilateral mitts as pt flails arms and\n putting self at risk for pulling out port\n Response:\n Pt remains on 10 mg/hr of morphine and appears comfortable. Spo2 97-92%\n on RA.\n Plan:\n Continue with morphine gtt to comfort; emotional support to\n family/friends\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610400,
"text": "41 y/o M w/ \ns lymphoma w/ extensive CNS mets. Admitted on\n w/ MS changes. Both his head CT and MRI were consistent w/\n progression of his disease. Mr. self extubated on and did\n not require re-intubation, however over the last several days his MS\n has continued to decline even in the absence of any sedating meds. A\n family meeting was held w/ his HCP on as oncology and neuro-onc\n do not feel that chemo would be of any benefit and his prognosis is\n exceptionally poor. If the patient were to decompensate or require\n re-intubation we would not perform any aggressive resuscitative\n measures and shift focus to comfort. He is now DNR/DNI.\n He has begun to decline rapidly\n tachypneic, agitated, and apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal.\n Comfort care\n Assessment:\n No change in patient\ns status\n occasionally moaning and appears in\n discomfort when repositioned ( bloused X2) . RR 6-10 and tachycardic to\n 120-150\ns. sats in 80\ns. On morphine gtt\n Action:\n Continue Morphine gtt and titrate to comfort.\n Response:\n Appears comfortable\n Plan:\n Continue to monitor patient status, comfort is the goal. HCP and\n caregivers notified\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610405,
"text": "Around 1645 patient became bradycardic to 20-30\n> VT-->VF-->arrest.\n HCP called when patient became bradycardic. Patient passed away at\n -----.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610407,
"text": "Around 1630 patient became bradycardic to 20-30\n> VT-->VF-->arrest.\n HCP called when patient became bradycardic. Patient passed away at\n 1645PM.\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610207,
"text": "41 y/o M w/ \ns lymphoma w/ extensive CNS mets. Admitted on\n w/ MS changes. Both his head CT and MRI were consistent w/\n progression of his disease. Mr. self extubated on and did\n not require re-intubation, however over the last several days his MS\n has continued to decline even in the absence of any sedating meds. A\n family meeting was held w/ his HCP on as oncology and neuro-onc\n do not feel that chemo would be of any benefit and his prognosis is\n exceptionally poor. If the patient were to decompensate or require\n re-intubation we would not perform any aggressive resuscitative\n measures and shift focus to comfort. He is now DNR/DNI.\n He has begun to decline rapidly\n tachypneic, agitated, and apparently\n uncomfortable. Rising LD is evidence lymphoma has recurred outside CNS\n as well as inside. No chemo to offer so comfort is appropriate goal.\n Comfort care\n Assessment:\n No change in mental status\n moaning, agitated and appears in\n discomfort when repositioned. RR 6-10 and tachycardic to 120\ns. NT\n suctioned for small amnt of thick brown secretions. On morphine gtt\n Action:\n Continue Morphine gtt and titrate to comfort.\n Response:\n Appears comfortable\n Plan:\n Continue to monitor patient status, comfort is the goal. HCP and\n caregivers notified\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610134,
"text": "Chief Complaint:\n 24 Hour Events:\n -talked to HCP and made patient \n -morphine drip started\n -3pm labs: uric acid 2.9 (up slightly), LDH 1096 (stable), K wnl,\n lactate 2.3\n -1L bolus given at 5pm because neg a liter for the day, putting out\n lots of urine\n -FYI: HCP will be in court tomorrow and unable to answer phone\n for part of day. If we need to update him, call his wife \n at as she will be available all day. He says he\n has been updating the patient's family. He also thinks that \n would want an autopsy.\n Had several desats to 80s yesterday, NG suctioning performed with\n improvment in Sats.\n Given 2 L NS because putting out tons of urine.\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:47 AM\n Metoprolol - 07:47 AM\n Morphine Sulfate - 01:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 125 (117 - 147) bpm\n BP: 119/60(75) {117/60(75) - 193/133(146)} mmHg\n RR: 6 (6 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,274 mL\n 130 mL\n PO:\n TF:\n IVF:\n 3,274 mL\n 130 mL\n Blood products:\n Total out:\n 3,840 mL\n 520 mL\n Urine:\n 3,640 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -566 mL\n -390 mL\n Respiratory support\n O2 Delivery Device: Face tent on 100 % FiO2\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n No new imaging\n Assessment and Plan\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Acute Mental Status Change, Pituitary Macroadenoma, Acromegaly\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610135,
"text": "Chief Complaint:\n 24 Hour Events:\n -talked to HCP and made patient \n -morphine drip started\n -3pm labs: uric acid 2.9 (up slightly), LDH 1096 (stable), K wnl,\n lactate 2.3\n -1L bolus given at 5pm because neg a liter for the day, putting out\n lots of urine\n -FYI: HCP will be in court tomorrow and unable to answer phone\n for part of day. If we need to update him, call his wife \n at as she will be available all day. He says he\n has been updating the patient's family. He also thinks that \n would want an autopsy.\n Had several desats to 80s yesterday, NG suctioning performed with\n improvment in Sats.\n Given 2 L NS because putting out tons of urine.\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:47 AM\n Metoprolol - 07:47 AM\n Morphine Sulfate - 01:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 125 (117 - 147) bpm\n BP: 119/60(75) {117/60(75) - 193/133(146)} mmHg\n RR: 6 (6 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,274 mL\n 130 mL\n PO:\n TF:\n IVF:\n 3,274 mL\n 130 mL\n Blood products:\n Total out:\n 3,840 mL\n 520 mL\n Urine:\n 3,640 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -566 mL\n -390 mL\n Respiratory support\n O2 Delivery Device: Face tent on 100 % FiO2\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Gen: Not responsive to verbal or tactile stimuli, does not follow\n commands\n HEENT: pupils mildly dilated left, mildly reactive bilaterally, stable\n from yesterday\n CV: RRR nl s1 s2 no m\n Pulm: Rhonchi bilaterally, increased from yesterday\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n No new imaging\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n , now secondary to metastatic disease to the brain.\n #. Tachypnea and Hypoxia: Overnight has had persistent tachypnea and\n hypoxia, requiring face mask for oxygen delivery. Possibly related to\n aspiration event overnight, but unfortunately more likely related to\n systemic lymphoma as LDH increasing. Feel that this represents a\n significant downtown in his clinical course and XRT very unlikely to\n benefit him at this time. Therefore, HCP and patient made\n .\n - Continue high-flow oxygen delivery in face tent form to make patient\n comfortable\n - Morphine drip for patient comfort\n - PRN fluid boluses to help treat tachycardia and perhaps help patient\n feel better on some level\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Now as above\n - Decadron stopped\n - Health care proxy being updated regularly\n - FU final LP results\n - Tumor lysis labs negative at this time\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, especially given LP results and increasing LDH. Still not\n responsive except to noxious stimuli.\n - Now as above\n #. Increased urine output: Some concern for central diabetes insipidus\n given known increased intracranial pressure and increased urine\n output.\n #. Hiccups: Unclear if thorazine had benefit yesterday but can continue\n for comfort.\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for comfort\n ICU Care\n Nutrition: None\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: lovenox stopped\n Stress ulcer: oral PPO\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610136,
"text": "Chief Complaint:\n 24 Hour Events:\n -talked to HCP and made patient \n -morphine drip started\n -3pm labs: uric acid 2.9 (up slightly), LDH 1096 (stable), K wnl,\n lactate 2.3\n -1L bolus given at 5pm because neg a liter for the day, putting out\n lots of urine\n -FYI: HCP will be in court tomorrow and unable to answer phone\n for part of day. If we need to update him, call his wife \n at as she will be available all day. He says he\n has been updating the patient's family. He also thinks that \n would want an autopsy.\n Had several desats to 80s yesterday, NG suctioning performed with\n improvment in Sats.\n Given 2 L NS because putting out tons of urine.\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:47 AM\n Metoprolol - 07:47 AM\n Morphine Sulfate - 01:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 125 (117 - 147) bpm\n BP: 119/60(75) {117/60(75) - 193/133(146)} mmHg\n RR: 6 (6 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,274 mL\n 130 mL\n PO:\n TF:\n IVF:\n 3,274 mL\n 130 mL\n Blood products:\n Total out:\n 3,840 mL\n 520 mL\n Urine:\n 3,640 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -566 mL\n -390 mL\n Respiratory support\n O2 Delivery Device: Face tent on 100 % FiO2\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Gen: Not responsive to verbal or tactile stimuli, does not follow\n commands\n HEENT: pupils mildly dilated left, mildly reactive bilaterally, stable\n from yesterday\n CV: RRR nl s1 s2 no m\n Pulm: Rhonchi bilaterally, increased from yesterday\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n LDH 1081, Uric Acid 3.9\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n CSF PEP pending\n CSF HSV pending\n No new imaging\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n , now secondary to metastatic disease to the brain.\n #. Tachypnea and Hypoxia: Overnight has had persistent tachypnea and\n hypoxia, requiring face mask for oxygen delivery. Possibly related to\n aspiration event overnight, but unfortunately more likely related to\n systemic lymphoma as LDH increasing. Feel that this represents a\n significant downtown in his clinical course and XRT very unlikely to\n benefit him at this time. Therefore, HCP and patient made\n .\n - Continue high-flow oxygen delivery in face tent form to make patient\n comfortable\n - Morphine drip for patient comfort\n - PRN fluid boluses to help treat tachycardia and perhaps help patient\n feel better on some level\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Now as above\n - Decadron stopped\n - Health care proxy being updated regularly\n - FU final LP results\n - Tumor lysis labs negative at this time\n #. Altered mental status: Most likely due to recurrence of lymphoma in\n CNS, especially given LP results and increasing LDH. Still not\n responsive except to noxious stimuli.\n - Now as above\n #. Increased urine output: Some concern for central diabetes insipidus\n given known increased intracranial pressure and increased urine\n output.\n #. Hiccups: Unclear if thorazine had benefit yesterday but can continue\n for comfort.\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for comfort\n ICU Care\n Nutrition: None\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: lovenox stopped\n Stress ulcer: oral PPO\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Comfort measures only, DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Nutrition",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 610144,
"text": "Noted patient\ns status changed to CMO. Tube feedings were discontinued.\n Will sign off at this time. Please re-consult if plan of care changes.\n 08:08 AM\n"
},
{
"category": "General",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Generic Note",
"row_id": 610154,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Proxy in last night\n aware of\n terminal condition.\n 97.6 121 119/68\n Obtunded\n Tachypneic\n Chest\n few mid insp crackles\n CV w/o m\n Extrem w/o edema\n LD 1081\n BUN 14\n Apprears comfortable. No evidence of pain or breathlessness. We are\n titrating morphine to comfort. HR up but SaO2 is 99.\n Time spent 35 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610155,
"text": "Chief Complaint:\n 24 Hour Events:\n -talked to HCP and made patient \n -morphine drip started\n -3pm labs: uric acid 2.9 (up slightly), LDH 1096 (stable), K wnl,\n lactate 2.3\n Had several desats to 80s yesterday, NG suctioning performed with\n improvment in Sats.\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:47 AM\n Metoprolol - 07:47 AM\n Morphine Sulfate - 01:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 125 (117 - 147) bpm\n BP: 119/60(75) {117/60(75) - 193/133(146)} mmHg\n RR: 6 (6 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 3,274 mL\n 130 mL\n PO:\n TF:\n IVF:\n 3,274 mL\n 130 mL\n Blood products:\n Total out:\n 3,840 mL\n 520 mL\n Urine:\n 3,640 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -566 mL\n -390 mL\n Respiratory support\n O2 Delivery Device: Face tent on 100 % FiO2\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Gen: Obtunded, Not responsive to verbal or tactile stimuli, does not\n follow commands, appears comfortably, slow breathing\n CV: RRR nl s1 s2 no m\n Pulm: Rhonchi bilaterally on anterior exam, increased from yesterday\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n LDH 1081, Uric Acid 3.9\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n CSF PEP pending\n CSF HSV pending\n No new imaging\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n , now secondary to metastatic disease to the brain.\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Now comfort measures only\n - all non-comfort medications stopped, no blood draws or imaging.\n - Health care proxy being updated regularly\n - FU final LP results\n #. Hiccups: Unclear if thorazine had benefit yesterday but can continue\n for comfort.\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for comfort\n ICU Care\n Nutrition: None\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: lovenox stopped\n Stress ulcer: oral PPI\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Comfort measures only, DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 610367,
"text": "TITLE: Resident Progress Note\n Chief Complaint: CNS Lymphoma\n 24 Hour Events:\n - Alerted organ bank to impending death\n - HCP requests measurement of waist for funeral planning\n - Friends and sister and her husband visited per social work\n note, twin brother on probation and trying to work out a visit\n - Stopped oxygen therapy\n Allergies:\n Vincristine\n Neurotoxicity;\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Vancomycin - 07:47 AM\n Infusions:\n Morphine Sulfate - 13 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.6\nC (96\n HR: 125 (116 - 125) bpm\n BP: 123/60(76) {104/48(66) - 129/83(90)} mmHg\n RR: 12 (5 - 16) insp/min\n SpO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72 kg (admission): 74.5 kg\n Height: 65 Inch\n Total In:\n 1,466 mL\n 142 mL\n PO:\n TF:\n IVF:\n 1,466 mL\n 142 mL\n Blood products:\n Total out:\n 1,052 mL\n 220 mL\n Urine:\n 1,052 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 414 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 88%\n ABG: ////\n Physical Examination\n Gen: Obtunded, Not responsive to verbal or tactile stimuli, does not\n follow commands, appears comfortably\n CV: RRR nl s1 s2 no m\n Pulm: Relatively clear breath sounds anteriorly with significant upper\n airway rales, slow gasping breaths\n Abd: +BS, soft NT, ND\n Ext: 2+ b/l LE pitting edema\n Labs / Radiology\n 189 K/uL\n 12.9 g/dL\n 136 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.5 %\n 8.3 K/uL\n [image002.jpg]\n NO LABS TODAY\n 11:25 PM\n 09:18 AM\n 04:25 AM\n 01:10 PM\n 02:31 AM\n 01:16 AM\n 12:17 PM\n 09:53 PM\n 05:06 AM\n 04:40 AM\n WBC\n 6.7\n 6.5\n 7.3\n 7.9\n 6.9\n 9.3\n 8.3\n Hct\n 33.2\n 31.2\n 32.5\n 37.6\n 33.8\n 38.6\n 38.5\n Plt\n \n 189\n Cr\n 0.4\n 0.4\n 0.3\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 21\n Glucose\n 90\n 92\n 81\n 95\n 136\n 126\n 123\n 136\n Other labs: PT / PTT / INR:16.6/30.9/1.5, ALT / AST:, Alk Phos / T\n Bili:73/0.3, Amylase / Lipase:17/11, Differential-Neuts:85.0 %,\n Lymph:9.2 %, Mono:4.2 %, Eos:1.4 %, Lactic Acid:2.3 mmol/L, Albumin:3.6\n g/dL, LDH:1081 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Sputum culture\n STAPH AUREUS COAG +. MODERATE GROWTH.\n resistant to oxacillin\n CSF Gram stain: 1+ PMNs, culture pending\n and B Cx pending\n CSF cytology pending\n Serum:\n Protein Electrophoresis\n HYPOGAMMAGLOBULINEMIA\n BASED ON IFE (SEE SEPARATE REPORT),\n NO MONOCLONAL IMMUNOGLOBULIN SEEN\n INTERPRETED BY , MD, PHD\n Beta-2 Microglobulin\n 2.1\n mg/L\n 0.8 - 2.2\n RESULTS FROM SAMPLES DRAWN PRIOR TO ARE IN OUTSIDE LAB SYSTEM\n Immunoglobulin G\n 572*\n mg/dL\n \n Immunoglobulin A\n 43*\n mg/dL\n 70 - 400\n Immunoglobulin M\n 23*\n mg/dL\n 40 - 230\n Immunofixation\n NO MONOCLONAL IMMUNOGLOBULIN SEEN\n NEGATIVE FOR BENCE- PROTEIN\n INTERPRETED BY , MD, PHD\n CSF PEP: OLIGOCLONAL BANDING IS PRESENT IN THE CSF NONE OF THESE BANDS\n HAS A CORRESPONDING\n BAND IN THE PATIENT'S SERUM\n CSF HSV negative\n No new imaging\n Assessment and Plan\n 41 yo gentleman with h/o acromegaly and high grade B-cell lymphoma (s/p\n admission at from to ) who was transferred\n from following episode of altered mental status\n that led to intubation for airway protection now s/p self extubation\n and CMO secondary to metastatic disease to the brain.\n LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): CSF results and\n clinical picture consistent with recurrent CNS lymphoma. Now with\n worsening altered mental status despite less sedation.\n - Now comfort measures only\n - All non-comfort medications stopped, no blood draws or imaging.\n - Health care proxy being updated regularly, will get waist measurement\n today per his request\n - FU final LP results\n #. Hiccups: Unclear if thorazine is having benefit but can continue for\n comfort.\n #. History of DVT in : Supposed to be on Lovenox for 6 months\n after the event.\n - Will stop Lovenox given CMO status\n # Sacral decubitus ulcer: Reportedly a stage IV ulcer with recent\n pseudomonal infection. Appears to be without obvious infection at this\n time as drainage is serosanguinous.\n - Wound care recs applied for comfort\n ICU Care\n Nutrition: None\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 04:37 PM\n 20 Gauge - 08:04 AM\n Prophylaxis:\n DVT: None\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments: (HCP): Primary ph ,\n Secondary ph \n Code status: Comfort measures only. DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2144-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610451,
"text": "HCP in at 1900\nspent time with deceased. Dr spoke with mother\n of deceased and she agreed upon an autopsy. Pt appropriately wrapped\n and labeled, transport called to bring pt to morgue.\n"
},
{
"category": "Echo",
"chartdate": "2144-12-25 00:00:00.000",
"description": "Report",
"row_id": 89482,
"text": "PATIENT/TEST INFORMATION:\nIndication: pericardial effusion?\nHeight: (in) 69\nWeight (lb): 174\nBSA (m2): 1.95 m2\nBP (mm Hg): 149/92\nStatus: Inpatient\nDate/Time: at 16:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Increased IVC diameter (>2.1cm) with >55% decrease\nduring respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild global\nLV hypokinesis. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. .\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-10mmHg. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. There is probably mild global left ventricular hypokinesis (LVEF =\n45-50 %). No masses or thrombi are seen in the left ventricle. There is no\nventricular septal defect. Right ventricular chamber size is normal. with\nborderline normal free wall function. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the LVEF is less\nvigorous. The pericardial effusion is slightly larger but still with no\nevidence for overt tamponade.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111736,
"text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any new infiltrates? ET tube position?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with intubation for airway protection.\n REASON FOR THIS EXAMINATION:\n Any new infiltrates? ET tube position?\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Intubation for airway protection.\n\n FINDINGS: In comparison to the previous chest radiograph, a new ET tube has\n been placed with the tip 2 cm above the carina. New bilateral infrahilar\n opacities could be due to recent aspiration or infection, bilateral\n atelectasis in the lower lobes are new. Mild upper lobe pulmonary venous\n congestion is stable. Cardiomediastinal silhouette is normal.\n\n IMPRESSION: Mild pulmonary vascular congestion. New patchy infrahilar\n opacities could be aspiration or pneumonia. Satisfactory position of ET\n tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112273,
"text": " 5:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with CNS lymphoma, now with worsening tachypnea and desats\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lymphoma, worsening dyspnea and desaturation. Evaluation for\n interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No evidence of pneumothorax, no pleural effusion. Mild retrocardiac\n atelectasis. No focal parenchymal opacity suggesting pneumonia, no\n overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112155,
"text": ", MED 11:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with CNS lymphoma (Burkitt-like), concern for cerebral edema or\n rapid growth of tumor, persitently poor mental status.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Relatively stable vasogenic edema in the temporal lobes as well as\n leptomeningeal hyperdensity and hyperdensity in the left temporal lobe.\n\n Question of increased hypodensity in the mid brain, recommend correlation with\n MRI to exclude the possibility of ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112010,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with intubation for airway protection.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Intubated for airway protection, question interval change.\n\n FINDINGS: The endotracheal tube is no longer visualized. This is a rotated\n film. There is bilateral lower lobe subsegmental atelectasis. The right\n Port-A-Cath is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-24 00:00:00.000",
"description": "SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING",
"row_id": 1111712,
"text": " 9:15 PM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR Clip # \n Reason: any metal?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with altered mental status needing MRI.\n REASON FOR THIS EXAMINATION:\n any metal?\n ______________________________________________________________________________\n WET READ: 9:36 PM\n Right chest port; no new metallic implant to contraindicate MRI. ETT 3.7 cm\n above carina; NGT in stomach; L basilar atelectasis. 9:30p.\n ______________________________________________________________________________\n FINAL REPORT\n 41-year-old male with altered mental status, needing MRI evalaute for metal.\n\n COMPARISON: Prior chest radiographs, abdominal radiographs of and\n respectively; also CT torso .\n\n SINGLE VIEW OF THE NECK: Study was made available for interpretation today,\n . No radiopaque retained foreign body is seen. Note is made of a\n dental filling of the right mandibular teeth. There has been endotracheal\n intubation, with the catheter tip terminating approximately 3.7 cm above the\n carina. A right Port-A-Cath device terminates with the catheter tip\n apparently making a sharp turn with apparent kink, possibly entering the\n azygos vein. A nasogastric tube terminates at the tip of the stomach. The\n left lung base demonstrates a streaky atelectasis, less likely developing\n consolidation.\n\n SINGLE VIEW OF THE ABDOMEN: There is a oral contrast in the and a\n relative paucity of bowel gas elsewhere. There is no radiopaque retained\n foreign body.\n\n IMPRESSION:\n\n 1. No metallic foreign body to contraindicate MRI.\n 2. Left lung base density, likely atelectasis vs developing consolidation.\n 3. Right chest port-o-cath with apparent kink in the catheter, possibly\n terminating in azygous.\n\n #3 was discussed w/ Dr. , but the patient had been made comfort\n care and passed away in the interim.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112154,
"text": " 11:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with CNS lymphoma (Burkitt-like), concern for cerebral edema or\n rapid growth of tumor, persitently poor mental status.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb MON 2:07 PM\n Relatively stable vasogenic edema in the temporal lobes as well as\n leptomeningeal hyperdensity and hyperdensity in the left temporal lobe.\n\n Question of increased hypodensity in the mid brain, recommend correlation with\n MRI to exclude the possibility of ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST\n\n HISTORY: Lymphoma with worsening mental status.\n\n Comparison is made with .\n\n FINDINGS:\n\n The foci of vasogenic edema in the right and left temporal lobes with\n associated hyperdensity are relatively stable. There is also increased\n density within the right occipital and temporal leptomeninges. These findings\n likely reflect the parenchymal and leptomeningeal abnormality seen on the\n prior MRI. There is some low density within the posterior mid brain which may\n be artifactual but would recommend correlation with MRI.\n\n No large parenchymal hematoma has developed. There is no midline shift.\n There is some lack of -white differentiation suggesting edema.\n\n IMPRESSION:\n\n Relatively stable vasogenic edema in the temporal lobes as well as\n leptomeningeal hyperdensity and hyperdensity in the left temporal lobe.\n\n Question of increased hypodensity in the mid brain, recommend correlation with\n MRI to exclude the possibility of ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-24 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1111706,
"text": " 8:29 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Any evidence of mass or edema?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with mental status changes, right pupillary change, history of\n lymphoma.\n REASON FOR THIS EXAMINATION:\n Any evidence of mass or edema?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 12:08 AM\n Note pt. also has history Burkitt's lymphoma, pituitary adenoma. MRI: New\n abnormal hyperintensity on T2/FLAIR in right temporal lobe and anterior left\n temporal lobe compared to MR one month ago. DDx includes neoplasm\n such as lymphoma (apparent mild enhancement of right temporal focus relative\n to background brain parenchyma; though the short-interval change argues\n slightly against). Also consider acute hemorrhage (iso T1, hyper T2; though\n CT density of only ~ 44, and no corresponding abnormality on GRE argue\n against). Pituitary mass again seen. MRA/MRV: No vascular occlusion or sinus\n thrombosis. D/W Dr. (medicine resident) 11:45 p .\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN\n\n CLINICAL HISTORY: 41-year-old male with metal status changes, right pupillary\n change, history of lymphoma.\n\n TECHNIQUE: MRI of the brain was performed both before and after the\n administration of intravenous contrast, as per the standard departmental\n protocol. Both MRA and MRV of the head were obtained utilizing time-of-flight\n technique (no intravenous gadolinium contrast).\n\n COMPARISONS: MRI of the brain dated and .\n\n FINDINGS: Image quality is degraded by patient motion.\n\n There is extensive FLAIR hyperintensity and leptomeningeal enhancement\n involving the right greater than left hemispheres, especially in the temporal\n and parietal lobes. Additionally, there is a more focal area of parenchymal\n FLAIR and T2 hyperintensity in the right temporal lobe. Another focus of\n parenchymal FLAIR and T2 hyperintensity is also noted at the anterior tip of\n the left temporal lobe as well as in the right occpital lobe. There is also\n enhancement in the right internal auditory canal. These findings are new\n since the prior examinations.\n\n The ventricles, sulci, and cisterns are mildly enlarged compared to the prior\n brain MRI from . There is periventricular hyperintensity that is\n similar in distribution. There is no midline shift.\n\n There are apparent areas of decreased diffusion on the trace images\n (Over)\n\n 8:29 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Any evidence of mass or edema?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n corresponding to the areas of leptomeningeal FLAIR and post-contrast\n enhancement in the leptomeninges. While some of this likely represents T2\n shine through, some of this does appear to represent true areas of decreased\n diffusion. Additionally, there is evidence of decreased diffusion in the\n posterior aspect of the right thalamus, as well as in the right hippocampus\n and the pineal gland. The pineal gland itself appears enlarged compared with\n the prior study.\n\n The pituitary gland is enlarged, and although dedicated pituitary imaging was\n not obtained, it does not appear significantly changed since the prior MRI\n from .\n\n There is fluid in the mastoid air cells, right greater than left. Secretions\n are also noted in the nasopharynx.\n\n MRA HEAD: Given the degree of patient motion, evaluation for aneurysm is\n grossly suboptimal. There is no definite hemodynamically significant\n stenosis, or dissection. There is irregularity at the anterior communicating\n artery, and a small aneurysm in this location cannot be excluded.\n\n MRV: Given the degree of patient motion both on the MRV time-of-flight\n imaging and on the post-contrast MPRAGE, evaluation is suboptimal. There is\n no evidence of thrombosis of the superior sagittal sinus, the confluence, the\n straight sinus, the internal cerebral veins, and the vein of .\n\n IMPRESSION:\n\n 1. Diffuse leptomeningeal enhancement and FLAIR hyperintensity involving the\n right greater than left temporal and parietal lobes, with more focal areas of\n parenchymal abnormality in the temporal lobe, also right greater than left.\n Differential diagnostic considerations primarily include recurrent lymphoma\n (especially given the patient's history of Burkitt's lymphoma) as well as a\n meningoencephalitis such as herpes encephalitis, although other viral or\n bacterial meningoencephalitides could also result in a similar appearance.\n\n 2. Areas of decreased diffusion corresponding to the leptomeningeal disease\n with additional foci involving the right thalamus and right hippocampus, which\n may represent acute infarcts, although they may be related to lymphomatous\n involvement versus infectious process given the findings above. Hypoxic\n injury would be a less likely differential consideration.\n\n 3. Suboptimal MRA and MRV given patient motion. There is no definite\n evidence of venous thrombosis, although the sigmoid sinuses and the visualized\n internal jugular veins are suboptimally evaluated.\n\n (Over)\n\n 8:29 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Any evidence of mass or edema?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. No evidence of a hemodynamically significant stenosis on the MRA of the\n head, although irregularity at the anterior communicating artery raises the\n possibility of a small aneurysm. This was suboptimally evaluated given the\n degree of patient motion. At the time of followup imaging, the MRA sequence\n could be repeated.\n\n 5. Pituitary adenoma, not significantly changed since the prior examination\n when accounting for differences in technique, although dedicated imaging of\n the sella was not obtained today.\n\n Findings were discussed with Dr. at the time of interpretation at\n 10:30 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111888,
"text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change. Check ET tube position\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with intubation for airway protection.\n REASON FOR THIS EXAMINATION:\n ? interval change. Check ET tube position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Intubation.\n\n One view. Comparison with the previous study of . Lung volumes are\n somewhat low, as before. There is bilateral streaky density most consistent\n with subsegmental atelectasis. The heart and mediastinal structures are\n unchanged. An endotracheal tube remains in place, terminating approximately 2\n cm above the carina, slightly low in position. A nasogastric tube and right\n Port-A-Cath device remain in place.\n\n IMPRESSION: Streaky density bilaterally most consistent with subsegmental\n atelectasis unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-12-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1111702,
"text": " 7:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Any evidence of ICH?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with possible hemorrhagic stroke.\n REASON FOR THIS EXAMINATION:\n Any evidence of ICH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:08 PM\n Study limited by motion (though 5 attempts made). However, impression of\n mildly increased density diffusely, interdigitating with sulci, especially\n near skull base. Given the concern for hemorrhage, and lack of IV contrast\n administration, this may represent subarachnoid hemorrhage. MRI had already\n been ordered, but discussed with Dr. 9p .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with \"possible hemorrhagic stroke\". Evaluate for\n evidence of intracranial hemorrhage.\n\n COMPARISON: Non-contrast head CT .\n\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\n vertex without IV contrast. Because the patient was agitated and there was\n significant motion, the scan was repeated four additional times (5 separate\n acquisitions).\n\n HEAD CT WITHOUT IV CONTRAST: The study is significantly limited by patient\n motion; however, even allowing for motion and streak artifact and increased\n noise, there are slightly rounded foci of mild hyperdensity in the right\n temporal lobe and anterior left temporal lobe (7:9).\n\n There is also equivocal increase in density interdigitating with the sulci,\n especially near the skull base (7:9). This finding appears new since the only\n comparison head CT from . There is no significant mass effect upon\n the ventricles, effacement of the basal cisterns, or evidence of herniation.\n There is no hydrocephalus.\n\n Enlargement of the pituitary gland is again seen, but better evaluated on\n previous MR pituitary (7:8). Within the limits of the study, the\n paranasal sinuses and soft tissues are unremarkable.\n\n IMPRESSION:\n\n 1. Limited study due to patient motion despite five repeat attempts.\n\n 2. Round mild densities in the temporal lobes, and possibly increased density\n interdigitating with the sulci. Note additional history obtained of Burkitt's\n lymphoma. The findings may relate to lymphoma involvement, less likely\n parenchymal and subarachnoid hemorrhage, though not quite as dense as typical\n hemorrhage products, especially in temporal lobes.\n (Over)\n\n 7:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Any evidence of ICH?\n Admitting Diagnosis: AROMEGLEY;BURKITTS LYMPHOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Enlarged pituitary gland, better evaluated on recent MR pituitary.\n\n These findings were discussed with Dr. at 9:00 p.m. , at\n which time MRI had been ordered and the patient had been brought for MRI.\n\n"
}
] |
20,238 | 162,171 | +3 edema to LUE imroving.GI: abd soft, nt,nd. ABGS ACCEPTABLE PER DR. . ABGs acceptable, weaning PSV as . PRN Lopressor admin x2 with short effect. followed for trach check/ mdis t/o shift. LIGHTEN SEDATION AND WEAN VENT AS TOLERATES . care note - Pt. EEG DONE F/U RESULTS.CV: HR 79-93, NSR, NO ECTOPY, SBP 147-160. Resp CarePt. HCT 25.4- awaitng 1u PRBC.RESP:LS coarse, suctioned fro scant thick white, blood tinged at times. LUE gross amt of edema. Pt slightly more responsive, opening OU spontaneously x2. F/U RESULTS EEG, ECHO. afebrile.CV:SR, no ectopy. By early AM pt developed diffuse wheezes Albuterol MDI administered with good effect. Spont mvmt of RUE and Rleg x1. SBP <150, briefly into 150's wtih stimulation. BS coarse->clear. remaines intubated and vented, suctioned for yellow secritiones. NEPRO RESTARTED WHEN RESIDUAL DOWN AGAIN. + GENERALIZED EDEMA.RESP: LS CLEAR, DIMINISHED. General edema noted, peripheral pulses palpable. Cont wtih +3 edema to UE, +2 to lower extrem. lytes replaced.RESP: Lungs clear to dim at bases. TUBE FEEDS CONTINUES.R: LOW GRADE TEMP, HYPOGLYCEMIC, NEURO UNCHANGED.P: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. STARTED ON MEROPENUM, VANCO, AND CASPOFUNGIN ON . WHEN PROPOFOL OFF, PT OPENING EYES SLIGHTLY TO VOICE AND FOLLOWING SIMPLE COMMANDS.CV/GU- HR MOSTLY 70'S NORMAL SINUS. CVP at beginning of shift and appeared slightly dampened. BS occ fine rhonchi Breath sounds diminished, MDI's given as ordered. Dialysis qod as ordered. CONDITION UPDATE:D/A: TMAX 99.0NEURO: UNCHANGED. Lungs coarse/clear after suction. RESIDUAL HIGH AGAIN, DR. TO START D5W WHEN LINE PLACEMENT CONFIRMED.ACCESS; PERIPH I.V BLOWN BY DEXTROSE ADMIN. Pt admin 2u prbc this eveing for low hct ( re-check pending), and during admin sbp 185-195 with CVP of 9. ABG sent and Mg and Phos levels added, all returned WNL. LUE scabbing over.PLAN: Follow HCT, NA.Await cx results, CSF.? At best exam, opens eyes spont, nods yes/no minimally, MAE's spont. O2 weaned to 2l NC.GI: Abd soft, nt, dist. + PPP.RESP: LS CLEAR TO COARSE. Monitor respstatus, ABG's q2h, CPT. Neuro was consulted today d/t patients lethargy. pt fluid status even overnoc. condition updatePlease see carevue for specifics.Pt vss with tmax 100.0 ax. care note - Pt. care note - Pt. Focus-Condition UpdateData-Pt remains sedated on Propofol gtt, pt withdraws to noxious stimuli, PERL. MDI'S given.Good ABG'S on .RSBI done on 0 peep/5 ips 52.6.Propfol to come off this AM for extubation.Will cont to monitor resp status. PER RESPIRATORY TERAPIST, NT SUCTION FOR MINIMAL AMOUNTS. TRACH CARE GIVEN.ID--AFEBRILE. edema noted. k+ 3.4 repleted w/ 20meq kcl iv. Trach care done, inner cannula changed. Bilat pedal edema noted. ROM DONE.CARDIAC--BP AND HR STABLE. Good ABG post extubation. thalmic hemmorage with lt. sided weakness. NO VERBAL RESPONSE ALTHOUGH PT IS STARTING TO MAKE SOME SOUNDS.CV: T MAX 99.8 AX. Continues to have loose BM's with FIB replaced. +bowel sounds. Trach care provided.CV: HR 70s, NSR no ectopy. condition updateD: SEE CAREVUE FOR SPECIFICSNEURO: OPENS EYES TO NAME, DOES NOT FOLLOW COMMANDS, MINIMAL MOVEMENT OF ALL EXTREMITIES. noted, moving RU and lower extremities, +. Mild dilatation of the supratentorial ventricular system appears unchanged when compared to prior examinations. Again seen are right-sided IJ central venous catheter and ET tube which are unchanged in position. The right subclavian central venous line has been withdrawn several centimeters, and tip is in the distal SVC in satisfactory position. IMPRESSION: Stable right thalamic hemorrhage. Intraparenchymal hemorrhage within the right thalamus measuring 2.1 x 2.1 cm is unchanged in size and configuration when compared to the most recent CT. TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT CONTRAST: There has been slight interval reduction in size of the right thalamic hemorrhage with surrounding edema. A Dubhoff tube is again seen, with the tip positioned in the gastroduodenal junction, and is unchanged in position. FINDINGS: Compared with , allowing for technique and superimposed respiratory apparatus, no definite change, but perhaps slight interval progression of the bilateral infiltrates/edema. There has been interval removal of right subclavian central venous line, and interval placement of right IJ central venous line, with the tip now visualized in the distal SVC. IMPRESSION: Evolution of the right thalamic hemorrhage with slight decreased mass effect. COMPARISON: , Head CT. HEAD CT w/o CONTRAST: A right thalamic hemorrhage is again noted. Mild degenerative changes are seen in the cervicothoracic and lumbar region. The left atrium iselongated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Trivialmitral regurgitation is seen.PERICARDIUM: There is a small to moderate sized pericardial effusion. IMPRESSION: Continued CHF with small bilateral pleural effusions. FINAL REPORT INDICATION: S/P tracheostomy, now with respiratory distress. There has been interval placement of a right internal jugular vascular catheter which terminates within the superior vena cava. The right subclavian IV catheter terminates in the superior vena cava. Single portable AP view of the chest shows interval removal of a Dobhoff tube and right-sided subclavian central venous line. At a lower level, below the tracheostomy tube, there is high grade tracheomalacia. Again note is made of retrocardiac opacity in the left lower lobe, obscuring the left hemidiaphragm. Comparison is made to earlier chest CT of . Diffuse severe tracheobronchomalacia below level of tracheostomy tube. went for a tracheostomy this AM and recieved a #7.0 Portex. temp max 99.5. sbp remains under 165 on lopressor and hydralazine. Pt with 2-3+ edema BUE & BLE. add: prograf d/c'd. Neuro: Pt remains on propofol. CT of chest.GI: abd soft, NPO. Respiratory CarePt remain intubated and on vent support, Pt was weand to CPAP 5/5 doing well on this setting,Good am RSBI, BS coares, SX mod /larg amout thick yellow/tan secreation, Count to wean ? PERL 2-3MM, SLUGGISH.CV: HR 78-90, NSR, NO ECTOPY, SBP 147-168. Post-intubation started on ppf gtt. See flowsheet for I&O's; continues on acyclovir pre-hydration.HAEM: No current issues.ID: Stable. abg sent result 7.41/41/111/27cards: pt remain in sr, please see flow sheet fro vs. pt started on lasix. pt appears to be tolerating tube feeds. No movement LUE, denies sensation on LUE up to shoulder.CV: Continues with hypertension, maintained with current antihypertensives. | 157 | [
{
"category": "Nursing/other",
"chartdate": "2156-08-31 00:00:00.000",
"description": "Report",
"row_id": 1528711,
"text": "Neuro:pupils 2mm brisk bilat. moved rt arm and leg on bed spontaneously and to painful stimuli. Continues to recieve acyclovir for viral meningitis, pre-acyclovir fluis bolus given per transplant team.\n\nResp: pt continues to bite on ET Tube whenever suctioning attempted. Propofol increased to 20 to prevent but pt still bites on tube.\nSIMV with PS 12 Fio2.30 overnoc tolerated well O2 sats 99%.\n\nGI:Tube feeds changed to FS Pro Balance at 55 ml/hr via postpyloric FT.. No residual. Liquid quiaic positive black stool malodorous 150.\nBowel sounds hyperactive. 1 Unit PRBCs for Hct 25 increased to27 and stable at 27 overnight.\n\nCV: when stimulated. Continues to recieve hydralazine and lopressor. Still has positive fluid balance. Goal to have pt 1 and 1/2 L neg over 24 hrs. Plan to minimize fluid intake and give Lasix as ordered.\n\n \n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-31 00:00:00.000",
"description": "Report",
"row_id": 1528712,
"text": "Resp care\nPt remains on mech. ventilation. ABGs acceptable, weaning PSV as . BS coarse->clear. Sx mod thick yellowish secretions. OET retaped, bite block placed. Will follow, wean as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-14 00:00:00.000",
"description": "Report",
"row_id": 1528661,
"text": "Respiratory Care\nPt remains orally intubated A/C .6 X 430. Vt titrated by wgt of 68Kg. MD. BS clear no inhailers needed. Sx for moderate amount thick yellow secretions. See careview for details. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-14 00:00:00.000",
"description": "Report",
"row_id": 1528662,
"text": "Respiratory Care\nPt remains on mechanical ventilation, weaning Fi02 and switching to SIMV. Breath sounds diminished, equal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-29 00:00:00.000",
"description": "Report",
"row_id": 1528706,
"text": "nursing note\nNeuro: Remains sedated on prop, withdraws to pain. Spont mvmt of RUE and Rleg x1. PERL. +Gag, cough. not opening eyes or following commands. afebrile.\nCV:SR, no ectopy. SBP <150 on current regimen of loprssor and hydralazine. IVF KVO'd, TPN and Tf going at 1/2 strength. +3 pedal edma, weight up. team aware.\nRESP:LS coarse, thick white blood tinged sputum via ET and bloody oral secretions. Pt biting on ET tube. Increase in propofol does not stop biting. Ateempt at CPAP unsuccessful due to high RR to 40 and low TV 200-300. o2 sat's 99-100%. +3 edema to LUE imroving.\nGI: abd soft, nt,nd. TF up to goal of 110cc/hour. Loose gauaic + stool, black.\nGU:foley patent clear yellow urine.\nSKIN: duoderm to buttocks intact. nystatin powder and double guard cream on. myconazole cream to dry feet. Zoster healing well.\nSOCIAL: parents called for update.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-29 00:00:00.000",
"description": "Report",
"row_id": 1528707,
"text": "Resp. care note - Pt. remaines intubated and vented, suctioned for yellow secritiones.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-30 00:00:00.000",
"description": "Report",
"row_id": 1528708,
"text": "NEURO:PT ON PROPOFOL. , LOCALIZES TO PAINFUL STIMULI. PT BITING ON ET-TUBE WHENEVER SHE IS SUCTIONED.\n\nTRANSPLANT:TRANSPLANT TEAM WOULD LIKE TO KEEP PT 1-1AND 1/2 L NEG. KEEP HCT >30 AND MONITOR WBC AS IT IS ON THE RISE.\n\nCV:ANASARCA PLUS BIBASILAR RALES NOTED. PT HAS BEEN RECIEVING LASIX QD ON DAY SHIFT.\n\nRESP: VERY DIFFICULT TO SUCTION ET TUBE BECAUSE PT BITES ON HER TUBE. PROPOFOL INCREASED TO TOTAL OF 4/HR.\n\nSKIN:NEW AREA LEFT BUTTOCKS SKIN BREAK, LOOKS LIKE A SMALL VERTICAL CRACK. PLAN TO PUT ON DUODERM TODAY.\n \n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-30 00:00:00.000",
"description": "Report",
"row_id": 1528709,
"text": "Respiratory Care:\nPt continues to be intubated & ventilated. Settings are SIMV/PS; please see Carevue for details of settings & subsequent ABG's. Pt placed on Cpap/PS for two hours today; tolerated well but became tachypneic when ETT was retaped/repositioned. Pt placed back on SIMV at this time. Secretions became frothy in afternoon; RN & MD aware. Plan to continue ventilatory support as ordered & wean when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-30 00:00:00.000",
"description": "Report",
"row_id": 1528710,
"text": "NURSING NOTE\nNEURO: pt remains on 10 mcg/kg/min to prevent biting, spont opens eyes with turns periodically. Withdraws to pain, not following commands. PERL, sluggish. Afebrile. Head CT done - stable per team, no cerebral edema.\nCV: SR, no ectopy. SBP <150, briefly into 150's wtih stimulation. +3 edema LUE, +2 LE edema. IVF at KVO. Bolused wtih 250cc pre acyclovir. Lasix 20 mg IV given this AM with good results. HCT 25.4- awaitng 1u PRBC.\nRESP:LS coarse, suctioned fro scant thick white, blood tinged at times. CXR with no change.\nGI:Tube feeds changed to probalance FS, goal 55 cc/hour. Abd sfot, nt,nd. Liquid stool, heme +- large amounts. Mushroom cath in and effective.\nGU:foley patent clear yellow urine.\nSKIN: Duoderm to coocyx/buttocks. LUE helaing well- red and peeling.\nSOCIAL: Family calling for updates- not coming in today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-31 00:00:00.000",
"description": "Report",
"row_id": 1528713,
"text": "CONDITION UPDATE A:\nPlease refer to and remarks for details.\n\nPPF gtt stopped at 0800. Pt slightly more responsive, opening OU spontaneously x2. Wiggles (R) toes to commands, occ tries to squeeze with (R) hand, (L) extremities withdraw to nailbed pressure. Spontaneously moveing RLE, none from (L). Pupils 2mm/2mm slug unchanged from Friday . Pt biting ETT preventing mouthcare and resp care. RT, nsg, and MD placed bite block during ETT repositioning. Pt vent changes to CPAP 5/5.\n\nPt becomes agitated with any type of care as evidenced by HTN ^160-170's and RR^35, and creased brow. Reoccuring hydralazine frequency increased and PRN lopressor dose increased. PRN Lopressor admin x2 with short effect. SBP 140-150. HR 80-108. No ectopy.\n\nNS bolus admin prior to infusion of acyclovir IV. Diuressed from Lasix 20mg IVP. K=4.2 iCa=1.43. Hct (P).\n\nMost scabs from varicella lesions gone, sites dry. Duoderm intact to coccyx.\n\nPLAN: Monitor neuro signs q2h. Keep SBP <=150. Titrate insulin gtt to keep glucose 80-120. Monitor resp status, and to vent changes. Cont with ICU care and monitoring. Call H.O. for changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-01 00:00:00.000",
"description": "Report",
"row_id": 1528714,
"text": " Update Condition\nPlease see carevue for specifics.\nPt vss with tmax 100.4 (ax). HR tachy 95-105. SBP goal less than 150- admin 10mg IV lopressor x 1 At 2345 secondary to sbp 160-170, and returned to baseline within 10 minutes. CVP 10-14 during the shift- with uop 80-300cc/hr cyu- 20mg lasix admin x 3 to finish at 0600a. pt tolerating cpap with 5/5 30% well- rr 25-32 (increases with agitation r/t turning etc.)- suctioned for small amounts thick white secretions- chest pt done; cont pulmonary toilet. Pt alert at times during shift, then will only become alert to stimuli at times- when alert will move rle on command ?unable to move other extrem- does not move on own. with 2mm/2mm sluggish reactions. Pt non-verbal overnoc. Cont to monitor labs, vs, i/o's, ns. ?extubation in am- transplant team wants to trach in am. Insulin gtt on for glucose control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-14 00:00:00.000",
"description": "Report",
"row_id": 1528663,
"text": "CONDITION UPDATE\nASSESSMENT:\nNEURO- SEDATED ON PROPOFOL, OCCASIONALLY OPENING EYES TO PAINFUL STIMULI BUT NOT FOLLOWING COMMANDS. MOVES ALL EXTREMITIES ON BED, PUPILS EQUAL AND BRISK BILATERALLY. PROPOFOL OFF FOR 15 MINUTES; RESP RATE INCREASED, PT OPENING EYES TO VOICE, GETTING SLIGHTLY AGITATED.\nCV/GU- HEART RATE MOSTLY 60'S AND NORMAL SINUS. ABP REMAINS STABLE, SYSTOLIC IN 90'S DURING DIALYSIS. 2 LITERS REMOVED DURING DIALYSIS, CREATININE REMAINS HIGH (4.0). SLIGHTLY HYPOTHERMIC, TEMP 96, WARM BLANKETS ON.\nRESP- LUNG SOUNDS WITH FAINT CRACKLES @ BASES. PT ON LASIX WITH MINIMAL EFFECT. PT CHANGED TO SIMV 12 X 430, AND FI02 DECREASED TO 40%, ABGS ACCEPTABLE.\nGI- ABDOMEN SOFTLY DISTENDED, HYPOACTIVE BOWEL SOUNDS. NEPRO STARTED @ 10CC/HR THRU NGT, GOAL RATE IS 65CC/HR.\nINTEG- SKIN INTACT & WARM, ? HERPES RASH LEFT ARM (ID FOLLOWING). PT STILL ON IV ANTIBIOTICS, NOT BEING RENALLY DOSED. CONTINUE ON CURRENT ABX SCHEDULE REGARDLESS OF DIALYSIS PER DR. (RENAL).\nPLAN:\nATTEMPT PRESSURE SUPPORT AND WEAN SEDATION . WILL NEED DIALYSIS PROBABLY. ADVANCE TUBE FEEDS TO GOAL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-15 00:00:00.000",
"description": "Report",
"row_id": 1528664,
"text": " Care\nPt remains orally intubated BS coarse improved after suctioning which produces moderate light yellow secretions with few brown plugs. By early AM pt developed diffuse wheezes Albuterol MDI administered with good effect. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-15 00:00:00.000",
"description": "Report",
"row_id": 1528665,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, chnaging to CPAP. MDI's given as ordered. Breath sounds diminished with scattered expiratory wheezes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-15 00:00:00.000",
"description": "Report",
"row_id": 1528666,
"text": "CONDITION UPDATE\nASSESSMENT:\n PT SEDATED ON PROPOFOL, OCCASIONALLY OPENING EYES TO PAIN BUT DOES NOT FOLLOW COMMANDS. MOVES ALL EXTREMITIES ON BED. PUPILS EQUAL AND BRISK BILATERALLY. PROPOFOL OFF FOR ~ 25 MINUTES, PT SLIGHTLY AGITATED, OPENING EYES TO VOICE, ATTEMPTING TO REACH FOR TUBES.\nCV/GU- HEART RATE 70'S NORMAL SINUS AND BP STABLE. CREATININE REMAINS HIGH ~ 4, NO DIALYSIS TODAY, MAKES MINIMAL URINE.\n PT ON CPAP & PS 14, PEEP 10. PAC02 LOW, PT BREATHING WITH RR ~ 30 BUT MAINTAINING TIDAL VOLUMES ~370. ABGS ACCEPTABLE PER DR. . LUNG SOUNDS MOSTLY CLEAR, NO SUCTIONING REQUIRED. CXR DONE, STILL WITH BILATERAL INFILTRATES BUT SLIGHT IMPROVEMENT FROM PREVIOUS XRAY.\nGI- ABDOMEN SOFTLY DISTENDED, NO BOWEL SOUNDS. NGT RESIDUAL HIGH THIS MORNING, NEPRO STOPPED AND NGT TO LCS (DRAINING OLD TAN TUBE FEEDS). INSULIN GTT ON THIS MORNING, BLOOD SUGARS NORMAL AFTER TUBE FEEDS STOPPED SO GTT NOW OFF.\nINTEG/ PT CONTINUES TO HAVE HERPES ZOSTER ON LEFT ARM EXTENDING TO NECK AND BACK, UNCHANGED FROM . ID FELLOW FOLLOWING, PT GREW YEAST FROM BRONCH SPECIMEN, ABX TO BE CHANGED.\nPLAN:\n? LIGHTEN SEDATION AND WEAN VENT AS TOLERATES . REPEAT CXR .\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-06 00:00:00.000",
"description": "Report",
"row_id": 1528729,
"text": "7p-7a; Full assessment in flow sheet.\n\nOpen eyes inconsistently to pain and voice. Inconsistent follow of commands. move slightly of right side and left toes - no left arm movement. Pupil sluggish. Good gag and cough reflex. Flat affect. No grimace for pain. VSS, afebrile. warm, dry, no edema. Lung sound - coarse in upper lobes, dimish at bases. Trach mask - trach care done, FiO2 35% - SaO2 - >97%. Suction for thick/white sputum. soft abd. +BSx4. loose golden stool - small. foley patent - clear/yellow urine. AM lab done - Potassium and magnesium replace.\n\nPlan; Continue to monitor. respiratory toileting. Transfer to floor?\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-06 00:00:00.000",
"description": "Report",
"row_id": 1528730,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: OPENS EYES TO STIMULI, APPEARS TO BE TRACKING, FOLLOWING SIMPLE COMMANDS, NO PURP MVMTS NOTED, RESPONDS TO PAINFUL STIMULI APPLIED TO NAILBED BY WITHDRAWING W/ ALL EXTREMETIES EXCEPT LT ARM. HEAD CT DONE, NO CHANGES PER DR. . EEG DONE F/U RESULTS.\n\nCV: HR 79-93, NSR, NO ECTOPY, SBP 147-160. ECHO DONE.\n\nRESP: REMAINS ON TRACH COLLAR W/ 40% HH, O2 SAT 97-99%.\n\nGI: ABD SOFTLY DIST, + BOWEL SOUNDS, TOLERATING TF PROBALANCE AT 55CC/HR AT GOAL VIA DOBHOFF.\n\nGU: FOLEY DRAINIG ADEQ U/O, CLEAR YELLOW URINE.\n\nID: TMAX 98.6 AX\n\nPLAN: CONT CURRENT MGMT. F/U RESULTS EEG, ECHO.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-07 00:00:00.000",
"description": "Report",
"row_id": 1528731,
"text": "Resp Care\nPt. followed for trach check/ mdis t/o shift. Strong cough exspectorating thick yellow sputum. BS: coarse bilat. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-07 00:00:00.000",
"description": "Report",
"row_id": 1528732,
"text": "STATUS\nD: AFEBRILE..NEURO ESSENTIALLY UNCHANGED..WILL FOLLOW SOME SIMPLE COMMANDS INCONSISTENTLY..NO MOVEMENT OF LF ARM\nA: REMAINS ON TRACH COLLAR @ 40% WITH GOOD SAT'S..SUCTIONED Q4H FOR SM AMT THICK WHITE..LASIX 20MGM GIVEN X1 WITH GOOD EFFECT..INCT STOOL X1 TF'S WELL\nR: ESSENTIALLY UNCHANGED\nP: TRANSFER TO FLOOR IN AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 1528733,
"text": "TSICU Nursing Note\n0640 Received pt from 10 accompanied per two nurses. Attached to monitor with stable VS seen. NSR. HR in 90's. SBP 130-140's. RR 20's. O2 sats >96% on 50% trach mask. Lung fields clear bilateral upper lobes with diminished bases. Suctioned for small amts of thick yellow secretions. Strong spontaneous cough noted. , pt mildly lethargic, but does arouse to strong verbal stimuli. Follows simple commands. Shakes head no when asked if in pain. Weak spontaneous movement seen in RUE. No movement from L sided extremities. LUE gross amt of edema. Good clear yellow urine output. Report given to oncoming nurse.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 1528734,
"text": "resp care\npt continues on 40%tm. b/s ess clear. sxn thk white secretions. will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-04 00:00:00.000",
"description": "Report",
"row_id": 1528724,
"text": "CONDITION UPDATE:\nD/A: TMAX 99.0\n\nNEURO: UNCHANGED. PT OPENS EYES TO VOICE, FOLLOWS MOST COMMANDS, WEAKER ON LEFT SIDE.\n\nCV: HR 80'S NSR. ABP~ 150/56. CVP ~ 7. FLUID BALANCE -213 CC'S. FLUID BALANCE MN-0600 -240 CC'S. + GENERALIZED EDEMA.\n\nRESP: LS CLEAR, DIMINISHED. SUCTIONED FOR THICK SECREATIONS. MORNING ABG ON TRACH COLLAR 7.42, 43, 94, 29, 2, 98.\n\nGI: STOOL X2, GUIAC +. TUBE FEEDS AT GOAL.\n\nGU: FOLEY-BSD CLEAR YELLOW URINE.\n\nENDO: 0400 LABS SENT, RESULTS RETURNED @ 0545 WITH GLUCOSE LEVEL OF 38. FSBS IMMEDIATELY DONE, 58. NO D50 GIVEN, DR. AWARE. WILL RECHECK IN ONE HOUR. TUBE FEEDS CONTINUES.\n\nR: LOW GRADE TEMP, HYPOGLYCEMIC, NEURO UNCHANGED.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1528668,
"text": "update\nneuro: propofol at 70 mcg/kg/min to maintain sedation. propofol off this am for neuro exam, pt opens eyes to name, follows simple commands, moves all extremities. propofol resumed at 70 mcg.\ncv: vss\npulm: vented, see flow sheet. sx thick brown to yellow. bs coarse.\ngu: lasix 80 mg iv bid with sl increase in u/o. dialysis will continue 3 x week.\ngi: tube feeds resumed at 10/hr, residuals high. tube feeds held. hypoactive bowel sounds. no stool/flatus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1528669,
"text": "nurisng note\nNeuro: sedated on propofol, following commands off propofol. Moving spont all extrem on propofol and grimacing with moves. Afebrile. PERL.\nCV:SR, no ectopy. SBP 130-160's. HD today x3 hours (goal -3L). Cont wtih +3 edema to UE, +2 to lower extrem. P-boots on.\nRESP:LS coarse, thick tan secretions. PEEP weaned to 8- o2 sat's remain 98-100%.\nGI: Abd soft, distended. Hernia remians L of umbilicus. Tube feeds restarted after residual 90cc. Nepro up at 10cc. No BM.\nGU:foley patent yellow urine with sediment.\nSKIN: Herpes zoster present to L arm. ? area to back between scapulae that looks vesicle like. ID aware and looked at it. Remians on IV acyclovir-dose increased. CTX, Bactrim, levaquin.\nSOCIAL: Mother an in to visit. Friend called and no info given. Friend to visit and spoke with oarents for update.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1528670,
"text": "Respiratory Care\nPt remainsd mechaniclly ventilated, weaned to CPAP. Breath sounds diminished, MDI's given as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1528671,
"text": "CONDITION UPDATE\nASSESSMENT:\nNEURO- PATIENT SEDATED ON PROPOFOL, NOT OPENING EYES (VERY SWOLLEN) & DOES NOT FOLLOW COMMANDS. MOVES ALL EXTREMITIES ON BED, PUPILS EQUAL AND BRISK BILATERALLY. WHEN PROPOFOL OFF, PT OPENING EYES SLIGHTLY TO VOICE AND FOLLOWING SIMPLE COMMANDS.\nCV/GU- HR MOSTLY 70'S NORMAL SINUS. PT @ BEGINNING OF THE SHIFT WITH SYSTOLIC BP 170'S-180'S. STARTED ON 10MG IV LOPRESSOR EVERY 6 HOURS, KEEPING SBP 160'S. DIALYZED , PT MAKING ADEQUATE URINE AFTER PM DOSE OF LASIX. TEMP 101.2, PAN-CULTURED, ON MULTIPLE IV ANTIBIOTICS.\nRESP- LUNG SOUNDS WITH FAINT CRACKLES AT BASES. MINIMAL SUCTIONING REQUIRED, THICK TAN SPUTUM. NO VENT CHANGES MADE.\nGI- ABDOMEN SOFTLY DISTENDED, + BOWEL SOUNDS. RESIDUAL HIGH AGAIN, DR. AWARE. NEPRO STOPPED FOR 1 HOUR AND THEN TUBE FEEDS RESUMED @ 10CC/HR. BLOOD SUGARS STABLE MOST OF NIGHT ON 0.5 UNITS/HOUR OF INSULIN, ALL MEDS MIXED IN NORMAL SALINE.\nPLAN:\nREPEAT RAPAMUNE LEVEL THIS MORNING. CONTINUE TO WEAN VENT AS PATIENT TOLERATES. AWAIT ALL CULTURE RESULTS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1528672,
"text": "RESP CARE: Pt remains intubated/ on vent on CPAP/PSV 8/14/.40. Bilat crackles/sxd thick white/tan sputum. RSBI-104\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1528673,
"text": "Respiratory Care\nPt remains on CPAP with PSV. MDI given as ordered. Breath sounds diminished, suction small amounts of pale secreations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1528667,
"text": "Respiratory Care\nPt remains orally invubated and ventilated on PSV. BS difuse wheezes on right, coarse LUL. MDI's as ordered with improved aeration and decreased wheezes. Suctioned for moderate amount thick, creamy yellow secretions. Will continue to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 1528735,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: LETHARGIC VS DEPRESSION. WILL NOD APPROP WHEN\n \"PUSHED\" TO ANSWER. OPENS EYES ALSO.\n NODS YES TO BEING \"HERE TO LONG\" AND \"WANTING\n TO BE LEFT ALONE.\" CONTINUES WITH EDEMA OF\n UPPER EXTREMITIES. US NEG.\n NO LEFT SIDED MVMT.\n\nCV: HR AND BP STABLE. PO MEDS GIVEN.\n\nRESP: 40% TRACH MASK. STRONG COUGH. RAISING SECRETIONS.\n OCCAS NEEDS SUCTION TO FULLY CLEAR. GOOD SATS.\n\nRENAL: LABS WNL. K REPLETED. CONTINUES WITH GOOD UO\n AFTER 4 AM LASIX DOSE.\n\nGI: NPO FOR PEG...CANCELLED. TF RESUME.\n NO BM TODAY.\n\nHEME: LABS STABLE. HEPARIN DECREASED TO .\n BOOTS ON.\n\nENDO: INSULIN PER SLIDING SCALE.\n\nID: LOW GRADE TEMPS. STABLE WBC\n IV ACYCLOVIR.\n\nLINE: CENTRAL LINE RED/SWOLLEN/PUS AT SITE...GREEN TEAM\n AND ICU TEAMS AWARE. ASSESSED BY IV FOR PICC LINE.\n ... POOR CANDIDATE. INTERVENTIAL RADIOLOGY CONSULT\n ..AND DECLINED LINE AT THIS TIME... GREEN TEAM MD'S\n INFORMED.\n\nSKIN: HEALING BLISTERS/PEELING SKIN.\n\nSOCIAL: FAMILY CALLED AND UPDATED. EXPRESSED FRUSTRATION\n WITH LACK OF \"COMMUNICATION\" FROM MDS'.\n REQUESTED TO HOLD ON PEG PLACEMENT AND\n WOULD LIKE FAMILY MEETING ON TUESDAY.\n\nA: WET BY CXR.\nP: LASIX GIVEN...WITH IMPROVEMENT. STABLE IN ICU TODAY.\n FOLLOW FOR SECRETIONS...EXPECTORATES,..BUT OCCAS NEEDS\n SUCTION TO CLEAR. FAMILY MEETING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-11 00:00:00.000",
"description": "Report",
"row_id": 1528736,
"text": "TRANSFER NOTE TO 10.\nPT ADM TO HOSPITAL ON FOR ACUTE RENAL FAILURE. PLEASE SEE OLD TX NOTE FOR PARTICULARS OF HOSPITALIZATION PRIOR TO THIS ADM TO TSICU.HOSPITALIZATION COMPLICATED WITH PULMONARY STATUS ISSUES REQUIRING INTERBATION AND A TRACH CURRENTLY ON TRACH MASK. SHINGLES RESULTING IN MENIGEAL ENCEPHALITIS AND R THALMIC BLEED RESULTING IN L HEMIPARESIS.PT ADM TO UNIT @ O728 FOR PULMONARY EDEMA.\n\nNEURO: PT ALERT TO LETHARGIC AT TIMES. PT IS WITH HER RESPONSE TO COMMANDS . PT APPEARS TO UNDERSTAND BUT OFTEN DOES NOT RESPOND. CLOSES EYES TIGHTLY WHEN CHECKING PUPILS . NOTED TO MOVE RT ARM BUT RARELY TO REQUEST. PT MAKES NO ATTEMPT TO COMMUNICATE . YET MAKES EYE CONTACT AT TIMES.\nCV :NSR NO ECTOPI CVP 8-15. RT SC 4 LUMEN PATENT. INSERTION SITE RED . HO AWARE. PALP DP.\nLUNGS: ON TRACH MASK. PT LUNGS COARSE TO CLEAR. PT COUGHS UP SPUTUM BUT NEEDS SUCTIONING AT TIME COPIOUS AMTS OF WHITE THIN SECREATIONS. TRACH CARE GIVEN GREENISH DRAINAGE AROUND TRACH SITE .\nGI: ABD SOFT. BS PRESENT. TF RESTARTED AT 55 PROBALANCE TOLERATING WELL.\nGU : URINE CLEAR YELLOW 40 TO 120 AND HOUR RECIEVE LAST DOSE OF DIAMOX AT 2AM.\nSKIN: GENERAALIZED EDEMA. COCCYX HEALING RED SOME SKIN SLOUGHING. DOUDERM GEL APPLIED. RT ARM RED PALM SKIN SLOUGHING SILVADENE CREAM APPLIED. NYSTATIN POWDER TO UNDER ARMS AND BREAST AND GROIN.\nA STABLE\nP TRANSFER TO 10. PLACE PICC IN IR . THEN DC RSC LINE\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1528676,
"text": "RESP CARE: Pt remains intubated/on vent on CPAP/PSV 8/14/.40. RSBI-83. Sxd small amt tan/white sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-29 00:00:00.000",
"description": "Report",
"row_id": 1528744,
"text": "npn 7p-7a (see also flownotes for objective data)\n\ndx: s/p ren tx '; admitted for rehab , w/ ARF ?d/t acute prograf toxicity? Rt thalmic hemorrhage--left sided weakness; failure ti wean, now with trach () and PEG (). Rigid bronch for obstruction;\n\nneuro:\nleft side remains weak; left LUE in AFO; communicative w/ nurse, though difficult to understand because of mouthing words;\n\nc-v:\nnot new aucte significant issues\n\nresp:\nusing trach mask mist; new 6.0 Portex trach with removable cannula;\n\ng-i/endo:\ntube feeds of Probalanced held at times d/t planned procedure; has stool occasionally. FS covered at timwe;\n\ng-u:\nlow side urine output; Lasix dose increased from 10 IV bid to 20 IV bid, received 11 p.m. dose with increased doseage;\n\nPLAN:\n1) goal of diuresis is 1-1.5 litres per day\n2) MD plan\n3) RISS\n4) clean inner cannula prn to prevent obstruction\n5) FULL CODE\n6) check results AM labs\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-29 00:00:00.000",
"description": "Report",
"row_id": 1528745,
"text": "npn addendum, re respiratory system:\n\npt tachypnic at times; suctioned for small amounts blood-tinged thick secretions; at 06:45 when asleep, pt's respirations 26-27 (compared to 30's when awake. Pt mouthing many questions to nurse this night; ?d/t PMHx of anxiety.\n\nre RISS:\nSSI given at 06:40, as well as a.m. dose NPH.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1528677,
"text": "Resp Care\n\nPt's PSV was changed to 5 and peep was decreased to 5 as well. Follow up abg 7.40/42/104/27. RR is slightly elevated and is the high 20's to 30's. MV 10-11LPM. SUctioning small amts of thick white sputum. BS occ fine rhonchi\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1528678,
"text": "Neuro: pt remains sedated on propofol. Held this am for neuro exam, at that time pt opens eyes spontaneously.MAE, unable to follow directions. withdraws to nailbed pressure.\nCV: low grade temp 99.8, HR 70-80's NSR with no ectopy, SBP 110-130's. CVP 9-13. extremities warm with +PP. generalized edema. lytes replaced.\nRESP: Lungs clear to dim at bases. requiring occasional suctioning of thin white sputum. Vent changed to CPAP 5/5 40%. ABG this afternoon WNL. O2 sats >97%.\nGI: Pt having large amounts of residual all day. Tube feed off from 8am until 1800 when residual <50cc. Tubefeed at 1800 started @ 10cc/hr. Abd soft with hypoactive BS. No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars remain very labile. Insulin gtt titrated all day. presently at 1u/hr.\nPLAN: wean to extubate in am. Fluroscopy tomorrow for post-pyloric tube placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1528679,
"text": "Condition Update\nD: see carevue flowsheet for specifics\n Patient continues to run low grade fevers TMAX 99.5. CVP at beginning of shift and appeared slightly dampened. Urine output picked up significantly during the night (compared to hourly outputs during the day. Currently CVP running . HCT down to 26.5 with afternoon labs and was treated with 1u prbc during the eve which pt tolerated well. Otherwise patient hemodynamically stable. HR 70's NSR no ectopy and BP 120/40's.\n Pt had been placed on CPAP 5/5 during the afternoon. RR climbed into the 30's and tidal volumes began to dip into the 200's. Pressure support was increased to 14 and pt settled down nicely with acceptable ABG's. Pt suctioned for thick secretions but not too often.\n Patient is awaiting post-pyloric feeding tube to be placed possible in am. Not tolerating TF via NGT due to high residuals. Even with a rate of 10cc/hr residuals remain >150cc. SICU resident notified that TF are on hold. Insulin gtt on/off. +BM this shift.\n No change in herpes blisters-some are open and weeping.\nPLAN:\n ? wean to CPAP 5/5 today\n Pulmonary toilet\n Post-pyloric feeding tube to be placed\n Notify H.O. with any change\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1528680,
"text": "RESP CARE: PT REMAINS INTUBATED/ON VENT. PT BEGAN SHIFT ON PS 5/5/.40 BUT RR WENT INTO THE 30S AND VTS DECREASED TO 200S. PT HAS REMAINED ON CPAP/PSV 5/14/.40 FOR THE REST OF THE SHIFT WITH VTS 400-500, RR-20S. SXD THICK WHITE.COPIOUS SECRETIONS SXD FROM MOUTH.RSBI-109\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1528674,
"text": "See data, MD notes/orders. Neuro: Sedated on propofol, intermitently follows commands with wake up. Moves feet away from plantar stimulation. CV: SR rare pac. Sbp 104-120's. Pulm: Vent settings per flow sheet. Lungs coarse/clear after suction. 02 sats >95%. Respitory effort unlabored. GU: Uo >30cc hr clear yellow. GI: Abd soft, has palpable hernia that parents say is of long standing. Bs+, tube feed residuals minimal. Skin: Herpes zoster spreading from left arm across chest. Samples taken by ID/see notes. Pt moved to negative flow room. General edema noted, peripheral pulses palpable. Endo: On insulin gtt to keep glucose <120. Soc: Parents travel from each day to visit. P: Titrate propofol prn for pt comfort/safety. Continue vent support, risbi in am, begin wean parameters as indicated. Monitor bun/cr, uo. Dialysis qod as ordered. Advance tube feed to goal rate 65cc/hr as residuals permit. Keep family up to date on plan of care, offer emotional support. R: Propofol currently at 70mcg/kg/min to effect. Tube feed currently at 30cc/hr. Parents spoke with MD/nurse with questions answered satisfactorily. All else as above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1528675,
"text": "CONDITION UPDATE\nASSESSMENT:\n PT SEDATED ON PROPOFOL, MOVES ALL EXTREMITIES AND WITHDRAWS TO PAIN. PUPILS EQUAL & BRISK BILATERALLY. WHEN PROPOFOL OFF, PT OPENING EYES TO VOICE AND FOLLOWING SIMPLE COMMANDS.\n AFEBRILE OVERNIGHT. CENTRAL LINE CHANGED OVER A WIRE, TIP SENT FOR CULTURE AND QUINTON CATHETER DISCONTINUED, TIP ALSO SENT. FOLEY CATHETER CHANGED DUE TO CLOUDY URINE AND ELEVATED WBC. PT REMAINS IN NEGATIVE PRESSURE ROOM AND ON CONTACT/AIRBORNE PRECAUTIONS FOR VARICELLA ZOSTER (? DISSEMINATED). VESICLES ON LEFT ARM BEGINNING TO OPEN & PUS, EXTENDING ACROSS CHEST AND BACK. STARTED ON MEROPENUM, VANCO, AND CASPOFUNGIN ON .\n HEART RATE AND BP STABLE, SEE FLOWSHEET FOR ALL VITAL SIGNS. NEW CENTRAL LINE PLACEMENT CONFIRMED BY CXR, OKAY TO USE PER DR. . PT MAKING ADEQUATE HOURLY URINE. LUNG SOUNDS CLEAR, NO SUCTIONING REQUIRED. NO VENT CHANGES MADE OVERNIGHT.\n ABDOMEN SOFTLY DISTENDED. RESIDUAL HIGH AGAIN AT BEGINNING OF THE SHIFT, DR. NOTIFIED AND TUBE FEEDS STOPPED. NEPRO RESTARTED WHEN RESIDUAL DOWN AGAIN. PT HAD LOOSE GREEN STOOL, GUIAC NEGATIVE, SENT FOR C-DIF. INSULIN GTT ON OFF, DIFFICULT TO GET BLOOD SUGAR IN GOAL RANGE DUE TO NO ACCESS DURING LINE CHANGE AND TUBE FEEDS OFF/ON.\nPLAN:\n FOLLOW TEMPS AND AWAIT ALL OTHER CULTURE RESULTS. CONTINUE WITH SEDATION AND WEAN VENT AS PT TOLERATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-27 00:00:00.000",
"description": "Report",
"row_id": 1528739,
"text": "NPN 0700-1500;\n\nNEURO; DROWSY BUT EASILY ROUSABLE AOOX3 DIFFICULT TO READ MOUTH AT TIMES. MOVES RT SIDE MORE THAN LT. LT ARM VERY SWOLLENELEVATED ON PILLOWS.\n\nRESP; LUNGS SOUNDS COARSE UPPER DIMINISHED AT BASES OCCASS EXP WHEEZE CLEARS AFTER SUCTION. SUCTIONED Q1-2 HOURS FOR MOD AMOUNTS OF THICK BLOOD TINGED SPUTUM STRONG PRODUCTIVE COUGH. SATS 93-96 %,\n\nCVS. T MAX 99.6 PO. NSR 84-74 BP 125-145 /55. NO ECTOPY NOTED.\n\nGU; U/O SUPPORTED BY LASIX UNABLE TO GIVE SCHEDULED DOSE AS HAD NO ACCESS.\n\nGI; NPO FOR BRONCH. MD SPOKE WITH PARENTS AND CONFIRMED PERMISSION FOR RIGID BRONCH IN OR. BELLY SOFT DISTENDED DENIES PAIN PASSED SMALL AMOUNTS BROWN SOFT STOOL.\n\nENDO BS AT 12 MD 31 GIVEN 1 AMP OF DEXTROSE 50% WITH BS TO 111 THEN 91 AT 1400. TO START D5W WHEN LINE PLACEMENT CONFIRMED.\n\nACCESS; PERIPH I.V BLOWN BY DEXTROSE ADMIN. UNABLE TO START PERIPH IV . IV TEAM CALLED UNABLE TO SSTART THEREFORE 3LL INSERTED ON RT IJ AT 1445 AWAITING CXR TO CONFIRM PLACEMENT.\n\nID. TO ADD FLUCONAZOLE TO REGIME.ZOSYN D/C\n\n\nHEME;TO RECEIVE PRBCX1 WITH LASIX 20 MGS I.V. AGAIN AWAITING LINE PLACEMENT CONFIRMATION.\n\nA/P NPO FOR RIDGID BRONCH INOR @ 3PM. PERMISSION OBTAINED OVER PHONE BY MD AND MYSELF. FAMILY IS AWARE OF CURRENT CONDITION AND PLAN OF CARE. RESTART T/F ON COMPLETION OF BRONCH IN MEANTIME TO RUN DEX 5% TO MAINTAIN BS CONTROL.\nTO RECEIVE PRBCX1 WITH LASIX 20 MGS I.V.\nSTART FLUCONAZOLE WHEN 3LL PLACEMENT IS CONFIRMED.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-27 00:00:00.000",
"description": "Report",
"row_id": 1528740,
"text": "MICU NPN 3PM-11PM:\nPt had been NPO since MN for planned rigid bronch today and by 6:30PM they ahd not come to get her. I called pulmonary team who said the OR had gotten very backed up and the procedure was now planned to be done tomorrow. Pt has had her tube feeds restarted and they need to be shut off again at MN for planned bronch tomorrow ?time.\n\nNeuro: Pt seems with drawn, laying quietly with eyes closed but nods her head yes and no to answer simple questions. She opens eyes to commands and mouths words that can be understood most of the time. She seems to be alert and oriented, follows commands. Moves right side to midline but moves left side slightly on the bed. Denies pain. Is very greatful for the care given and thanked me for calling her mom and dad to inform them of the change in plans.\n\nCV: Vital signs are stable. BP 130-1150's HR 70's-80's NSR no ectopy. Pt given 20mg IV lasix with her unit of PRBC's today and repeat K+ is pnd. New triple lumen central line inserted by the team at change of shift and placement confirmed by CXR.\n\nResp: Remains on trach mask with 50-60% high flow neb with sats 94%-96%. Lungs coarse. Productive cough noted for blood tinged sputum. RR 20's. Cough can sound a little stridorous at times.\n\nGI: Had been NPO but tube feeds restarted at 7PM at 55cc/hr full str probalance. She had had problems with hypoglycemia during the day and they ordered D10W at 10cc/hr to be hung but they want it off while she is getting her tube feeds. Please restart D10W at 10cc/hr at MN when she is once again made NPO for the bronch tomorrow.\n\nEndo: Pt ordered for reduced dose of NPH insulin tonight. She was given 4u NPH at 6PM and will need to be covered as necessary with sliding scale. 8PM glucose was 114. I have checked Q2hr fingersticks due to pt's instability with her glucose today.\n\nGU: Pt passing adequate amts urien via foley. Cloudy yellow. Pt is being seen by the renal transplant service.\n\nID: Pt low grade fevers 100.6 PO today. Getting fluconazole and meropenum as ordered.\n\nSocial: Pt's family called and updated.\n\nIV's: Triple lumen central line inserted at change of shift. White port was not drawing back shortly after insertion. Pt also has a-line which is slightly difficult to draw off and is a little positional.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-28 00:00:00.000",
"description": "Report",
"row_id": 1528741,
"text": "NPN 7p-7a\nNeuro: Alert and oriented. Able to mouth words appropriately. No movement of lower extremities.\n\nResp: sx q 2-3 hours for thick blood tinged sptum. Pt. has strong cough and is able to cough out secretions. Scheduled for rigid bronch in or today at 3am.\n\nCV: HR NSR 70-80's. BP 130-140. K 3.4 last eve-given 40KCL This am k pnd.\n\nGI: NPO since MN. tube feeds shut off at MN. IV switched to D10 at 10cc/hr once tube feeds shut off as pt. was hypglycemic yesterday. Will call ho to determine am standing insulin order. Had her usual evening dose. Small BM overnight.\n\nGU: foley draining adequate amounts of urine.\n\nACCESS: R IJ\n\nSocial: Pt. seems somewhat depressed. No family calls overnight. Did not sleep much.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-26 00:00:00.000",
"description": "Report",
"row_id": 1528737,
"text": "NPN 1630-1900\n\n45 YOF readmitted to ICU under care of NSICU service d/t resp. distress on 10 noted by nursing staff. Pt. transfered for increased monitoring of resp status, frequent sx'ing, CPT. Please see admission note and flowsheets for further information.\n\nSince arrival, pt. sat's >99% on 60-100% TM, RR 12-30 and pt. reports not distress. Expectorating copious amounts of frothy, blood tinged sputum. ? CHF had XRAY done on floor and lasix given prior to arrival at 1530. Also received scheduled dose of PO lasix in addition to anti-hypertensives upon arrival. Of note, pt. had recent trach size changes to aide in passemuir valve trials. However, smaller trache lead to difficulty with breathing and sx'ing. Therefore, lastnoc changed to #6. Pt. to have bronchoscopy tom'row to view trach site and possible disturbed anatomy. Pt. has been VSS. Afebrile. Interactive, writing on board to communicate, demonstrates left sided weakness from old stroke. BS 111, TF infusing. Pt. reports no distress or pain. Expectorating sputum as described. Awaiting pneumoboot machine (on SQ heparin). To be bronched tom'row and monitored for resp. distress overnoc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-27 00:00:00.000",
"description": "Report",
"row_id": 1528738,
"text": "Nursing Process Note: 1900-0700\nPleasant, cooperative 45 yo woman with extensive PMH significant for ESRD secondary to DM, renal transplant (?), stroke with left sided weakness, melana. Now trached/peg and transferred from 10 for closer monitoring of resp status after desaturation on floor. Please see admit note for particular details.\n\nNEURO: Alert/oriented; mouthing words. Follows commands. Moving right side but none noted on left. Denies pain. Sleepy but easily arousable.\n\nRESP: LS coarse throughout; expectorating large amt of blood tinged, thick sputum via trach; also sx for same. Sats generally mid 90s on humidified high flow O2 @ 60%. One episode of desaturation down to 88 but denied SOB. O2 increased to 80% for approx one hr increasing sats to 98%. RR high 20s up to 30s at times; patient indicates typical. Sputum sent this shift. Bronch planned for Monday.\n\nC/V: A line placed; ABP 120s-130s/40s-50s. Team attempted to place ctl line but unable. HR 80-90, SR, no ectopy. Left arm dependent edema. Hct 26.2 but unchanged from previous lab.\n\nID: Spiked temp to 101.5 PO; one set bld cx sent from Aline; sputum and urine recently sent. Receiving Meropenum. Ordered for Zosyn but transplant MD indicating not necessary secondary to Meropenum coverage.\n\nGI/GU: TF held at midnight secondary to bronch. Abdomen soft, distended, present sounds. No BM this shift. Foley patent for variable output; low of 45cc. Ordered for IV Lasix sched dosing.\n\nENDO: Episode of hypoglycemia at 54 secondary to NPO status; received one amp D50 with desired effect. Will receive NPH dosing this AM.\n\nSOCIAL: Husband is spokesperson; no contact from family overnight.\n\nDISPO: Full code, NSICU\n\nPLAN: Bronch planned for Monday.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Report",
"row_id": 1528701,
"text": "CONDITION UPDATE A:\nPLEASE REFER TO AND REMARKS FOR DETAILS.\n\nPT INTUBATED AT START OF SHIFT FOR AIRWAY PROTECTION AND IMPROVED AERATION. REQUIRED PPF GTT TO PREVENT PT FROM ETT AND INTERFERING WITH VENTILATION AND SUCTIONING. SUCTIONED FOR SCANT AMOUNTS SECRETIONS. ABG'S SHOWED INCREASING MET ALKALOSIS. IVF CHANGED TO D5 1/2 NS. NS BOLUS ADMIN X1 FOR LOW U/O.\n\nDOWN TO MRI FOR SCAN OF HEAD AND SPINE. REPORT (P). NEURO SIGNS UNCHANGED, PT NOT OPENING OU, WITH DRAWS TO NAILBED, OCC SPONTANEOUS NONPURPOSFUL MOVEMENT OF EXTREMITIES.\n\nPLAN: MONITOR RESP STATUS, ABG'S. MONITOR NEURO SIGNS, ATTEMPT TO WEAN PPF GTT OFF AS PT WILL . SBP <150. TO HEAD CT TONIGHT. CONT WITH ICU CARE AND MONITORING. CALL H.O. FOR CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Report",
"row_id": 1528702,
"text": "CONDITION UPDATE:\nD/A: TEMP 97\n\nNEURO: PT ON PROPOFOL GTT DUE TO BITING ON ETT. PUPILS SLUGGISH, REACTIVE. PT WILL CLOSE EYES TIGHTLY, BUT WILL NOT OPEN THEM. PT WITHDRAWS TO PAINFUL STIMULI. TO HEAD CT @ 2200. NO OTHER NEURO CHANGES.\n\nCV: HR 70'S NSR. NEW GOAL ABP < 140 PER NEUROLOGY, MET WITH CURRENT MED REGIMEN. + PPP.\n\nRESP: LS CLEAR TO COARSE. VENT CHANGES MADE FROM AC TO SIMV +PS, PLEASE SEE FOR SPECIFICS. ABG: 7.47, 36, 266, 27, 3, 98.\n\nGI: STOOL DARK BLACK/GREEN QUIAC +. NGT TO SUCTION, CLAMPED AT TIMES FOR MED ADMINISTRATION.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE LOW AMOUNTS.\n\nSX: FAMILY UPDATED BY DR. .\n\nR: REMAINS LETHARGIC, NEUROLOGIC EXAM RELATIVELY UNCHANGED. SKIN HEALING WELL. VSS.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Report",
"row_id": 1528703,
"text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICU without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Report",
"row_id": 1528704,
"text": "nursing note\nNeuro: remians sedated on propofol- withdraws slightly to deep stim. some spont movement up all extrem noted at various times throughout day. Pt biting on ET tube and tongue fiercly ecnough for toungue to bleed. Afebrile.\nCV:SR, no ectopy. Goal SBP <150 and maintaining on current regimen of lop and hydralazine. Cont with LUE swelling- +pulses.\nRESP: Suctioned for thick blood tinged sputum. Extremely hard to ET sx'n secondary to biting on ET tube. LS coarse.\nGI:POSt pyloric feeding tube placed by endoscopy. Tube feeds ot be restarted. Multiple loose liquid + guaic stools. Cdiff sent.\nGU:adeq yellow clear uirne output.\nSKIN: nystatin and crticare applied ot buttocks. myconazole to soels off feet.\nSOCIAL: parents in and spoke MD\"s re: plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-29 00:00:00.000",
"description": "Report",
"row_id": 1528705,
"text": "Focus-Condition Update\nData-Pt remains sedated on Propofol gtt, pt withdraws to noxious stimuli, PERL. Pt continues to bite down on ETT, oral airway inserted by Resp. Suctioned for thick tan secretions. Blood sugars labile during the night. Tube feeds increased q4 hrs by 20cc. Pt incont sm amt stool x2.\nAction-Insulin titrated according to scale. IV rate decreased as tube feeds increase.\nResponse-Ongoing evaluation.\nPlan-Continue to monitor closely.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Report",
"row_id": 1528697,
"text": "CONDITION UPDATE\nD: NEURO: OPENS EYES SPONT. TRACKS STAFF AROUND ROOM WITH QUESTIONING LOOK IN EYES. MINIMAL VERBAL RESPONSE. MOVES ALL EXTREMITES SPONT IN BED AND OCCASSIONALLY TO COMMAND.\nCV: T MAX 99.6 AX. HR 90-100 NSR. SBP STABLE- REMAINS ON HYDRALAZINE AND LOPRESSOR- SEE CAREVUE FOR SPECIFICS\nRESP: BS COARSE. SATS 97-100% ON NP AT 2 LITERS. INTERMITTENTLY COUGHS UP SM AMTS THICK YELLOW SECRETIONS TO BACK OF THROAT.\nGI: NPO. ON TPN. ABD DISTENDED WITH HYPERACTIVE BS. NGT PATENT WITH COFFEE GROUND DRAINAGE. MINIMAL STOOL VIA FIB.\nGU: ADEQUATE UO- SEE CAREVUE FOR SPECIFICS\nENDO: ON INSULIN GTT AT 0-4 UNITS PER HR.\nA: HEMODYNAMICS AND RESP STATUS MONITORED, PULM TOILET ENCOURAGED\nR: STABLE. CONT. TO MONITOR RESP AND NEURO STATUS CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Report",
"row_id": 1528698,
"text": "CONDITION UPDATE A:\nPlease refer to and remarks for details.\n\nPt increasingly more alert and speach clearer as recieved PRBC's (s/p hct 32.7) and thru the afternoon. At 1600 Fentanyl 25mcg IVP x1 for indications of pain as evidenced by SBP ^180, RR^37, and facial grimacing, with effect. Dr. aware.\n\n1800 assessment found pt unresponsive to verbal and painful stimuli, withdrew to nailbed all extremities, OU 3mm/3mm scant pupilary reaction. Attempted to suction audible oral secretions, pt clamping teeth down. Unable to pass suction cath via nare or orally, oral airway placed. Suctioned copious thick tan->creamy secretions. FSBS 63, insulin gtt stopped, D50 25g IVP admin, repeat cs 139. Narcan 0.1mg IVP admin x4 with no change in neuro status. ABG sent and Mg and Phos levels added, all returned WNL. Dr. at bedside from 1805-1840.\n\nPLAN: Monitor neuro status, hemodynamics. Monitor respstatus, ABG's q2h, CPT. Monitor glucose and titrate insulin gtt to keep 80-120. Monitor skin, admin treatments per med orders. Cont with ICU care and monitoring. Call H.O. for changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Report",
"row_id": 1528699,
"text": "CONDITION UPDATE\nD: NEURO: PT NOW RESPONSIVE TO VIGOROUS STIMULI, MAE ON BED BUT NOT TO COMMAND. PUPILS 2MM WITH VERY SLUGGISH RESPONSE. PT MAKING SOME SOUNDS AROUND ORAL AIRWAY BUT IS NOT ALERT ENOUGH TO ATTEMPT TO REMOVE AIRWAY.\nRESP: ABG CHECKED Q2HRS PER DR . PO2 72-121. HIGHER PO2 OCCUR AFTER PULM TOILET. SX VIA ORAL AIRWAY FOR THICK YELLOW SECRETIONS. NP AT 4 LITERS WITH SATS>95%. BS REMAIN COARSE.\nGI: ABD SOFT AND NON=TENDER. NGT PATENT WITH BROWN DRAINAGE. FIB INTACT. NO STOOL. TPN INFUSING\nGU: HUO ADEQUATE\nENDO: REMAINS ON INSULIN GTT- SEE CAREVUE FOR SPECIFICS\nA: NEURO STATUS MONITORED CLOSELY, PULM TOILET Q2-3 HRS\nR: SLOW IMPROVEMENT IN NEURO STATUS. CONTINUE TO MONITOR RESP PARAMETERS CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Report",
"row_id": 1528700,
"text": "Resp. care note - Pt. intubated with # 8 OET, 22 at the lip, transffered to MRI and back to SICU without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Report",
"row_id": 1528695,
"text": " condition update\nPlease see carevue for specifics.\nPt vss with tmax 100.0 ax. Pt wax and wane; pt not speaking and following commands at times- MAE upper extrem with less strength than lower- independently moving legs in bed and repositioning self. ; pupils had a stronger reflex , still briskly reactive, but change in pupils size is not as large as efore- ho aware and came to assess pt; not concerned. Pt was to have MRI this evening per neuro/ID- ok per ID if pt has dsds over all leisions and old herpes zosters for protection of others while traveling, but MRI to be 2.5-3 hours long, and pt unable to sustain flat position d/t resp status for stated amount of time- if needs mri , need intubation (dr. aware). Pt LS coarse throughout with weak cough effort- chest pt done throughout noc- pt not bringing up any sputum, suctioning performed but pt has a lot of trauma to area and scant amounts of thick bloody return- no good sputum out; cont to enc cough. Leision areas drying up. FIB placed for large amounts of guiac positive stool (melena) overnoc. pt fluid status even overnoc. Na+ levels checked q 1-2 hours overnoc 153 at first, then d5w @40 started- repeat na+, per lab, came back a t 150- na+ stopped, for the rest of noc K+ was 153 even with d5w running along with tpn. Ho aware will continue checks and cont with freee water- na+ levels should not drop more than 1 pt in 2 hour timeframe per team. Cont to monitor labs, vs, i/o's, NS, watch resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Report",
"row_id": 1528696,
"text": "Nursing note\nNeuro: Pt remains minimally responsive, waxes and wanes throughout day. At best exam, opens eyes spont, nods yes/no minimally, MAE's spont. At times, wiggles toes and squeezes hands. PERL. LP done and sent for many tests rec'd by ID. Afebrile.\nCV: SR to ST, no ectopy. SBP WNL. Remains on metroprolol. LUE remains swollen. NA falling- d5W at 60cchour. HCT dropping and team aarei, to be rechecked this PM.\nRESP:LS coarse, yankaured out thick yellow with blood tinge sputum. O2 weaned to 2l NC.\nGI: Abd soft, nt, dist. hyperactive BS. Loose black stools- FIB intact. TPN up. KUB done-awaiting results of KUB re: dobhoff placement. NGT placed and coffee ground MD aware.\nGU:foley patent adeq yellow urine output.\nSKIN: Butccoks excoriated- double guard and nystatin applied. LUE scabbing over.\nPLAN: Follow HCT, NA.\nAwait cx results, CSF.\n? MRI\nCont skin care.\nPulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-23 00:00:00.000",
"description": "Report",
"row_id": 1528691,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient continues to run low-grade temp with TMAX 101.0-sicu resident notified. ID following patient. Blood cultures obtained earlier in day from old IJ and new right subclavian, and line tip sent for culture after multilumen was resited. HR 90's and BP up for most of shift. 2 extra doses of lopressor 10mg iv given and scheduled dose increased to 100mg . Lasix dose kept at 40mg IV BID and diamox ordered. Making adequate amts of urine and renal function continues to improve. HCT down to ~26 this afternoon-clot to be drawn and will transfuse 2u PRBC.\n Vigorous Chest PT done. Needs frequent pulmonary toilet-coughs and raises thick secretions.\n Patient slightly more alert this afternoon. Inconsistenly follows commands, answers some questions yes/no. Denies any pain. No sedation given all day.\n Parents in to visit this afternoon.\nPLAN:\n Continue Pulmonary toilet\n OOB to chair tomorrow\n Cont to closely monitor mental status\n Notify H.O. with any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Report",
"row_id": 1528692,
"text": " B shift\nPlease see carevue for specifics.\nPt lethargic and not answering questions during shift; following commands at times- NSS. MAE. Pt sleeping during most of shift. Pt admin 2u prbc this eveing for low hct ( re-check pending), and during admin sbp 185-195 with CVP of 9. Team made aware, once prbc finished, admin 250 diamox a/o at 0100 (instead of scheduled 0200) with moderate effect- sbp into low 180's. Pt started on 10,g hydralazine with good effect- sbp 160-170 post admin. Pt rr 25-30- Chest PT done at various times throughout shift- pt hads poor cough and rarely coughs up sputum; nnaso suctioned x 2 with good effect- returning moderate amounts of thick white secretions. UOP 30-500cc/hr during shift; pt -183cc thus far. and tacro levels to be drawn in am. Cont to monitor labs, vs, i/o's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Report",
"row_id": 1528693,
"text": "Respiratory Care:\nPt has required no Tx's today by RT and seems to be stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Report",
"row_id": 1528694,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient continues to run low-grade temps no significant results from any cultures at this time. Unable to suction for sputum spec thus far this shift. Secretions have been bloody d/t trauma from NTSxn. Pt has been able to adequately protect airway so far despite decline in mental status. +gag/+cough but does seem to be pooling secretions a little bit more this eve. ABG's remain stable. O2 sats 98-99% on 4L NC. Lungs are coarse throughout.\n When residual via dobhoff was checked this am withdrew 200cc of dark brown heme +gastric contents. Transplant/SICU team both notified. Tube feed was turned off and a few hours later CXR showed that feeding tube was curled in the stomach and was not post-pyloric. Pt was lavaged (per instruction of Dr. via dobhoff with 1000cc and eventually became almost clear. Patient had had a couple of BM's both guiaic neg in am formed and then loose-however at 1600 had large liquid guiaic +stool, dark maroon/brown in color. Shortly there after pt vomitted a small amt of coffee grounds. Dr. at bedside and attempted to place NGT unsuccessfully. Dobhoff was removed and replaced by fluoro at bedside. HCT has remained stable but is dropping very slowly. Tube feeds remain on hold and will receive TPN overnight for nutrition. Insulin gtt covering blood sugars. NA still elevated and was started on D5W gtt until TPN was avail. Sodium to be checked Q2hrs and notify H.O. if level drops faster then 1pt/hr.\n Neuro was consulted today d/t patients lethargy. Noted to be twitching in extremeties. Right more so then left, not following commands, nonverbal, rarely opens eyes to voice. @2. No spontaneous/purposeful movement noted by afternoon. Does withdraw feet to stimuli and somewhat in LUE. Neuro recommending MRI to be done-checklist filled out with Mom. do LP after MRI.\nPLAN:\n Neuro checks\n Pulmonary toilet\n Repeat HCT at midnight\n Check sodium Q2hrs.\n MRI tonight ?LP afterwards\n Notify H.O. with any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-21 00:00:00.000",
"description": "Report",
"row_id": 1528687,
"text": "condition update\nD: SEE CAREVUE FOR SPECIFICS\nNEURO: OPENS EYES TO NAME, DOES NOT FOLLOW COMMANDS, MINIMAL MOVEMENT OF ALL EXTREMITIES. NO VERBAL RESPONSE ALTHOUGH PT IS STARTING TO MAKE SOME SOUNDS.\nCV: T MAX 99.8 AX. SBP 160-190. FEET WARM.\nRESP: BS REMAIN COARSE. OPEN FACE TENT AT 50%. PT INTERMITTENTLY HAS SPONT COUGH AND IS ABLE TO RAISE THICK TAN SECRETIONS TO BACK OF THROAT AND OCCASSIONALLY TO HER MOUTH. HOWEVER SHE DOES NOT LIKE TO BE ORALLY SX'D AND WILL CLINCH HER TEETH WHEN ATTEMPTING TO SX OUT SPUTUM.\nGI: ABD SOFT AND NON-TENDER, LOOSE BROWN BM X 2 (SM AMTS). ADVANCING TF AS ORDERED, PRESENTLY ON 50CC/HR FS NEPRO.\nGU: IMPROVED CR THIS AM (2). GOOD DIURESIS FROM AM LASIX DOSE.\nENDO: REMAINS ON INSULIN GTT - ABLE TO TITRATE GTT FROM 11 UNITS PER HOUR DOWN TO 3.\nID: VANCO AND MEROPENUM DOSES INCREASED PER ID SECONDARY TO IMPROVED RENAL FX.\nA: PRECAUTIONS MAINTAINED FOR VARICELLA, HEMODYNAMICS MONITORED, RESP STATUS MONITORED AND VIGOUROUS PULM TOILET GIVEN\nR: SLOW IMPROVEMENT IN MENTAL STATUS, IMPROVED RENAL FX, CONTINUE ANTIBIOTICS AS ORDERED\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-22 00:00:00.000",
"description": "Report",
"row_id": 1528688,
"text": "data/action: pt lethargic, opens eyes to name but not following any commands.\npt coughs and raises sputum to back of throath-able to sx out w/ yankauer. rr-low 20's o2sats 99 on 50%ofm.\nb/p elevated sb/p 184/ pt on lopressor 50mg down fdg tube-add'l lopressor 10mg iv (prn order) given w/ sb/p170.\ngood diuresis w/ lasix 80mg iv-K+ 2.7 rec'd kcl+ 40meg iv and 40meg down fdg tube->repeat K+ 4.0.\ninsulin gtt 6-3u/hr w/ very labile bs 83-274. t fdg @ goal 30cc/hr nepro. bm x1. very hyperactive bowel sounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-22 00:00:00.000",
"description": "Report",
"row_id": 1528689,
"text": "CONDITION UPDATE\nD: NEURO: MORE ALERT TODAY ESP THIS AFTERNOON. INTERMITTENTLY FOLLOWING SIMPLE COMMANDS. MRI OF HEAD DONE THIS AFTERNOON.\nCV: T MAX 99.8. CONTINUES TO BE - PO LOPRESSOR INCREASED AND PT GIVEN 10MG IV X 1(PRN DOSE). HR 90-105 NSR-ST. SEE CAREVUE FOR SPECIFICS.\nRESP: RESP STATUS SLOWLY IMPROVING. COUGHING AND RAISING TO BACK OF THROAT= THICK TAN SECRETIONS. CHANGED TO NP AT 4 LITERS= SATS 95-100%\nGI/GU: TOL TF AT GOAL. SM LOOSE STOOL QUAIAC NEG. LASIX DECREASED TO 40MG IV BID. GOOD UO.\nENDO: REMAINS ON INSULIN GTT- 3-6UNITS/HR- SEE CAREVUE FOR SPECIFICS\nA: PULM TOILET ENCOURAGED, MRI DONE, HEMODYNAMICS MONITORED\nR: IMPROVED NEURO AND RESP STATUS, CONTINUE VIGOROUS PULM TOILET\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-23 00:00:00.000",
"description": "Report",
"row_id": 1528690,
"text": "DATA/ACTION: low grade temp 100.4. neuro- pt responds to name-attempts to talk but not able to understand. moves lt arm and lt leg freely, some mvmt in rt leg but no mvmt in rt arm. did wiggle toes x1 and squeeze w/ lt hand but not rt.\nresp- pt coughs on own-not coughing as much as day before-not as much secretions. rr-20-26 w/ 02sat 99% on 4np. lasix 40mg iv x1 w/ good response. fiuld balance -680 for 24hrs. k+ 3.4 repleted w/ 20meq kcl iv. ins. gtt 0-4u/hr for bs q1hr 280-81-bs's are very labile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-30 00:00:00.000",
"description": "Report",
"row_id": 1528748,
"text": "Resp Care note\n\nPt ha drelatively comfortable night requiring sx only x 2. She has new PMV which she wore last evening but not overnight. Pt is on hi OP neb and trach mask\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-30 00:00:00.000",
"description": "Report",
"row_id": 1528749,
"text": "Pt. is 45 y.o. female s/p renal transplant ', transferred from rehab with ARF due to prograft toxicity, s/p shingles, encephalitis, rt. thalmic hemmorage with lt. sided weakness. Trached , Peg .\nNeuro: Pt. is A&Ox3, at times forgetful, talking, following commands, lt. sided weakness persists, c/o lt. arm and leg pain with repositioning, swelling noted. Plan unilateral u/s tonight.\nResp: On 40% flow trach mist mask with PMV, talking with no difficulty, strong productive cough noted, occasionally suctioned for tan thick sputum. Video swallow study performed, suggested that pt. can have ground solids and norm. liquids, pills either whole or crushed with apple ; no new orders yet. LS coarse, rr 20s, sats high 90s-100%.\nCV: HR 60s-70s, ABP 120s-140s/50s-70s, pt. on Hydralazine & Lopressor via Peg. Bilat pedal edema noted. Adequate UO after PO Lasix, changed back to IV per orders.\nGI/GU: Abd. soft, lt. hernia visible, nontender, +BS, rectal bag intact with soft brown stool min amt. Foley patent, cloudy yellow urine out. TF Probalance @55cc/hr, tolerating well.\nID: Afebrile. Cont on IV Fluc,\nSocial: Parents visited, updated on plan of care.\nPt. called out to floor, awaiting for bed, transfer note updated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-20 00:00:00.000",
"description": "Report",
"row_id": 1528685,
"text": " A shift\nPlease see carevue for specifics\nPt has been lethargic throughout the day- not speaking, and inconsistently following commands- unalbe to assess orientation. Medicating pain by grimmace scale- admin 25mcg fent x 2. , with good strength. Pt was extubated at 1300- LS coarse post nad pt unable to produce a strng cough to get up sputum- RT deep suctioning to try and expectorate sputum. 02 sats 97% on 40% facemask. ABG\"s post wnl- pt appears to be using acessory muscles to breathe- Team aware. Low grade temps throughout the day (99.8-100.0)- ID aware ? change antibx today? Wound therapy to see pt- use no creams on outbreaks, only DSD's; skin insame conditon with outbreaks on left arm o hand and front of trunk. new outbreak found on base of neck- team aware and in to see, dsd appplied. Labs checked hct stable and wbc decreasing slowly. insulin gtt d/c'd and placed on sliding scale q 4 hours. Nepro @ 10 stated at 4pm, check residuals q 4 and increase by 10 for a ghoal of 65. Pt with lg amounts of green liquid stool- C. diff pending. FIB replaced. Family in to visit and aware of all findings/POC. Cont to monitor labs, vs, i/o's, resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-21 00:00:00.000",
"description": "Report",
"row_id": 1528686,
"text": "CONDITION UPDATE:\nD/A: TMAX 100.1\n\nNEURO: VERY LETHARGIC, OPENS EYES SPONTANEOUSLY AND WHEN NAME CALLED, HOWEVER DID NOT FOLLOW COMMANDS. APPEARED TO MAKE AN ATTEMPT AT NOD HEAD. PERL. MAE TO PAINFUL STIMULI, MINIMAL SPONTANEOUS MOVEMENT ON BED.\n\nRESP: LS COARSE, POOR COUGH EFFORT. PT WILL NOT OPEN MOUTH/CLENCHES IT SHUT. PER RESPIRATORY TERAPIST, NT SUCTION FOR MINIMAL AMOUNTS. LAST ABG: 7.31, 42, 108, -4, 22.\n\nCV: HR 90'S NSR WITH SBP ~ 170 MOST OF SHIFT. AFTER BATHING AND PAIN MED, PT BP IN 130'S, APPEARS MUCH MORE COMFORTABLE. FLUID BALANCE MN-0600 : -645 C'S.\n\nGI: ~ 20 CC RESIDUAL FOR TUBE FEEDS, CURRENTLY @ 30 CC/HR. GLUCOSE LEVEL HIGH IN AM, TO 401. DR. AWARE, INSULIN BOLUS 10 UNITS REGULAR GIVEN, AND GTT STARTED @ 10 UNITS/HR.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE. LASIX AS ORDERED.\n\nSKIN: \"BLISTERS\" ON CHEST NOT OPEN, WHITE. AREA ON BACK WITH SAME WHITE AREAS. LEFT ARM WITH WEEPY AREAS.\n\nSX: FAMILY VISITED IN EVENING.\n\nR: MOST OF SHIFT, LOW GRADE TEMP, NEUROLOGICAL ASSESSMENT CONCERNING.\n\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT, INSULIN GTT TITRATE ACCORDINGLY WITH HOURLY BLOOD SUGARS, ? LP TODAY. ? NEURO CONSULT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-29 00:00:00.000",
"description": "Report",
"row_id": 1528746,
"text": "Neuro: Pt. is A&Ox3, mouthing words, occasional sounds with attempts to voice, following commands. Letf side remains weak, lt. arm edema, c/o pain with movement, lt. food edema > rt. noted, moving RU and lower extremities, +. Pt. states being \"tired, want to sleep\". PT came this AM, stated will come back pt. sleeping.\nResp: Remains on track mask mist @ flow of 60. LS coarse. Strong productive cough noted with blood tinged secretions. RR 20s, occasionally 30s, Sats hign 90s. Pt. denies SOB. Trach care provided.\nCV: HR 70s, NSR no ectopy. BP 130s-150s/50s-70s. Remains on Lasix 40mg , diuresin well, goal 1-1.5 L/day. Bilat pedal pulses palpable, lt.> rt. periph. edema noted. K 3.6, repleted with 40meq via Peg.\nGI/Gu: Abd. soft, distended, nontender, +BS, inc. of 2 BMs on this shift. TF Probalance @55cc/hr via Peg, tolerating well. Foley patent, clear yellow urine out.\nHepato/renal: BUN25, Cr 0.5. LFTs stable. Cont. immunosuppresant agents for renal transplant.\nEndo: BS 200s-300s this AM, RISS and NPH dose adjusted accordingly.\nSocial: Parents called, updated on plan of care by RN, team notified to update family on status.\nPlan: Start Diamox today for 24 hrs per orders.\nSpeech and swallow eval. Possible transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1528681,
"text": "nursing note\nNEURO: Remains sedated on prop gtt, weaned to comfort. Fent IV started for grimacing with pain. Follows commands to wiggles toes incosistently, opens eyes with stim. PERL.\nCV:SR, . SBP WNL. Remains on lopressor. LUE +4- elevated on pillow.\nRESP: LS clear. LLL coarse. Suctioned for scant thick white. O2 sat's 100%. Weaned to , RR slightly up to 30. Decision made not to extubate due to RR.\nGI: NPO most of day. FIB replaced, loose stool, CDIFF sent.\nGU: foley patent adeq clear yellow urine.\nSKIN: Zoster to LUE and L upper chest- ID following. Skin care nurse consulted and will see tomorrow. Bactroban ordered and waiting to get from pharm.\nSocial: Family in and updated on condition.\n\nPLAN: extubate in AM. Awaiting bactroban from pharm to apply to LUE and then wrap with kerlix. Fent for pain.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-20 00:00:00.000",
"description": "Report",
"row_id": 1528682,
"text": "Resp Care Note, Decreased ips to 5 this AM.Suctioned sml amts thick tan secretions. MDI'S given.Good ABG'S on .RSBI done on 0 peep/5 ips 52.6.Propfol to come off this AM for extubation.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-30 00:00:00.000",
"description": "Report",
"row_id": 1528747,
"text": " \"B\" Nsg Progress Note:\n\nCVS: Skin warm and dry. Pulses palpable. T=98.0-99.5 p.o. HR=67-84 NSR no ectopy noted. SBP=133-151.\n\nResp: Pt tolerated passe-muir valve well during day, taken out as instructed during night shift. Suctioned for small amts white sputum. Trach care done, inner cannula changed. No distress noted. Decreased O2 to 40% after ABG with PCO2=46. Sats=100% to 95-96% on 40%. Lung sounds coarse. Trach site, no redness.\n\nGI: TF Probalance at 55cc/h goal. Tolerated well. +bowel sounds. Incontinent loose brown stool, oozing continuously, fecal bag applied.\n\nGU: U/O=32-700cc/hr, receiving Lasix , urine cloudy. Goal of 1 to 1.5 liters negative/24 hr I&O achieved yesterday.\n\nEndo: BS in 60's during night Insulin held. Dosage may need adjusting.\n\nNeuro: A&Ox3. Speaks well and appropriately with valve in. Moves rt side well, Left leg does not move, left arm moves on bed.\n\nSkin: Left arm edematous with reddened area on inner aspect, elevated on pillow and splint on. Left leg with some edema noted also. Coccyx has small red area, not open.\n\nPlan: Return to rehab, physical therapy to get pt oob today. transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-20 00:00:00.000",
"description": "Report",
"row_id": 1528683,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient with low-grade fever tmax 100.7-sicu resident aware-no cultures ordered. HR 80's NSR with no ectopy. BP a little higher this shift on lower dose of propofol. Continues to receive Lopressor PO BID and BP maintained 150/50's. Given fentanyl 25mcg iv q2hrs for pain-(grimacing) with little effect on BP. CVP 0-4. Urine outputs avg 60-80cc/hr. Scheduled dose of lasix given with some diuresis. Currently neg fluid balance since midnight. Wt down 1kg from yesterday. AM labs are still pending at this time.\n TF advanced to goal via post-pyloric feeding tube with no residuals. Continues to have loose BM's with FIB replaced. Stools guiaic neg-cdiff results pending.\n No vent changes made overnight. CPAP with 10IPS and 5 Peep and ABG's acceptable-see resp flowsheet for specifics. Suctioned for min secretions but mod amt of oral secretions.\n LUE red/swollen and covered with weeping blisters. New treatment ointment ordered (awaiting to receive from Pharmacy)-bactroban applied overnight. LUE kept elevated. Blisters also noted on upper back and across chest area.\n Pt sedated on 40mcg/kg/min of propofol-requiring bolluses during repositioning. Does not follow commands and rarely opens eyes to stimuli. MAE to stim but no spontaneous movement noted. PERRLA.\nPLAN:\n Cont. pulmonary toilet\n ?extubation in AM\n Continue fent prn for pain\n New ointment for blisters\n Keep LUE elevated\n Notify H.O. with any changes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-20 00:00:00.000",
"description": "Report",
"row_id": 1528684,
"text": "Respiratory Care:\nPt extubated to a 40% cool neb. Good ABG post extubation. Will follow for A/A nebs PRN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-28 00:00:00.000",
"description": "Report",
"row_id": 1528742,
"text": "NURSING PROGRESS NOTE 0700-1900\nNEURO--ALERT. NODS HEAD TO SIMPLE QUESTIONS. FOLLOWS COMMANDS CONSISTENTLY. LUE AND LLE DO NOT MOVE. PASSIVE ROM GIVEN. RUE AND RLE FLEX AT FOREARM AND KNEE. ROM DONE.\n\nCARDIAC--BP AND HR STABLE. REMAINS IN SR WITHOUT OBSERVED VEA.\n\nRESP--DOWN FOR RIGID BRONCH TODAY AND PLACEMENT OF NEW TRACH. UNEVENTFUL. WEARING O2 AT 80% HI FLOW WITH SAO2 >95%. STRONG PRODUCTIVE COUGH. SX Q2-4 HRS FOR SMALL AMTS OF BLOOD TINGED SPUTUM. LUNGS ARE COARSE THROUGHOUT ALL FIELDS. TRACH CUFF REMAINS DEFLATED. WHEN OPENING IS COVERED WITH FINGER, PT CAN SPEAK. VOICE IS HOARSE BUT CLEAR MOST OF THE TIME.\n\nGI--RESTARTED TUBE FEEDS AT 55 CC HR VIA PEG. STOOL, SOFT FORMED X2.\n\nGU--FOLEY CATH PATENT DRAINING >30 CC HR OF YELLOW URINE. GOOD DIURESIS WITH LASIX.\n\nENDO--1800 BS 242. PT RECIEVED HER FULL DOSE OF NPH AND 6 U REG INSULIN SQ.\n\nSKIN--L GLUTEAL CHEEK WITH BREAKDOWN/EXCORIATION. DUODERM APPLIED. TURNED Q2HRS. TRACH CARE GIVEN.\n\nID--AFEBRILE. REMAINS ON IV ABX.\n\nPAIN--C/O BACK PAIN EARLIER IN SHIFT. GIVEN TYLENOL WITH RELIEF.\n\nCOPING-- PARENTS IN TO VISIT. THEY ARE HAPPY AS IS PT THAT SHE CAN SPEAK. THEY HAVE BEEN UPDATED REGARDING PROCEDURE. MD CALLED AFTER PROCEDURE FINISHED. ALL ARE AWARE THAT PT TX TO FLOOR TOMORROW.\n\nA--STABLE. ABLE TO CLEAR SECRETIONS. AFEBRILE.\n\nP--CON'T TO MONITOR. CHECK BS Q6HRS. CON'T TUBE FEEDS. OFFER SUPPORT TO PT AND FAMILY. ?TX TO FLOOR IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-29 00:00:00.000",
"description": "Report",
"row_id": 1528743,
"text": "Beginning about 0100 and continuing through 0200 pt had periof of agitation and resp distress. BS were with some crackles but no wheezes. The #6 inner cannula was removed and pt was suctioned, cannula was cleaned and replaced as there are no spares in room at present. Pt was given a med neb with U/D alb & ATRV. After Rx pt indicated she was feeling better, she then fell asleep\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-22 00:00:00.000",
"description": "PELVIS PORTABLE",
"row_id": 836741,
"text": " 11:48 AM\n PELVIS PORTABLE Clip # \n Reason: need to assess for foreign object in hip for MRI\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with need for MRI, hx of hip injury\n REASON FOR THIS EXAMINATION:\n need to assess for foreign object in hip for MRI\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45 y/o woman in need of an MRI, with history of hip injury.\n\n COMPARISONS: None.\n\n FINDINGS: There is total hip replacement of the right hip joint, which shows\n no evidence of hardware loosening. There is a screw within the inferior\n portion of the greater trochanter. Between the cortex of the greater cortical\n margin of the greater trochanter and the superior aspect of the femoral shaft\n of the prosthesis, there is a focal area of lucency. There is also a surgical\n clip in the right lower quadrant.\n\n No other fractures or dislocations are observed in this limited single view of\n the pelvis.\n\n IMPRESSION: Hardware in the right hip including total hip arthroplasty, screw\n in the greater tuberosity, and surgical clip in right lower quadrant.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 837413,
"text": " 10:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate extent of bleed.\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal tx, altered mental status and new hemorrhage on MRI\n REASON FOR THIS EXAMINATION:\n evaluate extent of bleed.\n CONTRAINDICATIONS for IV CONTRAST:\n recent ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant, altered mental status and new\n hemorrhage on MRI.\n\n Comparison is made to the MRI performed six hours prior.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is again identified an acute intraparenchymal hemorrhage\n centered in the right thalamus measuring approximately 2.0 x 1.7 cm in its\n largest dimensions with surrounding edema and associated mass effect. There\n is no new area of hemorrhage identified. There is mild prominence of the\n ventricles, unchanged compared to the recent MRI. There are periventricular\n white matter hypodensities consistent with chronic small vessel ischemic\n change. Fluid and mucosal thickening is appreciated in the ethmoid, right\n maxillary, and sphenoid sinuses with note of an NG tube and endotracheal tube.\n The surrounding osseous structures are unremarkable.\n\n IMPRESSION: Right thalamic intraparenchymal hemorrhage with appearance\n unchanged compared to with the recent MRI.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-26 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 837176,
"text": " 8:15 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LUE SWELLING, R/O DVT\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with lue swelling\n REASON FOR THIS EXAMINATION:\n lue swelling\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: A 45-year-old female with left upper extremity swelling. Rule\n out DVT.\n\n FINDINGS: -scale and Doppler ultrasound of the left jugular, subclavian,\n axillary, brachial, basilic, and cephalic veins were performed. Normal flow,\n augmentation, compressibility, and wave forms were demonstrated. No\n intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of DVT on left upper extremity ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837305,
"text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT PLACEMENT\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with mental status change, s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ETT ?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST: Compared to previous study of \n\n CLINICAL INDICATION: Status post intubation. Evaluate endotracheal tube.\n\n An endotracheal tube has been placed and terminates in the proximal right main\n stem bronchus. A nasogastric tube courses below the diaphragm and a feeding\n tube terminates in the region of the body of the stomach. The heart size is\n upper limits of normal for technique. There is persistent increased opacity\n in the left retrocardiac region. There is also an adjacent small left pleural\n effusion. The right lung shows near complete resolution of previously noted\n centrally located opacities.\n\n IMPRESSION:\n\n Mal-positioned endotracheal tube terminating in proximal right main stem\n bronchus. This finding has been communicated with the clinical service caring\n for the patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837843,
"text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with mental status change, s/p intubation, now febrile\n\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Mental status change with fever and intubation.\n\n ETT is 1.5 cm above carina. Right subclavian CV line is in distal SVC. Feeding\n tube is coiled in stomach. No pneumothorax. Heart size is within normal limits\n for technique. There is mild atelectasis in the left lower lobe.\n\n IMPRESSION: Mild atelectasis left lower lobe, unchanged. No pneumothorax or\n evidence for new pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836244,
"text": " 9:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p central line change over wire, check placement ?PTX,\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis, new fever 101.2\n\n REASON FOR THIS EXAMINATION:\n s/p central line change over wire, check placement ?PTX,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45 y/o female with acute renal failure and respiratory distress.\n New fever.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the previous\n chest radiograph dated from .\n\n FINDINGS: The tip of the ETT is terminating 3 cm above the carina. The tip of\n the right jugular line is terminating in SVC. There is no pneumothorax. The NG\n tube is coursing down to the left upper quadrant.\n\n The previously noted bilateral patchy opacities in both lungs has decreased\n compared to the previous study, representing improving multifocal pneumonia or\n improving ARDS.\n\n There is no suspicious lesion identified in skeletal structures or in the\n upper abdomen.\n\n IMPRESSION: Decreased bilateral patchy opacities in both lungs, representing\n improving multifocal pneumonia and/or improving ARDS. Central venous line in\n SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836854,
"text": " 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for R SC TLC placement..pulled back cm from first film\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress\n\n REASON FOR THIS EXAMINATION:\n eval for R SC TLC placement..pulled back cm from first film\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW.\n\n HISTORY: Status-post right subclavian line repositioning.\n\n COMPARISON: Chest film performed at 11:34 a.m. the same day.\n\n Compared to the prior study, the tip of the right IJ line remains in the\n proximal right atrium. The tip of the right subclavian line projects just at\n the junction of the SVC and right atrium. Compared to the prior study, the\n right IJ line has been pulled back. The feeding tube is coiled in the\n stomach. There is slight increased opacity at the left lung base, which is\n unchanged since the prior study.\n\n IMPRESSION: Compared to the prior study, the right subclavian line has been\n pulled back to the junction of the SVC and right atrium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837611,
"text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, ?chf\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with mental status change, s/p intubation\n\n REASON FOR THIS EXAMINATION:\n intubated, ?chf\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP FILM:\n\n HISTORY: Mental status change and intubation.\n\n Endotracheal tube is at the carina and below for optimal position. Right CV\n line is in distal SVC. Feeding tube is coiled in stomach with distal\n end overlying proximal second portion of duodenum. There is minimal\n atelectasis at the left base, improved since prior film of . No\n pneumothorax.\n\n IMPRESSION:\n\n Endotracheal tube is again noted with tip located at the carina as previously\n described. Partial resolution of left lower lobe atelectasis. No\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-30 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 837578,
"text": " 12:11 AM\n PORTABLE ABDOMEN Clip # \n Reason: Feed tube position\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with rf, meningitis\n\n REASON FOR THIS EXAMINATION:\n Feed tube position\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Feeding tube placement.\n\n The feeding tube is in the region of the duodenojejunal junction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-22 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 836756,
"text": " 2:40 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: assess for infarct, ischemia\n Admitting Diagnosis: GASTROPARESIS\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with FK/sirolimus toxicity, extubated and off sedation, still\n very confused\n REASON FOR THIS EXAMINATION:\n assess for infarct, ischemia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n\n 45 year old female with confusion to rule out infarct.\n\n Pre and post contrast MRI of the brain was performed along with diffusion-\n weighted images.\n\n FINDINGS:\n\n There is no evidence of hemorrhage, edema, midline shift, mass effect or\n hydrocephalus or extra-axial collections. Patchy areas of increased signal\n noted in the periventricular deep white matter, pons, and medulla, consistent\n with small vessel disease.\n\n Partially opacified left sphenoid sinus noted.\n\n IMPRESSION:\n\n 1. No focal areas of restricted diffusion noted to suggest acute infarct.\n\n 2. Small vessel disease as described above.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-24 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 837023,
"text": " 6:43 PM\n ABDOMEN (SUPINE ONLY); ABDOMINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: need bedside fluoro for post-pyloric tube placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with DM gastroparesis, with zoster in isolation - cannot\n leave room\n REASON FOR THIS EXAMINATION:\n need bedside fluoro for post-pyloric tube placement\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n For feeding tube placement.\n\n Distal end of feeding tube overlies distal antrum of stomach on this single\n hard copy film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837925,
"text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P TRACH\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH\n REASON FOR THIS EXAMINATION:\n S/P TRACH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45 year old female status post tracheostomy.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiographs dated .\n\n FINDINGS: The previously noted endotracheal tube is removed. The patient is\n status post tracheostomy, the tip of the tube terminating 5.6 cm above the\n carina. Right subclavian vein is unchanged. There is no pneumothorax.\n\n The heart is normal in size. The mediastinal contours are within normal\n limits. The pulmonary vasculature is increased in bilateral lungs, with\n patchy parenchymal opacity, most likely representing edema vs. aspiration.\n These findings have worsened compared to the previous study.\n\n IMPRESSION: Status post tracheostomy, tip of the tube terminating 5.6 cm\n above the carina. Increased parenchymal patchy opacity, representing\n increased pulmonary edema vs. aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 838350,
"text": " 11:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p thalmic bleed with somnolence\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal tx, altered mental status and new hemorrhage on\n MRI/CT scan\n REASON FOR THIS EXAMINATION:\n s/p thalmic bleed with somnolence\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant with altered mental status and\n thalamic hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT CONTRAST: There has been slight interval reduction in size\n of the right thalamic hemorrhage with surrounding edema. The ventricles are\n stably enlarged. No new areas of hemorrhage are present. Differentiation of\n the grey/white matter is otherwise preserved. There is opacification of the\n left sphenoid sinus and left ethmoid air cells. Additionally there is\n opacification of both mastoid air cells.\n\n IMPRESSION:\n\n Interval reduction in size of right thalamic hemorrhage. No significant\n change in surrounding edema or mass effect. Stable dilatation of the\n ventricles.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-29 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 837511,
"text": " 8:06 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval feed tube placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with rf, meningitis\n REASON FOR THIS EXAMINATION:\n eval feed tube placement\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, SINGLE FILM:\n\n Status-post feeding tube placement.\n\n Feeding tube is in proximal jejunum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 836443,
"text": " 3:04 PM\n PORTABLE ABDOMEN Clip # \n Reason: please check for position of dobhoff - post pyloric?\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress -- dobhoff placed at bedside\n REASON FOR THIS EXAMINATION:\n please check for position of dobhoff - post pyloric?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Dobbhoff placed at bedside.\n\n PORTABLE SUPINE ABDOMINAL RADIOGRAPH: No prior studies are available for\n comparison. The Dobbhoff tip is likely within the gastric pylorus. This does\n not appear to be in post-pyloric position. Air is seen in the colon. No\n evidence of bowel obstruction on this limited supine film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-01 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 837794,
"text": " 9:29 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please check Dobhoff placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n please check Dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n INDICATION: For feeding tube placement.\n\n The feeding tube is seen with line coiled within the stomach whereas\n previously its tip was located in the region of the duodenojujenal junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836498,
"text": " 6:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inc wbc, f/u exam\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress\n REASON FOR THIS EXAMINATION:\n inc wbc, f/u exam\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of acute renal failure and respiratory distress. Followup\n evaluation.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to study from .\n Again seen are right-sided IJ central venous catheter and ET tube which are\n unchanged in position. A Dubhoff tube is again seen, with the tip positioned\n in the gastroduodenal junction, and is unchanged in position. The previously\n described bilateral alveolar opacities are again seen, though there appears to\n be some interval improvement since the previous study. Left basilar\n atelectasis is again noted.\n\n IMPRESSION: Venous catheter, ET tube and Dubhoff tube are again seen and\n unchanged in position. Diffuse alveolar opacities are slightly improved from\n the previous exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 837464,
"text": " 3:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: F/u head bleeding\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal tx, altered mental status and new hemorrhage on\n MRI/CT scan\n REASON FOR THIS EXAMINATION:\n F/u head bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post renal transplant with new hemorrhage, presenting for\n reassessment.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: Head CT.\n\n HEAD CT: The appearance of the brain is unchanged from one (1) day prior.\n There is an intraparenchymal hemorrhage within the right thalamus with\n surrounding edema. The hemorrhage and edema are stable. Mass effect, which\n is also unchanged. Mild prominence of the ventricles is again noted, and\n unchanged in the interval. The /white matter differentiation and cisterns\n are unremarkable. There is fluid within the paranasal sinuses and within the\n mastoid air cells.\n\n IMPRESSION: Stable right thalamic hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836884,
"text": " 6:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line pulled out 3 cm, check placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress\n\n REASON FOR THIS EXAMINATION:\n s/p line pulled out 3 cm, check placement\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF EXAM: .\n\n INDICATIONS: Line retracted 3 cm. Check placement.\n\n PORTABLE AP CHEST: Comparison is made to the study from 4.5 hours earlier.\n The right internal jugular central venous line has been removed completely.\n The right subclavian central venous line has been withdrawn several\n centimeters, and tip is in the distal SVC in satisfactory position. No\n pneumothorax is seen. Heart and lungs are unchanged in the short interval\n since the prior study. The Dobbhoff remains coiled in the stomach.\n\n IMPRESSION: Removal of right internal jugular central venous line. Right\n subclavian central venous line tip in satisfactory position in the distal SVC.\n No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 837107,
"text": " 1:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval feeding tube position\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress -- dobhoff placed at bedside\n\n REASON FOR THIS EXAMINATION:\n eval feeding tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure and respiratory distress, Dobhoff placed at\n bedside, evaluate for tube position.\n\n FINDINGS: AP portable abdominal film shows Dobhoff feeding tube with tip in\n the body of the stomach. Noted is a hemiarthroplasty in the right hip.\n Otherwise there is a nondiagnostic bowel gas pattern, with no evidence of\n obstruction or ileus. There are no soft tissue masses or calcifications seen.\n\n IMPRESSION: Dobhoff feeding tube with its tip in the body of the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 837600,
"text": " 10:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: intracerebral bleed. check edema\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal tx, altered mental status and new hemorrhage on\n MRI/CT scan\n REASON FOR THIS EXAMINATION:\n intracerebral bleed. check edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old female status post renal transplant with hemorrhage in\n the right thalamus.\n\n TECHNIQUE: CT imaging of the head performed without IV contrast. Comparison is\n made to a prior MRI from , and a CT performed on .\n\n Intraparenchymal hemorrhage within the right thalamus measuring 2.1 x 2.1 cm\n is unchanged in size and configuration when compared to the most recent CT.\n Resultant surrounding edema and mass effect also appears unchanged with\n distortion of the 3rd ventricle. This area of edema also appears to extend\n into the posterior limb of the internal capsule. The supratentorial\n ventricular system is unchanged in size and configuration when compared to\n prior studies. No new areas of hemorrhage are identified. There is no evidence\n of acute major vascular territorial infarction. Bone windows show\n opacification of the left sphenoid sinus as well as air-fluid levels in the\n right maxillary sinus and opacification of the ethmoid air cells. Fluid is\n also present within both maxillary sinuses. No suspicious lytic or sclerotic\n lesions are identified.\n\n IMPRESSION:\n 1. Stable appearance of a right-sided thalamic intraparenchymal hemorrhage\n with resultant surrounding edema. Mild dilatation of the supratentorial\n ventricular system appears unchanged when compared to prior examinations. No\n new areas of hemorrhage identified.\n 2. Air-fluid levels and opacification of the paranasal sinuses as described\n above.\n\n"
},
{
"category": "Echo",
"chartdate": "2156-08-12 00:00:00.000",
"description": "Report",
"row_id": 65446,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 138/80\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 17:51\nTest: Portable TTE (Focused views)\nDoppler: Limited doppler and no color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall left ventricular systolic function is normal\n(LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild\nmitral annular calcification.\n\nPERICARDIUM: There is a moderate sized pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The mitral valve\nleaflets are structurally normal. There is a moderate sized pericardial\neffusion. There are no echocardiographic signs of tamponade. A pleural\neffusion is seen.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nthere is no significant change in the size of the pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-08-09 00:00:00.000",
"description": "Report",
"row_id": 65447,
"text": "PATIENT/TEST INFORMATION:\nIndication: .\nStatus: Inpatient\nDate/Time: at 11:23\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nA duplicate echocardiographic study was inadvertenly logged into the patient's\n record. Only one study was performed/billed on this day.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-09-06 00:00:00.000",
"description": "Report",
"row_id": 65416,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function. S/p renal transplant with fevers\nHeight: (in) 61\nWeight (lb): 170\nBSA (m2): 1.76 m2\nBP (mm Hg): 144/61\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 14:19\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. No masses or vegetations are seen on the aortic valve.\nThere is no aortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mass or\nvegetation is seen on the mitral valve. There is mild mitral annular\ncalcification. Trivial mitral regurgitation is seen.\n\nTRICUSPID VALVE: No tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. No vegetation/mass is seen on the pulmonic valve.\nPhysiologic (normal) pulmonic regurgitation is seen.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No masses or vegetations are\nseen on the aortic valve. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. Trivial mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. No\nvegetation/mass is seen on the pulmonic valve. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\nCompared to prior study from (tape reviewed), the pericardial\neffusion is smaller.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-08-09 00:00:00.000",
"description": "Report",
"row_id": 65417,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 119/62\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 11:54\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated. The left atrium is\nelongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Trivial\nmitral regurgitation is seen.\n\nPERICARDIUM: There is a small to moderate sized pericardial effusion. The\neffusion appears circumferential. There are no echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Bilateral pleural effusions are present.\n\nConclusions:\n1. The left atrium is moderately dilated. The left atrium is elongated.\n2.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Left ventricular systolic function is hyperdynamic\n(EF>75%).\n3.Right ventricular chamber size and free wall motion are normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation.\n5.The mitral valve leaflets are structurally normal. Trivial mitral\nregurgitation is seen.\n6.There is a small to moderate sized pericardial effusion. The effusion\nappears circumferential. There are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-13 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 835816,
"text": " 11:50 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval ARDS vs PNA, interval change in effusion\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n eval ARDS vs PNA, interval change in effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated for respiratory failure, on dialysis. Evaluate for\n ARDS or superimposed pneumonia.\n\n TECHNIQUE: Axial images of the chest were acquired helically at 5 mm\n intervals without IV contrast. Additional reformatted images in lung\n algorithm and at 1 mm intervals were made.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The patient's respiratory motion limits\n evaluation. An NG tube is present with the tip in the stomach. A right\n subclavian central venous line is seen with the tip in the distal SVC. An\n endotracheal tube is present with the tip in the mid-trachea. No\n pathologically-enlarged axillary, hilar or mediastinal lymph nodes are seen.\n Coronary arterial calcifications are seen. There is a small pericardial\n effusion.\n\n There are bilateral pleural effusions, right greater than left, the right\n effusion being large in size. There are extensive patchy areas of opacity in a\n predominantly central distribution in both lungs, with the large component\n within the upper lobes. In the lower lobes, there is diffuse ground glass\n opacity, with areas of consolidation and air bronchogram formation. The\n findings are likely due to pulmonary edema from CHF and ARDS. If the patient\n is immunosuppressed, diffuse infection or atypical infection (such as PCP) is\n also on the differential diagnosis. If the patient has symptoms of\n hemoptysis, diffuse pulmonary hemorrhage is also possible.\n\n Evaluation of the upper abdomen shows extensive arterial vascular\n calcification and small atrophic kidneys, consistent with the patient's known\n renal failure. Also noted is asymmetry in the left neck, possibly in the\n thyroid. This is not fully evaluated without IV contrast.\n\n IMPRESSION:\n 1. Extensive pulmonary edema in both lungs, likely secondary to a combination\n of volume overload/CHF and ARDS. If the patient is immuno- compromised,\n diffuse infection from fulminant pneumonia or atypical sources (such as PCP)\n are possible. Also, if the patient has a history of hemoptysis, diffuse\n pulmonary hemorrhage is also on the differential diagnosis.\n 2. Asymmetrical soft tissue in the upper neck in the region of the thyroid\n gland.\n 3. Small kidneys with extensive arterial calcifications in the abdomen. Mild\n coronary arterial calcification. Findings likely secondary to the patient's\n renal failure.\n (Over)\n\n 11:50 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval ARDS vs PNA, interval change in effusion\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835723,
"text": " 4:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for sings of chf, pulmonary effusions, infiltrates\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Respiratory Distress\n REASON FOR THIS EXAMINATION:\n Evaluate for sings of chf, pulmonary effusions, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n CHEST X-RAY: Portable AP view was obtained and compared to prior study of\n . There is a right subclavian central venous line with tip at\n the superior vena cava/right atrial border. The heart is mildly enlarged.\n Bilateral perihilar infiltrates are present and have progressed in the\n interval. There are bilateral pleural effusions.\n\n IMPRESSION: Worsened patchy bilateral perihilar opacities, concerning for\n worsened pneumonia. Less likely, this could represent congestive heart\n failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835739,
"text": " 8:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new changes; pneumonia vs ARDS vs CHF\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis; pericardial\n effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n eval for new changes; pneumonia vs ARDS vs CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW:\n\n INDICATION: Respiratory distress, now on dialysis, known pericardial\n effusion and pleural effusions. Evaluate for new changes.\n\n FINDINGS: The AP single view of the chest is analyzed in direct comparison\n with a similar study obtained 3 hours earlier the same date. Position of\n right subclavian approach central venous line is unchanged. The bilateral\n patchy confluent and parenchymal densities remain rather unchanged. Blunting\n of the lateral pleural sinuses and conceiled appearance of the diaphragmatic\n contours is consistent with bilateral pleural effusions. There is no\n pneumothorax.\n\n IMPRESSION: Unchanged status. Distribution of the patchy and confluent\n infiltrates favors pneumonic infiltrates rather than pulmonary edema which\n would have a very atypical distribution.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836834,
"text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for placement of R SCL TLC\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress\n\n REASON FOR THIS EXAMINATION:\n eval for placement of R SCL TLC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate placement of right-sided subclavian central line.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from . There has\n been interval placement of a right-sided subclavian central venous line with\n the tip positioned in the right atrium. The right-sided IJ central venous\n catheter is again seen with the tip positioned in the distal SVC at the\n junction of the right atrium. A Dobbhoff tube is again seen with the tip\n extending below the inferior margin of the imaged field. Left-sided pleural\n effusion is identified. The previously noted bilateral alveolar opacities are\n again seen, which are improved from the previous exam, and more prominent on\n the left than the right. Heart size and mediastinal contours are unchanged.\n\n IMPRESSION:\n\n 1) Interval placement of a right-sided subclavian central venous catheter\n with tip positioned in the right atrium.\n\n 2) Left pleural effusion.\n\n 3) Improving bilateral alveolar opacities, worse on the left than the right,\n representing asymmetric pulmonary edema likely related to fluid overload.\n\n Results called to SICU resident.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-27 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 837368,
"text": " 2:58 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: VIRAL MENINGITIS\n Admitting Diagnosis: GASTROPARESIS\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with FK/sirolimus toxicity, viral meningitis, sudden change\n of mental status\n REASON FOR THIS EXAMINATION:\n focal change ?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sudden change in mental status.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. Axial imaging was performed with long TR, long TE fast spin echo,\n FLAIR, gradient echo, and diffusion technique. After administration of\n gadolinium intravenous contrast axial and coronal short TR, short TE spin echo\n imaging was performed. Comparison to a brain MR .\n\n FINDINGS: There is a hemorrhage in the right thalamus with involvement of the\n posterior limb of the right internal capsule and extension into the right\n cerebral peduncle. This is new since the prior study. This produces local mass\n effect with slight right to left displacement of the third ventricle and\n slight pressure on the frontal and body of the right lateral ventricle.\n There is no evidence of hydrocephalus. Although the ventricles are mildly\n dilated, this has not changed since the prior study. There is no evidence of\n other acute hemorrhage. However, foci of hypointensity are again noted in the\n right cerebellar hemisphere and right medial temporal lobe, these are\n unchanged since the prior study. Again noted is extensive periventricular\n white matter hyperintensity, suggesting chronic small vessel ischemia. There\n is no abnormal enhancement after contrast administration. Incidentally noted\n is partial opacification of the mastoid air cells with small amounts of fluid\n in the maxillary, sphenoid, and ethmoid sinuses.\n\n CONCLUSION: New right thalamic hemorrhage with extension into the posterior\n limb of the internal capsule and into the cerebral peduncle. This most likely\n represents a hypertensive hemorrhage.\n\n Mastoid and paranasal sinus opacification.\n\n These findings were discussed with Drs. and at 5:10 PM on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-27 00:00:00.000",
"description": "MR C-SPINE SCAN WITH CONTRAST",
"row_id": 837369,
"text": " 2:58 PM\n MR SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST Clip # \n MR L SPINE WITH CONTRAST\n Reason: spinal abscess ?\n Admitting Diagnosis: GASTROPARESIS\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal transplant, with immunosuppression overdose,\n zoster, viral meningitis\n REASON FOR THIS EXAMINATION:\n spinal abscess ?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with renal transplant, immunosupression\n overdose with viral meningitis.\n\n TECHNIQUE: T1 and T2 sagittal images of the cervical, thoracic, and lumbar\n spine were obtained following gadolinium administration for brain MRI. There\n are no prior similar examinations for comparison.\n\n FINDINGS: Mild heterogenous marrow signal is visualized throughout the spinal\n canal. Mild degenerative changes are seen in the cervicothoracic and lumbar\n region. No evidence of high grade spinal stenosis noted. The spinal cord,\n skull base to cornus, demonstrates normal signal without intrinsic\n abnormalities or abnormal enhancement.\n\n Note is made of a large cystic area possibly within the thyroid with a fluid-\n fluid level measuring 4.5 x 3.0 cm. Clinical correlation recommended.\n\n IMPRESSION\n\n 1. Mild heterogeneous marrow signal on post-gadolinium images. This could be\n secondary to marrow hyperplasia, but clinical correlation recommended.\n\n 2. No evidence of spinal cord compression or intrinsic spinal cord signal\n abnormalities.\n\n 3. Cystic area within the thyroid with fluid-fluid level for which\n clinical correlation recommended.\n\n 4. Soft tissue changes within the sphenoid sinus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836142,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis, new fever 101.2\n REASON FOR THIS EXAMINATION:\n reassess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of acute renal failure, now with respiratory distress.\n New fever.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to study from . A right\n central venous line, ET tube and NG tube are again seen in unchanged\n positions. Bilateral alveolar opacities are again seen, and appear relatively\n unchanged from the previous exam. There appears to be slight worsening in the\n left lower lobe opacity. No new pleural effusions or pneumothoraces are seen.\n The heart size and mediastinal contours are unchanged.\n\n IMPRESSION: ET tube, central venous line, and NG tube are all again seen and\n unchanged. Bilateral diffuse patchy opacities are again seen and relatively\n unchanged. There has been interval worsening of the left lower lobe opacity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836442,
"text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check position of dobhoff - post pyloric? / also reassess \n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress -- dobhoff placed at bedside\n REASON FOR THIS EXAMINATION:\n check position of dobhoff - post pyloric? / also reassess lung fields -\n possible extubation today\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Feeding tube placement.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from two days\n earlier.\n\n The feeding tube is in place terminates in the region of the gastroduodenal\n junction. Other lines and tubes are unchanged in position. Cardiac and\n mediastinal contours are stable. There has been overall interval worsening of\n diffuse bilateral alveolar opacities, with most marked progression in the left\n retrocardiac region. There is also a probable left pleural effusion.\n\n IMPRESSION:\n\n 1. Feeding tube terminates in the region of the gastroduodenal junction.\n\n 2. Worsening diffuse alveolar opacities, most severe in the left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836008,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new changes\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis;\n pericardial effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n eval for new changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure and respiratory distress.\n\n FINDINGS: Compared with , allowing for technique and superimposed\n respiratory apparatus, no definite change, but perhaps slight interval\n progression of the bilateral infiltrates/edema. The left lung base appears\n better expanded and lung volumes overall have improved. No obvious pleural\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835762,
"text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new/worsening changes\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis; pericardial\n effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n eval for new/worsening changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for worsening changes.\n\n FINDINGS: AP single view of the chest is analyzed in direct comparison with\n the next previous examination obtained on the previous day within an\n approximate 10 hours time interval. The patient is now in supine position.\n Intubation has been performed and the ETT is seen to have advanced into the\n right main bronchus by approximately 2-3 cm. The consequences include reduced\n aeration of the entire left lung with volume reduction of the left hemithorax\n and mediastinal shift towards the left side. The right sided parenchymal\n infiltrates appear unchanged.\n\n IMPRESSION:\n\n Intubation with too far advanced tube into the right main bronchus. It should\n be withdrawn by at least 5 cm.\n\n At the time of the interpretation the subsequent film had already been\n obtained.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835837,
"text": " 2:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis;\n pericardial effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for line placement.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from same day approximately\n 6 hours prior. There has been interval removal of right subclavian central\n venous line, and interval placement of right IJ central venous line, with the\n tip now visualized in the distal SVC. No pneumothorax is seen. ET tube and\n NG tube are again seen and unchanged in position. Bilateral patchy appearing\n infiltrates are again seen and relatively unchanged. Pleural effusion is seen\n on the right side again. There has been some interval improvement in the left\n lower lobe atelectasis.\n\n IMPRESSION: Interval placement of right IJ central venous line catheter with\n the tip in the distal SVC. No pneumothorax seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835203,
"text": " 1:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST X-RAY, AT 1:49 A.M.:\n\n INDICATION: Query pneumonia.\n\n FINDINGS: Comparison is made with the prior examination dated .\n\n There are bilateral pleural effusions, left greater than right. Additionally,\n there is a moderate to large area of air space disease in the right perihilar\n area, containing air bronchograms, and to a lesser extent, the left suprahilar\n area. No evidence of congestive failure. A right subclavian line is in\n place, with the tip projecting over the right atrium. No evidence of\n pneumothorax.\n\n IMPRESSION: Bilateral pleural effusions, with bilateral opacities, right\n greater than left, consistent with air space disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835790,
"text": " 9:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: to check for tube placement\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis; pericardial\n effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n to check for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Adjustment of ETT, check position.\n\n FINDINGS: AP single view of chest obtained with patient in supine position is\n analyzed in direct comparison with the next preceding examination obtained\n three hours earlier. The ETT has been withdrawn and is now terminating in the\n trachea approximately 4 cm above the level of the carina. The airway\n obstruction of the left lung has been corrected and almost complete\n symmetrical appearance of the mediastinal structures has been restored.\n Bilateral patchy and confluenting parenchymal infiltrates however persist.\n Comparison shows now that some pleural effusion is present along the lateral\n wall of the right-sided pleural sinus. The rather dense atelectasis in the\n left lower lobe has improved somewhat. Overall the diffuse lateral infiltrates\n persist. There is no evidence of pneumothorax. The presence of an NG tube is\n recognized which reaches far below the diaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835961,
"text": " 11:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new changes\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and now with resp distress; now on dialysis;\n pericardial effusions; pleural effusions\n\n REASON FOR THIS EXAMINATION:\n eval for new changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: ARF, new respiratory distress.\n\n PORTABLE AP CHEST: ET tube and NG tube are in satisfactory position. Right IJ\n line with tip over right atrium near the SVC/RA junction. Diffuse interstitial\n and alveolar opacities throughout both lungs, probably with a small left\n effusion. Overall, the radiographic findings are unchanged compared with two\n days earlier. The right lateral chest wall is excluded from the film.\n\n IMPRESSION: Diffuse bilateral interstitial and alveolar opacities unchanged\n compared with two days earlier. Differential diagnosis includes CHF and\n infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836956,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of dobhoff tube, post-pyloric\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F with ARF and resp distress\n\n REASON FOR THIS EXAMINATION:\n eval placement of dobhoff tube, post-pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for Dobhoff tube placement.\n\n PORTABLE AP CHEST X-RAY:\n\n Comparison is made to the study of . Again seen is a right-sided\n subclavian central venous catheter with the tip positioned in the distal SVC.\n A Dobhoff tube is again seen, with the tip coiled in the stomach not extending\n to the post-pyloric lumen. Left lower lobe opacity is again seen,\n representing atelectasis/consolidation. Bilateral patchy opacities are noted\n in the lung fields, representing resolving previously noted pulmonary edema.\n No pleural effusions are identified. No pneumothorax is seen. Heart size and\n mediastinal contours are unchanged.\n\n IMPRESSION: Dobhoff tube is seen with the tip coiled in the stomach.\n Resolving pulmonary edema is noted. The remainder of the exam is relatively\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-04 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 841515,
"text": " 2:34 PM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: ? injury\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with left hip pain\n REASON FOR THIS EXAMINATION:\n ? injury\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HIP, 2 VIEWS:\n\n History of pain.\n\n No fracture. The hip joint is unremarkable. No evidence for avascular\n necrosis. Incidental note of right hip hemiarthroplasty.\n\n IMPRESSION: No significant abnormality of left hip joint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839001,
"text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH\n\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 1 VIEW PORTABLE:\n\n INDICATION: 45 y/o female s/p trach. Aspiration.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study at 1:48 a.m.\n\n The tracheostomy tube is seen in place. A feeding tube coiled within the\n stomach. The right subclavian IV catheter remains in place.\n\n There is increased patchy opacities in both lower lobes indicating aspiration\n pneumonia. There is continued mild congestive heart failure with cardiomegaly.\n\n IMPRESSION: 1) Probable aspiration in both lower lobes. Mild congestive heart\n failure with cardiomegaly. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-13 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 839093,
"text": " 10:33 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please ensure feeding tube is post-=pyloric\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F with renal tx, zoster - with DM and gastroparesis\n\n REASON FOR THIS EXAMINATION:\n please ensure feeding tube is post-=pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes mellitus and gastroparesis requiring post-pyloric\n feeding tube.\n\n Under fluoroscopic guidance, a nasojejunal catheter was placed. Confirmatory\n spot radiographs demonstrate the tip within the proximal jejunum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 839670,
"text": " 9:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: R/O bleeding\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p renal tx, altered mental status and new hemorrhage on\n MRI/CT scan\n REASON FOR THIS EXAMINATION:\n R/O bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post renal transplant with altered mental status and new\n hemorrhage on prior MRI/CT scan.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: , Head CT.\n\n HEAD CT w/o CONTRAST: A right thalamic hemorrhage is again noted. An\n interval decrease in the amount of high attenuation consistent with evolving\n blood products. Surrounding low attenuation change is present consistent with\n edema. There is slight decrease in the degree of mass effect with indentation\n on the right wall of the 3rd ventricle. The ventricles are stable in size.\n No new foci of hemorrhage are present. The basal cisterns and /white\n matter differentiation are unremarkable. The osseous structures are normal.\n There is almost complete opacification of the left mastoid air cells, and\n partial opacification of the right mastoid air cells. This was seen on a\n prior head CT. There is fluid within the sphenoid and ethmoid sinuses.\n\n IMPRESSION: Evolution of the right thalamic hemorrhage with slight decreased\n mass effect. No new areas of hemorrhage.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-30 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 841121,
"text": " 5:18 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: SWELLING LEFT LEG ASSESS FOR DVT\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with LLE edema\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: 7:27 PM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45 year old woman with left lower extremity edema.\n\n COMPARISONS: No comparisons are available.\n\n FINDINGS: scale and Doppler ultrasound examinations of the left common\n femoral, superficial femoral and popliteal veins were performed. There is\n normal flow, compressibility and augmentation of these vessels. No\n intraluminal thrombus is identified.\n\n IMPRESSION: There is no evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 841034,
"text": " 7:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress, diuresing\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45 year old woman with respiratory distress.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the previous chest radiographs dated \n and .\n\n FINDINGS: The tip of the endotracheal tube and right IJ line are unchanged\n compared to the previous study.\n\n Again note is made of mild cardiomegaly. Again note is made of retrocardiac\n opacity in the left lower lobe, obscuring the left hemidiaphragm. Again note\n is made of diffuse parenchymal and interstitial opacities in bilateral lungs,\n more prominently on the right. Due to the difference of the technique, exact\n comparison with the most recent study is difficult, however, the opacity is\n slightly better compared to the prior study dated , especially in the\n left upper lobe.\n\n Blunted left costophrenic angle is again noted, unchanged compared to the\n prior study.\n\n There is no apparent lesion noted in the skeletal structures.\n\n IMPRESSION: Continued cardiomegaly and bilateral patchy opacities, slightly\n better compared to the prior study of . Continued left lower\n lobe opacity, which may represent atelectasis vs. pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-30 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 841084,
"text": " 1:04 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: aspiration?\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n aspiration?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with a question of aspiration.\n\n COMPARISONS: None\n\n TECHNIQUE: Videotaped oropharyngeal swallowing study.\n\n FINDINGS: The study was performed in conjunction with the speech pathologist.\n Various consistencies of barium were administered orally. There was slow oral\n transit and chewing. There was some penetration of thin consistencies into the\n laryngeal vestibule, with likely trace aspiration of the barium of thin\n consistency, although only when mixed with other consistencies. Please see\n the report of the speech pathologist for further details.\n\n IMPRESSION: 1) Slow oral transit.\n 2) Mild penetration of thin consistencies into the laryngeal vestibule, with\n probable trace aspiration of thin liquid, although only when given as a mixed\n consistency. Please see the report of the speech pathologist for further\n details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840560,
"text": " 3:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress\n\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n AP PORTABLE SUPINE CHEST: Comparison is made to prior film dated .\n Tracheostomy tube remains in place.\n\n There is interval worsening in aeration diffusely, with worsened air space\n consolidation in the right upper lobe, and in the right base and left mid\n lung, findings which may reflect worsened CHF versus CHF with superimposed\n pneumonia. There may be a left pleural effusion.\n\n IMPRESSION: Extensive bilateral alveolar opacities, with worsened\n consolidation when compared to the prior film of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839565,
"text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new onset fever\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n new onset fever\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New onset fever.\n\n COMPARISON: \n\n FINDINGS: This dictation is to replace one that was lost. Single portable AP\n view of the chest shows interval removal of a Dobhoff tube and right-sided\n subclavian central venous line. There has been interval improvement in the\n left pleural effusion and perihilar pulmonary vascular markings, suggesting\n improved cardiac failure. Mid-line skin staples are seen overlying the upper\n abdomen. Osseous structures are unremarkable.\n\n IMPRESSION: Improving cardiac failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840630,
"text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cxr r/o infilt.\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress\n\n REASON FOR THIS EXAMINATION:\n cxr r/o infilt.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P tracheostomy, now with respiratory distress.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier.\n A tracheostomy tube is present and unchanged in position. The heart is mildly\n enlarged. There are extensive diffuse air space opacities which have slightly\n worsened in the left lung in the interval.\n\n IMPRESSION: Progression of diffuse marked air space opacities. The\n differential includes edema and diffuse infection. ARDS is a possible\n etiology.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840882,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress\n\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy now with respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: Single portable AP view of the chest shows increasing bilateral\n multifocal extensive pulmonary infiltrates. There are decreased lung volumes,\n which may enhance the intensity of these infiltrates. Cardiomegaly is\n present. Tracheostomy tube and right IJ central venous line remain unchanged.\n\n IMPRESSION: Worsening bilateral pulmonary infiltrates. Cardiomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838993,
"text": " 1:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for feeding tube replacement. Perform thoracoabd\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n\n REASON FOR THIS EXAMINATION:\n please eval for feeding tube replacement. Perform thoracoabdominal film\n ______________________________________________________________________________\n FINAL REPORT\n CHEST - ONE VIEW, PORTABLE\n\n INDICATION: 45 year old woman with feeding tube replacement.\n\n COMMENTS: Portable AP radiograph is reviewed, and compared with previous\n study of .\n\n The tracheostomy tube is seen in place. The right subclavian IV catheter\n terminates in the superior vena cava. The feeding tube is coiled within the\n stomach.\n\n The previously identified congestive heart failure has been improving. There\n is continued mild cardiomegaly. There is no evidence for pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839736,
"text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new onset fever\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH\n\n REASON FOR THIS EXAMINATION:\n new onset fever\n ______________________________________________________________________________\n FINAL REPORT\n Compared to previous study of .\n\n CLINICAL INDICATION: Status post tracheostomy tube placement.\n\n A tracheostomy tube is in satisfactory position allowing for slight rotation\n of the patient. There is no evidence of pneumothorax or pneumomediastinum.\n The heart is enlarged and there has been worsening confluent alveolar\n opacities in the perihilar and basilar regions. A small left pleural effusion\n is noted.\n\n IMPRESSION:\n 1. Tracheostomy tube in satisfactory position.\n 2. Worsening pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-23 00:00:00.000",
"description": "CT TRACHEA W/O C W/RECONS",
"row_id": 840236,
"text": " 4:25 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: assess vocal cords/subglottic stenosis\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with trach for prolonged intubation s/p renal transplant and\n thalamic bleed\n REASON FOR THIS EXAMINATION:\n assess vocal cords/subglottic stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy for prolonged intubation. Clinical\n suspicion for vocal cord abnormality or subglottic stenosis.\n\n Multidetector CT of the airways was performed, without intravenous or oral\n contrast administration. Per CT trachea protocol, the acquisition extended\n several cm below the carina but did not include the entirety of the chest. An\n initial standard dose technique was employed for end inspiratory imaging,\n followed by a low dose technique for a dynamic expiratory acquisition to\n assess for possible malacia. The axial data was used to create a series of\n multiplanar and 3D images which are reviewed in conjunction with axial images.\n\n Comparison is made to earlier chest CT of .\n\n Assessment of the airways demonstrate airway narrowing within the subglottic\n region, with posterior and lateral wall thickening. The minimal diameter of\n the airway is approximately 5 mm in transverse dimension and 7 mm in AP\n dimension. Within the left subglottic region, there is a focal polypoid\n opacity protruding into the airway, measuring approximately 8 mm in diameter\n and narrowing the coronal dimension of the airway to approximately 3 mm. This\n is located about 3 1/2 cm above the tracheostomy tube at the level of the\n cricoid cartilage. During dynamic expiration, this results in near complete\n occlusion of the airway coronal diameter. At a much higher level in the\n imaged portion of the oropharynx, there is asymmetry of the soft tissues in\n the left side compared to the right, of uncertain significance as the\n patient's head and neck are rotated. This apparent asymmetry may be due to\n asymmetrical positioning.\n\n At a lower level, below the tracheostomy tube, there is high grade\n tracheomalacia. There is also high grade bronchomalacia within the main stem\n bronchi, left greater than right, and within the bronchus intermedius.\n\n Please note that the patient was unable to fully cooperate with breathing\n instructions.\n\n Within the lungs, there are diffuse bilateral alveolar opacities, which have a\n central, parahilar predominance with relative sparing of the lung periphery in\n most areas of the lungs. This now affects the right lung to a much greater\n degree than the left and was previously more symmetrical in distribution.\n There are also ground-glass opacities and thickened septal lines.\n\n (Over)\n\n 4:25 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: assess vocal cords/subglottic stenosis\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiplanar and 3D images confirm the presence of diffuse\n tracheobronchomalacia below the level of the tracheostomy tube. They also\n confirm the presence of the subglottic stenosis.\n\n Soft tissue structures demonstrate enlargement of the left lobe of the thyroid\n gland with a low density appearance. There are numerous mediastinal lymph\n nodes present which are probably hypoplastic given the diffuse lung changes.\n The heart is mildly enlarged and note is made of coronary artery\n calcifications as well as a persistent small pericardial effusion. Bilateral\n pleural effusions are again demonstrated with interval increase in the left\n effusion and relatively stable appearance of the right pleural effusion.\n Precise comparison of the effusion is somewhat difficult, however, due to\n incomplete imaging of the chest on the current exam.\n\n Skeletal structures reveal no acute finding as compared to the recent study.\n\n There is apparent esophageal wall thickening in the imaged portion of the\n distal esophagus, possibly due to esophagitis as there has been a recent NG\n tube in this area.\n\n IMPRESSION:\n\n High grade focal subglottic stenosis above the level of the tracheostomy tube,\n with an associated dominant 8 mm diameter polypoid opacity arising from the\n left lateral wall of the airway and resulting in high grade coronal narrowing,\n with near complete occlusion during expiratory phase of respiration.\n\n Diffuse severe tracheobronchomalacia below level of tracheostomy tube.\n\n Persistent diffuse bilateral alveolar process, which now appears asymmetric,\n affecting the right lung to a greater degree than the left. This is most\n likely due to asymmetrical pulmonary edema, but it is difficult to exclude\n other process such as a component of infection or aspiration in the right\n lung.\n\n Enlarged low density left thyroid gland of uncertain etiology. If warranted\n clinically, thyroid ultrasound may be helpful to better assess this finding.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-16 00:00:00.000",
"description": "EXTREM UNILAT VENOGRAPHY",
"row_id": 839435,
"text": " 7:26 AM\n UNILAT SUBCLAV Clip # \n Reason: r/o central venous stenosis or obstruction, consent obtained\n Admitting Diagnosis: GASTROPARESIS\n Contrast: OPTIRAY Amt: 45\n ********************************* CPT Codes ********************************\n * EXTREM UNILAT VENOGRAPHY NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with CVA s/p renal transplant with LUE swelling\n REASON FOR THIS EXAMINATION:\n r/o central venous stenosis or obstruction, consent obtained by surgical team\n and in the front of the chart\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left upper extremity swelling, history of renal transplant.\n\n Comparison is made to the ultrasound performed on .\n\n PHYSICIANS: The procedure was performed by Drs. and with\n Dr. , the attending radiologist, being present and supervising\n throughout the procedure.\n\n PROCEDURE/FINDINGS: Written informed consent was obtained. The patient was\n placed supine on the angiography table. Left upper extremity venography was\n performed via a peripheral IV in the left hand using hand injection. Three\n successive venograms demonstrate normal forearm veins, axillary vein,\n subclavian vein and prompt emptying into the right heart without evidence of\n subclavian or brachiocephalic clot seen.\n\n CONTRAST: Approximately 50 cc of nonionic intravenous Optiray contrast.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful left upper extremity venogram demonstrating patent\n subclavian and brachiocephalic veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838776,
"text": " 3:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid status.\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH\n\n REASON FOR THIS EXAMINATION:\n fluid status.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n FINDINGS: Single portable AP view of the chest shows bilateral pleural\n effusions, with bilateral air space opacities and increased pulmonary vascular\n markings since the exam of . The tracheostomy tube, the right\n sided SVC line, and the feeding tube remain unchanged in position.\n\n IMPRESSION: Worsened bilateral infiltrates.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839027,
"text": " 1:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: asses CVL position\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH\n\n REASON FOR THIS EXAMINATION:\n asses CVL position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 45 y/o female patient status post tracheostomy.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from 9:05 a.m.\n There is continued moderate CHF with cardiomegaly and small bilateral pleural\n effusions. Patchy opacities are seen in both lower lobes indicating\n aspiration with superimposed pneumonia. The tip of the right jugular IV\n catheter is identified in the distal SVC. The tracheostomy tube is seen in\n place. No pneumothorax is identified. A feeding tube is coiled within the\n stomach.\n\n IMPRESSION: Continued CHF with small bilateral pleural effusions. Patchy\n opacities in both lower lobes, aspiration or superimposed pneumonia.\n Pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-10 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 838807,
"text": " 8:54 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: eval for thrombosis\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with lue swelling\n\n REASON FOR THIS EXAMINATION:\n eval for thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with left upper extremity swelling.\n\n COMPARISON: .\n\n TECHNIQUE/FINDINGS: scale and doppler son of the left cephalic,\n basilar, brachial, axillary, subclavian, and internal jugular veins were\n performed. The right subclavian vein was also interrogated.\n\n Normal flow, augmentation, compressibility, and waveforms are demonstrated in\n all veins. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep vein thrombosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840745,
"text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress\n\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post tracheostomy now with respiratory distress and\n shortness of breath.\n\n CHEST X-RAY, PORTABLE AP: Comparison is made to the prior study of one day\n earlier. There is a tracheostomy tube which is unchanged in position. A\n right internal jugular central venous line is present with tip in the upper\n superior vena cava. The cardiomediastinal silhouette is unchanged. There are\n stable bilateral diffuse air space opacities.\n\n IMPRESSION:\n\n Stable appearance of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840694,
"text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL NEW cvl R/O ptx\n Admitting Diagnosis: GASTROPARESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 y/o F S/P TRACH now respitory distress\n\n REASON FOR THIS EXAMINATION:\n EVAL NEW cvl R/O ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: Compared to recent study earlier the same day.\n\n CLINICAL INDICATION: New line placement.\n\n There has been interval placement of a right internal jugular vascular\n catheter which terminates within the superior vena cava. There is no evidence\n of pneumothorax. A tracheostomy tube remains in satisfactory position. There\n has been overall improvement in the degree of diffuse bilateral air space\n opacification. There has been particular improvement in aeration within the\n left retrocardiac region.\n\n IMPRESSION:\n\n 1) Vascular catheter in satisfactory position with no pneumothorax.\n 2) Improving diffuse pulmonary consolidation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 131043,
"text": "Sinus rhythm. Prominent P waves with rightward P wave axis. Low limb lead\nvoltage. Delayed precordial R wave progression. Compared to the previous\ntracing of the P waves are less prominent. Nonetheless, right atrial\nenlargement is suggested. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-12 00:00:00.000",
"description": "Report",
"row_id": 1528654,
"text": "TSICU Admission Note\n1600 Received pt from 10, reportedly in acute respiratory distress. Per ABG drawn earlier while on floor, PaO2 45. Pt accompanied by nurse and Dr. . Attached to monitors with NSR noted, HR in 80's. SBP per cuff 130's. O2 via NRB mask at 15L. Sats running low 90's. Respirations upper 20's to low 30's. Mild laboring noted. Clear bilateral upper lobes, but crackles heard in bases. Pt alert to person and place, following commands, moving all extremities. Mildly anxious. Denies any c/o chest pain or difficulty breathing. Abd soft with large hernia noted. Foley to gravity with small amts of clear yellow urine seen. Per report from 10, pt received H/D earlier today with 2L removed.\n\nAfter admission, CXR and EKG done(results given to Dr. .) R radial art line placed. R femoral dialysis catheter in place, ports x2 capped off. R SC TLC in place. Dressing covering line with date of . Dressing changed--yellow crusty drainage noted at insertion site. Two ports clotted off.\n\nO2 sats slowly climbed after admit to unit. Up to 98-99% on 100% NRB. ABG sent at 1600 showed PO2 climbed to 73. father in waiting room--he stated that he had not been informed of her condition. Notified NSICU resident of this. Labs ordered, but not obtained yet. Pt to be transferred to Transplant ICU. Report given to , RN--assisted with transport to there.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-02 00:00:00.000",
"description": "Report",
"row_id": 1528720,
"text": "Respiratory care:\nPt. went for a tracheostomy this AM and recieved a #7.0 Portex. Was on CMV for a while till she woke up and then was rapidly weaned to SBT. Her RSBI was 59 on SBT and was subsequently placed on a trach mask @ 35% and is to remain here as long as tolerated. All vitals seem WNL and her O2 sat. = 97-98%. Late this PM she was moved to room #2 since she doesn't need a neg P. room any longer.. (If needed she will rest on PSV 5/5 @ 30%)\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-03 00:00:00.000",
"description": "Report",
"row_id": 1528721,
"text": "COMMUNICATION UPDATE\n TEMPERATURE MAX.99.2. SBP REMAINS < 160 WITH MULTIPLE ANTIHYPERTENSIVES. CVP 11-15. RECIEVED 2 EXTRA DOSES IV LASIX FOR A TOTAL OF 100 MGS YESTERDAY IN 24 HOURS. GOOD RESPONSE TO LASIX, NEGATIVE FOR 740 CC FOR THE FIRST 6 HOURS OF TODAY.SEE FLOW SHEETS FOR DETAILS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-03 00:00:00.000",
"description": "Report",
"row_id": 1528722,
"text": "nuero: pt does open her eyes when you call her name. pt intermittently following commands. spontanoues movement noted from right arm, right let, left leg, no spontanous movement noted from left arm.\n\npulm: pt remains on trach collar.suctioning pt for whitish secretions. abg sent result 7.41/41/111/27\n\ncards: pt remain in sr, please see flow sheet fro vs. pt started on lasix. aline at times peaked, following cuff pressures along with aline pressures dr. aware.\n\ngi: pt tube feedings at goal. pt incontinent of black stool, guiac positive. dr. aware.\n\ngu: pt recieved lasix, which pt is diuresising from\n\nf/e: nph insulin increased to 18u nph, insulin gtt shut off. blood sugar at 1600 197 tx'd with 5u of regular insulin per sliding scale.\n\nacitivy: pt oob to chair with lift tolerated fine.\n\nplan: continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-03 00:00:00.000",
"description": "Report",
"row_id": 1528723,
"text": "add: prograf d/c'd. pt started on cellcept iv bid, pt to start first dose tonight at , dr. aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-12 00:00:00.000",
"description": "Report",
"row_id": 1528655,
"text": "nursing update\nPt transferred from TSICU after worsening resp status on floor. 100% NRB done, ABG done and PaO2 remians in 70's. Team aware and MD Kwaga by to see. LS crackles throughout. Poor cough effort, awaiting sputum for cx. Plan to assess overnoc-? intubation if worsens. Echo done on arrival. SR, no ectopy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-13 00:00:00.000",
"description": "Report",
"row_id": 1528656,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient remained afebrile overnight. HR stable in 80's with no ectopy. BP 100-110/40-50. Making min amts of urine-sicu resident aware. Lungs with crackles throughout. ABG at beginning of shift with PaO2 70. Pt became increasingly aggitated and confused. Ativan given with no effect. The ABG's obtained while aggitated showing worsening hypoxia and RR high 30's to 40's. Pt climbing oob pulling at lines. SICU resident notified Transplant team and given okay to intubate. ICU attending called and wanted to hold off on intubation and try haldol and nebs. Haldol given with no effect. Aggitation/confusion worsened. Anesthesia called and patient was intubated at 0600 without any difficulty using etomidate and succ. Post-intubation started on ppf gtt. CXR to be done to confirm placement.\n Stat lab called this am with elevated glucose in 400's -confirmed with fingerstick. 12u regular insulin given. Surgical team aware.\n Currently patient on AC 500x16 100%fio2 and 10 PEEP. No secretions when suctioned. Will draw post-intubation ABG.\nPLAN:\n Adjust vent as needed\n PPF for sedation\n Pulmonary toilet\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-13 00:00:00.000",
"description": "Report",
"row_id": 1528657,
"text": "Resp Care: Pt intubated for refractory hypoxemia with #8 ett, placement confirmed by bbs, etco2, placed on ventilatory support with a/c, will cont support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-13 00:00:00.000",
"description": "Report",
"row_id": 1528658,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, decreasing Fio2 to 60% based on ABG result. Taken to CT and back without incident. Pt placed under chicken pox isolation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-13 00:00:00.000",
"description": "Report",
"row_id": 1528659,
"text": "Neuro: Pt remains on propofol. Opens eyes to voice, pupils 2mm brisk. MAE. appears comfortable.\nCV: afebrile, HR-60-70's NSR with no ectopy, SBP 110-130's, extremities warm with +PP.\nRESP: lungs with crackles through-out. Vent remains unchanged AC 500X16 10 peep. O2 sats 100%. ABG acceptable. Bronch with specimens sent. CT of chest.\nGI: abd soft, NPO. Small stool neg guaiac.\nGU: foley patent draining 10cc very few hours.\nENdocrine: blood sugars normalized this eve. INsulin gtt ordered with no use at this point,\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-14 00:00:00.000",
"description": "Report",
"row_id": 1528660,
"text": "COMMUNICATION UPDATE\n VITALS STABLE WITH CVP 11-14,SBP110-120'S, HR60-70. URINE OUTPUT CONTINUES IN SMALL AMOUNTS DESPITE LASIX 80 .\n VENT SETTINGS CHANGED DUE TO ALKALOSIS. RATE DECREASED TO 12 WITH IMPROVEMENT IN ABG'S.SEE FLOW SHEET FOR SPECIFICS. IT WAS NECESSARY TO CONTINUE PROPOFOL TO KEEP PATIENT FROM BREATHING OVER THE VENT. PER DR. PROPOFOL INCREASED BACK UP TO 50 TO KEEP RESPIRATIONS DOWN.\nLUNGS WITH CRACKLES BILATERALLY IN THE BASES,UPPER LOBES CLEAR TO AUSCULTATION, SPUTUM PRODUCTION MINIMAL.\n ZOSTER RASH ON INNER ARM ON LEFT CONTINUES TO BE TREATED WITH IV ACYCLOVIR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-04 00:00:00.000",
"description": "Report",
"row_id": 1528725,
"text": "Nursing Progress Note\n 0700->\n\nS/O\n\nNEURO: remains withdrawn with flat affect, minimal eye contact. Denies pain of any kind, communicated by shaking head no to pain, yes to no pain. No movement LUE, denies sensation on LUE up to shoulder.\n\nCV: Continues with hypertension, maintained with current antihypertensives. See MARs.\n\nRESP: Strong, productive cough which clears airway. Shallow sxn x2 for thick white sputum. Trach site clean and intact with trach stistches intact. Tolerating trach mask @ 35% O2 with no distress.\nLS coarse -> clear in apices, diminished in bases. Tolerate bilateral CPT.\n\nGI: Abd soft, non-tender. Denies nausea; no vomiting; no BM; +RF.\n\nFEN: No current, new issues. See flowsheet for I&O's; continues on acyclovir pre-hydration.\n\nHAEM: No current issues.\n\nID: Stable. On Vanco and Acyclovir in addition to Sirolimus.\n\nGU: Continueson diuretics with short-lasting marginal diuresis -> see flowsheet.\n\nSKIN: Left arm, back and chest continues to heal, red and dried lesions with pink tissue.\n\nA/P\n\nContinue current care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-05 00:00:00.000",
"description": "Report",
"row_id": 1528726,
"text": "condition updatae\nD: pt opens eyes to stimulation and intermittantly. no movement of the left arm. withdraws the left leg. temp max 99.5. sbp remains under 165 on lopressor and hydralazine. pt remains on trache collar 35% with o2 sast of 100%. pt suctioned for thick white sputum. abg is good. ph is 7.46 and po2 is 92. bs are coarse and diminished in the basese. pt remains on probalace at 55cc/hr through feeding tube. 2 small bms. loose brown. duoderm changed. and small open area on coccyx.\na: suction as needed. continue to keep sbp less than 165. continue to monitor neuro status\nr: no change in neuro status. blood sugar down to 47 and treated with 1/2 amp of d50. up to 63. sbp remains less than 165 on lopressor and hydralazine. left arm remains swollen. pt appears to be tolerating tube feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-05 00:00:00.000",
"description": "Report",
"row_id": 1528727,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: DOZING MOST OF DAY, OCC OPENS EYES TO SPEECH BUT MOSTLY TO STIMULI. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS, ABLE TO MOVE ON BED AND WITHDRAW TO STIMULI W/ ALL EXTREMETIES EXCEPT LT ARM. PERL 2-3MM, SLUGGISH.\n\nCV: HR 78-90, NSR, NO ECTOPY, SBP 147-168. CVP 4-8.\n\nRESP: O2 SAT 97-100% VIA TRACH COLLAR ON HH 35%., RR 19-36. LUNG SOUNDS CLEAR BUT DIMINISHED AND OCC COARSE. ABLE TO OCC EXPECTORATE THICK YELLOW SECRETIONS.\n\nGI: ABD SOFTLY DIST, + BOWEL SOUNDS, TOLERATING TF PROBALANCE AT 55 CC/HR AT GOAL VIA DOBHOFF.\n\nGU: FOLEY DRAINING ADEQ U/O CLEAR YELLOW URINE.\n\nID: TMAX 99.1 AXILLARY.\n\nPLAN: CONT CURRENT MGMT, ? REPEAT HEAD CT, ? TRANSFER TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-05 00:00:00.000",
"description": "Report",
"row_id": 1528728,
"text": "Resp Care note\n\nPt sx for small to mod amts of thickish white secretions Q4-6 hrs. Albuterol MDI given Q 4 hrs. Pt on trach with O2 40%\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-01 00:00:00.000",
"description": "Report",
"row_id": 1528715,
"text": "Respiratory Care\nPt remain intubated and on vent support, Pt was weand to CPAP 5/5 doing well on this setting,Good am RSBI, BS coares, SX mod /larg amout thick yellow/tan secreation, Count to wean ? extubation today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-01 00:00:00.000",
"description": "Report",
"row_id": 1528716,
"text": "Please refer to and remarks for details.\nNo changes in MS. Pt able to spontaneously move RU/RLE in bed, however only moves LLE to painful stimulus. Bilat. pupils 2mm, nonreactive and sometimes sluggish to light accom. Pt's VSS, except for SBP^160-170's. After admin Ativan 1mg IV, SBP decreased to 130-140's. Hydralazine dose ^ to 30mg IV q4h and lopressor^150mg PO tid. Pt with brief episode of SVT at 1820, which resolved on its own. MD aware and electrolytes sent. Pt with 2-3+ edema BUE & BLE. BUE elevated on pillows. Blood cx, urine cx, and CXR done d/t ^temp overnight; results pending. Pt cont. to be on CPAP 5/5 which she is tolerating well. ABGs WNL. Frequent sxn with Yankeur required; deep sxn also performed. LS coarse, and diminished at bases. RISS started this AM, but insulin gtt had to be restarted d/t fs^ (refer to for frequent fs results). Insulin gtt currently running at 3 units/hr. BS hyperactive; no BM this shift. TF on hold secondary to residual 120cc. KUB performed this AM to confirm placement of pedi tube. NPO after MN for ? trach in AM. IVF: D5 1/2NS @ 55cc/h.\nPlan: Continue to monitor BS, keep SBP<150, NPO after MN, ?trach in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-02 00:00:00.000",
"description": "Report",
"row_id": 1528717,
"text": "/ condition update\nPlease see carevue for specifics.\n\npt high bp's tonight requiring increase of hydralazine dose to 40mg and increas prn lopressor to 15mg- with all meds sbp 145-155 during the noc and team aware; increases with movement and suctioning- ativan to pre-med helps to keep sbp stable. Afebrile. Cpap 30% 5/5 tolerating well. pt treated with ativan x 3 overnoc for anxiety. Glucose within good control on insulin gtt. Parents called for consent for trach this am- pt has been NPO since 1700 for high residuals- ?placement of tube. cont to monitor labs, vs, i/o's, NS. Pt moveing all extremities except lue- as per baseline, pupils appear nr- ho aware, cont to monitor. pt following commands at times, but not consistently- pt with good grip on rue on command x 2 tonoc. cont to asess ns.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-02 00:00:00.000",
"description": "Report",
"row_id": 1528718,
"text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV) without changes to any parameters throughout the night. Received mdi combivent with each vent check. Morning abg results revealed a normal acid-base status with excellent oxygenation on the current settings.\n\nRSBI = 76.9 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-02 00:00:00.000",
"description": "Report",
"row_id": 1528719,
"text": "STATUS\nD: TO O.R. @ 0800\nA: RETURNED FROM O.R. S/P #7.0 PORTEX TRACH..SEDATED ON A/C VENT INITIALLY BUT WEANED & AT 1700>>PLACED ON TRACH COLLAR 35% WELL..SUCTIONED FOR SM AMT BLD TINGED..OOZING SS FROM AROUND TRACH..NEURO ESSENTIALLY UNCHANGED WILL OPEN EYES & OCC FOLLOW SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S EXCEPT LF ARM TO PAINFUL STIMULI REMAINS ON INSULIN GTT TO KEEP BS <120..GOOD HUO LASIX X1..INCT LOOSE BLACK STOOL\nR: ESSENTIALLY UNCHANGED NEURO STATUS\nP: WEAN AS MONITOR NEURO STATUS CLOSELY\n"
}
] |
|
13,840 | 103,467 | Postoperatively the patient did well. The only complication was folliculitis which was treated with Clindamycin. Upon discharge, the patient's condition was stable, ambulatory status was 4. | FLUID BOLUS GIVEN.GI: OGT DC'D W/ EXTUBATION. PP VIA DOPPLER.CALCIUM AND K REPLACED. STERNAL DSG CHANGE X 1, OOZY SEVERAL STERI STRIPS REPLACED. LATER TRANSIENT HYPOTENSION - NEO ON AND OFF. C/O NAUSEA - DROPERIDOL GIVEN.GU: FOLEY W/ GOOD UOP.HEME: REC'D 2 FFP OVERNIGHT. NTG ON BRIEFLY. STERNAL DSG WITH SANGUINOUS DRAINAGE. INITIALLY HYPERTENSIVE AFTER EXTUBATION. CS CLR UPPER, DIMINISHED BASES. BP~^90'S TO LOW 100'S.POS PAL PEDAL PULSES BILAT. There is a retrocardiac density representing atelectasis vs. consolidation. There is bilateral diffuse linear atelectasis. MAG TO BE REPLACED.RESP: VENT AS PER FLOW, PRESENTLY ON CPAP 5/5. Rpt. OOB TO CHAIR TOL WELL.1 PERCOCET FOR INCISIONAL PAIN W/ GOOD EFFECT. SATS IMPROVED BY AM - NOW ON NP 4L ONLY.CARD: HR HIGH 90'S TO 120. SBP 110'S. 3) Left pleural effusion. HCT 23 . Sinus rhythm, rate 96QT long for rateAnterolateral T wave abnormalitiesConsistent with ischemiaFirst degree AV blockAbnormal ECG O2 SATS>98%. SBP 140'S NEO SHUT OFF, NTG TRANSIENT. MAE.PULM: EXTUBATED AT 0130. PAIN MED GIVEN W/ SOME RELIEF - BUT BP DROPPED W/ MSO4. PROTOCOL FOLLOWED.MISC: K+ REPLACED.PLAN: TRANSFER TO F6 LATER TODAY. OCCAS PVC'S. DR AWARE. AM COAGS IMPROVED.PAIN: MSO4 GIVEN SEVERAL TIMES W/ FAIR RELIEF. 2) Cardiomegaly and retrocardiac atelectasis vs. consolidation. CSRU PROGRESSNEURO: INTACT. There is moderate sized left pleural effusion. ORIENTED X 3. INCREASINGLY TACHYCARDIC. S/P CABG X 4.O: ARRIVED A PACED, SBP 100, PROPOFOL INCREASED TO 40 MCQ.CARDIAC: A PACED TO SR WITH IST DEGREE AVB , WITH ISOLATED PVC'S. Evaluate for pneumothorax. SX FOR SCANT AMOUNT OF WHITE DRAINAGE.NEURO: , , FOLLOWING COMMANDS, RAISING HEAD OFF PILLOW.GI: NPO, NGT TO LCS, ABSENT BOWEL SOUNDS,GU: GOOD UOSKIN: AS ABOVESOCIAL: SPOKE WITH COUSIN ON PHONE AND UPDATED.A: INCREASED CT DRAINAGE HAS RESOLVED SINCE. 4L NC W/ SATS OF 96%.LUNGS DIMINISHED @ BASES.GI/GU~TOL PO FOOD AND FLUIDS WELL. stable, ready for transfer to 609 REPEAT 50 MG PROTAMINE. Regular insulin 6 units sc given at 1530. GOOD URINE U/O. CHEST, SINGLE VIEW: The patient is s/p median sternotomy. TRANSFER NOTENEURO~A+O X3, PLEASANT . FILLING PRESSURES LOW. FSBS at 1630 was 165.Last K 4.5 (1400 )Pt. FAINT BOWEL SOUNDS. RECIEVED 50 MG PROTAMINE, 4 UFFP, 5 UNIT PLT, 2 L LR, 2 UPC FOR HCT 23. CT DRAINAGE DECREASED SIGNIFICANTLY. AWAITING EXTUBATION.P: MONITOR COMFORT, HR AND RYTHYM, SBP, CT DRAINAGE, RESP STATUS, NEURO STATUS, SKIN, I+O, PP, LABS, WEAN TO EXTUBATE. AS PER ORDERS. NP AND FACE TENT O2 INCREASED. 1500 GLU~203 GTT INCREASED TO 6 UNITS. 1600 GIVEN 6 UNITS SC.A/P~ PLAN TO DC INSULIN GTT PRIOR TO TRANSFER TO FLOOR. FAMILY IN TO VISIT TODAY.CARDIAC~HR:103 ST, LOPRESSOR 12.5 MG THIS AM. ALSO DSG CHANGE TO LEFT LEG, SL OOZY.NO FURHTER DRAINAGE NOTED FROM EITHER SITE.RESP~ CDB + INS , NON-PROD COUGH. PACER COMPETING - TURNED OFF. 1 DOSE OF TORADOL GIVEN THIS AM W/ GOOD RESPONSE.ENDO: REMAINS ON INSULIN GTT OVERNIGHT - 5 U/HR. STABLE FOR TRANSFER. INITIALLY SATS LOW 90'S ON 50% FACE TENT. IMPRESSION: 1) No pneumothorax. GIVEN LASIX 20 MG@ 1600.ENDO~@ 1400 INSULIN GTT RESTARTED @ 4 UNITS/HR, FOR GLU OF 200. No changes to general assessment as noted:Insulin gtt off. CT DRAINAGE INCREASED UPON ARRIVAL>200ML. CONT TO MONITOR BLOOD GLUCOSE. 5:56 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX MEDICAL CONDITION: 70 year old man s/p CABG s/p removal of chest tubes REASON FOR THIS EXAMINATION: r/o PTX FINAL REPORT INDICATION: 70 y/o s/p CABG, removal of chest tubes. | 6 | [
{
"category": "ECG",
"chartdate": "2172-11-03 00:00:00.000",
"description": "Report",
"row_id": 153519,
"text": "Sinus rhythm, rate 96\nQT long for rate\nAnterolateral T wave abnormalities\nConsistent with ischemia\nFirst degree AV block\nAbnormal ECG\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 743523,
"text": " 5:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CABG s/p removal of chest tubes\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70 y/o s/p CABG, removal of chest tubes. Evaluate for\n pneumothorax.\n\n CHEST, SINGLE VIEW: The patient is s/p median sternotomy. There is a\n retrocardiac density representing atelectasis vs. consolidation. There is\n moderate sized left pleural effusion. There is bilateral diffuse linear\n atelectasis. No pneumothorax.\n\n IMPRESSION: 1) No pneumothorax.\n\n 2) Cardiomegaly and retrocardiac atelectasis vs. consolidation.\n\n 3) Left pleural effusion.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-04 00:00:00.000",
"description": "Report",
"row_id": 1442832,
"text": "S/P CABG X 4.\nO: ARRIVED A PACED, SBP 100, PROPOFOL INCREASED TO 40 MCQ.\nCARDIAC: A PACED TO SR WITH IST DEGREE AVB , WITH ISOLATED PVC'S. SBP 140'S NEO SHUT OFF, NTG TRANSIENT. SBP 110'S. CT DRAINAGE INCREASED UPON ARRIVAL>200ML. RECIEVED 50 MG PROTAMINE, 4 UFFP, 5 UNIT PLT, 2 L LR, 2 UPC FOR HCT 23. REPEAT 50 MG PROTAMINE. CT DRAINAGE DECREASED SIGNIFICANTLY. STERNAL DSG WITH SANGUINOUS DRAINAGE. PP VIA DOPPLER.CALCIUM AND K REPLACED. MAG TO BE REPLACED.\nRESP: VENT AS PER FLOW, PRESENTLY ON CPAP 5/5. O2 SATS>98%. SX FOR SCANT AMOUNT OF WHITE DRAINAGE.\nNEURO: , , FOLLOWING COMMANDS, RAISING HEAD OFF PILLOW.\nGI: NPO, NGT TO LCS, ABSENT BOWEL SOUNDS,\nGU: GOOD UO\nSKIN: AS ABOVE\nSOCIAL: SPOKE WITH COUSIN ON PHONE AND UPDATED.\nA: INCREASED CT DRAINAGE HAS RESOLVED SINCE. HCT 23 . AWAITING EXTUBATION.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CT DRAINAGE, RESP STATUS, NEURO STATUS, SKIN, I+O, PP, LABS, WEAN TO EXTUBATE. AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-04 00:00:00.000",
"description": "Report",
"row_id": 1442833,
"text": "CSRU PROGRESS\nNEURO: INTACT. ORIENTED X 3. MAE.\n\nPULM: EXTUBATED AT 0130. INITIALLY SATS LOW 90'S ON 50% FACE TENT. NP AND FACE TENT O2 INCREASED. CS CLR UPPER, DIMINISHED BASES. SATS IMPROVED BY AM - NOW ON NP 4L ONLY.\n\nCARD: HR HIGH 90'S TO 120. OCCAS PVC'S. PACER COMPETING - TURNED OFF. INITIALLY HYPERTENSIVE AFTER EXTUBATION. NTG ON BRIEFLY. LATER TRANSIENT HYPOTENSION - NEO ON AND OFF. INCREASINGLY TACHYCARDIC. PAIN MED GIVEN W/ SOME RELIEF - BUT BP DROPPED W/ MSO4. FILLING PRESSURES LOW. FLUID BOLUS GIVEN.\n\nGI: OGT DC'D W/ EXTUBATION. FAINT BOWEL SOUNDS. C/O NAUSEA - DROPERIDOL GIVEN.\n\nGU: FOLEY W/ GOOD UOP.\n\nHEME: REC'D 2 FFP OVERNIGHT. AM COAGS IMPROVED.\n\nPAIN: MSO4 GIVEN SEVERAL TIMES W/ FAIR RELIEF. DR AWARE. 1 DOSE OF TORADOL GIVEN THIS AM W/ GOOD RESPONSE.\n\nENDO: REMAINS ON INSULIN GTT OVERNIGHT - 5 U/HR. PROTOCOL FOLLOWED.\n\nMISC: K+ REPLACED.\n\nPLAN: TRANSFER TO F6 LATER TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-04 00:00:00.000",
"description": "Report",
"row_id": 1442834,
"text": "TRANSFER NOTE\n\nNEURO~A+O X3, PLEASANT . OOB TO CHAIR TOL WELL.1 PERCOCET FOR INCISIONAL PAIN W/ GOOD EFFECT. FAMILY IN TO VISIT TODAY.\n\nCARDIAC~HR:103 ST, LOPRESSOR 12.5 MG THIS AM. BP~^90'S TO LOW 100'S.\nPOS PAL PEDAL PULSES BILAT. STERNAL DSG CHANGE X 1, OOZY SEVERAL STERI STRIPS REPLACED. ALSO DSG CHANGE TO LEFT LEG, SL OOZY.NO FURHTER DRAINAGE NOTED FROM EITHER SITE.\n\nRESP~ CDB + INS , NON-PROD COUGH. 4L NC W/ SATS OF 96%.\nLUNGS DIMINISHED @ BASES.\n\nGI/GU~TOL PO FOOD AND FLUIDS WELL. GOOD URINE U/O. GIVEN LASIX 20 MG\n@ 1600.\n\nENDO~@ 1400 INSULIN GTT RESTARTED @ 4 UNITS/HR, FOR GLU OF 200. 1500 GLU~203 GTT INCREASED TO 6 UNITS. 1600 GIVEN 6 UNITS SC.\n\nA/P~ PLAN TO DC INSULIN GTT PRIOR TO TRANSFER TO FLOOR. CONT TO MONITOR BLOOD GLUCOSE. STABLE FOR TRANSFER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-04 00:00:00.000",
"description": "Report",
"row_id": 1442835,
"text": "No changes to general assessment as noted:\n\nInsulin gtt off. Regular insulin 6 units sc given at 1530. Rpt. FSBS at 1630 was 165.\n\nLast K 4.5 (1400 )\n\nPt. stable, ready for transfer to 609\n"
}
] |
12,938 | 165,691 | Pt admitted to r/o MI and PE and assess IVC tumor. She was admitted to Cardiac surgery ICU started on heparin infusion, her cardiac enzymes as well as CTA were negative. On hospital day 2 she had a TEE was transferred to the general floors and was restarted on her coumadin. On hospital day 4 here INR was therapeudic and she was discharged home | Ectopic atrial or junctional rhythmNonspecific ST-T abnormalitiesLow precordial lead QRS voltage - is nonspecificSince previous tracing of , precordial lead QRS morphology now appearsmore normal Nursing progress NoteNeuro: intact no defecits noted, slight dizziness with standing.CVS: afebrile hr sinus to sinus brady no ectopy. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. No AR.MITRAL VALVE: Normal mitral valve leaflets. The ascending, transverse anddescending thoracic aorta are normal in diameter and free of atheroscleroticplaque. Normal RV systolic function.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). Contrast appears to flow around this filling defect into the right ventricle and there is no evidence of pulmonary embolus. Cardiac silhouette and mediastinum are within normal limits. Assess vs thrombusHeight: (in) 60Weight (lb): 200BSA (m2): 1.87 m2BP (mm Hg): 112/64HR (bpm): 74Status: InpatientDate/Time: at 10:57Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Tumor or myxoma in the RA. Large, nonenhancing filling defect within the IVC extending into the right atrium measuring up to 4 x 7 cm, which has not significantly changed in size (Over) 12:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval: PE (known reaction of hives to IV , PREMEDICAT FINAL REPORT (Cont) since the prior noncontrast examination of . There is unchanged probable scarring in the anterior segment of the right upper lobe. IMPRESSION: Low lung volumes without signs for acute cardiopulmonary process. Trivial mitral regurgitation is seen. Pulmonary vascularity appears within normal limits. CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Again seen is a massively dilated inferior vena cava containing a large non-enhancing filling defect, which extends into the right atrium. Pulses palp x 4 ext, skin pale, warm, dry, intact.Resp: rr regular, sob with oob to commode. No ASD by 2D orcolor Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size. 0.2 mg of IV glycopyrrolate was given as an antisialogogueprior to TEE probe insertion.Conclusions:No spontaneous echo contrast is seen in the body of the left atrium. The aorta is normal in caliber throughout. Cardiac and mediastinal contours appear stable. The mitral valve leafletsare structurally normal. The coronary arteries are normal. This has not significantly changed since the CT torso of . PORTABLE CHEST RADIOGRAPH There has been interval removal of the previously seen median sternotomy wires. IMPRESSION: No evidence of acute cardiopulmonary process. TECHNIQUE: Multidetector CT images were first obtained through the chest without contrast with a low-dose technique, followed by contrast-enhanced CT angiogram of the chest. There is no pathologically enlarged axillary, hilar, or mediastinal lymphadenopathy. The aortic valve leaflets (3) appear structurally normal with goodleaflet excursion. Borderline low voltage ij the limb leads.Compared to the previous tracing of T wave inversions have newlyappeared in leads V3-V5. No atrial septal defect is seen by 2D or colorDoppler. Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular systolic function is normal. Interval removal of median sternotomy wires. Non-specific T wave inversions in leads VI-V4. No aortic regurgitation is seen. There is noextension into the SVC. There is no focal consolidation, pulmonary edema, or large pleural effusions. There is no pericardial effusion. There is no pulmonary embolus. No TEE relatedcomplications. No focal consolidations are seen within the lungs. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. No evidence of pulmonary embolus. Lowvoltage in the precordial leads. There is no pleural effusion. No evidence of pleural effusion. 12:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval: PE (known reaction of hives to IV , PREMEDICAT MEDICAL CONDITION: 44 year old woman with h/o saddle PE in p/w CP, lightheadedness REASON FOR THIS EXAMINATION: eval: PE (known reaction of hives to IV , PREMEDICATE; please scan at noon) No contraindications for IV contrast WET READ: 12:51 PM Very large non-enhancing filling defect within the right atrium consistent with history of IVC thrombus extending into the right atrium. LS clear in uppers dim at lower lobes.GI: abd obese, bs present. The lungs are grossly clear. SBP > 100 no agents. There is no evidence of mass or thrombus in the right ventricle or pulmonary arteries. ATTEMPT TO KEEP PATIENT AS COMFORTABLE AS POSSIBLE. CT REFORMATS: Coronal and sagittal reformatted images confirm the axial findings. Ectopic atrial or junctional rhythmLow precordial lead QRS voltage with delayed R wave progression and lateprecordial QRS transition - in part positional or possible anterior myocardialinfarctionNonspecific ST-T abnormalitiesSince previous tracing of , precordial lead QRS changes now present The patient was sedated for the TEE.Medications and dosages are listed above (see Test Information section). Sinus rhythmNonspecific precordial/anterior T wave abnormalities - clinical correlation issuggestedSince previous tracing of , T wave changes more prominent A largehomogenous mass (suspicious for tumor; thrombus less likely given the size andappearance) is seen in the right atrium extending from the IVC and filling theIVC (3cm in diameter) with severely narrowed residual flow. | 12 | [
{
"category": "Radiology",
"chartdate": "2102-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949263,
"text": " 7:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: RA MASS W\\CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with CP\n\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 44-year-old woman with chest pain. Evaluate for pneumonia.\n\n FINDINGS: The lung volumes are low due to poor inspiratory effort. Cardiac\n silhouette and mediastinum are within normal limits. There is no focal\n consolidation, pulmonary edema, or large pleural effusions.\n\n IMPRESSION:\n\n Low lung volumes without signs for acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948823,
"text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval: CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with CP\n REASON FOR THIS EXAMINATION:\n eval: CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain. Evaluate for CHF.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH\n\n There has been interval removal of the previously seen median sternotomy\n wires. Cardiac and mediastinal contours appear stable. No focal\n consolidations are seen within the lungs. Pulmonary vascularity appears\n within normal limits. No evidence of pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process. Interval removal\n of median sternotomy wires.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-02-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 948829,
"text": " 12:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval: PE (known reaction of hives to IV , PREMEDICAT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with h/o saddle PE in p/w CP, lightheadedness\n REASON FOR THIS EXAMINATION:\n eval: PE (known reaction of hives to IV , PREMEDICATE; please scan at\n noon)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:51 PM\n Very large non-enhancing filling defect within the right atrium consistent\n with history of IVC thrombus extending into the right atrium. This measures\n nearly 4 x 7 cm. Contrast appears to flow around this filling defect into the\n right ventricle and there is no evidence of pulmonary embolus. Lungs are\n clear.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of pulmonary embolus and IVC thrombus/tumor. Please\n evaluate for pulmonary embolus.\n\n TECHNIQUE: Multidetector CT images were first obtained through the chest\n without contrast with a low-dose technique, followed by contrast-enhanced CT\n angiogram of the chest. Coronal, sagittal, and oblique sagittal reformatted\n images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Again seen\n is a massively dilated inferior vena cava containing a large non-enhancing\n filling defect, which extends into the right atrium. This has not\n significantly changed since the CT torso of . However, comparison is\n difficult secondary to different technique. There is no evidence of mass or\n thrombus in the right ventricle or pulmonary arteries. There is no pulmonary\n embolus. Probable contrast mixing defect in SVC. The aorta is normal in\n caliber throughout. The coronary arteries are normal. There is no pericardial\n effusion. The airways are patent to the segmental level bilaterally. There\n is unchanged probable scarring in the anterior segment of the right upper\n lobe. Dependent changes are seen in the lung fields bilaterally. There are\n no nodules or areas of airspace consolidation. There is no pleural effusion.\n There is no pathologically enlarged axillary, hilar, or mediastinal\n lymphadenopathy. Although this examination is not tailored evaluation of the\n abdominal organs, limited images through the upper abdomen show unremarkable\n portions of the spleen and kidneys. The liver shows a small amount of biliary\n air and metallic clips within the gallbladder fossa.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n CT REFORMATS: Coronal and sagittal reformatted images confirm the axial\n findings.\n\n IMPRESSION:\n 1. Large, nonenhancing filling defect within the IVC extending into the right\n atrium measuring up to 4 x 7 cm, which has not significantly changed in size\n (Over)\n\n 12:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval: PE (known reaction of hives to IV , PREMEDICAT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n since the prior noncontrast examination of .\n\n 2. No evidence of pulmonary embolus. The lungs are grossly clear.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2102-02-17 00:00:00.000",
"description": "Report",
"row_id": 60834,
"text": "PATIENT/TEST INFORMATION:\nIndication: History of IVC leiomyoma. Assess vs thrombus\nHeight: (in) 60\nWeight (lb): 200\nBSA (m2): 1.87 m2\nBP (mm Hg): 112/64\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 10:57\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Tumor or myxoma in the RA. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium. A large\nhomogenous mass (suspicious for tumor; thrombus less likely given the size and\nappearance) is seen in the right atrium extending from the IVC and filling the\nIVC (3cm in diameter) with severely narrowed residual flow. There is no\nextension into the SVC. No atrial septal defect is seen by 2D or color\nDoppler. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular systolic function is normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. Trivial mitral regurgitation is seen. There is a\nsmall pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2102-02-19 00:00:00.000",
"description": "Report",
"row_id": 117557,
"text": "Sinus rhythm\nNonspecific precordial/anterior T wave abnormalities - clinical correlation is\nsuggested\nSince previous tracing of , T wave changes more prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2102-02-16 00:00:00.000",
"description": "Report",
"row_id": 117558,
"text": "Ectopic atrial or junctional rhythm\nNonspecific ST-T abnormalities\nLow precordial lead QRS voltage - is nonspecific\nSince previous tracing of , precordial lead QRS morphology now appears\nmore normal\n\n"
},
{
"category": "ECG",
"chartdate": "2102-02-16 00:00:00.000",
"description": "Report",
"row_id": 117559,
"text": "Ectopic atrial or junctional rhythm\nLow precordial lead QRS voltage with delayed R wave progression and late\nprecordial QRS transition - in part positional or possible anterior myocardial\ninfarction\nNonspecific ST-T abnormalities\nSince previous tracing of , precordial lead QRS changes now present\n\n"
},
{
"category": "ECG",
"chartdate": "2102-02-16 00:00:00.000",
"description": "Report",
"row_id": 117560,
"text": "High junctional rhythm. Non-specific T wave inversions in leads VI-V4. Low\nvoltage in the precordial leads. Borderline low voltage ij the limb leads.\nCompared to the previous tracing of T wave inversions have newly\nappeared in leads V3-V5.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-02-16 00:00:00.000",
"description": "Report",
"row_id": 1431994,
"text": "YOUNG LADY ADMITTED FROM ER, REPORT RECEIVED OVER PHONE PRIOR TO TRANSFER.\nNEURO: AWAKE, ALERT ORIENTED X 3, MAE, FOLLOWING COMMANDS.\nCARDIAC: MP SB TO NSR. PALPABLE PULSES. HEPARIN GTT AT 1650, NEEDS PTT AT 2200.\nRESP: CS DIMINISHED IN BASES.\nGI: POOR APPETITE, HYPOACTIVE BOWEL SOUNDS.\nGU: HAS NOT VOIDED AS YET, 80 MG PO LASIX GIVEN AT 1800.\nPAIN: PATIENT C/O RT GROIN PAIN RADIATING DOWN LEG, THIS HAS BEEN PRESENT SINCE . C/O CHEST DISCOMFORT, DISCRIBES AS PRESSURE, NOW RADIATING TO HER LT BREAST, MEDICATED WITH VICODIN.\nFAMILY: NO INTERACTION: HER DAUGHTER JUST HAD A BABY BOY YESTERDAY AND SHE TOLD HER FAMILY NOT TO VISIT. APPARENTLY MOM AND SISTER KNOW SHE IS ILL BUT NOT ANY SPECIFICS. PATIENT HAS HEALTH CAR PROXY; OLDEST DAUGHTER WHO JUST HAD BABY.\n\nPLAN: NPO AFTER MN FOR TEE. ATTEMPT TO KEEP PATIENT AS COMFORTABLE AS POSSIBLE. PATIETN WA AN EMT AND WORKS FOR AMBULANCE COMPANY, MEDICALLY AWARE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-02-16 00:00:00.000",
"description": "Report",
"row_id": 1431995,
"text": "AFTER PATIENT BRUSHED HER TEETH SHE FELT A PIECE OF TOOTH # 6 LEFT SIDE BROKE AWAY. NO PAIN AT THIS TIME WILL TELL PA. TOOTH PLACED IN CUP WITH HER NAME ON IT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-02-17 00:00:00.000",
"description": "Report",
"row_id": 1431996,
"text": "Nursing progress Note\nNeuro: intact no defecits noted, slight dizziness with standing.\n\nCVS: afebrile hr sinus to sinus brady no ectopy. SBP > 100 no agents. PIV x 2 patent. heparin at 1300 units/hour, ptt pending. Pulses palp x 4 ext, skin pale, warm, dry, intact.\n\nResp: rr regular, sob with oob to commode. nc o2 at 2 L with sats > 95. LS clear in uppers dim at lower lobes.\n\nGI: abd obese, bs present. NPO after midnight for TEE in am.\n\nGU: evening po lasix working with brisk pale yellow urine, q 1 hour up to commode.\n\nPain: denies at this time.\n\nSocial: no contact from daughter this shift. Probable need for social worker/psych consult due to nature and risks associated with surgery, needs emotional support.\n\nEndo: fs bs not requiring ssri coverage at this time.\n\nPlan: continue monitoring, control pain and anxiety, tee in am.\n\nSee carevue flowsheet and mars for further details and values\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-02-17 00:00:00.000",
"description": "Report",
"row_id": 1431997,
"text": "shift cover 0700-1530-see nursing transfer note\n"
}
] |
2,057 | 126,559 | %0 yo male transferred to SICU from hospital following elective bronch for white-out right lung complicated by severe resp distress requiring emergent intubation. Pt remained intubated and sedated in the SICU during w/o of right beonchus-intermedius tumor was done. Pt was found to have adeno carcinoma of the lung w/ mets to brain and liver. Radiation and Heme-onc consulted and felt paliative treatment would not be beneficial. After lengthy discussions with family pt was declared CMO. Pt expired on at 19:45 | There has been placement of a right-sided chest tube and evacuation of a right pleural effusion with a residual small effusion remaining. Breath sounds diminished, right side expiratory wheezes noted. CLINICAL INDICATION: Obstruction of right bronchus intermedius. Large right effusion with a layering hematocrit level, likely secondary to the recent thoracentesis. Palpable pulses bilaterally.GI: +BS, abdomen soft, NPO. Endotracheal tube, nasogastric tube, and right-sided chest tube remain in place. IMPRESSION: Status post evacuation of large right pleural effusion with residual large hydropneumothorax with greater component of air within fluid. Endotracheal tube, right-sided chest tube, and nasogastric tube remain in place. There is a right hydropneumothorax, which is mostly comprised of air with a lesser amount of fluid. Nursing note:NEURO: Sedated on PPF gtt though pt. RS mass (bronchial tumor). Edema to lower extremities and scrotum. CLINICAL INDICATION: Thoracentesis. There is an abrupt termination of the right main stem bronchus. 500cc NS bolus x1 for borderline HUO and slight hypotension.GI: Abdomen soft, non-distended. Within the left lung, there remains perihilar haziness. The left lung demonstrates perihilar haziness and a subtle interstitial pattern but is otherwise grossly clear. IMPRESSION: Essentially unchanged appearance of right hydro-pneumothorax. TECHNIQUE: CT of the head without and with IV contrast. Small left pleural effusion and small pericardial effusion. There is a left inguinal hernia, with fluid tracking in the left inguinal hernial sac. Small ascites, including fluid tracking into the pelvis and into the left inguinal hernial sac. A suitable spot for biopsy was marked and infiltrated with lidocaine. TECHNIQUE: CT of the torso without and with IV contrast. The right-sided hydro-pneumothorax appears essentially unchanged allowing for difference in positioning. An endotracheal tube and nasogastric tube remain in place. There is left-sided hydronephrosis and left hydro-ureter. CLINICAL INDICATION: Status post bronchoscopy. Denies pain though grimacing at times, Morphine PRN.RESP: Lung sounds clear, dim to bases. CT CHEST W/O & W/IV CONTRAST: There is an air-fluid level within the right mainstem bronchus and complete collapse of the right lung with a large right pleural effusion and a layering hematocrit level posteriorly (status-post thoracentesis). Resp: pt via from osh intubated following acute decompensation after having a bronch. Condition UpdatePlease see carevue for specifics:Pt with tmax 100.8 orally overnoc and heart rate sinus tachy 105-135 and sbp 90's-120's/50-60's. The left lung demonstrates a persistent perihilar interstitial pattern. The major intracranial arteries are patent. Nursing note:NEURO: Arrived sedated/paralyzed via . A right-sided chest tube remains in place. There remains complete collapse of the right lung consistent with known obstructing endobronchial lesion. Ativan 1mg x1 given w/some relief. CT PELVIS W/O & W/IV CONTRAST: A Foley catheter is present within the decompressed bladder. The right lung is completely collapsed, and note is again made of abrupt termination of the right main stem bronchus. CLINICAL INDICATION: Chest tube placement. CLINICAL INDICATION: Chest tube placement. Respiratory CarePt remains mechaniclly ventilated, sedated and on IMV. Focus: Status updatePt lightly sedated oon propofol. Focus: Status updatePt sedated on propofol, titrated to comfort. Dr. notified. Focus: Status updatePt on propofol and ativan for comfort. Propofol/ativan for comfort. CT to suction. MS UP FOR PT COMFORT. Replete lytes as necessary. No BM this shift.Foley with adequate amounts concentrated urine.Plan: CMO and extubate in am per pt's wishes. Blood pressure within normal limits. Tylenol given for temp. 2+ pedal edema noted. 2+ pitting LE and scrotal edema. Resp CarePt remains on SIMV-parameters noted. Temp max 101.1. Propofol to comfort. Pt given tylenol per Dr. . P: Continue current plan of care. Had bronch today. + edema noted.Lung sounds absent on right side. Suction for scant secretions. Nursing note:NEURO: Lightly sedated on Propofol gtt, able to open eyes spont and follow commands. A-febrile. Pt continues on SIMV+PS. Slight LE edema.GI: Abdomen soft, -stool. Chest tube in place draining moderate amounts serosang drainage. Monitor fliud status. GI: Tube feed at goal, minimal residuals aspirated, abd flat/soft, non tender. See RT notes. Some respiratory distress noted when awake. Sedatives held today in order that pt would remain alert enough to make decision regarding CMO status. Suctioning small amounts of clear to pale tan secreations. Pt suctioned for mod/lg amounts thin tan secretions. PERRLA. CT to water suction. Suctioned infrequently for small amounts clear secretions.Abdomen soft, nondistended. Pt c/o left sided abd pain. Morning abg results revealed normal acid-base status with hyper-oxygenation. HO aware.Plan: Chest tube, sedation with propofol, pain management, emotional support, head MRI. Clarify questions/review information prn. Chest tube to water suction draining large amounts serous fluid.Abdomen soft, nondistended. 2+ LE edema.Lungs coarse at times. SEE CAREVUE FOR DETAILS:NEURO: ON PROPOFOL GTT, INCREASE LETHARGY NOTED IN PT, ABLE TO FOLLOW COMMANDS, PERLA, MAE'S, MEDICATED WITH ATIVAN AND MORPHINE FOR COMFORT.RESP: SX FOR THICK TAN SPUTUM, RR INCREASED 20'S, BS COARSE TO CLEAR AND DIMINISHED, REMAINS INTUBATED VENT SETTINGS UNCHANGED, ABG'S WNLCT H2O SX, DRAING COPIOUS AMT'S OF SEROUS SANGEERNOUS DRAINAGE, NO CREPITUS NOTEDCV: HR SINUS TACHYCARDIA NOTED WITH NO ECTOPY, PITTING EDEMA NOTED ON ALL EXT'S, IVF INFUSING PERIPHERAL ANGIO'S, TMAX 100.6 MED WITH TYLENOL,MAP > 70GI: TF AT GOAL, MINIMAL RESIDUAL,BS+, FLATUS+, NO BM, ABD SOFT, LIVER ENGORGED,GU: HOURLY U/O ADEQUATE, FOLEY HAND IRRIGATED X1A/P: RISBEE THIS AM, EMOTIONAL SUPPORT TO BOTH PT AND FAMILY, SPIRITUAL SUPPORT WITH ANNOITING OF THE SICK, EDUCATIONAL SUPPORT WITH LEVEL OF CARE Pleural fluid sent to lab as ordered.Abdomen soft, nondistended. Temp max 100.6. Breath sound are diminished bilat. Lung sounds clear, coarse at times, dim to bases. Pupils equal and reactive. Pupils equal and reactive. Pupils equal and reactive. DSG intact. Good fluctuation. Neuro: Lightly sedated, responding appropriately to questions. Respitory effort unlabored. No wean this shift.Will continue mech vent and wean as tol. Endo: Ssc with regular insulin. Palpable pulses bilaterally. Morning abg results determined a compensated respiratory acidemia with excellent oxygenation.No RSBI at this time. Denies pain but grimaces w/care, Morphine 2mg IV w/effect. | 35 | [
{
"category": "Radiology",
"chartdate": "2186-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853052,
"text": " 11:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH\n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest with no prior films for comparison.\n\n CLINICAL INDICATION: Obstruction of right bronchus intermedius.\n\n Endotracheal tube and nasogastric tube are in satisfactory position. There is\n complete opacification of the right hemithorax with associated ipsilateral\n shift of the mediastinum. There is an abrupt termination of the right main\n stem bronchus. The left lung demonstrates perihilar haziness and a subtle\n interstitial pattern but is otherwise grossly clear. No left pleural effusion\n is identified.\n\n IMPRESSION:\n\n 1) Complete collapse of the right lung likely due to obstructing central\n lesion. There is also likely a component of pleural effusion.\n\n 2) Left-sided perihilar haziness and interstitial pattern, most likely due to\n pulmonary edema from fluid overload, but lymphangitic spread of tumor may also\n produce a similar appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853138,
"text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct placement\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH\n REASON FOR THIS EXAMINATION:\n s/p ct placement\n ______________________________________________________________________________\n FINAL REPORT\n Portable semi-upright chest of .\n\n CLINICAL INDICATION: Chest tube placement.\n\n A right-sided chest tube remains in place. There remains complete collapse of\n the right lung due to a known centrally obstructing lesion. There is a right\n hydropneumothorax, which is mostly comprised of air with a lesser amount of\n fluid. There has been slight increase in the amount of pleural fluid since\n the recent study. Within the left lung, there remains perihilar haziness.\n Endotracheal tube and nasogastric tube remain in satisfactory position.\n\n IMPRESSION:\n\n 1) Persistent complete collapse of right lung and the patient with known\n centrally obstructing neoplasm.\n 2) Large right hydropneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-14 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 853103,
"text": " 12:42 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: r/o mets\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with mass obstructing right bronchus intermedius, hypoechoic\n liver lesions on CT from OSH.\n REASON FOR THIS EXAMINATION:\n r/o mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Probable lung cancer. Staging to evaluate for brain metastases.\n\n TECHNIQUE: CT of the head without and with IV contrast.\n\n FINDINGS:\n\n There is a subtle focus of enhancement at the -white junction, in the\n right frontal convexities. There is also left periventricular white matter\n low attenuation. No other focus of abnormal enhancement is detected. The\n major intracranial arteries are patent. There is no shift of normally midline\n structures. The ventricles, sulci, and cisterns are unremarkable, without\n effacement. There is no intraparenchymal or extra-axial hemorrhage.\n\n The visualized paranasal sinuses, soft tissues, and osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n Small focus of enhancement within the right frontal convexities, concerning\n for metastases. Left periventricular white matter low attenuation is of\n unclear etiology and could be unusual for microvascular ischemia in a 50-year-\n old patient. Underlying occult metastases cannot be excluded. An MRI of the\n brain is recommended for further evaluation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-14 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 853104,
"text": " 12:42 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate lung tumor and r/o mets\n Admitting Diagnosis: BRONCHIAL TUMOR\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with mass obstructing right bronchus intermedius, hypoechoic\n liver lesions on CT from OSH.\n REASON FOR THIS EXAMINATION:\n evaluate lung tumor and r/o mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right bronchus intermedius lesion seen on outside hospital\n broncoscopy. Staging study to evaluate for metastatic disease.\n\n TECHNIQUE: CT of the torso without and with IV contrast.\n\n CT CHEST W/O & W/IV CONTRAST: There is an air-fluid level within the right\n mainstem bronchus and complete collapse of the right lung with a large right\n pleural effusion and a layering hematocrit level posteriorly (status-post\n thoracentesis). There is no mediastinal shift. There is also a small left\n pleural effusion, and a small pericardial effusion. There is slight\n atelectasis within the left lung, but no nodule is detected. Several small\n mediastinal lymph nodes are present. The largest mediastinal lymph node is in\n the precarinal space, and measures 8.0 mm in maximum short- axis dimension.\n\n CT ABDOMEN W/O & W/IV CONTRAST: There are multiple low attenuation lesions\n throughout the liver, measuring up to 1.5 cm in diameter, and concerning for\n metastases. There are also multiple bilateral renal lesions. The largest\n renal lesion is located within the anterior mid right kidney and measures\n 3.2 cm in diameter. There is left-sided hydronephrosis and left hydro-ureter.\n The spleen, pancreas, gallbladder, and visualized portions of the bowel are\n unremarkable. There is a small amount of ascites.\n\n CT PELVIS W/O & W/IV CONTRAST: A Foley catheter is present within the\n decompressed bladder. The distal left ureter is not well-evaluated due to\n streak artifact. There is possibly an ill-defined low attenuation lesion in\n the region of the left ureteral-vesicular junction, but again, this region is\n not well-evaluated. Ascites tracks into the pelvis. There is a left inguinal\n hernia, with fluid tracking in the left inguinal hernial sac.\n\n Osseous structures are unremarkable.\n\n IMPRESSION\n 1. Complete collapse of the right lung, likely secondary to the reported\n endobronchial lesion.\n 2. Large right effusion with a layering hematocrit level, likely secondary to\n the recent thoracentesis.\n 3. Small left pleural effusion and small pericardial effusion.\n 4. Multiple low attenuation lesions throughout the liver, and throughout both\n (Over)\n\n 12:42 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate lung tumor and r/o mets\n Admitting Diagnosis: BRONCHIAL TUMOR\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n kidneys bilaterally, concerning for metastatic disease.\n 5. Small ascites, including fluid tracking into the pelvis and into the left\n inguinal hernial sac.\n 6. Left hydronephrosis and left hydro-ureter, with no etiology detected. The\n distal left ureter and the bladder are not well-evaluated on this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-16 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 853246,
"text": " 10:05 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: LUNG CANCER,MS, R/O METASTASIS\n Admitting Diagnosis: BRONCHIAL TUMOR\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with lung CA\n REASON FOR THIS EXAMINATION:\n r/o metastasis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50 year old man with lung cancer, rule out metastasis.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging without and with\n gadolinium enhancement.\n\n FINDINGS: In the peripheral right frontal lobe, there is a focus of abnormal\n enhancement. This is worrisome for metastatic disease in this patient with\n known metastatic cancer. Numerous foci of increased T2 signal in the\n periventricular and deep white matter are consistent with the patient's\n history of MS. areas of restricted diffusion or susceptibility are\n identified. There is no hydrocephalus or shift of normally midline\n structures. Osseous and soft-tissue structures are unremarkable.\n\n IMPRESSION:\n\n 1) Enhancing focus in the periphery of the right frontal lobe worrisome for\n metastatic disease.\n\n 2) Areas of high T2 signal in the periventricular and deep white matter are\n consistent with the patient's history of multiple sclerosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853206,
"text": " 3:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH\n REASON FOR THIS EXAMINATION:\n s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n Portable upright chest , compared to previous study of earlier\n the same date.\n\n CLINICAL INDICATION: Status post bronchoscopy.\n\n Endotracheal tube, nasogastric tube, and right-sided chest tube remain in\n place. There remains complete collapse of the right lung due to a known\n centrally obstructing endobronchial lesion. However, the volume of the\n collapsed lung has slightly increased, particularly when compared to the\n radiograph of at 17:38. There is a large right hydropneumothorax\n with progressively increasing fluid compared to prior serial chest\n radiographs. Left-sided perihilar haziness is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853129,
"text": " 5:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Locate chest tube and evaluate for re-expansion of the chest\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH\n REASON FOR THIS EXAMINATION:\n Locate chest tube and evaluate for re-expansion of the chest tube.\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest of compared to previous study of earlier\n the same date.\n\n CLINICAL INDICATION: Thoracentesis.\n\n An endotracheal tube and nasogastric tube remain in place. There has been\n placement of a right-sided chest tube and evacuation of a right pleural\n effusion with a residual small effusion remaining. The right lung is\n completely collapsed, and note is again made of abrupt termination of the\n right main stem bronchus. There is a large hydropneumothorax on the right,\n predominantly air filled, with a lesser component of fluid. Again,\n demonstrated is an interstitial pattern in the left lung, which appears\n unchanged allowing for lower lung volumes on the current study.\n\n IMPRESSION:\n\n Status post evacuation of large right pleural effusion with residual large\n hydropneumothorax with greater component of air within fluid. The right lung\n is entirely collapsed, due to a known obstructing central endobronchial\n lesion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-17 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 853370,
"text": " 10:21 AM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: perc biopsy liver mets for tissue diagnosis of metastatic di\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50M with large right lung cancer & concerning liver lesions\n REASON FOR THIS EXAMINATION:\n perc biopsy liver mets for tissue diagnosis of metastatic disease\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Ultrasound-guided liver biopsy.\n\n INDICATION: Patient with lung carcinoma and liver lesions on CT examination.\n To evaluate for histological analysis.\n\n TECHNIQUE: Informed consent was obtained from the patient's partner and\n sister. timeout was performed to confirm the patient identity\n and indication for examination. A suitable spot for biopsy was marked and\n infiltrated with lidocaine. The patient was cleansed and draped in the\n standard fashion.\n\n Using direct son visualization and 18-gauge needle, three cores were\n taken from a 2-cm hypoechoic lesion through the location within the anterior\n aspect of the right lobe of the liver. Onsite cytology confirmed adequate\n cellularity of the specimen. The patient tolerated the procedure well, and\n there are no immediate complications.\n\n The attending Dr. was present throughout the procedure.\n\n CONCLUSION:\n\n Successful ultrasound-guided liver biopsy.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853554,
"text": " 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o worsening pneumothorax\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH, s/p chest tube, and\n REASON FOR THIS EXAMINATION:\n r/o worsening pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 50-year-old with known obstructing endobronchial mass, assess\n pneumothorax.\n\n Portable supine frontal radiograph. Comparison and upright\n radiograph from .\n\n FINDINGS:\n\n There has been no change in the appearance of the position of the endotracheal\n tube, NG tube, or right-sided chest tube. The right-sided hydro-pneumothorax\n appears essentially unchanged allowing for difference in positioning. The\n mediastinum remains shifted towards the right.\n\n IMPRESSION:\n\n Essentially unchanged appearance of right hydro-pneumothorax. Stable position\n of ET tube and chest tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-01-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853173,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct placement\n Admitting Diagnosis: BRONCHIAL TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with obstructing R bronchus intermed sp thoracentesis and\n bronch at OSH\n REASON FOR THIS EXAMINATION:\n s/p ct placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n Compared to previous study of one day earlier.\n\n CLINICAL INDICATION: Chest tube placement.\n\n Endotracheal tube, right-sided chest tube, and nasogastric tube remain in\n place. Mediastinal and hilar contours are stable with persistent rightward\n shift. There remains complete collapse of the right lung consistent with\n known obstructing endobronchial lesion. There is a large hydropneumothorax on\n the right with gradually increasing fluid component. The left lung\n demonstrates a persistent perihilar interstitial pattern.\n\n IMPRESSION:\n\n 1. Persistent complete collapse of right lung due to known obstructing\n central endobronchial lesion.\n\n 2. Large right hydropneumothorax with gradually increasing fluid component.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-18 00:00:00.000",
"description": "Report",
"row_id": 1288199,
"text": "Pt remains on current vent settings, see carevue for details. Has episodes of ^RR on vent, possibly anxiety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-14 00:00:00.000",
"description": "Report",
"row_id": 1288183,
"text": "Nursing note:\nNEURO: Arrived sedated/paralyzed via . Begun on Propofol gtt, waking up later in evening. Opens eyes to voice when Propofol gtt decreased to 20mcg, following simple commands. PERRLA. MAE on bed w/normal strength. Nodding in response to questions. Denies pain.\nRESP: Lung sounds coarse, dim to bases. Expiratory wheezing noted at times. P02 76 on 40% Fi02, increased to 50% w/ABGs pending. No other vent changes. Suctioned for small amounts yellow thick sputum. CXR done x2.\nCV: Afebrile. SR-ST to 120s, no ectopy. SBP 90-110. Palpable pulses, +pedal edema. Begun on Heparin sq. Skin pale, warm and dry. 500cc NS bolus x1 for borderline HUO and slight hypotension.\nGI: Abdomen soft, non-distended. +Hypo BS, no stool. NPO, OGT to sxn for clear drainage.\nGU: Foley patent borderline amounts amber urine.\nENDO: Glucose stable, no SSRI given.\nSKIN: Intact, no areas of breakdown.\n\nA/P: Hemodynamically stable s/p transfer from OSH this evening after bronch done for known lung mass. Continue to monitor closely for change, follow ABGs, ? CT scan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-15 00:00:00.000",
"description": "Report",
"row_id": 1288190,
"text": "Respiratory Care\nPt remains on mechanical ventilation, no changes made to settings. Heated wire circuit added. Bronchoscopy reveal large amounts of clear to white secreations suction. Breath sounds diminished, right side expiratory wheezes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-19 00:00:00.000",
"description": "Report",
"row_id": 1288200,
"text": " Condition Update\nPlease see carevue for specifics:\n\nPt with tmax 100.8 orally overnoc and heart rate sinus tachy 105-135 and sbp 90's-120's/50-60's. Dr. and aware oof HR increasing to 130's- pt was very anxious and was attempitng to pull out ETT and OGT mouthing that he did not want them in and knew that he would not be able to breathe without the vent; pt at 2200 was calmed down by reassuring him that all was OK and no changes in care were going to be done tonight and pt calmed for approx 20 minutes- then t became extremely agitated and was fighting against his SO and the RN and was wirhting around in bed to attempt to get his arms free to self-extubate. Dr. saw episode and pt was admin 2.5mg haldol (QT interval= .30) and was repeated x 1 at 2400. Pt was also admin 2mg ativan, and morphine- propofol gtt was increased from 15mcg to 20mcg- at 2445 pt finally calmed down and slept for a few hours- for the rest of the noc pt has been sleeping but easilty arousable and following commands as asked; NSS. LS diminished to absent on right side and coarse on left side- clearing on the upper left field at 0400 afer suctioning with ABG's WNL and 02 sats 99-100% with no vent changes overnoc. CT at 20sonometers of suction and draining copious amounts of serosang fluid (MD's aware)- dressing CDI with no staining or crepitus noted. +pp/+dp. Foley draining 30-70cc cyu/hr- pt -500cc for today but +10L for total stay. Cont to monitor labs, vs, i/o's, give social support for fmaily. SO stated that pt had pt wanted to be extubated even though he understood he would not be able to breathe- pt also mouthed it to RN. Family meeting needs to be scheduled in am to discuss status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-14 00:00:00.000",
"description": "Report",
"row_id": 1288184,
"text": "Resp: pt via from osh intubated following acute decompensation after having a bronch. RS mass (bronchial tumor). HX: MS, smoker, xray reveals R sided whiteout. Drained for 2L fluid. Transferred for further pulmonary evaluation. MDI: Alb/Atr Q6 hrs prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-14 00:00:00.000",
"description": "Report",
"row_id": 1288185,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, sedated and on IMV. Attempted CPAP/PSV briefly while pt was awake, consistant RR and VT. Sedated for bronchoscopy and CT scan as well as possible chest tube placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-14 00:00:00.000",
"description": "Report",
"row_id": 1288186,
"text": "see carevue for details:\n\nPT HAD BEDSIDE BRONCHOSCOPY, DOWN FOR HEAD, ABDOMINAL, AND CHEST CT,\nRIGHT ANGLE 28 FRENCH CT INSERTED INITIAL FLUID 2350 CC'S FLUID BOLUS X1, REPEAT CXR DONE, AWAITING ABG RESULTS, MTN ON VENT, EMMOTIONAL AND EDUCATIONAL SUPPORT GIVEN TO FAMILY, MED WITH ATIVAN AND MORPHINE, MTN PROPOFOL GTT\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-15 00:00:00.000",
"description": "Report",
"row_id": 1288187,
"text": "Nursing note:\nNEURO: Sedated on PPF gtt though pt. does wake and become anxious/agitated at times. Following simple commands, MAE. PERRLA. Pt. is blind in R. eye. Ativan 1mg x1 given w/some relief. Denies pain though grimacing at times, Morphine PRN.\nRESP: Lung sounds clear, dim to bases. Suctioned occ. for thick yellow secretions. No vent changes, ABGs acceptable. Copious oral secretions. R. CT intact, dressing in place to suction, no leak, +fluctuation. No crepitus. Large amount sanguinous drainage, hct stable @ 30 at 2200.\nCV: Afebrile. SR-ST to 120s, no ectopy. SBP 90s-120s. Edema to lower extremities and scrotum. Palpable pulses bilaterally.\nGI: +BS, abdomen soft, NPO. OGT to sxn for bilious drainage. Tolerated PO meds via OGT.\nGU: Foley patent borderline amounts amber urine.\nENDO: Glucose stable.\nSOCIAL: and sister in to visit during evening, staying @ Best Western overnight.\nSKIN: Intact, no areas of breakdown.\n\nA/P: Stable, anxious at times overnight. CT in place for large amounts sanguinous drainage, am hct pending. Continue to monitor resp and all systems for change, follow labs, safety, medicate PRN pain/anxiety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-15 00:00:00.000",
"description": "Report",
"row_id": 1288188,
"text": "Respiratory care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results revealed normal acid-base status with hyper-oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-15 00:00:00.000",
"description": "Report",
"row_id": 1288189,
"text": "Focus: Status update\nPt lightly sedated oon propofol. Opens eyes to voice, follows commands consistently. Pupils equal and reactive. Moves all extremities. A-febrile. Medicated with morphine for pain with effect per pt.\n\nSinus tach on telemetry. HR < 110. Systolic blood pressure 90'-100's. 2+ pedal edema noted. Recieved 2 500cc Normal saline boluses for tachycardia, low BP and poor urine output.\n\nLungs clear other than right base which is deminished. Chest tube in place draining moderate amounts serosang drainage. No vent changes made today. Bronchoscopy done at 2pm. Sputum sample sent to lab.\n\nAbdomen soft, nondistended. Tube feedings initiated at 10cc/hr as ordered. No BM this shift.\n\nFoley with 25-30cc/hr amber urine. HO aware.\n\nPlan: Chest tube, sedation with propofol, pain management, emotional support, head MRI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-16 00:00:00.000",
"description": "Report",
"row_id": 1288191,
"text": "Nursing note:\nNEURO: Lightly sedated on Propofol gtt, able to open eyes spont and follow commands. MAE on bed. PERRLA. Denies pain but grimaces w/care, Morphine 2mg IV w/effect. Ativan PRN for anxiety, appears anxious and slightly agitated at times.\nRESP: No vent changes, suctioned infrequently for thick yellow secretions. Lung sounds clear, coarse at times, dim to bases. CT in place to 20cm sxn, negative for leak, patent for large amounts serosang. drainage. Dressing intact, no drainage, no crepitus.\nCV: SR-ST to 115, no ectopy. SBP 90-120. Given 500cc NS bolus x1 for SBP dropping to high 80s and HUO 20-25cc/hr w/some effect. Palpable pulses bilaterally. Slight LE edema.\nGI: Abdomen soft, -stool. +BS. Tolerating trophic TFs via OGT.\nGU: Foley patent amber urine, low urine outputs x2 hours, bolus given, effects pending.\nENDO: Glucose stable.\nSKIN: Intact.\n\nA/P: Stable, anxious at times.\nContinue w/large CT outputs, bolused x1 for low urine output, hypotension and tachycardia. Continue to monitor closely, MRI head, pain/anxiety control, update family w/plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-16 00:00:00.000",
"description": "Report",
"row_id": 1288192,
"text": "Respiratory Care\nPt remains mechaniclly ventilated, taken to MRI for scan of his head followed by bronchoscopy at the bedside by Dr . RSBI checked several hours after bronchoscopy. Suctioning large amounts of pale white to blood tinged secreations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-16 00:00:00.000",
"description": "Report",
"row_id": 1288193,
"text": "Focus: Status update\nPt sedated on propofol, titrated to comfort. Follows commands, nodds appropriately when asked questions. Pupils equal and reactive. Medicated for pain with morphine with effect. Ativan for anxiety. Moves all extremities. Had head MRI today which showed lesion.\n\nSinus tachy on telemetry. HR<110. SBP 90's-100's with transient dips to 80's. 2+ LE edema.\n\nLungs coarse at times. RSBI this afternoon 200. Pt continues on SIMV+PS. O2 sats 97-100%. Had bronch today. CT to suction draining large amounts serosang fluid. Poor fluctuation. HO aware. DSG intact. Pleural fluid sent to lab as ordered.\n\nAbdomen soft, nondistended. Pt c/o left sided abd pain. SICU team aware. TF increased as ordered. No insulin required. No BM this shift. To be NPO after MN for biopsy tomorrow.\n\nFoley with adequate amounts amber urine since rate of IVF increased to 150cc/hr.\n\nPlan: US guided liver bx tomorrow at 1015. Monitor for pain/anxiety and medicate accordingly. CT to suction. Propofol to comfort. Monitor VS, labs, I/o's. Replete lytes as necessary. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-17 00:00:00.000",
"description": "Report",
"row_id": 1288194,
"text": "see carevue for details:\n\nNEURO: REMAINS SEDATED ON PROPOFOL GTT, MED WITH ATIVAN AND MORPHINE FOR COMFORT, NEURO EXAM UNCHANGED\n\nRESP: REMAIN INTUBATED, NO VENT CHANGES, ABG'S WNL, CT TO H20 SX\n900CC'S OF SERSANGERNOUS DRAINAGE, PLEUROVAC CHANGED CT SITE NO CREPITOUS NOTED, NO AIR LEAKS NOTED SX BOTH ORALLY AND ETT FOR MOD AMT OF THICK TAN SECRETIONS, B/L BREATH SOUNDS CURRENTLY CLEAR BUT DIMINISHED THRU OUT\n\nCV: HR SINUS TACHYCARDIA NOTED MAX 110, T MAX 99.6, IVF 0.9NS WITH 20 MEQ KCL @ 150 HR, 500CC'S FLUID BOLUS X 3, PITTING EDEMA NOTED IN SCROTUM AND B/L FEET, COLOR IMPROVED, SKIN WARM AND DRY SYS B/P 80-100\n\nGI: NPO AFTER MN FOR LIVER BX IN AM, BS +, NO BM OR FLATUS, ABD SOFT,\nLIVER ENLARGED UPON PALPATATION, NO INSULIN REQUIRED ON SSI REGIME\n\nGU: HOURLY U/O ADEQUATELY WITH FLUID BOLUS'S, SEDIMENT NOTED IN URINE, U/A SENT\n\nA/P: LIVER BX TODAY EMOTIONAL AND EDUCATIONAL SUPPORT TO FAMILY, PT'S COMFORT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-17 00:00:00.000",
"description": "Report",
"row_id": 1288195,
"text": "Respiratory Care\nPt remains on full mechanical ventilatory support, transport to Ultrasound and back without incident. Liver biopsy preformed, oncology becoming involved in the pt's care. Breath sounds diminished. Suctioning small amounts of clear to pale tan secreations. Some respiratory distress noted when awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-17 00:00:00.000",
"description": "Report",
"row_id": 1288196,
"text": "Focus: Status update\nPt on propofol and ativan for comfort. Denies pain and refuesed pain med with nonverbal cues. Temp max 100.6. Pt given tylenol per Dr. . Pupils equal and reactive. Moves all extremities.\n\nSinus tach on telemetry. HR as high as 122. Dr. notified. Gave 2 250cc boluses with minimal effect. Tylenol given for temp. Awaiting effect. SBP 80's-100's. 2+ pitting LE and scrotal edema. Scrotum elevated on towel roll. IVF to be decreased to 100cc/hr when tube feedings at goal.\n\nNo vent changes made today. Suctioned infrequently for small amounts clear secretions. Chest tube to water suction draining large amounts serous fluid.\n\nAbdomen soft, nondistended. Tube feeding being increased to goal of 70cc/hr as ordered. No BM this shift. Blood glucose levels have not required any insulin sliding scale.\n\nFoley with adequate amounts yellow urine. Sediment noted.\n\nFamily in to visit all day. Had oncology consult after liver biopsy showing very poor prognosis. Social work notified of pt's case.\n\nPlan: Keep intubated and sedated overnight. ? extubate tomorrow. Propofol/ativan for comfort. Monitor for pain and medicate accordingly. Monitor fliud status. CT to water suction. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-18 00:00:00.000",
"description": "Report",
"row_id": 1288197,
"text": "SEE CAREVUE FOR DETAILS:\n\nNEURO: ON PROPOFOL GTT, INCREASE LETHARGY NOTED IN PT, ABLE TO FOLLOW COMMANDS, PERLA, MAE'S, MEDICATED WITH ATIVAN AND MORPHINE FOR COMFORT.\n\nRESP: SX FOR THICK TAN SPUTUM, RR INCREASED 20'S, BS COARSE TO CLEAR AND DIMINISHED, REMAINS INTUBATED VENT SETTINGS UNCHANGED, ABG'S WNL\nCT H2O SX, DRAING COPIOUS AMT'S OF SEROUS SANGEERNOUS DRAINAGE, NO CREPITUS NOTED\n\nCV: HR SINUS TACHYCARDIA NOTED WITH NO ECTOPY, PITTING EDEMA NOTED ON ALL EXT'S, IVF INFUSING PERIPHERAL ANGIO'S, TMAX 100.6 MED WITH TYLENOL,MAP > 70\n\nGI: TF AT GOAL, MINIMAL RESIDUAL,BS+, FLATUS+, NO BM, ABD SOFT, LIVER ENGORGED,\n\nGU: HOURLY U/O ADEQUATE, FOLEY HAND IRRIGATED X1\n\nA/P: RISBEE THIS AM, EMOTIONAL SUPPORT TO BOTH PT AND FAMILY, SPIRITUAL SUPPORT WITH ANNOITING OF THE SICK, EDUCATIONAL SUPPORT WITH LEVEL OF CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-18 00:00:00.000",
"description": "Report",
"row_id": 1288198,
"text": "See data, MD notes/orders. Neuro: Lightly sedated, responding appropriately to questions. Communicates some pain with deep inspiration, some anxiety. CV: ST/no ecotpy, sbp 90's-100's. Pulm: Risbi re-evaluated on rounds, >100. See RT notes. Pt suctioned for mod/lg amounts thin tan secretions. Right lung sounds decreased/left coarse, decreased at bases. 02 sats 96-98%. Respitory effort unlabored. GU: Uo 45-50cc hr. GI: Tube feed at goal, minimal residuals aspirated, abd flat/soft, non tender. Endo: Ssc with regular insulin. Skin: Surfaces grossly intact, small abrasion on left elbow, + pitting edema from knees to toes. Peripheral pulses present. Soc: Significant other \"\" and pts brother and sister at bedside. Family meeting was held and then options were discussed by Dr. with pt with family present. Pt unable to decide on comfort measures vs radiation therapy in hopes of shrinking tumor with goal of extubation. He did communicate desire to see other siblings and his father. P: Continue current plan of care. Prn morphine/ativan. Provide support for pt and family. Clarify questions/review information prn. Assist pt/family in any decision making as indicated. Offer clergy/social work assist. R: As above, pt declined clergy, social worker involved and has met with pt and family, see note. Family will coordinated visits with other siblilngs and pts elderly father.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-19 00:00:00.000",
"description": "Report",
"row_id": 1288201,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results determined a compensated respiratory acidemia with excellent oxygenation.\n\nNo RSBI at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-19 00:00:00.000",
"description": "Report",
"row_id": 1288202,
"text": "Resp Care\nPt remains on SIMV-parameters noted. Breath sound are diminished bilat. Suction for scant secretions. RSBI:149. No wean this shift.\nWill continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-19 00:00:00.000",
"description": "Report",
"row_id": 1288203,
"text": "Focus: Status update\nPt alert, appears oriented x3. Responds very appropriately to all questions by nodding and using letter board. Temp max 101.1. Recieving morphine around the clock with effect per pt. Moving all extremities. Sedatives held today in order that pt would remain alert enough to make decision regarding CMO status. Spoke with Dr. at 1700. RN in room. Pt clearly expressed wishes to visit with famly tonight and begin CMO in am.\n\nSinus tach <120 on tele. No ectopy noted. Blood pressure within normal limits. + edema noted.\n\nLung sounds absent on right side. Chest tube with large amouts serous drainage. No leak. Good fluctuation. Dressing dry and intact. Suctioned infrequently for small amounts clear secretions.\n\nAbdomen soft, nondistended. Bowel sounds present. Tube feeding discontinued this eve. No BM this shift.\n\nFoley with adequate amounts concentrated urine.\n\nPlan: CMO and extubate in am per pt's wishes. Family in all day and aware of plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-20 00:00:00.000",
"description": "Report",
"row_id": 1288204,
"text": "pt alert beginning of shift, med with ativan, propofol, and morphine for comfort, care unchanged see carevure for details, educational and emotional support continued with both patient and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-20 00:00:00.000",
"description": "Report",
"row_id": 1288205,
"text": "Respiratory Care:\nPatient remains on ventilatory support (SIMV/PSV) with no parameter changes made throughout the night. No morning abg results.\n\nPlan is to wean patient from the vent this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-20 00:00:00.000",
"description": "Report",
"row_id": 1288206,
"text": "CONDITION UPDATE\nD: FAMILY AND SIGNIFICANT OTHER MET WITH MD AND DISCUSSED PT'S WISHES. PT STARTED ON MS AND THEN EXTUBATED AT 1300 AFTER FAMILY ALL PRESENT. MS UP FOR PT COMFORT. FAMILY REMAINS AT BEDSIDE\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-20 00:00:00.000",
"description": "Report",
"row_id": 1288207,
"text": "NURSING UPDATE:\n PT AWAKE AND VERY RESTLESS AT 1900, NODDING IN RESPONSE TO NEED FOR INCREASED PAIN MEDICATION, MORPHINE GTTS INCREASED PER ORDER. PT REMAINED AWAKE BUT MORE RESTED UNTIL 2 MINS BEFORE DEATH. HR DROPPED FROM 140'S TO 30 @ AND PRESENTED WITH ASYSTOLE AT . PARTNER AND FAMILY AT BEDSIDE AT TIME OF DEATH. CARDIOTHORACIC TEAM NOTIFIED OF DEATH BY DR , AWAITING PRONUCNIATION AT THIS TIME.\n"
}
] |
3,866 | 155,490 | 50 year old man with history of end stage renal disease secondary to amyloidosis, paroxysmal atrial fibrillation, Type 2 diabetes on insulin admitted for dysfunction of hemodialysis line, transferred to ICU for hypotension after hemodialysis (3kg taken off) and fentanyl during interventional radiology procedure to declot and replace hemodialysis line. . # End Stage Renal Disease: - last hemodialysis , right femoral tunneled catheter functioning well - renal to attempt to clear catheter with local tPA failed -> interventional radiology for catheter change -> hypotension, extensive clot burden in right femoral vein through inferior vena cava up to right atrium -> ICU - Dialysis catheter tip growing E. Coli, sensitive to Ceftazidime, received 1g qHD for 2 weeks after catheter removed, last dose given in in dialysis - Right groin catheter in place functioning for now - sevelamer, cinacalcet, nephrocaps - Family meeting , decided on placement of peritoneal dialysis and placement of patient in facility that could perform peritoneal dialysis. - status post peritoneal dialysis catheter placement , needs 2-3 weeks to heal prior to use, renal doctor as outpatient. . # Finger ischemia: consistent with history of extensive microvascular disease. No anticoagulation - see rationale below. - status post Plastic Surgery consult - appreciate input - no surgery for now, awaiting demarcation, finger segment will likely autoamputate. No signs of infection necessitating amputation during this hospitalization. . # Thrombosis: - Extensive inferior vena cava burden to level of right atrium and likely involvement of superior vena cava. Risk associated with anticoagulation in this patient related to history of hemodynamically signficant epistaxis, recurrent epistaxis, and hemoptysis related to fungal lesion in left upper lobed of the lung. - Maintained active type and screen in blood bank - Heparin gtt was started after extensive clot discovered, stopped given epistaxis, possible hemoptysis vs. swallowed blood, peri-catheter oozing . Patient hemodynamically stable. Hematocrit 34.9->36.7 (dialysis in between draws). Will not anticoagulate now after discussing risks and benefits in family meeting on . . # Leukocytosis: - No fevers and no signs or symptoms to suggest infection. - WBC 12.8 early in hospital course, now no elevation in WBC - Treated for E. Coli sepsis after grew on HD cath tip with Ceftazidime as above - Blood cultures 4/30 - no growth (final) - Blood cultures 5/10, pending - were drawn after mildly hypotensive following dialysis, had no fever/WBC elevation . # Hypotension & tachycardia: Most likely due to fluid removal from dialysis + fentanyl. Sepsis also in DDx, especially with leukocytosis. Considered bleeding while on heparin gtt, adrenal insufficiency given chronic steroids for sarcoidosis. - Hemodialysis end goal weight increased - Blood cultures 4/30 - no growth (final) - Triggered for BP 60/Doppler -> 80s systolic after 1.5L, no signs of active bleeding, mentating at baseline, hematocrit stable - Morphine discontinued as likely contributed to hypotension - now oxycodone for finger pain - Still mildly hypotenisve post-hemodialysis, asymptomatic, pressure responds to IV fluids . # Sarcoidosis: - on chronic prednisone . # Pulmonary aspergillosis: - on chronic suppressive voriconazole . # h/o MRSA bacteremia: - no evidence of active infection - continue DS bactrim x 4 with HD for suppressive therapy - followed by as outpatient . # Paroxysmal Atrial fibrillation: - metoprolol 12.5 mg po 2x/day for rate control as outpatient, had been held in setting of hypotension -> restarted AM (held for systolic < 100) - initially no anticoagulation given history of bleeds -> started heparin gtt with discovery of extensive thrombosis -> heparin discontinued given mild nosebleed/hemoptysis/ooze from femoral catheter . # Type 2 Diabetes - Continued glargine at 8 units HS with SSI - Fingersticks good range when eating, hypoglycemic when NPO for catheter placement . # Possible Asthma: on albuterol PRN . # Recent nosebleeds: - per ENT consult on last admission, humidified air as much as possible, nasal saline spray Q2h, bacitracin to each nostril and massage gently for a few seconds qam and qhs. - Epistaxis precautions, including no straining, nose blowing, or temperature hot foods. Light activity only. Colace or other stool softener on a regular basis. . # Constipation: Standing Colace, Senna, Dulcolax (made standing ); PRN Lactulose added -> had bowel movement . # GERD: PPI . # FEN: renal, diabetic, low potassium diet . # PPx: PPI, bowel regimen, held anticoagulation . # Code: FULL (confirmed with patient) | Trivial mitral regurgitation is seen. Normal ascending aorta diameter. NO BM THIS SHIFT.GU: ANURIC. ]TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normaltricuspid valve supporting structures. Moderatemitral annular calcification. IS ANUREIC.PT. There is no pericardial effusion.The proximal inferior vena cava up to the junction with the right atrium isfilled with echodensity consistent with thrombus. Indeterminate PA systolicpressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Otherwise,no diagnostic interim change. DENIES ANY CHEST PAIN. NOT C/O PAIN. NEW HD LINE IS NOT FUNCTIONING D/T CLOT BURDEN. Non-specific ST-T wave flattening inleads I, aVL and V5-V6. There is mild symmetric left ventricularhypertrophy. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. There is moderatethickening of the mitral valve chordae. REMAINS NST 104-124 WIT NO NOTED ECTOPY. NO FLUID BOLUSES REQUIRED DURING THIS SHIFT. Normal LV cavity size. Focal calcifications inaortic root. Hypotensive. Lungs CTA bilaterally respirations even and unlaboredCardiac: Hemodynamically stable, Tele ST 100's without ectopy. No mass or thrombus in the RAor RAA.LEFT VENTRICLE: Mild symmetric LVH. The left ventricular cavity size is normal. CURRENTLY HAS HEMOSTATIC DRESSING- DO NOT REMOVE UNLESS SATURATED WITH FRESH BLOOD.GI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. PT. PT. PT. PT. PT. PT. PT. Compared to the previous tracingof there is no significant change. REMAINS BENIGN IN ASSESSMENT. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. These findings are consistentwith biatrial elargement. However, the echodensitydoes not appear to extend into the right atrium itself.Compared with the findings of the prior study (images reviewed) of , echodensities in the inferior vena cava are now seen. IS A DIALYSIS PT. AFEBRILE. No AS. There is no ventricularseptal defect. Sinus rhythm. REMAINS A FULL CODE AT THIS TIME.PT. post procedure remains sleepy D/T medications givenNeuro: A&Ox3, flat affect. There is no mitral valve prolapse. PASSING FLATUS. CURRENTLY NPO AT THIS TIME. no edema notedGI: NPO, + BS in 4 quadrents abdomen firm non distended. LUNGS REMAIN CLEAR THROUGHOUT.ABD. Prominentnegative reflection of the P wave in lead V1. REMAINS ON CONTACT PRECAUTIONS FOR MRSA.PT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT. No PS.Physiologic PR. HAS ALLERGIES TO BOTH CODEINE, AND ENALAPRIL.PT. REMAINS AFEBRILE THROUGHOUT THIS SHIFT. WITH A NON FUNCTIONING LINE. NO C/O N,V,D. No resting LVOT gradient. NO SEIZURE ACTIVITY NOTED.RR: BBS= ESSENTIALLY CLEAR THROUGHOUT ALL LUNG FIELDS. Focal calcifications inascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Full codePlan:1. Assess for clot in RA.Height: (in) 68Weight (lb): 105BSA (m2): 1.56 m2BP (mm Hg): 96/58HR (bpm): 110Status: InpatientDate/Time: at 09:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. REMAINS ON R/A AND SATS >95% RESP RATE IS CONTROLLED. Routine monitoring and care4. FOLLOWS COMMANDS WITHOUT DIFFICULTY. There is ST-T wave flattening. No MVP. HR 90-130'S. Peaked P waves and rightward P wave axis. Possible biatrial abnormality. No TS. Overall leftventricular systolic function is normal (LVEF 70%). DIFFICULT TO OBTAIN 02SAT D/T POOR VASCULAR STATE. No aortic regurgitation is seen. No MS. BLOOD SUGAR HAVE NOT REQUIRED COVERAGE AND HS INSULIN HELD DUE TO NPO STATUS. PATIENT/TEST INFORMATION:Indication: ESRD. THANK YOU! NO STOOL NOTED THIS SHIFT. DROPPED B/P AND WAS TRANSFERRED TO ICU. BS X 4 QUADRANTS. Moderate thickening of mitral valve chordae.Calcified tips of papillary muscles. No mass or thrombus is seen in the rightatrium or right atrial appendage. C/O to floor2. BILATERAL CHEST EXPANSION NOTED. No BM this shiftRenal: Anuric at baseline, scheduled for dialysis in AMID: afebrile, continues on home antibiotic regimenHeme: To restart heparin gtt at 1830 per protocolSkin: Intact no current issuesFEN: FS low ranging from 70-90's. The pulmonary artery systolic pressure couldnot be determined. SBP LABILE 80-90'S- RECEIVING FLUIDS FOR BOUTS OF HYPOTENSION. PT'S PRESENT/NEW LINE IS NON FUNCTIONING, DUE TO CLOTS. Sinus tachycardia. B/P HAS BEEN STABLE RANGING 84-104/50-60'S RENAL TEAM STATED THAT MID TO HIGH 80'S WOULD BE TOLERATED. Trivial MR. [Due to acousticshadowing, the severity of MR may be significantly UNDERestimated. Heparin gtt per protocol3. LAST DIALYSIS TODAY.PLAN: FLUIDS FOR HYPOTENSION. PT TX TO 787 WITH NO UNTOWARD INCIDENT.MR WAS INITIALLY ADMITTED ON AFTER HIS HD LINE BECOME NON-FUNCTIONAL HALFWAY THROUGH HIS LAST OUTPATIENT HD SESSION. [Due to acoustic shadowing, the severity of mitral regurgitation may besignificantly UNDERestimated.] WHEN ABLE TO READ- SP02 > OR = TO 95%.CV: S1 AND S2 AS PER AUSCULTATION. BOWEL SOUNDS ARE EASILY AUDIBLE. Overall normal LVEF(>55%). PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. PIG TAIL OFF THIS NEW LINE CONTINUES TO WORK. ON PT WAS IN IR FOR NEW HD LINE PLCMT- DURING THE PROCEDURE WAS FOUND TO HAVE A LARGE CLOT BURDEN IN HIS IVC AND RT FEMORAL VEIN. Nursing Progress Note 0700-1900Events: Pt sent down to IR with anesthesia s/o left double lumen midline placement & Left groin temporary dialysis line placement. The mitral valve leaflets aremoderately thickened. WILL INITIATE HEPARIN GTT FOR CLOTS. Good bed mobility.Resp: Sats 96-100% on 2 LNC. CONTINUES TO NOT WANT TO PARTICIPATE IN MANY ASPECTS OF HIS OWN CARE.PT. HAD NEW DAILYSIS LINE PLACED YESTERDAY IN I.R. MONITOR FEMORAL SITE- PAGE IR FOR ANY COMPLICATIONS. UPON PT'S HD LINE NOTED TO BE BLEEDING PROFUSELY, IR AT BEDSIDE APPLYING SADDLE SUTURES- IR WILL NEED TO REMOVE SUTURES WHEN LINE IS EVENTUALLY DC'D.NEURO: PT LETHARGIC BUT BECOMING MORE AS SHIFT PASSES- X 3. Emotional support to patient and family PLAN TO DRAW AM LABS VIA ARTERIAL STICK. Compared to the previous tracing of the rate has increased. Given IV morphine x 2 for finger pain with good effect. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2135-05-30 00:00:00.000",
"description": "Report",
"row_id": 1312288,
"text": "NURSING ADMISSION AND PROGRESS NOTE 1630-1900\nPT ARRIVED FROM IR WITH- REPORT RECEIVED FROM IR NURSE. PT TX TO 787 WITH NO UNTOWARD INCIDENT.\n\nMR WAS INITIALLY ADMITTED ON AFTER HIS HD LINE BECOME NON-FUNCTIONAL HALFWAY THROUGH HIS LAST OUTPATIENT HD SESSION. D/T HIS HX OF HYPERKALEMIA- IT WAS FELT HE WAS NOT SAFE TO RETURN TO THE NURSING HOME WITHOUT ACCESS. ON PT WAS IN IR FOR NEW HD LINE PLCMT- DURING THE PROCEDURE WAS FOUND TO HAVE A LARGE CLOT BURDEN IN HIS IVC AND RT FEMORAL VEIN. NEW HD LINE IS NOT FUNCTIONING D/T CLOT BURDEN. PT HAD RECEIVED TOTAL OF 50MCG FENTANYL IVP AND WAS FOUND TO HAVE SBP IN THE 50'S- TX TO ICU FOR FURTHER MANAGEMENT. UPON PT'S HD LINE NOTED TO BE BLEEDING PROFUSELY, IR AT BEDSIDE APPLYING SADDLE SUTURES- IR WILL NEED TO REMOVE SUTURES WHEN LINE IS EVENTUALLY DC'D.\n\nNEURO: PT LETHARGIC BUT BECOMING MORE AS SHIFT PASSES- X 3. NOT C/O PAIN. FOLLOWS COMMANDS WITHOUT DIFFICULTY. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY CLEAR THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. DIFFICULT TO OBTAIN 02SAT D/T POOR VASCULAR STATE. WHEN ABLE TO READ- SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. DENIES ANY CHEST PAIN. HR 90-130'S. SBP LABILE 80-90'S- RECEIVING FLUIDS FOR BOUTS OF HYPOTENSION. PT HAS RT FEMORAL TRAUMA LINE- NOTED TO BE BLEEDING PROFUSELY SITE- IR IN TO EVALUATE- APPLIED SADDLE SUTURES TO THE AREA. CURRENTLY HAS HEMOSTATIC DRESSING- DO NOT REMOVE UNLESS SATURATED WITH FRESH BLOOD.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. CURRENTLY NPO AT THIS TIME. BS X 4 QUADRANTS. NO C/O N,V,D. PASSING FLATUS. NO BM THIS SHIFT.\n\nGU: ANURIC. LAST DIALYSIS TODAY.\n\nPLAN: FLUIDS FOR HYPOTENSION. WILL INITIATE HEPARIN GTT FOR CLOTS. MONITOR FEMORAL SITE- PAGE IR FOR ANY COMPLICATIONS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-05-31 00:00:00.000",
"description": "Report",
"row_id": 1312289,
"text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO BOTH CODEINE, AND ENALAPRIL.\n\nPT. REMAINS ON CONTACT PRECAUTIONS FOR MRSA.\n\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT. PT. REMAINS AFEBRILE THROUGHOUT THIS SHIFT. PT. CONTINUES TO NOT WANT TO PARTICIPATE IN MANY ASPECTS OF HIS OWN CARE.\n\nPT. REMAINS NST 104-124 WIT NO NOTED ECTOPY. B/P HAS BEEN STABLE RANGING 84-104/50-60'S RENAL TEAM STATED THAT MID TO HIGH 80'S WOULD BE TOLERATED. NO FLUID BOLUSES REQUIRED DURING THIS SHIFT. HEPARIN GTT IS INFUSING AT GOAL RATE OF 700 UNITS/HR WITH AM LABS TO BE DRAWN BY M.D.\n\nPT. REMAINS ON R/A AND SATS >95% RESP RATE IS CONTROLLED. LUNGS REMAIN CLEAR THROUGHOUT.\n\nABD. REMAINS BENIGN IN ASSESSMENT. BOWEL SOUNDS ARE EASILY AUDIBLE. NO STOOL NOTED THIS SHIFT. BLOOD SUGAR HAVE NOT REQUIRED COVERAGE AND HS INSULIN HELD DUE TO NPO STATUS. PT. IS A DIALYSIS PT. WITH A NON FUNCTIONING LINE. PT. IS ANUREIC.\n\nPT. HAD NEW DAILYSIS LINE PLACED YESTERDAY IN I.R. PT. DROPPED B/P AND WAS TRANSFERRED TO ICU. PT'S PRESENT/NEW LINE IS NON FUNCTIONING, DUE TO CLOTS. PIG TAIL OFF THIS NEW LINE CONTINUES TO WORK. PT. IS SCHEDULE FOR MRI TO ASSESS CLOT SITUATION AS WELL PLAN TO POSSIBLE FUTURE LINE PLACEMENT.\n\nPLAN IS TO ASSESS FOR FUTURE LINE PLACEMENT. PLAN TO DRAW AM LABS VIA ARTERIAL STICK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-05-31 00:00:00.000",
"description": "Report",
"row_id": 1312290,
"text": "Nursing Progress Note 0700-1900\n\nEvents: Pt sent down to IR with anesthesia s/o left double lumen midline placement & Left groin temporary dialysis line placement. post procedure remains sleepy D/T medications given\n\nNeuro: A&Ox3, flat affect. Given IV morphine x 2 for finger pain with good effect. Good bed mobility.\n\nResp: Sats 96-100% on 2 LNC. Lungs CTA bilaterally respirations even and unlabored\n\nCardiac: Hemodynamically stable, Tele ST 100's without ectopy. no edema noted\n\nGI: NPO, + BS in 4 quadrents abdomen firm non distended. No BM this shift\n\nRenal: Anuric at baseline, scheduled for dialysis in AM\n\nID: afebrile, continues on home antibiotic regimen\n\nHeme: To restart heparin gtt at 1830 per protocol\n\nSkin: Intact no current issues\n\nFEN: FS low ranging from 70-90's. GIven amp dextrose prior to procedure\n\nSocial: Fiance Lorianne called multiple times through day for updates. Full code\n\nPlan:\n\n1. C/O to floor\n2. Heparin gtt per protocol\n3. Routine monitoring and care\n4. Emotional support to patient and family\n"
},
{
"category": "Echo",
"chartdate": "2135-05-31 00:00:00.000",
"description": "Report",
"row_id": 100472,
"text": "PATIENT/TEST INFORMATION:\nIndication: ESRD. Hypotensive. Assess for clot in RA.\nHeight: (in) 68\nWeight (lb): 105\nBSA (m2): 1.56 m2\nBP (mm Hg): 96/58\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No mass or thrombus in the RA\nor RAA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate\nmitral annular calcification. Moderate thickening of mitral valve chordae.\nCalcified tips of papillary muscles. No MS. Trivial MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No mass or thrombus is seen in the right\natrium or right atrial appendage. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF 70%). There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. There is no mitral valve prolapse. There is moderate\nthickening of the mitral valve chordae. Trivial mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The pulmonary artery systolic pressure could\nnot be determined. There is no pericardial effusion.\n\nThe proximal inferior vena cava up to the junction with the right atrium is\nfilled with echodensity consistent with thrombus. However, the echodensity\ndoes not appear to extend into the right atrium itself.\n\nCompared with the findings of the prior study (images reviewed) of , echodensities in the inferior vena cava are now seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2135-06-01 00:00:00.000",
"description": "Report",
"row_id": 274909,
"text": "Sinus tachycardia. Peaked P waves and rightward P wave axis. Prominent\nnegative reflection of the P wave in lead V1. These findings are consistent\nwith biatrial elargement. Non-specific ST-T wave flattening in\nleads I, aVL and V5-V6. Compared to the previous tracing of \nthe rate has increased. There is ST-T wave flattening. Otherwise,\nno diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-05-28 00:00:00.000",
"description": "Report",
"row_id": 274910,
"text": "Sinus rhythm. Possible biatrial abnormality. Compared to the previous tracing\nof there is no significant change.\n\n"
}
] |
17,855 | 131,030 | The patient was admitted to the Neurology Intensive Care Unit and given Decadron 10 mg intravenously and then 8.0 mg q4hours. Systolic blood pressure was kept less than 130. The patient was placed on a Nipride drip and A line was placed. He was made NPO and oncology was notified. On , the patient was brought to the operating room where he had a suboccipital craniotomy and tumor resection. Postoperatively, the patient was awake and alert. His cerebellar symptoms seemed to have improved. His vital signs revealed temperature 99.1, heart rate 90, blood pressure 130/75. He had no drift, no dysmetria on the left, improved dysmetria on the right. We kept the systolic blood pressure less than 150. He had a magnetic resonance scan which showed normal postoperative changes in the right cerebellar region with significant direction and edema, mass effect and midline shift. Diffusion weighted images did demonstrate no MR evidence of acute infarct. He was seen postoperatively by oncology who felt that the patient looked much better postoperatively and that he should start stereotactic radiation treatment to the tumor bed and that will be set up as an outpatient. The patient was transferred on , to the neurosurgical floor where he remained awake, alert, oriented, face symmetric, no pronator drift. He was evaluated by physical therapy who felt he had no postoperative physical therapy needs. The patient was discharged on , neurologically stable. | IMPRESSION: Status post surgical resection of a previously seen right-sided cerebellar lesion. The lesion has been resected and there has been already partial resolution of the previously vasogenic edema. There is minor petechial hemorrhage within the surgical site with significant resolution of the previously seen surrounding vasogenic edema. Prominent precordial and lateral"septal" Q waves - of uncertain significance and could be normal variant, butclinical correlation is suggest also for possible prior anterolateralmyocardial infarction. Probablyin part, left anterior fascicular block. The patient has undergone recent resection of a cerebellar lesion. There is a right-sided occipital craniotomy with slight increased T1 signal surrounding the operative bed most likely representing post surgical petechial hemorrhage. T1 axial, coronal and sagittal images were performed without and with gadolinium administration. INDICATION: Esophageal cancer with right-sided weakness. Consider left atrial abnormality. There is persistent effacement of the posterior quadrigeminal cistern and slight mass effect seen over the right aspect of the fourth ventricle. Patient is status post resection of a cerebellar lesion. There is normal signal flow void within the intracranial portions of the carotid and basilar arteries. There has been however improvement involving the appearance of the fourth ventricle which is now patent. Since the previous tracing of small Q wavesacross the precordial leads are now evident. In addition there is minimal peripheral enhancement seen which could be due to recent surgery surrounding the surgical site. The fourth ventricle is patent on today's exam. The cerebral hemispheres were unremarkable. Left axis deviation. Sinus rhythm. 4:29 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: ESOPHAGEAL CANCER,ATAIA,RT SIDED WEAKNESS Admitting Diagnosis: BRAIN METASTESIS Contrast: MAGNEVIST Amt: 18CC MEDICAL CONDITION: 48 year old man with h/o esoph cancer 1 year ago now with ataxia, garbled speech, right sided weakness REASON FOR THIS EXAMINATION: post op0 FINAL REPORT MRI OF THE BRAIN WITH CONTRAST. Multiplanar T1 and T2-weighted images of the brain are obtained. Further follow-up might be needed within six to eight weeks with gadolinium administration to assess stability. No other abnormal foci of enhancement are seen. | 2 | [
{
"category": "Radiology",
"chartdate": "2153-01-05 00:00:00.000",
"description": "MR CONTRAST GADOLIN",
"row_id": 813639,
"text": " 4:29 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ESOPHAGEAL CANCER,ATAIA,RT SIDED WEAKNESS\n Admitting Diagnosis: BRAIN METASTESIS\n Contrast: MAGNEVIST Amt: 18CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with h/o esoph cancer 1 year ago now with ataxia, garbled\n speech, right sided weakness\n REASON FOR THIS EXAMINATION:\n post op0\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITH CONTRAST.\n\n INDICATION: Esophageal cancer with right-sided weakness. Patient is status\n post resection of a cerebellar lesion.\n\n Multiplanar T1 and T2-weighted images of the brain are obtained. T1 axial,\n coronal and sagittal images were performed without and with gadolinium\n administration. The patient has undergone recent resection of a cerebellar\n lesion. There is a right-sided occipital craniotomy with slight increased T1\n signal surrounding the operative bed most likely representing post surgical\n petechial hemorrhage. The lesion has been resected and there has been already\n partial resolution of the previously vasogenic edema. There is persistent\n effacement of the posterior quadrigeminal cistern and slight mass effect seen\n over the right aspect of the fourth ventricle. There has been however\n improvement involving the appearance of the fourth ventricle which is now\n patent. In addition there is minimal peripheral enhancement seen which could\n be due to recent surgery surrounding the surgical site. No other abnormal\n foci of enhancement are seen. The cerebral hemispheres were unremarkable.\n There is normal signal flow void within the intracranial portions of the\n carotid and basilar arteries. There is no evidence for subdural hemorrhage.\n\n IMPRESSION: Status post surgical resection of a previously seen right-sided\n cerebellar lesion. There is minor petechial hemorrhage within the surgical\n site with significant resolution of the previously seen surrounding vasogenic\n edema. The fourth ventricle is patent on today's exam. Further follow-up\n might be needed within six to eight weeks with gadolinium administration to\n assess stability.\n\n"
},
{
"category": "ECG",
"chartdate": "2153-01-03 00:00:00.000",
"description": "Report",
"row_id": 278693,
"text": "Sinus rhythm. Consider left atrial abnormality. Left axis deviation. Probably\nin part, left anterior fascicular block. Prominent precordial and lateral\n\"septal\" Q waves - of uncertain significance and could be normal variant, but\nclinical correlation is suggest also for possible prior anterolateral\nmyocardial infarction. Since the previous tracing of small Q waves\nacross the precordial leads are now evident.\n\n"
}
] |
29,111 | 131,814 | In summary, this is a 77-year old gentleman with no prior medical history who presents with a pericardial effusion and atrial fibrillation with RVR. He was started on a diltiazem drip and admitted to the CCU for closer monitoring given his rapid ventricular rate. .. # PERICARDIAL EFFUSION: On echocardiogram, he was found to have a moderate-sized effusion (2 cm). Given his hemodynamic stability, we suspected that this was a chronic process. A repeat echo showed little interval progression. After evaluation of echo findings and symptoms, we felt that the effusion was not affecting hemodynamics in any marked way. By symptoms he was never hypotensive or showing clinical signs of tamponade. . We checked and PPD, both of which returned negative. We order a CT chest to evaluate his lung fields and possibly shed light on the etiology of the pericardial effusion. The full CT report is above; in brief, it showed interstitial septal thickening, as well as mediastinal LAD and pulmonary nodules, all highly concerning for malignancy (primary site not identified). Thus the pericardial effusion was felt to be due to metastatic cancer. . We discussed the findings with Mr. and explained to him that further work-up to diagnose and potentially treat his condition would involve tissue biospy and additional imaging. He was not interested in more work-up and expressed desire to go home. See below for more information. .. # CAD/ISCHMIA: We did not suspect ischemic disease as he had no risk factors, symptoms or EKG changes to suggest ACS. Furthermore, echocardiogram did not show any focal hypokinesis or akinesis to suggest myocardial infarction. .. # PUMP: There were so signs of fluid overload or clinical pump failure on physical exam. His echocardiogram showed a normal EF of 55-60%. .. # RHYTHM: He presented with atrial fibrillation with RVR that required a diltiazem drip in the emergency room. He converted back to sinus rhythm on the morning after admission. Unfortunately, he returned to AF intermittently throughout his hospital stay. We started him on PO metoprolol and diltiazem; however, he continued to have periods of AF with ventricular response to 90-110s while lying in bed. At time of discharge, his rate is 80-100 while lying in bed and increases to 150s when he is walking. His systolic blood pressure and oxygen sat are 120s and mid to low 90s, respectively, during these episodes. He remains asymptomatic. . We discussed starting anticoagulation, but felt that it was unnecessary and potentially harmful in this patient with a CHADS-2 score of 1 (age), potential medical non-compliance (history of homelessness), and significant fall risk (history of multiple mechanical falls in recent weeks). We started him on aspirin at a dose of 325 mg once daily. .. # HISTORY OF FALLS: History as above seemed most consistent with mechanical falls due to balance and gait problems. loss of consciousness or cardiac prodromal symptoms to suggest arrhythmic cause, although certainly AF could be contributing to his generalized weakness and propensity to fall. Neurologic exam was nonfocal and CT was negative for acute process. . He was seen by physical therapy who recommended rehab. However, he declined this option; in the end he left against medical advice so that he could return home. We arranged for him to have a walker as well as home PT/OT visits and VNA visits. . # LOW-GRADE FEVERS / PULMONARY INFILTRATE ON CXR: He had persistent fevers overnight with Tm of 101.6. Chest CT showed no infiltrate but did show diffuse nodules and adenopathy concerning for malignancy. Blood and urine cultures were negative and there were no localizing symptoms. White count was WNL with no bands on the differential. No source for his fevers was found, and he was not started on antibiotics. Further work-up would require tissue sample of his pericardial effusion or mediastinal lymph nodes. At time of discharge, he had remained afebrile for over 24 hours. .. # RENAL FAILURE: Urine electrolyes were consistent with prerenal azotemia. His ARF resolved with IVF boluses in ED. There were no further concerns. .. # ANEMIA: Iron, TSH, vitamin B12 and folate studies were normal. His anemia is likely secondary to marrow suppression from his underlying process, most likely a malignancy. .. # GOALS OF CARE: These were discussed with Mr. when his underlying disease remained uncertain. We explained that we would need a tissue sample to definitively diagnose the cause for his pericardial effusion and bilateral pleural effusions. We explained that this would likely provide an explanation for his presenting symptoms, namely his shortness of breath and anemia. He was also seen by physical therapy, who noted that he was too weak to go home and should be discharged to rehab. However, it was clear that Mr. wanted to return to his home and was not interested in any invasive procedures, even if these might reveal a potentially treatable cause for his symptoms. We suggested that he consider hospice care, but he did not want to leave his home for a hospice facility. . Prior to leaving, he signed an AMA form. Eventhough he returns home against medical advice, he has agreed to have VNA come visit him, as well as PT/OT, meals on wheels, and elderly services. We have provided home oxygen if he needs it during activities, although his O2 sats have been fine on RA when walking with walker. He has confirmed his code status is DNR/DNI. .. # He was given a regular diet. Subcutaneous heparin was used for DVT prophylaxis. Code status was discussed and at his request he was made DNR/DNI. | There is bilateral atelectasis and moderate simple fluid-attenuating effusions. Mild (1+) aorticregurgitation is seen. Physiologic TR.Normal PA systolic pressure.PERICARDIUM: Moderate pericardial effusion. Mildly dilated ascending aorta. There is a moderatesized pericardial effusion. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Moderate pericardial effusion.Compared with the prior study (images reviewed) of LV functionappear normal (largely secondary to a lower ventricular response rate inatrial fibrillation). There areno echocardiographic signs of tamponade.IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. There is a moderate sized pericardial effusion.Stranding is visualized within the pericardial space c/w organization. Noright atrial or right ventricular diastolic collapse is seen.IMPRESSION: Moderate circumfiretnial pericardial effusion without tamponade.LV/RV systolic function are preserved (difficult to assess due to irregularand very rapid pulse) Normal interatrial septum. Mild aortic regurgitation.Dilated thoracic aorta. There is mild symmetric left ventricular hypertrophy. Compared to the previous tracingof normal sinus rhythm has given way to atrial fibrillation. Trace aortic regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aortic arch is mildly dilated. FINDINGS: There is diffuse symmetric enlargement of the ventricles and sulci consistent with mild-to-moderate age-related atrophy. Atrial fibrillationNonspecific ST-T wave changesSince previous tracing of , slow ventricular rate, and arm leads are nowcorrect Rightventricular chamber size is normal with borderline normal free wall function.The aortic root is mildly dilated at the sinus level. The effusion is most prominent posterior to the leftventricle, with <1 cm anterior to the right ventricle in diastole. Mildlydilated aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No PS.Physiologic PR.PERICARDIUM: Moderate pericardial effusion. Borderline normal RV systolicfunction.AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. NoASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. There is a small heterogeneous lucency within the left parieto-occipital calvarium (2:24). The ascending aorta ismildly dilated. The ascending aorta ismildly dilated. Calcified mediastinal and small right hilar nodes also noted. Stable enlarged heart, consistent with pericardial effusion. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Multiple mildly enlarged mediastinal lymph nodes. Multiple mildly enlarged mediastinal lymph nodes. No echocardiographic signs of tamponade.GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.Conclusions:The left atrium is mildly dilated. Bilateral pleural effusions. Atrial fibrillation with rapid ventricular response rate at about 180.Non-specific repolarization abnormalities. The rhythm appears to beatrial fibrillation.Conclusions:The left atrium is normal in size. The cardiac silhouette is unchanged compared to the previous scan, enlarged, consistent with pericardial effusion. sq heparin. Compared to the previoustracing of the rhythm is now atrial fibrillation and QTc interval isshorter. Atrial fibrillation with controlled ventricular response. Noresting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size. Prematureventricular contractions. CT CHEST WITHOUT CONTRAST: There is asymmetric interstitial septal thickening with some nodularity involving the entire right lung. Thetricuspid valve leaflets are mildly thickened. Paranasal sinuses and ethmoid air cells are normally pneumatized and clear. Aortic regurgitation is slightly more prominent, alsolikely secondary to longer diastolic period. TECHNIQUE: Non-contrast MDCT of the chest displayed in 1.25- and 5-mm axial collimation. Atrial fibrillation with rapid ventricular response*** arm lead reversal ***Nonspecific T wave changesSince previous tracing of , arm lead reversal PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 69Weight (lb): 150BSA (m2): 1.83 m2BP (mm Hg): 108/54HR (bpm): 87Status: InpatientDate/Time: at 08:37Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Please evaluate for opacity, questionable left upper lobe. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There are coronary artery calcifications. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. Low normal LVEF. Asymmetric septal thickening in the right middle and lower lobes with some nodularity, and multiple pulmonary nodules in the right lung, and right hilar adenopathy. Asymmetric septal thickening in the right middle and lower lobes with some nodularity, and multiple pulmonary nodules in the right lung, and right hilar adenopathy. taking liquids well but no appitite for solids.A: 77yo male with new onset RAF and pericardial effusion by echo. Normal LV cavity size. Compared to theprevious tracing of ventricular ectopy is new. denies pain.Ls diminished. PATIENT/TEST INFORMATION:Indication: Evaluate for pericardial effusionHeight: (in) 69Weight (lb): 150BSA (m2): 1.83 m2BP (mm Hg): 129/75HR (bpm): 140Status: InpatientDate/Time: at 11:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Stable enlarged heart. Stable enlarged heart. Large pericardial effusion, with bilateral pleural effusions. Large pericardial effusion, with bilateral pleural effusions. COMPARISON: Compared to chest radiograph from . The mitral valve leaflets are mildly thickened. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for opacity, ? LV systolic function appears borderlinedepressed (difficult to assess to very rapid and irregular pulse). Non-specific ST-T wave changes. The estimated pulmonary arterysystolic pressure is normal. FINDINGS: There is gross cardiomegaly. The leftventricular cavity size is normal. This likely represents a hemangioma. Theestimated pulmonary artery systolic pressure is normal. The mitral valveleaflets are mildly thickened. converted to NSR on dilt gtt. tylenol x1. , E. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for opacity, ? | 17 | [
{
"category": "Echo",
"chartdate": "2174-09-29 00:00:00.000",
"description": "Report",
"row_id": 60379,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 108/54\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 08:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Stranding is visualized within the\npericardial space c/w organization. No echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is a moderate\nsized pericardial effusion. Stranding is visualized within the pericardial\nspace c/w organization. The effusion is most prominent posterior to the left\nventricle, with <1 cm anterior to the right ventricle in diastole. There are\nno echocardiographic signs of tamponade.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Mild aortic regurgitation.\nDilated thoracic aorta. Moderate pericardial effusion.\n\nCompared with the prior study (images reviewed) of LV function\nappear normal (largely secondary to a lower ventricular response rate in\natrial fibrillation). Aortic regurgitation is slightly more prominent, also\nlikely secondary to longer diastolic period.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-09-28 00:00:00.000",
"description": "Report",
"row_id": 60380,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for pericardial effusion\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 129/75\nHR (bpm): 140\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nNormal PA systolic pressure.\n\nPERICARDIUM: Moderate pericardial effusion. Stranding is visualized within the\npericardial space c/w organization. No RA or RV diastolic collapse.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. LV systolic function appears borderline\ndepressed (difficult to assess to very rapid and irregular pulse). Right\nventricular chamber size is normal with borderline normal free wall function.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. The estimated pulmonary artery\nsystolic pressure is normal. There is a moderate sized pericardial effusion.\nStranding is visualized within the pericardial space c/w organization. No\nright atrial or right ventricular diastolic collapse is seen.\n\nIMPRESSION: Moderate circumfiretnial pericardial effusion without tamponade.\nLV/RV systolic function are preserved (difficult to assess due to irregular\nand very rapid pulse)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033207,
"text": " 10:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with tachycardia\n REASON FOR THIS EXAMINATION:\n eval acute path\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with tachycardia to rule out an acute\n cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n There is gross cardiomegaly. There are bibasilar effusions. The appearances\n are suggestive of congestive heart failure. Followup is recommended post\n diuresis to ensure resolution of the effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1033539,
"text": " 4:36 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for evidence of malignancy\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with large pericardial effusion, with ?LUL infiltrate, with\n smoking history\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of malignancy\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:42 PM\n \n 1. Large pericardial effusion, with bilateral pleural effusions.\n 2. Asymmetric septal thickening in the right middle and lower lobes with some\n nodularity, and multiple pulmonary nodules in the right lung, and right hilar\n adenopathy. Multiple mildly enlarged mediastinal lymph nodes. The\n constellation of findings raises the suspicion for malignancy in the right\n lung, although each entity itself is nonspecific.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large pericardial effusion with smoking history, evaluate for\n evidence of malignancy.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT of the chest displayed in 1.25- and 5-mm axial\n collimation. Multiplanar reformations were also obtained and reviewed.\n\n CT CHEST WITHOUT CONTRAST: There is asymmetric interstitial septal thickening\n with some nodularity involving the entire right lung. Multiple pulmonary\n nodules in the lungs are also identified measuring 8 mm (series 4:100). There\n is bilateral atelectasis and moderate simple fluid-attenuating effusions.\n\n There are multiple mildly enlarged mediastinal lymph nodes measuring up to 12\n mm (precarinal, series 4, image 96). Although evaluation is limited without\n contrast, there is increased soft tissue in the right hilum concerning for\n adenopathy such as increased soft tissue posterior to the right main bronchus\n (series 4:125). Calcified mediastinal and small right hilar nodes also noted.\n No left hilar adenopathy is identified. There are coronary artery\n calcifications.\n\n Study was not tailored for subdiaphragmatic evaluation, but no abnormalities\n are identified. Please note that the adrenal glands were not imaged. No\n suspicious lesions are identified in the osseous structures, which otherwise\n demonstrate diffuse degenerative changes.\n\n IMPRESSION:\n 1. Constellation of findings including asymmetric nodular right lung\n interstitial septal thickening, mediastinal and right hilar adenopathy, and\n multiple pulmonary nodules are concerning for possible malignant disease,\n (Over)\n\n 4:36 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for evidence of malignancy\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n but no definite primary tumor site is identified. Consider PET CT for\n further assessment, if warranted clinically.\n 2. Large pericardial effusion.\n 3. Bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1033540,
"text": ", E. 4:36 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for evidence of malignancy\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with large pericardial effusion, with ?LUL infiltrate, with\n smoking history\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of malignancy\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PFI REPORT\n \n 1. Large pericardial effusion, with bilateral pleural effusions.\n 2. Asymmetric septal thickening in the right middle and lower lobes with some\n nodularity, and multiple pulmonary nodules in the right lung, and right hilar\n adenopathy. Multiple mildly enlarged mediastinal lymph nodes. The\n constellation of findings raises the suspicion for malignancy in the right\n lung, although each entity itself is nonspecific.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1033537,
"text": " 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for e/o bleed\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with pancytopenia, right sided hearing loss, and multiple\n recent falls\n REASON FOR THIS EXAMINATION:\n evaluate for e/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:14 PM\n No hemorrhage or other acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with pancytopenia, multiple recent falls, now with\n right-sided hearing loss. Evaluate for intracranial hemorrhage.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images are obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: There is diffuse symmetric enlargement of the ventricles and sulci\n consistent with mild-to-moderate age-related atrophy. There is no evidence\n for hemorrhage, edema, mass effect, or large vascular territory infarct. The\n -white matter differentiation is preserved. Paranasal sinuses and ethmoid\n air cells are normally pneumatized and clear. There is a small heterogeneous\n lucency within the left parieto-occipital calvarium (2:24). This likely\n represents a hemangioma. The osseous structures are otherwise unremarkable.\n\n IMPRESSION: No evidence for hemorrhage or other acute intracranial process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1033538,
"text": ", E. 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for e/o bleed\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with pancytopenia, right sided hearing loss, and multiple\n recent falls\n REASON FOR THIS EXAMINATION:\n evaluate for e/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PFI REPORT\n No hemorrhage or other acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033410,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for opacity, ? LUL\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with large pericardial effusion, spiked temp overnight\n REASON FOR THIS EXAMINATION:\n evaluate for opacity, ? LUL\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:35 PM\n PFI:\n 1. Bilateral pleural effusion, more prominent on the right.\n 2. Opacification in the right lung, which might be due to increased pleural\n effusion, consolidation, or atelectasis. Please evaluate clinically.\n 3. Left lower lobe atelectasis.\n 4. Stable enlarged heart.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old man with large pericardial effusion, spiked temperature\n overnight. Please evaluate for opacity, questionable left upper lobe.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Compared to chest radiograph from .\n\n FINDINGS: Interval increase in the bilateral opacification of the lungs, more\n prominent on the right. In the right lung, there is increase in the pleural\n effusion. The opacification of the lung might be due to increased pleural\n effusion, consolidation, atelectasis or combination. Please correlate\n clinically. On the left, there is increased opacification in the basal area,\n with more dense retrocardial appearance, which is most likely related to\n atelectasis in the left lower lobe. There is also increase in the effusion in\n the left costophrenic angle. The cardiac silhouette is unchanged compared to\n the previous scan, enlarged, consistent with pericardial effusion. The\n mediastinum and hila are unchanged compared to the previous study.\n\n IMPRESSION:\n 1. Bilateral pleural effusion, more prominent on the right.\n 2. Left lower lobe atelectasis.\n 3. Opacification in the right lung, which might be due to increased right\n pleural effusion, consolidation, atelectasis or combination. Please correlate\n clinically.\n 4. Stable enlarged heart, consistent with pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033411,
"text": ", E. 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for opacity, ? LUL\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with large pericardial effusion, spiked temp overnight\n REASON FOR THIS EXAMINATION:\n evaluate for opacity, ? LUL\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Bilateral pleural effusion, more prominent on the right.\n 2. Opacification in the right lung, which might be due to increased pleural\n effusion, consolidation, or atelectasis. Please evaluate clinically.\n 3. Left lower lobe atelectasis.\n 4. Stable enlarged heart.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-09-28 00:00:00.000",
"description": "Report",
"row_id": 1639695,
"text": "77 YR OLD MAN BROUGHT TO ER BY SOCIAL WORKER TODAY .FOUND TO BE IN RAPID AFIB 170,STABLE BP.ECHO SHOWED LG PERICARDIAL EFFUSSION.STARTED ON DILTIAZEM DRIP ,TITRATED TO 15MG.2L FLUID GIVEN .TO HAVE TAP,BUT NOT TODAY.PT LIVES ALONE.HAS BEEN HOMELESS FOR YEARS.HAS NOT SEEN A DR HE WAS 14 YRS OLD.HAS NEVER BEEN IN THE HOSPITAL.HAS RECENTLY BEEN PLACED IN AN APARTMENT BY SOCIAL SERVICES.HAS REFUSED TO HAVE OTHER HELP .HE IS ESTRANGED FROM HIS BROTHER AND SISTER .HIS WIFE HAS BEEN DEAD MANY YEARS .HE IS PLEASNAT,COOPERATIVE ,ORIENTED .SOMEWHAT ANXIOUS .HE RECENTLY WAS SEEN AT FOR DEAFNESS.HAS IMBALANCE PROBLEM AND HX FALLS MAYBE CONNECTED C A MASS.\n\nAFIB 100 TO 160.DILTIAZEM DRIP 15 MG .BP STABLE .DENIES SOB,CHEST PAIN.500CC FLUID BOLLUS .SAT 95 2L NP,BS C FRICTION RUB .\nPT NPO AT PRESENT UNTIL PLAN CL.ABD SOFT ,PO BS\nGOOD URINE OUT PUT VIA FOLEY\nBRUISE L HIP,NOT PAINFUL PER PT,OTHERWISE SKIN INTACT .\n\nCONTROL HEART RATE\nMONITIOR FLUID STATUS\nEMOTIONAL SUPPORT FOR ANXIETY\nMAINTAIN SAFETY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-09-29 00:00:00.000",
"description": "Report",
"row_id": 1639696,
"text": "CCU NPN 1900-0700\nS: \" I feel hot \"\nO: TS to 101.5po at MN. BC x1 at that time, urine sent. tylenol x1. T down to 100 at 0200. BC #2 to be sent with AM labs.\n\nHR 100-110AF, occas PVC. converted to NSR ~ 0130 80's -70's SR. no VEA. BP 117-120's/ in Afib, down to 97-102/50's in NSR. dilt gtt weaned to 7.5mg/hr. pt. denies pain.\n\nLs diminished. RR up to 30's with fever with exertional wheezes. pt. stating that his breathing feels the same as it always does. denies SOB. down to 20's after falling asleep at night. appearing more comfortable with lower temp.\ninitially on RA sats 95%, sats dropping to 93-94% during eve, requiring NC up to 4l. sats 99% at 0600.\n\nu/o 30-50cc/hr. urine for lytes sent. pt. taking liquids well but no appitite for solids.\n\nA: 77yo male with new onset RAF and pericardial effusion by echo. converted to NSR on dilt gtt. new TS overnight- cultured. u/o trending down.\nP: plan repeat echo today. follow fever, tylenol prn. monitor lytes, u/o. sq heparin. ASA.\n"
},
{
"category": "ECG",
"chartdate": "2174-10-03 00:00:00.000",
"description": "Report",
"row_id": 107709,
"text": "Atrial fibrillation with controlled ventricular response. Premature\nventricular contractions. Non-specific ST-T wave changes. Compared to the\nprevious tracing of ventricular ectopy is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-10-02 00:00:00.000",
"description": "Report",
"row_id": 107710,
"text": "Atrial fibrillation\nNonspecific ST-T wave changes\nSince previous tracing of , slow ventricular rate, and arm leads are now\ncorrect\n\n"
},
{
"category": "ECG",
"chartdate": "2174-09-30 00:00:00.000",
"description": "Report",
"row_id": 107711,
"text": "Atrial fibrillation with rapid ventricular response\n*** arm lead reversal ***\nNonspecific T wave changes\nSince previous tracing of , arm lead reversal\n\n"
},
{
"category": "ECG",
"chartdate": "2174-09-30 00:00:00.000",
"description": "Report",
"row_id": 107712,
"text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the rhythm is now atrial fibrillation and QTc interval is\nshorter.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-09-29 00:00:00.000",
"description": "Report",
"row_id": 107713,
"text": "Compared to the previous tracing atrial fibrillation has given way to\nsinus rhythm at rate 81.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2174-09-28 00:00:00.000",
"description": "Report",
"row_id": 107714,
"text": "Atrial fibrillation with rapid ventricular response rate at about 180.\nNon-specific repolarization abnormalities. Compared to the previous tracing\nof normal sinus rhythm has given way to atrial fibrillation. The\nventricular response rate has more than doubled.\nTRACING #1\n\n"
}
] |
24,506 | 169,862 | Patient was transferred from to the ICU at for further workup and treatment of pancreatic pseudocyst and pleural effusion. Thoracic surgery consult was obtained on HD2 for drainage of the effusion. A CT was placed on HD2, kept to sux until HD7, the placed on water seal until HD9. Patient was started on octreotide, TPN, NPO & IVF and antibiotics dc'd with a presumptive diagnosis or pancreatico-pleural fistula. HD3 patient was tranferred to the floor as in stable condition. Patient was slowly started back on clears on HD5. After CT scans and monitoring patient's clinical picture, it was decided to take the patient to the OR on HD9. However, that morning, patient spiked a tempurature to 103.0F. Blood & urince cultures were sent as well as a cxr. Patient was discovered to have phlebitis at his picc site with some pus drainage as well as positive blood cultures. Vascular surgery was consulted and monitored his phlebitis for a few days until it was decided that it did not need to be excised. vancomycin was started. Patient continued to have fevers for the next few days which finally disappeared after 48 hours of antibiotics. Patient was then taken to the OR on HD12 for Puestow, cystduodenostomy, distal pancreatectomy, G- and J-tube placements. Patient did well - was admitted to the ICU for monitoring, transferred to the floor on POD2. Got an epidural for pain which was well controlled, changed to a PCA on POD3. NGT remained unitl POD2. POD3 trophic tube feeds were started via the J port, PT was consulted and social work continued to work with patient. Again spiked a temp on POD3, cultures sent and cxr showed atelectasis vs aspiration and levoquin was started. POD4 Tf increased and advancing towards goal, reached on POD6 and started cycling on POD7. POD5 patient was allowed regular diet which he tolerated in small amounts. patient stayed in the hospital for the remainder of his 14d course of IV abx since he had no insurance. POD9 patient had a few bloody stools. serial hcts were done which were all stable. C dif cultures were negative. Patient had a repeat Ct on POD11 which showed improvemnt since pre-op. JP was dc'd on POD12. Patient was then dc'd on POD13 on regular diet, with staples dc'd and instructions to follow-up with dr | Course unremarkable except for episode desaturation with improved after plug suctioned from ETT. Right-sided PICC is again seen, extending to the lower SVC. Trace residual pleural effusions remain. HCT stableInt. Recieved Vanco and flagyl. There is evidence of a tiny right apical pneumothorax. Lactate stable. Right basilar chest tube is again seen, unchanged in position. Tiny right apical pneumothorax. Treated with anbx. Tm 99.1 PLTs and coags stable. IMPRESSION: Small right apical pneumothorax and minimal residual right effusion following right chest tube insertion. Status post right chest tube placement. +pp, pboots on, subq heparin. Stable-appearing rounded opacity adjacent to the minor fissure possibly representing loculated pleural fluid. turned & repositioned frequentyl.Endocrine: Max. A small right apical pneumothorax is visible. Bilateral breath sounds noted. Evaluate right pleural effusion. JP placed over cyst site. HR better after IVF bolus. Rule out pneumothorax. A PICC entering from the right upper extremity remains in similar position. ?if stable transfer to floor. Minimal right effusion persists. Dr. and Dr. aware. There is a central venous line seen with its tip in the mid SVC. Sig. Rounded opacity abutting the minor fissure which might represent loculation of pleural fluid. Resp Care: Pt received intubated and on ventilatory support with a/c, weaned to cpap with psv maintaining acceptable spo2, self extubated: appears to be exchanging well, no stridor noted, abg adequate @ this time, will cont o2 rx as needed. T/C for 2uPRBCs and following HCT Q4H, thus far stable. C/O of pruritis over entire body > benedryl with fair effect; backside intact. Afebrile. Epidural site intact, scant amt blood under dressing. IMPRESSION: 1. IMPRESSION: 1. Diminished BS bilaterally. BG wnl. LR bolus started. Again seen is a rounded pulmonary opacity adjacent to the minor fissure, unchanged from prior study. Nods yes to pain and MSO4 given. GJ brown drainage to gravity. Pt. CT was placed and fluid high in amylase drained. Pan cx'd via PICC and peripherally. encourage C&DB. SICU NPN ADMISSION:(Continued) OR for drain insertionFollow CIWA throuhghout day Following CIWA Q4hs overnight and 0. Last recorded at OSH 37.SEE FHP FOR DETAILED PMH.S-"No..no belly pain."O-A/O/X/3. NSR with rare PACs. ABD soft, tender to palpation at incision Absent BS. Pt then tapped for effusion with 2Ls removed with improvement in symptoms. The cardiomediastinal and hilar contours are normal. WBC elevated slightly on Zosyn at prior hospital and resumed. Oriented x 2: ", at ".CV: ST> HR 90's to 110's with occassional PVC's. C&DB encourage. The cardiac and mediastinal contours appear unchanged. Abdominal and axillary DSD intact with no drainage. Has small open areas/scabs over upper body and arms.GI/GU- Gtube to gravity, J tube clamped. Normal sinus rhythm. interval change--please do CXRY b/w 10-11am-thanks FINAL REPORT INDICATION: Pleural-pancreatic fistula, with chest tube now at waterseal. Small apical right-sided pneumothorax persists. Tiny enhancing fluid collection in the right diaphragmatic crus. The abdominal aorta is of normal caliber, with calcifications at the origin of the SMA. Stable tiny right apical pneumothorax. A small right pleural effusion is again demonstrated. There is conventional portal venous anatomy. IMPRESSION: Decreasing small right apical pneumothorax. FINDINGS: The right basilar chest tube has been removed. Bilateral pleural effusions are present, small on the left and small to moderate on the right with probable partial loculation of the right effusion laterally. A right internal jugular central venous line is again seen with tip in the upper SVC. Right chest tube at right costophrenic sulcus and right-sided PICC line terminate in the mid SVC. Small right pneumothorax. There is a gastrojejunostomy tube in place. There is a small pneumothorax on the right. Echogenic material consistent with thrombus is seen filling the cephalic vein, which is not compressible. There is a filling defect in the inferior mesenteric vein consistent with thrombus. An unusual rounded 2-cm opacity is seen along the minor fissure in the right middle lobe which given the history of prior effusions and given that it has developed acutely probably represents rounded atelectasis. Decreased small right pleural effusion. Central venous catheter has been placed in the interval terminating in the mid superior vena cava. Stable small right pleural effusion. Tiny right apical pneumothorax is stable. CT OF THE ABDOMEN WITH CONTRAST: The lung bases are clear. A previously noted right apical pneumothorax is no longer evident on this supine radiograph. There is residual fluid within the splenic hilum, measuring 2.9 x 1.6 cm. There is a small fluid collection in the right diaphragmatic crus measuring less than 4 mm wide. A Swan-Ganz catheter terminates in the proximal interlobar right pulmonary artery, and nasogastric tube terminates below the diaphragm. There is new right jugular IV catheter terminating in the mid SVC. A small right pleural effusion is unchanged, including a small amount of fluid in the right minor fissure. There are new bilateral perihilar opacities, as well as scattered patchy opacities in the right mid and lower lung zones. CT OF THE PELVIS WITH CONTRAST: The bladder, seminal vesicles, prostate, rectum, and sigmoid are normal. The celiac axis, common hepatic artery, left gastric artery, and splenic artery are patent. Diffuse echogenicities are noted throughout the pancreas. Interval placement gastrojejunostomy tube and JP drain as described. There is mild atelectasis at the right lung base. There has been interval removal of an endotracheal tube, Swan-Ganz catheter. CT ABDOMEN FINDINGS: Images of the lower thorax demonstrate a small right pleural effusion and a chest tube. Trachea is midline. There is consolidation/atelectasis at the right lower lobe. Bilateral pleural effusions. There is a tiny right apical pneumothorax, unchanged since . The study demonstrates simple cysts anterior to the body of the pancreas and in the porta hepatis a more complex approximately 6 cm cyst with septations is noted in the splenic hilum. | 24 | [
{
"category": "Nursing/other",
"chartdate": "2188-02-09 00:00:00.000",
"description": "Report",
"row_id": 1580801,
"text": "Sig. Events: Patient self extubated @ 430. Dr. up to see patient. No stridor noted. SpO2 remained 100% on non-rebreather. Respirations spontanous and shallow with diminshed BS throughout. strong cough, able to clear secretion; ABG good.\n\nNeuro: midaz drip turned off after extubation. c/o abdominal incision pain: given morphine x1 for pain with fair control; once BP stable epidural was started at 4cc/hr > patient with better pain control with epidural, 7.5>6. MAE, deconditioned. Pt. is cooperative, follows all commands and awakens spontanously, speaking. PERLA brisk; equal strength in all extremities. Oriented x 2: \", at \".\n\nCV: ST> HR 90's to 110's with occassional PVC's. HR better after IVF bolus. BP labile requiring 4 liters LR boluses to maintain SBP 100. BP 110's-teens/50's. PAP 20's/10s. Cardiac index greater than 4. Wedge . CVP 4-10. 2mg of Calcium gluconate and 2mg of mag. sulfate given. +pp, pboots on, subq heparin. HCT stable\n\nInt.: Cool, dry, intact. Abdominal and axillary DSD intact with no drainage. Red spotty rash on ULE/. C/O of pruritis over entire body > benedryl with fair effect; backside intact. turned & repositioned frequentyl.\n\nEndocrine: Max. BG 135, 2 units regular insulin given > coverage via RISS as indicated..\n\nRespitatory: self extubated as above > now on 100% non-rebreather. Spontaneous and shallow respirations. Diminished BS bilaterally. SpO2 remain 100%. C&DB encourage. strong cough able to expectorate secretions\n\nGI/GU: NG tube 50ml bilioius drainage, patent and placement verified. JP drain patent and draining 30ml. GJ brown drainage to gravity. ABD soft, tender to palpation at incision Absent BS. Urine output remains adequate and clear.\n\nID: tmax 99.5, WBC increasing, Vanco as ordered, trough to be drawn b/4 AM dose\n\nSocial: no contact from family/friends.\n\nPlan: Continue to monitor respitory status and BP. Control abdominal pain. encourage C&DB. Provide education to patient regarding post-op/operation. ?dc PA line today. ?if stable transfer to floor. continue to monitor & support, follow care plan as indicated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-09 00:00:00.000",
"description": "Report",
"row_id": 1580802,
"text": "Resp Care: Pt received intubated and on ventilatory support with a/c, weaned to cpap with psv maintaining acceptable spo2, self extubated: appears to be exchanging well, no stridor noted, abg adequate @ this time, will cont o2 rx as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-08 00:00:00.000",
"description": "Report",
"row_id": 1580799,
"text": "Respiratory Care\nPt admitted post op directly from OR with intent to wean to extubate in the AM. Bilateral breath sounds noted. Some difficulty with oxygenation while in OR as mentioned by anesthesia.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-02-08 00:00:00.000",
"description": "Report",
"row_id": 1580800,
"text": "NPN 0700-1900\n Pt admitted to hospital on . Has history on pancreatitis related to ETOH abuse. Found to have pancreatic pseudocyst with pleural fistula. CT was placed and fluid high in amylase drained. Decision to surgical treat was delayed due to fever spikes on floor secondary to phelbitis. Treated with anbx. Pt admitted to T/SICU postop longitudanal pancreatico jejunostomy, pancreatic cyst duodenostomy and G/J tube placement. JP placed over cyst site.\n Swan and aline placed in OR. Course unremarkable except for episode desaturation with improved after plug suctioned from ETT. Received 4700cc crystalloid, 2uPRBCs for hct 27 and EBL 650cc, UO 400cc. Recieved Vanco and flagyl. Epidural placed at T6-7. arrived with no infusion. VSS.\n\n Pt sedated on propofol at 45mcg/kg/min. Awaiting epidural infusion and pump. Pt opens eyes to voice and moving all extremeties. Follow commands and nodding yes/no to questions. Nods yes to pain and MSO4 given.\n\n Pt on A/C 600 12 60% PEEP 5. Lungs coarse throughout. Thick small amt secretions. Old CT site healing, no drainage.\n\nCV- Persistent ST. See carevue for hemodynamics. Wedge 9. CVP 8. Swan 57sm at sheath. Pt UO dropping off and repeat hct 36.7 from 27 after 2u. Most likely needs fluid. SBP dropped into 80s and UO 20cc at 1800. LR bolus started. Lactate decreasing. BG wnl. Afebrile. Skin intact. Coccyx pink. Epidural site intact, scant amt blood under dressing. Has small open areas/scabs over upper body and arms.\n\nGI/GU- Gtube to gravity, J tube clamped. Abd soft, flat. NGT patent and placement checked with air, bright green drainage in small amts. No BS. Foley patent with concentarted UO.\n\nSocial- No contact with any family/friends.\n\nPlan- To remain intubated overnight with plan to extubate in am if meets criteria.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-01-29 00:00:00.000",
"description": "Report",
"row_id": 1580797,
"text": "SICU NPN ADMISSION:\nHPI: 55 yo male with history of alchohol induced pancreatitis, currently an active drinker, presented to OSH on with severe SOB and chest pain without radiation to any extremeties after lifting boxes at work. No documented cardiac enzymes performed but instead CXR showing large pleural effusion on right. Later CT scan of chest and abdomen confirming effusion and pancreatitis with calcifications. Pt with known cardiomyopathy and cardiac echo performed with EF < 35% and LVH with trace insuffiencies througout. Pt then tapped for effusion with 2Ls removed with improvement in symptoms. Fluid sent gram stain and (-) but fluid showing very elevated lipase and amylase levels. Upon further work-up, ERCP performed today showing pancreatic pseudocysts, fistula near/at ampulla site with bleeding and pancreatic juice from duct, and nodular duodenitis. No stents placed. Pt then refered to Dr. service and transfered to ICU for monitoring of bleeding. Prior to leaving OSH, BPs down into 80s but pt asymptomatic, recieving 250cc bolus with some response. Last recorded at OSH 37.\n\nSEE FHP FOR DETAILED PMH.\n\nS-\"No..no belly pain.\"\n\nO-A/O/X/3. Pleasant and cooperative with care. Denies pain. Following commands consistently and asking appropriate questions. Forthcoming in regards to drinking history. Following CIWA Q4hs overnight and 0. Ativan 1mg given IV at HS for sleep with good affect. have Q4:PRN up to 2mg. HR 60-90s. NSR with rare PACs. SBP 80-100s. Recieving (2) 250ccs boluses with some response but SBPs remaining in the high 80-90s. Dr. and Dr. accepting MAPs > 60 where pt has remained throughout night. Pulses palpable throuhout with cool extremties but later warm to touch. Breath sound w/ crackles mid to base on right and left clear. O2Sats on 3Ls 99-100s. O2 off and remaining > 95%. Denies SOB. Breathing even and unlabored. Foley inserted upon admision with 350cc out of clear yellow urine, HUO since have been 30-45cc/hr. Arriving with TPN and resuming at 42cc/hr in addition to IVF started to total 100cc/hr of intakce. Abd soft with (+) bowel sounds, (+)appetite but NPO, passing black loose stool times one, guiac (+). Dr. and Dr. aware. Lactate stable. HCT on admission with 7pt drop. T/C for 2uPRBCs and following HCT Q4H, thus far stable. WBC elevated slightly on Zosyn at prior hospital and resumed. Pan cx'd via PICC and peripherally. No sputum sent. Tm 99.1 PLTs and coags stable. LFTs without abnormalities. Amylase elevated with lipase pending this AM. Glucose chronically over 200s at OSH while on TPN, here 252 on arrival and given 6uR, TPN held on admission and BS 63, since TPN restarted no issues. Pt works for post office and has girlfriend, of 9 years, who he states is HCP, also has two children but does not want them to know he is in hospital.\n\nA/P: 56 yo male admitted to SICU doing fair on current regimen of monitoring HCTs.\nContinue to follow HCT throughout day, next due at 2200\nPossible ERCP or to\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-01-29 00:00:00.000",
"description": "Report",
"row_id": 1580798,
"text": "SICU NPN ADMISSION:\n(Continued)\n OR for drain insertion\nFollow CIWA throuhghout day\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 898130,
"text": " 9:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusion\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p ERCP\n REASON FOR THIS EXAMINATION:\n eval pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE.\n\n INDICATION: 56-year-old man status post ERCP, evaluate pleural effusion.\n\n CHEST PORTABLE: No prior studies are available for comparison. There is a\n large pleural effusion on the right, which surrounds the entire right lung and\n extends into the apex. The left lung is not completely depicted on this film;\n however, depicted aspects are unremarkable. There is a central venous line\n seen with its tip in the mid SVC.\n\n IMPRESSION: Large right pleural effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-02-14 00:00:00.000",
"description": "Report",
"row_id": 201879,
"text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-01-28 00:00:00.000",
"description": "Report",
"row_id": 201880,
"text": "Sinus rhythm\nConsider left atrial abnormality\nModest low amplitude inferior T waves - are nonspecific and may be within\nnormal limits\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 898573,
"text": " 10:07 AM\n CHEST (PA & LAT) Clip # \n Reason: ?ptx\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man pleuro-pancreatico fistula w/ CT now to water seal.\n\n REASON FOR THIS EXAMINATION:\n ?ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pleural pancreaticofistula with chest tube now to waterseal.\n\n COMPARISON: .\n\n PA and lateral chest radiographs show right-sided PICC line and chest tube in\n right base both in stable, satisfactory position. The cardiac and mediastinal\n contours appear unchanged. There is evidence of a tiny right apical\n pneumothorax. Again seen is a rounded pulmonary opacity adjacent to the minor\n fissure, unchanged from prior study. Otherwise, no significant change from\n prior study.\n\n IMPRESSION:\n 1. Tiny right apical pneumothorax.\n 2. Stable-appearing rounded opacity adjacent to the minor fissure possibly\n representing loculated pleural fluid. Again, continued followup is\n recommended to document resolution.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 898201,
"text": " 11:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, change in effusion\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p ERCP now with CT placed on Right\n REASON FOR THIS EXAMINATION:\n PTX, change in effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man status post ERCP. Status post right chest tube\n placement. Evaluate right pleural effusion. Rule out pneumothorax.\n\n COMPARISON: .\n\n UPRIGHT AP PORTABLE CHEST: A right chest tube has been inserted, with its tip\n in the right base. Minimal right effusion persists. A small right apical\n pneumothorax is visible. Small atelectasis is present adjacent to the minor\n fissure. The left lung is clear. The cardiomediastinal and hilar contours\n are normal. A PICC entering from the right upper extremity remains in similar\n position.\n\n Findings were discussed with on the day of this study at\n 1200.\n\n IMPRESSION: Small right apical pneumothorax and minimal residual right\n effusion following right chest tube insertion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 898458,
"text": " 10:32 AM\n CHEST (PA & LAT) Clip # \n Reason: ? interval change\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man pleuro-pancreatico fistula w/ CT now to water seal.\n REASON FOR THIS EXAMINATION:\n ? interval change--please do CXRY b/w 10-11am-thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pleural-pancreatic fistula, with chest tube now at waterseal.\n Evaluate change.\n\n TECHNIQUE: PA and lateral views of the chest were obtained with comparison\n made to examination performed yesterday.\n\n FINDINGS: No evidence of pneumothorax. Right basilar chest tube is again\n seen, unchanged in position. Right-sided PICC is again seen, extending to the\n lower SVC.\n\n Again seen is a 2-cm pulmonary opacity which abuts the minor fissure,\n unchanged in configuration and size since the prior study. Cardiac and\n mediastinal silhouettes remain normal. Lung fields are otherwise clear aside\n from a couple of dense and peripheral 3-mm nodules probably representing\n calcified granulomas. Trace residual pleural effusions remain.\n\n IMPRESSION:\n 1. No evidence of pneumothorax.\n 2. Rounded opacity abutting the minor fissure which might represent\n loculation of pleural fluid. However, recommend followup to resolution in\n order to exclude underlying mass.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-19 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 900760,
"text": " 1:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEASE DO CT . pt s/p choledochoduodenosotmy, peusto\n Admitting Diagnosis: PANCREATIC FISTULA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with chronic pancreatitis, s/p peustow\n REASON FOR THIS EXAMINATION:\n PLEASE DO CT . pt s/p choledochoduodenosotmy, peustow procedure w/\n bloody BM'S, low-grade fever, leukocytosis. Eval for postop collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chronic pancreatitis, status post Puestow. Bloody BMs, low-grade\n fever and leukocytosis. Evaluate for postop collection.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of oral and 150 cc of Optiray contrast.\n Coronal and sagittal reconstructions were obtained.\n\n CT OF THE ABDOMEN WITH CONTRAST: The lung bases are clear. The liver,\n spleen, and adrenal glands are normal. The patient is status post Puestow\n procedure. Air is noted within the pancreatic duct, not unexpected following\n this procedure. Calcifications are again noted within the pancreas,\n consistent with chronic pancreatitis. There is interval resolution of\n multiple pseudocysts that were seen in the study. There is\n residual fluid within the splenic hilum, measuring 2.9 x 1.6 cm. There is\n interval appearance of a small focus of arterial enhancement just inferior to\n the splenic artery measuring 8 mm in diameter, likely representing a small\n splenic artery aneurysm. The kidneys enhance symmetrically and excrete\n normally. There is a gastrojejunostomy tube in place. There is also a drain\n entering the right upper quadrant of the abdomen, traversing the abdomen\n between the stomach and pancreas. Small bowel loops are not dilated, and the\n colon is unremarkable. Bowel anastomosis is noted within the left mid\n abdomen. There are post-surgical changes of the anterior abdominal walls,\n with staples still in place. The abdominal aorta is of normal caliber, with\n calcifications at the origin of the SMA. The portal and splenic veins remain\n patent. No filling defect is noted within the IMV on this study. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes.\n\n CT OF THE PELVIS WITH CONTRAST: The bladder, seminal vesicles, prostate,\n rectum, and sigmoid are normal. No free pelvic fluid, and no pathologically\n enlarged pelvic or inguinal lymph nodes.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case\n\n (Over)\n\n 1:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEASE DO CT . pt s/p choledochoduodenosotmy, peusto\n Admitting Diagnosis: PANCREATIC FISTULA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Status post Puestow procedure, nearly all of the prior pancreatic\n pseudocysts have resolved. There is small amount of residual fluid near the\n splenic hilum as described. This is amenable to drainage at this time.\n 2. Interval development of small splenic artery aneurysm, measuring 8 mm.\n 3. Interval placement gastrojejunostomy tube and JP drain as described.\n 4. No definite filling defect is noted within the IMV on the current exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 898296,
"text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p ERCP with CT\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:42 A.M.\n\n HISTORY: ERCP. Pneumothorax.\n\n IMPRESSION: AP chest compared to and 24th:\n\n Small right pleural effusion has increased since despite presence\n of a right basal pleural tube. Tiny right apical pneumothorax is stable.\n Left lung clear. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 898953,
"text": " 9:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 56 s/p chest tube pull\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ chest tube to wall sxn **should be done with a.m. rounds\n please **\n REASON FOR THIS EXAMINATION:\n 56 s/p chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post chest tube removal.\n\n COMPARISON: .\n\n FINDINGS: The right basilar chest tube has been removed. There is a tiny\n right apical pneumothorax, unchanged since . A small right pleural\n effusion is unchanged, including a small amount of fluid in the right minor\n fissure. There is mild atelectasis at the right lung base. The heart,\n mediastinum, and pulmonary vessels appear normal. The right PICC tip remains\n in unchanged position in the lower SVC.\n\n IMPRESSION:\n 1. Stable tiny right apical pneumothorax.\n 2. Stable small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 898304,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion **should be done with a.m. rounds please **\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ chest tube to wall sxn **should be done with a.m. rounds\n please **\n REASON FOR THIS EXAMINATION:\n ? effusion **should be done with a.m. rounds please **\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup of pneumothorax.\n\n Compared to the prior radiograph obtained yesterday there is slight decrease\n in the right apical pneumothorax. There is a small right pleural effusion\n without any air fluid level. An unusual rounded 2-cm opacity is seen along\n the minor fissure in the right middle lobe which given the history of prior\n effusions and given that it has developed acutely probably represents rounded\n atelectasis. A radiopacity along the right costophrenic sulcus also likely\n represents atelectasis. The left lung field is clear. The heart size is\n normal. The mediastinal and hilar contours are normal. Right chest tube at\n right costophrenic sulcus and right-sided PICC line terminate in the mid SVC.\n\n IMPRESSION: Decreasing small right apical pneumothorax. Right middle lobe\n rounded atelectasis and right basilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-30 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 898380,
"text": " 4:33 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: Assess for vascular malformations\n Admitting Diagnosis: PANCREATIC FISTULA\n Field of view: 36 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with chronic pancreatitis, possible pancreatico-pulmonary\n fistula, possible av fistulae\n REASON FOR THIS EXAMINATION:\n Assess for vascular malformations\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS\n\n There is no comparison exam.\n\n CLINICAL HISTORY: Chronic pancreatitis, possible pancreatic or pulmonary\n fistula, possible AV fistula. Assess for vascular malformation.\n\n TECHNIQUE: Axial MDCT images of the abdomen and pelvis obtained after pre and\n post-IV contrast enhancement. Multiplanar volume reformatted images were\n generated, which were essential in the evaluation of the abdomen and pelvis.\n\n CT ABDOMEN FINDINGS: Images of the lower thorax demonstrate a small right\n pleural effusion and a chest tube. There is consolidation/atelectasis at the\n right lower lobe. There is a small pneumothorax on the right. Small left\n pleural effusion is also present.\n\n Pre-contrast images of the abdomen demonstrate multiple small calcifications\n in the pancreas consistent with chronic pancreatitis. There is\n atherosclerosis.\n\n Post-contrast images demonstrate a normal appearance of the liver, spleen,\n adrenal glands, and kidneys. The pancreas is atrophic. The pancreatic duct\n is dilated. Numerous cystic structures are present adjacent to the pancreas.\n The largest is adjacent to pancreatic tail and extends between the stomach and\n spleen and measures 3.5 x 4.1 cm. Another large bilobed cyst is seen\n extending from the lesser sac to the pancreatic head. It contains a focus of\n gas.\n\n There is a small fluid collection in the right diaphragmatic crus measuring\n less than 4 mm wide. This is best seen on series 6, image 22.\n\n There are no dilated bowel loops. There are scattered prominent lymph nodes.\n\n CT PELVIS FINDINGS: There is no pelvic free fluid or lymphadenopathy. No\n dilated bowel loops are present within the pelvis. Gas is seen in the urinary\n bladder.\n\n Bone windows demonstrate no lytic or blastic lesions.\n (Over)\n\n 4:33 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: Assess for vascular malformations\n Admitting Diagnosis: PANCREATIC FISTULA\n Field of view: 36 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CTA FINDINGS: There is conventional hepatic vasculature. The celiac axis,\n common hepatic artery, left gastric artery, and splenic artery are patent.\n There is no splenic artery aneurysm. There is atherosclerosis at the origin\n of the SMA causing a high-grade stenosis but the distal SMA is patent. The\n renal arteries are patent. There is narrowing of the splenic vein likely\n second to pancreatitis. There is a filling defect in the inferior mesenteric\n vein consistent with thrombus.\n\n There is conventional portal venous anatomy. The hepatic venous anatomy is\n normal. There is no evidence of a fistula either within the abdomen or\n between the thorax and abdomen.\n\n IMPRESSION:\n 1. No AV fistula or pancreatic or pulmonary fistula as questioned.\n 2. Numerous cystic structures surrounding the pancreas consistent with\n pancreatic pseudocysts. One large one extending from the lesser sac to the\n pancreatic head contains a focus of air, which may represent infection.\n 3. Tiny enhancing fluid collection in the right diaphragmatic crus. This may\n be related to extension of pancreatitis, or alternatively extension from\n infection in the right lung. Close attention to this area should be paid on\n further follow-up studies to exclude early/small abscess.\n 4. Gas in the urinary bladder correlate with a recent Foley catheterization\n or instrumentation. If the patient has had neither of these, then a UA is\n recommended to exclude infection.\n 5. Narrowed splenic vein likely secondary to pancreatitis. Thrombus in the\n IMV also likely related to pancreatitis.\n 6. Small right pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-08 00:00:00.000",
"description": "US INTR-OP 90 MINS",
"row_id": 899410,
"text": " 1:33 PM\n US INTR-OP 90 MINS Clip # \n Reason: hx of pancreatis ,dil pd\n Admitting Diagnosis: PANCREATIC FISTULA\n ICD9 code from order: U89\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n pancreatitis\n REASON FOR THIS EXAMINATION:\n hx of pancreatis ,dil pd\n ______________________________________________________________________________\n FINAL REPORT\n INTRAOP ULTRASOUND 90 MINUTES\n\n INDICATION: Pancreatitis.\n\n Intraoperative ultrasound guidance was provided to Dr. to facilitate\n localization of several peripancreatic pseudocysts. The study demonstrates\n simple cysts anterior to the body of the pancreas and in the porta hepatis a\n more complex approximately 6 cm cyst with septations is noted in the splenic\n hilum.\n\n Diffuse echogenicities are noted throughout the pancreas. The dilated\n pancreatic duct as demonstrated on a contemporaneous CT scan is extremely\n difficult to identify and is filled with echogenic debris. Son\n guidance was provided to Dr. to facilitate insertion of a needle and\n probe into the dilated pancreatic duct.\n\n IMPRESSION: Satisfactory ultrasound-guided localization of peripancreatic\n pseudocysts and ultrasound-guided localization of debris-filled dilated\n pancreatic duct.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 899434,
"text": " 2:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess for pneumo (had prior small pneumo after CT pull a fe\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ chest tube to wall sxn **should be done with a.m.\n rounds please **\n REASON FOR THIS EXAMINATION:\n assess for pneumo (had prior small pneumo after CT pull a few days ago)now s/p\n cordis placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST: .\n\n COMPARISON: .\n\n INDICATION: Pneumothorax assessment.\n\n A previously noted right apical pneumothorax is no longer evident on this\n supine radiograph. An endotracheal tube is in place in the interval and is\n located above the thoracic inlet level, about 8-1/2 cm above the carina. A\n Swan-Ganz catheter terminates in the proximal interlobar right pulmonary\n artery, and nasogastric tube terminates below the diaphragm. Cardiac and\n mediastinal contours are normal. There are new bilateral perihilar opacities,\n as well as scattered patchy opacities in the right mid and lower lung zones.\n A small right pleural effusion is again demonstrated.\n\n IMPRESSION:\n 1. Proximal location of endotracheal tube, which could be advanced several\n centimeters for more optimal placement, as communicated by telephone to Dr.\n .\n 2. New asymmetrical alveolar opacities, involving the right lung to a greater\n degree than the left, with a normal heart size. Differential diagnosis\n includes asymmetrical noncardiogenic pulmonary edema and\n aspiration/aspiration pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 899963,
"text": " 9:13 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement r bas picc for abx call beeper \n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ chest tube to wall sxn **should be done with a.m.\n rounds please **\n REASON FOR THIS EXAMINATION:\n please check placement r bas picc for abx call beeper with wet read asap\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n COMPARISON: .\n\n AP UPRIGHT PORTABLE VIEW OF THE CHEST: The left costophrenic angle is not\n included on the image. A new right PICC is in place with tip at the junction\n of the superior vena cava and the right atrium. A right internal jugular\n central venous line is again seen with tip in the upper SVC. Previously noted\n bilateral lower lobe opacities are less extensive and dense. Right pleural\n effusion has decreased in size.\n\n PICC position was reported to IV therapy nursing at beeper at 10:20 a.m.\n on .\n\n IMPRESSION:\n 1. Satisfactory PICC position.\n 2. Improving bilateral lower lobe aspiration.\n 3. Decreased small right pleural effusion.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 899502,
"text": " 8:20 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ chest tube to wall sxn **should be done with a.m.\n rounds please **\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 56-year-old man with chest tube and central venous line\n placement.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The Swan-Ganz catheter has been removed. There is new right jugular IV\n catheter terminating in the mid SVC. No pneumothorax is identified.\n\n There is slightly increased opacity in the right lower lobe indicating\n atelectasis versus pneumonia. The right costophrenic angle is not included in\n the radiograph.\n\n The lungs are clear otherwise. The heart is normal in size. A nasogastric\n tube courses towards the stomach.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 898786,
"text": " 2:25 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for pneumothorax\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man pleuro-pancreatico fistula w/ CT now to water seal.\n\n REASON FOR THIS EXAMINATION:\n Assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax.\n\n Three radiographs of the chest again demonstrate a right-sided chest tube,\n unchanged from . Small apical right-sided pneumothorax persists.\n Right-sided PICC line is unchanged in position. Trachea is midline. Left\n lung is clear. No effusion. Cardiac contour is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-05 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 898976,
"text": " 11:17 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: PHLEBITIS, FEVERS, ? CLOT\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with phlebitis and fever 103\n REASON FOR THIS EXAMINATION:\n ? clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with phlebitis and fever of 103.\n\n -scale and pulse color Doppler imaging of the left internal jugular,\n axillary, subclavian, brachial, and cephalic veins was performed. Echogenic\n material consistent with thrombus is seen filling the cephalic vein, which is\n not compressible. No color flow is seen within the cephalic vein. There is\n normal color flow, compressibility, waveform, and augmentation elsewhere in\n the left arm.\n\n IMPRESSION:\n\n No deep vein thrombosis in the left arm. Thrombosis in the superficial left\n cephalic vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-02-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 899666,
"text": " 9:27 AM\n CHEST (PA & LAT) Clip # \n Reason: T 101.7\n Admitting Diagnosis: PANCREATIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n\n REASON FOR THIS EXAMINATION:\n T 101.7\n ______________________________________________________________________________\n FINAL REPORT\n Two view chest of with indication of fever.\n\n There has been interval removal of an endotracheal tube, Swan-Ganz catheter.\n The heart size is normal. Central venous catheter has been placed in the\n interval terminating in the mid superior vena cava.\n\n There has been interval worsening of multifocal airspace consolidation within\n the left perihilar region and both lower lobes. Bilateral pleural effusions\n are present, small on the left and small to moderate on the right with\n probable partial loculation of the right effusion laterally.\n\n IMPRESSION: Worsening bilateral lower lobe airspace disease, concerning for\n evolving aspiration pneumonia. Bilateral pleural effusions.\n\n\n"
}
] |
3,417 | 192,539 | pt was taken to the OR on for repair of an incarcerated hernia via the following procedures: Left thoracotomy with extensive intrapleural lysis of adhesions, Thoracoabdominal repair of incarcerated paraesophageal hernia with reduction of gastric volvulus, Repair of esophagotomy and gastrotomy, Dor fundoplication, Feeding jejunostomy, Drainage gastrostomy, Diagnostic esophagoscopy, Bronchoscopy with aspiration of secretions. OR course was w/o complications. Pt had a 2 chest tubes for drainage, a g-tube and a J-tube. Post operatively, pt remained intubated was admitted to the ICU for monitoring and management. POD#1 pt was extubated w/o difficulty. Rec'd 2UPRBC for post anemia. POD#2 trophic J-tube feeds started. g-tube remains to gravity d/t high vol output>1L/24hr period. POD#3 pt transferred from ICU to floor for ongoing post op care. POD#4 apical chest tube removed w/ stable CXR. POD# Tube feeds gradually increased to goal and is well. Good bowel function. Gastric tube still w/ high vol output ~1 liter/24hrs. Remaining chest tube d/c'd w/ stable CXR. POD#7 passed barium swallow w/slow but complete passage of barium into the stomach- see results section. POD#8 cleared by PT for d/c to home w/ VNA for supportive services. | + pp by doppler.resp: LS clear with dim bases. pleuroal tubes remain w/ min dng. ancef dosing complete.assess: symptomatic hypotension w/ dangle. dilaudid PCA w/ effect. GT remains to gravity, ngt to lwsx now dng bilous. sc heparin for dvt proph. pt reports + flatus. pulm hygiene. lytes repleted.Resp: ls clr, bases dim. bt orthostatic w/ dangle to . A very small left apical pneumothorax is again noted. ; pleural ct's to lcs, sm amt serosang drainage overnoc.Gi/gu: ngt to lcs w/brown bilious drainage noted; absent bs. gt to gravity for min brownish dng, JT to for scant bilous. thoracot dsg, origina; w/ mod old serosang dng.cv: vs as per flowsheet. oob after transfusion. .CV: ST -> RSR post fluid bolus and metoprolol. In AM wean and extubate. COMPARISON: Chest PA and lateral, . A small amount of postoperative pneumoperitoneum persists. + PT pulses via doppler. Linear and patchy atelectasis at both lung bases persists. re DR. left CT x2. NSR w/ rare pvc.gi: abd soft. BS essentially clear/dim sxing for minimal secretions. riss. updated by MD.id: . CONCLUSION: Post-operative changes as would be expected. A line with dampened trace -> trending BP by cuff. Chest tube removal. lungs clear w/ dim lt base much of time. INDICATION: Status post Boerhaave's repair. min ngt drainage to lwsx, gentle irrigate x2. extrems cool/dry. Tiny left apical pneumothorax is unchanged. COMPARISON: AP portable chest x-ray dated . Suctioned for mod -tinged secretions. Protonix for GI prophylaxis. Left pleural effusion unchanged. pao2 70s. Left lower lobe retrocardiac atelectasis and small left pleural effusion are unchanged. Connected to monitors and initial assessment completed as noted in care vue flow record.ROS:Neuro: on propofol. Two left chest tubes remain in place. Allowing for difference in patient positioning, a small left apical pneumothorax is stable or slightly smaller. The hiatus hernia has apparently been repaired and a nasogastric tube is seen in place and the tip would be just beyond the fundus of the stomach which is not well outlined below the diaphragm. replete w/ fiber began via JT. The aortic graft is seen and there appears to be a very tiny pneumothorax at the left apex. The tiny left apical pneumothorax is essentially unchanged. analgesia adjusted. bilateral pulses by doppler. There is atelectasis and effusion above the left hemidiaphragm. pain mgt. NG tube tip has been removed. Multiple lines and tubes, including two left chest tubes are in unchanged position. Abgs wnl. huo adequate, clr . Dilaudid IVP for pain mngt. Dilaudid IVP for pain mngt. Abd soft w/o bowel sounds. There is at least a small right pleural effusion. perrl.Cv: nsr 80s, no ectopy. Very small apical pneumothorax. c/o nausea x1-zofran given w/good effect. The appearance of the cardiomediastinum is unchanged including aortic graft. DR. afebrile. 1 unit prbc ordered. IMPRESSION: 1. IMPRESSION: 1. bp 80s-90s by cuff. Correlate clincially. J tub and G tube insertion. Resp CArePt remains on vent. nsr w/ rare pvc. cvicu updateneuro/pain: pt aaox3. COMPARISON: CT torso . art line remains dampened. Monitor, tx, support and comfort. IMPRESSION: Removal of one of the left pleural tubes with no increase in the small left apical pneumothorax. pulm toilet. RLE Right-sided central line is unchanged in position. cvp 2-3.resp: o2 2-3 l n/c. sbp 80-90's by NBP, lower BP by art line though dampened. Free air is still seen under the right hemidiaphragm. Patient's G- tube, left pleural tube, and central line are partially imaged. Luminal irregularity of the distal esophagus in the region of fundoplication is likely postoperative, with contrast passing through into the stomach. G tube to gravity draining billious fluid. There has been interval decrease in the amount of intraperitoneal air. floor today, continue TF, pulm toleit, pain control, advance activity as tolerated No resp distress noted, = rise and fall of chest. FINAL REPORT CLINICAL HISTORY: Chest tube removed. ordered as noted. TF replete with fiber given via J tube at 30 cc/hr - tolerating well - no residual. states pain "pretty good" today. Left chest wall loculated accumulation is incompletely imaged, probably unchanged. The patient is post-operative and there is a large amount of free intraperitoneal air beneath the diaphragm. cont pulm hygiene, analgesia. There is left lower lobe atelectasis and small left- sided pleural effusion, which may be loculated. COMPARISON: Radiographs . 12:29 PM CHEST (PA & LAT) Clip # Reason: Interval cardiopulmonary changes from prior CXR. Small left apical thorax is either stable or slightly smaller. Atelectasis of the left base is again seen. A left chest tube is present at the base. abd soft. POST OP ADM NOTES/P Flex bronch, repair of hiatal hernia, fundoplication, egd, diaphramatic repair, myotomy (esophageal) repair of esophageal/gastric perferation via left thoracoabd approach. Limited study secondary to patient positioning. pain issues.plan: transfusion. Pulmonary toileting. c/o nausea w/ oob attempt-> zofran w/ effect. Propofol for sedation. Aortic graft is again seen. FINDINGS: Redemonstrated is a soft tissue density in the left chest wall in the region of the overlying skin staples. unable to sleep -> given ambien -> slept ~ 1 hr.CV: pt remains NSR, rare PVC noted. No left radial or ulnar pulse on adm now w/dopplerable pulse, hand and arm cool to touch. Rsbi 33. IMPRESSION: Tubes/lines placed with no apparent pneumothorax. The right- sided internal jugular central line catheter is unchanged in appearance and position. NG tube to LCW suction draining billious fluid. NS 500cc x1 w/out effect. pain decreasing to 0-2 out of 10. cont to feel "crappy".resp: lungs dim bilat. | 17 | [
{
"category": "Radiology",
"chartdate": "2155-10-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 981761,
"text": " 12:29 PM\n CHEST (PA & LAT) Clip # \n Reason: Interval cardiopulmonary changes from prior CXR.\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man s/p Booerhaave's repair with hiatal hernia on UGI, s/p\n repair and chest tube removal\n REASON FOR THIS EXAMINATION:\n Interval cardiopulmonary changes from prior CXR.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Chest tube removed. Evaluate for change.\n\n Free air is still seen under the right hemidiaphragm. A very small left\n apical pneumothorax is again noted.\n\n A left chest tube is present at the base. Mediastinal changes are essentially\n unaltered. Atelectasis of the left base is again seen. The right lung\n remains clear.\n\n IMPRESSION: No significant change since prior chest x-ray. Very small apical\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 981911,
"text": " 4:49 PM\n CHEST (PA & LAT) Clip # \n Reason: left chest tube removal r/o PTX\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man s/p Booerhaave's repair with hiatal hernia on UGI, s/p\n repair and chest tube removal\n REASON FOR THIS EXAMINATION:\n left chest tube removal r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Boerhaave's repair; for post-operative evaluation.\n\n In comparison with the study of , there has been some increase in the\n lateral collection of air and fluid on the left. This information has been\n telephoned to Dr. .\n\n re\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2155-10-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 981998,
"text": " 8:41 AM\n CHEST (PA & LAT) Clip # \n Reason: eval interval changes, especially surrounding L chest wall l\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man s/p Booerhaave's repair with hiatal hernia on UGI, s/p\n repair and chest tube removal\n REASON FOR THIS EXAMINATION:\n eval interval changes, especially surrounding L chest wall loculated\n accumulation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL.\n\n COMPARISON: Chest PA and lateral, .\n\n HISTORY: 41-year-old male status post Booerhaave repair with left chest wall\n loculated accumulation.\n\n FINDINGS: Redemonstrated is a soft tissue density in the left chest wall in\n the region of the overlying skin staples. This area is only partially imaged\n on this study as well as partially imaged on the previous study. The right-\n sided internal jugular central line catheter is unchanged in appearance and\n position. There are sternotomy wires, aortic stents in place, and an aortic\n valve replacement. These are unchanged in appearance. The right lung is\n clear, without effusions or consolidation. There is left lower lobe\n atelectasis and small left- sided pleural effusion, which may be loculated.\n This is unchanged in appearance since previous exam. There is fluid seen in\n the left major fissure on the lateral view.\n\n IMPRESSION:\n 1. Small left pleural effusion, which may be loculated, is not significantly\n changed since previous examination.\n 2. Left chest wall loculated accumulation is incompletely imaged, probably\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 981603,
"text": " 1:51 PM\n CHEST (PA & LAT) Clip # \n Reason: PTX\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man s/p Booerhaave's repair with hiatal hernia on UGI, s/p\n repair and chest tube removal\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Status post Boerhaave's repair. Chest tube removal.\n\n A single AP view of the chest is obtained at 13:52 hours and is\n compared with the most recent study performed on at 10:46 hours. One\n of the left-sided pleural tubes has been removed. The tiny left apical\n pneumothorax is essentially unchanged. Left pleural effusion unchanged.\n Increased retrocardiac density consistent with airspace disease/atelectasis in\n left base is also unchanged. In the right chest the air under the right\n diaphragm has not significantly changed since the previous examination. Aortic\n graft is again seen. Right-sided central line is unchanged in position.\n\n IMPRESSION:\n\n Removal of one of the left pleural tubes with no increase in the small left\n apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981271,
"text": " 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate rt effusion and left ptx\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Marfan's s/p aortic replacement, now s/p\n endovascular stenting s/p R thoracoabdominal incision, repair of hiatal\n hernia\n REASON FOR THIS EXAMINATION:\n evaluate rt effusion and left ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable film of the chest on at 0938 hours. The patient\n is post-operative and there is a large amount of free intraperitoneal air\n beneath the diaphragm. The right lung appears clear and no definite\n atelectasis or effusions are seen on that side. A right jugular line extends\n down to the mid superior vena cava and a left-sided chest tube is in place,\n the tip in the upper third of the hemithorax. The hiatus hernia has\n apparently been repaired and a nasogastric tube is seen in place and the tip\n would be just beyond the fundus of the stomach which is not well outlined\n below the diaphragm. There is atelectasis and effusion above the left\n hemidiaphragm. The aortic graft is seen and there appears to be a very tiny\n pneumothorax at the left apex.\n\n CONCLUSION: Post-operative changes as would be expected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981424,
"text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls perform between 10:30-11am on water seal\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Marfan's s/p aortic replacement, now s/p\n endovascular stenting s/p R thoracoabdominal incision, repair of hiatal\n hernia\n REASON FOR THIS EXAMINATION:\n pls perform between 10:30-11am on water seal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Chest tube on waterseal.\n\n Comparison is made with prior study performed a day earlier.\n\n Tiny left apical pneumothorax is unchanged. Two left chest tubes remain in\n place. The right lung is clear with a small right pleural effusion. Left\n lower lobe retrocardiac atelectasis and small left pleural effusion are\n unchanged. Right internal jugular vein catheter tip is in the SVC. There has\n been interval decrease in the amount of intraperitoneal air. The appearance\n of the cardiomediastinum is unchanged including aortic graft. NG tube tip has\n been removed.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2155-10-28 00:00:00.000",
"description": "UGI SGL CONTRAST W/ KUB",
"row_id": 981834,
"text": " 9:14 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: please use thin barium for barium swallow study\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41M pod7 s/p L thoracoabdominal incision, hiatal hernia repair, \n fundoplication, diaphragmatic repair, G and J tube placement.\n REASON FOR THIS EXAMINATION:\n please use thin barium for barium swallow study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hiatal hernia repair and fundoplication.\n\n COMPARISON: CT torso .\n\n FINDINGS: The initial scout images demonstrate patient is status post median\n sternotomy, valve repair, and extensive aortic graft repair. Patient's G-\n tube, left pleural tube, and central line are partially imaged. A small\n amount of postoperative pneumoperitoneum persists.\n\n The oral administration of Conray contrast demonstrated no evidence of\n extravasation or obstruction which was confirmed with oral thin barium\n administration. Luminal irregularity of the distal esophagus in the region of\n fundoplication is likely postoperative, with contrast passing through into the\n stomach.\n\n IMPRESSION: No obstruction or extravasation. Luminal irregularity of\n the distal esophagus in region of fundoplication likely represents\n postoperative edema. Correlate clincially.\n\n Findings discussed with Dr. \n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981072,
"text": " 12:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p repair of hiatal hernia w/dropping HCT-r/o wffusion\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Marfan's s/p aortic replacement, now s/p\n endovascular stenting s/p R thoracoabdominal incision, repair of hiatal\n hernia\n REASON FOR THIS EXAMINATION:\n s/p repair of hiatal hernia w/dropping HCT-r/o wffusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old male status post abdominal surgery with dropping\n hematocrit.\n\n COMPARISON: AP portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The study is severely limited by\n technique. The left costophrenic angle is not imaged. Multiple lines and\n tubes, including two left chest tubes are in unchanged position. Allowing for\n difference in patient positioning, a small left apical pneumothorax is stable\n or slightly smaller. The appearance of the lungs is unchanged. Linear and\n patchy atelectasis at both lung bases persists. There is at least a small\n right pleural effusion. The patient is status post aortic endovascular stent\n grafting, aortic valve repair and sternotomy.\n\n IMPRESSION:\n 1. Limited study secondary to patient positioning. Small left apical thorax\n is either stable or slightly smaller.\n\n 2. No significant interval change with persistent bibasilar atelectasis and\n at least a small right pleural effusion.\n\n Paged To at 11:50 am on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-10-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 981014,
"text": " 2:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PTX\n Admitting Diagnosis: DIAPHRAGMATIC HERNIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Marfan's s/p aortic replacement, now s/p endovascular\n stenting s/p R thoracoabdominal incision, repair of hiatal hernia\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with Marfan's syndrome status post hiatal hernia\n repair. Evaluate for pneumothorax.\n\n COMPARISON: Radiographs .\n\n SINGLE PORTABLE VIEW OF THE CHEST: There is no pneumothorax. An ET tube, NG\n tube, left apical and basilar chest tubes, and a right internal jugular line\n in the mid SVC are all in satisfactory position. There is no change in the\n sternotomy wires or extensive aortic endovascular stenting. There is slight\n bibasilar atelectasis; the lungs are otherwise clear.\n\n IMPRESSION: Tubes/lines placed with no apparent pneumothorax.\n\n\n RLE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-23 00:00:00.000",
"description": "Report",
"row_id": 1306635,
"text": "Neuro: a&ox3, maes, follows commands, cooperative. PCA dilauded dose decreased d/t nausea and head \"feeling strange\"; states pain well controlled, but unable to sleep. perrl.\n\nCv: nsr 80s, no ectopy. bp 80s-90s by cuff. a-line dampened, unreliable. bilateral pulses by doppler. extrems cool/dry. sc heparin for dvt proph. afebrile. lytes repleted.\n\nResp: ls clr, bases dim. o2sats >95% on 2L nc. rr teens. pao2 70s. o2 ^ to 3L, pt encouraged to cdb & use I.S.; pleural ct's to lcs, sm amt serosang drainage overnoc.\n\nGi/gu: ngt to lcs w/brown bilious drainage noted; absent bs. j & g tubes to gravity w/sm amt brown-bilious drainage. c/o nausea x1-zofran given w/good effect. huo adequate, clr . d5.45ns @ 100cc/hr.\n\nEndo: rssi-coverage required overnoc.\n\nSocial: no telephone calls from family this shift.\n\nPlan: continue monitoring cardioresp status, labs. pulm toilet. pain mgt. increase activity. continue support & update pt re: status & plan of care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-23 00:00:00.000",
"description": "Report",
"row_id": 1306636,
"text": "cvicu update\nneuro/pain: pt aaox3. discouraged. c/o insomnia. dilaudid PCA w/ effect. states pain \"pretty good\" today. no changes in dilaudid dosing.\n\ncv: vs as per flowsheet. nsr w/ rare pvc. bp drifting to 80's by NBP this afternoon. art line remains dampened. 1 unit prbc ordered. cvp 2-3.\n\nresp: o2 2-3 l n/c. lungs clear w/ dim lt base much of time. o2 sats to high 80's on r/a. using IS to ~1000 cc. pleuroal tubes remain w/ min dng. no airleak.\n\ngi/gu: uop drifting to 20cc/hr this pm. ordered as noted. abd soft. no bsp. replete w/ fiber began via JT. GT remains to gravity, ngt to lwsx now dng bilous. brief nausea prior to feeds start, zofran w/ effect. no further nausea since feeds up.\n\nact: oob x2 today for 1 1/2 hr each.\n\nassess: borderline SBP and uop.\n\nplan: transfuse. cont pulm hygiene, analgesia.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-24 00:00:00.000",
"description": "Report",
"row_id": 1306637,
"text": "7pm-7am update\nneuro: pt and orieantated x3. MAE and able to follow commands. pt appears depressed. unable to sleep -> given ambien -> slept ~ 1 hr.\n\nCV: pt remains NSR, rare PVC noted. HR 80's. A line with dampened trace -> trending BP by cuff. BP by cuff 90-100's/40-50's. pt given 1 unit PRBC last night -> repeat HCT pending. CVP 1-3. pt continues to recieved D5 1/2 NS at 100 cc/hr. + pp by doppler.\n\nresp: LS clear with dim bases. pt remains on 3 L NC, o2 sats 95-97%. CT draining minimal serousanginous fluid, no airleak noted. using Is to 1000.\n\ngi/gu: pt with + hypoactive bs. pt reports + flatus. NG tube to LCW suction draining billious fluid. G tube to gravity draining billious fluid. TF replete with fiber given via J tube at 30 cc/hr - tolerating well - no residual. pt denies nausea\n\nendo: elvated BS treated with ss reg insulin as ordered\n\ncomfort: pt recieved diluadid PCA for pain control\n\nplan: ?? floor today, continue TF, pulm toleit, pain control, advance activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-22 00:00:00.000",
"description": "Report",
"row_id": 1306632,
"text": "Neuro: pt is lightly on propofol @ 15 mcg/kg/min for comfort, easily arousable, MAE's, following commands consistently, PERRL 3mm brisk, communicate well with non-verbal cues\n\nCV: low grade temp 99.3, SR with rare PVC's, HR 80's-90's, Ca & Mg repleted, SBP high 80's-100's, following , requires fluid bolus for decreased BP, TSURG team awared, 500 ml hespan given x1 for low BP, hct dropped from 28->25->23, currently is 22, won't transfuse until hct <20 per TSURG team, extremities warm to touch, weak palpable pulses x4, a line damping @ times\n\nResp: Intubated & vented on SIMV 40% FiO2, RR 15, lung sound clear, ABG slightly metabolic acidotic, improved from previous ABG after colloid & fluid, suctioned with scant amount tinged secretion; CT to suction x2, serrousang drainage, +air leak, - crepitus\n\nGI: Abd soft, hypo bowel sound; NGT to LCS with billious drainage, not to be manipulated per TSURG team, can be flushed with 10 ml water q shift, G & J tube to gravity, G tube with dark bloody drainage\n\nGU: Foley draining clear urine, auto diuresising\n\nInteg: No dressing change in AM per TSURG team, see carevue for details\n\nSocial: No call from spouse\n\nEndo: 0000 BNG 207, 4 units SC regualr insulin given, rechecked BG 167\n\nPain: managed with dilaudid with goo effect\n\nID: on post-o pdose cefazolin\n\nPlan: monitor hemodynamics, resp status & labs; ?extubate in AM; fluid resusitation ; keep MAP >60, start on PCA once extubated; emotional support\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-22 00:00:00.000",
"description": "Report",
"row_id": 1306633,
"text": "Resp CAre\nPt remains on vent. Intubated 7.0 ett @ 23, patent and secure. Suctioned for mod -tinged secretions. Abgs wnl. Rsbi 33. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-22 00:00:00.000",
"description": "Report",
"row_id": 1306634,
"text": "cvicu update\nneuro: aaox3. maew in bed.\n\npain: dilaudid switch to PCA this am. pt c/o increasing pain to \"12\" w/ cough. dilaudid 0.5 mg iv x 2 w/ effect, PCA dosing increased also. pain decreasing to 0-2 out of 10. cont to feel \"crappy\".\n\nresp: lungs dim bilat. left CT x2. min dng, no airleak. o2 sats 95-97% on 2L n/c. using IS to 750cc-1000cc. thoracot dsg, origina; w/ mod old serosang dng.\n\ncv: vs as per flowsheet. NS 500cc x1 w/out effect. sbp 80-90's by NBP, lower BP by art line though dampened. rue warmer than lue. pedal pulses by doppler, feet warm bilat. bt orthostatic w/ dangle to . BP down,nausea and \"going to pass out\". return to bed. hct 23.5 decision to transfuse 2 unit prbc made. 1st unit up. NSR w/ rare pvc.\n\ngi: abd soft. no bsp. gt to gravity for min brownish dng, JT to for scant bilous. min ngt drainage to lwsx, gentle irrigate x2. c/o nausea w/ oob attempt-> zofran w/ effect. NPO. riss. GU: uop qs via foley.\n\nsocial: wife at at present. updated by MD.\n\nid: . ancef dosing complete.\n\nassess: symptomatic hypotension w/ dangle. requiring transfusion. pain issues.\n\nplan: transfusion. analgesia adjusted. pulm hygiene. oob after transfusion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-21 00:00:00.000",
"description": "Report",
"row_id": 1306630,
"text": "POST OP ADM NOTE\n\nS/P Flex bronch, repair of hiatal hernia, fundoplication, egd, diaphramatic repair, myotomy (esophageal) repair of esophageal/gastric perferation via left thoracoabd approach. J tub and G tube insertion. 2 left pleural chest tubes.\n\n3L crystaolid, 2 units PRBC, 750 albumin, 700cc EBL, out on propofol.\n\nReceived via bed accompanied by anesthesia. Connected to monitors and initial assessment completed as noted in care vue flow record.\n\nROS:\n\nNeuro: on propofol. Arouses to voice and MAE x's 4 to command. Dilaudid IVP for pain mngt. .\n\nCV: ST -> RSR post fluid bolus and metoprolol. No ectopy. VSS. Has right radial abp line and RIJ triple lumen central line. No left radial or ulnar pulse on adm now w/dopplerable pulse, hand and arm cool to touch. No DP pulses. + PT pulses via doppler. Feet warm and pink. Dr. aware.\n\nResp: Intubated and on vent 650x15, , 40%. SATS 100%. Breathsounds clear. No resp distress noted, = rise and fall of chest. Has two left pleural chest tubes to sx draining serosang fluid.\n\nGI: sump via right nare to LCS draining thick dark red small amt. Abd soft w/o bowel sounds. Protonix for GI prophylaxis. Has G tube and J tube to gravity drng, draining scant dark red fluid from G tube, no drng from J tube.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nSocial: Wife in to visit, gone home for the noc.\n\nPlan: Leave and intubated over noc. In AM wean and extubate. Propofol for sedation. Dilaudid IVP for pain mngt. Switch to pca when extubated. Pulmonary toileting. Mobilize. DO NOT MANIPULATE NG TUBE, ok to flush w/10cc NS q shift. BP goal MAPs >60. Avoid pressors at all costs, resusitate w/fluids and albumin. Monitor, tx, support and comfort.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-10-21 00:00:00.000",
"description": "Report",
"row_id": 1306631,
"text": "Resp Care\n\nPt admitted from OR intubated and currently vented on SIMV with changes made accordingly to correct acidosis status. BS essentially clear/dim sxing for minimal secretions. Will maintain vent support and reassess for weaning when ready.\n"
}
] |
73,612 | 138,140 | Pt was taken to the OR. After sternotomy, his aorta was noted to be heavily calcified. Dr. then discussed the high risk nature of the operation with the family; they indicated that he should proceed with the operation. A CABG (LIMA -> LAD), AVR, MV annuloplasty, and PFO were performed. Upon rewarming of the heart, the LV failed to contract. An additional CABG (SVG -> OM) was performed. Pt again failed to wean from bypass. The aorta was reopened, and the AVR was confirmed to be well-seated with good flow through the coronary ostia. Family was notified; BiVAD was agreed to be futile. Pt was decannulated and closed. He expired at 4:23pm. | Left-to-right shunt acrossthe interatrial septum at rest.LEFT VENTRICLE: Mild symmetric LVH. Borderline normal RV systolicfunction.AORTA: Normal ascending aorta diameter. Mild (1+) aortic regurgitation is seen. There is mildsymmetric left ventricular hypertrophy. There is critical aortic valve stenosis (valve area<0.8cm2). Mildly depressed LVEF.RIGHT VENTRICLE: Normal RV chamber size. Moderate to severe (3+)mitral regurgitation is seen with blunting of E wave, no systolic flowreversal. Mitral valve disease.Status: InpatientDate/Time: at 09:54Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. Mild (1+) AR.MITRAL VALVE: Moderate to severe (3+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Complex (>4mm) atheroma in theascending aorta. There arecomplex (>4mm) atheroma in the ascending aorta. Complex (mobile)atheroma in the descending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Complex (>4mm) atheroma in the aortic arch. Results werepersonally reviewed with the MD caring for the patient.Conclusions:Prebypass:The left atrium is moderately dilated. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Hypertension. There are complex (mobile)atheroma in the descending aorta. Congestive heart failure. The aortic valve leaflets are severelythickened/deformed. Good(>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Overall estimated left ventricularsystolic function is mildly depressed (LVEF= 40-45 %). Bypass resumed and aortic balloon pumpplaced, position verified by TEE. Thepatient was under general anesthesia throughout the procedure. Aleft-to-right shunt across the interatrial septum is seen. A patent foramen ovale is present. Right ventricularchamber size is normal. Critical AS(area <0.8cm2). No PS.Physiologic PR.GENERAL COMMENTS: Written informed consent was obtained from the patient. Dr. was notified in person of the results on at 0830.Postbypass:There is minimal left ventricular function with estimated ejection fraction of5%. with borderline normal free wall function. Surgeon immediately notified. No mass/thrombus in the LAA. No mass/thrombus is seen in the leftatrium or left atrial appendage. | 1 | [
{
"category": "Echo",
"chartdate": "2195-08-14 00:00:00.000",
"description": "Report",
"row_id": 104344,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Hypertension. Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 09:54\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No mass/thrombus in the LAA. Good\n(>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across\nthe interatrial septum at rest.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the\nascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (mobile)\natheroma in the descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPrebypass:\n\nThe left atrium is moderately dilated. No mass/thrombus is seen in the left\natrium or left atrial appendage. A patent foramen ovale is present. A\nleft-to-right shunt across the interatrial septum is seen. There is mild\nsymmetric left ventricular hypertrophy. Overall estimated left ventricular\nsystolic function is mildly depressed (LVEF= 40-45 %). Right ventricular\nchamber size is normal. with borderline normal free wall function. There are\ncomplex (>4mm) atheroma in the ascending aorta. There are complex (mobile)\natheroma in the descending aorta. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area\n<0.8cm2). Mild (1+) aortic regurgitation is seen. Moderate to severe (3+)\nmitral regurgitation is seen with blunting of E wave, no systolic flow\nreversal. Dr. was notified in person of the results on \nat 0830.\n\nPostbypass:\n\nThere is minimal left ventricular function with estimated ejection fraction of\n5%. Surgeon immediately notified. Bypass resumed and aortic balloon pump\nplaced, position verified by TEE. There was no sign of aortic dissection.\n\n\n"
}
] |
70,615 | 137,377 | In summary, Mr. is a 50-year-old gentleman with a past medical history of hyperlipidemia and testosterone deficiency who presented to the ED on after acute onset of chest pain. He was found to have a STEMI with RCA occlusion found on emergent cardiac catheterization and an additional 70% ulcertated lesion of LAD was also identified. As aforementioned, the patient's presenting EKG showed ST elevations in II, III, AVF, V5, and V6 indicative of inferior and lateral acute myocardial infarction or STEMI. Mr. received 325mg of aspirin, 600mg load of clopidogrel, heparin eptifibitide,nitroglycerin IV and 15mg of IV metoprolol soon after arrival to the ED. He was taken emergently to the cardiac catheterization lab where he was found to have a distal sub-total occlusion in the RCA and an everolimus-eluting stent was placed after thrombectomy was performed. He had a small right groin hematoma after his catheterization sheath pull but otherwise he had no major complications post-operatively. He was given protamine and eptifibitide gtt was stopped soon after the procedure to limit the extension of his hematoma. At time of discharge the localized right groin ecchymoses and hematoma margins had decreased and the patient appeared to be improving nicely. The right groin catheterization entry site was less swollen and the patient was hemodynamically stable throughout his hospital stay and he maintained a stable hematocrit throughout his hospitalization. The patient was counseled on lifestyle and diet modifications during his hospitalization. He was continued on ASA 325mg daily, clopidogrel 75mg daily and he was gradually titrated up on his beta blocker and was asked to continue taking Toprol XL 150mg daily at time of discharge as well as Lisinopril 10mg daily for HTN control and afterload reduction as well as remodeling benefits. The patient was also started on Atorvastatin 80mg daily. He was advised that he should follow-up in approximately 3 weeks for a stress MIBI to help risk stratify the LAD lesion which was noted on cardiac catheterization. He will follow-up with Dr. on to review MIBI results and will discuss any additional interventions at that time. . Mr. had no signs or symptoms indicative of heart failure/CHF during his hospital stay. A follow-up echo post-cath showed LVEF 50%, mild LVH and some regional left ventricular systolic dysfunction with mild focal hypokinesis of the basal inferior/inferoseptal segments was seen. He will plan to continue ACE inhibitor and beta blockade as indicated above to prevent additional remodeling. Throughout his CCU stay the patient was monitored on telemetry and he had no significant ectopy, just a few episodes of sinus tachycardia. No bradycardia, sinus pauses, or AV block was demonstrated despite setting of recent RV infarct. Also of note, the patient had a slight elevation in his BUN/Cr which was attributed to mild dehydration and the patient was encouraged to increase his fluid intake. Electrolytes were repleted as needed and BUN/Cr were monitored daily. He will plan to follow-up on repeat Chem-7 labs as an outpatient with his PCP over the next 1-2 weeks. Electrolyte labs revealed some hypophosphatemia which was felt to be secondary to respiratory alkalosis in the setting of ACS. He was given Neutra-Phos and his Phosphorus level bumped from 2.5 to 3.3. He reported no diarrhea or antacid use. On hospital day 2 the patient complained of some mild urinary urgency and a basic UA was sent along with a urine culture. Both studies were negative for any signs of infection and the patient's urgency had resolved by time of discharge. A lipid profile was done and showed Triglycerides 231, total cholesterol 177, LDL 98 and HDL 33. For ongoing management of his CAD and dyslipidemia issues atorvastatin 80mg daily was started for tighter control in the setting of ACS. He will plan to recheck a lipid panel and Chem-7 on and results will be called into Dr. . The patient will continue to monitor LFTs as outpatient given statin increase. He had a slight LFT increase during his hospitalization which was attributed to his acute MI. AST and ALT levels gradually tapered down towards a normal baseline prior to discharge. The patient resumed a regular, cardiac diet on hospital day 2 and maintained good PO intake for his hospital stay. He was given additional SC heparin daily as DVT prophylaxis and his groin region hematoma pain was well-controlled with Tylenol. A bowel regimen was started with colace to allow for stool softening and to avoid any excess strain during ACS recovery period. The patient remained as a full code status for the entirety of his hospitalization. He was also seen by a social worker after being referred to SW by nursing staff. Social work assessed patient's support system and coping skills during this acute phase of his newly diagnosed HTN and MI. He was offered therapy and given contact information for additional support. | Pt with R groin hematoma with procedure, integrilin stopped, protamine given, and pressure held to site. Pt with R groin hematoma with procedure, integrilin stopped, protamine given, and pressure held to site. Pt with R groin hematoma with procedure, integrilin stopped, protamine given, and pressure held to site. Pt with R groin hematoma with procedure, integrilin stopped, protamine given, and pressure held to site. Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Peak CPK 2103/ MB 11.7. Activity Intolerance Assessment: Action: Response: Plan: Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Peak CPK 2103/ MB 11.7. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Peak CPK 2103/ MB 11.7. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Peak CPK 2103/ MB 11.7. Cardiac Echo and ECG done. Cardiac Echo and ECG done. Cardiac Echo and ECG done. Normal sinus rhythm with marked ST segment elevations in II, III, aVF, V4-V6suggestive of inferior and lateral acute myocardial infarction. Response: ECG evolvings inf/lat, tolerating ^ lopressor , groin stable without Hct drop. Response: ECG evolvings inf/lat, tolerating ^ lopressor , groin stable without Hct drop. Pt started on , , lopressor, ACE-I. Pt started on , , lopressor, ACE-I. Procedure c/b hematoma on initial cath insertion therefore integ dc'd. Myocardial infarction.Height: (in) 75Weight (lb): 215BSA (m2): 2.26 m2BP (mm Hg): 130/72HR (bpm): 81Status: InpatientDate/Time: at 10:24Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Came to EW, ST ^ inf/lat. Came to EW, ST ^ inf/lat. Came to EW, ST ^ inf/lat. Came to EW, ST ^ inf/lat. Marked ST segment elevations are consistent withacute inferior wall myocardial infarction. Q waves in leads II, III, aVF and V4-V6 are consistentwith inferior and lateral myocardial infarction. Pt understands, and has questions concerning Viagra and cardiac medications. Rec'd ASA, integrillin, plavix and heparin> cath lab. Denies hx of HTN but SBP has been in the hypertensive range. Denies hx of HTN but SBP has been in the hypertensive range. There is mild regional left ventricularsystolic dysfunction with mild focal hypokinesis of the basalinferior/inferoseptal segments (RCA disease). ST segment elevations in theinferior and lateral leads are consistent with acute inferior wall myocardialinfarction. Cath revealed occluded distal RCA > drug eluding stent placed, also has a 70% mid LAD. Compared to tracing #3there has been complete resolution of the ST segment elevations and evolutionof the inferior myocardial infarction with prominent Q waves as noted.TRACING #4 IV NTG weaned to off. IV NTG weaned to off. Pt started on , , lopressor, captopril. Pt started on , , lopressor, captopril. Given verbal info on medications. Given verbal info on medications. Given verbal info on medications. Given verbal info on medications. Action: Started lopressor 12.5mg and captopril 6.25. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Hr 70-80s sr with no vea noted, bp remains elevated 130-150s. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - hypo; remaining LV segments contractnormally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Sinus rhythmInferior infarct, age indeterminateAnterolateral myocardial infarct, age indeterminateST-T wave configuration consistent with acute/recent/in evolution processSince previous tracing of , further ST-T wave changes present To have stress test as outpt to follow up on LAD lesion. To have stress test as outpt to follow up on LAD lesion. Response: ECG evolvings inf/lat, tolerating lopressor and captopril Plan: Continue to assess response to meds, follow up on echo results. Cardiac Echo and ECG done Response: ECG evolvings inf/lat, tolerating lopressor and captopril Plan: Continue to assess response to meds, follow up on echo results. Right ventricular chamber size and free wall motion arenormal. Response: Pt understands info given verbally and is pamphlets on heart disease, stress. Action: On lopressor and captopril as ordered. Action: On lopressor and captopril as ordered. Sinus rhythmInferior infarct, age indeterminateAnterolateral myocardial infarct, age indeterminateST-T wave configuration consistent with acute/recent/in evolution processSince previous tracing of , no significant change Response: Pt understands info given verbally and is pamphlets on heart disease, stents. Response: Pt understands info given verbally and is pamphlets on heart disease, stents. Pt with questions re: Viagra with cardiac meds. Pt with questions re: Viagra with cardiac meds. Pt with questions re: Viagra with cardiac meds. Plan: Continue OOB to C with supervision, assess VS with activity, awaiting PT consult. Plan: Continue OOB to C with supervision, assess VS with activity, awaiting PT consult. Normal ascending aorta diameter. Compared to tracing #2 there has been some reduction in theST segment elevations and the development of new Q waves in the inferior leadssuggesting progression of inferior myocardial infarction.TRACING #3 Reviewed pts signs of MI with pt/wife. Reviewed pts signs of MI with pt/wife. PT consult ordered. PT consult ordered. Lungs with few R basilar crackles this am, now clear. Lungs with few R basilar crackles this am, now clear. The mitral valve appears structurally normal withtrivial mitral regurgitation. | 13 | [
{
"category": "Nursing",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538711,
"text": "Pt is a 50 yo male admitted with acute Inf/Lat STEMI. PMH:^\n cholesterol (lipitor 10 mg qd) , hypotestosterone (Viagra). Had\n episode of diaphoresis after working out at gym. Pt attributed this to\n hypoglycemia, had juice, symptoms recurred accompanied by bilateral arm\n tingling. Came to EW, ST ^ inf/lat. Went to cath lab, DES to RCA,\n also with 70% ulcerated mid LAD. Pt with R groin hematoma with\n procedure, integrilin stopped, protamine given, and pressure held to\n site.\n Knowledge Deficit\n Assessment:\n CRF: (+) ^chol, ?FH (father with HF, but no known MI). (-)smoker, HTN,\n denies DM, non-sedentary lifestyle (lifts weights, limited aerobic\n exercise) . Pt started on , , lopressor, captopril.\n Action:\n Pt given written info on heart disease, heart healthy diet and stent.\n Given verbal info on medications. Pt understands, and has questions\n concerning Viagra and cardiac medications. Discussed interaction of\n NTG and Viagra and have requested Dr. follow up with discussion.\n Response:\n Pt understands info given verbally and is pamphlets given.\n Plan:\n Continue to assess pt\ns understanding of information, Dr to\n provide further education of drug interaction, particularly with\n Viagra.\n Activity Intolerance\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak CPK 2103/ MB 11.7. Troponin: HR 60\ns-80\ns NSR without\n ectopy. SBP initially 180 in cath lab, 114-130 this am. Lungs with\n few R basilar crackles, O2 sat 95% on RA.\n Action:\n On lopressor and captopril as ordered. IV NTG weaned to off. Cardiac\n Echo and ECG done\n Response:\n ECG evolving\ns inf/lat, tolerating lopressor and captopril\n Plan:\n Continue to assess response to meds, follow up on echo results. To\n have MIBI study as outpt to follow up on LAD lesion.\n"
},
{
"category": "Nursing",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 538687,
"text": "50yo after working out in gym (lifting weights), felt he was\n hypoglycemic had OJ with no effect, cont to drive home. Called\n neighbor who was a nurse , she called 911> ED where he\n had st ^ inferiorly>code STEMI. Rec'd ASA, integrillin, plavix and\n heparin> cath lab. Cath revealed occluded distal RCA > drug eluding\n stent placed, also has a 70% mid LAD. Procedure c/b hematoma on\n initial cath insertion therefore integ dc'd. NTG iv started for ^^ bp\n 180-200/100's. Sheaths removed before arrival to CCU.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr 70-80\ns sr with no vea noted, bp remains elevated 130-150\ns. R\n groin with small ooze on admit. Lungs clear throughout with sats in\n the upper 90\ns on 2lnp.\n Action:\n Started lopressor 12.5mg and captopril 6.25. Held pressure on groin\n for approx 5-10mins.\n Response:\n No significant decrease in bp/hr. Groin and hct have remained stable\n throughout night.\n Plan:\n ? increase cardiac meds, cont to follow groin increasing activity as\n tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538728,
"text": "Pt is a 50 yo male admitted with acute Inf/Lat STEMI. PMH:^\n cholesterol (lipitor 10 mg qd) , hypotestosterone (Viagra). Had\n episode of diaphoresis after working out at gym. Pt attributed this to\n hypoglycemia, had juice, symptoms recurred accompanied by bilateral arm\n tingling. Came to EW, ST ^ inf/lat. Went to cath lab, DES to RCA,\n also with 70% ulcerated mid LAD. Pt with R groin hematoma with\n procedure, integrilin stopped, protamine given, and pressure held to\n site.\n Knowledge Deficit\n Assessment:\n CRF: (+) ^chol, ?FH (father with HF, but no known MI). (-)smoker, HTN,\n denies DM, non-sedentary lifestyle (lifts weights, limited aerobic\n exercise) . Pt started on , , lopressor, captopril. Pt with\n questions re: Viagra with cardiac meds.\n Action:\n Pt given written info on heart disease, heart healthy diet and stent.\n Given verbal info on medications. Reinforced with wife. Cardiology\n attending has advised pt not to use Viagra for the next 6-8 weeks until\n follow up cardiology evaluation/ stress test. Pt understands.\n Response:\n Pt understands info given verbally and is pamphlets on heart\n disease, stress. Understands the need to continue for a year.\n Plan:\n Continue to assess pt\ns understanding of information. Reinforce info\n as needed.\n Activity Intolerance\n Assessment:\n OOB to chair, without orthostatic changes.\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak CPK 2103/ MB 11.7. Troponin: HR 60\ns-80\ns NSR without\n ectopy. SBP initially 180 in cath lab, 114-130 this am. Lungs with\n few R basilar crackles, O2 sat 95% on RA. R groin ecchymotic, occ\n trickle of blood.\n Action:\n On lopressor and captopril as ordered. IV NTG weaned to off. Cardiac\n Echo and ECG done. Cardiology in to assess R groin, no hematoma, no\n bruit.\n Response:\n ECG evolving\ns inf/lat, tolerating lopressor and captopril\n Plan:\n Continue to assess response to meds, follow up on echo results. To\n have MIBI study as outpt to follow up on LAD lesion.\n"
},
{
"category": "Nursing",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538739,
"text": "Pt is a 50 yo male admitted with acute Inf/Lat STEMI. PMH:^\n cholesterol (lipitor 10 mg qd) , hypotestosterone (weekly testosterone\n injection,Viagra). Had episode of diaphoresis after working out at\n gym. Pt attributed this to hypoglycemia, had juice, symptoms recurred\n accompanied by bilateral arm tingling. Came to EW, ST ^ inf/lat. Went\n to cath lab, DES to RCA, also with 70% ulcerated mid LAD. Pt with R\n groin hematoma with procedure, integrilin stopped, protamine given, and\n pressure held to site.\n Knowledge Deficit\n Assessment:\n CRF: (+) ^chol, ?FH (father with HF, but no known MI). (-)smoker,\n denies DM (HbA1C 5.7%), non-sedentary lifestyle (lifts weights, limited\n aerobic exercise) . Denies hx of HTN but SBP has been in the\n hypertensive range. Pt started on , , lopressor, ACE-I. Pt\n with questions re: Viagra with cardiac meds.\n Action:\n Pt given written info on heart disease, heart healthy diet and stent.\n Given verbal info on medications. Reinforced with wife. Cardiology\n attending has advised pt not to use Viagra for the next 6-8 weeks until\n follow up cardiology evaluation/ stress test. Pt understands. Reviewed\n pt\ns signs of MI with pt/wife.\n Response:\n Pt understands info given verbally and is pamphlets on heart\n disease, stents. Understands the need to continue for a year.\n Plan:\n Continue to assess pt\ns understanding of information. Reinforce info\n as needed. Give written info on medications when medications are\n stabilized.\n Activity Intolerance\n Assessment:\n OOB to chair, without orthostatic changes, with supervision. Transient\n lightheadedness standing.\n Action:\n Instructed not to get OOB or out of chair without assistance. PT\n consult ordered.\n Response:\n Transient lightheadedness, no orthostatic changes.\n Plan:\n Continue OOB to C with supervision, assess VS with activity, awaiting\n PT consult.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak CPK 2103/ MB 11.7. Troponin: HR 60\ns-80\ns NSR with one 10\n beat run of monomorphic, irregular NSVT, rate of 180-75. SBP\n initially 180 in cath lab, 114-157/ 67-93 today. Lungs with few R\n basilar crackles this am, now clear. O2 sat 95% on RA. R groin\n ecchymotic, occ trickle of blood, Hct 43.6 (45).\n Action:\n Lopressor dose titrated up to 25 , IV NTG weaned to off, captopril\n changed to lisinopril 10 mg qd\nfirst dose given this afternoon as per\n CCU team. Cardiac Echo and ECG done. Cardiology in to assess R groin,\n no hematoma, no bruit.\n Response:\n ECG evolving\ns inf/lat, tolerating ^ lopressor , groin stable without\n Hct drop.\n Plan:\n Continue to assess response to meds, follow up on echo results. To\n have stress test as outpt to follow up on LAD lesion.\n"
},
{
"category": "Nursing",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538740,
"text": "Pt is a 50 yo male admitted with acute Inf/Lat STEMI. PMH:^\n cholesterol (lipitor 10 mg qd) , hypotestosterone (weekly testosterone\n injection,Viagra). Had episode of diaphoresis after working out at\n gym. Pt attributed this to hypoglycemia, had juice, symptoms recurred\n accompanied by bilateral arm tingling. Came to EW, ST ^ inf/lat. Went\n to cath lab, DES to RCA, also with 70% ulcerated mid LAD. Pt with R\n groin hematoma with procedure, integrilin stopped, protamine given, and\n pressure held to site.\n Knowledge Deficit\n Assessment:\n CRF: (+) ^chol, ?FH (father with HF, but no known MI). (-)smoker,\n denies DM (HbA1C 5.7%), non-sedentary lifestyle (lifts weights, limited\n aerobic exercise) . Denies hx of HTN but SBP has been in the\n hypertensive range. Pt started on , , lopressor, ACE-I. Pt\n with questions re: Viagra with cardiac meds.\n Action:\n Pt given written info on heart disease, heart healthy diet and stent.\n Given verbal info on medications. Reinforced with wife. Cardiology\n attending has advised pt not to use Viagra for the next 6-8 weeks until\n follow up cardiology evaluation/ stress test. Pt understands. Reviewed\n pt\ns signs of MI with pt/wife.\n Response:\n Pt understands info given verbally and is pamphlets on heart\n disease, stents. Understands the need to continue for a year.\n Plan:\n Continue to assess pt\ns understanding of information. Reinforce info\n as needed. Give written info on medications when medications are\n stabilized.\n Activity Intolerance\n Assessment:\n OOB to chair, without orthostatic changes, with supervision. Transient\n lightheadedness standing.\n Action:\n Instructed not to get OOB or out of chair without assistance. PT\n consult ordered.\n Response:\n Transient lightheadedness, no orthostatic changes.\n Plan:\n Continue OOB to C with supervision, assess VS with activity, awaiting\n PT consult.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Peak CPK 2103/ MB 11.7. Troponin: HR 60\ns-80\ns NSR with one 10\n beat run of monomorphic, irregular NSVT, rate of 180-75. SBP\n initially 180 in cath lab, 114-157/ 67-93 today. Lungs with few R\n basilar crackles this am, now clear. O2 sat 95% on RA. R groin\n ecchymotic, occ trickle of blood, Hct 43.6 (45).\n Action:\n Lopressor dose titrated up to 25 , IV NTG weaned to off, captopril\n changed to lisinopril 10 mg qd\nfirst dose given this afternoon as per\n CCU team. Cardiac Echo and ECG done. Cardiology in to assess R groin,\n no hematoma, no bruit.\n Response:\n ECG evolving\ns inf/lat, tolerating ^ lopressor , groin stable without\n Hct drop.\n Plan:\n Continue to assess response to meds, follow up on echo results. To\n have stress test as outpt to follow up on LAD lesion.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n STEMI\n Code status:\n Height:\n 6 feet 3 inches\n Admission weight:\n 100 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: ^ cholesterol on lipitor\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:157\n D:93\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,258 mL\n 24h total out:\n 1,550 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:07 AM\n Potassium:\n 4.2 mEq/L\n 01:12 PM\n Chloride:\n 100 mEq/L\n 04:07 AM\n CO2:\n 24 mEq/L\n 04:07 AM\n BUN:\n 16 mg/dL\n 01:12 PM\n Creatinine:\n 1.1 mg/dL\n 01:12 PM\n Glucose:\n 154 mg/dL\n 04:07 AM\n Hematocrit:\n 43.6 %\n 01:12 PM\n Finger Stick Glucose:\n 179\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 1500\n"
},
{
"category": "Echo",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Report",
"row_id": 87838,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Myocardial infarction.\nHeight: (in) 75\nWeight (lb): 215\nBSA (m2): 2.26 m2\nBP (mm Hg): 130/72\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 10:24\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with mild focal hypokinesis of the basal\ninferior/inferoseptal segments (RCA disease). The remaining segments contract\nnormally (LVEF = 50%). Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nMildly dilated aortic root.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038286,
"text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evalaute for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with chest pain, STEMI\n REASON FOR THIS EXAMINATION:\n Evalaute for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old male with chest pain, to assess for a cardiopulmonary\n process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS: There is atelectasis at the left costophrenic angle. The\n cardiomediastinal silhouette is unremarkable. There is mild prominence of\n pulmonary vasculature suggestive of pulmonary vascular congestion.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-24 00:00:00.000",
"description": "Report",
"row_id": 222446,
"text": "Sinus rhythm\nInferior infarct, age indeterminate\nAnterolateral myocardial infarct, age indeterminate\nST-T wave configuration consistent with acute/recent/in evolution process\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-23 00:00:00.000",
"description": "Report",
"row_id": 222666,
"text": "Sinus rhythm\nInferior infarct, age indeterminate\nAnterolateral myocardial infarct, age indeterminate\nST-T wave configuration consistent with acute/recent/in evolution process\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-22 00:00:00.000",
"description": "Report",
"row_id": 222667,
"text": "Normal sinus rhythm. Q waves in leads II, III, aVF and V4-V6 are consistent\nwith inferior and lateral myocardial infarction. Compared to tracing #3\nthere has been complete resolution of the ST segment elevations and evolution\nof the inferior myocardial infarction with prominent Q waves as noted.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-21 00:00:00.000",
"description": "Report",
"row_id": 222668,
"text": "Normal sinus rhythm. Left atrial abnormality. ST segment elevations in the\ninferior and lateral leads are consistent with acute inferior wall myocardial\ninfarction. Compared to tracing #2 there has been some reduction in the\nST segment elevations and the development of new Q waves in the inferior leads\nsuggesting progression of inferior myocardial infarction.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-21 00:00:00.000",
"description": "Report",
"row_id": 222669,
"text": "Normal sinus rhythm. Marked ST segment elevations are consistent with\nacute inferior wall myocardial infarction. Compared to tracing #2\nthere has been no diagnostic interval change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-21 00:00:00.000",
"description": "Report",
"row_id": 222670,
"text": "Normal sinus rhythm with marked ST segment elevations in II, III, aVF, V4-V6\nsuggestive of inferior and lateral acute myocardial infarction. Left atrial\nabnormality. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
17,137 | 174,999 | The patient was admitted as a Same Day surgery patient to the Cardiac Surgery Service. He was taken to the operating room where he had coronary artery bypass grafting time four. His grafts are LIMA to LAD, saphenous vein graft to LAD/diagonal, saphenous vein graft to OM and saphenous vein graft to right PDA. Patient's procedure itself was unremarkable. Postoperative he was taken intubated to the Intensive Care Unit on Neosynephrine and insulin drips. Overnight he was extubated. His Lopessors were weaned off on the first postoperative day and his insulin drip was converted to his home insulin regimen after his sugars normalized. He did have problems with sugars as high as 400 but these subsequently corrected. By the evening of the first postoperative day he was on the hospital floor. The remainder of the hospitalization was unremarkable. His Foley catheter, chest tube and pacing wires were all discontinued in normal fashion. His primary care physician was involved in managing his sugars. He was restarted on his appropriate home medications. By his fifth postoperative day he was eating, ambulating, voiding and was cleared by physical therapy to be safely discharged home. He did have some lability of his sugars and that extended his hospitalization for one day. He also had no changes in his insulin regimen as it was felt that his eating habits would normalize once he arrived home. On patient was discharged home in stable condition under the care of his family. He will have a visiting nurse his wound status and ensure that he is managing adequately at home. He is discharged on the following medications: 1) Lopressor 50 mg p.o. b.i.d., 2) aspirin 325 mg p.o. q.d., 3) Asacol 800 mg b.i.d., 4) Lipitor 10 mg q.d., 5) Zantac 150 mg b.i.d., 6) Colace 100 mg b.i.d., 6) Xanax 0.25 mg q.h.s. p.r.n., 7) Lasix 20 mg q.d. times seven days, 8) potassium chloride 10 mEq q.d. times seven days, 9) NPH 30 units q. A.M., 40 units q.h.s., 10) Humolog 12 units q.A.M., 10 units q. P.M. at dinner, 11) Percocet 325 1 to 2 p.o. q 4 to6 hours p.r.n. Patient is to follow up with his primary care physician, . within the next two to three weeks. In addition, he is to see Dr. in six weeks. | 10:24 AM CHEST (PA & LAT) Clip # Reason: Assess for CHF,effusion,PTx. d/c tubes later this am.C/V: Heart rate down to 90's sinus no ectopy. chest tubes patent draining sangunious to serous sangunious fluid small amounts ? Assess for CHF, effusion, pneumothorax. Suctioned before extubation for small amt. Chest tubes with mod amt. Neuro: Pt awake, MAE, follows commands, a&Ox3CV: Heart rate 90's to 100's NSR to ST with rare PVC. K+ replaced and Ica replaced. *** Perform exam on Fri *** FINAL REPORT INDICATION: S/P CABG, 1 day s/p chest tube removal. Lungs clear upper lobes and dim bilat. OGT drained 150cc prior to dc.GU:Foley to gravity, clear yel urinePlan: Chest PT, IS, coughing and deep breathing, start po liqs andget insulin gtt off. bases.O2 sat now 98%.GI:Abd soft and quiet. Sternal wires are again identified and epicardial pacing leads are in place. plan to switch to percocets when taking po's well.Plan: wean neo off and transfer to floor as tolerted. REASON FOR THIS EXAMINATION: Assess for CHF,effusion,PTx. PA & LATERAL CHEST: The cardiac and mediastinal contours are unremarkable. pt remains on Neo overnight for blood pressure support. of S/S drainage.RESP: Pt extubated at 18:30 to 50% OFM, Sat's to 94%, pt dozing off and on, OFM to 70%. Neuro: pt awake alert oriented following commands.Resp: o2 weaned to 4l np with o2 sats 98-99% pt deep breaths well but needs encouragement to cough. Sinus tachycardiaSince previous tracing of rate increasedNormal ECG except for rate There is bibasilar atelectasis and bilateral small pleural effusions. Will attempt to wean as tolerated.GI: tolerating sips of clear fluids will advance diet this am.GU: passing good amounts of urine via foley cath.Skin: Incisions clean and dry no breakdown.Pain: Good pain control with prn morphine 4mgs sc and torodol. The pulmonary vasculature appears normal. of clear thin secretions. *** Perform exam on Fri * MEDICAL CONDITION: 66 year old man s/p CABG, now 1 day s/p chest tube removal. IMPRESSION: No evidence for pneumonia, failure, or pneumothorax. 2V pacing wires,sense and capture. cvp 5-6. COMPARISON: . Right IJ double lumen with CVP transduced and 5 to 6 last hour, getting another 500 of N/Sin addition to 1000 from earlier. not raising. No focal consolidations are identified. Neo at .5 mcq, Insulin gtt on at 2units per hour increased to 2 at 18:30 for BS of 142. There is no evidence for pneumothorax. | 4 | [
{
"category": "Radiology",
"chartdate": "2156-07-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 762256,
"text": " 10:24 AM\n CHEST (PA & LAT) Clip # \n Reason: Assess for CHF,effusion,PTx. *** Perform exam on Fri *\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p CABG, now 1 day s/p chest tube removal.\n REASON FOR THIS EXAMINATION:\n Assess for CHF,effusion,PTx. *** Perform exam on Fri ***\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG, 1 day s/p chest tube removal. Assess for CHF, effusion,\n pneumothorax.\n\n COMPARISON: .\n\n PA & LATERAL CHEST: The cardiac and mediastinal contours are unremarkable.\n There is bibasilar atelectasis and bilateral small pleural effusions. No focal\n consolidations are identified. There is no evidence for pneumothorax. The\n pulmonary vasculature appears normal. Sternal wires are again identified and\n epicardial pacing leads are in place.\n\n IMPRESSION: No evidence for pneumonia, failure, or pneumothorax.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-06-29 00:00:00.000",
"description": "Report",
"row_id": 115887,
"text": "Sinus tachycardia\nSince previous tracing of rate increased\nNormal ECG except for rate\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-06-29 00:00:00.000",
"description": "Report",
"row_id": 1486967,
"text": "Neuro: Pt awake, MAE, follows commands, a&Ox3\nCV: Heart rate 90's to 100's NSR to ST with rare PVC. 2V pacing wires,\nsense and capture. No A wires. Neo at .5 mcq, Insulin gtt on at 2units per hour increased to 2 at 18:30 for BS of 142. Right IJ double lumen with CVP transduced and 5 to 6 last hour, getting another 500 of N/S\nin addition to 1000 from earlier. K+ replaced and Ica replaced. Chest tubes with mod amt. of S/S drainage.\nRESP: Pt extubated at 18:30 to 50% OFM, Sat's to 94%, pt dozing off and on, OFM to 70%. Suctioned before extubation for small amt. of clear thin secretions. Lungs clear upper lobes and dim bilat. bases.\nO2 sat now 98%.\nGI:Abd soft and quiet. OGT drained 150cc prior to dc.\nGU:Foley to gravity, clear yel urine\nPlan: Chest PT, IS, coughing and deep breathing, start po liqs and\nget insulin gtt off.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-06-30 00:00:00.000",
"description": "Report",
"row_id": 1486968,
"text": "Neuro: pt awake alert oriented following commands.\nResp: o2 weaned to 4l np with o2 sats 98-99% pt deep breaths well but needs encouragement to cough. not raising. chest tubes patent draining sangunious to serous sangunious fluid small amounts ? d/c tubes later this am.\nC/V: Heart rate down to 90's sinus no ectopy. pt remains on Neo overnight for blood pressure support. cvp 5-6. Will attempt to wean as tolerated.\nGI: tolerating sips of clear fluids will advance diet this am.\nGU: passing good amounts of urine via foley cath.\nSkin: Incisions clean and dry no breakdown.\nPain: Good pain control with prn morphine 4mgs sc and torodol. plan to switch to percocets when taking po's well.\nPlan: wean neo off and transfer to floor as tolerted.\n"
}
] |
65,854 | 137,145 | Patient was admitted to on with a left parietal brain lesion. On she underwent a CTA of the head as well as a functional MRI of the brain. She was seen by medicine for operative clearance who felt she needed no additional workup. On she underwent MRI WAND study and there was a family dicussion with Dr regarding the surgery. She arrived in pre-op and was complaining of chest pain. A cardiac consult was called and the surgery was aborted. She was transferred to cardiology for futher management. Serial enzymes were obtained which showed no evidence of elevation. She was optimized for surgery. On a repeat echo showed no evidence of hypokiness with EF > 55%. She was then taken to OR on . Post op CT showed expected post op changes. She c/o of left shoulder pain and enzymes were again negative. She did well postoperatively and remained stable during her floor course. PT/OT were consulted and they recommended home with 24-hour supervision. She also will be set up with VNA for medication management. She was deemed fit for discharge on the afternoon of . She was given instructions for followup and prescriptions for all required medications. | Non-specificintraventricular conduction delay. Non-specific intraventricularconduction delay. Noaortic regurgitation is seen. Trivial mitral regurgitation is seen. There is nopericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Compared to the previoustracing of no diagnostic change. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The rhythm is probably ectopic atrial bradycardia.Non-diagnostic Q wave in lead II. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Noclinically-significant valvular disease seen. The mitral valve leaflets are mildly thickened.There is no mitral valve prolapse. Intraventricular conduction delay. Sinus rhythm with diffuse non-diagnostic repolarization abnormalities.Compared to the previous tracing of there is no significant change. These are unchangedcompared to tracing of . The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Ectopic atrial bradycardia with baseline artifact. Repolarization abnormalities. No AS. Baseline artifact. No MVP. Thepulmonary artery systolic pressure could not be determined. Diffuseand extensive ST-T wave abnormalities in leads V1-V6, likely secondary torepolarization but cannot exclude myocardial ischemia. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. PATIENT/TEST INFORMATION:Indication: pre-op evaluationHeight: (in) 61Weight (lb): 180BSA (m2): 1.81 m2BP (mm Hg): 151/83HR (bpm): 68Status: InpatientDate/Time: at 08:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Suboptimalimage quality - body habitus.Conclusions:The left atrium is normal in size. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Sinus rhythm. ST segment and T wave abnormalities, predominantly inleads V1-V5, may be non-specific, although cannot rule out the possibility ofischema. Early R wave transition. Early R wave transition. Rightventricular chamber size and free wall motion are normal. EarlyR wave transition. Clinicalcorrelation is suggested. Compared to the previous tracing of the ST-T wave changesin the precordial leads are more pronounced on the current tracing. Clinical correlation is suggested. | 5 | [
{
"category": "Echo",
"chartdate": "2107-05-27 00:00:00.000",
"description": "Report",
"row_id": 100950,
"text": "PATIENT/TEST INFORMATION:\nIndication: pre-op evaluation\nHeight: (in) 61\nWeight (lb): 180\nBSA (m2): 1.81 m2\nBP (mm Hg): 151/83\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 08:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\nclinically-significant valvular disease seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-26 00:00:00.000",
"description": "Report",
"row_id": 295659,
"text": "Baseline artifact. The rhythm is probably ectopic atrial bradycardia.\nNon-diagnostic Q wave in lead II. Intraventricular conduction delay. Early\nR wave transition. ST segment and T wave abnormalities, predominantly in\nleads V1-V5, may be non-specific, although cannot rule out the possibility of\nischema. Compared to the previous tracing of the ST-T wave changes\nin the precordial leads are more pronounced on the current tracing. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-25 00:00:00.000",
"description": "Report",
"row_id": 295660,
"text": "Sinus rhythm with diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-27 00:00:00.000",
"description": "Report",
"row_id": 295657,
"text": "Sinus rhythm. Early R wave transition. Non-specific intraventricular\nconduction delay. Repolarization abnormalities. Compared to the previous\ntracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-26 00:00:00.000",
"description": "Report",
"row_id": 295658,
"text": "Ectopic atrial bradycardia with baseline artifact. Non-specific\nintraventricular conduction delay. Early R wave transition. Diffuse\nand extensive ST-T wave abnormalities in leads V1-V6, likely secondary to\nrepolarization but cannot exclude myocardial ischemia. These are unchanged\ncompared to tracing of . Clinical correlation is suggested.\n\n"
}
] |
25,610 | 181,098 | Given the patient's loss of consciousness and sodium of 122, the patient was initially admitted to the Intensive Care Unit for overnight monitoring, but was sent to the Medicine floor the next day. The etiology of the syncope was initially considered to be most likely vasovagal given the loss of consciousness accompanied by drop in blood pressure, drop in heart rate, lightheadedness and diaphoresis, nausea, vomiting, however hypoglycemic episodes as well as hyponatremic seizures were also considered. Etiology for the hyponatremia was often not initially obvious. Under consideration was decrease due to cortisol, hypothyroidism, Paxil which was recently started and possible SIADH given the finding of a right apical density on her initial chest x-ray. | The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Prior anterior myocardial infarction.Compared to the previous tracing of no change.TRACING #1 3) Cholelithiasis without cholecystitis. 2) Moderate hiatal hernia. Syncope.Height: (in) 65Weight (lb): 129BSA (m2): 1.64 m2BP (mm Hg): 140/82Status: InpatientDate/Time: at 15:53Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. There is a tiny pulmonary nodule in the lingula. 2) Hiatal hernia. pager REASON FOR THIS EXAMINATION: r/o obstruction, ileus No contraindications for IV contrast WET READ: 11:03 PM Nonspecific findings. PT WITH NODULE ON CXR AND PLAN FOR CHEST CT.GI: ABD SOFT AND NONTENDER. COMPARISON is made to recent CXR of which describes a right apical abnormality. The aorta is slightly tortuous. Trivial mitralregurgitation is seen. Trivial mitralregurgitation is seen. In the ER, pt had 3 syncopal episodes that were associated with bradycardia, hypotension, N/V, and brief LOC (episodes were spontaneous, not associated with wretching/movement etc.). ABD soft, ND, pt c/o occasional cramping. Incidentally noted is a small granuloma within the spleen. PT C/O N IN AM WHICH SPONTANEOUSLY RESOLVED. Hilar contours and pulmonary vascularity are within normal limits. Pt with hyponatremia with Na=122--team ? Right ventricular chamber size is normal.2. DENIES CP OR DISCOMFORT. REASON FOR THIS EXAMINATION: Evaluation of R-apical nodule No contraindications for IV contrast FINAL REPORT INDICATION: Right apical lung nodule on chest radiograph. Trace aortic regurgitation is seen.3. Helical CT of the thorax was performed without iv or oral contrast. GI: Pt able to take PO meds with out difficulty. CT of head negative. Review of the soft tissues of the thorax demonstrate no significantly enlarged mediastinal or hilar lymph nodes on this enhanced study. TECHNIQUE: Contiguous axial images were obtained from the foramen magnum to the cranial vertex without the administration of IV contrast. The imaged portions of the kidneys are remarkable for a focal low density rounded lesion in the mid-pole portion of the right kidney, likely reflects a small cyst. IMPRESSION: 1) No CT evidence of small bowel obstruction or acute inflammatory process. CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are unremarkable. Evaluate for obstruction or ileus. The kidneys enhance symmetrically and are without evidence of hydronephrosis or renal masses. CT OF THE ABDOMEN WITH IV CONTRAST: There is a moderate-sized hiatal hernia. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There are multiple gallstones within the gallbladder without evidence of cholecystitis. Heart size is at the upper limits of normal. Pt had small nodule in R apical lobe on CXR. Mildly prominent fluid-filled small bowel suggest gastroenteritis. Note is made of a focal calcified pleural plaque posteriorly in the left hemithorax. No obstructing central endobronchial lesions are observed. Assessment of the remaining portions of the lungs is remarkable for dependent areas of density at the lung bases, suggestive of dependent atelectasis. The urinary bladder contains a Foley balloon and is within normal limits. IMPRESSION: 1) Two small calcified granulomas in the right lung apex account for the observed radiographic abnormality on recent chest radiograph. The liver is within normal limits without focal hepatic lesions. Right apical density can be further evaluated by apical lordotic views to exclude a pulmonary nodule. There are multiple low-attenuation lesions within both kidneys which are most consistent with simple renal cysts. +BS NOTED. HEAD CT WITHOUT IV CONTRAST: No intra- or extraaxial hemorrhage is identified. NORVASC AND ACCUPRIL REMAIN ON HOLD FOR NOW. Note is made of a large hiatal hernia. pager REASON FOR THIS EXAMINATION: r/o mass or bleed. Soft tissues are unremarkable. Finally, a small elliptical opacity is seen at (Over) 5:21 PM CT CHEST W/O CONTRAST Clip # Reason: Evaluation of R-apical nodule Field of view: 32 FINAL REPORT (Cont) the extreme right lung base adjacent to an area of dependent atelectasis. Osseous structures show wedging of mid thoracic vertebrae and decreased bone mineralization. 3) Calcified gallstones. There is a right apical density overlying the clavicle. Otherwise she is NPO. The proximal small bowel loops are slightly prominent and fluid-filled. Pulm: Lungs CTA. Linear opacities at the left lung base are suggestive of subsegmental atelectasis or scarring. The ventricles and sulci are age-appropriate. Evaluate for hemorrhage or mass. Pt has hx of constipation--colase to be started in am. Compared to the previous tracing of no change.TRACING #2 | 10 | [
{
"category": "Radiology",
"chartdate": "2185-09-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 770517,
"text": " 6:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: SYNCOPE, SEIZURES,HA ? BLEED OR MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with syncope ?seizure, headache. pager \n REASON FOR THIS EXAMINATION:\n r/o mass or bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT.\n\n CLINICAL INDICATION: 74 year old woman with syncopal episode. Evaluate for\n hemorrhage or mass.\n\n TECHNIQUE: Contiguous axial images were obtained from the foramen magnum to\n the cranial vertex without the administration of IV contrast.\n\n COMPARISONS: None.\n\n HEAD CT WITHOUT IV CONTRAST: No intra- or extraaxial hemorrhage is\n identified. There is no mass effect or shift of the normally midline\n structures. The ventricles and sulci are age-appropriate. No large vascular\n territorial infarcts are seen.\n\n IMPRESSION: No CT evidence of acute intracranial hemorrhage or edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-15 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 770526,
"text": " 9:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: ABD PAIN, VOMITING\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with vomiting, vague abdominal pain. pager \n REASON FOR THIS EXAMINATION:\n r/o obstruction, ileus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:03 PM\n Nonspecific findings. Mildly prominent fluid-filled small bowel suggest\n gastroenteritis. No obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN.\n\n CLINICAL INDICATION: 74 year old woman with vomiting and vague abdominal\n pain. Evaluate for obstruction or ileus.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis following the administration of 150 cc\n of Optiray contrast IV. Oral contrast was administered in light of the\n patient's cardiac history. In addition, coronal reconstructions were\n performed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a moderate-sized hiatal hernia.\n There is a tiny pulmonary nodule in the lingula. There is bibasilar\n atelectasis with focal bronchiectasis medially on the right. The liver is\n within normal limits without focal hepatic lesions. There are multiple\n gallstones within the gallbladder without evidence of cholecystitis. The\n adrenal glands, pancreas and spleen are unremarkable. The kidneys enhance\n symmetrically and are without evidence of hydronephrosis or renal masses.\n There are multiple low-attenuation lesions within both kidneys which are most\n consistent with simple renal cysts. The proximal small bowel loops are\n slightly prominent and fluid-filled. However, there is no evidence of wall\n thickening or pathologic dilatation. There is no free air or free fluid in\n the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are\n unremarkable. There are calcified fibroids in the uterus. The urinary\n bladder contains a Foley balloon and is within normal limits. There is no\n free fluid in the pelvis.\n\n The osseous structures are demineralized with marked degenerative changes. No\n destructive bone lesions are seen.\n\n IMPRESSION:\n\n 1) No CT evidence of small bowel obstruction or acute inflammatory process.\n Mildly prominent fluid-filled small bowel loops suggest an entity such as\n (Over)\n\n 9:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: ABD PAIN, VOMITING\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gastroenteritis.\n\n 2) Moderate hiatal hernia.\n\n 3) Cholelithiasis without cholecystitis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 770513,
"text": " 5:55 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf vs. consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with syncope, c/o \"lung pain\", crackles on exam. Also s/p\n recent fall, ? rib fx.\n REASON FOR THIS EXAMINATION:\n r/o chf vs. consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Syncope and crackles on lung exam.\n\n COMPARISONS: None.\n\n AP AND LATERAL CHEST: The patient is rotated. Heart size is at the upper\n limits of normal. There is a large hiatal hernia. The aorta is slightly\n tortuous. Hilar contours and pulmonary vascularity are within normal limits.\n There is a right apical density overlying the clavicle. Linear opacities at\n the left lung base are suggestive of subsegmental atelectasis or scarring.\n There are no pleural effusions. Osseous structures show wedging of mid\n thoracic vertebrae and decreased bone mineralization. No rib fractures are\n seen. Soft tissues are unremarkable.\n\n IMPRESSION: 1. No acute cardiopulmonary process. 2. Compression fractures of\n mid thoracic vertebrae, of uncertain age. No rib fractures. 3. Right apical\n density can be further evaluated by apical lordotic views to exclude a\n pulmonary nodule.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 770605,
"text": " 5:21 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluation of R-apical nodule\n Field of view: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with syncopal episode and hyponatremia. Pt had small nodule\n in R apical lobe on CXR.\n REASON FOR THIS EXAMINATION:\n Evaluation of R-apical nodule\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Right apical lung nodule on chest radiograph.\n\n COMPARISON is made to recent CXR of which describes a right apical\n abnormality. No prior chest CT's are available for comparison.\n\n Helical CT of the thorax was performed without iv or oral contrast. Images\n were acquired with 7 mm collimation and reconstructed at 7 mm intervals.\n Additionally, a series of 1 mm collimation images were obtained through a\n selected region of interest in the right apex.\n\n CT CHEST W/O CONTRAST: Assessment of the lungs reveals two densely calcified\n granulomas within the right lung apex which account for the observed\n radiographic finding on recent chest radiograph. There are a few adjacent\n linear band-like areas, suggestive of focal scarring within the adjacent lung\n parenchyma.\n\n Assessment of the remaining portions of the lungs is remarkable for dependent\n areas of density at the lung bases, suggestive of dependent atelectasis. A\n few scattered areas of linear opacification are seen in both lungs and may be\n related to focal discoid atelectasis and/or areas of focal scarring. This is\n most pronounced at the lung bases posteriorly, but also effects the upper\n lobes, middle lobe and lingula to a lesser degree. No obstructing central\n endobronchial lesions are observed.\n\n Skeletal structures reveal no suspicious lytic or blastic skeletal lesions.\n Review of the soft tissues of the thorax demonstrate no significantly\n enlarged mediastinal or hilar lymph nodes on this enhanced study. Note is\n made of a large hiatal hernia. The heart size is normal and no pericardial\n or pleural effusion is evident. Note is made of a focal calcified pleural\n plaque posteriorly in the left hemithorax.\n\n Imaging of the upper portion of the abdomen demonstrates no suspicious lesions\n within the adrenal glands. The imaged portions of the kidneys are remarkable\n for a focal low density rounded lesion in the mid-pole portion of the right\n kidney, likely reflects a small cyst. Numerous dependent gallstones layering\n within the gallbladder. The imaged portions of the liver, spleen, and\n pancreas reveal no suspicious lesions. Incidentally noted is a small\n granuloma within the spleen. Also noted is relative high attenuation of the\n liver, compared to the spleen. Finally, a small elliptical opacity is seen at\n (Over)\n\n 5:21 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluation of R-apical nodule\n Field of view: 32\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the extreme right lung base adjacent to an area of dependent atelectasis.\n This most likely represents a focal area of atelectasis or scarring.\n\n IMPRESSION:\n 1) Two small calcified granulomas in the right lung apex account for the\n observed radiographic abnormality on recent chest radiograph.\n\n 2) Hiatal hernia.\n\n 3) Calcified gallstones.\n\n 4) Relative high attenuation of the liver compared to other soft tissue\n structures on this unenhanced study. Is there a history of Amioderone\n therapy?\n\n 5) Dependent opacities at the lung bases, right greater than left, most\n likely due to dependent atelectasis and/or focal scarring.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-09-16 00:00:00.000",
"description": "Report",
"row_id": 1596265,
"text": "MICU NSG Admit Note:\n Pt is a 74 y/o female with hx of HTN, DM (insulin dependent), depression and hypothyroidism. She has been in her USOH until a few weeks ago when she began having syncopal episodes. Yesterday pt had witnessed LOC X 2 minutes that was associated with diaphoresis, nausea, bladder incontinence--she was transferred to ER via EMS. In the ER, pt had 3 syncopal episodes that were associated with bradycardia, hypotension, N/V, and brief LOC (episodes were spontaneous, not associated with wretching/movement etc.).\n Neuro: Pt A + O pleasant, cooperative with POC. She c/o some anxiety and usually takes 1-1.5mg of ativan at home. Team did not want to perscribe ativan for sleep aid in case pt developed MS changes. Instead pt recieved 25 mg trazadone X 2 with limited response. She slept in brief naps overnight. She moves all extremities strongly and is able to help with movment in the bed. CT of head negative.\n CV: Afebrile. Pt in NSR rate of 70's. No episodes of bradycardia. BP stable. Pt recieved about 1.5 L of NS in ER with hypotension. UOP brisk 100-200 cc/hr. For access pt has #16/#20 PIV. Pt with hyponatremia with Na=122--team ?'s whether this is related to recent addition of paxil. Plan to restrict free water. Atropine at BS.\n Pulm: Lungs CTA. Pt on 2 L NC with spo2 97-100%. No cough. No DOE.\n GI: Pt able to take PO meds with out difficulty. Otherwise she is NPO. Pt has hx of constipation--colase to be started in am. ABD soft, ND, pt c/o occasional cramping.\n GU: Foley draining large amts pale yellow clear urine.\n Family: Pt has 9 children and 22 grandchildren. She has designated her oldest son, , as spokesperson. His contact info is in the computer.\n Skin intact, pt able to reposition herself in bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-09-16 00:00:00.000",
"description": "Report",
"row_id": 1596266,
"text": "NEURO: A+OX3. PURPOSEFUL MOVEMENT OF EXTREMITIES X4 NOTED. COUGH/GAG INTACT. PT REMAINS ANXIOUS AT TIMES AND EMOTIONAL SUPPORT GIVEN. NO SEIZURE ACTIVITY NOTED.\nCV: MONITOR SHOWS NSR WITH NO ECTOPY NOTED. DENIES CP OR DISCOMFORT. NO SYNCOPAL EPISODES THIS SHIFT. NORVASC AND ACCUPRIL REMAIN ON HOLD FOR NOW. PLAN FOR ECHO.\nRESP: LSCTA. NO SOB OR RESP DISTRESS NOTED. O2 WEANED TO OFF. PT WITH NODULE ON CXR AND PLAN FOR CHEST CT.\nGI: ABD SOFT AND NONTENDER. +BS NOTED. PT C/O N IN AM WHICH SPONTANEOUSLY RESOLVED. TEAM AWARE. NO STOOLS. STARTED ON STOOL SOFTENER.\nGU: FOLEY INTACT AND PATNENT DRAINING AMBER COLORED URINE WITHOUT SEDIMENTATION NOTED.\nSKIN: D+I WITH NO OPEN AREAS NOTED.\nENDO: REMAINS ON FINGERSTICKS Q6HR AND STARTED ON DIET. PT 20 UNITS NPH THIS AM. NO S/S COVERAGE REQUIRED.\nPSY-SOC: PT HAS SUPPORTIVE FAMILY AND UPDATED ON STATUS AND PLAN OF CARE BY TEAM. PT HAS BEEN CALLED OUT TO FLOOR AND AWAITING BED TO BECOME AVAILABLE.\nPAIN: DENIES PAIN OR DISCOMFORT.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2185-09-19 00:00:00.000",
"description": "Report",
"row_id": 67436,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Syncope.\nHeight: (in) 65\nWeight (lb): 129\nBSA (m2): 1.64 m2\nBP (mm Hg): 140/82\nStatus: Inpatient\nDate/Time: at 15:53\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Right ventricular chamber size is normal.\n2. Trace aortic regurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2185-09-15 00:00:00.000",
"description": "Report",
"row_id": 142764,
"text": "Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2185-09-15 00:00:00.000",
"description": "Report",
"row_id": 142765,
"text": "Sinus rhythm. Diffuse low voltage. Prior anterior myocardial infarction.\nCompared to the previous tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2185-09-15 00:00:00.000",
"description": "Report",
"row_id": 142763,
"text": "Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #3\n\n"
}
] |
4,766 | 119,554 | A/P: 42 y/o male with CAD, depression who presents with anti-cholingergic toxicity suicide attempt with benadryl ingestion. 1. Benadryl overdose -evaluated by toxicology in the ED. 2mg Physostigmine given with some improvement in mental status. 30min later another 1.5 mg given without significant change. OG tube placed and activated charcoal given. 3 liters NS IVF given in ED (UOP 2 liters) as well. Patient did not require further doses of physostigmine. Was monitored in the ICU for ~24 hours and then transferred to the floor without incident. 2. Suicide attempt/Depression -patients antidepressants and benzodiazepines were held per psychiatry's recommendation. He did not exhibit any symptoms of BZD withdrawal. -was maintained on 1:1 sitter -transferred to Deac4 for in-patient psychiatric evaluation and treatment -patient is MEDICALLY CLEARED FOR FUTURE TREATMENTS. 3. CAD/Chest pain -had ST depression v2-v6 on admission ekg which was likely rate-related; resolved on subsequent ekgs. -ruled out for MI by serial enzymes; has had recent caths , without evidence of flow limiting disease; also with recent ED evaluation (including CTA, V/Q scans) which ruled out other serious etiologies of chest pain (ie. PE, aortic dissection) -cont (), plavix, bb, statin, norvasc -current chest pain is NON-CARDIAC; continue ibuprofen 800 tid 4. Leukocytosis -patient had transient increase in WBC to 12 which resolved without treatment -unclear etiology given pt afebrile; no localizing symptoms; ?lab artifact -had a negative u/a and urine culture -a cxr showed a ?rml infiltrate but patient with NO clinical signs of pneumonia, therefore does not need abx. If he were to become febrile and/or develop a productive cough, would recommend levofloxacin 500mg po qd x7 days 5. F/E/N -cardiac diet 6. PPx - SQ Heparin, PPI 7. Dispo - to 4 for in-patient psych evaluation and treatment. | OVER/NOC BECOMING INC. MORE LUCID - THIS AM AXOX3. Cont to have twiching movements of extremities. + nastatgmus. DIMIN. STATUS AND CONT. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to tracing #2 nosignificant diagnostic change..TRACING #3 RECEIVED ON 3L NC - REMOVED BY PT. SOFT, NTND W+BS. Probable old inferior myocardial infarction. cdry nonprodiuctive cough. INDWELLING FOLEY IN PLACE; PATENT AND DRAINING ADEQUATE AMTS. S/P DRUG OVER/DOSE - INITIALLY AXOX1 - QUITE CONFUSED W/OCCAS. OCCAS. PT. PT. COUGH. Compared tothe previous tracing of sinus tachycardia is new. Prominent inferior Q waves - possible prior inferior myocardialinfarction clinical correlation is suggested. HAD BEEN UPDATED ON PT. Diffuse non-specificST-T wave changes are new. PA AND LATERAL CHEST: Comparison is made to the prior study from . Sinus tachycardia. ABD. LS CLEAR UPPER W/BILAT. MAE random nonpuposeful. Prominent inferior Q waves - possible prior inferior myocardialinfarction but clinical correlation is suggested. Prominent inferior Q waves - possible prior inferior myocardialinfarction but clinical correlation is suggested. Clinical correlation is suggested.TRACING #1 PERPHERAL PULSES PALPABLE. There is a normal bowel gas pattern. Non-specificdiffuse ST-T wave abnormalities may be partly related to the rate. NOTED.C/V - HD STABLE OVER/NOC/ HR 80'S-90'S, NSR W/NO ECTOPY NOTED. Since the previous tracingof no significant change.TRACING #1 PLAN OF CARE. DENIES PAIN. @ 1815 recieved Physostigmine 1mg.Cv: HR 104-118 ST no ectopy SBP 120-132 MAPS>80, IV #18 L Ant. There is silhouetting of the right heart border consistent with a right middle lobe pathology.consolidation. Clinicalcorrelation is suggested.TRACING #2 Seriel CK #1 Neg # 2 sent @ 1800.Resp: RR 18-22 Reg Nonlabored Dim BS. Please check position. CYCLING CARDIAC ENZYMES - AM CK'S PENDING.ID - AFEBRILE.GI/GU - NPO OVER/NOC. This might be confirmed by lateral chest radiograph. NON-PROD. IMPRESSION: Satisfactory position of NG tube with tip in fundus of stomach. BASES. Since the previous tracingearlier this date no significant change. IN AT CHANGE OF SHIFT. Admitted to MICUB Neuro: Arrived @ 1530 responding minimally eyes open not focusing Pupils 4mm equal react brisk. NO CONTACT OVER REMAINDER OF/NOC. Drug overdose and now needs irrigation/charcol treatment. Minimal subsegmental atelectasis in the left lung base is seen. Compared to tracing #1 the heart rate is significantly slower.Diffuse non-specific ST-T wave changes are slightly improved. NBP ONE-TEENS-140'S/60'S-90'S. SO & Proxy present met with team. O2 3L/min NC Sat 98-100%.GI: Abd soft nontender + BS NPO,GU: Foley U/o >100cc/hrSocial: Full code status. Unresponsive recieved Physosstigmine and OGT placed for charcoal. MICU-B NPN 1900-0700NEURO - PT. FINDINGS: An NG tube is partially coiled with its tip in the fundus of the stomach. HALLUCINATIONS AND GARBLED SPEECH. Cont to have chest pain post with medical management. PERRLA 4MM/4MM W/BRISK RESPONSE. Lead V3 was not recorded.Since the previous tracing of no significant change.TRACING #2 RR TEENS>20'S. The lungs otherwise appear clear. Pt has had mult cardiac caths/angioplasy and 6 CA Stents placed. Post discharge referred to psych and had undergone ECT therapy last treatment . Leads VI and V5-V6 were not recorded. Given the history, The appearances are worrisome for pneumonia in the right middle lobe. NO STOOL THIS SHIFT. NO EDEMA NOTED TO EXTREM. IV D5NS @100cc/hr, Plan to obtain EKG when HR to 90. ON RA W/O2SATS 95-97%. No evidence of aspiration. EARLY AND DOING WELL REMAINDER OF EVE. CLEAR, YELLOW URINE OVER/NOC.ACCESS - LAC PIV - PATENT, SITE WNL.SOCIAL - S.O. @1700 recieved Physosstigmine 1mg over 10min with improved responsiveness able to verbalize short sentences. There is no free air. confussed eyes focus and tracks surroundings. PLEASANT AND COOPERATIVE. 1:1 SITTER AT BEDSIDE PER STANDARD S/P SUICIDE ATTEMPT. STATES THAT EVERYTHING IN HIS LIFE WAS FINE UNTIL THIS PAST YEAR WHEN HE STARTED HAVING CARDIAC ISSUES AND NOW HAS JUST GOTTEN OUT OF CONTROL.RESP - STABLE. Recent depression with suicide attempt took several cardiac meds requiried intubation/TV pacing. Today took meds and while home with Significant other informed SO that he was in "Code Red" (suicide attempt) Brought to ED 45min post ingestion. MICUB 1530-1900 RN Note Suicide precautions Sitter42yo male adm to MICUB for close monitoring post intentional OD on Benadryl 50mg took 60 tabs.Pt has an extensive cardiac hx as of . 8:57 PM CHEST (PA & LAT) Clip # Reason: eval for evidence of aspiration Admitting Diagnosis: DRUG OVERDOSE MEDICAL CONDITION: 41 year old man with recent toxic OD, now with leukocytosis REASON FOR THIS EXAMINATION: eval for evidence of aspiration FINAL REPORT INDICATIONS: Leukocytosis. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2108-07-12 00:00:00.000",
"description": "Report",
"row_id": 1324296,
"text": "MICUB 1530-1900 RN Note\n Suicide precautions Sitter\n42yo male adm to MICUB for close monitoring post intentional OD on Benadryl 50mg took 60 tabs.Pt has an extensive cardiac hx as of . Pt has had mult cardiac caths/angioplasy and 6 CA Stents placed. Cont to have chest pain post with medical management. Recent depression with suicide attempt took several cardiac meds requiried intubation/TV pacing. Post discharge referred to psych and had undergone ECT therapy last treatment . Today took meds and while home with Significant other informed SO that he was in \"Code Red\" (suicide attempt) Brought to ED 45min post ingestion. Unresponsive recieved Physosstigmine and OGT placed for charcoal. Admitted to MICUB\n Neuro: Arrived @ 1530 responding minimally eyes open not focusing Pupils 4mm equal react brisk. + nastatgmus. MAE random nonpuposeful. @1700 recieved Physosstigmine 1mg over 10min with improved responsiveness able to verbalize short sentences. confussed eyes focus and tracks surroundings. Cont to have twiching movements of extremities. @ 1815 recieved Physostigmine 1mg.\n\nCv: HR 104-118 ST no ectopy SBP 120-132 MAPS>80, IV #18 L Ant. IV D5NS @100cc/hr, Plan to obtain EKG when HR to 90. Seriel CK #1 Neg # 2 sent @ 1800.\n\nResp: RR 18-22 Reg Nonlabored Dim BS. cdry nonprodiuctive cough. O2 3L/min NC Sat 98-100%.\n\nGI: Abd soft nontender + BS NPO,\n\nGU: Foley U/o >100cc/hr\n\nSocial: Full code status. SO & Proxy present met with team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-07-13 00:00:00.000",
"description": "Report",
"row_id": 1324297,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. S/P DRUG OVER/DOSE - INITIALLY AXOX1 - QUITE CONFUSED W/OCCAS. HALLUCINATIONS AND GARBLED SPEECH. PT. OVER/NOC BECOMING INC. MORE LUCID - THIS AM AXOX3. PLEASANT AND COOPERATIVE. PERRLA 4MM/4MM W/BRISK RESPONSE. DENIES PAIN. 1:1 SITTER AT BEDSIDE PER STANDARD S/P SUICIDE ATTEMPT. PT. STATES THAT EVERYTHING IN HIS LIFE WAS FINE UNTIL THIS PAST YEAR WHEN HE STARTED HAVING CARDIAC ISSUES AND NOW HAS JUST GOTTEN OUT OF CONTROL.\n\nRESP - STABLE. RECEIVED ON 3L NC - REMOVED BY PT. EARLY AND DOING WELL REMAINDER OF EVE. ON RA W/O2SATS 95-97%. RR TEENS>20'S. LS CLEAR UPPER W/BILAT. DIMIN. BASES. OCCAS. NON-PROD. COUGH. NOTED.\n\nC/V - HD STABLE OVER/NOC/ HR 80'S-90'S, NSR W/NO ECTOPY NOTED. NBP ONE-TEENS-140'S/60'S-90'S. PERPHERAL PULSES PALPABLE. NO EDEMA NOTED TO EXTREM. CYCLING CARDIAC ENZYMES - AM CK'S PENDING.\n\nID - AFEBRILE.\n\nGI/GU - NPO OVER/NOC. ABD. SOFT, NTND W+BS. NO STOOL THIS SHIFT. INDWELLING FOLEY IN PLACE; PATENT AND DRAINING ADEQUATE AMTS. CLEAR, YELLOW URINE OVER/NOC.\n\nACCESS - LAC PIV - PATENT, SITE WNL.\n\nSOCIAL - S.O. IN AT CHANGE OF SHIFT. NO CONTACT OVER REMAINDER OF/NOC. HAD BEEN UPDATED ON PT. STATUS AND CONT. PLAN OF CARE.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-07-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 836427,
"text": " 1:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: PLEASE CHRCK FOR NG-tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with drug overdose on total bowel irrigation with OD on\n benadryl\n REASON FOR THIS EXAMINATION:\n PLEASE CHRCK FOR NG-tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement. Please check position. Drug overdose and now\n needs irrigation/charcol treatment.\n\n FINDINGS: An NG tube is partially coiled with its tip in the fundus of the\n stomach. There is no free air. There is a normal bowel gas pattern. No\n evidence of aspiration.\n\n IMPRESSION: Satisfactory position of NG tube with tip in fundus of stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-07-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 836593,
"text": " 8:57 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for evidence of aspiration\n Admitting Diagnosis: DRUG OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with recent toxic OD, now with leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for evidence of aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Leukocytosis.\n\n PA AND LATERAL CHEST: Comparison is made to the prior study from .\n There is silhouetting of the right heart border consistent with a right middle\n lobe pathology.consolidation. Minimal subsegmental atelectasis in the left\n lung base is seen. Given the history, The appearances are worrisome for\n pneumonia in the right middle lobe. This might be confirmed by lateral chest\n radiograph. The lungs otherwise appear clear.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-10 00:00:00.000",
"description": "Report",
"row_id": 166042,
"text": "Sinus rhythm. Prominent inferior Q waves - possible prior inferior myocardial\ninfarction clinical correlation is suggested. Since the previous tracing\nof no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-13 00:00:00.000",
"description": "Report",
"row_id": 169707,
"text": "Sinus rhythm. Leads VI and V5-V6 were not recorded. Compared to tracing #2 no\nsignificant diagnostic change..\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-12 00:00:00.000",
"description": "Report",
"row_id": 169708,
"text": "Sinus rhythm. Compared to tracing #1 the heart rate is significantly slower.\nDiffuse non-specific ST-T wave changes are slightly improved. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-12 00:00:00.000",
"description": "Report",
"row_id": 169709,
"text": "Sinus tachycardia. Probable old inferior myocardial infarction. Non-specific\ndiffuse ST-T wave abnormalities may be partly related to the rate. Compared to\nthe previous tracing of sinus tachycardia is new. Diffuse non-specific\nST-T wave changes are new. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-11 00:00:00.000",
"description": "Report",
"row_id": 169710,
"text": "Sinus rhythm. Prominent inferior Q waves - possible prior inferior myocardial\ninfarction but clinical correlation is suggested. Since the previous tracing\nearlier this date no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2108-07-11 00:00:00.000",
"description": "Report",
"row_id": 169711,
"text": "Sinus rhythm. Prominent inferior Q waves - possible prior inferior myocardial\ninfarction but clinical correlation is suggested. Lead V3 was not recorded.\nSince the previous tracing of no significant change.\nTRACING #2\n\n"
}
] |
11,578 | 115,245 | The patient was admitted to the trauma surgery service and was taken to the intensive care unit. The patient was started on steroids with a bolus and a drip for the concern for spinal cord injury. Cardiology was consulted and recommended continuing supportive medical care. Ortho- spine was consulted who recommended continuing the collar. The patient had an elevated coag with 2.4 INR and that was reversed and the patient was continued on ventilation. On hospital day #2, the patient was continued on C-collar. The patient had echocardiogram that showed significant pulmonary artery hypertension with systolic around 80s with a very poor right ventricular function. Per cardiology, recommend to continue supportive care. The patient was kept NPO with a Foley and the patient was slowly weaned from the ventilation. On hospital day #3, the patient had acute change in ability to move the upper extremity. The patient was given vitamin K and FFP to reverse the coagulopathy for concern for possible hemorrhage into the C-spinal canal. CT of the C-spine showed a superior fragment of odontoid fracture, most posteriorly displaced but not impinging on the cord. MR of the spinal cord showed no cord compression but continued to have spinal cord edema. CT of the head showed no acute process. The patient also had acute respiratory decompensation where the patient had CTA that initially showed no PE. The patient was continued to be supported throughout. On hospital day #4, the patient remained afebrile with stable vital signs and was continued to be weaned from the propofol. The patient had decreased movement of the upper extremity and only moved the lower extremity with decreasing the vent support. The patient was placed on Augmentin for Enterococcus urinary tract infection. Approximately noon on hospital day #4, the patient developed a significant respiratory and cardiac decompensation. The patient was hypotensive, also tachycardic to 150s, and urgent echocardiogram was obtained which showed that the patient did not have a functioning right ventricle and also the patient desaturated which were clinically consistent with pulmonary emboli. At this time with her injuries and also development of a new pulmonary emboli, discussion was made with the family who made her DNR. The patient was continuously supported with pressors and full vent support and after subsequent discussion, the patient was then made CMO. After the patient was CMO, the patient expired at 5:38 p.m. on . | Echocardiographic signs of tamponade may be absent in thepresence of elevated right sided pressures.Conclusions:The right atrium is markedly dilated. Right atrial abnormality.Diffuse non-specific ST-T wave changes. There isabnormal septal motion/position consistent with right ventricularpressure/volume overload. Right ventricular hypertrophy. right vertebral artery diminutive. Abnormal septal motion/position consistent with RVpressure/volume overload.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Atrial fibrillationRight ventricular hypertrophyDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing of same date, atrial fibrillation now present Bilateral pleural effusions and apparent bibasilar atelectatic changes are again demonstrated without significant interval change. Underfilled,hyperdynamic left ventricle. The right vertebral artery is diminutive throughout its course. The right ventricularfree wall is hypertrophied. Sinus rhythm with atrial premature complexesConsider biatrial abnormalityRight ventricular hypertrophyDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing of same dat, atrial flutter now absent Severe PA systolic hypertension.PERICARDIUM: Small pericardial effusion. Normal regional LV systolic function.RIGHT VENTRICLE: Markedly dilated RV cavity. Incidental note is made of a calcified granuloma in the left mid lung zone. Bilateral small-to-moderate pleural effusions. Severe global RV free wallhypokinesis.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. The LV now appears underfilled.IMPRESSION: Acute on chronic pulmonary hypertension. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Severe [4+] TR. There is mild symmetric left ventricularhypertrophy. The visualized upper thoracic canal is patent. CT CHEST BEFORE AND AFTER IV CONTRAST: There are bilateral small pleural effusions, with associated compressive atelectasis. PATIENT/TEST INFORMATION:Indication: Pulmonary embolus.Height: (in) 64Weight (lb): 155BSA (m2): 1.76 m2BP (mm Hg): 135/110HR (bpm): 124Status: InpatientDate/Time: at 14:49Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. The right ventricular cavity is markedly dilated.There is severe global right ventricular free wall hypokinesis. Severe [4+] TR.Severe PA systolic hypertension.PERICARDIUM: Small to moderate pericardial effusion. The right ventricular cavity is markedly dilated. There is severe globalright ventricular free wall hypokinesis.4. Hyperdynamic LVEF.RIGHT VENTRICLE: RV hypertrophy. Atrial fibrillation with an average ventricular response. There are small bilateral pleural effusions with associated atelectasis as seen on the prior CT. A small focus of susceptibility artifact within the cord at this level is consistent with hemorrhage/cord contusion. FINAL REPORT Non-contrast head CT. FINDINGS: Prevertebral edema and a small fluid collection are identified anterior to the C2 to C4 level. Foley patent with borderline to low UO. These may represent focal atelectasis, single bleb is present in the right upper lobe. The cerebellum and visualized posterior fossa structures appear within normal limits. A 2.5 cm left indeterminant adrenal nodule. There is continued cardiomegaly and small left pleural effusion with bibasilar patchy atelectasis. These likely represent simple cysts. FINDINGS: AP single view of the chest has been obtained with patient in supine position. IMPRESSION: Moderate cardiac enlargement, but no evidence for acute CHF or acute infiltrates. Slight overdistention of the ET tube cuff. However, the left ventricular contour is somewhat prominent, a finding coinciding with a moderately widened and elongated thoracic aorta. CT PELVIS WITH CONTRAST: The distal ureters and bladder are normal. To ascertain this structure as an adenoma, a non- contrast phase is necessary. ASSESSMENT AS NOTEDNEURO: SLIGHTLY MOVES BOTH LEGS TO COMMAND, + SENSATION LEGS, ON/OFF ARMS, NO ARM MOVEMENT, ATTEMPTS TO SQUIEZE TO COMMAND, CER ON,AROUSABLE TO VOICE, APPROPRIATE WHEN OFF SEDATIONRES: SO2 MOSTLY STAYS 93-95. FINDINGS: There is ventricular and sulcal prominence consistent with generalized involutional changes. There appears to be moderate cardiac enlargement without typical configurational abnormality. There are small bilateral pleural effusions. The gallbladder has been removed. Left frontal scalp soft tissue swelling, mild- moderate in degree. There are mild degenerative changes of the lower cervical spine. TECHNIQUE: Non-contrast head CT in 5 mm sections. The rectum, sigmoid, and large bowel are normal. NPN 0700-1900Events- No changes.Neuro- Off propofol and ativan and roxicet PRN. Levoflox added for + urine cx.GI/GU- Abd soft, +BS. Latest abg results determined a partially compensated metabolic alkalemia with mild hypoxemia on the current settings.RSBI = 78.2 on 0-PEEP and 5 cm PSV.Plan is to wean to extubation. protonix given.gu- pt with mag and kcl replenished. shortly after, pt became diaphoretic, tachypneic, hypoxic, tachycardic and hypertensive. propofol increased to sedate pt d/t asynchrony w/ vent. afebrile.endo- bs maintained with riss. K WAS REPLEATED TODAY 60MEQ IV AND 60MEQ PO. Pt is now a DNR. S:PT SEDATED AND INTUBATEDO:CV:SB C PROLONGED QTC. Pt volume resuscitated. Pt off propofol and placed on spont breathing trial. Propofol restarted after pt desaturated later in am. ekg initially showing sinus rhythm to sinus tachy w/ large amt ectope in form of pac's w/ transient ST depressions. HCT stable.GI/GU- TF held this am for possible extubation. eyes initially deviated to right when open, midline throughout shift.cardio- pt sinus brady with prolonged qtc, mag given. CarePt received intubated and ventilated on a/c but quickly weaned to cpap/psv,maintaining adequate sats/abgs. ogt d/c'd and ett removed. resp careremains intub/vented in psv mode. CXR SHOWS ATELECTASIS TO RIGHT SIDENEURO: PT SEDATED ON PROPOFOL. PT WAS INTUBATED ONSITE. Afebrile, tmax 100.5. Mod strength cough. Weaned down following CT scans. SR with htn this am. Q2hr neuro checks. hypo bowel sounds. Respiratory CarePt remains intubated and on CPAP with PS. Pt started on pressors and Heparin. pt with negative troponin in ed. rhythm suddenly converted to afib/flutter after fluid bolusing, rate transient. cxr shows some atelectasis to right side.gi- npo. Given ativan for cont anxiety with effect. diminished to right base. Pt's vent settings are as in carevue. pt profoundly acidotic, lactate 7.4. pt given LR bolus x2 w/ little effect to bp, dopamine drip started, titrated to adeq. Pt's care plan is to wean the oxygen as tol. Respiratory Care NotePt received on AC as noted. BG with SSIC.GI/GU- ABD soft, +bs. (+) CPR (+) RESP ARREST. Antidepressant started. INR treated with Vit K and FFP and CT head and neck ordered. bp normotensive. Had been given 2 uFFP and vit K prior to CT scan. mrsa cultures sent. Resp. Not restarted after scans for agian possible extubation if reads neg. | 41 | [
{
"category": "Echo",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 67264,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus.\nHeight: (in) 64\nWeight (lb): 155\nBSA (m2): 1.76 m2\nBP (mm Hg): 135/110\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 14:49\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Dilated IVC (>2.5 cm),\nwith minimal respiratory variation c/w elevated RA pressure of >20 mmHg.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF.\n\nRIGHT VENTRICLE: RV hypertrophy. Markedly dilated RV cavity. Severe global RV\nfree wall hypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR.\nSevere PA systolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. No echocardiographic\nsigns of tamponade. Echocardiographic signs of tamponade may be absent in the\npresence of elevated right sided pressures.\n\nConclusions:\nThe right atrium is markedly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is small and underfilled. Left\nventricular systolic function is hyperdynamic (EF>75%). The right ventricular\nfree wall is hypertrophied. The right ventricular cavity is markedly dilated.\nThere is severe global right ventricular free wall hypokinesis. There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The tricuspid valve leaflets are mildly thickened.\nSevere [4+] tricuspid regurgitation is seen. There is severe pulmonary artery\nsystolic hypertension. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade. Echocardiographic signs of tamponade may\nbe absent in the presence of elevated right sided pressures.\n\nCompared with the prior study (images reviewed) of , the RV systolic\nfunction appears worse and the degreee of pulmonary hypertension detected has\nfurther increased. The LV now appears underfilled.\n\nIMPRESSION: Acute on chronic pulmonary hypertension. RV failure. Underfilled,\nhyperdynamic left ventricle.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2151-05-28 00:00:00.000",
"description": "Report",
"row_id": 67265,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 155\nBSA (m2): 1.76 m2\nBP (mm Hg): 120/50\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 14:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Severe [4+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\n1. The left atrium is mildly dilated. The right atrium is markedly dilated.\n2. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\n3. The right ventricular cavity is markedly dilated. There is severe global\nright ventricular free wall hypokinesis.\n4. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation\nis seen.\n5. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n6. Severe [4+] tricuspid regurgitation is seen.\n7. There is severe pulmonary artery systolic hypertension.\n8. There is a small pericardial effusion. There are no echocardiographic signs\nof tamponade.\n9. Compared with the report of the prior study (images unavailable for review)\nof , the RV failure and pulmonary hypertension are worse.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2151-05-27 00:00:00.000",
"description": "Report",
"row_id": 143295,
"text": "Sinus rhythm. First degree A-V conduction delay. QTc interval is prolonged.\nRight axis deviation. Right ventricular hypertrophy. Right atrial abnormality.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing these\nchanges are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 143291,
"text": "Atrial fibrillation with an average ventricular response. Since the previous\ntracing of there are some aberrant beats noted. Increased ST-T wave\nabnormalities are seen diffusely throughout the electrocardiogram. The\nventricular response rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 143292,
"text": "Atrial fibrillation\nRight ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of same date, atrial fibrillation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 143293,
"text": "Sinus rhythm with atrial premature complexes\nConsider biatrial abnormality\nRight ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of same dat, atrial flutter now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 143294,
"text": "Possible atrial flutter with rapid ventricular response\nRight ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , atrial flutter now present\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909992,
"text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval interval chancge\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84F s/p fall, intubated, hx multiple PEs , sudden desat, now back on AC\n ventilation\n REASON FOR THIS EXAMINATION:\n pls eval interval chancge\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Oxygen desaturation.\n\n Endotracheal tube and nasogastric tube remain in standard position. There is\n stable cardiac enlargement. Bilateral pleural effusions and apparent\n bibasilar atelectatic changes are again demonstrated without significant\n interval change. Incidental note is made of a calcified granuloma in the left\n mid lung zone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 909989,
"text": " 11:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls eval interval chancge\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dens fx, acutely not moving upper extremities\n REASON FOR THIS EXAMINATION:\n pls eval interval chancge\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with dens fracture. Not moving upper\n extremities. Please evaluate for interval change.\n\n Comparison is made to the prior examination of .\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, shift of the\n normally midline structures, or major vascular territorial infarct.\n -white matter differentiation is preserved. Periventricular white matter\n hypodensities are consistent with chronic microvascular infarction. There is\n no hydrocephalus. There is decrease in size of a left frontal scalp hematoma.\n The osseous structures are unremarkable. Air-fluid levels and inspissated\n secretions in the right maxillary sinus, sphenoid sinus and right ethmoid\n sinus are likely secondary to intubation.\n\n IMPRESSION:\n\n No intracranial hemorrhage or mass effect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-30 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 910052,
"text": " 12:26 AM\n MR CERVICAL SPINE Clip # \n Reason: ? cord involvement\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with with odontoid fx / recent CT shows superior fragment has\n moved posteriorly / ? cord involvement / pt decrease movement B/L UE\n REASON FOR THIS EXAMINATION:\n ? cord involvement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI EXAM OF THE CERVICAL SPINE.\n\n CLINICAL INDICATION: Odontoid fracture, question cord compression.\n\n MRI exam of the cervical spine was obtained according to standard departmental\n protocol. Correlation is made to the recent cervical spine MRI from .\n\n There is persistent area of T2 hyperintensity involving the upper cervical\n cord extending from C1-C2 to lower C3 level suggestive of underlying cord\n contusion and edema. There is a fracture involving the odontoid process\n without retropulsion. The visualized upper cervical canal is patent. There\n is disruption of the anterior longitudinal ligament as a result of the C2\n fracture.\n\n There is mild disc space degeneration and cervical spondylosis at C5-C6 and\n C6-C7 levels. Slight narrowing of the foramina is noted at those levels. No\n epidural hematomas are seen.\n\n Inversion recovery images reveal slightly increased T2 signal along the\n interspinous ligaments of C2-C3 and C3-C4 levels suggestive of avulsion\n injury. There is no fracture seen involving the spinous processes. The\n visualized upper thoracic canal is patent.\n\n IMPRESSION: Persistent T2 hyperintensity involving the upper cervical cord\n suggestive of cord contusion/edema. Fracture of the odontoid process with\n disruption of the anterior longitudinal ligament. There is no retropulsion\n seen and the cervical medullary junction including the upper cervical canal\n remains patent. There is interspinous ligament avulsion of the posterior\n upper cervical spine at C2-C3 and C3-C4 levels. The findings have been stable\n since the previous MRI exam. Further follow up is suggested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910238,
"text": " 12:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECL RT SCL PLACEMENT; ASSESS FOR PTX,EDEMA\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84F s/p fall, intubated, hx multiple PEs , sudden desat, now back on AC\n ventilation\n REASON FOR THIS EXAMINATION:\n assess for ptx, edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall, multiple pulmonary emboli.\n\n CHEST: Endotracheal tube in satisfactory position, the nasogastric tube lies\n within the stomach. A right subclavian line is present with the tip in the\n lower SVC. No evidence of pneumothorax is present. Blunting of the\n costophrenic angle is present in the left side and general increase in\n opacification is seen in the supine film, indicating presence of a probably\n sizable left pleural effusion. This was not present on the prior chest x-ray\n of .\n\n IMPRESSION: Sizable left effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-29 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 909991,
"text": " 11:09 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: pls eval interval change\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dens fx, acutely not moving upper extremities\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with dens fracture, now not moving upper\n extremities. Evaluate for interval change.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT non-contrast axial images of the cervical spine were\n obtained. Sagittal and coronal reformatted images were also obtained.\n\n CT C-SPINE: On sagittal images, the skull base to T2 vertebrae are\n visualized. Again seen is a comminuted fracture of the mid odontoid process.\n When compared to the prior examination, there is now posterior displacement of\n the superior fragment (5 mm). There is rotational subluxation of C1 on C2. No\n other fractures are noted. The remainder of the cervical vertebrae appear\n well aligned. CT does not provide intrathecal detail comparable to MRI. The\n displaced dens fracture does not appear to impinge on the thecal sac.\n\n There are mild degenerative changes of the lower cervical spine.\n\n IMPRESSION:\n\n 1. Interval posterior displacement of superior fragment of comminuted\n fracture of the odontoid process. No gross evidence of spinal cord\n compromise, although this is not well evaluated on CT examination.\n\n These findings were discussed with Dr. at 4:30 p.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-29 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 909993,
"text": " 11:28 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: ARREST\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with h/o PE, now acutely desat\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of PE, now acutely desaturating.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic\n inlet to the lung bases before and after administration of IV contrast.\n Multiplanar reformats were also obtained. This study was compared to that of\n .\n\n CT CHEST BEFORE AND AFTER IV CONTRAST: There are bilateral small pleural\n effusions, with associated compressive atelectasis. Mosaic pattern of\n densities and peripheral septal thickening again seen, which is also unchanged\n since the prior. Several scattered blebs are identified. No pneumothorax\n identified. Left upper lobe granuloma again identified. The patient is\n intubated. There is a nasogastric tube in place that courses below the\n diaphragm.\n\n The aorta is normal in caliber, without evidence of dissection or aneurysm.\n There is no pulmonary embolism identified. Coronary artery calcifications\n seen.\n\n Small superior mediastinal nodes again seen, none of which are pathologically\n enlarged; for example, two precarinal nodes are both 7 mm in short-axis\n diameter. No axillary or hilar lymphadenopathy. The abdomen is incompletely\n imaged, but the superiormost aspect of the liver and spleen are unremarkable.\n\n Bone windows show no suspicious sclerotic or lytic lesions. The bones are\n diffusely demineralized, with degenerative changes.\n\n Multiplanar reformats were essential in delineating the findings above\n particularly of the pulmonary arteries.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism or aortic dissection.\n\n 2. Coronary vascular calcifications.\n\n 3. Bilateral small-to-moderate pleural effusions.\n\n 4. Failure and unchanged appearance of lungs since last exam.\n\n (Over)\n\n 11:28 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: ARREST\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-27 00:00:00.000",
"description": "CTA NECK W&W/OC & RECONS",
"row_id": 909780,
"text": " 5:08 PM\n CTA NECK W&W/OC & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? vertebral dissection\n Admitting Diagnosis: ARREST\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with dens fracture\n REASON FOR THIS EXAMINATION:\n ? vertebral dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:32 PM\n no acute injury. right vertebral artery diminutive.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question vertebral dissection.\n\n TECHNIQUE: Contrast-enhanced axial CT imaging with coronal and sagittal\n reformats was performed of the neck.\n\n FINDINGS: There is no evidence for a vertebral artery dissection. The right\n vertebral artery is diminutive throughout its course. The left vertebral\n artery opacifies without filling defect or evidence for dissection. The\n internal carotid arteries are patent without evidence for dissection or\n aneurysm. Calcification is present within the internal carotid artery at the\n left common carotid bifurcation. ET tube and NG tube are present. Bilateral\n pleural effusions and atelectasis is present within the visualized portions of\n the lungs as well as right apical thickening and calcification. Extensive\n degenerative disease is present throughout the cervical spine.\n\n IMPRESSION: No evidence for vertebral artery dissection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-27 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 909781,
"text": " 5:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval torso for secondary evidence of injury; thanks\n Admitting Diagnosis: ARREST\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fall.\n REASON FOR THIS EXAMINATION:\n please eval torso for secondary evidence of injury; thanks\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced axial CT imaging with coronal and sagittal\n reformats was reviewed.\n\n CT CHEST WITH CONTRAST: The ET tube is approximately 3 cm above the carina.\n The great vessels of the mediastinum are unremarkable. The heart is\n unremarkable. An NG tube is in the stomach. There is apical scarring. There\n is bibasilar atelectasis. There are small bilateral pleural effusions. There\n are multiple peripheral ill-defined ground-glass opacities that are\n predominantly located along the right anterior lung. These may represent\n focal atelectasis, single bleb is present in the right upper lobe. A\n calcified granuloma is present in the left upper lobe.\n\n CT ABDOMEN WITH CONTRAST: The liver, pancreas, spleen, small bowel, and\n kidneys demonstrate no evidence for injury. Multiple hypodense lesions are\n present in both kidneys, varying in size. These likely represent simple\n cysts. The gallbladder has been removed. There is no free fluid or free air\n in the abdomen. There is a small ventral defect. A 2.5-cm nodule is present\n within the left adrenal gland. This may represent an adenoma, but this cannot\n be determined on this study. To ascertain this structure as an adenoma, a non-\n contrast phase is necessary. The aorta is heavily calcified, and major\n branches also demonstrate calcification.\n\n CT PELVIS WITH CONTRAST: The distal ureters and bladder are normal. A Foley\n is present within a trabeculated bladder. The rectum, sigmoid, and large\n bowel are normal. The uterus is normal, no adnexal masses are present. There\n is no free fluid in the pelvis. Multiple injection calcifications are present\n in the buttocks.\n\n BONE WINDOWS: There is no evidence for acute injury, but degenerative disease\n is present throughout the thoracolumbar spine.\n\n IMPRESSION:\n\n 1. A 2.5 cm left indeterminant adrenal nodule. To determine a benign\n etiology, a non-contrast phase is necessary.\n (Over)\n\n 5:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval torso for secondary evidence of injury; thanks\n Admitting Diagnosis: ARREST\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. No evidence for acute injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 909737,
"text": " 2:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fall\n REASON FOR THIS EXAMINATION:\n please eval r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:00 PM\n No intracranial hemorrhage. Left frontal scalp soft tissue swelling, mild-\n moderate in degree.\n ______________________________________________________________________________\n FINAL REPORT\n Non-contrast head CT.\n\n INDICATION: 84-year-old female status post fall.\n\n TECHNIQUE: Non-contrast head CT in 5 mm sections.\n\n FINDINGS: There is ventricular and sulcal prominence consistent with\n generalized involutional changes. There are periventricular hypodensities in\n the white matter of both cerebral hemispheres consistent with chronic\n microvascular infarction.\n\n There is no evidence of acute intra or extra-axial hemorrhage. There is no\n shift of normally midline structures.\n\n There is a moderate sized scalp hematoma overlying the left frontal bone.\n There is no evidence of a skull fracture.\n\n IMPRESSION: No evidence of an acute intracranial hemorrhage.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-28 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 909807,
"text": " 3:17 AM\n MR CERVICAL SPINE Clip # \n Reason: hematoma? contusion?\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with c2 fx\n REASON FOR THIS EXAMINATION:\n hematoma? contusion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with C2 fracture.\n\n COMPARISOIN: CTA neck dated .\n\n TECHNIQUE: T1- and T2-weighted sagittal images, gradient-echo axial images\n and T-weighted coronal images performed. STIR images not obtained\n (FLAIR images were obtained in error). Full evaluation of possible\n ligamentous injury would require SITR images. It may be appropriate for the\n patient to return for these.\n\n FINDINGS: Prevertebral edema and a small fluid collection are identified\n anterior to the C2 to C4 level. There is disruption of the anterior\n longitudinal ligament at the site of the previously identified C2 fracture.\n The vertebral body heights and alignment is well maintained. There is\n increased T2 signal intensity within the spinal cord at the C2 level,\n consistent with edema. A small focus of susceptibility artifact within the\n cord at this level is consistent with hemorrhage/cord contusion. Given the\n lack of STIR sequence images, evaluation of ligamentous injury to the spinous\n processes/posterior elements cannot be fully evaluated. The cerebellum and\n visualized posterior fossa structures appear within normal limits. No\n significant spinal stenosis is identified. There is no evidence of hemorrhage\n within the epidural space. Increased signal intensity at the site of the type\n 2 dens fracture, likely represents marrow edema.\n\n IMPRESSION: Spinal cord contusion with edema at the level of the C2 vertebral\n body fracture. Prevertebral edema with likely disruption of the anterior\n longitudinal ligament. Due to the lack of STIR images, assessment of injury\n to the posterior elements and spinous processes is limited. This study can be\n repeated at no cost to the patient if clinically indicated.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909818,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: atelectasis?\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with sudden onset of CP, SOB\n\n REASON FOR THIS EXAMINATION:\n atelectasis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old post fall and cardiac arrest.\n\n Portable supine frontal radiograph. Comparison is made to radiographs\n performed yesterday and as well as CT scan performed\n yesterday.\n\n FINDINGS: Moderate cardiomegaly is stable. There are small bilateral pleural\n effusions with associated atelectasis as seen on the prior CT. Lung fields are\n unchanged. There is no pneumothorax. Patient remains intubated with an NG\n tube in place as well. The cuff of the ET tube is slightly over-inflated.\n\n IMPRESSION:\n\n Cardiomegaly without CHF or pneumonia. Slight overdistention of the ET tube\n cuff.\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909893,
"text": " 3:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for infiltrate, edema\n Admitting Diagnosis: ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84F s/p fall, intubated, hx multiple PEs\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 84-year-old female patient status post fall.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of 4:29 a.m.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. A\n nasogastric tube courses towards the stomach. Previously identified mild\n congestive heart failure has been improving. There is continued cardiomegaly\n and small left pleural effusion with bibasilar patchy atelectasis. Again,\n note is made of prominent proximal pulmonary arteries indicating pulmonary\n hypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909734,
"text": " 1:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with cardiac arrest\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tube placement, 78-year-old female patient with cardiac arrest.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. The patient is intubated; the ETT is seen to terminate in\n the trachea some 5 cm above the level of the carina. No pneumothorax or any\n other placement related complication is present. An NG tube is identified,\n seen to reach far below the diaphragm.\n\n There appears to be moderate cardiac enlargement without typical\n configurational abnormality. However, the left ventricular contour is\n somewhat prominent, a finding coinciding with a moderately widened and\n elongated thoracic aorta. No local aortic contour abnormality is identified.\n No pneumothorax or mediastinal abnormal widening identified. The pulmonary\n vasculature is not congested. The lateral pleural sinuses remain free. In\n the left lung mid field, a local well-demarcated density is seen, most likely\n representing a small granuloma.\n\n IMPRESSION: Moderate cardiac enlargement, but no evidence for acute CHF or\n acute infiltrates. Telephone report transmitted to emergency unit.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-05-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 909738,
"text": " 2:11 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for c-spine fract\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fall\n REASON FOR THIS EXAMINATION:\n eval for c-spine fract\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:22 PM\n Comminuted type 2 dens fracture, with nearly 30 degrees of leftward rotation\n of C1 on C2- urgent spinal consultation mandated!\n Degenerative arthritic changes at multiple levels.\n ______________________________________________________________________________\n FINAL REPORT\n CT scan of the cervical spine .\n\n INDICATION: 78-year-old female status post fall.\n\n TECHNIQUE: Helical acquisition through the cervical spine with coronal and\n sagittal reformatted images. No previous exams are available for comparison.\n Comparison is made with a CT scan of the neck from and a\n plain film from of the cervical spine.\n\n FINDINGS: There is a non-displaced comminuted fracture of the mid odontoid\n process (type II), and there is approximately 30 degrees rotational\n subluxation of C1 on C2. The bony central spinal canal is patent. No other\n associated fractures are identified.\n\n There are mild degenerative changes of the lower cervical spine.\n\n IMPRESSION: Non-displaced comminuted fracture of the odontoid process (type\n II). No evidence of spinal canal compromise. Findings communicated\n immediately following completion of the study via the ED dashboard.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413807,
"text": "NPN 0700-1900\nEvents- No changes.\n\nNeuro- Off propofol and ativan and roxicet PRN. Pt awake and though Russian speaking able to follow simple commands. Extremely weak movement of RUE, none of LUE and weak movement on bed with BLEs, withdraws with BLEs too.\n\nResp- Vent weaned and tolerated fair. PaO2 in 70s and sats 93%, pt is home O2 dependeent with interstial lung disease. Team discussed trach and PEG and will address issue with family tommorrow. Lungs coarse diminished bases and thick small to mod amts tan sputum. Cx sent. ETT rotated.\n\nCV- SR with HTN. Lopressor changed to OGT. SBP 150s. Afebrile. Skin w/d/i. Levoflox added for + urine cx.\n\nGI/GU- Abd soft, +BS. TF changed to 2/3 stregnth and rate increased to 90cc/h to provide for additional free water. Foley patent with borderline to low UO. No BM and bowel regimen started.\n\nSocial- Daughter called and will be in to visit tommorrow.\n\nPLan- Dicuss trach and PEG with family. ? halo, need to discuss further with Dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413808,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a partially compensated metabolic alkalemia with mild hypoxemia on the current settings.\n\nRSBI = 78.2 on 0-PEEP and 5 cm PSV.\n\nPlan is to wean to extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413809,
"text": "ASSESSMENT AS NOTED\n\nNEURO: SLIGHTLY MOVES BOTH LEGS TO COMMAND, + SENSATION LEGS, ON/OFF ARMS, NO ARM MOVEMENT, ATTEMPTS TO SQUIEZE TO COMMAND, CER ON,\nAROUSABLE TO VOICE, APPROPRIATE WHEN OFF SEDATION\n\nRES: SO2 MOSTLY STAYS 93-95. DIPS TO 88% WHEN PT ON LEFT SIDE, THICK TAN/YELLOW SPUTUM IN ETT, +CONGESTED COUGH,\n\nCV:SBP 140-160, STABLE, REMAINS IN NSR, ON LOPRESSOR 12.5 , NO ECTOPY, +WEAK PULSES, SLIGHT EDEMA ON BIL HANDS/FEET\n\nGI: STR T.FEEDING TOL WELL W/O RESIDUALS, DENIES NAUSEA, ABD SOFT, + BS, NO BM , BOWEL REGIMEN ONGOING\n\nGU: SMALL AMNT CONCENTRATED YELLOW 30-60/H\n\nENDO: HIGHER BS LAST NIGHT, RISS IN USE\n\nSOCIAL: DAUGHTER CALLED LAST NIGHT AND WAS UPDATED ON PT CONDITION\n\nPLAN: WEAN OFF VENT AS POSSIBLE, MONITOR NEURO, RES, ENDO\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413810,
"text": "Respiratory Care (addendum):\nPatient switched to A/C, due to cardiac instability (developed a-fib), as charted in CareVue. ABG's to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413811,
"text": "CV: WENT INTO RAPID A/FIB-S.TACH IN AND OUT OF SR AT 0515, H/O WAS INFORMED, GOT 20 LOPRESSOR IV W/O EFFECT, REMAINS IN S.TACH>120, EKG WAS DONE AND ENZYMES DRAWN. BP REMAINES STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413812,
"text": "Social Work\n\nSW was present during family meeting with pt's daughter to discuss code status and possible CMO in context of pt's PE. Daughter decided to make pt DNR and is contemplating having pt's husband come to the hospital before making decision re: CMO. SW will provide support throughout day as needed, and is available for page for this afternoon/evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413802,
"text": "assessment as noted\n\n: awake when off sedation, follows simple commands, does not move arms, attemps to squize , moves both legs weakly, MRI was done 2am and was read by resident: was not singnificant changed since last MRI \ncer collar is on\n\nres: on AC after MRI and back to CPAP at 5am, po2 in 80s, metabolic alkalosis, thick tan sputum in sm amnts, ls clear/coarse\n\ncv: in NSR/s.brady, on lopressor, sbp stable , dips with sedation, bil hands swelling, slight bil feet edema, +weak pulses\n\ngi: tf restarted -tol well, no residual, +bs, soft abd\n\ngu: fair diureses with lasix, slowed down in am\n\nheme: got one more unit FFP for inr 1.5 which decreased it to 1.4, no obvious bleeding was noted, hct 36-39\n\nsocial: daugher called last night to fill in mri questionere and was updated on pt's condition\n\nplan: wean off vent, monitor neuro, heme, comfort and care\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413803,
"text": "resp care\nremains intub/vented in psv mode. no further weaning done tonight, still requiring fio2 60%. appears comfortable with rr teens on above. transported to mri on ventilator, briefly on control mode due to sedation/mri vent. sxning thick tan sputum. cough effort is fair to good.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413804,
"text": "NPN 0700-1900\nEvents- Weaned to trach collar today.\n\n Pt alert, calm and cooperative with care. Nods yes/no to questions and able to communicate mouthing words. Orientated x 3. No movement of extremeties or sensation below the neck. When pain applied to BLEs they withdraw but seems more of reflex. Pt stated she could feel touch to R foot but cont to say she could feel touch when no longer applying nailbed pressure. Pt given fent several times for c/o pain in neck. Antidepressant started. OOB to chair.\n\nResp- Weaned to 50% humidified trach collar after moved to chair. ABGs virtually unchanged, good paO2. RR 16-20. Denies SOB. Mod strength cough. Scant amt thick yellow secretions. Sputum cx sent due to rise in WBCs. Lungs diminished throughout.\n\nCV- Afebrile. SR with htn this am. Given lopressor with little effect then dose of hydralazine and SBP went from 170s to 130s. Lopressor changed to PO. Skin w/d/i. BG with SSIC.\n\nGI/GU- ABD soft, +bs. This am pt burping and swallowing alot when asked if nausested pt nodding yes, but no to feeling like vomiting.\nTreated with po anzamet IVs. Later feeling as though she is going to vomit. Droperidol given with little effect and dose repeated. UAdequate UO.\n\nSocial- Family at beside very concrnedanbappropriate.\n\nPlan- Cont to wean F2. rovide oniung support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413805,
"text": "NPN 0700-1900\nThis note was written on wrong patient. This note is about pt MR#.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-30 00:00:00.000",
"description": "Report",
"row_id": 1413806,
"text": "Respiratory care\nPt remains on psv weaned to will continue to wean fio2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-28 00:00:00.000",
"description": "Report",
"row_id": 1413797,
"text": "S:PT SEDATED AND INTUBATED\n\nO:CV:SB C PROLONGED QTC. HR 40'S-50'S.PULSES PALPABLE . PT ON COUMADIN AT HOME. 2UNITS FFP GIVEN TODAY. BP 130/62. PT HAD ONE EPISODE OF HYPOTENSION TODAY 500CC NS BOLUS C GOOD EFFECT. K WAS REPLEATED TODAY 60MEQ IV AND 60MEQ PO. K RECHECKED AT 1800 WAITING FOR RESULTS.\n\nRESP: AC 550/12 FIO2 50%/PEEP 10. O2 SATS 98%. WHEN PT LAYS ON RIGHT SIDE O2 SATS DROPPED 89%, TODAY ONCE PLACED BACK TO LEFT SIDE PTS O2 SATS INCREASED. LUNG SOUNDS CLEAR. CXR SHOWS ATELECTASIS TO RIGHT SIDE\n\nNEURO: PT SEDATED ON PROPOFOL. WHEN PT WAS AWAKE TO TALK TO RUSSIAN SPEAKING DOCTOR SHE APPEARED TO NOD APPROPRIATLEY WHEN ASKED QUESTIONS PT DID APPEAR TO BE ORIENTED. PT ALSO FELT PAIN IN HER NECK PT DID RECEIVE MORPHINE FOR PAIN 2MG IVP. PT WILL FOLLOW COMMANDS WHEN SHOWED WHAT TO DO IE. STICK OUT . WHEN FEET ARE TOUCHED SHE WILL MOVE HER EXTREMITIES. PT WILL TRACK WHEN AWAKENED.\n\nGI: TUBE FEEDS ADVANCED TO 30CC/HR GOAL IS 60CC/HR. BS (+) (-) BM.\n\nGU:PT IS PUTTING OUT MNIMAL URIN 15-20CC/HR HOUSE STAFF AWARE. PT HAD MAG AND K REPLEATED TODAY.500CC BOLUS GIVEN C MINIMAL EFFECT ON URIN OUTPUT.\n\nSKIN: ECCHY AREA OVER LEFT EYE BE DUE TO HER FALL.\n\nENDO: BS MAINTAINED C RISS. SOLUMEDROL GTT FINISHED AT 1600 FINISHED 23 HRS.\n\nSOCIAL: PT HAS RUSSIAN SPEAKING DAUGHTER AND GRANDSON SPEAKS ENGLISH.\n\nA:PT FOUND DOWN PULSELESS AT ACTIVITY CENTER. (+) CPR (+) RESP ARREST. PT WAS INTUBATED ONSITE. PT WAS FOUND TO HAVE C2 FX, NO NEED FOR SPINAL . PT TO WEAR C-COLLAR FOR 6-8WEEKS.\n\nP: FOLLOW LYTES REPLEAT AS NEEDED. MONITOR NEURO STATUS AND RESP STATUS. CONT TO MONITOR URIN OUTPUT. FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-29 00:00:00.000",
"description": "Report",
"row_id": 1413798,
"text": "Resp. Care\nPt received intubated and ventilated on a/c but quickly weaned to cpap/psv,maintaining adequate sats/abgs. RSBI= 41. Currently on cpap 5/5/50%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-29 00:00:00.000",
"description": "Report",
"row_id": 1413799,
"text": "assessment as noted in carevue\n\nres: abg wnl on 5x5, good res effort, ls dim, sm amnt thick white sputum in suction\n\nneuro: follows commands,, mae, weak, russian speaking only-needs translator, cer collar is on\n\ncv: stable bp, in nsr/s.brady, warm skin, +weak puses, slight pedal edema\n\ngi: tol t.feed well, now up to 50/h, +bs, soft abd\n\ngu: scant u/o 15-25/h-h/o aware, cont to monitor\n\nendo: bs remains high, riss was tightned\n\nsocial: family was in last night and talked to md, signed blood+icu\n concents\n\nplan: try to wean and extubate, monitor neuro, res, endo\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-29 00:00:00.000",
"description": "Report",
"row_id": 1413800,
"text": "Respiratory Care\nPt remains intubated and on CPAP with PS. Pt had a CT scan today of the chest and C-Spine. Pt had a desat and required an increase in oxygen. Pt's vent settings are as in carevue. Pt's care plan is to wean the oxygen as tol. Pt was sxn for a good amount of tanish thick sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-29 00:00:00.000",
"description": "Report",
"row_id": 1413801,
"text": "NPN 0700-1900\nEvents- This am pt unable to move BUEs. Pt getting very anxious about immobility. Team aware, Dr notified. INR treated with Vit K and FFP and CT head and neck ordered. Held extubation for tests. Hour later while awaiting CT Sats began dropping to 87%. Increased Fio2 and ABGs showed paO2 60s. Sats with little improvement on higher fio2 and switched vent to A/C, sats increased to mid 90s. CTA chest added to tests.\n\n Pt off propofol and placed on spont breathing trial. Became very anxious when unable to move arms, BUEs with little tone and move slightly as pt trying to raise them to command. Given ativan for cont anxiety with effect. Propofol restarted after pt desaturated later in am. Weaned down following CT scans. With Dr translating pt nodding appropriately to questions and FCs as able. Pt now able to weakly squeeze hands and move weakly on bed. Conts to move BLEs on bed but LLE weaker than Right. CT head neg, Ct cervical spine showed no protrusion on cord but posterior segment of cervical fracture more displaced than previous study. MRI ordered, awaiting family to call back to fill in checklist.\n\nResp- on spont breathing trial this am for planned extubation. Back to PS when unable to move BUEs and became anxious. Later desat to 87% as mentioned above. In afternoon weaned back to PS and ABGs WNL except PaO2 77 on 60% FiO2. Lungs clear to coarse with diminished bases. CTA neg for PE, shows small effusions. Scant amt secretions.\n\nCV- SR 60-90s. HTN upon return from Ct, persisting in 180s. Pt not anxious or restless at the time. Dr aware and pt started on standing dose lopressor and given 5mg x 2 when first dose had little effect. Also given lasix 20mg and improved UO. Had been given 2 uFFP and vit K prior to CT scan. Repeat INR 1.8 and 2 more units ordered, 1u started at 1840. Afebrile, tmax 100.5. Skin W/D/I, Hematoma over L eye unchanged. IVF TKO. HCT stable.\n\nGI/GU- TF held this am for possible extubation. Not restarted after scans for agian possible extubation if reads neg. MD aware and not restarted later as pt going to MRI and if neg should extubate in am. Abd soft, +BS. No BM. Low UO, improved response with lasix.\n\nSocial- Family are supposed to visit in evening.\n\nPLan- Need MRI checklist and scan this evening of C-spine. Cont wean vent as tolerated. Monitor BP closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-28 00:00:00.000",
"description": "Report",
"row_id": 1413795,
"text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, peep increased to enhance oygenation, fio2 down to acceptable level with mild compensatory resp alkalosis; bs diminished @ bases, sxn thick yell secretions, transported to & from mri without incident, rsbi not indicated @ current peep level, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-28 00:00:00.000",
"description": "Report",
"row_id": 1413796,
"text": "T-SICU nsg note\n pt with unwittnessed colapse in activity center of , prone and without pulse. +cpr, +resp arrest, +intubate on scene. pupils were 2mm and fixed. on arrival had full ct which showed c2 fx, spinal surgery with no need to operate, pt to wear c-collar for 6-8wks per attending. mri results pending to r/o soft tissue damage. pt with negative troponin in ed. creatinine of 1.3 in ed bicarb given.\n\nneuro-pt sedated on propofol. Q2hr neuro checks. pt able to move all extremities to stimuli, pt not following commands. she is russian speaking per daughter, but not able to follow commands for daughter. pt opens eyes when name is called. no pain noted with vitals or non verbal cues. absent gaze, no tracking noted. eyes initially deviated to right when open, midline throughout shift.\n\ncardio- pt sinus brady with prolonged qtc, mag given. bp normotensive. pulses palpable to all extremities. p- boots on, no heparin sQ. pt on coumadin at home. 2units ffp given in ed.\n\nresp- pt intubated on cmv fio2 50% peep of 10. 550x12. abgs sent this am, on arrival to unit pt with pao2 of 75 on 100%fio2. lung sounds coarse throughout, clearing w/ sx. diminished to right base. cxr shows some atelectasis to right side.\n\ngi- npo. ogt draining bilious fluid. hypo bowel sounds. protonix given.\n\ngu- pt with mag and kcl replenished. foley draining clear yellow urine. u/o tapered throughout night, 500cc lr bolus given x2 w/ minimal effect.\n\nskin- pt with ecchy area over left eye with small abrasion. some ecchy areas to arms/hands due to venipuncture.\n\nid- no abx at this time. mrsa cultures sent. afebrile.\n\nendo- bs maintained with riss. covered x2 for bs in 160s. solumedrol gtt started @1700 for 23 hrs.\n\nsocial- pt is russian speaking, per daughter. daughter is hcp, she was md - pathologist. daughter very appropriate and will be in to see pt in evening.\n\nap- monitor neuro status, continue q2h neuro checks. continue sedation with intubation wean appropriately. monitor respiratory status. follow up with mri finding. continue to support pt and family needs. likely family meeting in next 24h for plan of care discussion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413813,
"text": "Respiratory Care Note\nPt received on AC as noted. Pt placed on PSV 6/6 with VT 400's and RR 21. BS essentially clear, but diminished throughout. Pt placed on AC secondary to low BP with systolic in the 50's. Pt placed on 100% and PEEP increased to 14cm for cyanosis and low sats. IMV increased according to ABG's. ? pulmonary embolism. Pt started on pressors and Heparin. Pt volume resuscitated. Plan to travel to CT Scan when pt is stable. Plan to continue on current settings at this time. Pt is now a DNR. Pt will become CMO this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-05-31 00:00:00.000",
"description": "Report",
"row_id": 1413814,
"text": "T-SICU event note\n\n1200 pt turned to left side, not able to tolerate. pt turned supine after being on left side for <5 min. shortly after, pt became diaphoretic, tachypneic, hypoxic, tachycardic and hypertensive. 2mg morphine given for pain with no effect. pt suctioned for thick/yellow sputum. vent changed to ac mode. abg sent along with lytes, h/h, coags and cardiac enzymes. pt profoundly acidotic, lactate 7.4. pt given LR bolus x2 w/ little effect to bp, dopamine drip started, titrated to adeq. bp. propofol increased to sedate pt d/t asynchrony w/ vent. ekg initially showing sinus rhythm to sinus tachy w/ large amt ectope in form of pac's w/ transient ST depressions. rhythm suddenly converted to afib/flutter after fluid bolusing, rate transient. tlc placed in rsc by icu team, opening cvp 35. dopamine w/ only small effect, levophed started, titrated to adeq bp, able to wean dopamine to off. bp extremely labile despite pressors, sodium bicarb, ca chloride given ivp. echo performed, right sided heart failure per icu attending, likely large pulmonary embolus cause. unable to transport pt to CT d/t hemodynamic instability.\n1400 pts daughter, arrived for family meeting, Dr. (surgery resident) in to assist w/ translation. family meeting took place with icu attending, sw, and rn present. explanation of pt's sudden medical crisis explained to family, likely causes, tx, grave prognosis discussed. decision made by daughter, w/ collaboration of pt's husband, rest of family to make pt DNR, comfort measures status.\n1500 husband of pt visited along with daughter. other family members also present.\n1700 family decided to withdraw pressors and ventilator. morphine 4mg given ivp. pressors turned off, propofol turned off. ogt d/c'd and ett removed. pt w/ very little agonal breathing noted, only strong breaths taken over course of 15 minutes.\n1728 pt became asystolic, time of death determined by Dr. . primary team aware, in to complete documentation.\n"
}
] |
3,559 | 108,468 | The patient was admitted on and underwent a panniculectomy performed by Dr. , which excised a total of 35 lb. The procedure was successful and there were no immediate postoperative complications. Please see operative note for further details. Due to her extensive cardiac and diabetic history, the patient was admitted to the ICU for overnight observation. The patient did well on postop day one and was encouraged to get out of bed, though the patient refused to get out of bed. The patient was found in the morning not to have pneumatic boots, and an incident report was filed. Later that afternoon, the pneumatic boot machine was brought to her bedside. Her hematocrit on postoperative day zero was 27.9, and she received one unit of red blood cells. Her hematocrit on postoperative day one following transfusion was 30.6 and remained stable throughout the rest of her hospital course. Her coags were within normal limits during her hospital stay. She did express a considerable amount of clot material postoperatively from the wounds, but she did not demonstrate any persistent bleeding, and by postoperative day three, her wounds remained dry. On postoperative day three, the patient was finally transferred out of the unit. Because the patient did not have any MRSA cultures that were positive in her last day, her antibiotics were changed from vancomycin to Ancef. On postoperative day three, her Foley was discontinued and her IV was heplocked. Her diet was fully advanced which the patient tolerated. The podiatry team also came by and recommended that the patient follow up with Dr. . Wound cultures and x-rays of her feet were taken during the hospital stay per podiatry. By postoperative day four, the patient was ambulating and passed her voiding trial. We felt that the patient would be ready for discharge home per patient preference. It was recommended that the patient go to a rehab facility, but the patient clearly refused this option. Physical therapy also was consulted and they felt that she would be sufficient with home P.T. | has hx of a fib, and came out of the or reportedly in afib, now in nsr.resp- 3lnasal cannula, ls clear.gi/gu- npo presently. BS cl but diminished bilat.GI - Abd dsg with old areas of bldy saturation. Pedal pulses dopplerable, swollen from cellulitis. Responds well to lasix.Neuro - A & O X3. ICU resident and intern notified of low systolic pressures. Clinical correlation issuggested. Lung sounds clear over BUL's, diminished over bases. Respirations wnl, no distress.GI/GU: Foley to gravity, urine output has been wnl. Urine output has been wnl. mae.cv- pt in nsr hr 60's, bp 150's via r brachial a line. DP and PT pulses dopplerable only due to massive edema of bil lower extremities. Tmax overnight 100.6f oral. Pt is warm and well-perfused.RESP: Pt on 2.0 liters NC, SaO2> 94%. Using PCA MSO4 appropriately for pain. Respirations wnl. Right arm PICC line intact.Resp - Continues on 2L NC. PICC and right IJ line as above. AP PORTABLE UPRIGHT CHEST: There is a right-sided PICC line with tip in the subclavian vein. Moves all extremities, weaker with lower extremities d/t obesity and cellulitis.CV: HR has been NSR 60-80, no ectopy. upper lobes, diminished over bil. The P-R interval is 0.19.Prominent voltage in leads I and aVL for left ventricular hypertrophy.ST segment depression and biphasic to inverted T waves in leads I and aVL.ST-T wave flattening in leads V4-V6. Diabetic Ulcer present on outer portion of right foot, wrapped with gauze at this time. 1 mg/hr , total of one mg given. SBP has been 95-130. +bs. BP 110-70 and HR 60's NSR. JP with min output. missing sev toes on r foot, ace wrap for compression to l leg. A right internal jugular central venous catheter has its tip at the cavoatrial junction. Nursing Progress NoteNeuro: Pt A&O x's 3. Sinus rhythm and paroxysms of atrial tachycardia. on ms pca for pain. Tmax overnight, 99.5f po. SaO2 has been > 95%.GI/GU: Bowel sounds present. Nursing Progress NOtePlease see carevue and MARs for more details of pt's care.NEURO: Pt very appropriate, PEARL, GCS=15. Tolerating PO's very well.GU - Foley cath draining adequate amt cl yellow urine. Nsg Progress Note 0700-1900CV - Stable day. abd incision w/sm amt serosag drainage, jp w/sm output as well, sangunous drainage.pt s/p pannulectomy, cont ms pca for pain prn, follow i/o, ?begin lasix in am, hydrate o/n, monitor resp status, labs, etc. foley to gravity.SKIN: Surgical incision across abdomen covered with DSD. Turning pt and encouraging her to cough/deep breath.Please see carevue and MARs for more details. 2liters NC. : Abdominal incision oozing moderate amount of blood, resident aware, reinforcing with dressing and gauze. In addition, there is focal osteopenia with cortical loss both at the base and at the head of the first metatarsal. IMPRESSION: Findings concerning for osteomyelitis at the base and the head of the first metatarsal. RLE warm, red and swollen d/t cellulitis. Compared to the previous tracingof T wave inversions are less prominent in leads I and aVL. Radial pulses palpable. PEARL. Evaluate for osteomyelitis. Moves all extremities but right foot very sore. Thesechanges may reflect interim lateral ischemic process. COMPARISON: . COMPARISON: . pt c/o pain on arrival after rolling off dirty sheets, etc. Diastolic has been in the 30's. LLE swollen, pt states she has had cellulitis in this leg before.1 unit PRBC's transfused over 4 hrs for a crit of 27. All extremities warm and well-perfused.RESP: Lung sounds clear over bil. JP to bulb suction. PICC line intact. micu nursing admission noteplease see flowsheet for all objective data, and fhpa for details on admissionpt arrived via stretcher at 1430 from the pacu accompanied by RN.brief rosneuro- pt alert, oriented x3. RIJ remaoved this morning per consent of resident. 40 of lasix given after transfusion. Compared to the prior study, there is increased demineralization within the foot. IVF at 20cc/hr via R IJ VIP cath. Will continue to monitor pt per ICU protocol. 11:50 AM CHEST (PORTABLE AP) Clip # Reason: ?PTX ?line tip Admitting Diagnosis: EXCESS SKIN OF ABDOMINAL WALL/SDA MEDICAL CONDITION: 64 year old woman s/p R CVL in IJ REASON FOR THIS EXAMINATION: ?PTX ?line tip FINAL REPORT HISTORY: Right central venous line placement. Crit sent this morning. FINAL REPORT HISTORY: Right lateral mid foot ulceration which probes to the bone at the level of the inferior lateral malleolus. Soft tissue detail within the foot is obscured by the overlying cast. Able to get OOB to chair. She is comfortable with medication response to pain at this time. These findings are very concerning for osteomyelitis. RIGHT FOOT & ANKLE, 3 VIEWS: There is marked osseous disorganization about the ankle joint, with heterotopic bone formation medially. Only 20cc's of output from it overnight.Pt remains on Morphine PCA. REASON FOR THIS EXAMINATION: Right lateral midfoot ulceration which probes to bone at the level of inferior lateral malleolus. Needs encouragement to deep breath due to abd discomfort. JP drain has had minimal output. bases. Bowel sounds present, pt eating diet. Alternatively, this may be an artifact related to the increased demineralization. SBP 95-120, A-line d/c'd last night per resident. No neuro deficits recognized.CV: HR has been 70-90, NSR, no ectopy. no c/o no pain/. sleepy but arousable. The soft tissues are obscured by the overlying cast. foley w/good u/o, received lasix in the or, on lasix at home, also receiving lr 120cc/hr.. still awaiting orders.skin- pt w/new ulcer on r foot d/t her wearing wrong size boot for walking at home. | 7 | [
{
"category": "Radiology",
"chartdate": "2161-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819399,
"text": " 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PTX ?line tip\n Admitting Diagnosis: EXCESS SKIN OF ABDOMINAL WALL/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p R CVL in IJ\n REASON FOR THIS EXAMINATION:\n ?PTX ?line tip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right central venous line placement.\n\n COMPARISON: .\n\n AP PORTABLE UPRIGHT CHEST: There is a right-sided PICC line with tip in the\n subclavian vein. A right internal jugular central venous catheter has its tip\n at the cavoatrial junction.\n\n IMPRESSION: No pneumothorax. PICC and right IJ line as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-04-13 00:00:00.000",
"description": "R ANKLE/FOOT (AP, LAT & OBL) RIGHT",
"row_id": 819783,
"text": " 1:46 PM\n ANKLE/FOOT (AP, LAT & OBL) RIGHT Clip # \n Reason: Right lateral midfoot ulceration which probes to bone at the\n Admitting Diagnosis: EXCESS SKIN OF ABDOMINAL WALL/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman Diabetes, CAD, Anemia, s/p panniculectomy , right\n lateral rearfoot ulcer.\n REASON FOR THIS EXAMINATION:\n Right lateral midfoot ulceration which probes to bone at the level of inferior\n lateral malleolus. Evaluate for osteomyelitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right lateral mid foot ulceration which probes to the bone at the\n level of the inferior lateral malleolus.\n\n COMPARISON: .\n\n RIGHT FOOT & ANKLE, 3 VIEWS: There is marked osseous disorganization about the\n ankle joint, with heterotopic bone formation medially. The soft tissues are\n obscured by the overlying cast.\n\n Compared to the prior study, there is increased demineralization within the\n foot. In addition, there is focal osteopenia with cortical loss both at the\n base and at the head of the first metatarsal. These findings are very\n concerning for osteomyelitis.\n\n There is also a suggestion of a new periosteal reaction along the lateral\n cortex of the 5th metatarsal. Alternatively, this may be an artifact related\n to the increased demineralization. There are no osseous erosions and no gas in\n this area. Soft tissue detail within the foot is obscured by the overlying\n cast.\n\n IMPRESSION: Findings concerning for osteomyelitis at the base and the head of\n the first metatarsal.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-04-10 00:00:00.000",
"description": "Report",
"row_id": 1308212,
"text": "Nsg Progress Note 0700-1900\n\nCV - Stable day. BP 110-70 and HR 60's NSR. No temp spikes. IVF at 20cc/hr via R IJ VIP cath. Right arm PICC line intact.\n\nResp - Continues on 2L NC. Needs encouragement to deep breath due to abd discomfort. BS cl but diminished bilat.\n\nGI - Abd dsg with old areas of bldy saturation. JP with min output. Using PCA MSO4 appropriately for pain. Tolerating PO's very well.\n\nGU - Foley cath draining adequate amt cl yellow urine. Responds well to lasix.\n\nNeuro - A & O X3. Very pleasant and cooperative. Moves all extremities but right foot very sore. Able to get OOB to chair. Needs two people and a walker.\n\nEndocrine - continues on sliding scale insulin q 6 hours - does require coverage.\n\nSocial - Husband and two sons in visiting today. She also is able to talk to family on the phone.\n\nID - pt was exposed to MRSA pt in and is back on MRSA precautions again.\n\nPt can be transferred to floor when bed available.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-04-11 00:00:00.000",
"description": "Report",
"row_id": 1308213,
"text": "Nursing Progress NOte\n\nPlease see carevue and MARs for more details of pt's care.\n\nNEURO: Pt very appropriate, PEARL, GCS=15. No neuro deficits recognized.\n\nCV: HR has been 70-90, NSR, no ectopy. SBP has been 95-130. Diastolic has been in the 30's. ICU resident and intern notified of low systolic pressures. Tmax overnight, 99.5f po. DP and PT pulses dopplerable only due to massive edema of bil lower extremities. Radial pulses palpable. Pt is warm and well-perfused.\n\nRESP: Pt on 2.0 liters NC, SaO2> 94%. Lung sounds clear over BUL's, diminished over bases. Respirations wnl, no distress.\n\nGI/GU: Foley to gravity, urine output has been wnl. Bowel sounds present, pt eating diet.\n\n: Abdominal incision oozing moderate amount of blood, resident aware, reinforcing with dressing and gauze. Crit sent this morning. JP drain has had minimal output. RIJ remaoved this morning per consent of resident. PICC line intact. Will continue to monitor pt per ICU protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-04-09 00:00:00.000",
"description": "Report",
"row_id": 1308210,
"text": "micu nursing admission note\nplease see flowsheet for all objective data, and fhpa for details on admission\npt arrived via stretcher at 1430 from the pacu accompanied by RN.\n\nbrief ros\n\nneuro- pt alert, oriented x3. very pleasant. on ms pca for pain. 1 mg/hr , total of one mg given. pt c/o pain on arrival after rolling off dirty sheets, etc. no c/o no pain/. sleepy but arousable. mae.\n\ncv- pt in nsr hr 60's, bp 150's via r brachial a line. has hx of a fib, and came out of the or reportedly in afib, now in nsr.\n\nresp- 3lnasal cannula, ls clear.\n\ngi/gu- npo presently. +bs. foley w/good u/o, received lasix in the or, on lasix at home, also receiving lr 120cc/hr.. still awaiting orders.\n\nskin- pt w/new ulcer on r foot d/t her wearing wrong size boot for walking at home. missing sev toes on r foot, ace wrap for compression to l leg. abd incision w/sm amt serosag drainage, jp w/sm output as well, sangunous drainage.\n\npt s/p pannulectomy, cont ms pca for pain prn, follow i/o, ?begin lasix in am, hydrate o/n, monitor resp status, labs, etc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-04-10 00:00:00.000",
"description": "Report",
"row_id": 1308211,
"text": "Nursing Progress Note\n\nNeuro: Pt A&O x's 3. GCS 14-15. No neuro deficits noticed at this time. PEARL. Moves all extremities, weaker with lower extremities d/t obesity and cellulitis.\n\nCV: HR has been NSR 60-80, no ectopy. SBP 95-120, A-line d/c'd last night per resident. Tmax overnight 100.6f oral. Pedal pulses dopplerable, swollen from cellulitis. All extremities warm and well-perfused.\n\nRESP: Lung sounds clear over bil. upper lobes, diminished over bil. bases. Respirations wnl. 2liters NC. SaO2 has been > 95%.\n\nGI/GU: Bowel sounds present. Drinking water and on diet. Pt had small bites of noodles last night without difficulty. Urine output has been wnl. foley to gravity.\n\nSKIN: Surgical incision across abdomen covered with DSD. No drainage present at this time, only scant amount of dried blood. Diabetic Ulcer present on outer portion of right foot, wrapped with gauze at this time. RLE warm, red and swollen d/t cellulitis. LLE swollen, pt states she has had cellulitis in this leg before.\n\n1 unit PRBC's transfused over 4 hrs for a crit of 27. 40 of lasix given after transfusion. JP to bulb suction. Only 20cc's of output from it overnight.Pt remains on Morphine PCA. She ahs only pressed her button 4-5 times overnight. She is comfortable with medication response to pain at this time. Turning pt and encouraging her to cough/deep breath.Please see carevue and MARs for more details.\n"
},
{
"category": "ECG",
"chartdate": "2161-04-09 00:00:00.000",
"description": "Report",
"row_id": 137980,
"text": "Sinus rhythm and paroxysms of atrial tachycardia. The P-R interval is 0.19.\nProminent voltage in leads I and aVL for left ventricular hypertrophy.\nST segment depression and biphasic to inverted T waves in leads I and aVL.\nST-T wave flattening in leads V4-V6. Compared to the previous tracing\nof T wave inversions are less prominent in leads I and aVL. These\nchanges may reflect interim lateral ischemic process. Clinical correlation is\nsuggested.\n\n"
}
] |
6,085 | 174,506 | # BRBPR: With time frame and lack of other symptoms, BRBPR most likely secondary to prostate biopsy. However, with abdominal pain, may need to consider intraabdominal etiologies such as diverticular bleed, variceal bleed (but no hematemesis), brisk UGI bleed from other sources including PUD, Dieulafoy's, gastritis/duodenitis. Further eval postponed since HCT stable and no active bleeding. CT abd neg for retroperitoneal bleed. Hct down to 24 from baseline of 42 now stable at 33. No stooling x day. On day of discharge, pt had one formed melanotic stool. Although bleed has been blamed on rectal biopsy, pt may need further eval for possible upper GIB. Pt hemodynamically stable and will follow up with the liver clinic in 6 days. - f/u with urology in 3 weeks | Noted occn. call out if hct stable. Received pt. starting usual dose of klonopin Post transfusion Hct was 29.9.Neuro: Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Transfused one unit of platelets, post platelet count pending. SBP 100-153. Today he came to ED with presyncopy and continued brbpr. His bp 80/'s and HR 100 ST. Starting bowel regime. 98.9 oral. Today he presented to ED presyncopal and tachycardic. Guiac +. Transfuse if appropriate. Guaic + below. Allergies asa. No BM this shift, + flatulence. At present alert and oriented x 3. Last fs was 98. Able to MAE's with purpose. is A/O x3. GI/GU: Abdomen soft with + bs. brbpr post transrectal biopsyhypergylcemiaARFelevated troponinhcvbipolar dzhypnatremiap. Compared to the previous tracingof no definite change.TRACING #1 Last Hct 35.9. ?starting bowel regime if no BM overnight. Plan for d/c to floor.Endo: Pt Tolerating PO diet.Skin: Intact.Endo: Pt. on sliding scale, last FS 201. RR 12-24 and non labored. HR 80's nsr occ pvc bp 120/75. Monitor Hct and transfuse if appropriate. 2 peripheral iv's intact. is no longer NPO and has orders for regular diet.Endo: Pt. NAD. need bowel regimen. Events: Transfused with 2 units prbc's. Integ: Skin grossly intact. Nbp mid 90's to low 120's systolic. Plan: Monitor hct and transfuse as required. ? ? Transfer note already started. Neuro: Alert and oriented x 3. continues to be in NSR with no ectopy noted this shift. Plan for call out. MAE. Gag and cough intact.CV: Pt. Denies discomfort. Denies discomfort. PLEASE SEE CAREVIEW FOR OBJECTIVE DATA. Bowel sounds present. Able to ambulate without assistance. Independent with self care and turning. Results pending. Temperature max. Ns kvo infusing lt ac. Is hemodynamically stable. Labs to be drawn in am. SBP 107-125 and stable. voids on his own, greater than 30cc/hr. MAE with purpose. Provides own self-care.CV: SB-NSR, no ectopy noted. Encourage sliding scale for DM management. Fixed dose and sliding scale ordered and is in med book. O2 saturatio on ra 98-100%. CV: Sinus brady to sinus rhythm with no ectopy noted, rate 54-80. Compared to the previous tracing of heart rate isslower.TRACING #2 Last FS 120, no coverage needed.Skin: Intact.ID: AfebrileSocial: Family in to visit this shift and updated by this RN.Plan: Continue to monitor Hct. Sinus rhythm, without diagnostic abnormalitty. Encourage regular diet. Q hour FS and titrate insulin gtt per protocol. MICU NURSING PROGRESS NOTE. MICU NURSING PROGRESS NOTE. Denies pain. with a 3 point improvement in Hct at 25.9. Sat's >95% on RA.GI/GU: No BM this shift. +PP.Resp: Lung sounds are clear throughout. changes in speach patterns, usually soft and relaxed with occn rapid speach. is able to provide self care. Taking po's with out difficulty. MICU 7 0700-1900 NPNPlease refer to flowsheet for all objective data.Neuro: A/O x3. SBP 100-114.Respiratory: Lung sounds remain clear throughout. is A/Ox3. Sinus bradycardia. MICU 7 0700-1900 NPNNeuro: Pt. Follow labs and replete lytes if necessary. has been bleeding rectally since. continues to maintain an O2 sat >95% on RA.GI/GU: Pt NPO most of shift. MAP>60. Pt had abdominal CT scan with and without contrast. Denies abd. Speach is clear and is able to make needs known verbally. Pedal pulses easily palpated bilaterally. 1900-0700 PLEASE SEE CAREVIEW FOR OBJECTIVE DATA. Continues to take PO medication with no complications. Please see nursing transfer note for subjective data. His hct was 23.9 down from around 40. 1900-0700. of urine. Transfused with 2 units prbc's for hct of 26.3, down from hct of 29.9 s/p 2 units prbc's on previous shift. Awaiting am lab results. able to perform all self care: Bath, oral care, toileting. His Hct was 23.9 down from 42.3 preprocedure and his bld sugar was 714 and INR 1.3. Respiratory: Lung sounds are clear throughout. 1 mg of Magnesium sulfate given to correct for level of 1.8.Respiratory: Lung sounds are clear throughout. Still no BM this shift. No bm as of this time. Very talkative rambling he is a/o x3cvs vss. He had RLQ pain on exam. Voiding clear yellow urine > than 30cc/hr.Endo: No longer on insulin gtt. His troponin level was .02 He received a total of 3 liters of normal saline IV. Continue to monitor for s/sx of bleeding. Calm and cooperative. FS 63-160 this shift.Skin: IntactSocial: Family in to visit and updated by this RN.Plan: Continue to monitor for s/sx of bleeding. He was given 2 units of rbc and 3 liters of fluid. Pedal pulses are easy to palpate bilaterally. to ambulate without assistance.CV: SB (55-60 HR) most of shift with no signs of ectopy. Fs 259 at midnight, covered per ssri. discomfort. Passing flatus but no stool as of this time. Voiding clear yellow urine in adequate amts, also incont. O2 sat >95% on RA.GI/GU: Voiding on own clear yellow urine greater than 30cc/hr. Full code, called out to floor, awaiting bed. He has taken 2 aleve qd for pain since procedure. He was given 2u prbu and crossed for 8u given total of 24u reg insulin sq, and given 5mg po vit K for INR 1.3. He had been taking around two Aleive for pain q day. Last BM was at 0100 and did have bright red blood. hct after 2u prbc in ed 25.9 skin w+d pp+2 cardiac enzymes pndingresp lungs cta on rm airgi BRBPR with clots 300cc abd soft tender RLQ to palp BS+gu voidingendo BS 446 started insulin gttaccess 16g and 18g peripherala. Endo: Fs every hour, insulin gtt presently at 2 units/hr. Covered with 4 units.Social: Wife, and sister updated by this RN.Plan: Pt is called out to non tele floor. Still waiting for bed. monitor hct q 6 and prn transfuse prn, monitor coags consider gi consult, npo, on insulin gtt titrate prn fs q 1hr, monitor u/o send urine lytes, r/o mi send cardiac enzymes q 8 x3, ekg in am, monitor NA, liver consult, cont lithium ? | 8 | [
{
"category": "Nursing/other",
"chartdate": "2104-10-04 00:00:00.000",
"description": "Report",
"row_id": 1342178,
"text": "62 yo man who had transrectal prostate biopsy 9 days ago and has been having brbpr ever since. Today he came to ED with presyncopy and continued brbpr. His bp 80/'s and HR 100 ST. He has taken 2 aleve qd for pain since procedure. He had RLQ pain on exam. His Hct was 23.9 down from 42.3 preprocedure and his bld sugar was 714 and INR 1.3. He was given 2u prbu and crossed for 8u given total of 24u reg insulin sq, and given 5mg po vit K for INR 1.3. His troponin level was .02 He received a total of 3 liters of normal saline IV. PMH HCV on colchicine week 146 in copilot study, last biopsy , DMII on insulin, parkinson's disease, PTSD, adenomatous rectal polyp and sigmoid diverticulosis, s/p cholecystectomy and rt inguinal hernia repair. He lives with wife and son in a retired veteran, smokes occasionally 1qd no etoh or illicit drugs. Allergies asa. Meds colchicine .6mg , clonazepam 500mcg , lithium 300mg tid, humulin N 100 16 u q am and 10u q pm pt states that he checks his bld sugars, neurontin 300mg tid, lisinopril 5mg qd, sinemet 25/100mg 2 pills tid, rhinocort 2 sprays \nO. Pt arriving via stretcher able to transfer to bed without assistance. NAD. HR 80's nsr occ pvc bp 120/75. Very talkative rambling he is a/o x3\ncvs vss. hct after 2u prbc in ed 25.9 skin w+d pp+2 cardiac enzymes pnding\nresp lungs cta on rm air\ngi BRBPR with clots 300cc abd soft tender RLQ to palp BS+\ngu voiding\nendo BS 446 started insulin gtt\naccess 16g and 18g peripheral\na. brbpr post transrectal biopsy\nhypergylcemia\nARF\nelevated troponin\nhcv\nbipolar dz\nhypnatremia\np. monitor hct q 6 and prn transfuse prn, monitor coags consider gi consult, npo, on insulin gtt titrate prn fs q 1hr, monitor u/o send urine lytes, r/o mi send cardiac enzymes q 8 x3, ekg in am, monitor NA, liver consult, cont lithium ? starting usual dose of klonopin\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-05 00:00:00.000",
"description": "Report",
"row_id": 1342181,
"text": "MICU 7 0700-1900 NPN\n\nPlease refer to flowsheet for all objective data.\n\nNeuro: A/O x3. Pt. able to perform all self care: Bath, oral care, toileting. MAE with purpose. Denies pain. Pt. to ambulate without assistance.\n\nCV: SB (55-60 HR) most of shift with no signs of ectopy. Pedal pulses easily palpated bilaterally. Transfused one unit of platelets, post platelet count pending. Last Hct 35.9. SBP 100-114.\n\nRespiratory: Lung sounds remain clear throughout. Pt. continues to maintain an O2 sat >95% on RA.\n\nGI/GU: Pt NPO most of shift. Pt had abdominal CT scan with and without contrast. Results pending. No BM this shift, + flatulence. Continues to take PO medication with no complications. Voiding clear yellow urine > than 30cc/hr.\n\nEndo: No longer on insulin gtt. Fixed dose and sliding scale ordered and is in med book. Last FS 120, no coverage needed.\n\nSkin: Intact.\n\nID: Afebrile\n\nSocial: Family in to visit this shift and updated by this RN.\n\nPlan: Continue to monitor Hct. Transfuse if appropriate. Encourage regular diet. ?starting bowel regime if no BM overnight. Plan for call out.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-06 00:00:00.000",
"description": "Report",
"row_id": 1342182,
"text": "MICU NURSING PROGRESS NOTE. 1900-0700.\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Please see nursing transfer note for subjective data. At present alert and oriented x 3. Calm and cooperative. Is hemodynamically stable. Labs to be drawn in am. Passing flatus but no stool as of this time. Denies discomfort. need bowel regimen. Fs 259 at midnight, covered per ssri. Full code, called out to floor, awaiting bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-06 00:00:00.000",
"description": "Report",
"row_id": 1342183,
"text": "MICU 7 0700-1900 NPN\n\nNeuro: Pt. is A/O x3. Able to ambulate without assistance. Provides own self-care.\n\nCV: SB-NSR, no ectopy noted. SBP 100-153. MAP>60. +PP.\n\nResp: Lung sounds are clear throughout. O2 sat >95% on RA.\n\nGI/GU: Voiding on own clear yellow urine greater than 30cc/hr. Still no BM this shift. Tolerating PO diet.\n\nSkin: Intact.\n\nEndo: Pt. on sliding scale, last FS 201. Covered with 4 units.\n\nSocial: Wife, and sister updated by this RN.\n\nPlan: Pt is called out to non tele floor. Still waiting for bed. Continue to monitor for s/sx of bleeding. ? Starting bowel regime. Transfer note already started.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-04 00:00:00.000",
"description": "Report",
"row_id": 1342179,
"text": "MICU 7 0700-1900 NPN\n\n62 yo male with hx of hecpatitis C, GI bleed, perirectal abscess, s/p cholecystectomy, bph, post traumatic stress and bipolar dx, colonic polyps, parkinson's disease, hemorroids, perirectal abscess, and glaucoma.\n\nReason for Admit: Prostate biopsy done 9 days ago. Pt. has been bleeding rectally since. He had been taking around two Aleive for pain q day. Today he presented to ED presyncopal and tachycardic. His hct was 23.9 down from around 40. He was given 2 units of rbc and 3 liters of fluid. Received pt. with a 3 point improvement in Hct at 25.9. Team decided to give patient 2 more units of rbc even though patient was not showing any signs of continued bleeding. Post transfusion Hct was 29.9.\n\nNeuro: Pt. is A/Ox3. Able to MAE's with purpose. Turns self in bed. Pt. is able to provide self care. Gag and cough intact.\n\nCV: Pt. continues to be in NSR with no ectopy noted this shift. Pedal pulses are easy to palpate bilaterally. SBP 107-125 and stable. 1 mg of Magnesium sulfate given to correct for level of 1.8.\n\nRespiratory: Lung sounds are clear throughout. Sat's >95% on RA.\n\nGI/GU: No BM this shift. Bowel sounds present. Last BM was at 0100 and did have bright red blood. Pt. voids on his own, greater than 30cc/hr. Pt. is no longer NPO and has orders for regular diet.\n\nEndo: Pt. continues on insulin gtt at 2.5 units per hour. FS 63-160 this shift.\n\nSkin: Intact\n\nSocial: Family in to visit and updated by this RN.\n\nPlan: Continue to monitor for s/sx of bleeding. Monitor Hct and transfuse if appropriate. Follow labs and replete lytes if necessary. Q hour FS and titrate insulin gtt per protocol. Encourage sliding scale for DM management. Plan for d/c to floor.\n\nEndo: Pt\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-05 00:00:00.000",
"description": "Report",
"row_id": 1342180,
"text": "MICU NURSING PROGRESS NOTE. 1900-0700\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Transfused with 2 units prbc's. Guiac +.\n\n Neuro: Alert and oriented x 3. Independent with self care and turning. MAE. Denies discomfort. Speach is clear and is able to make needs known verbally. Noted occn. changes in speach patterns, usually soft and relaxed with occn rapid speach. Temperature max. 98.9 oral.\n\n Respiratory: Lung sounds are clear throughout. RR 12-24 and non labored. O2 saturatio on ra 98-100%.\n\n CV: Sinus brady to sinus rhythm with no ectopy noted, rate 54-80. Nbp mid 90's to low 120's systolic. 2 peripheral iv's intact. Ns kvo infusing lt ac. Transfused with 2 units prbc's for hct of 26.3, down from hct of 29.9 s/p 2 units prbc's on previous shift. Awaiting am lab results.\n\n GI/GU: Abdomen soft with + bs. No bm as of this time. Denies abd. discomfort. Taking po's with out difficulty. Guaic + below. Voiding clear yellow urine in adequate amts, also incont. of urine.\n\n Endo: Fs every hour, insulin gtt presently at 2 units/hr. Last fs was 98.\n\n Integ: Skin grossly intact.\n\n Social: No social contacts this shift.\n\n Plan: Monitor hct and transfuse as required. ? call out if hct stable.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-05 00:00:00.000",
"description": "Report",
"row_id": 291421,
"text": "Sinus bradycardia. Compared to the previous tracing of heart rate is\nslower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-03 00:00:00.000",
"description": "Report",
"row_id": 291422,
"text": "Sinus rhythm, without diagnostic abnormalitty. Compared to the previous tracing\nof no definite change.\nTRACING #1\n\n"
}
] |
25,300 | 118,394 | The patient was admitted to the Trauma Intensive Care Unit. Neurosurgery was consulted. Blood pressure was controlled. Repeat computerized tomography scans were performed. Goal was to keep the INR less than 1.3, keep the blood pressure less than 150, advance the diet and discontinue the patient's groin line. Occupational therapy and physical therapy were consulted. The patient was transferred to the floor on and the patient was doing well, had normal vital signs and was walking. Good strength was noted in all examined areas, and it was decided the patient could be discharged home with physical therapy and occupational therapy. On , it was decided the patient made discharge criteria and was discharged with sliding scale insulin, Metoprolol tartrate, thiamine and Keflex. The patient is to follow up in two weeks with Dr. with a head CT and to have a Flexion extension filmsof cervical spine or to have his neck cleared clinically. , M.D. Dictated By: MEDQUIST36 D: 10:52 T: 15:02 JOB#: | CHEST, TWO VIEWS: There is borderline cardiomegaly, with slight unfolding of the aorta. ON LOPRESSOR AN DHYDRALIZIN PRNSEE CHART FOR BPDIET : ON CLEAR LIQ. extubated @, ng tube d/c d.lungs clear/ dim. Nonionic contrast was used for the CTA technique performed. Allowing for lung volumes, the cardiomediastinal silhouette is within normal limits. The heart appears mildly enlarged, and the pericardium is within normal limits. Visuzlied vertebral body and disc heights are preserved. TECHNIQUE: CT of the head is performed without IV contrast. FINDINGS: Single AP view of the chest on a trauma board is obtained. Alignment in the coronally reformatted images is within normal limits. FINDINGS: Upper thoracic vertebral bodies and posterior elements are onscured onthe lateral view, due to overlying structures. TECHNIQUE: Axial non-contrast head CT CT HEAD WITHOUT CONTRAST: The tiny, punctate foci of hemorrhage within both frontal lobes near the vertex are essentially unchanged. MD IS AWARESOCIAL : ? R. RADIAL A-LINE WAS PUT IN -INTACT. There is atelectasis in the right cardiophrenic angle. NO SIGNS OF ALCOHOL WITHDROAL YET.CV- ON NICADEPINE GTT STILL 0.8MCG, SBP IN 130-160 RANGE, NSRLABS IMR 1.3 -MD IS AWARE. IMPRESSION: Essentially unchanged appearance of tiny, punctate hemorrhages within the bilateral frontal lobes. The visualized paranasal sinuses and the mastoid air cells are aerated. The large bowel, bladder, and visualized portions of the ureters are within normal limits. There has been interval opacification of the ethmoid air cells. NSG NOTEROS: CV:NIPRIDE TO MAINTAIN SYS BP<140.AFTER PROPOFOL INCREASED TO BETTER SEDATE PT FOR CT/XRAYS,NIPRIDE ABLE TO BE WEANED OFF.WILL USE NICARPIDINE QTT IF BP CONTROL NEEDED.T MAX 100.3.REMAINS IN NSR WITHOUT ECTOPI. There is mild asymmetry of the L5 transverse processes, with the right one extending more superiorly within the contralateral side. @2 AM FOLLOWS SIMPLE COMMANDS, NODS TO QUESTIONS, MAE, PERL.CT HEAD REVEALED FRONTAL LOBE CONTUSION, SPINE IS NOT CLEARED YET. The liver, pancreas, adrenal glands, kidneys, stomach, and abdominal bowel are within normal limits. TRAUMA ICU NURSING PROGRESS NOTEREVIEW OF SYSTEMS:NEURO: SEDATED ON PROPOFOL...WAKES EASILY. The ventricles, cisterns, and sulci are within normal limits. CT OF THE ABDOMEN WITH CONTRAST: There is a heterogeneous and patchy enhancement pattern of the spleen. Single portable AP view of the pelvis on a trauma board is obtained. The hemorrhage within the left frontal lobe near the falx at the level of the centrum semiovale is also not significantly changed in appearance. A tiny amount of blood is seen within the interpeduncular fossa which indicates a subarachnoid blood component. There are calcifications of the coronary arteries. Abnormal appearance of the right 6th thoracic rib posteriorly does not have an acute post traumatic appearance, and likely represents chronic change. FINAL REPORT INDICATION: Status post MVC, unrestrained. Heterogeneous enhancement of the spleen is consistent with splenic contusion. (Over) 8:53 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: trauma Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Multiplanar reformatted images were obtained. CT OF THE PELVIS WITH CONTRAST: A Foley catheter is present. GOOD UO.GI: OGT WITH BILIOUS OUT.HEME: REPEAT HCT AND COAGS PENDING...ONE FFP GIVEN FOR INR 1.8ENDO: BS UP TO 212....NEEDS INCREASE IN SLIDING SCALE, OR DRIP.ID: AFEBRILE.SKIN: HEAD BRUISING/LACERATION.SOCIAL: OTHER SISTER/ IN LAW AT BESIDE.A: HIGH BP.P: CONTROL BP. Abnormalities of the right T6 rib do not appear acutely post traumatic, and likely represents old change. TECHNIQUE: CT of the cervical spine is performed without IV contrast. SEDATED IN )W/D TO DEEP PAIN.PUPILS WERE PINPOINT NON REACTIVE.GRADUALY WAS WAKING UP.PUT ON PROPOFOL GTT. There is fluid within the dependent nasopharynx. There are marked calcifications of the carotid arteries at the bifurcation. The alignment of the lumbar vertebral bodies is normal, and there is normal intervertebral disk height. Resp Care Note:Pt cont sedated intub on mech vent as per Carevue. There are clips adjacent to the right hilum. CERVICAL STILL ON. IMPRESSION: Unremarkable trauma series. RES: KEEPS SO2> 98 ON 2LNC, DENIES SOB OR CHEST PAIN, LS WITH OCCATIONAL RHONCHI, PRODUCTIVE COUGHNEURO- NO DEFICIT GROSSLY INTACT,MAE. BP LABILE...NICARDIPINE DRIP AND PRN HYDRALAZINE GIVEN..WITH NO IMPROVEMENT. Reformatted images show disc space narrowing at the C5-C6 level, with mild retrolisthesis of C5 on C6. However, this may be sometimes be seen during early phases of contrast enhancement in a normal spleen. There are calcifications of the seminal vesicles. C COLLAR INTACT.CV: HR STABLE. IMPRESSION: Postoperative changes, for which clinical correlation is requested. IMPRESSION: Two foci of parenchymal hemorrhage within the frontal lobes, in the region of -white matter interfaces, are consistent with axonal shear injury. SHARP WAVE.LAB: INR WAS 1.4, PLT 70. ....PROPOFOL UP IN MEANTIME.RESP: AWAITING WEAN TO EXTUBATE WHEN BP UNDER CONTROL.RENAL: LABS WNL. FINDINGS: The patient is intubated, with an NG tube in place as well. round densities in the right upper quadrant consistent with gallstones. WHEN AWAKE OR DISTURBED BP SDOOTS UP TO 200S.IN NSR, NO ECTOPY. IMPRESSION: No evidence of cervical spine fracture; degenerative changes as described above. probably old change of right posterior T6 rib. WEAN AND EXTUBATE. RHONCHI, THICK WHITE SPUTUM.SEE ABG LABSNEURO- WAS UNRESPONSIVE INITIALLY(? An endotracheal tube appears to lie just below the thoracic inlet on the frontal view. WEAN PROPOFOL. REASON.ON ADDMITION INTUBATED #8 22CM, ON A/C FULLY VENTED.KEEPS SO2 100%LS WITH SCATT. | 15 | [
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592405,
"text": "ADMITTING NOTE 1900-0700\n\nCAME FROM ED CAT SCAN @ 2200. MVA UNRESTRAINED DRIVER HIGH ALCOHOL LEVEL, NO DRUGS.Hx FOR HEP. C AND IDDM, SMOKER. WAS POS. LOC @ THE SCEEN OF ACCIDENT. WAS ALERT IN OUTSIDE HOSPITAL ER , TALKING TO THE FAMILY.\nMEDFLIGHTED TO AND WAS INTUBATED DURING THE -?? REASON.\n\nON ADDMITION INTUBATED #8 22CM, ON A/C FULLY VENTED.KEEPS SO2 100%\nLS WITH SCATT. RHONCHI, THICK WHITE SPUTUM.SEE ABG LABS\n\nNEURO- WAS UNRESPONSIVE INITIALLY(? SEDATED IN )W/D TO DEEP PAIN.PUPILS WERE PINPOINT NON REACTIVE.GRADUALY WAS WAKING UP.PUT ON PROPOFOL GTT. @2 AM FOLLOWS SIMPLE COMMANDS, NODS TO QUESTIONS, MAE, PERL.CT HEAD REVEALED FRONTAL LOBE CONTUSION, SPINE IS NOT CLEARED YET. IS ON.\n\nCV : ON NIPRIDE TO KEEP SBP<140. WHEN AWAKE OR DISTURBED BP SDOOTS UP TO 200S.IN NSR, NO ECTOPY. R. RADIAL A-LINE WAS PUT IN -INTACT. SHARP WAVE.\n\nLAB: INR WAS 1.4, PLT 70. WAS GIVEN PLT 6 UNITS AND UNIT OF FFP.\nLAB REPEATED @ 3AM(SEE FLOW SHEET)\n\nSKIN : MOSTLY INTACT, SMALL CUT(HEALED)ON R. TEMPORAL SCALP AND SOME SCALP ABRASIONS-OPEN TO AIR\n\nSOCIAL: GIRLFRIEND HAS VISITED AND STAYING IN FAMILY ROOM\n\nCONT. TO MONITOR NEURO,BP AND LABS\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592406,
"text": "Resp Care Note:\n\nPt cont sedated intub on mech vent as per Carevue. Lung sounds sl coarse suct sm th white sput. Able to wean FIO2. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592411,
"text": "extubated @, ng tube d/c d.lungs clear/ dim. @bases. maintains so2>98, good productive cough.denies chest pain or SOB.\n\nNEURO- EASILY REORIENTED, ALERT, COOPERATIVE. MAE, PERL 3MM, NO NEURO DEFICIT. CERVICAL STILL ON. NO SIGNS OF ALCOHOL WITHDROAL YET.\n\nCV- ON NICADEPINE GTT STILL 0.8MCG, SBP IN 130-160 RANGE, NSR\n\nLABS IMR 1.3 -MD IS AWARE. WILL REPEAT IN AM . PLT COUNT DOWN TO 80S - WILL RECEIVE 6 UNITS\n\nFAMILY VISITED AND AWARE OF EXTUBATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-29 00:00:00.000",
"description": "Report",
"row_id": 1592412,
"text": "RES: KEEPS SO2> 98 ON 2LNC, DENIES SOB OR CHEST PAIN, LS WITH OCCATIONAL RHONCHI, PRODUCTIVE COUGH\n\nNEURO- NO DEFICIT GROSSLY INTACT,MAE. PERL=3MM, FORGETFUL, DISORIENTED, WEAK. STILL ON.MOVES FREELY IN BED.\n\nID: TEMP UP TO 101.6, CULTURED BLOOD+URINE, NO ANTIBIOTICS GIVEN, WITH TYLENOL TEMP DOWN TO 100\n\nLABS- WAS GIVEN PLT LAST NIGHT, REPEATED COUNT WAS 133 TWICE. MD IS AWARE\n\nSOCIAL : ? RISK OF DT/ETOH WITHDROAL.ON ATIVAN PRN.\n\nCV: NICARDIPIN GTT IS FF @ 430 AM. ON LOPRESSOR AN DHYDRALIZIN PRN\nSEE CHART FOR BP\n\nDIET : ON CLEAR LIQ. DIET-TOLERATES WATER WELL, NO NAUSEA REPORTED\n\nENDO: ON RI GTT STARTED FOR BS >300.,CURRENTLY ON 5U\n\nCONT. TO MONITOR TEMP, NEURO, CV, SUGER\n\nPLAN :TO CLEAR SPINE, STABILIZE GLUCOSE, REDUCE FEVER AND TRANSFFER\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592407,
"text": "PROPOFOL IS OFF, PT NODS, FOLLOWS COMMANDS, NIPRIDE UP TO 2MCG TO CONTROL BP.NG TUBE -200CC OUT,NO BLEEDING NOTED\nPLAN- TO EXTUBATE\nPT'S GIRLFRIEND TOOK ALL VALUBLES HOME\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592408,
"text": "SOCIAL WORK\nSW met with pts girlfriend, at bedside to introduce role of sw and for supportive intervention. was in the vehicle with pt at the time of the accident but believes she was not injured as she was restrained. Pt and gfriend have been together for 17 years and are planning on marrying. Pts sister is also present at hospital. Pts mother and pts son, who lives in , are not yet aware of pts condition. All family members are in good relations and have agreed to wait until later today to inform mother and son.\n\nPt is on disability for diabetes and has had ICU hospitalizations in the past. Pt lost a son to an overdose two years ago. states that they have faced many significant crisis together in the past, but that this time \"feels different\" because the exact prognosis is not yet known. reports that she is close with pts whole family, and that he own son is very supportive and concerned. Gfriend was tearful at times during interview but appears to be coping very well under extreme stress. She also shows a good grasp of medical information. SW will continue to follow. Pls pg prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592409,
"text": "NSG NOTE\nROS:\n\n CV:NIPRIDE TO MAINTAIN SYS BP<140.AFTER PROPOFOL INCREASED TO BETTER SEDATE PT FOR CT/XRAYS,NIPRIDE ABLE TO BE WEANED OFF.WILL USE NICARPIDINE QTT IF BP CONTROL NEEDED.T MAX 100.3.REMAINS IN NSR WITHOUT ECTOPI.\n\n RESP:PT ON CPAP WHEN SHIFT STARTED.AGITATED WITH RR 30'S SO PT HEAVILY SEDATED WITH PROPOFOL AND PUT ON CMV UNTIL HEAD CT AND TLS FILMS DONE AND READ.ONCE TLS CLEARED,WILL WEAN AND EXTUBATE PT.\n\n NEURO:APEARED AWARE BEFORE SEDATION INCREASED.NODDED APPROPIATELY AND FOLLOW COMMANDS.PUPILS =&+.\n\n GU:ADEQUATE UO.\n\n GI:NPO,ON IVF,OGT DRNG LARGE AMT GREEN FLD.\n\n SOCIAL:(SIGN OTHER)AND SISTER IN.SHE IS AWARE OF PLANS,RXS,ETC.ALSO SPOKE TO SOCIAL WORKER.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-03-28 00:00:00.000",
"description": "Report",
"row_id": 1592410,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL...WAKES EASILY. FOLLOWS\n COMMANDS...SLIGHTLY AGITATED...BUT BP UP TO 200/\n LOGROLL D/C'D. C COLLAR INTACT.\n\nCV: HR STABLE. BP LABILE...NICARDIPINE DRIP AND\n PRN HYDRALAZINE GIVEN..WITH NO IMPROVEMENT.\n ....PROPOFOL UP IN MEANTIME.\n\nRESP: AWAITING WEAN TO EXTUBATE WHEN BP UNDER CONTROL.\n\nRENAL: LABS WNL. GOOD UO.\n\nGI: OGT WITH BILIOUS OUT.\n\nHEME: REPEAT HCT AND COAGS PENDING...ONE FFP GIVEN\n FOR INR 1.8\n\nENDO: BS UP TO 212....NEEDS INCREASE IN SLIDING SCALE,\n OR DRIP.\n\nID: AFEBRILE.\n\nSKIN: HEAD BRUISING/LACERATION.\n\nSOCIAL: OTHER SISTER/ IN LAW AT BESIDE.\n\nA: HIGH BP.\nP: CONTROL BP. WEAN PROPOFOL. WEAN AND EXTUBATE.\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 817520,
"text": " 10:59 AM\n CHEST (PA & LAT) Clip # \n Reason: fever, course BS\n Admitting Diagnosis: HEAD TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n fever, course BS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever, coarse bronchial sounds.\n\n CHEST, TWO VIEWS:\n\n There is borderline cardiomegaly, with slight unfolding of the aorta. There\n are clips adjacent to the right hilum. There is atelectasis in the right\n cardiophrenic angle. No CHF, frank consolidation or effusion is identified.\n Subsegmental atelectasis is present at the left base.\n\n The patient is status post resection of a portion of the right sixth rib.\n\n IMPRESSION: Postoperative changes, for which clinical correlation is\n requested. Borderline cardiomegaly. No acute infiltrate identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-27 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 817039,
"text": " 8:46 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unrestrained in MVC.\n\n TECHNIQUE: Trauma series.\n\n FINDINGS:\n\n Single AP view of the chest on a trauma board is obtained. The endotracheal\n tube is present, 4 cm above the carina. An nasogastric tube courses beyond\n the inferior confines of this film at least to the stomach. Also the study is\n limited by the trauma board and overlying hardware. Allowing for lung\n volumes, the cardiomediastinal silhouette is within normal limits. No focal\n pulmonary opacities are seen. There is no evidence of pneumothorax. No\n fractures are identified.\n\n Single portable AP view of the pelvis on a trauma board is obtained. The\n hips are rotated inwards, but no overt fracture is seen. No pelvic\n abnormalities are seen. There is stool within the rectum.\n\n IMPRESSION: Unremarkable trauma series. ETT is 4 cm above the carina.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 817095,
"text": " 11:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Neurosurgery requests for eval for change since prior\n Admitting Diagnosis: HEAD TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with head trauma and contusions b/l\n REASON FOR THIS EXAMINATION:\n Neurosurgery requests for eval for change since prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Head trauma.\n\n COMPARISON: .\n\n TECHNIQUE: Axial non-contrast head CT\n\n CT HEAD WITHOUT CONTRAST: The tiny, punctate foci of hemorrhage within\n both frontal lobes near the vertex are essentially unchanged. It is unclear\n whether this is intraparenchymal blood or subarachnoid blood overlying the\n parenchyma at these points. The hemorrhage within the left frontal lobe near\n the falx at the level of the centrum semiovale is also not significantly\n changed in appearance. A tiny amount of blood is seen within the\n interpeduncular fossa which indicates a subarachnoid blood component. There\n also may be a small amount of blood within the occipital of the left\n lateral ventricle. There is no evidence of hydrocephalus, shift of normally\n mid-line structures or space occupying mass lesions. The white matter\n differentiation appears intact throughout.\n\n The extraaxial space overlying the left frontal lobe appears slightly wider\n when compared to the previous study. This increase in the extra-axial space\n may indicate a tear of the arachnoid with a subdural collection.\n\n There has been interval opacification of the ethmoid air cells. There has\n also been interval bilateral maxillary mucosal thickening.\n\n IMPRESSION: Essentially unchanged appearance of tiny, punctate hemorrhages\n within the bilateral frontal lobes. These may indicate findings of diffuse\n axonal injury; however, these hemorrhages may be overlying the parenchyma at\n these areas and within the subarachnoid space. Blood is also seen within the\n intrapeduncular fossa and left lateral ventricle indicating subarachnoid\n hemmorhage.\n After the patient is extubated, a careful neurologic exam should be obtained.\n If there is still concerns of diffuse axonal injury at that time, an MRI\n should be obtained. These findings were discussed with Dr. in the ICU\n at the time of the study.\n (Over)\n\n 11:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Neurosurgery requests for eval for change since prior\n Admitting Diagnosis: HEAD TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 817041,
"text": " 8:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JLLW TUE 11:57 PM\n axonal shear injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC, unrestrained.\n\n TECHNIQUE: CT of the head is performed without IV contrast. No comparisons\n are available.\n\n FINDINGS: There is a 6 mm focus of left frontal hemorrhage adjacent to the\n falx cerebri on the left, and probably in the subarachnoid space. There is a\n 4 mm focus of hemorrhage at the vertex in, or adjacent to, the right frontal\n lobe as well. The ventricles, cisterns, and sulci are within normal limits.\n There is preservation of - white matter differentiation.\n\n The visualized paranasal sinuses and the mastoid air cells are aerated. There\n is fluid within the dependent nasopharynx. No fractures are identified.\n\n IMPRESSION: Two foci of parenchymal hemorrhage within the frontal lobes, in\n the region of -white matter interfaces, are consistent with axonal shear\n injury.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-28 00:00:00.000",
"description": "T-SPINE",
"row_id": 817091,
"text": " 11:38 AM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: trauma\n Admitting Diagnosis: HEAD TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with MVA\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle collision.\n\n FINDINGS:\n\n Upper thoracic vertebral bodies and posterior elements are onscured\n onthe lateral view, due to overlying structures. Visuzlied vertebral body and\n disc heights are preserved. No fracture or listhesis is identified. An\n endotracheal tube appears to lie just below the thoracic inlet on the frontal\n view. There is an NG tube lying in the stomach.\n\n There is mild asymmetry of the L5 transverse processes, with the right one\n extending more superiorly within the contralateral side. No fracture is\n identified. The alignment of the lumbar vertebral bodies is normal, and there\n is normal intervertebral disk height. round densities in the right upper\n quadrant consistent with gallstones.\n\n IMPRESSION: No fracture or dislocation detected. See comment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 817042,
"text": " 8:51 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JLLW WED 12:07 AM\n no fx; changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC, unrestrained.\n\n TECHNIQUE: CT of the cervical spine is performed without IV contrast.\n Additionally, multiplanar reformatted images were obtained.\n\n FINDINGS: The patient is intubated, with an NG tube in place as well.\n\n There is no evidence of fracture involving the cervical spine. Reformatted\n images show disc space narrowing at the C5-C6 level, with mild retrolisthesis\n of C5 on C6. There are anterior syndesmophytes at the C3-4, C4-5, and C5-6\n levels. A small amount of posterior spurring is also present at the C5-6\n level. Alignment in the coronally reformatted images is within normal limits.\n\n There are marked calcifications of the carotid arteries at the bifurcation.\n There are multiple blebs present at the right lung apex.\n\n IMPRESSION: No evidence of cervical spine fracture; degenerative changes as\n described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-27 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 817043,
"text": " 8:53 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JLLW WED 12:35 AM\n splenic contusion. probably old change of right posterior T6 rib.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC, unrestrained.\n\n TECHNIQUE: CT of the chest, abdomen, and pelvis is performed using trauma\n protocol. 150 cc of Optiray nonionic contrast was given. Nonionic contrast\n was used for the CTA technique performed.\n\n COMPARISONS: None.\n\n FINDINGS:\n\n CTA AORTA: Examination of the aorta and pulmonary artery demonstrates no\n evidence of vascular injury.\n\n CT OF THE CHEST WITH CONTRAST: There are several blebs at the right lung\n apex. There are dependent atelectatic changes. There is no evidence of\n pneumothorax or pneumonia. There is no axillary, mediastinal, or hilar\n lymphadenopathy. The heart appears mildly enlarged, and the pericardium is\n within normal limits.\n\n CT OF THE ABDOMEN WITH CONTRAST: There is a heterogeneous and patchy\n enhancement pattern of the spleen. No frank hematoma or hemorrhage is seen.\n The liver, pancreas, adrenal glands, kidneys, stomach, and abdominal bowel are\n within normal limits. Several dependent 5 mm gallstones are present within\n the gallbladder. There is no pericholecystic fluid or overt wall thickening.\n There is no significant abdominal lymphadenopathy or free fluid.\n\n CT OF THE PELVIS WITH CONTRAST: A Foley catheter is present. The large\n bowel, bladder, and visualized portions of the ureters are within normal\n limits. There is no pelvic lymphadenopathy or free fluid. There are\n calcifications of the seminal vesicles.\n\n Examination of bone windows show marked vascular calcifications involving the\n infrarenal aorta, as well as the aorta at the takeoffs of the celiac axis and\n SMA. There are calcifications of the coronary arteries. Abnormalities of the\n right T6 rib do not appear acutely post traumatic, and likely represents old\n change.\n\n (Over)\n\n 8:53 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiplanar reformatted images were obtained. These support the findings as\n described above.\n\n IMPRESSION:\n 1. Heterogeneous enhancement of the spleen is consistent with splenic\n contusion. However, this may be sometimes be seen during early phases of\n contrast enhancement in a normal spleen. Followup study is suggested to\n confirm this finding.\n 2. Abnormal appearance of the right 6th thoracic rib posteriorly does not have\n an acute post traumatic appearance, and likely represents chronic change.\n 3. No evidence of vascular injury.\n\n"
}
] |
43,599 | 154,308 | Pt is 56yo M p/w fever, neck pain, s/p OLT for HCV/cirrhosis who had recent ERCP stent re-placement . On admission he was tacyhcardic, hypotensive, and febrile to Tmax 104.0. The patient was admitted to the SICU, where he received over 10L of fluid and was placed on vasopressors for septic shock, and placed on vanco, ceftriax, unasyn, cipro, acyclovir. Blood culture Gram Negative Rods which were speciated as E coli. Antibiotics were narrowed initially to Zosyn and then switched to Ceftriaxone in anticipation of discharge on 2 weeks of antibiotics, to be completed if repeat surveillance blood cultures from remain negative as they are now at discharge. Head and Abdominal CTs were unrevealing for source of headache/abscess. An LP was performed which was negative. He was given a trial of Fiorocet which by patient report has helped greatly in reducing his headache. Patient received Neupogen x 3 over the course of the hospitalization, in addition his cellcept was initially held and then restarted at a lower dose of 250 . The WBC responded slightly. Prograf dose was titrated up and repeat outpatient labs will be obtained on to evaluate these changes. He was also having complaints of back pain for which Ortho spine was consulted. An MRI did not reveal any acute processes. It was recommended that patient be discharged with plans for outpatient PT. By time of discharge he was afebrile, ambulating and tolerating regular diet. PICC line is in place for antibiotics, home therapy is arranged. | Try to wean neo gtt Pulmonary: Stable on NC Gastrointestinal / Abdomen: D/C NGT Nutrition: NPO Renal: Foley, Adequate UO, Would decrease NS now and potentially switch to maintenanc in PM if tolerating Hematology: Serial Hct, Stable anemia -- monitor. Re-check PLT in PM Endocrine: RISS, Slightly hyperglycemic. Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Patient low grade temp 99.1-99.3 overnight Action: Iv antibiotics continued as ordered. Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Patient low grade temp 99.1-99.3 overnight Action: Iv antibiotics continued as ordered. Immunosuppressive agents have been held and nupogen has been ordered. On Zosyn, cipro, vanc (check levels) empirically, valgancyclovir and fluconazole Lines / Tubes / Drains: Foley Wounds: Imaging: CXR today Fluids: NS, Decrease to 100 cc/h now and potentially change to maintenance in PM Consults: Transplant Billing Diagnosis: Sepsis ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: 18 Gauge - 09:32 AM Arterial Line - 01:14 PM Multi Lumen - 05:22 PM Prophylaxis: DVT: Boots, SQ UF Heparin (Hold SQ heparin for now as thrombocytopenic) Stress ulcer: PPI VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Disposition: ICU Total time spent: 33 minutes Patient is critically ill IV sodium bicarb completed as per orders, oral contrast given via NG tube. IV sodium bicarb completed as per orders, oral contrast given via NG tube. Acute Pain Assessment: Pt continues to c/o pain of 7 to 8 in head, back and neck pain team aware, Action: Dilaudid ivp and floricet po given Response: No untoward effects noted, pt stating that pain level decreased to mild in back area with HA zero after dosing of Dilaudid at 1030am, at 1400 pt again c/o pain 7 range in head, back and neck, Dilaudid given ivp Plan: Cont to monitor pain, medicate prn. Patient has been weaned off of NEO infusion this morning. On presentation to , fever 95, HR 140, BP 98/53 and given 1.5L IVF thus far. On presentation to , fever 95, HR 140, BP 98/53 and given 1.5L IVF thus far. On presentation to , fever 95, HR 140, BP 98/53 and given 1.5L IVF thus far. The previously described inappropriately directed left sided subclavian line persists in unchanged position. The aortic arch is tortuous but unchanged in appearance. A new right subclavian approach central venous line is now identified seen to terminate overlying the SVC some 2 cm below the level of the carina. IMPRESSION: AP chest compared to through 4:53 p.m.: Left subclavian line has been removed. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. CT PELVIS WITH CONTRAST: The rectum, sigmoid, large bowel, prostate, seminal vesicles, distal ureters, bladder are normal. SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is normal. FINDINGS: There is a right-sided central venous catheter whose tip terminates in the upper SVC. Sepsis without organ dysfunction Assessment: Patient afebrile this shift. would like water soluble contrast PO No contraindications for IV contrast WET READ: RSRc FRI 4:09 AM Right small pleural effusion and atelectasis. T6-7 rt paracentral protrusion indents cord, T11-12 left paracentral protrusion deforms cord. There are no pleural effusions; however, the left costophrenic sulcus is excluded from this radiograph. Small amount of fluid in right paracolic gutter without more focal fluid collection or abscess. There is unchanged appearance to bibasilar atelectasis. There is likely minimal basilar atelectasis bilaterally. FINAL REPORT Status post right subclavian central venous line placement. Study is limited for detection of abscess secondary to lack of intravenous gadolinium contrast. There is an area of T1 hyperintensity at the superior endplate of the L4 vertebral body that likely represents a benign bone island. Indwelling foley and mild perinephric stranding but per report urine sample normal. Right atrial abnormality. Mild bilateral tiny pleural effusions. Small central protrusion at L5- S1. TECHNIQUE: MDCT of the abdomen and pelvis after the uneventful intravenous administration of 130 ml Optiray contrast displayed in 5-mm axial collimation with multiplanar reformations. Compared to the previous tracing of right atrialabnormality is now manifest. There is mild prominence of the sulci and ventricles most likely due to age-appropriate atrophy. There is overall better lung aeration with no pleural effusion or focal consolidation. No intra-abdominal pathology. FINDINGS: The alignment of the thoracic and lumbosacral spines are normal. Right subclavian line can be traced as far as the superior cavoatrial junction but the tip is indistinct. Right-sided central venous catheter with tip in upper SVC. There are mild tiny bilateral pleural effusions. IMPRESSION: No acute cardiopulmonary process. CT ABDOMEN WITH CONTRAST: There are small bilateral pleural effusions (right greater than left), with associated atelectasis. Small bilateral pleural effusions. On the present study, a left subclavian approach central venous line has been placed. No pneumothorax or appreciable pleural effusion. The cardiac silhouette is top normal in size and unchanged. No bulging of the optic discs are noted. Non-diagnostic repolarizationabnormalities. Heart size top normal. Mild atelectatic changes at the bases. The transplant liver appears normal. | 30 | [
{
"category": "Nursing",
"chartdate": "2137-11-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543589,
"text": "CC: fever, neck pain\n HPI: 56yo M s/p liver transplant ~2 months ago was in USGH until\n awoke ~2am this morning with fever and neck pain. Oral temp 104,\n + rigors, with malaise. Also reports frontal headache, as well\n as non-bilious emesis once without much nausea. Denies visual\n scotoma or light sensitivity. On presentation to , fever\n 95, HR 140, BP 98/53 and given 1.5L IVF thus far. Of note,\n underwent ERCP one week ago with finding of persistent CBD\n stricture and thus a stent replacement was performed.\n ROS: Wife reports mild viral illness over past week. Denies\n lightheadedness. Tolerating diet well recently, no diarrhea,\n mild constipation. Mild r-sided abdominal pain radiating to\n back, which is not new since post-op. Denies CP, SOB, dysuria.\n + thirsty. No rashes.\n Sepsis without organ dysfunction\n Assessment:\n Patient arrived to SICU, hypotensive (80\ns/40\ns), febrile (103.5\n orally, rectal 104), tachycardic and is complaining of general\n malaise. Patient is complaining of headache, a stiff sore neck, and\n back pain. Abdomen is soft and mildly tender.\n Action:\n Patient placed on cooling blanket, and a rectal probe was placed to\n trend core temperature, placed on phenelyephrine infusion after\n receiving 1.5 liter bolus of crystalloid. Placed on maintenance fluid\n at 200cc/hr.\n Response:\n Patient has been able to maintain a MAP greater than 60 with the\n support of pressors and IV fluid. Core temperature has trended down\n from 104 C to 101.5 throughout the day. Blood cultures returned gram\n negative rods in blood. WBC\ns found in patient\ns CSF from LP in ED.\n Plan:\n Continue to monitor temperature hourly and treat appropriately with\n cooling blanket. Continue to trend patient\ns blood pressure and treat\n with fluid and pressors as necessary. Continue to treat with IV\n antibiotics and immunosuppressive agents as ordered.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient arrived to the SICU with an oral temperature of 103.5.\n Action:\n Placed a rectal temperature probe in patient to trend a core\n temperature and placed patient on a cooling blanket.\n Response:\n Patient\ns temperature has trended down to 101.5 throughout the day.\n Plan:\n Continue to monitor and treat temperature appropriately.\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543558,
"text": "CC: fever, neck pain\n HPI: 56yo M s/p liver transplant ~2 months ago was in USGH until\n awoke ~2am this morning with fever and neck pain. Oral temp 104,\n + rigors, with malaise. Also reports frontal headache, as well\n as non-bilious emesis once without much nausea. Denies visual\n scotoma or light sensitivity. On presentation to , fever\n 95, HR 140, BP 98/53 and given 1.5L IVF thus far. Of note,\n underwent ERCP one week ago with finding of persistent CBD\n stricture and thus a stent replacement was performed.\n ROS: Wife reports mild viral illness over past week. Denies\n lightheadedness. Tolerating diet well recently, no diarrhea,\n mild constipation. Mild r-sided abdominal pain radiating to\n back, which is not new since post-op. Denies CP, SOB, dysuria.\n + thirsty. No rashes.\n Sepsis without organ dysfunction\n Assessment:\n Patient arrived to SICU, hypotensive (80\ns/40\ns), febrile (103.5\n orally), tachycardic and is complaining of general malaise. Patient is\n complaining of headache, a stiff sore neck, and back pain. Abdomen is\n soft and mildly tender.\n Action:\n Patient placed on cooling blanket, and a rectal probe was placed to\n trend core temperature, placed on phenelyephrine infusion after\n receiving 1.5 liter bolus of crystalloid. Placed on maintenance fluid\n at 200cc/hr.\n Response:\n Patient has been able to maintain a MAP greater than 60 with the\n support of pressors and IV fluid. Core temperature has trended down\n from 104 C to 101.5 throughout the day.\n Plan:\n Continue to monitor temperature hourly and treat appropriately with\n cooling blanket. Continue to trend patient\ns blood pressure and treat\n with fluid and pressors as necessary. Continue to treat with IV\n antibiotics and immunosuppressive agents as ordered.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient arrived to the SICU with an oral temperature of 103.5.\n Action:\n Placed a rectal temperature probe in patient to trend a core\n temperature and placed patient on a cooling blanket.\n Response:\n Patient\ns temperature has trended down to 101.5 throughout the day.\n Plan:\n Continue to monitor and treat temperature appropriately.\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 543954,
"text": "Acute Pain\n Assessment:\n Pt continues to c/o pain of 7 to 8 in head, back and neck pain team\n aware,\n Action:\n Dilaudid ivp and floricet po given\n Response:\n No untoward effects noted, pt stating that pain level decreased to mild\n in back area with HA zero after dosing of Dilaudid at 1030am, at 1400\n pt again c/o pain 7 range in head, back and neck, Dilaudid given ivp\n Plan:\n Cont to monitor pain, medicate prn.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt afebrile, + e coli bactermia per team, continues on zosyn,\n fluconazole, bactrim\n Action:\n Droplet precautions dc\nd per team, pt maintained on neutropenic\n precautions per team\n Response:\n Pt remains afebrile, no change in antibiotics\n Plan:\n Conintue to monitor temp and wbc, maintain neutropenic precautions\n Sepsis without organ dysfunction\n Assessment:\n Wbc 1.5, afebrile, droplet prec. Dc\nd , vss\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n R/O MENINGITIS\n Code status:\n Height:\n 71 Inch\n Admission weight:\n 103.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Liver Failure\n CV-PMH:\n Additional history: DM, Hepatocellular CA and Hepatitis C. Liver tx.\n .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:142\n D:93\n Temperature:\n 96\n Arterial BP:\n S:111\n D:71\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 830 mL\n 24h total out:\n 1,090 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 05:19 AM\n Potassium:\n 3.6 mEq/L\n 05:19 AM\n Chloride:\n 108 mEq/L\n 05:19 AM\n CO2:\n 30 mEq/L\n 05:19 AM\n BUN:\n 9 mg/dL\n 05:19 AM\n Creatinine:\n 1.0 mg/dL\n 05:19 AM\n Glucose:\n 110 mg/dL\n 05:19 AM\n Hematocrit:\n 24.2 %\n 05:19 AM\n Finger Stick Glucose:\n 168\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Action:\n Cvl dc\nd and foley dc\nd, pt continues on zosyn , fluconazole and\n bactrim,\n Response:\n Pt afebrile, no s and sxs of infection although pt continues to c/o\n pain in head, neck and back.\n Plan:\n Continue to monitor wbc, and temp,\n"
},
{
"category": "Social Work",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 543755,
"text": "Social Work Progress Note, Transplant Service:\n Clinical Data: SW continuing to follow pt who is admitted to SICU for\n r/o meningitis. Pt well known to SW from previous admissions and\n outpt transplant center. He is s/p liver transplantation. Pt presents\n reclined in bed, lightly sleeping. Pt\ns wife and mother also present.\n Pt was alert and oriented. Thought process/content was\n normal/appropriate. Pt\ns wife reported on events leading up to\n admission. Both pt and wife express relieve in recovery over last 24\n hrs. Pt\ns wife noted that pt had been\ndoing so well,\n having returned\n to jogging and increasing other daily activities. She and pt expressed\n an understanding that setbacks do occur post liver transplantation. Pt\n and wife named no outstanding concerns at this time.\n Clinical assessment/plan: Pt and wife appear to be coping well. There\n appears to be no outstanding psychosocial concerns at this time. SW\n will continue to follow throughout hospitalization to provide emotional\n support to pt and family as indicated.\n , LICSW #\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543552,
"text": "CC: fever, neck pain\n HPI: 56yo M s/p liver transplant ~2 months ago was in USGH until\n awoke ~2am this morning with fever and neck pain. Oral temp 104,\n + rigors, with malaise. Also reports frontal headache, as well\n as non-bilious emesis once without much nausea. Denies visual\n scotoma or light sensitivity. On presentation to , fever\n 95, HR 140, BP 98/53 and given 1.5L IVF thus far. Of note,\n underwent ERCP one week ago with finding of persistent CBD\n stricture and thus a stent replacement was performed.\n ROS: Wife reports mild viral illness over past week. Denies\n lightheadedness. Tolerating diet well recently, no diarrhea,\n mild constipation. Mild r-sided abdominal pain radiating to\n back, which is not new since post-op. Denies CP, SOB, dysuria.\n + thirsty. No rashes.\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543611,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient admitted with temp of 104, tachycardia, headache.\n Nausea/vomiting. Overnight patient complained of back pain, mild\n headache. Hr now sinus rhythm, Blood pressure SBP 95-118.\n Action:\n Iv neo to maintain map >60, iv fluids to hydrate patient. Iv\n antibiotics, dilaudid for back pain.\n Response:\n Patient remains in sinus rhythm, Map >60, afibrile.\n Plan:\n To continue to hydrate patient, monitor input/output closely. Continue\n with iv antibiotics per ID team. Administer analgesia for comfort.\n Titrate iv neo to maintain Map >60.\n Tachycardia, Other\n Assessment:\n Patient remained in a sinus rhythm overnight, no ectopy noted\n Action:\n Will continue to monitor patient and treat accordingly\n Response:\n Remained in sinus rhythm\n Plan:\n Will continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient low grade temp 99.1-99.3 overnight\n Action:\n Iv antibiotics continued as ordered. Patient also had ctscan of\n /pelvis\n Response:\n Remained afibrile\n Plan:\n Will continue to monitor temp, with rectal temp probe, labs monitored\n and reported to MD\ns. Await report of ctscan.\n IV sodium bicarb completed as per orders, oral contrast given via NG\n tube. After ctscan of /pelvis Ng tube placed to low con suction,\n drained @450cc bilious, no complaints of nausea. Patient remains npo,\n oral hygiene maintained. IV magnesium and calcium replaced as per\n sliding scale.\n"
},
{
"category": "Nutrition",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 543751,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 56yo M p/w fever, neck pain, s/p OLT . recent ERCP stent\n re-placement . Pt now extubated, alert and oriented. Diet\n remains NPO. If pt unable to take po\ns in the next 2-3 days, consider\n start of nutrition support to prevent nutritional decline.\n Please page with ?\ns \n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543781,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient has been afebrile this shift. Temperature has been 97-98\n Orally. Patient\ns MAP has been between 65-75 today, urine output has\n been between 150-400 per hour today. Patient has been complaining of\n headache today. WBC count this afternoon was 1.6\n Action:\n IV maintenance fluid has been discontinued and NEO has been weaned this\n morning, which remains off. Patient has a regular diet ordered.\n Continues to receive Dilaudid IV and Tylenol and caffeine for headache\n as well. Immunosuppressive agents have been held and nupogen has been\n ordered.\n Response:\n Patient reports having a less severe headache this evening. Blood\n pressure has been stable with a MAP greater than 65 throughout the\n shift. Urine output remains adequate (100-200 cc\ns per hour) this\n afternoon.\n Plan:\n Continue to monitor patient\ns labs, and will hold immunosuppressive\n agents as ordered. Nupogen will be given as ordered. Will continue to\n treat headache with pain meds as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 543685,
"text": "SICU\n HPI:\n 56yo M p/w fever, neck pain, s/p OLT . recent ERCP stent\n re-placement .\n Chief complaint:\n Fever, headache\n PMHx:\n HCV s/p OLT c/b bile leak s/p ERCP stent, HCC s/p cyberknife\n , HTN, DM diet-controlled\n : FK 2.5/2.5, Prednisone 5', MMF 1000'', valcyte 900', fluconazole\n 400', bactrim ss', protonix 40', cardura 2', celexa 20', oxycodone prn,\n colace 100'', lasix 20', NPH 22u'am, HISS\n Current medications:\n 1000 mL NS 3. Acetylcysteine 20% 4. Calcium Gluconate 5. CeftriaXONE 6.\n Citalopram Hydrobromide\n 7. Ciprofloxacin 8. Filgrastim 9. Fluconazole 10. HYDROmorphone\n (Dilaudid) 11. Heparin 12. Influenza Virus Vaccine\n 13. Insulin 14. Lidocaine 2% 15. Magnesium Sulfate 16. MetRONIDAZOLE\n (FLagyl) 17. Pantoprazole 18. Phenylephrine\n 19. Piperacillin-Tazobactam Na 20. PredniSONE 21. Sodium Chloride 0.9%\n Flush 22. Sulfameth/Trimethoprim SS\n 23. Tacrolimus 24. Vancomycin 25. ValGANCIclovir\n 24 Hour Events:\n MULTI LUMEN - START 01:14 PM\n ARTERIAL LINE - START 01:14 PM\n MULTI LUMEN - START 03:57 PM\n MULTI LUMEN - STOP 03:58 PM\n MULTI LUMEN - STOP 05:16 PM\n MULTI LUMEN - START 05:22 PM\n FEVER - 104.0\nC - 11:00 AM\n Post operative day:\n : L subclavian line inserted, CXR showed line in L IJ vein; R\n subclavian line inserted, CXR confirmed placement, L subclavian line\n pulled out; NG tube inserted, pt given zofran for nausea; BCx grew out\n GNR, CT abd to r/o abdominal process (mucomyst/bicarb)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 12:21 AM\n Metronidazole - 01:00 AM\n Ceftriaxone - 05:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:14 AM\n Vancomycin - 07:27 AM\n Ciprofloxacin - 07:28 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:55 PM\n Hydromorphone (Dilaudid) - 03:18 AM\n Other medications:\n Flowsheet Data as of 08:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 97.1\nC (206.8\n T current: 97.1\nC (206.8\n HR: 71 (66 - 123) bpm\n BP: 118/64(85) {97/53(69) - 119/67(88)} mmHg\n RR: 22 (12 - 43) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (-4 - 18) mmHg\n Total In:\n 12,495 mL\n 2,741 mL\n PO:\n 1,000 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n 6,495 mL\n 2,541 mL\n Blood products:\n Total out:\n 2,933 mL\n 4,675 mL\n Urine:\n 2,683 mL\n 4,025 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n 9,562 mL\n -1,934 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.40/44/104/29/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Peritoneal sign\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 63 K/uL\n 10.0 g/dL\n 150 mg/dL\n 1.2 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 15 mg/dL\n 108 mEq/L\n 141 mEq/L\n 27.1 %\n 3.6 K/uL\n [image002.jpg]\n 02:06 PM\n 06:02 PM\n 07:31 PM\n 07:58 PM\n 04:03 AM\n 05:02 AM\n 05:25 AM\n WBC\n 4.8\n 6.6\n 3.6\n Hct\n 30.6\n 32\n 28.5\n 27.1\n Plt\n 105\n 102\n 63\n Creatinine\n 1.4\n 1.3\n 1.2\n Troponin T\n 0.01\n TCO2\n 24\n 31\n 28\n Glucose\n 118\n 152\n 150\n Other labs: CK / CK-MB / Troponin T:82//0.01, ALT / AST:33/47, Alk-Phos\n / T bili:75/0.4, Lactic Acid:1.1 mmol/L, Albumin:3.1 g/dL, Ca:7.7\n mg/dL, Mg:2.7 mg/dL, PO4:2.6 mg/dL\n Imaging: CT head w/o contrast (): No evidence of acute\n intracranial hemorrhage, mass effect, or increased intracranial\n pressure.\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER\n Assessment and Plan: 56yo M p/w fever, neck pain, s/p OLT .\n recent ERCP stent re-placement .\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain controlled with\n dilaudid prn.\n Cardiovascular: Hypotensive overnight, but improving. Sepsis\n physiology. BP improving. Try to wean neo gtt\n Pulmonary: Stable on NC\n Gastrointestinal / Abdomen: D/C NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO, Would decrease NS now and potentially switch\n to maintenanc in PM if tolerating\n Hematology: Serial Hct, Stable anemia -- monitor. would not transfuse\n at this point. Send HIT pannel as acute decrease in PLT. Re-check PLT\n in PM\n Endocrine: RISS, Slightly hyperglycemic. Keep < 150\n Infectious Disease: Check cultures, GNR bacteremia. On Zosyn, cipro,\n vanc (check levels) empirically, valgancyclovir and fluconazole\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CXR today\n Fluids: NS, Decrease to 100 cc/h now and potentially change to\n maintenance in PM\n Consults: Transplant\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:32 AM\n Arterial Line - 01:14 PM\n Multi Lumen - 05:22 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Hold SQ heparin for now as thrombocytopenic)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2137-11-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 543911,
"text": "SICU\n HPI:\n 56yo M p/w fever, neck pain, s/p OLT . recent ERCP stent\n re-placement .\n Chief complaint:\n PMHx:\n PMH: HCV s/p OLT c/b bile leak s/p ERCP stent, HCC s/p\n cyberknife , HTN, DM diet-controlled\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:41 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 12:21 AM\n Metronidazole - 04:17 PM\n Ceftriaxone - 05:49 PM\n Vancomycin - 06:58 PM\n Ciprofloxacin - 08:25 PM\n Piperacillin/Tazobactam (Zosyn) - 05:17 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 05:58 AM\n Other medications:\n Flowsheet Data as of 08:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.1\nC (96.9\n HR: 62 (60 - 83) bpm\n BP: 117/72(84) {117/72(84) - 122/83(92)} mmHg\n RR: 13 (10 - 27) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 9 (5 - 10) mmHg\n Total In:\n 4,855 mL\n 500 mL\n PO:\n 580 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 4,275 mL\n 100 mL\n Blood products:\n Total out:\n 7,065 mL\n 640 mL\n Urine:\n 6,415 mL\n 640 mL\n NG:\n 650 mL\n Stool:\n Drains:\n Balance:\n -2,210 mL\n -140 mL\n Respiratory support\n SPO2: 95%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 40 K/uL\n 8.4 g/dL\n 110 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 24.2 %\n 2.3 K/uL\n [image002.jpg]\n 02:06 PM\n 06:02 PM\n 07:31 PM\n 07:58 PM\n 04:03 AM\n 05:02 AM\n 05:25 AM\n 03:13 PM\n 05:19 AM\n WBC\n 4.8\n 6.6\n 3.6\n 1.5\n 2.3\n Hct\n 30.6\n 32\n 28.5\n 27.1\n 24.7\n 24.2\n Plt\n 105\n 102\n 63\n 43\n 40\n Creatinine\n 1.4\n 1.3\n 1.2\n 1.0\n Troponin T\n 0.01\n TCO2\n 24\n 31\n 28\n Glucose\n 118\n 152\n 150\n 110\n Other labs: PT / PTT / INR:15.5/31.9/1.4, CK / CK-MB / Troponin\n T:82//0.01, ALT / AST:33/47, Alk-Phos / T bili:75/0.4, Lactic Acid:1.1\n mmol/L, Albumin:3.1 g/dL, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER\n Assessment and Plan: 56yo M p/w fever, neck pain, s/p OLT .\n recent ERCP stent re-placement, admitted with sepsis (E. coli\n bacteremia)\n Neurologic: Neuro checks Q: 4 hr, Headach slightly improved with\n dilaudid and fiorocet. No evidence of meningitis\n Cardiovascular: Stable now. Off pressor.\n Pulmonary: IS, Stable on NC. OOB --> chair\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, Stable anemia -- monitor. Thrombocytopenia.\n Will monitor. F/u on HIT. Pancytopenia. On neupogen\n Endocrine: RISS, BG well controlled\n Infectious Disease: Zosyn/bactrim/fluconazole. E. coli bacteremia\n Lines / Tubes / Drains: Foley, D/C CVL\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:31 AM\n Multi Lumen - 05:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543831,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient vitals stable overnight, continues to complain of back pain,\n tolerating house diet no nausea. Remains off neo. Iv kvo. Passing\n adequate amounts of urine.\n Action:\n Will continue to monitor, encourage po intake.\n Response:\n Patient remains stable overnight.\n Plan:\n Patient to transfer to step down in am. Continue with iv antibiotics ,\n will monitor and treat accordingly\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient remains afibrile overnight\n Action:\n Monitored temp, iv antibiotics given as ordered.\n Response:\n Continues to be afibrile\n Plan:\n Will continue to monitor and treat accordingly\n Tachycardia, Other\n Assessment:\n Patient remains in sinus rhythm, no ectopy\n Action:\n Will continue to monitor\n Response:\n No change in vitals\n Plan:\n Will continue to monitor and treat accordingly\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543598,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient admitted with temp of 104, tachycardia, headache.\n Nausea/vomiting. Overnight patient complained of back pain, mild\n headache. Hr now sinus rhythm, Blood pressure SBP 95-118.\n Action:\n Iv neo to maintain map >60, iv fluids to hydrate patient. Iv\n antibiotics, dilaudid for back pain.\n Response:\n Patient remains in sinus rhythm, Map >60, afibrile.\n Plan:\n To continue to hydrate patient, monitor input/output closely. Continue\n with iv antibiotics per ID team. Administer analgesia for comfort.\n Titrate iv neo to maintain Map >60.\n Tachycardia, Other\n Assessment:\n Patient remained in a sinus rhythm overnight, no ectopy noted\n Action:\n Will continue to monitor patient and treat accordingly\n Response:\n Remained in sinus rhythm\n Plan:\n Will continue to monitor.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient low grade temp 99.1-99.3 overnight\n Action:\n Iv antibiotics continued as ordered. Patient also had ctscan of\n /pelvis\n Response:\n Remained afibrile\n Plan:\n Will continue to monitor temp, with rectal temp probe, labs monitored\n and reported to MD\ns. Await report of ctscan.\n IV sodium bicarb completed as per orders, oral contrast given via NG\n tube. After ctscan of /pelvis Ng tube placed to low con suction,\n drained @450cc bilious, no complaints of nausea. Patient remains npo,\n oral hygiene maintained. IV magnesium and calcium replaced as per\n sliding scale.\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543771,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient has been afebrile this shift. Temperature has been 97-98\n Orally. Patient\ns MAP has been between 65-75 today, urine output has\n been between 150-400 per hour today.\n Action:\n IV maintenance fluid has been discontinued and patient has been\n approved for a regular diet. Patient has been weaned off of NEO\n infusion this morning.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543592,
"text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543768,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient has been afebrile this shift. Temperature around 97-98\n Orally.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543797,
"text": "Sepsis without organ dysfunction\n Assessment:\n Patient afebrile this shift. Temperature 97-98 Orally. Patient\ns MAP\n between 65-75 today, urine output between 150-400 per hour today.\n Patient has been complaining of headache today. WBC count this\n afternoon was 1.6\n Action:\n IV maintenance fluid has been discontinued and NEO has been weaned this\n morning, which remains off. Patient has a regular diet ordered.\n Continues to receive Dilaudid IV and furoset for headache as well.\n Immunosuppressive agents have been held and nupogen has been\n ordered.\n Response:\n Patient reports having a less severe headache this evening. Blood\n pressure has been stable with a MAP greater than 65 throughout the\n shift. Urine output remains adequate (100-200 cc\ns per hour) this\n afternoon.\n Plan:\n Continue to monitor patient\ns labs, and will hold immunosuppressive\n agents as ordered. Nupogen will be given as ordered. Will continue to\n treat headache with pain meds as ordered.\n"
},
{
"category": "Case Management ",
"chartdate": "2137-11-07 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 543494,
"text": "Insurance information\n Primary insurance: NETWORK HEALTH\n Secondary insurance: SELF PAY\n Insurance reviewer::tba\n Free Care application: N/A\n Status: Referred\n Medicaid application: N/A\n Pre-Hospitalization services: Homecare\n DME / Home O[2]: no\n Functional Status / Home / Family Assessment:\n live w wife in /p liver trans 2m ago\n Primary Contact(s): \n Health Care Proxy: Yes - But NO copy of signed proxy form in medical\n record.\n Dialysis: No\n Referrals Recommended: Physical Therapy\n Current plan: Undetermined\n re-eval after intial consults\n Patient (s) to Discharge:\n sepsis\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1045575,
"text": " 6:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p liver txp now with fever and tachycardia\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male status post liver transplant, now with fever and\n tachycardia. Please evaluate for pneumonia.\n\n COMPARISON: Chest radiograph .\n\n SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is\n normal. The heart is not enlarged. There is overall better lung aeration\n with no pleural effusion or focal consolidation. There is likely minimal\n basilar atelectasis bilaterally. The right upper quadrant demonstrates a\n biliary stent. Osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1045721,
"text": " 4:38 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: R Subclavian\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n R Subclavian\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 7:29 PM\n PFI: Well placed right-sided subclavian approach central venous line. No\n pneumothorax. Left-sided _____ line persists in unchanged position.\n ______________________________________________________________________________\n FINAL REPORT\n _____ Status post right subclavian central venous line placement.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a similar preceding study\n obtained two hours earlier during the same date. The previously described\n inappropriately directed left sided subclavian line persists in unchanged\n position. A new right subclavian approach central venous line is now\n identified seen to terminate overlying the SVC some 2 cm below the level of\n the carina. No pneumothorax has developed. No new pulmonary abnormalities\n are present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1045722,
"text": ", R. SICU-A 4:38 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: R Subclavian\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n R Subclavian\n ______________________________________________________________________________\n PFI REPORT\n PFI: Well placed right-sided subclavian approach central venous line. No\n pneumothorax. Left-sided _____ line persists in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1045736,
"text": " 6:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess position of NG tube\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with Gram neg bacteremia\n REASON FOR THIS EXAMINATION:\n assess position of NG tube\n ______________________________________________________________________________\n WET READ: AGLc FRI 12:59 AM\n Right subclavian CVC unchanged; left subclavian CVC in neck removed. New NGT\n courses into stomach and out of view inferiorly. Else little change from 2\n hours prior. No new pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:50 P.M. \n\n HISTORY: Bacteremia. Assess nasogastric tube.\n\n IMPRESSION: AP chest compared to through 4:53 p.m.:\n\n Left subclavian line has been removed. Right subclavian line can be traced as\n far as the superior cavoatrial junction but the tip is indistinct.\n Heterogeneous opacification at the base of the right lung which worsened\n earlier in the day has begun to improve. This may represent aspiration.\n Lungs are otherwise clear. Heart size top normal. No pneumothorax or\n appreciable pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1045690,
"text": " 2:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: verify line position\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with fever, headache, s/p left subclavian central line\n placement\n REASON FOR THIS EXAMINATION:\n verify line position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (): SP 5:12 PM\n Left subclavian approach central venous line running upwards into left lower\n neck area. Requires adjustment of position. No other chest abnormalities in\n comparison with previous study same day.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Fever, headache, status post left subclavian central venous line\n placement, verify position.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a preceding similar chest\n examination obtained eight hours earlier during the same date. On the present\n study, a left subclavian approach central venous line has been placed. It is\n noted that the tip is running in retrograde direction into the lower left neck\n area apparently entering the cephalic vein. There is no pneumothorax or any\n other placement-related complication.\n\n Telephone report was delivered to number as indicated on the\n requisition signed by . Coordinator who answered the telephone\n could not identify patient or requesting physician. report was issued\n usually.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1045691,
"text": ", R. SICU-A 2:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: verify line position\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with fever, headache, s/p left subclavian central line\n placement\n REASON FOR THIS EXAMINATION:\n verify line position\n ______________________________________________________________________________\n PFI REPORT\n Left subclavian approach central venous line running upwards into left lower\n neck area. Requires adjustment of position. No other chest abnormalities in\n comparison with previous study same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1045768,
"text": " 11:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess position of central line\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n assess position of central line\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 1:36 PM\n Right subclavian with tip in upper SVC. No pneumothorax. Pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH:\n\n HISTORY: 56-year-old man with central line. Evaluate for position.\n\n COMPARISON: Multiple prior chest radiographs, most recent from at 6:50 P.M. This study was performed at 11:43 p.m.\n\n FINDINGS: There is a right-sided central venous catheter whose tip terminates\n in the upper SVC. There is no pneumothorax. There is unchanged appearance to\n bibasilar atelectasis. There has been slight increased pulmonary vascular\n engorgement and slight increase in width of the mediastinal pedicle as\n evidenced by a more prominent azygos vein all related to increased volume\n overload. The cardiac silhouette is top normal in size and unchanged. The\n aortic arch is tortuous but unchanged in appearance. There are no pleural\n effusions; however, the left costophrenic sulcus is excluded from this\n radiograph. There is a nasogastric tube which courses through the esophagus\n and off the field of view of this radiograph.\n\n IMPRESSION:\n 1. Right-sided central venous catheter with tip in upper SVC. No\n pneumothorax.\n 2. Pulmonary vascular engorgement representative of volume overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1045769,
"text": ", R. SICU-A 11:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess position of central line\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n assess position of central line\n ______________________________________________________________________________\n PFI REPORT\n Right subclavian with tip in upper SVC. No pneumothorax. Pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1045766,
"text": " 10:30 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: S/P LIVER TX. GRAM NEG BACTEREMIA.\n Admitting Diagnosis: R/O MENINGITIS\n Field of view: 44 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with S/P liver transplant\n REASON FOR THIS EXAMINATION:\n Gram neg bacteremia possibly intraabd pathology. would like water soluble\n contrast PO\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 4:09 AM\n Right small pleural effusion and atelectasis. Small amount of fluid in right\n paracolic gutter without more focal fluid collection or abscess. Indwelling\n foley and mild perinephric stranding but per report urine sample normal. \n D/W Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant. Gram-negative bacteremia.\n\n TECHNIQUE: MDCT of the abdomen and pelvis after the uneventful intravenous\n administration of 130 ml Optiray contrast displayed in 5-mm axial collimation\n with multiplanar reformations.\n\n COMPARISON: .\n\n CT ABDOMEN WITH CONTRAST: There are small bilateral pleural effusions (right\n greater than left), with associated atelectasis. Visualized heart is normal.\n The patient is status post liver transplant. The transplant liver appears\n normal. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.\n The stomach is dilated with oral contrast. The NG tube tip terminates in the\n stomach. Small bowel loops are normal. There is no pathologic adenopathy.\n There is a small amount of fluid in the right paracolic gutter, but no\n organized collection. There are two catheters within the common bile duct.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, large bowel, prostate, seminal\n vesicles, distal ureters, bladder are normal. A Foley catheter and rectal\n tube are in situ. There is trace free fluid in the pelvis. There is no\n pathologic adenopathy. There are no fluid collections.\n\n BONE WINDOWS: No suspicious lesions are identified in the bones.\n\n IMPRESSION:\n 1. No intra-abdominal pathology.\n 2. Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1045586,
"text": " 7:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? mass/bleed, evidence for increased ICP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with headache, fever, neck pain\n REASON FOR THIS EXAMINATION:\n ? mass/bleed, evidence for increased ICP\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:20 AM\n no acute intracranial process - stable exam\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year old man with headache, fever, neck pain, question mass or\n bleed. Evidence for increased intracranial pressure?\n\n COMPARISON: Head CT of .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, large areas\n of edema, or mass effect. There is normal preservation of -white matter\n differentiation. There is mild prominence of the sulci and ventricles most\n likely due to age-appropriate atrophy. No bulging of the optic discs are\n noted. Visualized portions of the paranasal sinuses and mastoid air cells are\n clear.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage, mass effect, or\n increased intracranial pressure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1046215,
"text": " 3:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check PICC placement left basilic 59 cm\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n please check PICC placement left basilic 59 cm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: Left subclavian PICC line extends to the lower portion of the SVC.\n Mild atelectatic changes at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-11-12 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1046516,
"text": " 12:17 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: question etiology back pain in pt s/p liver transplant, no T\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with OLT p/w GNR in blood\n REASON FOR THIS EXAMINATION:\n question etiology back pain in pt s/p liver transplant, no TTP on exam, pt on\n immunosuppresives\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl TUE 6:04 AM\n s/p recent LP w/ back pain. T6-7 rt paracentral protrusion indents cord,\n T11-12 left paracentral protrusion deforms cord. Small central protrusion at\n L5- S1. No cord signal abnormality, no epidural hematoma. fluid in\n subcutaneous tissues overlying L-spine likely due to recent LP. d/ \n 6am .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 56-year-old male status post liver transplant, now\n presenting with Gram-negative rod bacteremia. Now also with back pain status\n post liver transplant and on an immunosuppressive. Please evaluate for\n possible etiology of back pain.\n\n EXAMINATION: MRI of the thoracic and lumbar spine.\n\n COMPARISONS: There are no prior comparisons to plain films of the thoracic\n and lumbar spine.\n\n TECHNIQUE: Sagittal short TR, short TE spin echo, long TR, long TE fast spin\n echo, and STIR images were obtained. Axial imaging was performed with short\n TR, short TE spin echo, and long TR, long TE fast spin echo technique. No\n administration of gadolinium intravenous contrast was performed.\n\n FINDINGS: The alignment of the thoracic and lumbosacral spines are normal.\n There are no spinal cord signal intensity abnormalities. There are no acute\n fractures identified. There are no intradural abnormalities seen. There is\n no evidence for spinal cord compression. There is no evidence for an abnormal\n fluid collection suggestive of abscess. However, the study is limited for the\n evaluation of epidural abscess without the administration of intravenous\n gadolinium contrast. There is multilevel degenerative joint disease as\n outlined below:\n\n At the level of T5-T6, there is a posterior disc protrusion with slight\n anterior impingement on the thecal sac.\n\n At the level of T6-T7, there is a posterior disc protrusion with associated\n impingement on the anterior thecal sac and associated moderate spinal canal\n narrowing. There is no associated abnormal signal intensity within the cord\n at this region to suggest cord edema.\n\n At the level of T11-T12, there is a left paracentral disc protrusion with\n (Over)\n\n 12:17 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: question etiology back pain in pt s/p liver transplant, no T\n Admitting Diagnosis: R/O MENINGITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n associated impingement on the anterior thecal sac on the left.\n\n At the level of L5-S1, there is a left paracentral disc protrusion with\n associated neural foraminal narrowing on the left. There is also a mild\n amount of facet hypertrophy on the left, which also contributes to the left-\n sided neural foraminal narrowing.\n\n There are mild tiny bilateral pleural effusions. There is an area of T1\n hyperintensity at the superior endplate of the L4 vertebral body that likely\n represents a benign bone island. Incidentally noted is fluid in the\n subcutaneous tissue overlying the lumbar spine that would be expected\n secondary to recent lumbar puncture.\n\n IMPRESSION:\n 1. No evidence for epidural abscess, hematoma, or spinal cord compression.\n Study is limited for detection of abscess secondary to lack of intravenous\n gadolinium contrast.\n\n 2. Multilevel degenerative joint disease as outlined above with most\n prominent disc protrusion at T6-T7 with associated moderate spinal canal\n stenosis at this level.\n\n 3. Mild bilateral tiny pleural effusions. Posterior subcutaneous fluid\n within the back, likely secondary to recent lumbar puncture.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-11-07 00:00:00.000",
"description": "Report",
"row_id": 181499,
"text": "Sinus tachycardia. Right atrial abnormality. Non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of right atrial\nabnormality is now manifest.\n\n"
}
] |
32,128 | 191,194 | Patient went to the OR on and underwent left orbital extenteration and reconstruction using a radial forearm flap and STSG from thigh to forearm. Post-op she went to the PACU initially, she was then transferred to the ICU secondary to some hypotension and EKG changes post-op. | dopplerable pulses to L face. vap mouth care done. breath sounds course.cardiac; remains in nsr. Monistat supp as ordered. unstable vent status, minimal cuff leak. We are sxTn ~Q2h small to mod amt of thick blooe tinged secretions from ETT. focus hemodynmicsdata: alert tonite. normal cap refill. JP FROM ARM WITH MINIMAL SEROSNAGUINES DRAINAGE. vac dsg dc'd. The preexisting atelectasis has resolved. Assess CHF. Aloe vesta antifungal applied. NURSING VSS, NSR, OCCASIONAL PVC'S. CONDITION UPDATED: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: REMAINS SEDATED ON PROPOFOL, AROUSABLE TO STIMULI, RIGHT PUPIL 3MM WITH BRISK REACTION.CV: AFEBRILE. There is a minimal right-sided pleural effusion. R arm ace wrapped with JP and VAC dsg intact. while propfol gtt off, pt bites et tube. ALL PULSES ON FACE POSITIVE BY DOPPLER. CPAP, ABGs wnl. NPnPlease see carevue for further detailssedated on propofol. Bs are dim clear bil. Q2hr doppler checks cont without incident. good capillary refill on nailbeds. jp d/c'd. penrose drains intact. left side of face edematous and 3 graft sites pulse good. K+ 4.1, RIGHT FINGERS COOL AT TIMES= WARM BLANKET APPLIED, + CAPPILLARY REFILLRESP: PT STILL WITHOUT CUFF LEAK, BS DIMINSHED, SX FOR SM AMT THICK BLOOD TINGED SECRETIONS. Monistat ordered for HS. LUNGS CTA UPPER, DIMINISHED BASES. Plan to remain intubated and on PSV as noted. right facial graft sites intact and audible by doppler. Ls CTA, diminished. Begin monistat, antifungal for rash, transfer to floor if cleared by plastics. BS are diminished throughout, but essentially clear. NPO, TF tol well, roxicet for pain w/good effect. Cool aerosol mask cont, sats 96-100. PLAN: Cont Q2hr pulse checks, pulm toilet, transfer to floor when cleared by plastics. lytes repleted as indicated. focus hemodymodicsdata: neuro: on propofol gtt. right upper leg graft site intact with xeroform gauze intact. MONTIOR RESP STATUS= ? R thigh skin graft with xeroform intact. ABDOMEN SOFT, POSITIVE BOWEL SOUNDS. 4:20 AM CHEST (PORTABLE AP) Clip # Reason: evaluate fluid status . The endotracheal tube and the previous nasogastric tube have been removed. HR 45-80 NSR WITH OCCASIONAL PVC'S. vac dsg intact with no drainage. right thigh skin graft site intact and xeroform gauze applied. with doppler checks q2 without incidence. SEE CARE VUE FOR FULL ASSESSMENT. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Low lung volumes are reflected in mild subsegmental atelectasis, more pronounced at the right base. Facial swelling cont to decrease. CONTINUES ON PROPOFOL FOR SEDATION. no stool tonite.graft sites: right arm dsg intact and elevated on pillow. There is slight decrease in laryngeal elevation with some residue in the valleculae. pedal pules intact. MONITER HEMODYNAMICS. As compared to the previous radiograph, the Dobbhoff catheter has been inserted. Extubate as tolerated. Vac dressing intact w/ sml amts of serosang drainage noted. ls clear, dimin to bases bilat. + facial edema noted. Dobhoff placed and verified by CXR. care note - Pt. care note - Pt. EKG done this am. VAC dsg to R arm intact with small amounts of serosang drainage. Wean vent settings to extubate as tolerated. Tmax 100.1 SR w/ occasinal to frequent PVC's. Chest PT done. Pt to remain intubated overnoc. large amts serosang drainage from penrose sites, areas cleansed w/ saline prn. Antifungal ordered and applied. Lopressor given as needed for hypertension.BLSCTA even unlabored. sliding scale as written.id: afebrile, am wbc pending. PPF gtt for sedation. po meds given per tube w/out issue. Venous and arterial pulses dopplerable in graft site. doppler signals to L facial graft strong, venous and arterial signals+ cap refill adeq.gi/gu: belly obese, ngt to lws, sm amts old bloody output. nsr, beta blockade cont., freq pvc's noted. Resp. Resp. RISS for bs coverage. RISS for bs coverage. cough, gag strong.cv: mildly hypotensive upon arrival to unit, sedation adjusted, pt repositioned w/ improvement to bp. LS CTA. Pt's L eye enucleated . Penrose drains w/ sml amts of serosang drainage. ls clear, dimin to bases. SBT done this am. remains intubated for airway protection, doign well w/ cpap+ps. condition updateplease see carevue for specifics.pt intubated and sedated on a ppf gtt. Family updated re: POC. NPNPlease see carevue for further detailsExtubated this a.m. + cuff leak, following commands. Vac and Jp to right arm. Dobhoff pulled back by Dr. after checking CXR. Right forearm has vac to sxn and a jp to bulb sxn and is covered w/ an acewrap. Cap refill good. <3 sec cap to right hand. Non-specific inferior, anterior and lateral T wave flattening.Early precordial QRS transition. R radial pulse intact, good cap refill to area.gi/gu: belly large, soft, bs hypo. R thigh STSG site w/ dsd, serosang drainage shadowing through. graft signals checked per plastics protocol, arterial and venous signals very strong, tissue w/ brisk cap refill. STSG from Pt's right thigh w/ dsd to cover. mae well, strength wnl. + BS x4 abd soft nt/nd.Coccyx rash- ? abg wnl. Sinus rhythm. Baseline artifactSinus rhythmVentricular premature complexModest nonspecific precordial/anterior T wave changesSince previous tracing of the same date, ventricular ectopy now present Able to cough and expectorate. RSBI done ~61. IVF also kvo'd.Plan: continue w/ current plan of care per sicu, plastics teams. hypothermic on arrival, warmed w/ bair hugger to normothermia.skin: R forearm graft donor site w/ VAC intact, ACE splint on top. wean to elective extubation. Foley patent and draining adequate amts of clear urine. answered.a/p: doing well post op day 1 s/p L orbital enucleation, facial reconstruction for SCC. sedation being weaned, plan to attempt extubation today if +air leak, gag improves. JP to bulb sxn also at right arm w/ sml amts of serosang drainage. condition updateplease see carevue for specifics.Pt remains intubated and sedated on a ppf gtt. | 27 | [
{
"category": "Radiology",
"chartdate": "2108-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012699,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate fluid status . H/ o CHF\n Admitting Diagnosis: LEFT RECURRENT SQUAMOUS CELL CARCINOMA LEFT EYEBROW & FRONTAL SCALP/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n REASON FOR THIS EXAMINATION:\n evaluate fluid status . H/ o CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Volume overload. Assess CHF.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Low lung volumes are reflected in mild subsegmental atelectasis, more\n pronounced at the right base. Lungs are otherwise clear. Heart size normal.\n No edema, vascular congestion, or pleural effusion.\n\n ET tube tip at the upper margin of the clavicles is at least 6 cm from the\n carina, reasonable placement given elevation of the head and neck.\n Nasogastric tube passes into the stomach and out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-04-13 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1013625,
"text": " 10:32 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: can she take PO\n Admitting Diagnosis: LEFT RECURRENT SQUAMOUS CELL CARCINOMA LEFT EYEBROW & FRONTAL SCALP/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p eye surgery\n REASON FOR THIS EXAMINATION:\n can she take PO\n ______________________________________________________________________________\n FINAL REPORT\n VIDEO OROPHARYNGEAL SWALLOW\n\n INDICATION: 75-year-old woman with recent eye surgery, question ability to\n take p.o.\n\n COMPARISON: None available.\n\n FINDINGS: Barium of various consistencies was administered to the patient\n under fluoroscopic guidance in conjunction with the speech and swallow\n therapist.\n\n There was premature spillover of thin liquids. There was prolonged chewing\n of the ground solids. There is slight decrease in laryngeal elevation with\n some residue in the valleculae.\n\n There is no evidence of aspiration or penetration.\n\n IMPRESSION: No evidence of aspiration or penetration. For further details\n see speech and swallow report from the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013297,
"text": " 12:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dobhoff placement\n Admitting Diagnosis: LEFT RECURRENT SQUAMOUS CELL CARCINOMA LEFT EYEBROW & FRONTAL SCALP/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with SCC\n REASON FOR THIS EXAMINATION:\n dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup of Dobhoff catheter.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the Dobbhoff catheter has been\n inserted. The tip of the catheter loops back to the the proximal parts of the\n stomach. There is a minimal right-sided pleural effusion. The preexisting\n atelectasis has resolved. The endotracheal tube and the previous nasogastric\n tube have been removed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-09 00:00:00.000",
"description": "Report",
"row_id": 1669491,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on minimal spontaneous ventilation. RSBI done ~43. Still No air leak noted & ausculted. Bsa re coarse & dim midly bil. We are sxTn ~Q2h small to mod amt of thick blooe tinged secretions from ETT. Plan: ?elective extuabtion once airway protection is established. See Careview for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-09 00:00:00.000",
"description": "Report",
"row_id": 1669492,
"text": "focus hemodymodics\ndata: neuro: on propofol gtt. while propfol gtt off, pt bites et tube. moving mouth. bp >180. right pupil #2 and reacts briskly.\n\nresp: remains intubated and suctioned for thick tan blood tinge sputum. no cuff ieak. rsbi 43. o2sats 99-100%. vap mouth care done. breath sounds course.\n\ncardiac; remains in nsr. k 4.2 and magnesium 2.0 lopressor held due to heart rate down to 50's.\n\ngu: foley patent and draining yellow urine.\n\ngi abd soft. no stool tonite.\n\ngraft sites: right arm dsg intact and elevated on pillow. good capillary refill on nailbeds. jp draining serosang drainage. vac dsg intact with no drainage. right upper leg graft site intact with xeroform gauze intact. good pedal pulses. left side of face edematous and 3 graft sites pulse good. head turned to the left.\n\nsocial: update to daughter .\n\nresponse: monitor closely\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-09 00:00:00.000",
"description": "Report",
"row_id": 1669493,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: REMAINS SEDATED ON PROPOFOL, AROUSABLE TO STIMULI, RIGHT PUPIL 3MM WITH BRISK REACTION.\nCV: AFEBRILE. HR 45-80 NSR WITH OCCASIONAL PVC'S. K+ 4.1, RIGHT FINGERS COOL AT TIMES= WARM BLANKET APPLIED, + CAPPILLARY REFILL\nRESP: PT STILL WITHOUT CUFF LEAK, BS DIMINSHED, SX FOR SM AMT THICK BLOOD TINGED SECRETIONS. ON CPAP WITH 5 IPS AND 5 PEEP\nGI: ABD SOFT, +BS, STARTED ON TF REPLETE WITH FIBER AT 20CC/HR, MINIMAL RESIDUAL. NO STOOL\nGU: EXCELLENT DIURESIS FROM 20 MG LASIX\nENDO: BS WNL\nWOUNDS: RIGHT THIGH DONOR GRAFT SITE CLEAN AND DRY WITH XEROFORM GUAZE\nRIGHT ARM VAC DRESSING INTACT WITH SM AMT SEROSANG DRAINAGE,\nLEFT EYE GRAFT SITE CLEAN, + GRAFT PULSES BY DOPPLER\nA/P: MONITOR HEMODYNAMICS AND NEURO STATUS. MONTIOR RESP STATUS= ? EXTUBATE IN AM IF CUFF LEAK PRESENT, MAINTAIN HOB AT 30-45 DEGREES, INCREASE TF BY 10CC Q4HRS IF MINIMAL RESIDUAL TO GOAL OF 60. MEDICATE FOR PAIN AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-09 00:00:00.000",
"description": "Report",
"row_id": 1669494,
"text": "Respiratory Care Note\nPt received on PSV 5/5 as noted with no vent changes this shift. BS are diminished throughout, but essentially clear. Plan to remain intubated and on PSV as noted. Plan to possibly extubate in am if cuff leak is present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-10 00:00:00.000",
"description": "Report",
"row_id": 1669495,
"text": "NURSING\n VSS, NSR, OCCASIONAL PVC'S. TEMPERATURE MAX 99.6. ON ONLY KVO IVF, DIURESED WELL FROM LASIX DOSE GIVEN IN AFTERNOON. NEGATIVE AT 2400, 1500 ML.\n REMAINS ON CPAP 5/5 40%. RSBI IN THE 40'S. STILL REMAINS WITHOUT CUFF LEAK. LUNGS CTA UPPER, DIMINISHED BASES. CONTINUES ON PROPOFOL FOR SEDATION.\n FOLEY WITH GOOD URINE OUTPUT. REPLETE WITH FIBER AT GOAL OF 40 VIA OGT. NO STOOL OUT OVERNIGHT. ABDOMEN SOFT, POSITIVE BOWEL SOUNDS. UTERINE PROLAPSE.\n ALL DRESSINGS INTACT. VAC DRESSING ON ARM. JP FROM ARM WITH MINIMAL SEROSNAGUINES DRAINAGE. XEROFORM GUAZE TO RIGHT THIGH SKIN GRAFT SITE. ALL PULSES ON FACE POSITIVE BY DOPPLER. MEDICATED FOR PAIN USING VS AS INDICATOR WITH 50 MG FENTANYL WITH GOOD EFFECT.\n SEE CARE VUE FOR FULL ASSESSMENT. CONTINUE TO MONITER FOR CUFF LEAK, AGGRESSIVE PULMONARY TOILET.. MEDICATE FOR PAIN AS NEEDED. MONITER HEMODYNAMICS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-12 00:00:00.000",
"description": "Report",
"row_id": 1669502,
"text": "focus hemodynmics\ndata: alert tonite. moves legs on the bed. limited arm movement due to arm dsgs. right arm dsg changed by the plastic service. vac dsg dc'd. jp d/c'd. right thigh skin graft site intact and xeroform gauze applied. pedal pules intact. right facial graft sites intact and audible by doppler. head of bed elevatd at 30 degrees. medicated with 25mcg iv fentanyl x4 wwith relief. tube fdg tolerated well and at goal rate of 40cc/hr. red rash noted on buttocks and miconazole cream applied x3. pt asking to get oob and sit in chair.\n\naction: iv to see pt today for picc line. ? speech and swallow test today.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-12 00:00:00.000",
"description": "Report",
"row_id": 1669503,
"text": "nursing note\nplease see careview for notes\n\nPt cont. with doppler checks q2 without incidence. Swelling decreasing. Pt failed speech & swallow, to go to video swallow tomorrow. Medicated with roxicet prn for pain. Ls CTA, diminished. O2 weaned easily. Tol tube feeds at goal. no bm. Per wound team, rash looks yeast like. + yeast vaginal infection. Monistat ordered for HS. Aloe vesta antifungal applied. awaiting plastics team for question of transfer to floor.\n\nPLAN: pulse checks q2, pulm toilet. Begin monistat, antifungal for rash, transfer to floor if cleared by plastics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-13 00:00:00.000",
"description": "Report",
"row_id": 1669504,
"text": "Nursing Progress Note\n Please see carevue for details of care. Alert and oriented, MAEW. Q2hr doppler checks cont without incident. Facial swelling cont to decrease. NPO, TF tol well, roxicet for pain w/good effect. Cool aerosol mask cont, sats 96-100. Mycolog to yeast on labia, antifungal barrier cream to buttocks. Monistat supp as ordered.\n\n PLAN: Cont Q2hr pulse checks, pulm toilet, transfer to floor when cleared by plastics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-10 00:00:00.000",
"description": "Report",
"row_id": 1669496,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on minimal spontaneous ventilation. RSBI done ~53. We checked air leak o/n & even had cuff deflated >45 min with no leak. Bs are dim clear bil. We are sxtn for mod amt of thick whitish to blood tinged secretions & some orally. Plan: keep checking air leak & Continue present Icu monitoring. See Careview for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-10 00:00:00.000",
"description": "Report",
"row_id": 1669497,
"text": "NPn\nPlease see carevue for further details\nsedated on propofol. unstable vent status, minimal cuff leak. diuresing with lasix gtt- complicated by SBP 90s. goal diuresis negative 2-3L. keeping HOB>30 degrees to decrease swelling. BLSCTA even unlabored. CPAP, ABGs wnl. NSR with occasional PVCs. lytes repleted as indicated. weak palpable PTs. dopplerable pulses to L face. penrose drains intact. normal cap refill. all extremities warm. R thigh skin graft with xeroform intact. R arm ace wrapped with JP and VAC dsg intact. TF at goal, currently 60. + BS x4 abd obese nd.\nPLAN: Continue to closely monitor hemodynamics, pulses and graft sites, keep HOB >30. Turn tube feeds off at 0500 for probable extubation tomorrow. Continue to provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-10 00:00:00.000",
"description": "Report",
"row_id": 1669498,
"text": "Respiratory Care:\nPt remains on PSV 5/5 @ 40% with no changes today. No Sx by rt since the RN had just done suctioning. No new RT issues. Needs to be at 45 degrees to promote upper head and neck fluid drainage to allow for a cuff leak and subsequent extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-11 00:00:00.000",
"description": "Report",
"row_id": 1669499,
"text": "Resp Care\nRemains intubated and ventilated on psv/cpap 5/5/50%. ABGs with good oxygenation and slight met. alkalosis. Breath sounds mostly clear. Suctioned for small amounts of thick white sputum. A.M. rsbi = 68. Possible extubation later this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-11 00:00:00.000",
"description": "Report",
"row_id": 1669500,
"text": "NPN\nPlease see carevue for further details\nExtubated this a.m. + cuff leak, following commands. Alert, oriented x2 (person and place, not time). Moving all extremities well.\nDopplerable pulses to flap site. Weak palpable pulses to BLE. <3 sec cap to right hand. Ace wrap intact. R thigh graft site intact with xeroform dressing. JP with small amounts of serosang drainage. VAC dsg to R arm intact with small amounts of serosang drainage. NSR/ST 90-100s. SBP 120-160s. Lopressor given as needed for hypertension.\nBLSCTA even unlabored. on 70% face tent with sats 96-98. RR 20s, unlabored. Able to cough and expectorate. Chest PT done. Hoyered OOB to chair.\nOGT discontinued after extubation. Dobhoff placed and verified by CXR. Dobhoff pulled back by Dr. after checking CXR. Awaiting kangaroo pump to start TFs. + BS x4 abd soft nt/nd.\nCoccyx rash- ? pustule in origin, most likely not shingles per SICU team d/t \"crossing over midline\" around coccyx area. Antifungal ordered and applied. Afebrile.\nFoley draining clear yellow urine large amounts. Prolapsed uterus. Lasix gtt at 1-4 mg/hr for goal diuresis of negative 2-3L.\nPLAN: Continue to closely monitor i/o and fluid status. Monitor hemodynamics and flap/graft checks. Awaiting PICC placement- most likely tomorrow at bedside. ? c/o floor tomorrow if able to d/c lasix gtt and otherwise stable. Provide comfort and support. Family updated re: POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-11 00:00:00.000",
"description": "Report",
"row_id": 1669501,
"text": "resp care\npt with positive cuff leak this morning, extubated without incident. refer to flow sheet for further data.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-08 00:00:00.000",
"description": "Report",
"row_id": 1669487,
"text": "nursing progress note\n\nneuro: sedated w/ propofol, slowly weaning over course of night. mae well, strength wnl. when lightened, opens eyes, nods and shakes head to questions, inconsistently following commands. intermittent doses fentanyl w/ good effect.\n\nresp: remains on cpap+ps mode, 40%, . rr teens to low 20s when stimulated. cough strong, gag weak. abg wnl. ls clear, dimin to bases. scant yellow/tan secretions when sx, copious oral secretions noted. note: tongue very edematous, neck appears slightly more so than last night.\n\ncv: intermit. fluid shifts evident overnight, at times pt hypertensive as high as 180s. nsr, beta blockade cont., freq pvc's noted. extrem warm, pulses intact. doppler signals to L facial graft strong, venous and arterial signals+ cap refill adeq.\n\ngi/gu: belly obese, ngt to lws, sm amts old bloody output. po meds given per tube w/out issue. foley patent dilute yellow urine, autodiuresing well.\n\nendo: glucose levels remain elevated, note dextrose in maintenance ivf. sliding scale as written.\n\nid: afebrile, am wbc pending. ancef dosing as written.\n\nskin: sutured areas to facial graft clean, approximated. large amts serosang drainage from penrose sites, areas cleansed w/ saline prn. R thigh STSG site w/ dsd, serosang drainage shadowing through. R forearm w/ VAC intact.\n\nsocial: daughter called for update, all ques. answered.\n\na/p: doing well post op day 1 s/p L orbital enucleation, facial reconstruction for SCC. remains intubated for airway protection, doign well w/ cpap+ps. sedation being weaned, plan to attempt extubation today if +air leak, gag improves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-08 00:00:00.000",
"description": "Report",
"row_id": 1669488,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on minimal spontaneous ventilation. RSBI done ~61. BS are dim & bil, We are sxtn for small amt of thick yel to tan secretions from ETT, Plan: check air leak & ? wean to elective extubation. See Careview for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-08 00:00:00.000",
"description": "Report",
"row_id": 1669489,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-08 00:00:00.000",
"description": "Report",
"row_id": 1669490,
"text": "condition update\nplease see carevue for specifics.\n\nPt remains intubated and sedated on a ppf gtt. With the ppf lightenend, pt opening her eyes to voice and following commands inconsistently. She is able to MAE. Right eye reactive and brisk. Tmax 99.5 SR-SB. Pt's hr 50's after receiving scheduled lopressor dose. Venous and arterial pulses dopplerable in graft site. Cap refill good. Penrose drains w/ sml amts of serosang drainage. STSG site on pt's right leg w/ xeroform drsg is open to air. Right arm still bandaged w/ ace wrap. Vac dressing intact w/ sml amts of serosang drainage noted. JP to bulb sxn also at right arm w/ sml amts of serosang drainage. Pt received fentanyl for pain mgmt. No vent changes made. Pt remains on cpap 5/5 fi02 40% Pt w/ no cuff leak. Pt's neck and tongue also w/ increased swelling. Pt received a 1x dose of 10mg IV lasix and a 1x dose of iv decadron. IVF also kvo'd.\n\nPlan: continue w/ current plan of care per sicu, plastics teams. Continue to monitor resp status, checking for cuff leak. Extubate as tolerated. Pulmonary toilet. PRN electrolyte repletions. RISS for bs coverage. Continue to closely monitor graft pulses Q 2 hours. PPF gtt for sedation. Fentanyl for pain mgmt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 1669483,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated, received on vent support. We were able to switch to PSV early this morning. RSBI done ~45. ABG on PSV WNL. BS are dim & clear bil. We are sxtn for small amt of thick brownish secretions from ETT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 1669484,
"text": "nursing admit/progress note\n\npt is a 75 yo female w/ known SCC of L orbital area. admitted for L orbit exeneration, facial reconstruction involving tissue flap, vascular reconfiguring. total time in OR close to 12 hrs, pt hemodynamically stable throughout per anesth. report. pt transferred to ICU intubated, sedated. plan to wean and extub if able today.\n\nsee h+p for full medical, surgical history, medications.\n\nneuro: sedated lightly w/ propofol, prn fentanyl dosing for surgical pain. opens eyes to stimulus, nodding and shaking head at times to communicate.\n\nresp: weaned to cpap+ps 40%, at this time. abg wnl, breathing unlabored, rr teens. ls clear, dimin to bases bilat. cough, gag strong.\n\ncv: mildly hypotensive upon arrival to unit, sedation adjusted, pt repositioned w/ improvement to bp. at 0200 pt w/ sudden acute drop in bp to 50s systolic w/ aline and cuff correlating. given 1L NS w/ very good effect. graft signals checked per plastics protocol, arterial and venous signals very strong, tissue w/ brisk cap refill. R radial pulse intact, good cap refill to area.\n\ngi/gu: belly large, soft, bs hypo. og placed, sm amt old bloody output, irrigated freq to keep patent. foley patent clear yellow urine, qs.\n\nendo: glucose levels elevated, sliding scale as written.\n\nid: wbc 14, ancef as written. hypothermic on arrival, warmed w/ bair hugger to normothermia.\n\nskin: R forearm graft donor site w/ VAC intact, ACE splint on top. split thickness skin graft donor site to R thigh (tissue graft for R arm). all sutures to facial graft site intact, area edematous. large amt serosang drainage weeping from mult penrose drains.\n\nsocial: pt's daughter called for update, all questions answered, very supportive of patient. plan for visit today.\n\na/p: s/p L orbital enucleation, facial reconstruction w/ grafting for SCC to L face. hypotensive, improved w/ fluid, likely will require further resuscitation. plan to wean and extubate today if able, will monitor in light of hemodynamic issues overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 1669485,
"text": "Resp. care note - Pt. remaines intubated and vented, no cuff leak present, unable to extubate at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 1669486,
"text": "condition update\nplease see carevue for specifics.\n\npt intubated and sedated on a ppf gtt. Off the ppf gtt pt opening her eyes to voice, following commands, and mouthing words. Pt getting increasingly aggitated by thrashing about in the bed, so ppf gtt increased to keep sedated. Pt's right pupil reactive and brisk. Tmax 100.1 SR w/ occasinal to frequent PVC's. Pt's electrolytes wnl and rechecked at 1700. HR 70-90's. EKG done this am. Cardiac enzymes 2nd set drawn at 1030am. 3rd set due 1830. Pt received 1 unit PRBC this am for a hct of 26.7 post hct 27.9 Pt receiving fentanyl prn for pain mgmt. LS CTA. SBT done this am. AGB's good. Pt had no cuff leak or gag. + facial edema noted. Pt to remain intubated overnoc. Pt remains on cpap 40% Fi02 . Pt sxn'd several times for sml amts of thick, tan secretions. IVF infusing for hydration. Foley patent and draining adequate amts of clear urine. Pt's OGT is to LCWS and draining sml amts of Dark bld. Pt's L eye enucleated . flap checks done hourly and are dopplerable. STSG from Pt's right thigh w/ dsd to cover. Right forearm has vac to sxn and a jp to bulb sxn and is covered w/ an acewrap. Pt's family in to see her and updated.\n\nPlan: Continue w/ current plan of care per sicu, plastics teams. Continue to check flap pulses hourly. Wean vent settings to extubate as tolerated. Fentanyl prn for pain mgmt. RISS for bs coverage. PRN electrolyte repletions. #3 set of cardiac enzymes to be drawn @ 1830 PPF gtt for sedation. Vac and Jp to right arm. Continue to closely monitor hemodynamics.\n"
},
{
"category": "ECG",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 220476,
"text": "Baseline artifact\nSinus rhythm\nVentricular premature complex\nModest nonspecific precordial/anterior T wave changes\nSince previous tracing of the same date, ventricular ectopy now present\n\n"
},
{
"category": "ECG",
"chartdate": "2108-04-07 00:00:00.000",
"description": "Report",
"row_id": 220477,
"text": "Sinus rhythm. Non-specific inferior, anterior and lateral T wave flattening.\nEarly precordial QRS transition. Compared to the previous tracing of \nT wave flattening is more pronounced.\n\n"
}
] |
9,611 | 122,449 | This 64 year-old gentleman with a history of alcoholic cirrhosis, prostate CA s/p brachytherapy and radiation therapy, COPD, and dementia was admitted to the ICU for a 2 to 3 week history of increasing abdominal girth, bright red blood per rectum, and malaise that had been worsening d PTA. In pt found to be hypotensive and tachycardic P in 100's BP at 95/50, BP improved with 3 L NS but tachycardia persisted. On exam pt was jaundiced with tense abdominal ascites. Some bright red blood per rectum. Neurologically the pt had a tremor. Creatinine was normal. Liver enzymes found to be markedly elevated. Ceftriaxone started empirically for the possibility of subacute bacterial peritonitis. Hepatology service consulted, recommended commencing pentoxifylline for prevention of development of HRS. Pt was transferred to MICU for concern for hypotension which could have been secondary to one or all of the following possibilities 1) sepsis 2) liver failure 3) acute blood loss. In addition, given his history of alcohol abuse and the presence of tachycardia and tremor concern was also raised for alcohol withdrawal syndrome progressing to delirium tremens and CIWA protocol was started. On transfer to MICU pt went into respiratory distress, this resolved adequately with inhaler therapy and continuous positive airway pressure support. Throughout his hospital course, the patients hemodynamic status was tenuous, frequently having elevated respiratory rates along with low normal blood pressure and frequent tachycardia. Per his partner, it was established on HD 2 that he wished to be DNR/DNI from a living will he had earlier wrote. Other major events of his hospital course included a paracentesis on HD 4 that removed 2 L and resulted in some symptomatic improvement. Analysis of this fluid was remarkable only for serum ascites albumin gradient consistent with portal hypertension. Pt was generally afebrile and, until HD 6 did not appear septic. His BRBPR resolved and hematocrit remained generally stable throughout his course. In early morning of HD 7, pt was found to be in respiratory distress with oxygen saturations falling to 80-90 range and respiratory rate ranging from 30-40. Serial chest x-ray demonstrated rapidly evolvling L lung field infiltrates, consolidation and collapse consistent with aspiration pneumonia. Levofloxacin and flagyl were started along with continuous positive airway pressure support. In spite of these measures the patient rapidly deteriorated into respiratory failure. No further interventions could be performed in the patient as his code status was DNR/DNI. The patient expired on 1:30 PM on . | A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. with Valium PRN.Neuro: Pt. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter.Height: (in) 75Weight (lb): 151BSA (m2): 1.95 m2BP (mm Hg): 133/69HR (bpm): 117Status: InpatientDate/Time: at 13:51Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV cavity size. Marked spot for paracentesis. Foley patent with incteric urine out. FINAL REPORT CHEST ONE VIEW PORTABLE. Also noted on this study, which does not persist on subsequent studies, is mild tracheal narrowing at the level of the aortic arch. There is slight sclerotic appearance at the fracture line, suggesting subacute time frame of chronicity. Generalized jaundice noticed.ID: Afebrile. Single tiny gallstone or polyp is again identified along the posterior wall of the gallbladder. @2300 tried to get OOB, pulled off post pyloric tube, team aware. Small volume of ascites, insufficient for marking and bedside paracentesis. Palpable pedal pulses bilat.GI/GU: NPO due to resp. Compared to the previous tracing of there is continuedearly precordial R wave progression and slight slowing of the rate. 12:08 AM CHEST (PORTABLE AP) Clip # Reason: Verify NG tube placement. There is a small pericardial effusion. Sinus tachycardiaPoor R wave progression - probable normal variantLateral T wave changes are nonspecificLow QRS voltages in precordial leadsSince previous tracing of , no significant change Sinus tachycardiaPoor R wave progression - probable normal variantLateral T wave changes are nonspecificLow QRS voltages in precordial leadsSince previous tracing of , no significant change A small volume of ascites is present anterior to the liver and within the extreme lower quadrants bilaterally. Local anesthesia with 1% lidocaine was achieved overlying the site of entry. 12:28 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ? Evaluate for fluid reaccumulation. The portal vein is patent with hepatopetal flow. monitor resp. The PICC line was trimmed to length and advanced over a 4- French introducer sheath under fluoroscopic guidance into the superior vena cava. NG tube tip is below the hemidiaphragm. 7:47 AM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC line Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. CONTINUES ON CEFTRIAXONE.SKIN: W/D JAUNDICED. NA REPORTED TO BE 151 ON HEMOLYZED SPECIMEN, RESENT. CONT ON CEFTRIAXONE.SKIN: JAUNDICED. Lactulose TID.CV-HR 110-130 ST with short bursts of PAT rate 180's see strips in chart. Continues on inhalors.CV: HR 110s-120s, ST, this AM HR was 140s, resolved with Valium. LUNGS WITH SCATTERED RHONCHI/COARSE.GI/GU: ABD FIRM, DISTENDED-ASCITES FLUID. DIURETICS DC'D. FS Q6HRS WITH SSRI.ID: TMAX 101 WITH BAIRHUGGER ON. HCT reamins stable 30.1 (28.9)serial HCT q8hrs.Endo-started on SSRI QID with FS 168.Comfort-c/o peristant mild headaches. Foley patent with icteric clear urine out.ID: T 95.4, pt. bp stable.RESP-wearing ventimask pt had o2 sats of ~95%, lungs and throat sounded congested.had a weak nonproductive cough. DWINDLING THIS AM, MD AWARE. pmicu nursing progress 7p-7areview of systems:CV-has been slightly more tachycardic to the 110's-120 range with rare pvcs noted. pt NPO, bit can have water.endo: cont RISSaccess:2pivsocial : full code, significant other visited.plan: cont monitoring neuro status cont monitoring HCT, signs of bleeding QTc q4hr CIWA Q 1hr, goal <10 cont Valium. HCT 29 DOWN FROM 31, PLTS 93 DOWN FROM 133 AND INR UP TO 1.8. Foley patent with icteric urine out. WBC 11.2.Hepato/renal: LFTs elevate Total bili 23.5, pt. OFF TEMP DOWN TO 99.1. speach slurred/ garbled, periods of restlessness and const tremors, CIWA , goal <10, cont VALIUM 5-10mg q2-3hg. LS CLEAR WITH DIMINISHED BASES. LS CLEAR AND GREATLY DIMINISHED AT THE BASES. LYTES PER CAREVUE. AP SUPINE PORTABLE CHEST: Compared to . LS remain diminished at bases R>L. UOP 35-60CC/HR ICTERIC AND CLOUDY.FEN: LYTES PER CAREVUE. PNA FINAL REPORT INDICATION: Left lower lobe crackles and sepsis. RECEIVING LACTULOSE PNGT PLACED AND CONFIRMED BY CXR. with ascitis, +BS, inc. of greenish stool with BRBPR. LFT'S AND TBILI TRENDING DOWN. ABG DRAWN WAS 7.48/31/67/24. DURING THIS TIME PATIENT MORE TACHYPNIC AND TACHYCARDIC WITH TEMP 101. HCT dropped from 33.1 to 26.1 d/t rectal bleeding, received 1u PC. Encouraged to cough, IS provided.CV: HR 100s-120s, ST, no ectopy. Right CP angle is excluded. last Qtc 0.28.gi/gu: foley in place, u/o 20-30cc of icteric/cloudy urine, given fluid bolus 500cc with minimal response. Continues with IVF hydration D5NS with 40meq KCL at 150cc/hr.GI-NPO except clear liquids with medications. K+ 3.7, Phos 1.8, repleted with Kphos. CIWA scale 7, medicated with Valium x1 at 0800 due to HR 140s, restlessness.Resp: On RA Sats 92-96, currently pt is on NC 2L s/p scope, sats high 90s. CIWA scale 14-18 receiving valium 5mg q30-60 minuntes for CIWA >10. "O-Neuro-alert and oriented x3, initially oriented only to name.Speech is slurred and garbled at times. BP 101-126/43-65. PT IS DNR/DNI HR STARTED TO TREND DOWN TO 110'S WITH FLUID AND TEMP DECREASE. ABD ascitis, BS +, pt had broon with blood stoolx1, team aware. | 31 | [
{
"category": "Echo",
"chartdate": "2131-06-29 00:00:00.000",
"description": "Report",
"row_id": 61179,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 75\nWeight (lb): 151\nBSA (m2): 1.95 m2\nBP (mm Hg): 133/69\nHR (bpm): 117\nStatus: Inpatient\nDate/Time: at 13:51\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nAORTA: Normal aortic root diameter.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade, however study is technically suboptimal.\nValvular regurgitation could not be adequately assessed due to suboptimal\nacoustic windows.\n\nCompared with the prior study (tape reviewed) of , there is no\ndefinite change but the studies are technically suboptimal for comparison.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-29 00:00:00.000",
"description": "R WRIST(3 + VIEWS) RIGHT",
"row_id": 876225,
"text": " 10:02 AM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: ? fracture\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, s/p fall onto L wrist\n REASON FOR THIS EXAMINATION:\n ? fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall on to left wrist.\n\n Three views of the right wrist were obtained without comparisons. Please note\n that the patient indicated the region of concern to be the right wrist rather\n than the left wrist, and therefore, right wrist images were obtained.\n\n Images show a slightly impacted distal radius fracture, with both dorsal\n angulation and slight dorsal translation of the distal fragment. This does\n not clearly extend into the radioulnar or radiocarpal joints. There is slight\n sclerotic appearance at the fracture line, suggesting subacute time frame of\n chronicity. There is generalized demineralization. No other fractures are\n identified.\n\n IMPRESSION: Impacted distal radius fracture, with slight dorsal angulation\n and translation of the distal radial fragment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 876346,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumonia, infiltrates.\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, LLL crackles increased respiratory effort.\n\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia, infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with sepsis.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n to previous study of .\n\n Patchy opacity is seen in both lower lobes, which could indicate pneumonia\n versus atelectasis. If clinically indicated, please obtain PA and lateral\n radiographs of the chest.\n\n The lungs are clear otherwise. The heart and mediastinum are within normal\n limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-02 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 876549,
"text": " 10:52 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please evaluate for ascites\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with h/o prostate CA s/p xrt, alcohol abuse, now with\n asictes s/p paracentesis x 1, worsening distention, and dyspnea. Please\n re-evaluate for fluid for tap.\n REASON FOR THIS EXAMINATION:\n please evaluate for ascites\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND\n\n INDICATION FOR STUDY: Prostate cancer. Alcohol abuse. Ascites. Evaluate\n for fluid reaccumulation.\n\n Ultrasound of the abdomen reveals reaccumulation of ascitic fluid throughout\n the belly, but to a lesser degree than the study from . In\n addition, multiple fluid filled loops of small bowel are floating within this\n fluid. The bowel wall is edematous.\n\n IMPRESSION: Reaccumulation of ascitic fluid, but to a lesser volumetric\n degree than study from . We did not mark a site for tap since\n the multiple fluid filled loops of small bowel floating in the fluid make this\n a clinically dangerous procedure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-27 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 875946,
"text": " 12:28 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? cholestasis, please mark spot for paracentesis if ascites\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with h/o prostate CA s/p xrt, alcohol abuse, now with new\n asictes and jaundice\n REASON FOR THIS EXAMINATION:\n ? cholestasis, please mark spot for paracentesis if ascites is found\n ______________________________________________________________________________\n WET READ: CCqc WED 1:25 PM\n fatty liver; small amount of ascites anterior to liver and in extreme low\n quadrants not sufficient/safe for bedside tap (spot not marked)\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Alcoholic cirrhosis with increasing ascites and jaundice.\n\n ABDOMINAL ULTRASOUND: Comparison is made to a prior study dated .\n Examination is technically suboptimal due to patient habitus. Liver is\n diffusely echogenic, consistent with fatty infiltration. No focal liver\n lesions are identified, although assessment is somewhat limited. The portal\n vein is patent with hepatopetal flow. There is mild to moderate\n circumferential wall thickening and edema of the gallbladder wall without\n associated pericholecystic fluid or son sign, finding likely\n secondary to patient's underlying liver disease. Single tiny gallstone or\n polyp is again identified along the posterior wall of the gallbladder. The\n common bile duct measures 5 mm in diameter. A small volume of ascites is\n present anterior to the liver and within the extreme lower quadrants\n bilaterally. Given the small volume and location of the fluid, this was\n not felt to be safe and insufficient for bedside tap and a spot for\n paracentesis was not marked. The pancreas could not be visualized due to\n bowel gas.\n\n IMPRESSION:\n\n 1. Unchanged appearance of echogenic liver, consistent with fatty\n infiltration. Other forms of liver disease including significant hepatic\n cirrhosis and fibrosis cannot be excluded.\n 2. Small volume of ascites, insufficient for marking and bedside paracentesis.\n\n 3. Circumferential thickening and edema of the gallbladder wall without any\n additional secondary signs of cholecystitis most likely secondary to patient's\n underlying liver disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 876652,
"text": " 3:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: contd resp distress\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, incd WOB, severe ascites\n\n REASON FOR THIS EXAMINATION:\n contd resp distress\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Sepsis. Increased work of breathing.\n\n PORTABLE SUPINE AP CHEST AT 3:43: Comparison is made to the study from one\n hour earlier. A left PICC is present with the tip in the distal SVC. NG tube\n tip is below the hemidiaphragm. Heart size is unchanged. There is worsening\n volume loss in the left lung with now complete collapse or consolidation of\n the left lower lobe. There is also worsening left upper lobe opacity which\n could be due to aspiration or further atelectasis. The left effusion has\n increased in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-29 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 876261,
"text": " 3:09 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: please evaluate and mark spot of paracentesis\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with h/o prostate CA s/p xrt, alcohol abuse, now with new\n asictes and jaundice, worsening distention\n REASON FOR THIS EXAMINATION:\n please evaluate and mark spot of paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old with prostate cancer, alcohol abuse, and new ascites.\n Marked spot for paracentesis.\n\n Limited 4-quadrant ultrasound demonstrates a moderate amount of ascites\n throughout the abdomen. The greatest pocket is in the right lower quadrant\n with the patient rotated approximately 25 degrees.\n\n A spot was marked by the technician in this area. Skin to the center of\n pocket is approximately 4.5 cm. Dr. was present during the\n examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 876421,
"text": " 12:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Verify NG tube placement.\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, LLL crackles increased respiratory effort.\n\n REASON FOR THIS EXAMINATION:\n Verify NG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 64-year-old man with sepsis.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The previously identified bibasilar patchy opacity has been improving. The\n lungs are clear otherwise. The heart and mediastinum are within normal\n limits. A nasogastric tube terminates in the gastric body. No pneumothorax\n is seen.\n\n IMPRESSION: Improving bibasilar opacities indicating atelectasis versus\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-02 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 876522,
"text": " 7:47 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with alcoholic hepatitis\n REASON FOR THIS EXAMINATION:\n Please place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient needs long-term IV antibiotic therapy.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the Attending Radiologist, was present during the\n entire procedure. Dr. reviewed this case. The left arm was\n prepped in a sterile fashion. The basilic vein was localized by ultrasound and\n was patent and compressible. Local anesthesia with 1% lidocaine was achieved\n overlying the site of entry. The basilic vein was then entered under\n ultrasonographic guidance with a 21- gauge access needle. Hardcopies of the\n ultrasound images were obtained. A 0.018 guidewire was advanced under\n fluoroscopy into the superior vena cava. Based on the markers on the\n guidewire, it was determined that a length of 46 cm would be suitable for this\n PICC line. The PICC line was trimmed to length and advanced over a 4- French\n introducer sheath under fluoroscopic guidance into the superior vena cava. The\n sheath was then removed. The catheter was flushed. Final chest x- ray was\n obtained and determined the position of the tip of the PICC line at the\n junction of the SVC and right atrium. The line is ready for use. A StatLock\n was applied and the line was heplocked. There were no immediate complications.\n\n IMPRESSION: Successful placement of a 46-cm single lumen PICC line with the\n tip in the superior vena cava, ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 876649,
"text": " 2:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, effusion, edema\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, incd WOB, severe ascites\n REASON FOR THIS EXAMINATION:\n eval for pna, effusion, edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Increasing work of breathing. Evaluate for pneumonia, effusion,\n or edema.\n\n PORTABLE AP CHEST AT 2:30: Comparison is made to . NG tube tip\n remains within the stomach. The left PICC tip is in the distal SVC. There is\n evidence of volume loss in the left hemithorax with herniation of the right\n lung across the midline and leftward displacement of the anterior junctional\n line. There is no pneumothorax. The volume loss is likely in the left lower\n lobe as there is evolving retrocardiac opacity. Also noted on this study,\n which does not persist on subsequent studies, is mild tracheal narrowing at\n the level of the aortic arch. There is slight worsening opacity in the left\n upper lobe, which could be due to aspiration or asymmetrical edema, or\n pneumonia.\n\n Results were discussed with the medical team caring for the patient at 11:30\n a.m. on .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-29 00:00:00.000",
"description": "Report",
"row_id": 115532,
"text": "Sinus tachycardia. Low precordial lead voltage. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of there is continued\nearly precordial R wave progression and slight slowing of the rate. Otherwise,\nno diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-28 00:00:00.000",
"description": "Report",
"row_id": 115533,
"text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nLateral T wave changes are nonspecific\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-27 00:00:00.000",
"description": "Report",
"row_id": 115534,
"text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nLateral T wave changes are nonspecific\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-30 00:00:00.000",
"description": "Report",
"row_id": 1389164,
"text": "1900-0700 rn notes micu\n\nneuro: pt received lethargic, but easily arousable to voice, overnight became more alert, oriented x1-2, follows commands, opens eyes spont. @2300 tried to get OOB, pulled off post pyloric tube, team aware. plan: ? put NGT tommorow. pt put on 4 point restrains, 1:1 sitter. CIWA , no VAlium given.\n\nresp: NC 4L, SAT 94-95%, LS dim, weak nonproductive cough.denies SOB.\n\ncv: HR 117-120, ocass up to 125-127, ST, no ectopy. SBP 120-150's. last Qtc 0.32. Cardio ECHO: LVEF>55%, small pericardial effision, no sighs of tamponada.pt afebrile Tmax 97.2.\n\ngi/gu: foley, in place, drainge icteric/cloudy urine , u/o 20-40c/hr, team aware. ABD ascites, BS +, no stool this shift, no signs of bleeding, cont LACTOLOSE. ABD U/S shown moderate amount of ascites.\n\nskin: redness on coccyx, double guard applied.\n\nsocial: full code, partner called several times during night for update.\n\nplan: cont monitoring neuro/resp/cardio status, u/o\n ? put NGT again.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-30 00:00:00.000",
"description": "Report",
"row_id": 1389165,
"text": "Patient is placed on NIV @ 8.30 AM. Alert.coop.BS congested without wheezes.Patient treated with albuterol/atrovent*2.Tachycardic with HR 132,BP 113/32,sat 98%.Last ABG on NRM acceptable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-30 00:00:00.000",
"description": "Report",
"row_id": 1389166,
"text": "Pt. is 64 y.o. male with hx. of ETOH, Hep, COPD, Liver Failure presented with three day hx of BRBPR, hypotension, fever. EGD and colonoscopy unsignificant for source of bleeding. Transfused with PRBC, FFPs due to initial INR 2.5. CIWA scale initiated DT withrdawals, tx. with Valium PRN.\nNeuro: Pt. recieved lethargic, easily arousable, orineted x1-2, denies pain, occasionally pulling of face mask. Follows commands, MAE, +PERRLA. 1:1 sitter at bedside. No Valium required on this shift.\nResp: Pt. received in resp. disstress, c/o SOB, sats low 90s on 100%NRB, LS wheezy, diminished. Treated with Nebs, place on Bipap mask for few hours. Currently weaned to 50% Venturi mask, sats high 90s, occasional congested cough noted, no apparent resp. disstress. RR 20s-30s.\nCV: HR 120s-130s, ST, occasionally up in 140s. SBP 90s-110s. Medicated with Lasix total 60mg IVP with good diuresis (see carewiev for I&O). Palpable pedal pulses bilat.\nGI/GU: NPO due to resp. status. Abd with ascitis unchanged since yesterday. Plan parasenthesis at 1800. Foley patent with incteric urine out. Pt. inc of 2 lrg green loose stools, minimal rectal bleeding noted with cleaning excoriated anal area. Cont. on Lactulose titrate to stools/day per liver team.\nSkin: Perineal area with few small abrasions, double guard cream applied. Generalized jaundice noticed.\nID: Afebrile. WBC 11.2. Continues on Ceftaz IV.\nSocial: Partner at bedside, updated by MICU and liver teams. Will stay in waiting room overnight.\nFULL CODE.\nPlan: Cont. monitor resp. status. Will need central access, ? NGT if doesn't tolerate POs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-30 00:00:00.000",
"description": "Report",
"row_id": 1389167,
"text": "As patient improved he was removed from NIV to a NRM then to a 50% venturi mask with sat in mid 90's.Patient has liver disease,ABG displays metabolic acidosis.Ventilating with paco2 in the low 30's with good saturation.Will only provide NIV if necessary,watch sat and subjectives and objectives observation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-03 00:00:00.000",
"description": "Report",
"row_id": 1389174,
"text": "Nursing Note:\n** pt expired at official time of death of 1340 as pronounced by md. pt had been with unstable bp this shift with sbp in 60's despite 2l boluses of NS. md's did not wish to start a pressor;pt code status was dnr/dni and plan was to discuss cmo/withdrawal of care status. pt had decompensated overnight-desatted and placed on bipap with high settings and morphine gtt initiated due to reported discomfort with breathing. Partner/significant other was called to bedside overnight at 2a and made aware of grave prognosis and remained here throughout this shift. Pt hr started dropping in addition to low bp -md's asked pt to discuss prognosis via family meeting at which time pt passed away. Social work called and to unit but pt's partner with best friend (supportive) and did not wish to to have s.w. expressed emotion and support given. Partner aware to notify funeral home. post mortem care given-no autopsy to be done. cont with transport to morgue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-01 00:00:00.000",
"description": "Report",
"row_id": 1389168,
"text": "MICU NPN 7P-7A\nNEURO: INITIALLY PATIENT LETHARGIC/DROWSY, SPEECH SLURRED. ORIENTED TO SELF ONLY. RESTLESS AND PULLING AT O2 MASK. BECOMING MORE AGITATED ?CONCERN AS TO WHETHER HE WAS NOT VENTILATING AND BUILDING UP CO2 BUT THAT WAS NORMAL BY ABG. GIVEN 5MG VALIUM WITH GOOD EFFECT. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES. RESTRAINED FOR SAFETY OF LINES/TUBES. SITTER AT BEDSIDE. ABLE TO PLACE NGT FOR LACTULOSE. PATIENT MORE ALERT AND CLEARER THIS AM. ORIENTED X3, BUT STILL NEEDS REMINDERS TO NOT PULL AT EQUIPMENT. DENIED PAIN WHEN ASKED.\n\nCARDIAC: HR 105-121 ST WITH NO ECTOPY. BP 90-109/42-51. PPP. HCT 29 DOWN FROM 31, PLTS 93 DOWN FROM 133 AND INR UP TO 1.8. NO SIGNS OF BLEEDING. RECEIVED 50GM ALBUMIN AFTER PARACENTESIS.\n\nRESP: ON 50% VENTI MASK WITH RR 16-27 AND SATS 97-100%. LS CLEAR WITH DIMINISHED BASES. OCCASIONAL CONG NONPRODUCTIVE COUGH. ABG 7.41/37/88/24 LAST NIGHT.\n\nGI/GU: ABD SOFT AND SLIGHTLY DISTENDED. TAPPED FOR 2L OF ASCITES. +BS, LOOSE GREEN STOOL X3. RECEIVING LACTULOSE PNGT PLACED AND CONFIRMED BY CXR. UOP 35-60CC/HR ICTERIC AND CLOUDY.\n\nFEN: LYTES PER CAREVUE. K+ 3.3 REPLETED WITH 40MEQ KCL X2. FS 113/120. LFT'S AND TBILI TRENDING DOWN. TUBE FEEDS @20CC/HR TOLERATED WELL.\n\nID: TMAX 96.6 AXILLARY. WBC 7. ON CEFTRIAXONE.\n\nSKIN: PERINEUM RED AND EXCORIATED. DOUBLEGUARD CREAM APPLIED.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. S.O. AND FAMILY WITH QUESTIONS ABOUT PROCEDURES. INTERN SPOKE WITH S.O. ABOUT ADDRESSING CODE STATUS. HE WANTS TO SPEAK WITH THE LIVER DOCTORS BEFORE MAKES A FINAL DECISION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-01 00:00:00.000",
"description": "Report",
"row_id": 1389169,
"text": "Neuro: Pt. remains lethargic, arousable to voice, orineted x2, at times restless. Denies pain or discomfort, states \"feeling better\". Sitter remains at bedside. No Valium given this shift.\nResp: Denies SOB.From Venturi mask switched to OFM, weaned to NC 5L. LS remain diminished at bases R>L. Sats mostly high 90s, rr 20s. Encouraged to cough, IS provided.\nCV: HR 100s-120s, ST, no ectopy. SBP 90s-120s. Received Lasix 40mg at 1700, duiresed ~350.\nGI/GU: TF at goal, tolerating well. Abd. ascitis improved since parasethesis . +BS, inc. of frequent green loose stools with occasional mod. rectal bleeding. Lactulose held at 1400. Foley patent with icteric clear urine out.\nID: T 95.4, pt. placed on warming blanket at 1700, rectal temp at 1800 96.8. Continues on IV Ceftaz.\nAccess: 1 #18 PIV placed by IV nurse, bedside PICC placement unsuccessful, will need IR tomorrow.\nSkin: Perineal area excoriated, red, soar due to frequent stooling, double guard applied, skin care provided frequently.\nEndo: BS checked QID, covered per sliding scale.\nSocial: Significant other at bedside, updated by team and nursing, will initiate long term care planning tomorrow with case management.\nCode status changed to DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-02 00:00:00.000",
"description": "Report",
"row_id": 1389170,
"text": "MICU NPN 7P-7A\nNEURO: RECEIVED PATIENT DOZING, EASILY AROUSABLE. ORIENTED X3. FOLLOWING COMMANDS AMD MOVING ALL EXTREMITIES. LATER MORE LETHARGIC AND DIFFICULT TO AROUSE EVEN WITH ABG STICK. MUMBLING, UNABLE TO ASSESS ORIENTATION. NOT FOLLOWING COMMANDS BUT WAS LOCALIZING PAIN. DURING THIS TIME PATIENT MORE TACHYPNIC AND TACHYCARDIC WITH TEMP 101. PREVIOUS LACTULOSE HELD # OF STOOLS. RECEIVED 0200 DOSE AND THIS AM SLIGHTLY MORE AROUSABLE. THIS MORNING ABLE TO WHISPER THAT HE WAS IN . STILL LETHARGIC. NA REPORTED TO BE 151 ON HEMOLYZED SPECIMEN, RESENT. RESTRAINED FOR SAFETY OF LINES/TUBES. DENIED PAIN WHEN ABLE. NO VALIUM GIVEN THIS SHIFT.\n\nCARDIAC: HR TREENDING UP TO 130'S AT BEGINNING OF SHIFT. THOUGHT IS THAT PATIENT WAS DRY. ALSO FEBRILE. MAINTAINING BP. GIVEN 500CC FB WITH MODERATE EFFECT. HR STARTED TO TREND DOWN TO 110'S WITH FLUID AND TEMP DECREASE. HAS BEEN IN ST WITH NO ECTOPY. BP 101-126/43-65. PPP. HCT STABLE @30, INR 1.6. GI ASPIRATES NOTED TO BE OB+.\n\nRESP: RECEIVED ON 5L N/C WITH RR TRENDING UP TO THE 30'S. SATS 97-100% BUT PLETH DIFFICULT TO MAINTIN. ABG DRAWN WAS 7.48/31/67/24. SAT DOWN TO 92%. PLACED ON 50% VENTI MASK. WITH SATS UP TO 96%. RR COMING DOWN BACK TO MID 20'S. LS CLEAR AND GREATLY DIMINISHED AT THE BASES. CONCERN THAT ASCITES REACCUMULATING AND CAUSING RESP COMPROMISE. OCCASIONAL CONG NONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT AND SLOWLY BECOMING MORE DISTENDED. +BS. SEVERAL LOOSE STOOL. 1ST STOOL BLOODY BUT HAVE RESULTED FROM MUSHROOM CATH EARLIER INSERTED LATER STOOL GREEN AND LOOSE. NGT IN PLACE. UOP 55-15CC/HR. DWINDLING THIS AM, MD AWARE. URINE ICTERIC AND CLEAR. CREAT STABLE.\n\nFEN: THOUGHT TO BE DRY AND RESPONDED TO 500CC FB. WAS WRITTEN FOR LASIX AND SPIRONOLACTONE THIS AM, SPOKE WITH TEAM AND THEY WILL REEEVALUATE THAT DECISION ON , HOLD FOR NOW. LYTES PER CAREVUE. CHEM WAS HEMOLYZED AND RESENT. NA 150, MD AWARE. WILL NEED FREE WATER WITH TUBE FEEDS. K+ WILL NEED REPLETION. TUBE FEEDS @30CC/HR WITH MINIMAL RESIDUALS. LFTS TRENDING UP. FS Q6HRS WITH SSRI.\n\nID: TMAX 101 WITH BAIRHUGGER ON. OFF TEMP DOWN TO 99.1. WBC 10 WITH LA OF 2.3. CONTINUES ON CEFTRIAXONE.\n\nSKIN: W/D JAUNDICED. PERI AREA RED AND EXCORIATED, DOUBLEGUARD CRWAM APPLIED.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: DNR/I. S/O WENT HOME. PLAN FOR IR TODAY FOR PICC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-02 00:00:00.000",
"description": "Report",
"row_id": 1389171,
"text": "NURSING PROGRESS NOTE 0700-1900 HOURS:\n** DNR/DNI\n\n** ALLERGY: NKDA\n\n** ACCESS: PICC LEFT ARM, I PIV\n\nNEURO: LETHARGIC. INTERMITTENTLY ABLE TO ANSWER YES AND NO QUESTIONS WITH MUFFLED VOICE AND WAS ABLE TO SAY HE WAS AT . CONT TO RECEIVE LACTULOSE DOSES TODAY AND STOOLED X 4. DID NOT FOLLOW ANY COMMANDS ; INTERMITTENTLY TRIED TO HELP WITH TURNS MIXED WITH RESISTING CARE. THIS AM SODIUM OF 150-PM LABS SENT AND PENDING. RESTRAINTS IN PLACE TO BIL ARMS FOR SAFETY-DOES ATTEMPT TO PULL OFF O2 MASK AND HAS REPORTEDLY PULLED MANY NGTS'S.\n\nCARDIAC: HR 100-120 WITH ONE BURST OF 159 THIS AM-RESOLVED IMMED ON OWN WITHOUT INTERVENTION. THOUGHT TO BE DRY-DIURETICS DC'D; DID NOT GIVEN ANY BOLUSING TODAY; BP HAS BEEN STABLE BUT RECEIVED SOME FLUID OVERNIGHT. HAS BEEN IN ST WITH NO ECTOPY. SBP 95-120'S. LAST HCT 29.9, INR OF 1.6\n\nRESP: PT RECEIVED ON 50% VENTI MASK-SATS WERE 97-99%-TITRATED DOWN TO 4L NC-SLOWLY TRENDED DOWN TO 92%-PLACED BACK ON 50% MASK NEEDING TO GO DOWN TO IR FOR PICC PLACEMENT IN ADDITION TO LOWER SATS. SATS CAME UP TO > 95%. RR IN 20'S. LUNGS WITH SCATTERED RHONCHI/COARSE.\n\nGI/GU: ABD FIRM, DISTENDED-ASCITES FLUID. WENT TO U/S TODAY TO EVALUATE FOR TAP-TO MUCH BOWEL AROUND AREA WHERE TAP WAS NEEDED. ON LACTULOSE ATC AS ORDERED-LOOSE STOOLS X 4 -LACTULOSE CONT PT . MUSH CATH INSERTION ATTEMPTED BY FELLOW NURSE-APPEARED WITH BSMALL AMT BLOODY RETURN-REMOVED AND RECTAL INC BAG PLACED-WILL CONT TO ASSESS. FOLEY INPLACE-INCTERIC URINE WITH BORDERLINE OUTPUT AT 15-30CC/HR. MORNING BUN/CR 11/0.8. DIURETICS DC'D. TF'S ARE DELIVER AT 20CC/HR VIA NGT WITH MINIMAL RESIDUALS. FREE WATER ADDED TO REGIMEN TO HELP IMPROVE SODIUM LEVEL.\n\nID: AFEBRILE TODAY. WBC THIS AM OF 9.7 (DOWN SLIGHTLY). CONT ON CEFTRIAXONE.\n\nSKIN: JAUNDICED. NO OPEN AREAS OF BREAKDOWN.\n\nPSYCHOSOCIAL: PARTNER AT BEDSIDE-UPDATED BY NURSE AND FINDINGS-CONT TO SUPPORT AND UPDATE.\n\nDISP: CONT TO ASSESS NEED FOR PARACENTESIS AS APPROPRIATE. LAB REPLETION, ATTEMPT TO CORRECT SODIUM WITH FW. CONT MED REGIMEN/ICU SUPPORTIVE CARE. PT IS DNR/DNI\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-03 00:00:00.000",
"description": "Report",
"row_id": 1389172,
"text": "pmicu nursing progress 7p-7a\nreview of systems:\nCV-has been slightly more tachycardic to the 110's-120 range with rare pvcs noted. bp stable.\n\nRESP-wearing ventimask pt had o2 sats of ~95%, lungs and throat sounded congested.had a weak nonproductive cough. after his turn at 12am his sats were ~95%.turned onto L side. ~ 2am noted to have gradually decreasing sats to ~80%, lowest 78%.pt also less responsive.\nplaced on 6L nasal cannula with no improvement- a 100% NRB was added.\nno real improvement.CXR done.abg with po2 63, pco2 59 and pH 7.26.pt then placed on bipap.noted to have decreased inflation on L side of chest with inspiration-repeat cxr done-looked worse. decided against CT due to inability to lie flat, bipap and instability.pt currently on bipap with sats 92.\n\nGI-abd is firm and distended with ascites-hypoactive bowel sounds.\npassing freq liquid green stools.had been receiving tube feeds-these were held once o2 sats dropping.on ppi.\n\nID-afebrile.am wbc pnd.started on clindamycin for ?aspiration pneumonia.also on ceftriaxone.\n\nNEURO-had been lethargic all evening-did resist during turns, bathing.received lactulose x 1, then held due to constant diarrhea.\nwas less responsive to partner upon his return.was tx with 1 mg ivp morphine and started on a drip at 1 mg/hr.partner encouraging pt to interact.\n\nF/E-on free water boluses.held 4am one due to hypoxia,increasing ascites.has had minimal urinary output of brown cloudy urine.please see am labs-pnd.\n\nSKIN-rectal bag falling off begining of shift.perianal area is beet red and raw looking with few open spots.double guard cream applied after each freq washing.otherwise skin looks grossly intact.\n\nIV ACCESS-has a PICC L antecub\n\nSOCIAL-partner in this evening and then called back in when sats dropped precipitiously.very devoted and concerned-focusing on monitor and minute details.looks shaky and exhausted.is at bedside.has met with doctors.\n\na-pt with sudden drop in sats-? aspiration pneumonia vs other etiology.\n\nP-will support with antibx, bipap.partner understands pt cannot travel to CT, etc.increase morphine to patients comfort.continue with good skin care.need to have freq discussions with partner to update and clarify patients status.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-03 00:00:00.000",
"description": "Report",
"row_id": 1389173,
"text": "Respiratory Care\nRespiratory status deteriorated overnight. Breathing became increasingly labored with desaturation down to 70s on 100% non rebreather +nasal prongs. CXR- increased effusion on left. Vision bipap started on 100% 20/5 with slow improvement in sat up to 90-91%; appears comfortable on mask.\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 876020,
"text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: GASTROINTESTINAL BLEED;ASCITES;FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sepsis, LLL crackles\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left lower lobe crackles and sepsis.\n\n AP SUPINE PORTABLE CHEST: Compared to . Right CP angle is\n excluded. The heart size is within normal limits. The mediastinal and hilar\n contours are unremarkable. Multiple lines overlying the chest. There is\n stable widening of the right paratracheal and azygos contours, unchanged from\n prior. The lungs were visualized are clear.\n\n IMPRESSION:\n 1) No evidence of pneumonia; right CP angle excluded.\n 2) Stable right paratracheal thickening, unchanged from .\n 3) Probable emphysema.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-27 00:00:00.000",
"description": "Report",
"row_id": 1389158,
"text": "MICUB 1800-1900 RN Note\n Adm to MICUB from ED 64yo male with 3day BRBPR feeling weak. Brought to ED by ambulance hypotensive SBP 90 ST 100-110, Temt 102, Active BRBPR x3 2PIV established and Fluid resustiation. ABD U/S revealled sm ascites and fatty liver lactate 3.5, hct 35.\nAdm to MICUB for monitoring and plan EGD/colonscopy.\n\nNeuro: awake alert oriented x3 follow commands, trembulous. Pupils 3mm equal react , equal strength.\n\nCV: SR-ST no ectopy NIBP sbp 100-110 MAPS>60 IV Access 2 PIV NS 500cc/hr.\n\nResp: RA Sat 92-95%, Lungs clear dim Mid/lower lobes.\n\nGI: abd distednded + BS Inc BRBPR mod amt.\n\nFoley: Icteric urine.\n\nSocial: Significant other present . code status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-29 00:00:00.000",
"description": "Report",
"row_id": 1389162,
"text": "1900-0700 rn notes micu\n\nneuro: pt received A/Ox2-3, at time needs to be reoriented in place follows commnads, open yes spont. speach slurred/ garbled, periods of restlessness and const tremors, CIWA , goal <10, cont VALIUM 5-10mg q2-3hg. explaine to pt about foley, but pt's const asking to go to the bathroom. @ 0400 was trying to OOB/ confused/agitated, d/ced x2 2 piv received,VAlIUM 5mg, put 4-points restrains, pt needs 1:1 siitter, but no staff avalable.\n\nresp: RA sat 94-96%, LS CLEAR with episode of exp wheezing, cont inhaler.\n\ncv: HR 117-120, rare PAC's, with episode x1 of V tach. SBP 130-150. K+ 3.7, Phos 1.8, repleted with Kphos. HCT dropped from 33.1 to 26.1 d/t rectal bleeding, received 1u PC. morning labs pending. last Qtc 0.28.\n\ngi/gu: foley in place, u/o 20-30cc of icteric/cloudy urine, given fluid bolus 500cc with minimal response. ABD ascitis, BS +, pt had broon with blood stoolx1, team aware. pt NPO, bit can have water.\n\nendo: cont RISS\n\naccess:2piv\n\nsocial : full code, significant other visited.\n\nplan: cont monitoring neuro status\n cont monitoring HCT, signs of bleeding\n QTc q4hr\n CIWA Q 1hr, goal <10 cont Valium.\n sitter 1:1.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-29 00:00:00.000",
"description": "Report",
"row_id": 1389163,
"text": "Neuro: Pt. received lethargic, easily arousable, oriented x . Follow commands, verbalizes, speech slurred. MAE, +PERRLA, intact cough/gag. Denied pain. Currently asleep s/p 100mcg of Fentanyl, 2mg of Versed for EGD.\nSitter remained at bedside untill 3p.m, significant other will stay untill 2100. At times pt. noted to pull on tubes, move around in bed, soft limb restrains on for safety. CIWA scale 7, medicated with Valium x1 at 0800 due to HR 140s, restlessness.\nResp: On RA Sats 92-96, currently pt is on NC 2L s/p scope, sats high 90s. Denies SOB, occasional coughing noted, nonproductive. LS diminished. Continues on inhalors.\nCV: HR 110s-120s, ST, this AM HR was 140s, resolved with Valium. OTc measured at 0800 0.35. BP 110s-130s/ 60s-70s. Palpable pedal pulses. UO 30-60cc/hr.\nGI/GU: Abd. with ascitis, +BS, inc. of greenish stool with BRBPR. EGD and colonoscopy performed with no source of bleeding indetified, ? anal area due to multip. small skin breakdow areas. Pt's INR was 2.5 this AM, given Vit K and 2u FFPs. 1300 Hct 31. Post-pyloric tube placed during EGD, will start TF tonight. Foley patent with icteric urine out. Abd u/s ordered to evaluate increased ascitis, possible tap.\nRt. wrist x-ray taken today, showed few weeks old fracture, OT will place splint tomorrow.\nID: Pt slightly hypothermic with T 95.9, denies being cold, covered with blankets. WBC 11.2.\nHepato/renal: LFTs elevate Total bili 23.5, pt. is followed by hepatology.\nSocial: Partner at bedside, updated by status and plan of care by liver and MICU teams.\nFULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-28 00:00:00.000",
"description": "Report",
"row_id": 1389159,
"text": "cv:run of vtach~ 20 beats ekg done and pt received 4 grams mag. this a.m. sr to afib ekg done hr up to 120's. fluid boluses given throughout night for increase hr..low bp low urine ouput. 500 ccns bolus times 2 i 500 cc d5ns bolus. hr decreased with fluid boluses and uo improved a bit from a low of cc/hr to 25-30 cc/hr a.m. K = 2.9 so pt received 40 kcl po times 2 also phosphorous low so received po phosphorous repletion.\n\ngi: abd distended. positive bowel sounds. bright red blood per rectum times 2.. mixed with liquid brown stool,\n\ngu: uo 5-35 cc/hr icteric.\n\nresp: after first dose of valium o2 sat decreased to 92 % so 4 liters prongs applied,sats increased to96-97 %.bs coarse and diminished at bases\n\nintegumentary: area around anus is excoriated. doublegard applied\n\nneuro: ciwa scale..see careview. pt with increase tremors, increase restless and disorientation and anxiety also increase hr .so valium 5 iv given times 4 ...last dose at 0630.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-28 00:00:00.000",
"description": "Report",
"row_id": 1389160,
"text": "cv: cardiac echo ordered.\n\nresp: o2 decreased to 2 l nc sats 06 % so o2 removed o2 sat on room air= 95 %\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-06-28 00:00:00.000",
"description": "Report",
"row_id": 1389161,
"text": "MICU Nursing Progress Note\nS-\"I'm thirsty, can I have some more water?\"\nO-Neuro-alert and oriented x3, initially oriented only to name.Speech is slurred and garbled at times. Periods of restlessness and constant tremors starting during the early morninig. CIWA scale 14-18 receiving valium 5mg q30-60 minuntes for CIWA >10. Good calming effect and decrease in HR appropiately. Lactulose TID.\nCV-HR 110-130 ST with short bursts of PAT rate 180's see strips in chart. QTC V3 .69 team aware. Following serial electrolytes closely. Repeat K+ 3.6 (2.9) and Magnesium 2.3 (1.6). SBP 110-130/\nResp-LS diminished at bases with O2 sats 92-95% on RA. h/o COPD on inhalers, no cough or sputum.\nID afebrile on cefriaxone\nGU-foley draining 10-15cc/hr urine icteric. Continues with IVF hydration D5NS with 40meq KCL at 150cc/hr.\nGI-NPO except clear liquids with medications. no c/o nausea or emesis. Small incontinent stools loose green with BRB mucous. Perianal area is very excoriated and bleeding. Using barrier cream. HCT reamins stable 30.1 (28.9)serial HCT q8hrs.\nEndo-started on SSRI QID with FS 168.\nComfort-c/o peristant mild headaches. No c/o pain right wrist h/o fall and plan for xray when pt is stable.\nSocial-significant other calling and visiting. Concerned and supportive.\nAccess-2 PIV.\nCode Status-Full\nA/P-Stable GIB, now with active delirium tremors day #3 last ETOH.\nNPO for possible endoscopy.\nCheck QTC q4hrs.\nContinue to closely monitor serial electrolytes and HCT.\nCIWA scale q1hr until total < 10, aggressive benzo Rx.\nAssessment for a bedside sitter per psych consult.\nContinue to keep pt and family aware of POC as discussed in multi disciplanary rounds.\n\n"
}
] |
74,394 | 105,310 | 52 yo female with history of hypertension, congestive heart failure, and asthma with an upper respiratory tract infection who presented with acute mental status changes and left proximal humerus fracture s/p fall and was found to have pneumonia, intubated for airway protection and respiratory distress. . # Respiratory distress: She was not requiring high amounts of oxygen initially. CT chest showed scattered nodular infiltrates suggestive of pneumonia. It was unclear whether this was a bacterial superinfection from her viral URI, aytpical pneumonia, or aspiration pneumonia secondary to her acute mental status changes. CTA did not reveal a PE. Microbiology work-up for respiratory infection, including influenza DFA, urine legionella antigen, MRSA swab, and sputum culture, was negative. Bronchoscopy with broncheoalveolar lavage showed no organisms. Patient was extubated and remained stable. She was empirically treated for severe community-acquired pneumonia with ceftriaxone, vancomycin, and levofloxacin, then transitioned to ceftriaxone and doxycycline given concern for QT prolongation on levofloxacin, for a 7-day total course of antibiotics. Patient was also treated with oseltamivir x 5 days despite negative influenza A. Antibiotics and oseltamivir were stopped on day of discharge due to patient's resolved respiratory symptoms and completed course. . # Acute mental status changes: Her presentation was initially concerning for meningitis/encephalitis, however CSF was negative for growth of any organisms. Head CT and MRI did not show any acute pathology. EEG showed mild encephalopathy without evidence of seizure. She had received Ativan, morphine, and possibly Dilantin at the OSH; however, she was altered prior to arrival and had a negative tox screen. Her mental status returned to baseline after extubation. She was kept on telemetry on the floor and had no recorded events. Her transthoracic echo was normal without valvular abnormalities. In the end, her change in mental status was thought to be possibly due to a concussion from a mechanical fall as pt denied loss of sensation, chest pain, shortness of breath, dizziness, palpitations or any prodrome to fall. Patient insisted that she simply lost her balance and may have tripped over one of her dogs sleeping on the floor. She was at her baseline, alert and oriented, on discharge. . # Left proximal humeral fracture: Patient suffered a fracture of her left proximal humerus s/p her fall at home. Orthopedic consult recommended a sling for her arm, and she was given Percocet and Tylenol as needed for her pain. She was discharged with home PT and has a scheduled appointment with ortho in 2 weeks. . # Hypertension: Her antihypertensives were held initially in the ICU on sedation, then restarted on the floor with normal blood pressure on discharge. . # Congestive heart failure: She was not noted to be volume-overloaded on exam throughout her hospitalization. Her TTE showed a left ventricular ejection fraction > 55%. | Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. # L humeral fracture: - Needs sling, likely nonoperative - Ortho following, appreciate recs # HTN: Was on triamterene/HCTZ and verapamil at home - have been holding antihypertensives for now - given only peripheral access and concern for sepsis will continue to hold for now and treat prn # CHF: Not on ACEI, , or Lasix at home. # L humeral fracture: - Needs sling, likely nonoperative - Ortho following, appreciate recs # HTN: Was on triamterene/HCTZ and verapamil at home - have been holding antihypertensives for now - given only peripheral access and concern for sepsis will continue to hold for now and treat prn # CHF: Not on ACEI, , or Lasix at home. # L humeral fracture: - Needs sling, likely nonoperative - Ortho following, appreciate recs # HTN: Was on triamterene/HCTZ and verapamil at home - have been holding antihypertensives for now - given only peripheral access and concern for sepsis will continue to hold for now and treat prn # CHF: Not on ACEI, , or Lasix at home. # L humeral fracture: - Needs sling, likely nonoperative - Ortho following, appreciate recs # HTN: Was on triamterene/HCTZ and verapamil at home - have been holding antihypertensives for now - given only peripheral access and concern for sepsis will continue to hold for now and treat prn # CHF: Not on ACEI, , or Lasix at home. # L humeral fracture: - Needs sling, likely nonoperative - Ortho following, appreciate recs # HTN: Was on triamterene/HCTZ and verapamil at home - have been holding antihypertensives for now - given only peripheral access and concern for sepsis will continue to hold for now and treat prn # CHF: Not on ACEI, , or Lasix at home. # HTN: - hold antihypertensives for now . # HTN: - hold antihypertensives for now . # HTN: - hold antihypertensives for now . # HTN: - hold antihypertensives for now . Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Respiratory failure, acute (not ARDS/) Assessment: Pt remains intubated. Was admitted to OSH following fall ing Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: Fracture, other Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: Fracture, other Assessment: Action: Response: Plan: was cleared of C-fracture. was cleared of C-fracture. Altered mental status (not Delirium) Assessment: Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr. Altered mental status (not Delirium) Assessment: Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr. Altered mental status (not Delirium) Assessment: Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr. Here, CTA s PE, LP failed treated with acyclovir, vanco, ctx, flagyl. Fall likely d/t medical illness, ortho eval of humeral fx. The position of the previously too far advanced ETT terminating in the proximal portion of the right main bronchus has been adjusted. Normal PAsystolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Right ventricular chamber size and free wall motion arenormal. The diameters of aorta at the sinus, ascending and arch levels arenormal. Left ventricular function.Height: (in) 62Weight (lb): 180BSA (m2): 1.83 m2BP (mm Hg): 140/82HR (bpm): 65Status: OutpatientDate/Time: at 15:00Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%decrease during respiration (estimated RA pressure (0-5mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Mild mitral annularcalcification. CT OF THE CHEST WITH AND WITHOUT CONTRAST: The ET tube has been withdrawn since the prior chest radiograph and is now in appropriate position. Mild mitral regurgitation withnormal valve morphology. The acromioclavicular joint demonstrates mild degenerative spurring. Noted is partial opacification of the left mastoid air cells. The mitral valve appearsstructurally normal with mild [1+] mitral regurgitation. FINDINGS: An ET tube is seen ending in the proximal right main stem bronchus. Subjective Intubated. Subjective Intubated. Subjective Intubated. Subjective Intubated. Left humeral fracture incompletely imaged. Multilevel neural foraminal narrowing is noted, mild on the right at C3-4 level, moderate-to-severe at C5-6 level on both sides, and moderate at C6-7 level on both sides, from uncovertebral, disc and facet osteophytes. The estimated cardiac index isnormal (>=2.5L/min/m2). A left humeral head fracture is incompletely imaged. NG tube is seen with its sideport ending within the esophagus superior to the GE junction. Reversal of cervical lordosis, multilevel degenerative changes as described above, with moderate-to-severe neural foraminal narrowing at C5-6 level and C6-7 level, along with mild spinal canal stenosis, evaluation of the intrathecal contents being limited on the present study. NG tube ending in the esophagus. No AR.MITRAL VALVE: Normal mitral valve leaflets. There is an 8x9 mm rounded lesion in the right parotid gland with low signal on T1 and T2 weighted images, and low level enhancement after gadolinium. | 49 | [
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518774,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen:\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Neuro:\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518480,
"text": "Chief Complaint: altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:00 PM\n BRONCHOSCOPY - At 03:41 PM\n evidence of trauma thought to be from intubation. Old blood. BAL\n performed\n ARTERIAL LINE - START 06:51 PM\n LUMBAR PUNCTURE - At 08:26 PM\n MAGNETIC RESONANCE IMAGING - At 10:15 PM\n Trop <0.01 --> 0.20 --> 0.09\n EKG - At 12:20 AM: unchanged from baseline\n FEVER - 101.1\nF - 08:00 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:03 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:51 PM\n Fentanyl - 10:30 PM\n Midazolam (Versed) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (80 - 125) bpm\n BP: 111/67(84) {99/57(72) - 150/91(111)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,667 mL\n 1,109 mL\n PO:\n TF:\n IVF:\n 537 mL\n 1,109 mL\n Blood products:\n Total out:\n 538 mL\n 260 mL\n Urine:\n 538 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,129 mL\n 849 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 8\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 8 cmH2O\n Plateau: 18 cmH2O\n Compliance: 43.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/45/114/22/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bronchial: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bruising on left shoulder\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 10.4 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.5 %\n 7.4 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n WBC\n 7.8\n 7.4\n Hct\n 34.5\n 30.5\n Plt\n 364\n 309\n Cr\n 0.9\n 0.8\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n Other labs:\n PT / PTT / INR:13.4/24.7/1.1,\n CK / CKMB / Troponin-T:330/5/0.09 TROP <0.01\n 0.20\n 0.09\n ALT / AST:23/27, Alk Phos / T Bili:68/0.3\n Ca++:7.7 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs:\n Source: LP; TUBE#2\n CSF\n Chemistry\n Protein\n 45\n Glucose\n 78\n CSF\n WBC\n 2\n RBC\n 8\n Poly\n 3\n Lymph\n 75\n Mono\n 22\n EOs\n SOURCE: LP TUBE #4\n Imaging:\n ? need for NG tube to be advanced\n ECG:\n Small ST depressions V4-V6\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FRACTURE, OTHER\n PNEUMONIA, OTHER\n HYPERTENSION, BENIGN\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - at this point still too altered to extubate\n - wean sedation\n - cont empiric CTX, vanc, and levaquin\n # Acute mental status changes: Concerning for meningitis/encephalitis.\n CSF and h/o of URI could be c/w aseptic meningitis. Currently, she is\n too sedated for an adequate neuro exam. Reportedly, her neuro exam was\n normal at . CT head does not show any acute pathology. be a\n concussion from the fall. She also had ativan, morphine, and possibly\n dilantin at the OSH; however, she was altered prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and\n .\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO\n .\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518769,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n EEG - At 09:30 AM\n BRONCHOSCOPY - At 12:50 PM\n INVASIVE VENTILATION - STOP 02:30 PM\n ARTERIAL LINE - STOP 08:00 PM\n \n - Started tamiflu\n - Stopped acyclovir, vanc\n - Cont levo, cftx (decreased dose)\n - Bronch looked like old blood, nothing new; Got extubated\n - CT neck no acute fx, multilevel DJD mild spinal canal stenosis\n - MRI no acute IC process, chronic small vessel disease, R parotid\n enhancing nodule (ddx: pleomorphic adenoma)\n - EEG mild encephalopathy, nothing focal\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 871 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 631 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Imaging: CT C-SPINE W/O CONTRAST Study Date of 11:32 AM\n PRELIMINARY REPORT:\n There are no acute fractures. There is multilevel degenerative disease\n of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple\n levels, most pronounced at C5-C6 with moderate-severe neural foraminal\n narrowing on both sides.\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n EEG :\n IMPRESSION: This is an abnormal routine EEG due to a mildly slow and\n disorganized background. There were no focal, lateralized or\n epileptiform abnormalities noted. The background is suggestive of a\n mild encephalopathy.\n Microbiology: DFA : Negative for Influenza A and B\n CSF :\n GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO\n MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n Blood Cx : NGTD\n VIRAL CULTURE (Preliminary):\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518773,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n EEG - At 09:30 AM\n BRONCHOSCOPY - At 12:50 PM\n INVASIVE VENTILATION - STOP 02:30 PM\n ARTERIAL LINE - STOP 08:00 PM\n \n - Started tamiflu\n - Stopped acyclovir, vanc\n - Cont levo, cftx (decreased dose)\n - Bronch looked like old blood, nothing new; Got extubated\n - CT neck no acute fx, multilevel DJD mild spinal canal stenosis\n - MRI no acute IC process, chronic small vessel disease, R parotid\n enhancing nodule (ddx: pleomorphic adenoma)\n - EEG mild encephalopathy, nothing focal\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 871 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 631 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Imaging: CT C-SPINE W/O CONTRAST Study Date of 11:32 AM\n PRELIMINARY REPORT:\n There are no acute fractures. There is multilevel degenerative disease\n of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple\n levels, most pronounced at C5-C6 with moderate-severe neural foraminal\n narrowing on both sides.\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n EEG :\n IMPRESSION: This is an abnormal routine EEG due to a mildly slow and\n disorganized background. There were no focal, lateralized or\n epileptiform abnormalities noted. The background is suggestive of a\n mild encephalopathy.\n Microbiology: DFA : Negative for Influenza A and B\n CSF :\n GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO\n MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n Blood Cx : NGTD\n VIRAL CULTURE (Preliminary):\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F HTN, CHF, asthma recent URI sx c cough /\n weakness / malaise x1 week, found down by niece, confused but\n conscious, BIBA to OSH, head / neck CT negative, L humeral fx -\n transferred to , intubated on arrival. Bronch, art line, LP o/n.\n Exam notable for Tm 101.1 BP 110/60 HR 95 RR 14 with sat 96 on VC 550x8\n 5 0.4 7.37/45/114. Minimally reactive. PERRL CTA B. RRR s1s2 2/6Sm.\n Soft +BS. No edema. Labs notable for WBC 7K, HCT 30, K+ 3.5, Cr 0.8.\n Agree with plan to manage acute encephalopathy and respiratory failure\n with antibiotics for CAP - will use CTX, levo and tamiflu. Await BAL\n results, continue flu precautions for now. Given hemoptysis and concern\n for tracheal lac, will rebronch today to confirm resolution and to\n exclude lower bleeding source. Continue propofol for sedation and\n transition to PSV. For altered mental status, LP negative for\n infectious process, will check spot EEG and f/u MRI read. Fall likely\n d/t medical illness, ortho eval of humeral , need clinical\n clearance of c-spine following extubation. Will also check echo and\n continue to hold antihypertensives in the setting of medical illness\n and bump in troponins. Remainder of plan as outlined above.\n ADDENDUM\n Bronch with substantial improvement in bloody secretions, no\n lower bleeding source identified. See note in MetaVision for details.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:52 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518775,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen:\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Neuro:\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518884,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 62 y o lady with HTN, CHF, asthma, here s/p fall/being found\n down, AMS, ?CAP, now extubated\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Narrowed to Levo + CTX for CAP\n Tamiflu added empirically\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Colace\n Heparin 5000 TID\n Levoflox 750 Q48 hours\n Singulair 10 mg daily\n ASA 325 daily\n Ranitidine 150 \n Tamiflu 75 \n CTX 1gm Q24 hours\n PRNs: morphine 2 mg x 1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate\n Neck: supple, no TTP\n Chest: scattered R ant rales, no wheezes\n CV: RRR, no murmurs\n Abd: soft, NT/ND + BS\n Extr: warm, no edema, R shoulder TTP\n Neuro: awake, A + O x 3, moving all extr\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Micro: NP swab neg for flu, BAL: insufficient cells\n Studies:\n MRI head : IMPRESSION: 1. No evidence of acute intracranial\n process. 2. Nonspecific T2/FLAIR hyperintensities in the\n periventricular and subcortical white matter, likely due to chronic\n small vessel ischemic disease. 3. Right parotid enhancing nodule.\n Differential includes pleomorphic adenoma. Clinical correlation\n recommended.\n EEG: mild encephalopathy\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress, now\n extubated.\n 1. Respiratory distress: extubated yesterday, imaging c/w atypical\n PNA, bacterial vs. viral. NP flu swab neg, insufficient cells on BAL.\n Repeat bronch yest with much less blood, extubated and no hemoptysis.\n 100% on 2L today.\n - Cont Levo + CTX for CAP\n - Cont Tamiflu\n - H1N1 PCR to State lab\n - wean O2\n 2. Acute mental status changes: LP neg for meningitis/encephalitis.\n MRI unremarkable. No SZ on EEG. MS clear this am, recalls the fall and\n denies LOC, however, was confused on presentation to OSH.\n - monitor\n 3. s/p fall: patient today recalls all events, and denies LOC. Denies\n any CV symptoms as prodrome.\n - continue tele\n - consider oupt echo\n 4. Troponin bump; trending down, likely demand in a setting of acute\n illness/fall.\n - continue ASA\n 5. L humeral fracture: ortho following, non-operative mgmt.\n - Needs sling, likely nonoperative\n - PT/OT consults\n 6. HTN: Was on triamterene/HCTZ and verapamil at home\n - monitor BPs, consider restarting home Rx once high\n 7. Asthma: no wheezes on exam.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: H2 blocker\n Communication: with patient\n Code status: Full code\n Disposition: stable for floor\n Total time spent: 30 min CCT\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518954,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n EEG - At 09:30 AM\n BRONCHOSCOPY - At 12:50 PM\n INVASIVE VENTILATION - STOP 02:30 PM\n ARTERIAL LINE - STOP 08:00 PM\n \n - Started tamiflu\n - Stopped acyclovir, vanc\n - Cont levo, cftx (decreased dose)\n - Bronch looked like old blood, nothing new; Got extubated\n - CT neck no acute fx, multilevel DJD mild spinal canal stenosis\n - MRI no acute IC process, chronic small vessel disease, R parotid\n enhancing nodule (ddx: pleomorphic adenoma)\n - EEG mild encephalopathy, nothing focal\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 871 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 631 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate, pleasant\nI want to go home\n Neck: supple, no TTP\n Chest: Scattered rhales\n CV: RRR, no murmurs, rubs, gallops\n Abd: soft, NT/ND + BS\n Extr: warm, no edema, R shoulder TTP, moving R fingers w/o difficulty,\n good R radial pulse, nl cap refill\n Neuro: awake, A + O x 3, moving all extremities\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Imaging: CT C-SPINE W/O CONTRAST Study Date of 11:32 AM\n PRELIMINARY REPORT:\n There are no acute fractures. There is multilevel degenerative disease\n of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple\n levels, most pronounced at C5-C6 with moderate-severe neural foraminal\n narrowing on both sides.\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n EEG :\n IMPRESSION: This is an abnormal routine EEG due to a mildly slow and\n disorganized background. There were no focal, lateralized or\n epileptiform abnormalities noted. The background is suggestive of a\n mild encephalopathy.\n Microbiology: DFA : Negative for Influenza A and B\n CSF :\n GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO\n MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n Blood Cx : NGTD\n VIRAL CULTURE (Preliminary):\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: Resolved. Not requiring high amounts of oxygen\n initially. There is some evidence of pneumonia on her chest CT. It was\n unclear whether this is a bacterial superinfection from her viral URI,\n aytpical pneumonia, or aspiration pneumonia secondary to her acute\n mental status changes. CTA did not reveal a PE. She did not seem volume\n overloaded.\n - flu swab, sputum culture, urine legionella - NGTD and legionella ag\n negative\n - bronch for bal, - Bronch performed. Showed evidence of trauma thought\n to be from intubation. Old blood. BAL performed NGTD. Repeat bronch\n looked like old blood, nothing new, was then extubated and remained\n stable.\n - well covered with CTX, vanc, and levaquin initially, vancomycin dc'd\n on the and CTX and levoquin continued to cover CAP (double\n coverage for severe PNA)\n - Monitor respiratory status\n - Treat CAP with levoquin and CTX\n # ? tracheal injury from intubation: Blood outside ET tube on BAL and\n in lung w/o e/o active bleeding. Repeat BAL wnl with only old blood and\n no e/o bleeding.\n - Monitor airway\n # AMS: This was initially concerning for meningitis/encephalitis,\n however CSF nl and cultures negative for growth. CT head does not show\n any acute pathology. Likely due to a concussion from a mechanical fall\n as pt denied LOS, CP, SOB, dizziness, or palpitations or any prodrome\n to fall. Says she simply lost her balance. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - MRI to assess for temporal lobe enhancement, stroke - MRI no acute IC\n process, chronic small vessel disease, R parotid enhancing nodule (ddx:\n pleomorphic adenoma)\n - EEG - mild encephalopathy no e/o seizures\n - MS improving\n # s/p fall\n Still unclear etiology, although likely mechanical based on history.\n consider further w/u for syncope when able to obtain more h/o from\n patient. No e/o arrhythmia on telemetry.\n - Consider outpatient echo\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n - Monitor for symptoms\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518402,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen. Head CT was negative. During ambulance transfer\n from OSH to pts respiratory status continued to decline\n and pt was intubated on arrival to ED. Head CT negative.\n Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, ABG 7.43/40/178.\n LS clear upper, diminished bases. Minimal secretions.\n Vitals stable, urine output diminished (15-25cc/hr)\n Action:\n FIO2 reduced to 40% and placed on PSV 10/5.\n Received 1 liter NS bolus for low UO.\n Suctioned PRN.\n Remains on IV abx.\n Response:\n 02 sats remain 100% on PSV, ABG 7.37/45/114\n Urine output improved to 30-80cc/hr following IVF bolus.\n Plan:\n Cont close monitoring of resp status.\n Wean vent settings as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr.\n Pt not responsive, no eye opening, no following commands, some\n non-purposeful movement of legs.\n PERRL.\n Pt has cervical collar in place.\n Action:\n LP performed by house staff and attending MD to r/o meningitis.\n MRI of brain done overnight.\n Versed/fentanyl gtts D/C\nd and pt received total 2.5mg versed and\n 100mcs fentanyl IVP for MRI.\n Cont neuro checks by RN.\n Response:\n Pt tolerated LP and MRI well.\n Pt off sedation for several hours but became agitated (biting on ETT,\n HTN) and not following any commands.\n Started on propofol gtt for sedation\n Cervical collar remains in place.\n Plan:\n Cont propofol gtt and daily wake-up/neuro checks.\n f/u with results of LP and MRI.\n ? cervical collar status.\n Fracture, other\n Assessment:\n Pt fractured left humerus during fall.\n Left upper arm bruised.\n Action:\n Attempted to minimize movement with left arm during\n turning/repositioning.\n Response:\n Left upper arm remains bruised.\n Plan:\n ? obtaining sling of left arm.\n Ortho following.\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518491,
"text": "Chief Complaint: altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:00 PM\n BRONCHOSCOPY - At 03:41 PM\n evidence of trauma thought to be from intubation. Old blood. BAL\n performed\n ARTERIAL LINE - START 06:51 PM\n LUMBAR PUNCTURE - At 08:26 PM\n MAGNETIC RESONANCE IMAGING - At 10:15 PM\n Trop <0.01 --> 0.20 --> 0.09\n EKG - At 12:20 AM: unchanged from baseline\n FEVER - 101.1\nF - 08:00 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:03 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:51 PM\n Fentanyl - 10:30 PM\n Midazolam (Versed) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (80 - 125) bpm\n BP: 111/67(84) {99/57(72) - 150/91(111)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,667 mL\n 1,109 mL\n PO:\n TF:\n IVF:\n 537 mL\n 1,109 mL\n Blood products:\n Total out:\n 538 mL\n 260 mL\n Urine:\n 538 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,129 mL\n 849 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 8\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 8 cmH2O\n Plateau: 18 cmH2O\n Compliance: 43.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/45/114/22/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Overweight / Obese, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 10.4 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.5 %\n 7.4 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n WBC\n 7.8\n 7.4\n Hct\n 34.5\n 30.5\n Plt\n 364\n 309\n Cr\n 0.9\n 0.8\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n Other labs:\n PT / PTT / INR:13.4/24.7/1.1,\n CK / CKMB / Troponin-T:330/5/0.09 TROP <0.01\n 0.20\n 0.09\n ALT / AST:23/27, Alk Phos / T Bili:68/0.3\n Ca++:7.7 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs:\n Source: LP; TUBE#2\n CSF\n Chemistry\n Protein\n 45\n Glucose\n 78\n CSF\n WBC\n 2\n RBC\n 8\n Poly\n 3\n Lymph\n 75\n Mono\n 22\n EOs\n SOURCE: LP TUBE #4\n Imaging:\n ? need for NG tube to be advanced\n ECG:\n Small ST depressions V4-V6\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 518862,
"text": "62 yo female with signif PMH for HTN, CHF and asthma had an unwitnessed\n fall at home. Pt has been complaining of URI for the last week and a\n half with fatigue and a cough. Neice heard a thump in the middle of\n the night and found pt on the floor. At that time she was complaining\n of left arm pain. She was also very confused. She was taken by\n ambulance to OSH and there became increasingly confused. She had\n multiple imaging studies which were all negative. Labs were normal\n and they decided to transfer pt to . Prior to transfer pt\n received 2mg MSO4, 1 mg ativan and undetermined amount of dilantin.\n During transfer to , pt began to desaturate requiring ambuing in\n the ambulance. In the \n pt responsive to only painful stimuli and\n had no gag reflex. Pt received narcan which did not change\n anything. Pt intubated for airway protection. Multiple attempts at\n LP failed. CXR and CTA showed PNA but no PE. CT head was negative.\n Pt transferred to MSICU for further treatment and evaluation.\n Pt able to be extubated in the ICU on .\n Course in ICU includes:\n CV\n Pt hemodynamically stable. Afebrile with stable labs. Pt has\n chronic low K due to lasix she takes for CHF. She has recently stopped\n taking her potassium meds. She has been replenished while in ICU but\n level continues to be low.\n Resp - Pt on L NC. Tolerating this well. Strong spont non prod\n cough. When pt ambulates she does get slightly SOB but recovers\n quickly and sats did not drop below 91% on RA during transfer to chair.\n GI\n Tolerating PO\ns well. Diet advanced to heart healthy.\n GU - Foley cath draining adequate amt cl yellow urine. Pt could\n probably have foley out when she is more stable on her feet and able to\n ambulate to BR.\n Neuro -\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 518864,
"text": "62 yo female with signif PMH for HTN, CHF and asthma had an unwitnessed\n fall at home. Pt has been complaining of URI for the last week and a\n half with fatigue and a cough. Neice heard a thump in the middle of\n the night and found pt on the floor. At that time she was complaining\n of left arm pain. She was also very confused. She was taken by\n ambulance to OSH and there became increasingly confused. She had\n multiple imaging studies which were all negative. Labs were normal\n and they decided to transfer pt to . Prior to transfer pt\n received 2mg MSO4, 1 mg ativan and undetermined amount of dilantin.\n During transfer to , pt began to desaturate requiring ambuing in\n the ambulance. In the \n pt responsive to only painful stimuli and\n had no gag reflex. Pt received narcan which did not change\n anything. Pt intubated for airway protection. Multiple attempts at\n LP failed. CXR and CTA showed PNA but no PE. CT head was negative.\n Pt transferred to MSICU for further treatment and evaluation.\n Pt able to be extubated in the ICU on .\n Course in ICU includes:\n CV\n Pt hemodynamically stable. Afebrile with stable labs. Pt has\n chronic low K due to lasix she takes for CHF. She has recently stopped\n taking her potassium meds. She has been replenished while in ICU but\n level continues to be low.\n Resp - Pt on L NC. Tolerating this well. Strong spont non prod\n cough. When pt ambulates she does get slightly SOB but recovers\n quickly and sats did not drop below 91% on RA during transfer to chair.\n GI\n Tolerating PO\ns well. Diet advanced to heart healthy.\n GU - Foley cath draining adequate amt cl yellow urine. Pt could\n probably have foley out when she is more stable on her feet and able to\n ambulate to BR.\n Neuro - Pt much more alert and oriented. Has some difficulty\n remembering that she is at but knows she is at the hospital next\n to . She was able to get OOB with min assist and\n walk around the bed to a cardiac chair and has been sitting up for\n several hours. She has no memory of the fall or the day following.\n Ortho\n Left arm sore. Has not required much pain med\n was medicated\n x1 with 2mg MSO4 IV overnight but has not required any since then. Is\n comfortable with pillows propped under arm and is able to get OOB with\n min assist. Left hand is warm with positive pulses. A sling might\n be helpful but pt does not want one at this point.\n Social\n Pt lives with niece and her husband and has a sister. \n are involved and have been kept up to date of POC.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 89.2 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: Airborne/Respiratory, Droplet\n PMH: Asthma\n CV-PMH: CHF, Hypertension\n Additional history: HTN, CHF\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:67\n Temperature:\n 97.9\n Arterial BP:\n S:130\n D:64\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 925 mL\n 24h total out:\n 475 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 06:02 AM\n Potassium:\n 4.0 mEq/L\n 06:02 AM\n Chloride:\n 110 mEq/L\n 06:02 AM\n CO2:\n 23 mEq/L\n 06:02 AM\n BUN:\n 11 mg/dL\n 06:02 AM\n Creatinine:\n 0.6 mg/dL\n 06:02 AM\n Glucose:\n 94 mg/dL\n 06:02 AM\n Hematocrit:\n 30.2 %\n 06:02 AM\n Finger Stick Glucose:\n 96\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MSICU F4\n Transferred to: 1182\n Date & time of Transfer: 1500\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518605,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen. Head CT was negative. During ambulance transfer\n from OSH to pts respiratory status continued to decline\n and pt was intubated on arrival to ED. Head CT negative.\n Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, LS clear upper, diminished bases. Minimal secretions.\n Vitals stable, urine output diminished (15-25cc/hr)\n Action:\n Broinch today , then extubated\n Response:\n Tol extubation w/o diffaculty , on hi flow shovel mask , maint sats\n 95-97%\n Plan:\n Cont close monitoring of resp status. Cont on flu precations for now\n as per Dr. AS Pt has high probability of flu and BAL was non\n diagnostic\n Altered mental status (not Delirium)\n Assessment:\n Received pt on propofol 20mg/kg/min , moving in bed , arousing to\n voice and stim\n Pt has cervical collar in place.\n Action:\n Pt had yet another CT today to r/o neck injury\n Response:\n Pt has not been cleared as yet , Pt able to answer questions\n appropriately, but continues to yell help occasionally\n Plan:\n ? cervical collar status\n Fracture, other\n Assessment:\n Pt fractured left humerus during fall.\n Left upper arm bruised.\n Action:\n Attempted to minimize movement with left arm during\n turning/repositioning.\n Response:\n Left upper arm remains bruised.\n Plan:\n ? obtaining sling of left arm.\n Ortho following.\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518838,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 62 y o lady with HTN, CHF, asthma, here s/p fall/being found\n down, AMS, ?CAP, now extubated\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Narrowed to Levo + CTX for CAP\n Tamiflu added empirically\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Neuro:\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Micro:\n Studies:\n CXR:\n MRI head:\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518841,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 62 y o lady with HTN, CHF, asthma, here s/p fall/being found\n down, AMS, ?CAP, now extubated\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Narrowed to Levo + CTX for CAP\n Tamiflu added empirically\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Colace\n Heparin 5000 TID\n Levoflox 750 Q48 hours\n Singulair 10 mg daily\n ASA 325 daily\n Ranitidine 150 \n Tamiflu 75 \n CTX 1gm Q24 hours\n PRNs: morphine 2 mg x 1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate\n Neck:\n Chest:\n CV:\n Abd:\n Extr:\n Neuro:\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Micro:\n Studies:\n MRI head : IMPRESSION: 1. No evidence of acute intracranial\n process. 2. Nonspecific T2/FLAIR hyperintensities in the\n periventricular and subcortical white matter, likely due to chronic\n small vessel ischemic disease. 3. Right parotid enhancing nodule.\n Differential includes pleomorphic adenoma. Clinical correlation\n recommended.\n EEG: mild encephalopathy\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 518843,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 62 y o lady with HTN, CHF, asthma, here s/p fall/being found\n down, AMS, ?CAP, now extubated\n 24 Hour Events:\n Bronch yesterday - scant blood in distal segmental airways, decreased\n from the day prior, no active bleeding\n Extubated\n Narrowed to Levo + CTX for CAP\n Tamiflu added empirically\n Neck CT done, neck cleared clinically and C collar removed\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Colace\n Heparin 5000 TID\n Levoflox 750 Q48 hours\n Singulair 10 mg daily\n ASA 325 daily\n Ranitidine 150 \n Tamiflu 75 \n CTX 1gm Q24 hours\n PRNs: morphine 2 mg x 1\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 872 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 632 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 582 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate\n Neck: supple, no TTP\n Chest: scattered R ant rales, no wheezes\n CV: RRR, no murmurs\n Abd: soft, NT/ND + BS\n Extr: warm, no edema, R shoulder TTP\n Neuro: awake, A + O x 3, moving all extr\n Labs / Radiology\n 10.2 g/dL\n 351 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Micro: NP swab neg for flu, BAL: insufficient cells\n Studies:\n MRI head : IMPRESSION: 1. No evidence of acute intracranial\n process. 2. Nonspecific T2/FLAIR hyperintensities in the\n periventricular and subcortical white matter, likely due to chronic\n small vessel ischemic disease. 3. Right parotid enhancing nodule.\n Differential includes pleomorphic adenoma. Clinical correlation\n recommended.\n EEG: mild encephalopathy\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress, now\n extubated.\n 1. Respiratory distress: extubated yesterday, imaging c/w atypical\n PNA, bacterial vs. viral. NP flu swab neg, insufficient cells on BAL.\n Repeat bronch yest with much less blood, extubated and no hemoptysis.\n 100% on 2L today.\n - Cont Levo + CTX for CAP\n - Cont Tamiflu\n - H1N1 PCR to State lab\n - wean O2\n 2. Acute mental status changes: LP neg for meningitis/encephalitis.\n MRI unremarkable. No SZ on EEG. MS clear this am, recalls the fall and\n denies LOC, however, was confused on presentation to OSH.\n - monitor\n 3. s/p fall: patient today recalls all events, and denies LOC. Denies\n any CV symptoms as prodrome.\n - continue tele\n - consider oupt echo\n 4. Troponin bump; trending down, likely demand in a setting of acute\n illness/fall.\n - continue ASA\n 5. L humeral fracture: ortho following, non-operative mgmt.\n - Needs sling, likely nonoperative\n - PT/OT consults\n 6. HTN: Was on triamterene/HCTZ and verapamil at home\n - monitor BPs, consider restarting home Rx once high\n 7. Asthma: no wheezes on exam.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n 20 Gauge - 01:43 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: H2 blocker\n Communication: with patient\n Code status: Full code\n Disposition: stable for floor\n Total time spent: 30 min CCT\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518948,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n EEG - At 09:30 AM\n BRONCHOSCOPY - At 12:50 PM\n INVASIVE VENTILATION - STOP 02:30 PM\n ARTERIAL LINE - STOP 08:00 PM\n \n - Started tamiflu\n - Stopped acyclovir, vanc\n - Cont levo, cftx (decreased dose)\n - Bronch looked like old blood, nothing new; Got extubated\n - CT neck no acute fx, multilevel DJD mild spinal canal stenosis\n - MRI no acute IC process, chronic small vessel disease, R parotid\n enhancing nodule (ddx: pleomorphic adenoma)\n - EEG mild encephalopathy, nothing focal\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 871 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 631 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Imaging: CT C-SPINE W/O CONTRAST Study Date of 11:32 AM\n PRELIMINARY REPORT:\n There are no acute fractures. There is multilevel degenerative disease\n of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple\n levels, most pronounced at C5-C6 with moderate-severe neural foraminal\n narrowing on both sides.\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n EEG :\n IMPRESSION: This is an abnormal routine EEG due to a mildly slow and\n disorganized background. There were no focal, lateralized or\n epileptiform abnormalities noted. The background is suggestive of a\n mild encephalopathy.\n Microbiology: DFA : Negative for Influenza A and B\n CSF :\n GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO\n MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n Blood Cx : NGTD\n VIRAL CULTURE (Preliminary):\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation: Blood outside ET tube on BAL and\n in lung w/o e/o active bleeding. Repeat BAL wnl with only old blood and\n no e/o bleeding.\n - Monitor airway\n # AMS: This was initially concerning for meningitis/encephalitis,\n however CSF nl and cultures negative for growth. CT head does not show\n any acute pathology. Likely due to a concussion from a mechanical fall\n as pt denied LOS, CP, SOB, dizziness, or palpitations or any prodrome\n to fall. Says she simply lost her balance. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - MRI to assess for temporal lobe enhancement, stroke - MRI no acute IC\n process, chronic small vessel disease, R parotid enhancing nodule (ddx:\n pleomorphic adenoma)\n - EEG - mild encephalopathy no e/o seizures\n - MS improving\n # s/p fall\n Still unclear etiology, although likely mechanical based on history.\n consider further w/u for syncope when able to obtain more h/o from\n patient. No e/o arrhythmia on telemetry.\n - Consider outpatient echo\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n - Monitor for symptoms\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F HTN, CHF, asthma recent URI sx c cough /\n weakness / malaise x1 week, found down by niece, confused but\n conscious, BIBA to OSH, head / neck CT negative, L humeral fx -\n transferred to , intubated on arrival. Bronch, art line, LP o/n.\n Exam notable for Tm 101.1 BP 110/60 HR 95 RR 14 with sat 96 on VC 550x8\n 5 0.4 7.37/45/114. Minimally reactive. PERRL CTA B. RRR s1s2 2/6Sm.\n Soft +BS. No edema. Labs notable for WBC 7K, HCT 30, K+ 3.5, Cr 0.8.\n Agree with plan to manage acute encephalopathy and respiratory failure\n with antibiotics for CAP - will use CTX, levo and tamiflu. Await BAL\n results, continue flu precautions for now. Given hemoptysis and concern\n for tracheal lac, will rebronch today to confirm resolution and to\n exclude lower bleeding source. Continue propofol for sedation and\n transition to PSV. For altered mental status, LP negative for\n infectious process, will check spot EEG and f/u MRI read. Fall likely\n d/t medical illness, ortho eval of humeral , need clinical\n clearance of c-spine following extubation. Will also check echo and\n continue to hold antihypertensives in the setting of medical illness\n and bump in troponins. Remainder of plan as outlined above.\n ADDENDUM\n Bronch with substantial improvement in bloody secretions, no\n lower bleeding source identified. See note in MetaVision for details.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:52 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518950,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n EEG - At 09:30 AM\n BRONCHOSCOPY - At 12:50 PM\n INVASIVE VENTILATION - STOP 02:30 PM\n ARTERIAL LINE - STOP 08:00 PM\n \n - Started tamiflu\n - Stopped acyclovir, vanc\n - Cont levo, cftx (decreased dose)\n - Bronch looked like old blood, nothing new; Got extubated\n - CT neck no acute fx, multilevel DJD mild spinal canal stenosis\n - MRI no acute IC process, chronic small vessel disease, R parotid\n enhancing nodule (ddx: pleomorphic adenoma)\n - EEG mild encephalopathy, nothing focal\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Morphine Sulfate - 03:00 AM\n Heparin Sodium (Prophylaxis) - 06:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 89 (88 - 121) bpm\n BP: 132/67(83) {109/57(69) - 145/81(97)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,772 mL\n 871 mL\n PO:\n 100 mL\n 240 mL\n TF:\n IVF:\n 1,582 mL\n 631 mL\n Blood products:\n Total out:\n 1,010 mL\n 290 mL\n Urine:\n 1,010 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 762 mL\n 581 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 325) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 5 cmH2O\n SpO2: 96%\n ABG: ///23/\n Ve: 6.4 L/min\n Physical Examination\n Gen: awake, alert, appropriate, pleasant\nI want to go home\n Neck: supple, no TTP\n Chest: CTAB no WRR\n CV: RRR, no murmurs\n Abd: soft, NT/ND + BS\n Extr: warm, no edema, R shoulder TTP\n Neuro: awake, A + O x 3, moving all extremities\n Labs / Radiology\n 351 K/uL\n 10.2 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 110 mEq/L\n 141 mEq/L\n 30.2 %\n 7.0 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n 08:25 PM\n 06:02 AM\n WBC\n 7.8\n 7.4\n 7.9\n 7.0\n Hct\n 34.5\n 30.5\n 31.3\n 30.2\n Plt\n 364\n 309\n 327\n 351\n Cr\n 0.9\n 0.8\n 0.6\n 0.6\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n 113\n 94\n Other labs: PT / PTT / INR:13.1/21.9/1.1, CK / CKMB /\n Troponin-T:330/5/0.09, ALT / AST:18/23, Alk Phos / T Bili:58/0.2,\n Amylase / Lipase:/19, Lactic Acid:0.9 mmol/L, Albumin:2.9 g/dL, LDH:221\n IU/L, Ca++:8.1 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Imaging: CT C-SPINE W/O CONTRAST Study Date of 11:32 AM\n PRELIMINARY REPORT:\n There are no acute fractures. There is multilevel degenerative disease\n of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple\n levels, most pronounced at C5-C6 with moderate-severe neural foraminal\n narrowing on both sides.\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n EEG :\n IMPRESSION: This is an abnormal routine EEG due to a mildly slow and\n disorganized background. There were no focal, lateralized or\n epileptiform abnormalities noted. The background is suggestive of a\n mild encephalopathy.\n Microbiology: DFA : Negative for Influenza A and B\n CSF :\n GRAM STAIN (Final ): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO\n MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n Blood Cx : NGTD\n VIRAL CULTURE (Preliminary):\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Pt. orientated x2, no agitation\n FRACTURE, OTHER\n stablized left arm, bruises were marked\n PNEUMONIA, OTHER\n Still on antibiotics\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n Levels trending down, potassium repletion\n HYPERTENSION, BENIGN\n Hypertensive medications held\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation: Blood outside ET tube on BAL and\n in lung w/o e/o active bleeding. Repeat BAL wnl with only old blood and\n no e/o bleeding.\n - Monitor airway\n # AMS: This was initially concerning for meningitis/encephalitis,\n however CSF nl and cultures negative for growth. CT head does not show\n any acute pathology. Likely due to a concussion from a mechanical fall\n as pt denied LOS, CP, SOB, dizziness, or palpitations or any prodrome\n to fall. Says she simply lost her balance. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - MRI to assess for temporal lobe enhancement, stroke - MRI no acute IC\n process, chronic small vessel disease, R parotid enhancing nodule (ddx:\n pleomorphic adenoma)\n - EEG - mild encephalopathy no e/o seizures\n - MS improving\n # s/p fall\n Still unclear etiology, although likely mechanical based on history.\n consider further w/u for syncope when able to obtain more h/o from\n patient. No e/o arrhythmia on telemetry.\n - Consider outpatient echo\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n - Monitor for symptoms\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F HTN, CHF, asthma recent URI sx c cough /\n weakness / malaise x1 week, found down by niece, confused but\n conscious, BIBA to OSH, head / neck CT negative, L humeral fx -\n transferred to , intubated on arrival. Bronch, art line, LP o/n.\n Exam notable for Tm 101.1 BP 110/60 HR 95 RR 14 with sat 96 on VC 550x8\n 5 0.4 7.37/45/114. Minimally reactive. PERRL CTA B. RRR s1s2 2/6Sm.\n Soft +BS. No edema. Labs notable for WBC 7K, HCT 30, K+ 3.5, Cr 0.8.\n Agree with plan to manage acute encephalopathy and respiratory failure\n with antibiotics for CAP - will use CTX, levo and tamiflu. Await BAL\n results, continue flu precautions for now. Given hemoptysis and concern\n for tracheal lac, will rebronch today to confirm resolution and to\n exclude lower bleeding source. Continue propofol for sedation and\n transition to PSV. For altered mental status, LP negative for\n infectious process, will check spot EEG and f/u MRI read. Fall likely\n d/t medical illness, ortho eval of humeral , need clinical\n clearance of c-spine following extubation. Will also check echo and\n continue to hold antihypertensives in the setting of medical illness\n and bump in troponins. Remainder of plan as outlined above.\n ADDENDUM\n Bronch with substantial improvement in bloody secretions, no\n lower bleeding source identified. See note in MetaVision for details.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:52 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 518272,
"text": "Chief Complaint: Mental status changes and hypoxia\n HPI:\n Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma who was\n brought to OSH after being found down. She lives with her niece, the\n niece's daughter and husband. She had been complaining of an URI\n infection for the last 1.5 weeks with symptoms of fatigue and cough.\n No fevers or other complaints as far as the niece knows. She was\n bedridden for the first 3 days or so but had been improving, enough to\n clean the house yesterday. Overnight, her neice had heard a thump and\n found the patient on the floor. She was complaining of L arm pain.\n She was also confused, repeatedly calling for help and asking about her\n dead dog. She has had her flu and H1N1 shots this year.\n .\n The patient was takent to Hospital. There, she became\n increasingly altered without focal neuro deficits. She had multiple\n imaging studies. Head and neck CT scans were negative. X-rays showed\n a R humeral fracture. Her labs, inc. chemistries and cardiac enzymes,\n were normal except for Cr of 1.3. She received 1 mg of ativan, 2 mg of\n morphine, and ???dilantin. On the way over in the ambulance, pt had\n reportedly son respirations with desaturations, requiring bagging\n in the ambulance.\n .\n In the ED, she only responded to painful stimuli, no gag reflex.\n Mental status did not improve with 0.4 mg of Narcan. She was intubated\n for airway protection and ventilatory support. She had some \n blood in the ETT, though the intubation was not difficult. Labs were\n sig. for neg serum tox screen, mild leukocytosis of 11.7, Cr 1.2.\n Lactate was 1.4. 1st of cardiac enzymes were neg. CXR and CTA showed\n pneumonia, no PE. CT head showed no acute process. X-rays showed\n comminuted fracture of the left proximal humerus, no hip fractures. ED\n failed multiple LP attempts. Patient was acyclovir, vanc, CTX,\n levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67, 20, 96%\n on 40% FiO2, AC 500 x 20.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n CHF\n Asthma\n .\n Medications:\n Atenolol 25 mg daily\n Verapamil SR 240 mg daily\n Triamterene 37.5 and HCTZ 25 daily\n ASA 325 mg daily\n Montelukast 10 mg daily\n Advair 500/50\n Piroxicam 1 cap daily\n KCl 20 meq daily\n Heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt lives with her niece's family. She used to work for the\n state, caring for the mentally challenged. She is active at home,\n helping with chores and going to the gym. She is a remote smoker, no\n etoh, no recreational drugs.\n Review of systems:\n Flowsheet Data as of 03:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 97 (97 - 103) bpm\n BP: 123/71(83) {123/71(83) - 123/71(83)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 100%\n Total In:\n 1,028 mL\n PO:\n TF:\n IVF:\n 28 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 828 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST:\n IMPRESSION:\n 1. No pulmonary embolism or acute aortic pathology.\n 2. Scattered ill-defined nodular opacities within the lungs, likely\n infectious in etiology.\n 3. NG tube ending in the esophagus. Recommend advancement past the GE\n junction.\n 4. Left humeral fracture incompletely imaged.\n .\n CXR:\n 1. ET tube ending in the right main stem bronchus. Recommend\n withdrawal.\n 2. NG tube with sideport in the distal thoracic esophagus. Recommend\n advancement.\n 3. Incompletely imaged left humeral head fracture.\n 4. Left lower lobe ill-defined opacity, likely representing pneumonia.\n .\n CT HEAD\n No acute intracranial process. Sinus disease as noted above.\n .\n BILAT HIPS (AP,LAT & AP PELVIS) PORT\n IMPRESSION: No fracture or dislocation.\n .\n HUMERUS (AP & LAT) LEFT Study Date of \n IMPRESSION: Comminuted fracture of the left proximal humerus\n Microbiology: BCxs pending\n ECG: NSR at 77 bpm. Nl axis. No ischemic changes.\n Assessment and Plan\n Assessment and Plan: 52 yo female with PMHx sig. for HTN, CHF, asthma\n who presents with URI symptoms, acute mental status changes, found to\n have pneumonia, intubated for airway protection and respiratory\n distress.\n .\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - flu swab, sputum culture, urine legionella\n - bronch for bal, assess for bleeding source\n - send CBC\n - well covered with CTX, vanc, and levaquin\n - will plan to lighten sedation, try PS\n .\n # Acute mental status changes: This is most concerning for\n meningitis/encephalitis. It could be a viral meningitis as she had URI\n symptoms. The concern would be bacteria meningitis from complication\n of pneumonia. However, she has no fever and only a very mild\n leukocytosis, no bands. Currently, she is too sedated for an adequate\n neuro exam. Reportedly, her neuro exam was normal at . CT head\n does not show any acute pathology. be a concussion from the fall.\n She also had ativan, morphine, and possibly dilantin at the OSH;\n however, she was altered prior to arrival.\n - switch to propofol to assess mental status\n - attempt LP, may need to be IR guided\n - obtain MRI to assess for temporal lobe enhancement, stroke\n - EEG to assess for seizures but will hold AEDs for now\n .\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n .\n # HTN:\n - hold antihypertensives for now\n .\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO\n .\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n .\n FEN: IVF boluses for hypotension, replete electrolytes, NPO/TFs\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full, confirmed with niece\n Communication: Niece home , cell ,\n Nephew in law \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518438,
"text": "Chief Complaint: altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:00 PM\n BRONCHOSCOPY - At 03:41 PM\n evidence of trauma thought to be from intubation. Old blood. BAL\n performed\n ARTERIAL LINE - START 06:51 PM\n LUMBAR PUNCTURE - At 08:26 PM\n MAGNETIC RESONANCE IMAGING - At 10:15 PM\n Trop <0.01 --> 0.20 --> 0.09\n EKG - At 12:20 AM: unchanged from baseline\n FEVER - 101.1\nF - 08:00 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:03 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:51 PM\n Fentanyl - 10:30 PM\n Midazolam (Versed) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (80 - 125) bpm\n BP: 111/67(84) {99/57(72) - 150/91(111)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,667 mL\n 1,109 mL\n PO:\n TF:\n IVF:\n 537 mL\n 1,109 mL\n Blood products:\n Total out:\n 538 mL\n 260 mL\n Urine:\n 538 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,129 mL\n 849 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 8\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 8 cmH2O\n Plateau: 18 cmH2O\n Compliance: 43.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/45/114/22/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bronchial: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bruising on left shoulder\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 10.4 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.5 %\n 7.4 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n WBC\n 7.8\n 7.4\n Hct\n 34.5\n 30.5\n Plt\n 364\n 309\n Cr\n 0.9\n 0.8\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n Other labs:\n PT / PTT / INR:13.4/24.7/1.1,\n CK / CKMB / Troponin-T:330/5/0.09 TROP <0.01\n 0.20\n 0.09\n ALT / AST:23/27, Alk Phos / T Bili:68/0.3\n Ca++:7.7 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs:\n Source: LP; TUBE#2\n CSF\n Chemistry\n Protein\n 45\n Glucose\n 78\n CSF\n WBC\n 2\n RBC\n 8\n Poly\n 3\n Lymph\n 75\n Mono\n 22\n EOs\n SOURCE: LP TUBE #4\n Imaging:\n ? need for NG tube to be advanced\n ECG:\n Small ST depressions V4-V6\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FRACTURE, OTHER\n PNEUMONIA, OTHER\n HYPERTENSION, BENIGN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 518439,
"text": "Chief Complaint: altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:00 PM\n BRONCHOSCOPY - At 03:41 PM\n evidence of trauma thought to be from intubation. Old blood. BAL\n performed\n ARTERIAL LINE - START 06:51 PM\n LUMBAR PUNCTURE - At 08:26 PM\n MAGNETIC RESONANCE IMAGING - At 10:15 PM\n Trop <0.01 --> 0.20 --> 0.09\n EKG - At 12:20 AM: unchanged from baseline\n FEVER - 101.1\nF - 08:00 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:03 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:51 PM\n Fentanyl - 10:30 PM\n Midazolam (Versed) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (80 - 125) bpm\n BP: 111/67(84) {99/57(72) - 150/91(111)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,667 mL\n 1,109 mL\n PO:\n TF:\n IVF:\n 537 mL\n 1,109 mL\n Blood products:\n Total out:\n 538 mL\n 260 mL\n Urine:\n 538 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,129 mL\n 849 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 8\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 8 cmH2O\n Plateau: 18 cmH2O\n Compliance: 43.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/45/114/22/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bronchial: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bruising on left shoulder\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 10.4 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.5 %\n 7.4 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n WBC\n 7.8\n 7.4\n Hct\n 34.5\n 30.5\n Plt\n 364\n 309\n Cr\n 0.9\n 0.8\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n Other labs:\n PT / PTT / INR:13.4/24.7/1.1,\n CK / CKMB / Troponin-T:330/5/0.09 TROP <0.01\n 0.20\n 0.09\n ALT / AST:23/27, Alk Phos / T Bili:68/0.3\n Ca++:7.7 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs:\n Source: LP; TUBE#2\n CSF\n Chemistry\n Protein\n 45\n Glucose\n 78\n CSF\n WBC\n 2\n RBC\n 8\n Poly\n 3\n Lymph\n 75\n Mono\n 22\n EOs\n SOURCE: LP TUBE #4\n Imaging:\n ? need for NG tube to be advanced\n ECG:\n Small ST depressions V4-V6\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FRACTURE, OTHER\n PNEUMONIA, OTHER\n HYPERTENSION, BENIGN\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n .\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - flu swab, sputum culture, urine legionella\n - bronch for bal, assess for bleeding source\n - send CBC\n - well covered with CTX, vanc, and levaquin\n - will plan to lighten sedation, try PS\n .\n # Acute mental status changes: This is most concerning for\n meningitis/encephalitis. It could be a viral meningitis as she had URI\n symptoms. The concern would be bacteria meningitis from complication\n of pneumonia. However, she has no fever and only a very mild\n leukocytosis, no bands. Currently, she is too sedated for an adequate\n neuro exam. Reportedly, her neuro exam was normal at . CT head\n does not show any acute pathology. be a concussion from the fall.\n She also had ativan, morphine, and possibly dilantin at the OSH;\n however, she was altered prior to arrival.\n - switch to propofol to assess mental status\n - attempt LP, may need to be IR guided\n - obtain MRI to assess for temporal lobe enhancement, stroke\n - EEG to assess for seizures but will hold AEDs for now\n .\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n .\n # HTN:\n - hold antihypertensives for now\n .\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO\n .\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518384,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen. Head CT was negative. During ambulance transfer\n from OSH to pts respiratory status continued to decline\n And pt was intubated on arrival to ED. Head CT negative.\n Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, ABG 7.43/40/178.\n LS clear upper, diminished bases. Minimal secretions.\n Vitals stable, urine output diminished (15-25cc/hr)\n Action:\n FIO2 reduced to 40%.\n Received 1 liter NS bolus for low UO.\n Suctioned PRN.\n Remains on IV abx.\n Response:\n 02 sats remain 100% on AC 14/550, 40%.\n Urine output improved to 30-80cc/hr following IVF bolus.\n Plan:\n Cont close monitoring of resp status.\n Wean vent settings as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr.\n Pt not responsive, no eye opening, no following commands, some\n non-purposeful movement of legs.\n PERRL.\n Pt has cervical collar in place.\n Action:\n LP performed by house staff and attending MD to r/o meningitis.\n Pt went for MRI of brain overnight.\n Versed/fentanyl gtts D/C\nd and pt received total 2.5mg versed and\n 100mcs fentanyl IVP for MRI.\n Cont neuro checks by RN.\n Response:\n Pt tolerated LP and MRI well.\n Pt off sedation for several hours but became agitated (biting on ETT,\n HTN) and not following any commands.\n Started on propofol gtt for sedation.\n Cervical collar remains in place.\n Plan:\n Cont propofol gtt and daily wake-up/neuro checks.\n f/u with results of LP and MRI.\n ? cervical collar status.\n Fracture, other\n Assessment:\n Pt fractured left humerus during fall.\n Left upper arm bruised.\n Action:\n Attempted to minimize movement with left arm during\n turning/repositioning.\n Response:\n Left upper arm remains bruised.\n Plan:\n ? obtaining sling of left arm.\n Ortho following.\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 518265,
"text": "Chief Complaint: Mental status changes and hypoxia\n HPI:\n Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma who was\n brought to OSH after being found down. She lives with her niece, the\n niece's daughter and husband. She had been complaining of an URI\n infection for the last 1.5 weeks with symptoms of fatigue and cough.\n No fevers or other complaints as far as the niece knows. She was\n bedridden for the first 3 days or so but had been improving, enough to\n clean the house yesterday. Overnight, her neice had heard a thump and\n found the patient on the floor. She was complaining of L arm pain.\n She was also confused, repeatedly calling for help and asking about her\n dead dog. She has had her flu and H1N1 shots this year.\n .\n The patient was takent to Hospital. There, she became\n increasingly altered without focal neuro deficits. She had multiple\n imaging studies. Head and neck CT scans were negative. X-rays showed\n a R humeral fracture. Her labs, inc. chemistries and cardiac enzymes,\n were normal except for Cr of 1.3. She received 1 mg of ativan, 2 mg of\n morphine, and ???dilantin. On the way over in the ambulance, pt had\n reportedly son respirations with desaturations, requiring bagging\n in the ambulance.\n .\n In the ED, she only responded to painful stimuli, no gag reflex.\n Mental status did not improve with 0.4 mg of Narcan. She was intubated\n for airway protection and ventilatory support. She had some \n blood in the ETT, though the intubation was not difficult. Labs were\n sig. for neg serum tox screen, mild leukocytosis of 11.7, Cr 1.2.\n Lactate was 1.4. 1st of cardiac enzymes were neg. CXR and CTA showed\n pneumonia, no PE. CT head showed no acute process. X-rays showed\n comminuted fracture of the left proximal humerus, no hip fractures. ED\n failed multiple LP attempts. Patient was acyclovir, vanc, CTX,\n levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67, 20, 96%\n on 40% FiO2, AC 500 x 20.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n CHF\n Asthma\n .\n Medications:\n Atenolol 25 mg daily\n Verapamil SR 240 mg daily\n Triamterene 37.5 and HCTZ 25 daily\n ASA 325 mg daily\n Montelukast 10 mg daily\n Advair 500/50\n Piroxicam 1 cap daily\n KCl 20 meq daily\n Heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt lives with her niece's family. She used to work for the\n state, caring for the mentally challenged. She is active at home,\n helping with chores and going to the gym. She is a remote smoker, no\n etoh, no recreational drugs.\n Review of systems:\n Flowsheet Data as of 03:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 97 (97 - 103) bpm\n BP: 123/71(83) {123/71(83) - 123/71(83)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 100%\n Total In:\n 1,028 mL\n PO:\n TF:\n IVF:\n 28 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 828 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST:\n IMPRESSION:\n 1. No pulmonary embolism or acute aortic pathology.\n 2. Scattered ill-defined nodular opacities within the lungs, likely\n infectious in etiology.\n 3. NG tube ending in the esophagus. Recommend advancement past the GE\n junction.\n 4. Left humeral fracture incompletely imaged.\n .\n CXR:\n 1. ET tube ending in the right main stem bronchus. Recommend\n withdrawal.\n 2. NG tube with sideport in the distal thoracic esophagus. Recommend\n advancement.\n 3. Incompletely imaged left humeral head fracture.\n 4. Left lower lobe ill-defined opacity, likely representing pneumonia.\n .\n CT HEAD\n No acute intracranial process. Sinus disease as noted above.\n .\n BILAT HIPS (AP,LAT & AP PELVIS) PORT\n IMPRESSION: No fracture or dislocation.\n .\n HUMERUS (AP & LAT) LEFT Study Date of \n IMPRESSION: Comminuted fracture of the left proximal humerus\n Microbiology: BCxs pending\n ECG: NSR at 77 bpm. Nl axis. No ischemic changes.\n Assessment and Plan\n Assessment and Plan: 52 yo female with PMHx sig. for HTN, CHF, asthma\n who presents with URI symptoms, acute mental status changes, found to\n have pneumonia, intubated for airway protection and respiratory\n distress.\n .\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - flu swab, sputum culture, urine legionella\n - well covered with CTX, vanc, and levaquin\n - will plan to lighten sedation, try PS\n .\n # Acute mental status changes: This is most concerning for\n meningitis/encephalitis. It could be a viral meningitis as she had URI\n symptoms. The concern would be bacteria meningitis from complication\n of pneumonia. However, she has no fever and only a very mild\n leukocytosis, no bands. Currently, she is too sedated for an adequate\n neuro exam. Reportedly, her neuro exam was normal at . CT head\n does not show any acute pathology. be a concussion from the fall.\n She also had ativan, morphine, and possibly dilantin at the OSH;\n however, she was altered prior to arrival.\n - lighten sedation to assess mental status\n - obtain MRI to assess for temporal lobe enhancement, stroke\n - attempt LP, may need to be IR guided\n .\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n .\n # HTN:\n - hold antihypertensives for now\n .\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO\n .\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n .\n FEN: IVF boluses for hypotension, replete electrolytes, NPO\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full, confirmed with niece\n Communication: Niece home , cell ,\n Nephew in law \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518379,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen, Head CT\ns negative. During ambulance transfer\n from OSH to pts respiratory function started fail and required\n ambu-bagging. Pt was intubated on arrival to ED. Head CT\n negative. Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, ABG 7.43/40/178.\n LS clear upper, diminished bases. Minimal secretions.\n Vitals stable, urine output diminished (15-25cc/hr)\n Action:\n FIO2 reduced to 40%.\n Received 1 liter NS bolus for low UO.\n Suctioned PRN.\n Remains on IV abx.\n Response:\n 02 sats remain 100% on AC 14/550, 40%.\n Urine output improved to 30-80cc/hr following IVF bolus.\n Plan:\n Cont close monitoring of resp status.\n Wean vent settings as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr.\n Pt not responsive, no eye opening, no following commands, some\n non-purposeful movement of legs.\n PERRL.\n Pt has cervical collar in place.\n Action:\n LP performed by house staff and attending MD to r/o meningitis.\n Pt went for MRI of brain overnight.\n Versed/fentanyl gtts D/C\nd and pt received total 2.5mg versed and\n 100mcs fentanyl IVP for MRI.\n Cont neuro checks by RN.\n Response:\n Pt tolerated LP and MRI well.\n Pt off sedation for several hours but became agitated (biting on ETT,\n HTN) and not following any commands.\n Started on propofol gtt for sedation.\n Cervical collar remains in place.\n Plan:\n Cont propofol gtt and daily wake-up/neuro checks.\n f/u with results of LP and MRI.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 518385,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 49.9 None\n Ideal tidal volume: 199.6 / 299.4 / 399.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Press:\n cuff pressure: 25 cmH2O\n : Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 2200\n uneventfull transport\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 518590,
"text": "Chief Complaint: altered mental status\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:00 PM\n BRONCHOSCOPY - At 03:41 PM\n evidence of trauma thought to be from intubation. Old blood. BAL\n performed\n ARTERIAL LINE - START 06:51 PM\n LUMBAR PUNCTURE - At 08:26 PM\n MAGNETIC RESONANCE IMAGING - At 10:15 PM\n Trop <0.01 --> 0.20 --> 0.09\n EKG - At 12:20 AM: unchanged from baseline\n FEVER - 101.1\nF - 08:00 PM\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:15 PM\n Acyclovir - 09:18 PM\n Ceftriaxone - 12:03 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:51 PM\n Fentanyl - 10:30 PM\n Midazolam (Versed) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (80 - 125) bpm\n BP: 111/67(84) {99/57(72) - 150/91(111)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,667 mL\n 1,109 mL\n PO:\n TF:\n IVF:\n 537 mL\n 1,109 mL\n Blood products:\n Total out:\n 538 mL\n 260 mL\n Urine:\n 538 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,129 mL\n 849 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 8\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 8 cmH2O\n Plateau: 18 cmH2O\n Compliance: 43.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.37/45/114/22/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Overweight / Obese, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 309 K/uL\n 10.4 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.5 %\n 7.4 K/uL\n [image002.jpg]\n 03:15 PM\n 07:04 PM\n 07:52 PM\n 04:20 AM\n 04:43 AM\n WBC\n 7.8\n 7.4\n Hct\n 34.5\n 30.5\n Plt\n 364\n 309\n Cr\n 0.9\n 0.8\n TropT\n 0.20\n 0.09\n TCO2\n 27\n 27\n Glucose\n 113\n 137\n Other labs:\n PT / PTT / INR:13.4/24.7/1.1,\n CK / CKMB / Troponin-T:330/5/0.09 TROP <0.01\n 0.20\n 0.09\n ALT / AST:23/27, Alk Phos / T Bili:68/0.3\n Ca++:7.7 mg/dL, Mg++:1.5 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs:\n Source: LP; TUBE#2\n CSF\n Chemistry\n Protein\n 45\n Glucose\n 78\n CSF\n WBC\n 2\n RBC\n 8\n Poly\n 3\n Lymph\n 75\n Mono\n 22\n EOs\n SOURCE: LP TUBE #4\n Imaging:\n ? need for NG tube to be advanced\n ECG:\n Small ST depressions V4-V6\n Assessment and Plan\n 52 yo female with PMHx sig. for HTN, CHF, asthma who presents with URI\n symptoms, acute mental status changes, found to have pneumonia,\n intubated for airway protection and respiratory distress.\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - f/u micro including flu and BAL cultures\n - wean sedation\n - cont empiric CTX and levaquin for CAP\n - start tamiflu for empiric concern given preceding URI sx\n - send BAL washings to state for PCR\n # ? tracheal injury from intubation\n Blood outside ET tube on BAL and in lung w/o e/o active bleeding.\n -Repeat BAL and if e/o active bleeding may be wise to hold off on\n extubation. If no further blood, extubate and monitor for changes in\n Hct, vitals. Concern would be for development of tracheo-esophageal\n fistula, pneumothorax/pneumomediastinum\n # Acute mental status changes: Concerning for\n meningitis/encephalitis. CSF and h/o of URI could be c/w aseptic\n meningitis. Currently, she is too sedated for an adequate neuro exam.\n Reportedly, her neuro exam was normal at . CT head does not show\n any acute pathology. be a concussion from the fall, which was\n severe enough to cause humeral fracture. She also had ativan,\n morphine, and possibly dilantin at the OSH; however, she was altered\n prior to arrival.\n - switch to propofol to assess mental status\n - f/u CSF\n - f/u MRI read\n - EEG to assess for seizures but will hold AEDs for now\n - d/c acyclovir as no WBCs in CSF\n - no need to treat for bacterial meningitis so decrease CTX to 1g for\n PNA\n # s/p fall\n Still unclear etiology. consider further w/u for syncope when able\n to obtain more h/o from patient. No e/o arrhythmia on telemetry.\n # Troponin bump\n Was normal in ED. Peaked at 0.2 and now trending down. No change on ECG\n but does have minimal ST dep V4-V6 on ECG from ED. Would recommend\n outpt f/u. On aspirin.\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n # HTN: Was on triamterene/HCTZ and verapamil at home\n - have been holding antihypertensives for now\n - given only peripheral access and concern for sepsis will continue to\n hold for now and treat prn\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO (also for sycope w/u if indicated)\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n ICU Care\n Nutrition:\n Will place NGT prior to extubation\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Arterial Line - 06:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F HTN, CHF, asthma recent URI sx c cough /\n weakness / malaise x1 week, found down by niece, confused but\n conscious, BIBA to OSH, head / neck CT negative, L humeral fx -\n transferred to , intubated on arrival. Bronch, art line, LP o/n.\n Exam notable for Tm 101.1 BP 110/60 HR 95 RR 14 with sat 96 on VC 550x8\n 5 0.4 7.37/45/114. Minimally reactive. PERRL CTA B. RRR s1s2 2/6Sm.\n Soft +BS. No edema. Labs notable for WBC 7K, HCT 30, K+ 3.5, Cr 0.8.\n Agree with plan to manage acute encephalopathy and respiratory failure\n with antibiotics for CAP - will use CTX, levo and tamiflu. Await BAL\n results, continue flu precautions for now. Given hemoptysis and concern\n for tracheal lac, will rebronch today to confirm resolution and to\n exclude lower bleeding source. Continue propofol for sedation and\n transition to PSV. For altered mental status, LP negative for\n infectious process, will check spot EEG and f/u MRI read. Fall likely\n d/t medical illness, ortho eval of humeral , need clinical\n clearance of c-spine following extubation. Will also check echo and\n continue to hold antihypertensives in the setting of medical illness\n and bump in troponins. Remainder of plan as outlined above.\n ADDENDUM\n Bronch with substantial improvement in bloody secretions, no\n lower bleeding source identified. See note in MetaVision for details.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:52 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518737,
"text": "62 y/o woman with PMH hypertension, CHF, CAD, and asthma. Was admitted\n to OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen. During ambulance transfer from OSH to pts\n respiratory status continued to decline\n and pt was intubated on arrival to ED. Head/neck CT negative,\n cervical collar off at 6pm yesterday after pt. was cleared of\n C-fracture.\n Altered mental status (not Delirium)\n Assessment:\n Pt. is orientated x 2 (person and time), GCS at 15, pt. able to answer\n questions but having trouble finding words, MRI and head CT is\n negative, fall risk , LP negative\n Action:\n Re-orientating the pt. to place, bed is low and lock, call in reach,\n bed alarm is on, and 3 sides up\n Response:\n Improving but still with episodes of confusion\n Plan:\n Continue to assess LOC q4 hrs, keep safe\n Hypokalemia (Low potassium)\n Assessment:\n Potassium serum levels consistently low after repletion within last 24\n hrs (3.1), pt. is asymptomatic (no muscle weakness, aches, etc.), pt.\n state it is a problem due to diuretic use for CHF and reported stopping\n potassium medication at home\n Action:\n Administering potassium repletion at a total of 60 mEq (20 mEq in\n powder form (packet) and 40 mEq/500 cc over 4hrs)\n Response:\n Current K+ is pending\n Plan:\n Continue to monitor potassium levels and replete as needed\n Pneumonia, other\n Assessment:\n Pt. extubated yesterday, received on high flow mask sating at 97-98%,\n upper LS clear with diminishment at bases, No SOB, WBC within normal\n range at 7.9, Chest X-ray show consolidation in the lobes representing\n pneumonia apiration vs. infection, initally pt. had blood tinge\n secretions secondary to traumatic intubation, bronchoscopy revealed no\n source of bleeding, Influenza A&B negative but remains on droplet\n precaution\n Action:\n O2 weaned to 2L NC, aspiration precaution maintained, continues on\n ceftriaxone, levofloxacin, TamiFlu\n Response:\n Pt. Afebrile, non-productive cough, no SOB, ? confusion\n Plan:\n Continue to administer ceftriaxone, levofloxacin, TamiFlu as ordered ,\n follow up on whether to keep pt. on droplet precaution, follow up BAL\n specimen to rule out flu\n order to send specimen to state done this am\n Fracture, left humerus\n Assessment:\n X-ray revealed fracture of left humerus, bruising located on upper left\n arm extending to upper back shoulder, pain excruciating\n Action:\n Bruised area marked, ortho following pt., maintaining L arm in a stable\n position, minimizing movement during repositioning/turn, administered\n morphine sulfate 2mg IV Push @ 0300, applied ice pack to L shoulder\n Response:\n Pain medication effective, stable vital signs\n Plan:\n Continue to assess bruising and pain level and maintain arm stablized\n * Hypertension: Pt. has stable BP, maintained below 160 systolic,\n antihypertensive medication held.\n *Diet changed from NPO to Clear liquids, medications administered with\n applesause\n *Skin Integrity: Swelling, redness, and bruising at A-line insertion\n site, A-line removed\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518372,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen, Head CT\ns negative. During ambulance transfer\n from OSH to pts respiratory function started fail and required\n ambu-bagging. Pt was intubated on arrival to ED. Head CT\n negative. Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, ABG 7.43/40/178.\n LS clear upper, diminished bases. Minimal secretions.\n Vitals stable, urine output diminished (15-25cc/hr)\n Action:\n FIO2 reduced to 40%.\n Suction as needed.\n Received 1 liter NS bolus for low UO.\n Remains on IV abx.\n Response:\n 02 sats remain 100% on AC 14/550, 40%.\n Urine output improved to 30-80cc/hr following IVF bolus.\n Plan:\n Cont close monitoring of resp status.\n Wean vent settings as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Received pt sedated on versed gtt 5mg/hr and fentanyl gtt 50mcs/hr.\n Pt not responsive, no eye opening, no following commands, some\n non-purposeful movement of legs.\n PERRL.\n Action:\n LP performed by house staff and attending MD to r/o meningitis.\n Pt went for MRI of brain overnight.\n Versed/fentanyl gtts D/C\nd and pt received total 2.5mg versed and\n 100mcs fentanyl IVP for MRI.\n Cont neuro checks by RN.\n Response:\n Pt tolerated LP and MRI well.\n Pt off sedation for several hours but became agitated (biting on ETT)\n and not following any commands.\n Started on propofol gtt for sedation.\n Plan:\n Cont propofol gtt and daily wake-ups as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2169-02-23 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 518296,
"text": "Chief Complaint: Mental status changes and hypoxia\n HPI:\n Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma who was\n brought to OSH after being found down. She lives with her niece, the\n niece's daughter and husband. She had been complaining of an URI\n infection for the last 1.5 weeks with symptoms of fatigue and cough.\n No fevers or other complaints as far as the niece knows. She was\n bedridden for the first 3 days or so but had been improving, enough to\n clean the house yesterday. Overnight, her neice had heard a thump and\n found the patient on the floor. She was complaining of L arm pain.\n She was also confused, repeatedly calling for help and asking about her\n dead dog. She has had her flu and H1N1 shots this year.\n .\n The patient was takent to Hospital. There, she became\n increasingly altered without focal neuro deficits. She had multiple\n imaging studies. Head and neck CT scans were negative. X-rays showed\n a R humeral fracture. Her labs, inc. chemistries and cardiac enzymes,\n were normal except for Cr of 1.3. She received 1 mg of ativan, 2 mg of\n morphine, and ???dilantin. On the way over in the ambulance, pt had\n reportedly son respirations with desaturations, requiring bagging\n in the ambulance.\n .\n In the ED, she only responded to painful stimuli, no gag reflex.\n Mental status did not improve with 0.4 mg of Narcan. She was intubated\n for airway protection and ventilatory support. She had some \n blood in the ETT, though the intubation was not difficult. Labs were\n sig. for neg serum tox screen, mild leukocytosis of 11.7, Cr 1.2.\n Lactate was 1.4. 1st of cardiac enzymes were neg. CXR and CTA showed\n pneumonia, no PE. CT head showed no acute process. X-rays showed\n comminuted fracture of the left proximal humerus, no hip fractures. ED\n failed multiple LP attempts. Patient was acyclovir, vanc, CTX,\n levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67, 20, 96%\n on 40% FiO2, AC 500 x 20.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n CHF\n Asthma\n .\n Medications:\n Atenolol 25 mg daily\n Verapamil SR 240 mg daily\n Triamterene 37.5 and HCTZ 25 daily\n ASA 325 mg daily\n Montelukast 10 mg daily\n Advair 500/50\n Piroxicam 1 cap daily\n KCl 20 meq daily\n Heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt lives with her niece's family. She used to work for the\n state, caring for the mentally challenged. She is active at home,\n helping with chores and going to the gym. She is a remote smoker, no\n etoh, no recreational drugs.\n Review of systems:\n Flowsheet Data as of 03:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 97 (97 - 103) bpm\n BP: 123/71(83) {123/71(83) - 123/71(83)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 100%\n Total In:\n 1,028 mL\n PO:\n TF:\n IVF:\n 28 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 828 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST:\n IMPRESSION:\n 1. No pulmonary embolism or acute aortic pathology.\n 2. Scattered ill-defined nodular opacities within the lungs, likely\n infectious in etiology.\n 3. NG tube ending in the esophagus. Recommend advancement past the GE\n junction.\n 4. Left humeral fracture incompletely imaged.\n .\n CXR:\n 1. ET tube ending in the right main stem bronchus. Recommend\n withdrawal.\n 2. NG tube with sideport in the distal thoracic esophagus. Recommend\n advancement.\n 3. Incompletely imaged left humeral head fracture.\n 4. Left lower lobe ill-defined opacity, likely representing pneumonia.\n .\n CT HEAD\n No acute intracranial process. Sinus disease as noted above.\n .\n BILAT HIPS (AP,LAT & AP PELVIS) PORT\n IMPRESSION: No fracture or dislocation.\n .\n HUMERUS (AP & LAT) LEFT Study Date of \n IMPRESSION: Comminuted fracture of the left proximal humerus\n Microbiology: BCxs pending\n ECG: NSR at 77 bpm. Nl axis. No ischemic changes.\n Assessment and Plan\n Assessment and Plan: 52 yo female with PMHx sig. for HTN, CHF, asthma\n who presents with URI symptoms, acute mental status changes, found to\n have pneumonia, intubated for airway protection and respiratory\n distress.\n .\n # Respiratory distress: She is not requiring high amounts of oxygen.\n There is some evidence of pneumonia on her chest CT. It's unclear\n whether this is a bacterial superinfection from her viral URI, aytpical\n pneumonia, or aspiration pneumonia secondary to her acute mental status\n changes. CTA did not reveal a PE. She does not seem volume\n overloaded.\n - flu swab, sputum culture, urine legionella\n - bronch for bal, assess for bleeding source\n - send CBC\n - well covered with CTX, vanc, and levaquin\n - will plan to lighten sedation, try PS\n .\n # Acute mental status changes: This is most concerning for\n meningitis/encephalitis. It could be a viral meningitis as she had URI\n symptoms. The concern would be bacteria meningitis from complication\n of pneumonia. However, she has no fever and only a very mild\n leukocytosis, no bands. Currently, she is too sedated for an adequate\n neuro exam. Reportedly, her neuro exam was normal at . CT head\n does not show any acute pathology. be a concussion from the fall.\n She also had ativan, morphine, and possibly dilantin at the OSH;\n however, she was altered prior to arrival.\n - switch to propofol to assess mental status\n - attempt LP, may need to be IR guided\n - obtain MRI to assess for temporal lobe enhancement, stroke\n - EEG to assess for seizures but will hold AEDs for now\n .\n # L humeral fracture:\n - Needs sling, likely nonoperative\n - Ortho following, appreciate recs\n .\n # HTN:\n - hold antihypertensives for now\n .\n # CHF: Not on ACEI, , or Lasix at home. Currently not volume\n overloaded.\n - monitor volume status\n - consider ECHO\n .\n # Asthma: Not currently wheezy.\n - albuterol/ipratropium MDIs prn\n .\n FEN: IVF boluses for hypotension, replete electrolytes, NPO/TFs\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full, confirmed with niece\n Communication: Niece home , cell ,\n Nephew in law \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n 20 Gauge - 01:44 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F HTN, CHF, asthma recent URI sx c cough /\n weakness / malaise x1 week, found down by niece, confused but\n conscious, BIBA to OSH, head / neck CT negative, L humeral fx -\n transferred to , intubated on arrival. Here, CTA s PE, LP failed\n treated with acyclovir, vanco, ctx, flagyl.\n Exam notable for Tm 98.9 BP 120/70 HR 95 RR 14 with sat 96 on VAC\n 550x14 5 0.7. PERRL CTA B. RRR s1s2 2/6Sm. Soft +BS. No edema. Labs\n notable for WBC 11K, HCT 35, K+ 4.0, Cr 1.2, lactate 1.4. CXR with\n mildy haziness L>R. CTA c subtle GG changes, LLL infiltrate, no\n effusions.\n Agree with plan to manage acute encephalopathy and respiratory failure\n with antibiotics for possible meningitis or CAP - will use high dose\n CTX, vanco, acyclovir, levo and tamiflu. Will pan cx, check legionella,\n viral panel, try LP, and bronch esp given subtle changes on CT and\n hemoptysis after intubation. Continue AC vent for now, transition to\n propofol for sedation in the setting of encephalopathy, and place\n arterial line. For altered mental status, LP, spot EEG and MRI. Fall\n likely d/t medical illness, ortho eval of humeral fx. Will also check\n echo and continue to hold antihypertensives. Remainder of plan as\n outlined above.\n ADDNEDUM\n Bronch revealed likely posterior injury to airway with\n bleeding visible behind ETT and aspirated blood in the airways. No\n bleeding from lower lung or EB lesions. BAL sent without complication\n see procedure note in MetaVision.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:46 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518358,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518359,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall ing\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518368,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen, Head CT\ns negative. During ambulance transfer\n from OSH to pts respiratory function started fail and required\n ambu-bagging. Pt was intubated on arrival to ED. Admitted to\n M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518370,
"text": "52 y/o woman with PMH hypertension, CHF, and asthma. Was admitted to\n OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen, Head CT\ns negative. During ambulance transfer\n from OSH to pts respiratory function started fail and required\n ambu-bagging. Pt was intubated on arrival to ED. Head CT\n negative. Admitted to M/SICU for further mgt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated.\n Received pt on AC 14/550, FIO2 60%, PEEP 5.\n 02 sats 100%, ABG 7.43/40/178.\n LS clear upper, diminished bases. Minimal secretions.\n Vitals stable.\n Action:\n FIO2 reduced to 40%.\n Suction as needed.\n Remains on IV abx.\n Response:\n 02 sats remain 100% on AC 14/550, 40%.\n Plan:\n Cont close monitoring of resp status.\n Wean vent settings as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518340,
"text": "Assessment and Plan: 52 yo female with PMHx sig. for HTN, CHF, asthma\n who presents with URI symptoms, acute mental status changes, found to\n have pneumonia, intubated for airway protection and respiratory\n distress.\n .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.1, wbc\ns wnl, lactate wnl.\n Action:\n BC sent in ED. Urine and sputum cultures after arrival to ICU. Pt is on\n multiple antibiotics.\n Response:\n Pending.\n Plan:\n Continue antibiotics, f/u cultures, to have LP tonight.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Arrived from on AC 550X14X100%X5. Lung sounds diminished throughout,\n heavily sedated on midaz at 15mg/hr. O2 sats 96-98%. Chest CT showed\n some evidence of pneumonia which could be bacterial superinfection from\n viral URI vs atypical pneumonia vs asp pna to altered mental\n status. Pt has fair amt of bloody secretions ? from traumatic\n intubation although ED reports pt was not a particularly difficult\n intubation.\n Action:\n Sedation changed to fent 50mcg/hr and midaz 5mg/hr, pt responsive to\n deep stimulation only. Pt is on droplet precautions for r/o flu. BAL\n done. Arterial line placed.\n Response:\n ABG 7.43/40/178/2/27. Large amt of bloody secretions seen L bronchus,\n specs sent.\n Plan:\n Wean O2 and other settings as tolerated, suction prn, change sedation\n to propofol to assess mental status more easily.\n Altered mental status (not Delirium)\n Assessment:\n Pt unresponsive upon arrival to ICU most likely from high dose\n midazolam gtt. Acute MS change concerning for encephalitis/meningitis\n although wbc\ns wnl. Could also be attributed to concussion from fall or\n sedation meds. Per ED nurse pt\ns BP dropped when given propofol.\n Action:\n Sedation changed to fent 50/midaz 5.\n Response:\n Pt responsive to physical stimulation, but inconsistently. Does not\n open eyes or follow commands.\n Plan:\n LP and head MRI tonight. Change sedation to propofol so can assess MS\n more easily.\n"
},
{
"category": "Nursing",
"chartdate": "2169-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 518713,
"text": "62 y/o woman with PMH hypertension, CHF, CAD, and asthma. Was admitted\n to OSH following fall at home with confusion/disorientation with\n undetermined cause. Pt was taken to OSH ED where pts mental status\n continued to worsen. During ambulance transfer from OSH to pts\n respiratory status continued to decline\n and pt was intubated on arrival to ED. Head/neck CT negative,\n cervical collar off at 6pm yesterday after pt. was cleared of\n C-fracture.\n Altered mental status (not Delirium)\n Assessment:\n Pt. is orientated x 2 (person and time), GCS at 15, pt. able to answer\n questions but having trouble finding words, MRI and head CT is\n negative, fall risk , LP negative\n Action:\n Re-orientating the pt. to place, bed is low and lock, call in reach,\n bed alarm is on, and 3 sides up\n Response:\n Improving but still with episodes of confusion\n Plan:\n Continue to assess LOC q4 hrs, keep safe\n Hypokalemia (Low potassium)\n Assessment:\n Potassium serum levels consistently low after repletion within last 24\n hrs (3.1), pt. is asymptomatic (no muscle weakness, aches, etc.), pt.\n state it is a problem due to diuretic use for CHF and reported stopping\n potassium medication at home\n Action:\n Administering potassium repletion at a total of 60 mEq (20 mEq in\n powder form (packet) and 40 mEq/500 cc over 4hrs)\n Response:\n Current K+\n Plan:\n Continue to monitor potassium levels and replete as needed\n Pneumonia, other\n Assessment:\n Pt. extubated yesterday, received on high flow mask sating at 97-98%,\n upper LS clear with diminishment at bases, No SOB, WBC within normal\n range at 7.9, Chest X-ray show consolidation in the lobes representing\n pneumonia apiration vs. infection, initally pt. had blood tinge\n secretions secondary to traumatic intubation, bronchoscopy revealed no\n source of bleeding, Influenza A&B negative but remains on droplet\n precaution\n Action:\n O2 weaned to 2L NC, aspiration precaution maintained, continues on\n ceftriaxone, levofloxacin, TamiFlu\n Response:\n Pt. Afebrile, non-productive cough, no SOB, ? confusion\n Plan:\n Continue to administer ceftriaxone, levofloxacin, TamiFlu as ordered ,\n folow up on whether to keep pt. on droplet precaution (no brochial\n lavage specimen pending to be sent to state per micro)\n Fracture, left humerus\n Assessment:\n X-ray revealed fracture of left humerus, bruising located on upper left\n arm extending to upper back shoulder, pain excruciating\n Action:\n Bruised area marked, ortho following pt., maintaining L arm in a stable\n position, minimizing movement during repositioning/turn, administered\n morphine sulfate 2mg IV Push @ 0300\n Response:\n Pain medication effective, stable vital signs\n Plan:\n Continue to assess bruising and pain level and maintain arm stablized\n * Hypertension: Pt. has stable BP, maintained below 160 systolic,\n antihypertensive medication held.\n *Diet changed from NPO to Clear liquids, medications administered with\n applesause\n *Skin Integrity: Swelling, redness, and bruising at A-line insertion\n site, A-line removed\n"
},
{
"category": "Nutrition",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518542,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 89.2 kg\n ?\n 35.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 179%\n 59.7 kg\n ?\n -\n Diagnosis: Altered Mental Status\n PMHx:\n Food allergies and intolerances: none noted.\n Pertinent medications: propofol.\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 04:20 AM\n BUN\n 12 mg/dL\n 04:20 AM\n Creatinine\n 0.8 mg/dL\n 04:20 AM\n Sodium\n 141 mEq/L\n 04:20 AM\n Potassium\n 3.3 mEq/L\n 04:20 AM\n Chloride\n 109 mEq/L\n 04:20 AM\n TCO2\n 22 mEq/L\n 04:20 AM\n PO2 (arterial)\n 114 mm Hg\n 04:43 AM\n PCO2 (arterial)\n 45 mm Hg\n 04:43 AM\n pH (arterial)\n 7.37 units\n 04:43 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:43 AM\n Albumin\n 2.9 g/dL\n 04:20 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:20 AM\n Phosphorus\n 2.7 mg/dL\n 04:20 AM\n Magnesium\n 1.5 mg/dL\n 04:20 AM\n ALT\n 18 IU/L\n 04:20 AM\n Alkaline Phosphate\n 58 IU/L\n 04:20 AM\n AST\n 23 IU/L\n 04:20 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:20 AM\n WBC\n 7.4 K/uL\n 04:20 AM\n Hgb\n 10.4 g/dL\n 04:20 AM\n Hematocrit\n 30.5 %\n 04:20 AM\n Current diet order / nutrition support: NPO pending tube feed consult.\n GI:\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, intubated.\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 78-90 (1.3-1.5 g/kg)\n Fluid: per team.\n Calculations based on: Adjusted weight\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518543,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 89.2 kg\n ?\n 35.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 179%\n 59.7 kg\n ?\n -\n Diagnosis: Altered Mental Status\n PMHx:\n HTN\n CHF\n Asthma\n Food allergies and intolerances: none noted.\n Pertinent medications: propofol.\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 04:20 AM\n BUN\n 12 mg/dL\n 04:20 AM\n Creatinine\n 0.8 mg/dL\n 04:20 AM\n Sodium\n 141 mEq/L\n 04:20 AM\n Potassium\n 3.3 mEq/L\n 04:20 AM\n Chloride\n 109 mEq/L\n 04:20 AM\n TCO2\n 22 mEq/L\n 04:20 AM\n PO2 (arterial)\n 114 mm Hg\n 04:43 AM\n PCO2 (arterial)\n 45 mm Hg\n 04:43 AM\n pH (arterial)\n 7.37 units\n 04:43 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:43 AM\n Albumin\n 2.9 g/dL\n 04:20 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:20 AM\n Phosphorus\n 2.7 mg/dL\n 04:20 AM\n Magnesium\n 1.5 mg/dL\n 04:20 AM\n ALT\n 18 IU/L\n 04:20 AM\n Alkaline Phosphate\n 58 IU/L\n 04:20 AM\n AST\n 23 IU/L\n 04:20 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:20 AM\n WBC\n 7.4 K/uL\n 04:20 AM\n Hgb\n 10.4 g/dL\n 04:20 AM\n Hematocrit\n 30.5 %\n 04:20 AM\n Current diet order / nutrition support: NPO pending tube feed consult.\n GI:\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, intubated.\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 78-90 (1.3-1.5 g/kg)\n Fluid: per team.\n Calculations based on: Adjusted weight\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518545,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 89.2 kg\n ?\n 35.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 179%\n 59.7 kg\n ?\n -\n Diagnosis: Altered Mental Status\n PMHx:\n HTN\n CHF\n Asthma\n Food allergies and intolerances: none noted.\n Pertinent medications: propofol.\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 04:20 AM\n BUN\n 12 mg/dL\n 04:20 AM\n Creatinine\n 0.8 mg/dL\n 04:20 AM\n Sodium\n 141 mEq/L\n 04:20 AM\n Potassium\n 3.3 mEq/L\n 04:20 AM\n Chloride\n 109 mEq/L\n 04:20 AM\n TCO2\n 22 mEq/L\n 04:20 AM\n PO2 (arterial)\n 114 mm Hg\n 04:43 AM\n PCO2 (arterial)\n 45 mm Hg\n 04:43 AM\n pH (arterial)\n 7.37 units\n 04:43 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:43 AM\n Albumin\n 2.9 g/dL\n 04:20 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:20 AM\n Phosphorus\n 2.7 mg/dL\n 04:20 AM\n Magnesium\n 1.5 mg/dL\n 04:20 AM\n ALT\n 18 IU/L\n 04:20 AM\n Alkaline Phosphate\n 58 IU/L\n 04:20 AM\n AST\n 23 IU/L\n 04:20 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:20 AM\n WBC\n 7.4 K/uL\n 04:20 AM\n Hgb\n 10.4 g/dL\n 04:20 AM\n Hematocrit\n 30.5 %\n 04:20 AM\n Current diet order / nutrition support: NPO pending tube feed consult.\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, intubated.\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 78-90 (1.3-1.5 g/kg)\n Fluid: per team.\n Calculations based on: Adjusted weight\n Specifics:\n 52 yo female with PMHx significant for HTN, CHF& asthma who presents\n with URI symptoms, acute mental status changes, found to have\n pneumonia, intubated for airway protection and respiratory distress.\n Medical Nutrition Therapy Plan - Recommend the Following\n"
},
{
"category": "Nutrition",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 518551,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 89.2 kg\n ?\n 35.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 179%\n 59.7 kg\n ?\n -\n Diagnosis: Altered Mental Status\n PMHx:\n HTN\n CHF\n Asthma\n Food allergies and intolerances: none noted.\n Pertinent medications: propofol.\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 04:20 AM\n BUN\n 12 mg/dL\n 04:20 AM\n Creatinine\n 0.8 mg/dL\n 04:20 AM\n Sodium\n 141 mEq/L\n 04:20 AM\n Potassium\n 3.3 mEq/L\n 04:20 AM\n Chloride\n 109 mEq/L\n 04:20 AM\n TCO2\n 22 mEq/L\n 04:20 AM\n PO2 (arterial)\n 114 mm Hg\n 04:43 AM\n PCO2 (arterial)\n 45 mm Hg\n 04:43 AM\n pH (arterial)\n 7.37 units\n 04:43 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:43 AM\n Albumin\n 2.9 g/dL\n 04:20 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:20 AM\n Phosphorus\n 2.7 mg/dL\n 04:20 AM\n Magnesium\n 1.5 mg/dL\n 04:20 AM\n ALT\n 18 IU/L\n 04:20 AM\n Alkaline Phosphate\n 58 IU/L\n 04:20 AM\n AST\n 23 IU/L\n 04:20 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:20 AM\n WBC\n 7.4 K/uL\n 04:20 AM\n Hgb\n 10.4 g/dL\n 04:20 AM\n Hematocrit\n 30.5 %\n 04:20 AM\n Current diet order / nutrition support: NPO pending tube feed consult.\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, intubated.\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 78-90 (1.3-1.5 g/kg)\n Fluid: per team.\n Calculations based on: Adjusted weight\n Specifics:\n 52 yo female with PMHx significant for HTN, CHF& asthma who presents\n with URI symptoms, acute mental status changes\nlikely with\n meningitis/encephalitis, found to have pneumonia, intubated for airway\n protection and respiratory distress. Currently not volume overloaded &\n not on lasix. Recommend Replete with Fiber at goal 55mL/hr, providing\n 1320kcals & 82g protein. On Propofol at currently 10.7mL/hr (provides\n ~283kcals x 24hrs).\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Once able to start tube feeds, start at 10mL/hr, advance by\n 15mL every 4hrs to goal 55mL/hr\n 2. check residuals every 4hrs & hold for 1hr if greater than\n 150mL & consider raglan/standing order\n 3. Adjust free water flushes per hydration\n 4. Monitor & replete labs PRN\n 5. Monitor volume status & fluid restrict as needed\n Will follow plan/progress.\n"
},
{
"category": "Echo",
"chartdate": "2169-02-28 00:00:00.000",
"description": "Report",
"row_id": 90532,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Syncope. Troponin elevation. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 180\nBSA (m2): 1.83 m2\nBP (mm Hg): 140/82\nHR (bpm): 65\nStatus: Outpatient\nDate/Time: at 15:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%\ndecrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting or Valsalva inducible LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). The estimated cardiac index is\nnormal (>=2.5L/min/m2). There is no left ventricular outflow obstruction at\nrest or with Valsalva. Right ventricular chamber size and free wall motion are\nnormal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with mild [1+] mitral regurgitation. There is no mitral\nvalve prolapse. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global and\nregional biventricular systolic function. Mild mitral regurgitation with\nnormal valve morphology. No structural cardiac cause of syncope identified.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-24 00:00:00.000",
"description": "Report",
"row_id": 228903,
"text": "Sinus rhythm. Delayed precordial R wave transition. There is variation in\nprecordial lead placement as compared with previous tracing of .\nOtherwise, no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-02-23 00:00:00.000",
"description": "Report",
"row_id": 228904,
"text": "Sinus rhythm and baseline artifact. Non-specific inferior ST segment changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1120891,
"text": " 8:21 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please eval for PE, effusion, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with blood from ETT, AMS since this AM\n REASON FOR THIS EXAMINATION:\n please eval for PE, effusion, pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:25 AM\n Bilateral peribronchial thickening and consolidations predominantly in lower\n lobes representing pneumonia, aspiration vs infectious. No\n endobronchial/tracheal mass or traumatic injury noted. No pulmonary embolism.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with blood from ETT, altered mental status\n since this AM please evaluate for pleural effusion or pneumonia.\n\n COMPARISON: Chest radiograph from .\n\n TECHNIQUE: MDCT images were acquired through the chest without contrast in\n full inspiration and with contrast in shallow inspiration. Multiplanar\n reformations were obtained and reviewed.\n\n CT OF THE CHEST WITH AND WITHOUT CONTRAST:\n\n The ET tube has been withdrawn since the prior chest radiograph and is now in\n appropriate position. The NG tube has also been withdrawn and is now ending\n in the esophagus. It should be advanced past the GE junction. The visualized\n thyroid gland is unremarkable. There is no axillary or mediastinal\n lymphadenopathy present. There is diffuse aortic arch and triple vessel\n coronary artery calcifications. Also present are aortic valvular\n calcifications. The heart size is unremarkable. There is no pericardial\n effusion present. There are no tracheal or endobronchial lesions present. No\n evidence of vascular injury.\n\n Both lobes show ground-glass as well as ill-defined nodular opacities\n scattered within the lower lobes in right upper and middle lobes, with\n relative sparing the left upper lobe. No effusions are present. The\n pulmonary arteries are patent down to the subsegmental level. The distal\n bronchioles are thickened and somewhat narrowed, otherwise the airways are\n patent.\n\n The visualized abdomen is unremarkable.\n\n OSSEOUS STRUCTURES:\n\n The visualized osseous structures show anterior osteophyte formation of the\n lower thoracic spine. There is also a left humeral fracture incompletely\n imaged.\n\n IMPRESSION:\n (Over)\n\n 8:21 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please eval for PE, effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No pulmonary embolism or acute aortic pathology.\n\n 2. Scattered ill-defined nodular opacities within the lungs, likely\n infectious in etiology.\n\n 3. NG tube ending in the esophagus. Recommend advancement past the GE\n junction.\n\n 4. Left humeral fracture incompletely imaged.\n\n These findings were communicated via telephone to MD at 11\n am on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1120892,
"text": " 8:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with AMS after fall\n REASON FOR THIS EXAMINATION:\n please evaluate for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:58 AM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with altered mental status after fall. Please\n evaluate intracranial hemorrhage.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the brain without contrast.\n Bone coronal reconstructions and multiplanar reformations were obtained and\n reviewed.\n\n FINDINGS: There is no hemorrhage, acute large vascular territory infarct,\n shift of midline structures or mass effect present. The ventricles and sulci\n are normal in size and configuration. No fractures are present. The\n bilateral maxillary and sphenoidal sinuses shows moderate mucosal thickening.\n Noted is partial opacification of the left mastoid air cells. No fractures\n are noted specifically in the temporal bone on the left.\n\n IMPRESSION:\n\n No acute intracranial process. Sinus disease as noted above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120887,
"text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with changed ms, snoring resp s/p intubation\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with change in mental status, snoring,\n respiratory distress, post intubation, question tube placement.\n\n COMPARISON: None available.\n\n TECHNIQUE: Supine portable frontal chest radiograph.\n\n FINDINGS:\n\n An ET tube is seen ending in the proximal right main stem bronchus. NG tube\n is seen with its sideport ending within the esophagus superior to the GE\n junction. A left humeral head fracture is incompletely imaged. The\n visualized lungs show an ill-defined opacity in the left lower lobe. The\n cardiomediastinal silhouette is otherwise unremarkable. No effusions or\n pneumothorax are noted. The remaining osseous structures are intact.\n\n IMPRESSION:\n\n 1. ET tube ending in the right main stem bronchus. Recommend withdrawal.\n\n 2. NG tube with sideport in the distal thoracic esophagus. Recommend\n advancement.\n\n 3. Incompletely imaged left humeral head fracture.\n\n 4. Left lower lobe ill-defined opacity, likely representing pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1121031,
"text": " 9:25 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: pls assess for temporal lobe enhancement, stroke\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with URI symptoms x2 weeks, then developed acute mental\n status changes, now intubated.\n REASON FOR THIS EXAMINATION:\n pls assess for temporal lobe enhancement, stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with URI symptoms for two weeks, now with acute\n mental status change and intubated.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: MRI of the brain was performed per standard departmental protocol\n before and after the administration of gadolinium.\n\n MRI OF THE BRAIN WITH AND WITHOUT CONTRAST: There is no acute infarct,\n hemorrhage, edema, mass, or abnormal enhancement. There is a focus of\n punctate T2/FLAIR hyperintensity in the right frontal subcortical white matter\n and a second in the left frontal subcortical white matter, in addition to mild\n periventricular T2/FLAIR hyperintensity. These are most suggestive of chronic\n small vessel ischemic disease. The ventricles, sulci, and extra-axial CSF\n spaces are within normal limits. There is no abnormal parenchymal or\n leptomeningeal enhancement.\n\n There is mucosal thickening and fluid within the maxillary sinuses, ethmoid\n air cells, frontal and sphenoid sinuses as well as in the mastoid air cells\n bilaterally, likely at least in part due to intubation.\n\n There is an 8x9 mm rounded lesion in the right parotid gland with low signal\n on T1 and T2 weighted images, and low level enhancement after gadolinium.\n\n IMPRESSION:\n 1. No evidence of acute intracranial process.\n\n 2. Nonspecific T2/FLAIR hyperintensities in the periventricular and\n subcortical white matter, likely due to chronic small vessel ischemic disease.\n\n 3. Right parotid enhancing nodule. Differential includes pleomorphic\n adenoma. Clinical correlation recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-24 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1121117,
"text": " 11:32 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture/compression/disc disease\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n INDICATION: Trauma, to evaluate for injury.\n\n Preliminary report given earlier.\n\n FINDINGS:\n\n Again visualized is a comminuted left proximal humeral fracture, on the scout\n image, better evaluated on the plain radiograph of the shoulder done on\n .\n\n There is straightening of the cervical spine. Multilevel anterior and\n posterior osteophytes along with endplate sclerosis are noted.\n\n There are disc osteophyte complexes, at multiple levels C4-5, C5-6, and C6-7\n levels, causing indentation on the ventral thecal sac and possibly the ventral\n aspect of the cord. Evaluation of the intrathecal contents is limited due to\n the technique. Multilevel facet degenerative changes are noted.\n\n There is no evidence of acute fracture or dislocation. No pre- or para-\n vertebral soft tissue swelling or masses are noted. The patient is intubated,\n with endotracheal tube as well as nasogastric tube partially imaged on the\n present study.\n\n Multilevel neural foraminal narrowing is noted, mild on the right at C3-4\n level, moderate-to-severe at C5-6 level on both sides, and moderate at C6-7\n level on both sides, from uncovertebral, disc and facet osteophytes. There is\n diffuse osteopenia noted, with lucent areas in several bones.\n\n Moderate bilateral maxillary sinus mucosal thickening, and areas of increased\n attenuation in the visualized portions of the lungs on both sides, right more\n than left, are noted. These can be better evaluated with dedicated chest\n imaging.\n\n IMPRESSION:\n 1. No acute fracture or malalignment. Reversal of cervical lordosis,\n multilevel degenerative changes as described above, with moderate-to-severe\n neural foraminal narrowing at C5-6 level and C6-7 level, along with mild\n spinal canal stenosis, evaluation of the intrathecal contents being limited on\n the present study. If there is continued concern based on the examination,\n MRI can be considered (if not contra-indicated) for better assessment of cord,\n ligamentous/neural structures.\n\n 2. Other details as above. Areas of increased attenuation in the visualized\n lung apices can be better evaluated with dedicated chest imaging.\n\n (Over)\n\n 11:32 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture/compression/disc disease\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL ADDENDUM\n (Cont)\n 3. Comminuted left humeral fracture proximal, better evaluated on the prior\n plain radiograph of the shoulder.\n\n 4. Some of the anterior osteophytes are obliquely oriented, with lucencies\n likely related to the obliquely. There is no soft tissue swelling adjacent,\n to suggest acute injury.\n\n\n\n\n\n 11:32 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture/compression/disc disease\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n please eval for fracture/compression/disc disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female with fall on .\n\n There are no prior examinations for comparison.\n\n TECHNIQUE: Helical MDCT images were acquired from the skull base through the\n T2 vertebral body, using bone and soft tissue kernels. Sagittal and coronal\n multiplanar reformations were generated.\n\n PRELIMINARY REPORT:\n\n There are no acute fractures. There is multilevel degenerative disease of the\n cervical spine with loss of the normal cervical lordosis.\n Anterior osteophytes and disc space narrowing are present at multiple levels,\n most pronounced at C5-C6 with moderate-severe neural foraminal narrowing on\n both sides.\n\n FINAL REPORT WILL BE DICTATED AS AN ADDENDUM.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "P BILAT HIPS (AP,LAT & AP PELVIS) PORT",
"row_id": 1120904,
"text": " 9:22 AM\n BILAT HIPS (AP,LAT & AP PELVIS) PORT Clip # \n Reason: please eval for R hip fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with fall, externally rotated R leg\n REASON FOR THIS EXAMINATION:\n please eval for R hip fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall with externally rotated right leg. Evaluate for right hip\n fracture.\n\n COMPARISON: None.\n\n AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT HIP: There is no fracture or\n dislocation. There are mild degenerative changes involving both hips with\n mild joint space narrowing. The sacroiliac joints and pubic symphysis are not\n diastatic. Mild degenerative changes are also noted within the lower lumbar\n spine. A Foley catheter is seen within the bladder which contains excreted\n contrast. There are calcifications adjacent to both greater trochanters,\n which could represent calcific tendinopathy.\n\n IMPRESSION: No fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "L HUMERUS (AP & LAT) LEFT",
"row_id": 1120897,
"text": " 9:10 AM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: please eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hematoma, OSH report of fracture\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hematoma with report of fracture.\n\n COMPARISON: None.\n\n TWO VIEWS OF THE LEFT HUMERUS: There is a comminuted fracture of the left\n proximal humerus involving the left humeral head and surgical neck. There\n appears to be lateral displacement of a dominant fracture fragment. The\n glenohumeral articulation remains preserved. The acromioclavicular joint\n demonstrates mild degenerative spurring. Visualized right lung is clear. The\n imaged left elbow appears grossly unremarkable.\n\n IMPRESSION: Comminuted fracture of the right proximal humerus\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120977,
"text": " 3:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ett\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with respiratory distress, acute mental status changes,\n intubated.\n REASON FOR THIS EXAMINATION:\n ett\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 62-year-old female patient with respiratory distress, acute\n mental status changes, intubated with ETT.\n\n Follow up examination.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Available for comparison is the next preceding\n similar study obtained seven hours earlier during the same day. The position\n of the previously too far advanced ETT terminating in the proximal portion of\n the right main bronchus has been adjusted. The ETT terminates now in the\n trachea some 5 cm above the level of the carina. No pneumothorax has\n developed. NG tube as before. No new parenchymal abnormalities are present.\n\n IMPRESSION: Successful adjustment of ETT position.\n\n\n"
}
] |
99,985 | 176,670 | 53-year-old male patient with h/o of hodgkins lymphoma in BMT ', h/o splenectomy, h/o pericarditis, hypothyroidism was initially admitted for fever in setting +sick contacts. In ER, confirmed Influenza B + (Rx with Tamiflu X7days). Pt initially did well first night, but then had rapidly worsened hypoxia am of with CT chest showing new multilobar consolidations. Developed septic shock and ARDS, started broad Abx (vanc/cefepime/azithromycin), transfered to MICU, was intubated for hypoxemic resp failure . Resp cultures grew MSSA and Abx changed to nafcillin to complete 3week course per ID (until via R PICC). Was finally extubated and transfered to Gen Med on . On Gen Med, continued with rapid improvement, weaned off O2. There was some concern initially with persistant leukocytosis in 20s with fevers and imaging with pleural effusions that raised concern for parapneumonic efffuisons or empyema. However, WBC did start to trend down so was deferred. He will have ID f/u after Abx and needs repeat imaging. Still having low grade fevers and imaging with L>R infiltrates but clinically much better. Other infectious w/u negative. Of note, during hospitalization, pt had some LFT elevation with US/CT showing sludge but no evidence of cholecystitis and this was likely acute illness and possible TPN which he recieved for few days (improving by time of discharge). Also developed Anemia 12-->8 w/o gross evidence of bleeding or hemolysis, s/p 1U prbc with hgb stable 9s thereafter. this can be followed up as outpt. . . See progress note below for details according to each problem: 53 year-old male with a history of hodgkin's s/p BMT in 93, s/p splenectomy, h/o pericarditis, hypothyroidism, anemia, admitted with influenza B (received antiviral treatment in ICU) complciated by severe MSSA bacterial superinfection-->ARDS/intubation, extubated , t/f to floor , doing very well, ambulating, tolerating PO, plan to d/c home today . . MSSA CAP, superinfection (Influenza B): ARDS, extubated . Doing well, off oxygen. Some concern initially with persistant leukocytosis/fevers and CT with persistant L>>R pleural effusions concerning for parapneumonic effusions but white count finally down. Pt has been afebrile (low grade temps) - continue Nafcillin 2 gm IV q 4hr through for total of 3 weeks per ID (confirmed plan) -since downtrending wbc, can hold off on , but needs repeat imaging to ensure resolved effusions, f/u clinic in - continue incentive spirometry - guiafenisin prn, duonebs -note, pt is post splenectomy, asked to confirm pneumovax and meningitis vaccine, but none here while PNA . . Leukocytosis: as above, 20s for several days, today down to 12, as above, concern for parapneumonic effusions but holding as above with repeat CXR in 1week. Currently with low grade temps, no fevers. As for other sources, LIJ tip not sent, PICC site looks good, no urinary complaints, no diarrhea. note, baseline elevated wbc partly due to post-splenectomy. . . Anemia and thrombocytosis: baseline hgb 12s, here 9-->7s s/p 1U prbc , now 9s. No obvious bleeding or hemolysis but was acutely ill. -Fe studies will be unreliable since got blood t/f, hold supp since Fe load with transfusion -will need to be followed as outpt -as for thrombocytosis, likely reactive (anemia, illness) and post-splenectomy . . Hodgkins disease s/p BMT', no issues . . Hypothyroidism: cont levothyroxine 88mcg . . GERD: protonix 40-->prilosec at home . . Dyslipidemia; resume lipitor 10 . . Elevated Alk phos: RUQ with sludge, no dilation, bili normal, no RUQ pain -slow trend down, monitor, follow as outpt . | Hypoxemic Respiratory Failure- -A/Cwill maintain PEEP at 10-12 -Continue FIO2=1.0 -Will need to replace volume with patient currently hypotensive -PIP=30, Pplat-27 consistent with presentation -Wean FIO2 as possible -Advance ETT -Will place A-line Pneumonia- -Linezolid/Cefepime/Axithro -Sputum GS C+S -Follow up culture results -Urine Legionella pending -Bronch and BAL if patient improved stability to tolerate procedure or with inadequate sampling Sepsis- -Patient with significant hypotension with intubation and leading to respiratory failure -Will need CVL and volume replacement -Follow up cultures results -Will titrate therapy to stability of blood pressure. If unable will need PPN until placed Glycemic Control: Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: Hep SQ Stress ulcer: PPI VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition :ICU Total time spent: 65 minutes Response: Currently normotensive, remains febrile Plan: Monitor hemodynamic status, cont IV abx Will give TF until early am for possible am extubation #) Access: 2 PIVs; right IJ #) PPx: hep sc, PPI #) Dispo: ICU until respiratory status improves #) Comm: With wife ICU Nutrition: TPN without Lipids - 06:01 PM 42 mL/hour Glycemic Control: Blood sugar well controlled Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition:ICU ventilation) Comments: Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated, Reduce PEEP as tolerated Reason for continuing current ventilatory support: Underlying illness not resolved Respiratory Care Shift Procedures Transports: Destination (R/T) Time Complications Comments Bedside Procedures: Comments: Respiratory failure, acute (not ARDS/) Assessment: Pt is sedated and intubated on AC for ARDS. Started on MDI Albuterol Q4PRN Reason for continuing current ventilatory support: Underlying illness not resolved Assessment of breathing comfort: No claim of dyspnea Trigger work assessment: Triggering synchronously Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated Reason for continuing current ventilatory support: Underlying illness not resolved Respiratory Care Shift Procedures Transports: Destination (R/T) Time Complications Comments CT 1400 pt vomitted contrast, orally suctioned for copious amounts of think yellow secretions. Chief Complaint: s/p resp failure 24 Hour Events: PICC LINE - START 09:29 PM MULTI LUMEN - STOP 06:00 AM -PICC placed and IJ d'c'd -KUB checked to evaluate dobhoff -speech and swallow bedside eval passed with pt cleared to take thin liquids and MOIST soft solids. Chief Complaint: s/p resp failure 24 Hour Events: PICC LINE - START 09:29 PM MULTI LUMEN - STOP 06:00 AM -PICC placed and IJ d'c'd -KUB checked to evaluate dobhoff -speech and swallow bedside eval passed with pt cleared to take thin liquids and MOIST soft solids. 6) Access: 2 PIVs; right IJ 7) PPx: hep sc, PPI 8 Code: FULL (confirmed with patient) 8) Dispo: ICU until respiratory status improves 9) Comm: With wife ICU Nutrition: TPN without Lipids - 06:54 PM 42 mL/hour Glycemic Control: Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: hep sc, PPI Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: 6) Access: 2 PIVs; right IJ 7) PPx: hep sc, PPI 8 Code: FULL (confirmed with patient) 8) Dispo: ICU until respiratory status improves 9) Comm: With wife PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) SEPSIS WITHOUT ORGAN DYSFUNCTION ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition:ICU 5) FEN: NPO for now, given potential for prolonged intubation will initiate nutrtition consult to start tube feeds 6) Access: 2 PIVs; right IJ (pulled back yesterday and more appropriately sited on follow up scans) 7) PPx: hep sc, ppi as outpt 8 Code: FULL (confirmed with patient) 8) Dispo: ICU until respiratory status improves 9) Comm: With wife PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) SEPSIS WITHOUT ORGAN DYSFUNCTION ICU Care Nutrition: Replete with Fiber (Full) - 03:58 AM 60 mL/hour Glycemic Control: Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: SQ UF Heparin, LMW Heparin Stress ulcer: VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition: Chief Complaint: s/p resp failure 24 Hour Events: PICC LINE - START 09:29 PM MULTI LUMEN - STOP 06:00 AM -PICC placed and IJ d'c'd -KUB checked to evaluate dobhoff -speech and swallow bedside eval passed with pt cleared to take thin liquids and MOIST soft solids. Action: Levophed resumed at 0.01 mcg.kg/min then weaned down to 0.001, then stopped at 0630, continues on antibiotics as ordered. Successfully extubated - Has completed course of oseltamavir - continue nafcillin - plan for 21 D course today abx from when linezolid was started -monitor diuresis and consider bolus lasix PRN. Successfully extubated - Has completed course of oseltamavir - continue nafcillin - plan for 21 D course today abx from when linezolid was started -monitor diuresis and consider bolus lasix PRN. Post extubation pt c/o nausea Action: Fluid balance followed closely. 5) FEN: NPO for now, given potential for prolonged intubation will initiate nutrtition consult to start tube feeds 6) Access: 2 PIVs; right IJ (pulled back yesterday and more appropriately sited on follow up scans) 7) PPx: hep sc, ppi as outpt 8 Code: FULL (confirmed with patient) 8) Dispo: ICU until respiratory status improves 9) Comm: With wife PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) SEPSIS WITHOUT ORGAN DYSFUNCTION ICU Care Nutrition: Replete with Fiber (Full) - 03:58 AM 60 mL/hour Glycemic Control: Lines: Multi Lumen - 09:05 AM Arterial Line - 09:30 AM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition: | 133 | [
{
"category": "Physician ",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658365,
"text": "Chief Complaint: Hypoxia/ARDS\n 24 Hour Events:\n FEVER - 102.5\nF - 12:00 PM\n -put back on Levo in afternoon hypotension then weaned back in\n evening - on 0.1 at 9p\n - ID consulted- d/c azithro and flagyl. ? Rpt Chest CT possibly in a\n couple days. Still on linezolid, cefepime, tamiflu, course still to be\n determined\n - TF were started per nutrition recs\n -d/c statin elevated LFTs\n -lipase 13\n -f/u on RUQ u/s - prelims are mildly distended gallbladder with sludge,\n no secondary signs of cholecystitis, no ductal dilation, right pleural\n effusion\n -bowel regimen ordered\n -EKG and pulsus checked - no sign of pericardial disease - no TTE\n -Vent on PS with FiO2 50%\n -Fungal Blood culture ordered\n - BNP 574\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 11:01 PM\n Cefipime - 04:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:09 AM\n Heparin Sodium (Prophylaxis) - 11:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.7\nC (99.8\n HR: 92 (75 - 106) bpm\n BP: 111/49(67) {89/45(60) - 172/88(118)} mmHg\n RR: 23 (15 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (4 - 14)mmHg\n Total In:\n 2,942 mL\n 487 mL\n PO:\n TF:\n 167 mL\n 246 mL\n IVF:\n 2,445 mL\n 241 mL\n Blood products:\n Total out:\n 1,615 mL\n 440 mL\n Urine:\n 1,615 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,327 mL\n 47 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 465 (435 - 465) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 19 cmH2O\n SpO2: 99%\n ABG: 7.38/40/94./24/0\n Ve: 8.7 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 334 K/uL\n 8.8 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 103 mEq/L\n 133 mEq/L\n 26.6 %\n 20.4 K/uL\n [image002.jpg]\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n WBC\n 12.3\n 15.8\n 20.4\n Hct\n 28.9\n 28.1\n 26.6\n Plt\n \n Cr\n 1.0\n 0.9\n 0.8\n TCO2\n 24\n 21\n 25\n 23\n 24\n 23\n 25\n Glucose\n 96\n 122\n 112\n Other labs: PT / PTT / INR:13.5/35.5/1.2, ALT / AST:67/64, Alk Phos / T\n Bili:381/0.9, Amylase / Lipase:/13, Differential-Neuts:85.9 %,\n Lymph:5.3 %, Mono:8.1 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\n to infectious process/ ARDS. Patient with known influenza and with\n PaO2/FiO2<200 he does meet criteria for ARDS. Main differential is\n Post flu ARDS vs influenza with bacterial superinfection leading to\n ARDS. The patient\ns chest radiograph is worsened today with increased\n non-anatomic hazy opacity consistent with atelectasis vs effusion per\n radiology. Nevertheless he maintains good ventilation and adequate\n oxygenation on pressure support currently. Tidal volumes are\n relatively low (450-475) so minimal concern for barotrauma secondary to\n allowing patient to set own tidal volumes.\n -wean pressure support\n - On day 4 of linezolid (or vanc), cefepime, azithromycin. Will plan\n to d/c azithromycin tomorrow after completion of five day course.\n Will continue typical coverage until the patient\ns final respiratory\n cultures are negative.\n -F/U cultures\n - Continue oseltamavir for influenza B\n 2) SIRS/ Hypotension: Presumedly due to sepsis/SIRS. Blood cultures\n remain negative as yet but patient was still febrile last night.\n Possibly flu vs persistent bacterial infection. Patient received 3L NS\n for hypotension in context of low CVP\ns. Received norepinephrine for\n persistent hypotension despite CVP of 10. Now off pressors and some\n concern LOS positive fluid balance could worsen ARDS and make weaning\n more difficult.\n -If pressures will tolerate attempt gentle diuresis.\n -Continue broad abx coverage pending final respiratory cultures per\n above, culture if spikes\n - Broadly covered if he is septic, will continue abx per above\n -Given elevated LFT\ns and increased leukocytosis will obtain RUQ u/s to\n rule out choleycystitis and look for drainable source of infection\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion. Will obtain ECG to\n assess voltages as patient\ns clinical picture not consistent with\n tamponade (no chest pain, SOB) and have more compelling causes of\n hypotension and CXR findings. Still if ECG abnormal or continued\n concern would obtain TTE to assess for pericarditis.\n -ECG +/- TTE as indicated.\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:15 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 06:27 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658683,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n THORACENTESIS - At 12:36 PM\n FEVER - 102.3\nF - 04:00 PM\n 500cc of fluid from right pleural space--exudative\n MSSA identified from sputum\n Recurrent hypotension and return to IV pressors required\n Rising WBC count seen\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:20 PM\n Linezolid - 12:35 PM\n Cefipime - 06:00 AM\n Nafcillin - 09:53 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.7\nC (99.8\n HR: 83 (72 - 113) bpm\n BP: 94/54(67) {79/44(56) - 161/92(109)} mmHg\n RR: 21 (19 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (11 - 23)mmHg\n Total In:\n 2,076 mL\n 477 mL\n PO:\n TF:\n 514 mL\n IVF:\n 1,383 mL\n 477 mL\n Blood products:\n Total out:\n 818 mL\n 555 mL\n Urine:\n 818 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,258 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 97%\n ABG: ///24/\n Ve: 12.9 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.1 g/dL\n 509 K/uL\n 118 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 131 mEq/L\n 24.7 %\n 22.4 K/uL\n [image002.jpg]\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n Plt\n 293\n 334\n 439\n 509\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:84/80, Alk Phos / T\n Bili:419/1.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:193 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: PF-\n 6900 WBC\n RBC\n pH-7.42\n Simple exudative effusion\n Imaging: CXR-ETT, CVL, OGT in good position. He has bilateral patchy\n opacities which persist\n Assessment and Plan\n 53 yo male with admission for febrile illness now seen with Influenza B\n and subsequent MSSA pneumonia. In this setting patient has had\n continued high fever and recurrent hypotension with only pulmonary\n source of pneumonia identified despite look with CT scan, tap of\n effusion. He has likely continued and persistent left sided effusion.\n The source of fevers may well be continued SIRS in the setting of\n pneumonia as we have failed to find alternative source of infection.\n In the setting of influenza and S. Auresus PNA with associated ARDS\n does carry significant mortality. Favorable here is patient has\n preserved organ function outside of original pulmonary insult.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) with Influenza B-\n -Continue with naf/Cefepime\n -Appreciate ID input and will continue for 7 days Cefepime and 14 day\n course of NAF and continue Influenza Rx\n -Follow up pleaural fluid culture\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\nBarriers to extubation do\n include persistent hypoxemia and high Ve requirement.\n -Continue with A/C Support\n -Wean FIO2 to 0.4\n -If successful will continue to wean PEEP to 5\n -Rx for PNA and lung protective ventilation to continue with A/C\n -Will follow left sided effusion and move to tap only if unable to wean\n FIO2 or PEEP\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n -Cefepime\n -Nafcillin\n -CT scan not seen\n -Sinusitis\nAfrin and Nasal Washing\n -Will recheck U/S if worsening seen and continue to trend\n Amylase/Lipase\n ICU Care\n Nutrition: Tube Feeds to continue only with post pyloric tube and will\n place today. If unable will need PPN until placed\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 65 minutes\n"
},
{
"category": "Echo",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Report",
"row_id": 103979,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. ARDS\nHeight: (in) 71\nWeight (lb): 159\nBSA (m2): 1.91 m2\nBP (mm Hg): 120/57\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 08:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. There is\nmoderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nModerate pulmonary hypertension. No pericardial effusion.\n\nCompared with the prior study (images reviewed) of , moderate\npulmonary hypertension has developed. The other findings are similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Report",
"row_id": 298852,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthe rate has slowed. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-27 00:00:00.000",
"description": "Report",
"row_id": 298853,
"text": "Sinus tachycardia. RSR' pattern in leads V1-V2, probably a normal variant.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658089,
"text": "Chief Complaint: 53 y.o. male with hypoxemia, respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM (Right internal jugular)\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n -Rapid test came back with influenza B\n -Put on linezolid and oseltamavir (for MRSA and flu) vanco d/c'd\n -Will d/c linezolid if cultures negative\n -Got 1L NS for SBP in 80s with good response\n -UCx sent\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Linezolid - 12:23 AM\n Cefipime - 06:13 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 PM\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.3\nC (99.1\n HR: 92 (74 - 121) bpm\n BP: 124/65(85) {82/43(56) - 145/73(96)} mmHg\n RR: 22 (18 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 6 (6 - 342)mmHg\n Total In:\n 4,792 mL\n 444 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 444 mL\n Blood products:\n Total out:\n 985 mL\n 305 mL\n Urine:\n 985 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/41/81./22/-1\n Ve: 9.8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 253 K/uL\n 9.7 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient required intubation yesterday for\n worsening respiratory status and was started on linezolid and\n oseltamavir for MRSA pneumonia (had continued to decompensate on\n vancomycin) and influenza respectively. Given presumptively negative\n respiratory cultures and current appearance of diffuse process seems\n more likely to be virally induced ARDS than bacterial superinfection\n but given severity will continue abx until final cultures.\n - cont linezolid/cefepime/azithro until final respiratory cultures\n negative\n - Continue oseltamavir for influenza B\n - Ventilation per ARDSnet protocol\n 2) SIRS/ Hypotension: Still possiblity of sepsis thought blood cx are\n still negative. Other major differential is for SIRS due to ARDS.\n Most recent CVP low at 3.\n - NS bolus of 1000 cc and repeat to CVP of \n - Broadly covered if he is septic, will continue abx per above\n - culture with fevers; monitoring leukocytosis curve\n 3) Hypothyroidism: cont home levothyroxine\n 4) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 5) Access: 2 PIVs; right IJ\n 6) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 10) Comm: With wife\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658210,
"text": "Chief Complaint: ARDS\n Influenza\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:45 PM\n URINE CULTURE - At 10:15 PM\n SPUTUM CULTURE - At 12:00 AM\n FEVER - 101.7\nF - 08:00 PM\n _Patient move to PSV this morning\n -Patient with hypotension requiring pressors overnight\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:56 PM\n Linezolid - 12:30 AM\n Cefipime - 05:30 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:09 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 09:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.6\nC (101.4\n HR: 91 (75 - 101) bpm\n BP: 127/56(77) {87/43(57) - 146/79(99)} mmHg\n RR: 17 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (3 - 349)mmHg\n Total In:\n 3,324 mL\n 716 mL\n PO:\n TF:\n 60 mL\n 73 mL\n IVF:\n 3,179 mL\n 523 mL\n Blood products:\n Total out:\n 940 mL\n 675 mL\n Urine:\n 940 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,384 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 504 (460 - 504) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/36/74/21/-1\n Ve: 13.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.2 g/dL\n 293 K/uL\n 122 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 103 mEq/L\n 134 mEq/L\n 28.1 %\n 15.8 K/uL\n [image002.jpg]\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n WBC\n 12.6\n 12.3\n 15.8\n Hct\n 28.5\n 28.9\n 28.1\n Plt\n \n Cr\n 0.9\n 1.0\n 0.9\n TCO2\n 26\n 24\n 21\n 25\n 23\n 24\n 23\n Glucose\n 117\n 96\n 122\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:66/106, Alk Phos /\n T Bili:307/1.1, Differential-Neuts:77.4 %, Lymph:12.3 %, Mono:8.9 %,\n Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:215 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR-Patient with bilateral lower lung field opacities\n consistent with effusion in addition to consolidations\n Microbiology: Sputum--1+ GPC in P+C--on gram stain\n Assessment and Plan\n 53 yo male admit with influenza and now with progression to ARDS and\n hypoxemic respiratory failure. He has shown some substantial\n improvement in oxygenation and ventilation over past 24 hours. Of note\n he has shown recurrent fever and requirement for pressor support--this\n is in the setting of elevation of AP and TA's.\n 1)Respiratory Failure/ARDS-patient with substantial improvement in\n ventilation and oxygenation over the past 24 hours. This is consistent\n with substantial improvement and in the setting of supportive care with\n lung protective strategy\nhe now has excellent tolerance of PSV with\n spontaneous tidal volumes in the range of 450cc.\n -Continue with PSV and wean PEEP when PO2 has stabilized\n -Will wean PSV level today\n -Will discuss influenza Rx with ID as have not been able to delive\n inhaled\n 2)Sepsis--Patient with hypotension noted overnight\n -Vanco/Linezolid/Cefepime/Azithro\n10 day course and 5 days for Azithro\n -Concerning worsening hypotension\n -With increased LFT\ns and AP\nwill need to evaluate RUQ for possible\n acalculous cholecystitis\n -Follow up cultures and RUQ U/S\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n -ABX as above\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n -Cefepime/Azithro/Linezolid\n -Wean levophed as possible with volume replete\n ICU Care\n Nutrition: Tube Feeds to continue\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658221,
"text": "Chief Complaint: Hypoxemic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 08:45 PM\n URINE CULTURE - At 10:15 PM\n SPUTUM CULTURE - At 12:00 AM\n FEVER - 101.7\nF - 08:00 PM\n -Put on ARDSnet protocol for ventilation given concern for ARDS\n -Febrile to 101.7, then became hypotensive to SBP's in 80's but as CVP\n in range given 2L NS bolus, at that time CVP of so started on\n norepinephrine\n -Got trial of CPAP early in AM on for agitation and resistance\n to rate\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:56 PM\n Linezolid - 12:30 AM\n Cefipime - 05:30 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 04:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.2\nC (98.9\n HR: 95 (75 - 101) bpm\n BP: 114/50(70) {87/43(57) - 146/79(99)} mmHg\n RR: 22 (18 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (3 - 12)mmHg\n Total In:\n 3,324 mL\n 655 mL\n PO:\n TF:\n 60 mL\n 76 mL\n IVF:\n 3,179 mL\n 518 mL\n Blood products:\n Total out:\n 940 mL\n 570 mL\n Urine:\n 940 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,384 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 504 (460 - 504) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 93%\n ABG: 7.40/36/74/21/-1\n Ve: 13.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : at tops of lungs)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: No C/C/E appreciated\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 293 K/uL\n 9.2 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 103 mEq/L\n 134 mEq/L\n 28.1 %\n 15.8 K/uL\n [image002.jpg]\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n WBC\n 12.6\n 12.3\n 15.8\n Hct\n 28.5\n 28.9\n 28.1\n Plt\n \n Cr\n 0.9\n 1.0\n 0.9\n TCO2\n 26\n 24\n 21\n 25\n 23\n 24\n 23\n Glucose\n 117\n 96\n 122\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:66/106, Alk Phos /\n T Bili:307/1.1, Differential-Neuts:77.4 %, Lymph:12.3 %, Mono:8.9 %,\n Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:215 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\n to infectious process/ ARDS. Patient with known influenza and with\n PaO2/FiO2<200 he does meet criteria for ARDS. Main differential is\n Post flu ARDS vs influenza with bacterial superinfection leading to\n ARDS. The patient\ns chest radiograph is worsened today with increased\n non-anatomic hazy opacity consistent with atelectasis vs effusion per\n radiology. Nevertheless he maintains good ventilation and adequate\n oxygenation on pressure support currently. Tidal volumes are\n relatively low (450-475) so minimal concern for barotrauma secondary to\n allowing patient to set own tidal volumes.\n -wean pressure support\n - On day 4 of linezolid (or vanc), cefepime, azithromycin. Will plan\n to d/c azithromycin tomorrow after completion of five day course.\n Will continue typical coverage until the patient\ns final respiratory\n cultures are negative.\n -F/U cultures\n - Continue oseltamavir for influenza B\n 2) SIRS/ Hypotension: Presumedly due to sepsis/SIRS. Blood cultures\n remain negative as yet but patient was still febrile last night.\n Possibly flu vs persistent bacterial infection. Patient received 3L NS\n for hypotension in context of low CVP\ns. Received norepinephrine for\n persistent hypotension despite CVP of 10. Now off pressors and some\n concern LOS positive fluid balance could worsen ARDS and make weaning\n more difficult.\n -If pressures will tolerate attempt gentle diuresis.\n -Continue broad abx coverage pending final respiratory cultures per\n above, culture if spikes\n - Broadly covered if he is septic, will continue abx per above\n -Given elevated LFT\ns and increased leukocytosis will obtain RUQ u/s to\n rule out choleycystitis and look for drainable source of infection\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion. Will obtain ECG to\n assess voltages as patient\ns clinical picture not consistent with\n tamponade (no chest pain, SOB) and have more compelling causes of\n hypotension and CXR findings. Still if ECG abnormal or continued\n concern would obtain TTE to assess for pericarditis.\n -ECG +/- TTE as indicated.\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n HN (Full) - 06:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP: HOB elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 657951,
"text": "This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenze B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is intubated on vent in AC mode settings 500X18X60%X8. He is sedated\n well on fentanyl 50mcg/versed 1mg/hr. Suctioned for moderate amts thin\n yellow secretions.\n Action:\n fiO2 was 70% but decreased to 60% when ABG showed pO2 of 109. Fentanyl\n decreased to 40mcg when pt hypotensive but back up to 50mcg/hr when he\n became tachypneic and hypertensive after turning.\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Tmax 100.8ax. SBP in the 70\ns at beginning of shift.\n Action:\n IVF bolus of NS 1L given X1 over an hour.\n Response:\n SBP remained >100 the rest of the night.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658063,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Cefipime - 06:13 AM\n - 11:28 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:00 PM\n Midazolam (Versed) - 03:00 PM\n Lansoprazole (Prevacid) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.3\nC (100.9\n HR: 86 (74 - 92) bpm\n BP: 127/64(84) {82/43(56) - 145/73(96)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (4 - 342)mmHg\n Total In:\n 4,792 mL\n 772 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 772 mL\n Blood products:\n Total out:\n 985 mL\n 495 mL\n Urine:\n 985 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 277 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.37/41/81./22/-1\n Ve: 8.3 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 253 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR - Bilateral infiltrates concerning for ARDS. CL needs to\n be pulled back 3cm.\n Microbiology: Influenza B +, sputum culture negative to date.\n Assessment and Plan\n 53 yo male with Hodgkin's disease now admitted with influenza and who\n has evolved significant worsening of hypoxemic respiratory failure\n across the admission. Patient was intubated with severe hypoxemic\n respiratory failure likley related to bilateral and dependent\n consolidations with likley ARDS, although still considering bacterial\n superinfection of previous viral pneumonitis.\n Hypoxemic Respiratory Failure- Influenza B, ARDS, +/- bacterial\n superinfection\n - ARDS net protocol\n - F/U sputum cultures\n on cefepime/azithro/, consider\n d/c\ning if cultures negative\n - Relenza for influenza\n Hypotension- SIRS vs sepsis\n - Adequately volume resussitated yesterday, will run even today (CVP 7)\n - F/U cultures\n Nutrition\n Will start TF today.\n ICU Care\n Nutrition: tube feeds.\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658058,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Cefipime - 06:13 AM\n Linezolid - 11:28 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:00 PM\n Midazolam (Versed) - 03:00 PM\n Lansoprazole (Prevacid) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.3\nC (100.9\n HR: 86 (74 - 92) bpm\n BP: 127/64(84) {82/43(56) - 145/73(96)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (4 - 342)mmHg\n Total In:\n 4,792 mL\n 772 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 772 mL\n Blood products:\n Total out:\n 985 mL\n 495 mL\n Urine:\n 985 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 277 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.37/41/81./22/-1\n Ve: 8.3 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 253 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR - Bilateral infiltrates concerning for ARDS. CL needs to\n be pulled back 3cm.\n Microbiology: Influenza B +, sputum culture negative to date.\n Assessment and Plan\n 53 yo male with Hodgkin's disease now admitted with influenza and who\n has evolved significant worsening of hypoxemic respiratory failure\n across the admission. This is with evolution of bilateral and patchy\n consolidations consistent with superinfection of initial viral insult.\n This is suggested by evolution of cough/plegm/feve/infiltrate.\n 7.46/34/47 was repeat ABG following arrival in ICU. Patient was\n intubated with severe hypoxemic respiratory failure likley related to\n bilateral and dependent consolidations with likley bacterial\n superinfection of previous viral pneumonitis.\n Hypoxemic Respiratory Failure-\n -A/C\nwill maintain PEEP at 10-12\n -Continue FIO2=1.0\n -Will need to replace volume with patient currently hypotensive\n -PIP=30, Pplat-27 consistent with presentation\n -Wean FIO2 as possible\n -Advance ETT\n -Will place A-line\n Pneumonia-\n -Linezolid/Cefepime/Axithro\n -Sputum GS C+S\n -Follow up culture results\n -Urine Legionella pending\n -Bronch and BAL if patient improved stability to tolerate procedure or\n with inadequate sampling\n Sepsis-\n -Patient with significant hypotension with intubation and leading to\n respiratory failure\n -Will need CVL and volume replacement\n -Follow up cultures results\n -Will titrate therapy to stability of blood pressure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658073,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Cefipime - 06:13 AM\n - 11:28 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 03:00 PM\n Midazolam (Versed) - 03:00 PM\n Lansoprazole (Prevacid) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.3\nC (100.9\n HR: 86 (74 - 92) bpm\n BP: 127/64(84) {82/43(56) - 145/73(96)} mmHg\n RR: 18 (18 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 5 (4 - 342)mmHg\n Total In:\n 4,792 mL\n 772 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 772 mL\n Blood products:\n Total out:\n 985 mL\n 495 mL\n Urine:\n 985 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 277 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.37/41/81./22/-1\n Ve: 8.3 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 253 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR - Bilateral infiltrates concerning for ARDS. CL needs to\n be pulled back 3cm.\n Microbiology: Influenza B +, sputum culture negative to date.\n Assessment and Plan\n 53 yo male with Hodgkin's disease now admitted with influenza and who\n has evolved significant worsening of hypoxemic respiratory failure\n across the admission. Patient was intubated with severe hypoxemic\n respiratory failure likley related to bilateral and dependent\n consolidations with likley ARDS, although still considering bacterial\n superinfection of previous viral pneumonitis.\n Hypoxemic Respiratory Failure- Influenza B, ARDS, +/- bacterial\n superinfection\n - ARDS net protocol\n - F/U sputum cultures\n on cefepime/azithro/, consider\n d/c\ning if cultures negative\n - Relenza for influenza\n -Will need continued lung protective strategy for ventilatory support\n going forward\n Hypotension- SIRS vs sepsis\n - Adequately volume resussitated yesterday, will run even today (CVP 7)\n - F/U cultures\n Nutrition\n Will start TF today.\n ICU Care\n Nutrition: tube feeds to start today\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658127,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt changed to ards net setting vt 6 cc/kg IBW\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol; Comments: fio2 weaned to\n 50% today with sats >96% plan to continue with ards net protocol\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 658225,
"text": "Subjective\n Imtubated & versed.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 71 kg\n Appears stable\n 22.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 91\n 70kg ()\n 68.6kg ()\n Diagnosis: Fever\n PMH : Stage lllA Hodgkins lymphoma,myelodysplasia, s/p XRT/Chemo ?\n & BMT (matched related donor from brother) ?, pericarditis,\n hypothyroidism, splenectomy, GERD, >lipids\n Food allergies and intolerances: none noted.\n Pertinent medications: fentanyl, midazolam, norepinephrine.\n Labs:\n Value\n Date\n Glucose\n 122 mg/dL\n 03:59 AM\n BUN\n 17 mg/dL\n 03:59 AM\n Creatinine\n 0.9 mg/dL\n 03:59 AM\n Sodium\n 134 mEq/L\n 03:59 AM\n Potassium\n 3.4 mEq/L\n 03:59 AM\n Chloride\n 103 mEq/L\n 03:59 AM\n TCO2\n 21 mEq/L\n 03:59 AM\n PO2 (arterial)\n 74 mm Hg\n 07:11 AM\n PCO2 (arterial)\n 36 mm Hg\n 07:11 AM\n pH (arterial)\n 7.40 units\n 07:11 AM\n pH (urine)\n 6.0 units\n 10:17 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 07:11 AM\n Albumin\n 2.4 g/dL\n 03:19 AM\n Calcium non-ionized\n 7.4 mg/dL\n 03:59 AM\n Phosphorus\n 2.1 mg/dL\n 03:59 AM\n Magnesium\n 1.9 mg/dL\n 03:59 AM\n ALT\n 66 IU/L\n 03:59 AM\n Alkaline Phosphate\n 307 IU/L\n 03:59 AM\n AST\n 106 IU/L\n 03:59 AM\n Total Bilirubin\n 1.1 mg/dL\n 03:59 AM\n WBC\n 15.8 K/uL\n 03:59 AM\n Hgb\n 9.2 g/dL\n 03:59 AM\n Hematocrit\n 28.1 %\n 03:59 AM\n Current diet order / nutrition support: NPO pending TF c/s\n GI: abdomen distended, soft, NT, +BS.\n Assessment of Nutritional Status\n Pt at risk due to: Hx of CA\n Estimated Nutritional Needs\n Calories: 1775 - 2130 (BEE x or / 25 - 30 cal/kg)\n Protein: 85 - 107 (1.2 - 1.5 g/kg)\n Fluid: per team.\n Specifics:\n 53 YO male with hx of hodgkins lymphoma s/p BMT in ?, admitted with\n influenza B, now with worsening hypoxia & respiratory distress &\n currently intubated. Consulted for TF recs. Recommend FS Promote with\n Fiber at goal 75mL/hrm providing 1800kcals & 112g protein. Noted low K+\n & PO4\npls replete.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Replete potassium & Phos\n 2. Once ready to start TF; start FS Replete with Fiber; start at\n 10mL/hr, advance by 10-15mL Q 4-6hrs or as tolerated to goal 75mL/hr\n 3. Check residuals & hold TF x 1hr if >150mL & consider reglan\n 4. Adjust free water boluses per hydration\n 5. Monitor & replete Lytes PRN\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658199,
"text": "Chief Complaint: Hypoxemic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 08:45 PM\n URINE CULTURE - At 10:15 PM\n SPUTUM CULTURE - At 12:00 AM\n FEVER - 101.7\nF - 08:00 PM\n -Put on ARDSnet protocol for ventilation given concern for ARDS\n -Febrile to 101.7, then became hypotensive to SBP's in 80's but as CVP\n in range given 2L NS bolus, at that time CVP of so started on\n norepinephrine\n -Got trial of CPAP early in AM on for agitation and resistance\n to rate\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:56 PM\n Linezolid - 12:30 AM\n Cefipime - 05:30 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:13 AM\n Heparin Sodium (Prophylaxis) - 04:27 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.2\nC (98.9\n HR: 95 (75 - 101) bpm\n BP: 114/50(70) {87/43(57) - 146/79(99)} mmHg\n RR: 22 (18 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 10 (3 - 12)mmHg\n Total In:\n 3,324 mL\n 655 mL\n PO:\n TF:\n 60 mL\n 76 mL\n IVF:\n 3,179 mL\n 518 mL\n Blood products:\n Total out:\n 940 mL\n 570 mL\n Urine:\n 940 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,384 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 504 (460 - 504) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 93%\n ABG: 7.40/36/74/21/-1\n Ve: 13.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : at tops of lungs)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 293 K/uL\n 9.2 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 103 mEq/L\n 134 mEq/L\n 28.1 %\n 15.8 K/uL\n [image002.jpg]\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n WBC\n 12.6\n 12.3\n 15.8\n Hct\n 28.5\n 28.9\n 28.1\n Plt\n \n Cr\n 0.9\n 1.0\n 0.9\n TCO2\n 26\n 24\n 21\n 25\n 23\n 24\n 23\n Glucose\n 117\n 96\n 122\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:66/106, Alk Phos /\n T Bili:307/1.1, Differential-Neuts:77.4 %, Lymph:12.3 %, Mono:8.9 %,\n Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:215 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient required intubation yesterday for\n worsening respiratory status and was started on linezolid and\n oseltamavir for MRSA pneumonia (had continued to decompensate on\n vancomycin) and influenza respectively. Given presumptively negative\n respiratory cultures and current appearance of diffuse process seems\n more likely to be virally induced ARDS than bacterial superinfection\n but given severity will continue abx until final cultures.\n - cont linezolid/cefepime/azithro until final respiratory cultures\n negative\n - Continue oseltamavir for influenza B\n - Ventilation per ARDSnet protocol\n 2) SIRS/ Hypotension: Still possiblity of sepsis thought blood cx are\n still negative. Other major differential is for SIRS due to ARDS.\n Most recent CVP low at 3.\n - NS bolus of 1000 cc and repeat to CVP of \n - Broadly covered if he is septic, will continue abx per above\n - culture with fevers; monitoring leukocytosis curve\n 3) Hypothyroidism: cont home levothyroxine\n 4) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 5) Access: 2 PIVs; right IJ\n 6) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 10) Comm: With wife\n ICU \n Nutrition:\n HN (Full) - 06:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658292,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received on PSV 12/8 as noted. PS weaned to 10 with good\n follow up ABG. ABG is within normal limits with good oxygenation.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658838,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt conts to have a fever, t max has been 100.4, LS coarse throughout,\n suctioning tan sputum from his ETT, he has been coughing less today\n than yesterday.\n Action:\n To have a chest CT with contrast to r/o abcess from his staph pneumonia\n Response:\n Less coughing today but his WBC conts to rise and was 24 this morning\n and he conts to have fevers while on antibiotics\n Plan:\n CT\n he will need D5W with Bicarb 1 hr prior to the CT and the to\n continue at a lower rate after the exam to try and protect his kikneys,\n follow his temps, WBC, cont abx, f/u on sputum\n a spec was sent today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on A/C400x20, 8 PEEP, his FI02 was decreased to 40% from\n 50%\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658839,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt conts to have a fever, t max has been 100.4, LS coarse throughout,\n suctioning tan sputum from his ETT, he has been coughing less today\n than yesterday.\n Action:\n To have a chest CT with contrast to r/o abcess from his staph pneumonia\n Response:\n Less coughing today but his WBC conts to rise and was 24 this morning\n and he conts to have fevers while on antibiotics\n Plan:\n CT\n he will need D5W with Bicarb 1 hr prior to the CT and the to\n continue at a lower rate after the exam to try and protect his kikneys,\n follow his temps, WBC, cont abx, f/u on sputum\n a spec was sent today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on A/C400x20, 8 PEEP, his FI02 was decreased to 40% from\n 50%\n Action:\n Weaned his FI02, to have a CT of his chest as above\n Response:\n Tolerating the wean of his FI02\n Plan:\n Chest CT, try to wean his PEEP to 5, f/u with CT results, sputum clx.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658836,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt conts to have a fever, t max has been 100.4, LS coarse throughout,\n suctioning tan sputum from his ETT, he has been coughing less today\n than yesterday.\n Action:\n To have a chest CT with contrast to r/o abcess from his staph pneumonia\n Response:\n Less coughing today but his WBC conts to rise and was 24 this morning\n and he conts to have fevers while on antibiotics\n Plan:\n CT\n he will need D5W with Bicarb 1 hr prior to the CT and the to\n continue at a lower rate after the exam to try and protect his kikneys,\n follow his temps, WBC, cont abx, f/u on sputum\n a spec was sent today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on A/C\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658879,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt with periods of brochospasm and frequent suctioning of thin white\n secretions.\n Action:\n Bolus of fentanyl 25mg x1 with good effect in controlling\n bronchospasms. Continues on antibiotics. Had Large soft brown stool in\n bedpan. C-diff spec sent.\n Response:\n No temp spike over night\n Plan:\n Continue antibiotic rx, pulm toilet, supportive care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on AC ventilation. No vent changes.\n Action:\n No vent changes over night. Wife had called twice asking for CT scan\n results and to speak with MD.\n Response:\n Resident spoke with wife re: pt.s progress.\n Plan:\n Continue plan of care. Wean to cpap if pt. tolerates.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659239,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n - pt failed. ABG 7.52/41/64\n -resumed TF until midnight.\n -lasix gtt turned off in afternoon as CVP down to 4\n - diamox TID started\n -KCL repleted\n -TPN reordered\n -Afrin d/c'd\n -added cefepime to allergy list given rash\n - plan for extubation during rounds in am. Respiratory aware.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:15 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt very anxious having trouble breathing with ?\n muscous plug this am. Denies pain.\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.1\nC (98.8\n HR: 104 (81 - 116) bpm\n BP: 148/70(98) {99/49(65) - 175/86(117)} mmHg\n RR: 22 (18 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 19 (4 - 19)mmHg\n Total In:\n 2,153 mL\n 522 mL\n PO:\n TF:\n 150 mL\n 13 mL\n IVF:\n 979 mL\n 207 mL\n Blood products:\n Total out:\n 6,100 mL\n 1,255 mL\n Urine:\n 6,100 mL\n 1,255 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,947 mL\n -733 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 711 (289 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 71\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/36/60/24/0\n Ve: 14.4 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\n Labs / Radiology\n 781 K/uL\n 7.9 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 101 mEq/L\n 133 mEq/L\n 24.7 %\n 23.6 K/uL\n [image002.jpg]\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n WBC\n 22.4\n 24.7\n 25.6\n 26.7\n 23.6\n Hct\n 24.7\n 24.9\n 23.9\n 23.9\n 24.7\n Plt\n 14\n 781\n Cr\n 0.8\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 118\n 151\n 131\n 144\n 135\n 128\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:54/50, Alk Phos / T\n Bili:299/0.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% today and on PS 5/5\n but blood gas this noon 7.52/41/64\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS. Trying to wean PS daily but did not tolerate today.\n Will try again tomorrow.\n - Has completed course of oseltamavir\n - continue nafcillin day 5 today\n - F/U cultures\n - lasix gtt stopped today contraction alkylosis. Consider lasix\n boluses for CVP >4. Started Diamox 500 TID \n -added cefepime to allergy list given likely elevation LFT\ns with this.\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will give TF until early am for possible am extubation\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:01 PM 42 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659227,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient with CAP and know influenza B, currently being treated with\n Nafcillin MSSA growth. Did suffer hypoxic respiratory failure on\n this admission with subsequent intubation.\n Action:\n Remains mechanically ventilated on PS 5/5 with sedation of fent/midaz\n at 50mg and 2mg respectively. Sedation has been weaned from fent/midaz\n 75/3 to previously mentioned settings. Sedation turned off at 0500.\n Suctioned for small amount of thick pale yellow secretions with strong\n cough. He is s/p thoracentesis with exudative effusion and lung\n re-expansion.\n Response:\n Tolerating vent settings well and will probably will be extubated this\n am. Remains afebrile during shift, WBC trending down slowly now 23.6.\n Plan:\n Continue with antibiotic management as ordered f/u labs and cultures.\n Has been NPO since midnight Tube feeding off as ordered. TPN in\n progress. Does have a h/s of NHL with esophageal strictures so Dobhuff\n was placed on \n Started on diamox for metabolic alkalosis. Now s/p Lasix infusion for\n fluid excess more than 9l. Infusion stopped yesterday eventing with\n patient maintaining CVP greater than 14mmHg throughout the shift. No\n further diuresing done overnight, has maintained adequate urinary\n output.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658347,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Pt remained on psv overnight with acceptable oxygenation and\n ventilation. Suct for mod amts of frothy yellow sput amd occ thick\n yellow sput.RSBI acceptable.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 657839,
"text": "53 yo male pt with h/o ? PNA transffered from 11R .sats 85-90\ns with\n open face mask and NRBM. Transffered to for ? intubation.\n Neuron:alert oriented x 3,denies any pain. Looking comfortable.\n Resp: came with NRBM ,sats showed mid 80\ns. rechecked with probe on\n forehead, sats showed high 90\ns. intubation on hold now.blood gas sent\n to confirm. LS with ronchi.having productive cough.\n CVS: HR 100-110\ns, ST,no PVC\nS. BP stable.\n Gu/gi: abd soft,BS pos. not voided after admission.\n Social:no family contact during the shift. Wife HCP\n SKIN: INTACT. On droplet precaution for flu.\n PLAN: To monitor Resp status .anticipating intubation.\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 657848,
"text": "TITLE:\n Chief Complaint: respiratory distress, hypoxemia\n HPI:\n Please see admit H&P for full details. Briefly, this is a 53 year-old\n male with a history of Hodgkin's s/p BMT in the 80s, hypothyroidism,\n h/o pericarditis, h/o splenectomy who was admitted to the medicine\n service for fever, URI symptoms, tachycardia, found to have Influenza\n B. During his hospital course, the patient has become progressively\n hypoxic, initially satting mid 90s on RA/2L, and desatting then to the\n 80s requiring increased levels of nasal cannula. On the day prior to\n transfer, patient desatted to the low 80s on 6L, and was switched to a\n face tent/humidified O2 (15L) with sats in the mid 90s. On , ABG\n was 7.46/35/56. Earlier this AM, he desatted to the mid 80s on the\n face tent requiring NRB. On the NRB, he was mid 90s, though at the\n time of evaluation, was noted to be around 87%. ABG done at that time\n was 7.41/39/39. Lactate 2.1. Of note, the patient had a CT chest done\n on with prelim read no PE but noted to have multilobar infiltrate.\n Concern was for bacterial superinfection in the setting of influenza B,\n ? MRSA. He was initially being treated with levofloxacin (given h/o\n splenectomy), but then switched to vanco, cefepime, and azithromycin on\n . Cultures have been NGTD. Sputum was not a good sample.\n At the time of transfer, the patient states he has had a fairly non\n productive cough that seems to be worsening. His dyspnea has worsened,\n but he denies chest pains. He denies palpitations. He was febrile on\n , but denies feeling febrile prior to transfer. He otherwise had\n no complaints.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS ON TRANSFER:\n 1. Levothyroxine Sodium 88 mcg PO DAILY\n 2. Acetaminophen 650 mg PO/PR Q4H:PRN pain/fever\n 3. Omeprazole 20 mg PO DAILY\n 4. Atorvastatin 10 mg PO DAILY\n 5. Ondansetron 4 mg IV Q8H:PRN nausea\n 6. Azithromycin 500 mg IV Q24H\n 8. CefePIME 2 g IV Q12H\n 9. Prochlorperazine 10 mg PO/IV Q6H:PRN\n 10. Docusate Sodium 100 mg PO BID:PRN constipation\n 11. Vancomycin 1000 mg IV Q 12H\n 12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough\n 13. traZODONE 25 mg PO HS:PRN\n 14. Heparin 5000 UNIT SC TID\n MEDICATIONS AT HOME\n ATORVASTATIN 10 mg Tablet daily\n LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet daily\n LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet daily\n OMEPRAZOLE [PRILOSEC] - 10 mg Capsule daily\n Past medical history:\n Family history:\n Social History:\n -splenectomy\n -pericarditis\n -Hodgkin's disease, and bone marrow transplant in , Hodgkin's\n treatment was in \n Mother with Breast CA/Uterine CA\n Occupation: real estate developer\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: lives with wife and 2 children\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 113 (113 - 118) bpm\n BP: 139/103(110) {139/82(102) - 168/103(110)} mmHg\n RR: 39 (33 - 39) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 230 mL\n PO:\n TF:\n IVF:\n 230 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 230 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: 7.46/34/47//0\n PaO2 / FiO2: 59\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n few scattered, Bronchial: left base, Rhonchorous: right posterior)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A2/2/ 06:07 AM\n \n 10:20 P2/2/ 06:36 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 26\n 25\n Other labs: Lactic Acid:2.1 mmol/L\n Imaging: CXR \n PA and lateral radiographs of the chest demonstrate a similar\n cardiomediastinal contour to that seen on . In particular, the\n superior mediastinal changes previously attributed to external beam\n radiation fibrosis are unchanged. No consolidation is evident. No\n effusion. No pneumothorax. Trachea is midline. Surgical staples are\n again seen in the epigastrium. Overall, there is little interval\n change.\n CT CHEST:\n There is no evidence of pulmonary embolus. There is dense consolidation\n in the left lower lobe, and to a lesser extent the right lower lobe and\n lingular segment of left upper lobe.\n Microbiology: blood cx: NGTD\n urine cx: NGTD\n ECG: ECG: Sinus tachycardia; no ischemic ST segment changes\n Assessment and Plan\n Assesment: This is a 53 year-old male with a history of hodkin's s/p\n BMT in 93, h/o pericarditis, hypothyroidism, admitted with influenze B\n now with worsening hypoxia and respiratory distress and CT concerning\n for multilobar PNA.\n Plan:\n 1) Respiratory failure: a/w influenza B, now with worsening hypoxemia.\n CT chest concerning for multilobar PNA, no e/o PE. concern for MRSA or\n other bacterial superinfection with flu positive. could be volume\n overload, but unlikely- patient appears quite dry on exam. legionella\n negative\n - cont vanco/cefepime, and azithro for now\n - check sputum culture; f/u blood cx\n - if positive for MRSA, or decompensates further, can consider\n switching vanco to linezolid for improved pulmonary MRSA coverage\n - legionella negative\n - on NRB now; repeat ABG with significant hypoxemia and A-a gradient;\n given tachypnea, may need to be intubated. d/w anesthesia\n - meeting SIRS criteria with tachypnea, tachycardia, and leukocytosis;\n will consider CVL placement for CVP monitoring\n 2) SIRS: likely source pulmonary given CT findings. urine negative.\n blood cx no growth to date. h/o splenectomy increases risk for\n encapsulated organisms\n - consider CVL placement for CVP monitoring; BP currently normal\n - NS bolus 500 cc\n - abx as above\n - culture with fevers; monitoring leukocytosis curve\n 3) Hypothyroidism: cont home levothyroxine\n 4) FEN: NPO for now\n - NS 500 cc bolus\n 5) Access: 2 PIVs; consider CVL\n 6) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 10) Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 657855,
"text": "Chief Complaint: Hypoxemic Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with admission with febrile illness and respiratory distress\n and who on the medical floor had worsening hypoxemia with RA-->Face\n mask required and ABG with PO2=56 of face tent. 100% NRB required with\n persistent saturations <90% and patient to ICU for further care.\n Patient with Vanco/Cefepime/Azithro with dense multilobar infiltrates\n seen on CT scan.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Splenectomy\n Hodgkin's Disease\n HYpothyroidism\n NON-Contributory\n Occupation: Real Estate Developer\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, Dyspnea, Tachypnea, Productive, dyspnea\n significantly worse over time.\n Flowsheet Data as of 08:48 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 117 (113 - 121) bpm\n BP: 131/87(99) {131/82(99) - 168/103(110)} mmHg\n RR: 31 (30 - 39) insp/min\n SpO2: 89%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 350 mL\n PO:\n TF:\n IVF:\n 350 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 350 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 100%\n PIP: 31 cmH2O\n Plateau: 26 cmH2O\n SpO2: 89%\n ABG: 7.46/34/47//0\n Ve: 7 L/min\n PaO2 / FiO2: 47\n Physical Examination\n General Appearance: No(t) No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : , Bronchial: LEft base, Rhonchorous: Right\n side)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 32\n 19\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n WBC\n 19\n TC02\n 26\n 25\n Other labs: Lactic Acid:2.1 mmol/L\n Fluid analysis / Other labs: Lactate-2.1\n Imaging: CTA--NO PE\n Multilobar infiltrate noted--with dense consolidation dependently in\n both lungs--with left>right\n Microbiology: Urine/Bloood-NGTD\n Infulenza DFA--Pos-B\n Assessment and Plan\n 53 yo male with Hodgkin's disease now admitted with influenza and who\n has evolved significant worsening of hypoxemic respiratory failure\n across the admission. This is with evolution of bilateral and patchy\n consolidations consistent with superinfection of initial viral insult.\n This is suggested by evolution of cough/plegm/feve/infiltrate.\n 7.46/34/47 was repeat ABG following arrival in ICU. Patient was\n intubated with severe hypoxemic respiratory failure likley related to\n bilateral and dependent consolidations with likley bacterial\n superinfection of previous viral pneumonitis.\n Hypoxemic Respiratory Failure-\n -A/C\nwill maintain PEEP at 10-12\n -Continue FIO2=1.0\n -Will need to replace volume with patient currently hypotensive\n -PIP=30, Pplat-27 consistent with presentation\n -Wean FIO2 as possible\n -Advance ETT\n -Will place A-line\n Pneumonia-\n -Linezolid/Cefepime/Axithro\n -Sputum GS C+S\n -Follow up culture results\n -Urine Legionella pending\n -Bronch and BAL if patient improved stability to tolerate procedure or\n with inadequate sampling\n Sepsis-\n -Patient with significant hypotension with intubation and leading to\n respiratory failure\n -Will need CVL and volume replacement\n -Follow up cultures results\n -Will titrate therapy to stability of blood pressure.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 06:28 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 75 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659329,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n - pt failed. ABG 7.52/41/64\n -resumed TF until midnight.\n -lasix gtt turned off in afternoon as CVP down to 4\n - diamox TID started\n -KCL repleted\n -TPN reordered\n -Afrin d/c'd\n -added cefepime to allergy list given rash\n - plan for extubation during rounds in am. Respiratory aware.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:15 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt very anxious having trouble breathing with ?\n muscous plug this am. Denies pain.\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.1\nC (98.8\n HR: 104 (81 - 116) bpm\n BP: 148/70(98) {99/49(65) - 175/86(117)} mmHg\n RR: 22 (18 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 19 (4 - 19)mmHg\n Total In:\n 2,153 mL\n 522 mL\n PO:\n TF:\n 150 mL\n 13 mL\n IVF:\n 979 mL\n 207 mL\n Blood products:\n Total out:\n 6,100 mL\n 1,255 mL\n Urine:\n 6,100 mL\n 1,255 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,947 mL\n -733 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 711 (289 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 71\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/36/60/24/0\n Ve: 14.4 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\n Labs / Radiology\n 781 K/uL\n 7.9 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 101 mEq/L\n 133 mEq/L\n 24.7 %\n 23.6 K/uL\n [image002.jpg]\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n WBC\n 22.4\n 24.7\n 25.6\n 26.7\n 23.6\n Hct\n 24.7\n 24.9\n 23.9\n 23.9\n 24.7\n Plt\n 14\n 781\n Cr\n 0.8\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 118\n 151\n 131\n 144\n 135\n 128\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:54/50, Alk Phos / T\n Bili:299/0.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% and on PS 5/5 but\n blood gas this noon 7.52/41/64. This am, did well on (although had\n some mucous plugging around 7a).\n - Has completed course of oseltamavir\n - continue nafcillin day 6 today- plan for 14 D course\n - F/U cultures\n - extubate this am. Will start Incentive spirometry\n -monitor diuresis and consider bolus lasix PRN. D/c diamox\n -will need speech and swallow eval but will hold off until tomorrow\n -of note, since pt has been on fent/versed for sedation for >1wk, may\n have benzo withdrawl. Will consided valium or versed PRN\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 14 D course\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN. If stable tomorrow, will likely pull CVL.\n - F/U cultures and culture if spikes\n - F/U ID recs- they rec thoracentesis but do not think this is\n medically necessary for now.\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will restart TF today after extubation. Cont TPN for today\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:01 PM 42 mL/hour\n Restart TF today after extubation\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\n c/b MSSA pneumonia. Improving with lasix, fevers and rash decreasing.\n Exam notable for Tm 100.7 BP 118/58 HR 90 RR 24 with sat 96 on PSV 5/5,\n 7.52/37/70 -3+L/24h. Rash on anterior chest improved, lungs clearer.\n RRR s1s2. Soft +BS. Trace edema. Labs notable for WBC 23K, HCT 24, K+\n 4.0, Cr 0.8. CXR improving B ASD.\n Agree with plan to extubate today. Will d/c diamox and continue lasix\n bolus PRN for goal negative and CVP <4. Will continue naf for MSSA\n pneumonia x 11/14 days total. Given recent benzo use, will need ativan\n or valium PRN following extubation. Will continue TPN and initiate\n Doboff feeds after extubation. Above d/w wife and PCP. of\n plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:36 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658497,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient switched from A/C to CPAP/PSV. Most\n recent abg results determined a normal acid-base balance with adequate\n oxygenation ( on A/C).\n RSBI = 100 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658490,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Norepi shut off at 1800 last evening. Continues on Linezolid and\n cefipime IV.\n Pt remains intubated on low dose sedation, fent and versed drips.\n Remained on AC overnight with the plan to switch to PSV in AM.\n Plan for cardiac echo today. Pt may also go to IR for drainage of\n pleural effusions.\n Pt\ns wife is contact person and has been updated by team overnight. She\n wants to speak to Attending today before any invasive procedures are\n done. Visitors are limited to a few people written on a paper at the\n front desk. She was upset that his co-workers were let in to visit on\n .\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains on the vent. ARDS protocol with low tidal volumes\n maintained. Lungs diminished at both bases. Clear breath sounds right\n upper lobe and coarse rhonchi on the left upper lobe. Suctioned for\n thick white secretions.\n Action:\n Seems to be requiring less suctioning tonight than previously\n described. Suctioned orally and nasally for large amts secretions.\n Response:\n Stable ABG on the AC overnight.\n Plan:\n Plan to switch to PSV in AM. Will need to repeat ABG omce on PSV for\n one hour.\n Sepsis without organ dysfunction\n Assessment:\n Remains off norepinephrine with goal MAP>60 most of the night. UO\n adequatevia foley. CVP 13-14.\n Action:\n Continues on antibiotics, Cefipime and Linezolid as ordered.\n Response:\n Pt with low grade fever overnight. Given Tylenol once as pt had been\n cultured in past 24hr.\n Plan:\n Will need to be cultured if spikes temp again. Follow vital signs\n closely and try to keep pt off pressors if possible.\n RSBI was 100 this AM and pt put on PSV 10/8cm peep at 5AM. I will draw\n repeat ABG prior to 7AM.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 657928,
"text": "Briefly this is a 53 y/o M w/ a PMH significant for hodgkins disease\n s/p BMT in the 80\ns who was initially admitted to the floor for\n influenza B. On the night of he developed increasing resp distress\n and was transferred to the M/SICU for further management of influenza\n B/PNA.\n This AM Mr. was hypoxic w/ a PaO2 of 36 on 100% non rebreather,\n he was intubated for hypoxic resp distress shortly thereafter.\n Events:\n Intubated and sedated this AM\n R IJ TLCL and R radial A line placed\n Spike to 101.5 this afternoon\n BCs, sputum, Urine sent\n Abx changed now on cefepime/linezolid\n 2500 cc NS hypotension w/ resolution of hypotension\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Nasal aspirate significant for influenza B, CXR showed bilateral PNA\n Action:\n Broad spectrum abx.\n Response:\n Remains febrile w/ elevated WBC\n Plan:\n Cont broad spectrum abx, to be started on inhaled antivirals once\n approved\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated this AM for hypoxia, LS clear upper lobes/dimished @ bases,\n suctioned for small amounts thick yellow secretions\n Action:\n Currently on AC 70% 500 x 18 PEEP 8\n Response:\n ABG now wnl satting 100%\n Plan:\n Cont to Fi02 and vent support as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n WBC 12.6, febrile to 101.5, hypotensive to 88 systolic\n Action:\n 2.5 L NS bolus, started on linezolid, blood, sputum, urine cxs sent.\n Response:\n Currently normotensive, remains febrile\n Plan:\n Monitor hemodynamic status, cont IV abx\n"
},
{
"category": "Social Work",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 658590,
"text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record\n Family Spokesperson designated: , (Wife) Phone:\n ; Other Phone: \n Communication or visitation restriction: Restriction on visitors. \n wife has given nursing a list of people who can see him.\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: First admission; he\n was last hospitalized in AZ approximately two years with what his wife\n reports as similar symptoms.\n Past psychiatric history: None known.\n Past addictions history: None known.\n Employment status: Employed\n Legal involvement: None known.\n Additional Information:\n Patient / Family Assessment: This worker met with pt's wife in response\n to RN concerns about her level of stress. Her 53 y/o husband was\n admitted with what had initially been flu symptoms. Recently, one of\n her 18 y/o twin sons had the flu and he is apparently concerned that he\n might have caused his father's illness. At this time, they have not\n seen the pt, nor does their mother want them to see him unless they are\n eager to do so. Ms. , in addition to her concern re her\n husband\ns well-being, was much stressed about his real estate business\n and not having access to his bank account to pay outstanding bills.\n (She too is a realtor.) Other stressors including trying to support her\n sons, anticipating today that one would be hearing re an early college\n admission. Twice during the 30 minute meeting, her phone rang; it was\n her mother-in-law with whom she did not want to talk, but did take her\n second call. The pt\ns mo recently had surgery for stage 1 uterine CA;\n she will soon begin chemo. His mother also has a HX of depression,\n having had a one one-week psych hospitalization. Following Mr.\n \ns hospitalization in AZ, his older brother committed suicide;\n he had been the pt\ns bone marrow donor. This event seems to continue to\n traumatize the family. He had been the primary overseer of their\n parents\n well-being, a responsibility that Mr. has now assumed.\n Mr. did not inform them of his hospitalization in AZ because of\n concerns as to how his mo would respond given her depression.\n Additionally, he did not want his parents to know about this admission,\n but his sister finally told them because he is not able to maintain his\n regular telephone and e-mail contact with them. His sister, who lives\n in , has a child with a major anxiety disorder who has refused\n to go to school for the past 1.5 years; he receives private tutoring.\n Ms. said that this boy\ns symptoms are similar to those of her\n brother-in-law who committed suicide. Over the course of the interview,\n Ms. revealed more and more information, and it felt that had\n the meeting been longer, she would have continued to do so. A number of\n times she referred to a multitude of family issues.\n This worker tried to problem-solve with her, such as possibly speaking\n with a lawyer who might assist her in dealing with her husband\n business clients. They do not have a lawyer; there are family members\n who are and she might speak with one of them. She suggested, and this\n worker supported her having her sister-in-law be the conduit for\n information re the pt\ns parents. Encouragement was also given to her\n not spending extend periods in the hospital and being with her\n children. The only non-family member she mentioned as a source of\n support is their rabbi, who is more a friend than their spiritual\n leader. She was not able to give a clear indication of how she copes\n with stress.\n Communication with Team:\n 1. , RN\n Plan / Follow up:\n 1. This worker will meet with Ms. on Monday to continue\n offering support.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 657922,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658015,
"text": "Chief Complaint: 53 y.o. male with hypoxemia, respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n -Rapid test came back with influenza B\n -Put on linezolid and zanamavir (for MRSA and flu) vanco d/c'd\n -Will d/c linezolid if cultures negative\n -Got R IJ CVL\n -Got 1L NS for SBP in 80s with good response\n -Had to change zanamavir to oseltamivir b/ not available in po\n (just inhaled). OK'd the change with ID.\n -UCx sent\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Linezolid - 12:23 AM\n Cefipime - 06:13 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 PM\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.3\nC (99.1\n HR: 92 (74 - 121) bpm\n BP: 124/65(85) {82/43(56) - 145/73(96)} mmHg\n RR: 22 (18 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 6 (6 - 342)mmHg\n Total In:\n 4,792 mL\n 444 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 444 mL\n Blood products:\n Total out:\n 985 mL\n 305 mL\n Urine:\n 985 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/41/81./22/-1\n Ve: 9.8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 253 K/uL\n 9.7 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n Chief Complaint: Respiratory Distress, hypoxemia\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n -Rapid flu test came back with influenza B\n -Put on linezolid and oseltamavir (for MRSA and flu) vanco d/c'd\n -Will d/c linezolid when sputum cultures negative\n -Got R IJ CVL\n -Got 1L NS for SBP in 80s with good response\n -Had to change zanamavir to oseltamivir b/ not available in po\n (just inhaled). OK'd the change with ID.\n -UCx sent\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Linezolid - 12:23 AM\n Cefipime - 06:13 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 PM\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs Hemodynamic monitoring Fluid balance 24\n hours Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.3\nC (99.1\n HR: 92 (74 - 121) bpm\n BP: 124/65(85) {82/43(56) - 145/73(96)} mmHg\n RR: 22 (18 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 6 (6 - 342)mmHg\n Total In: 4,792 mL 443 mL\n PO:\n TF:\n IVF: 4,732 mL 443\n mL\n Blood products:\n Total out: 985 mL 305 mL\n Urine: 985 mL 305 mL\n NG:\n Stool:\n Drains:\n Balance: 3,807\n mL 138 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74 PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/41/81./22/-1\n Ve: 9.8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Appears unwell\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 06:07 AM 06:36\n AM 08:57 AM 10:07\n AM 10:26 AM 03:08\n PM 11:32 PM 03:19\n AM 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2 26 25 26\n 26 24 21 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n 53 yo male with Hodgkin's disease now admitted with influenza and who\n has evolved significant worsening of hypoxemic respiratory failure\n across the admission. This is with evolution of bilateral and patchy\n consolidations consistent with superinfection of initial viral insult.\n This is suggested by evolution of cough/plegm/feve/infiltrate.\n 7.46/34/47 was repeat ABG following arrival in ICU. Patient was\n intubated with severe hypoxemic respiratory failure likley related to\n bilateral and dependent consolidations with likley bacterial\n superinfection of previous viral pneumonitis.\n Hypoxemic Respiratory Failure-\n -A/C\nwill maintain PEEP at 10-12\n -Continue FIO2=1.0\n -Will need to replace volume with patient currently hypotensive\n -PIP=30, Pplat-27 consistent with presentation\n -Wean FIO2 as possible\n -Advance ETT\n -Will place A-line\n Pneumonia-\n -Linezolid/Cefepime/Axithro\n -Sputum GS C+S\n -Follow up culture results\n -Urine Legionella pending\n -Bronch and BAL if patient improved stability to tolerate procedure or\n with inadequate sampling\n Sepsis-\n -Patient with significant hypotension with intubation and leading to\n respiratory failure\n -Will need CVL and volume replacement\n -Follow up cultures results\n -Will titrate therapy to stability of blood pressure.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658018,
"text": "Chief Complaint: 53 y.o. male with hypoxemia, respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n -Rapid test came back with influenza B\n -Put on linezolid and zanamavir (for MRSA and flu) vanco d/c'd\n -Will d/c linezolid if cultures negative\n -Got R IJ CVL\n -Got 1L NS for SBP in 80s with good response\n -Had to change zanamavir to oseltamivir b/ not available in po\n (just inhaled). OK'd the change with ID.\n -UCx sent\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Linezolid - 12:23 AM\n Cefipime - 06:13 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 PM\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.3\nC (99.1\n HR: 92 (74 - 121) bpm\n BP: 124/65(85) {82/43(56) - 145/73(96)} mmHg\n RR: 22 (18 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 6 (6 - 342)mmHg\n Total In:\n 4,792 mL\n 444 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 444 mL\n Blood products:\n Total out:\n 985 mL\n 305 mL\n Urine:\n 985 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/41/81./22/-1\n Ve: 9.8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 253 K/uL\n 9.7 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658020,
"text": "Chief Complaint: 53 y.o. male with hypoxemia, respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 AM\n MULTI LUMEN - START 09:05 AM (Right internal jugular)\n ARTERIAL LINE - START 09:30 AM\n SPUTUM CULTURE - At 10:30 AM\n BLOOD CULTURED - At 05:00 PM\n URINE CULTURE - At 05:00 PM\n BLOOD CULTURED - At 05:15 PM\n FEVER - 101.5\nF - 04:00 PM\n -Rapid test came back with influenza B\n -Put on linezolid and oseltamavir (for MRSA and flu) vanco d/c'd\n -Will d/c linezolid if cultures negative\n -Got 1L NS for SBP in 80s with good response\n -UCx sent\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:00 PM\n Linezolid - 12:23 AM\n Cefipime - 06:13 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:00 PM\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.3\nC (99.1\n HR: 92 (74 - 121) bpm\n BP: 124/65(85) {82/43(56) - 145/73(96)} mmHg\n RR: 22 (18 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 6 (6 - 342)mmHg\n Total In:\n 4,792 mL\n 444 mL\n PO:\n TF:\n IVF:\n 4,732 mL\n 444 mL\n Blood products:\n Total out:\n 985 mL\n 305 mL\n Urine:\n 985 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,807 mL\n 139 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI: 74\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/41/81./22/-1\n Ve: 9.8 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 253 K/uL\n 9.7 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.9 %\n 12.3 K/uL\n [image002.jpg]\n 06:07 AM\n 06:36 AM\n 08:57 AM\n 10:07 AM\n 10:26 AM\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n WBC\n 12.6\n 12.3\n Hct\n 28.5\n 28.9\n Plt\n 250\n 253\n Cr\n 0.9\n 1.0\n TCO2\n 26\n 25\n 26\n 26\n 24\n 21\n 25\n Glucose\n 117\n 96\n Other labs: PT / PTT / INR:12.5/47.7/1.1, ALT / AST:31/29, Alk Phos / T\n Bili:89/0.8, Differential-Neuts:80.5 %, Lymph:11.7 %, Mono:6.6 %,\n Eos:0.9 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:162 IU/L,\n Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenze B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient required intubation yesterday for\n worsening respiratory status and was started on linezolid and\n oseltamavir for MRSA pneumonia and influenza respectively. Respiratory\n status currently stable on ventilator.\n - cont vanco/cefepime, and azithro for now\n - check sputum culture; f/u blood cx\n - if positive for MRSA, or decompensates further, can consider\n switching vanco to linezolid for improved pulmonary MRSA coverage\n - legionella negative\n - on NRB now; repeat ABG with significant hypoxemia and A-a gradient;\n given tachypnea, may need to be intubated. d/w anesthesia\n - meeting SIRS criteria with tachypnea, tachycardia, and leukocytosis;\n will consider CVL placement for CVP monitoring\n 2) SIRS: likely source pulmonary given CT findings. urine negative.\n blood cx no growth to date. h/o splenectomy increases risk for\n encapsulated organisms\n - consider CVL placement for CVP monitoring; BP currently normal\n - NS bolus 500 cc\n - abx as above\n - culture with fevers; monitoring leukocytosis curve\n 3) Hypothyroidism: cont home levothyroxine\n 4) FEN: NPO for now\n - NS 500 cc bolus\n 5) Access: 2 PIVs; consider CVL\n 6) PPx: hep sc, ppi as outpt\n 7) Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 10) Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:28 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658431,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt w/ large amt thick tan secretions , ?? consolidation /plural\n effusions\n Action:\n To CT to r/o infectious source, CT of chest , abd and sinuses done.\n Response:\n Pt tolerated procedure well.\n Plan:\n Awaiting results of scan, cont mech vent support , freq suctioning ,\n ab tx\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658642,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments No AM RSBI, no spont resp efforts at this time/?\n Thoracentesis.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658169,
"text": "FULL CODE\n CC: Respiratory failure influenza B/PNA\n Sepsis without organ dysfunction\n Assessment:\n Pt febrile to 101.7, BP\ns declining, CVP=5. u/o WNL, pt arouses to\n voice and follows commands\n Action:\n Pan cultured, NS 1L bolus x2 with minimal improvement in BP. Started on\n Levophed, initially .1mcg, Tylenol 650mg x1\n Response:\n Able to wean levo to .02mcg for several hours, to off at 05:30 but ABP\n slowly drifting down. T=98.9\n Plan:\n Monitor fever curve, maintain CVP~12, IV abx, pressor support prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of patient on CMV 50%/400/24/8. LS clear upper, dim at\n bases but maintaining sat >95%. Occasionally coughing , minimal\n secretions\n Action:\n RT placed on humidified air. CPAP trial started at 0600\n Response:\n Able to suction intermittently for mod amts thin, tan secretions.\n Currently maintaining sat at 97% on CPAP with improved HR and more\n comfortable appearance.\n Plan:\n Obtain abg. Sxn prn, iv abx/tamilflu\n Wife telephoned in for an update twice on this shift. She will be in\n to visit in the am.\n"
},
{
"category": "General",
"chartdate": "2181-02-01 00:00:00.000",
"description": "ICU Event Note",
"row_id": 658432,
"text": "Clinician: Attending\n Wife updated in full and clinical course of concern discussed--we have\n evolution of worsening fever, rising WBC count and worsening\n hypotension. We have influenza and S. Aureus in pulmonary secretions\n to explain evolution of ARDS and respiratory failure, however--on\n optimal antibiotic therapy we have raised a concern for additional\n infectious source and are pursuing CT scan to evaluate. Agreed to have\n her call at end of day for update on progress or decline of the day.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658481,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Norepi shut off at 1800 last evening. Continues on Linezolid and\n cefipime IV.\n Pt remains intubated on low dose sedation, fent and versed drips.\n Remained on AC overnight with the plan to switch to PSV in AM.\n Plan for cardiac echo today. Pt may also go to IR for drainage of\n pleural effusions.\n Pt\ns wife is contact person and has been updated by team overnight. She\n wants to speak to Attending today before any invasive procedures are\n done. Visitors are limited to a few people written on a paper at the\n front desk. She was upset that his co-workers were let in to visit on\n .\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains on the vent. ARDS protocol with low tidal volumes\n maintained. Lungs diminished at both bases. Clear breath sounds right\n upper lobe and coarse rhonchi on the left upper lobe. Suctioned for\n thick white secretions.\n Action:\n Seems to be requiring less suctioning tonight than previously\n described. Suctioned orally and nasally for large amts secretions.\n Response:\n Stable ABG on the AC overnight.\n Plan:\n Plan to switch to PSV in AM. Will need to repeat ABG omce on PSV for\n one hour.\n Sepsis without organ dysfunction\n Assessment:\n Remains off norepinephrine with goal MAP>60 most of the night. UO\n adequatevia foley. CVP 13-14.\n Action:\n Continues on antibiotics, Cefipime and Linezolid as ordered.\n Response:\n Pt with low grade fever overnight. Given Tylenol once as pt had been\n cultured in past 24hr.\n Plan:\n Will need to be cultured if spikes temp again. Follow vital signs\n closely and try to keep pt off pressors if possible.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658581,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 102.3 oral, appeared to have aspirated his tube feedings, LS\n clear in the apices, bronchial on the L base and diminished in the R\n base, he has been coughing through the day, his sputum is thick and\n yellow. Remains off of pressors.\n Action:\n Sputum sent for clx and leginella, his tube feedings were stopped for\n now due to his aspiration. His sputum is MSSA so the linazolid was\n d/ced and he is now on naffcillin, he will need Tamaflu for 2 more\n days. He had a thoracentesis done, they removed ~600cc of serous fluid\n and this was sent for clx and chemistries. He was changed back to A/C\n since his resp rate was in the 30s and it was felt that he needed to\n rest.\n Response:\n Cont to cough despite an increase in his sedation, yellow secreations,\n febrile, WBC still elevated.\n Plan:\n Cont to follow temp, high aspiration risk - will need to discuss food\n in the near future, 2 more days of Tamaflu after today, f/u with clx\n results.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented, conts to cough frequently, suctioned for thick yellow\n sputum\n Action:\n Changed to A/C from PSV due to his resp rate of 30\n Response:\n Plan:\n Cont to follow, wean the vent as he tolerates, f/u on clx\n Sepsis without organ dysfunction\n Assessment:\n His BP has remained stable today, he conts off of pressors, T max\n 102.3, his u/o is ~ 40cc/hr\n Action:\n He had a thorocentesis done today, his sputum his MSSA so he is on\n nafcillian and off of linezolid\n Response:\n Stable BP but still febrile\n Plan:\n f/u on clx results, follow temp curve\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658776,
"text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has coughing spasms when sedation is decreased\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM RSBI-94. Started on MDI Albuterol Q4PRN\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658166,
"text": "FULL CODE\n CC: Respiratory failure influenza B/PNA\n Sepsis without organ dysfunction\n Assessment:\n Pt febrile to 101.7, BP\ns declining, CVP=5. u/o WNL, pt arouses to\n voice and follows commands\n Action:\n Pan cultured, NS 1L bolus x2 with minimal improvement in BP. Started on\n Levophed, initially .1mcg, Tylenol 650mg x1\n Response:\n Able to wean levo to .02mcg for several hours, finally to off at\n 05:30. ABP current =104/47. T=\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 657985,
"text": "This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenze B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is intubated on vent in AC mode settings 500X18X60%X8. He is sedated\n well on fentanyl 50mcg/versed 1mg/hr. Suctioned for moderate amts thin\n yellow secretions.\n Action:\n fiO2 was 70% but decreased to 60% when ABG showed pO2 of 109. Fentanyl\n decreased to 40mcg when pt hypotensive but back up to 50mcg/hr when he\n became tachypneic and hypertensive after turning.\n Response:\n Pt slept quietly all night, no desating, no restlessness,\n Plan:\n Wean vent and sedation slowly as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 100.8ax. SBP in the 70\ns at beginning of shift.\n Action:\n IVF bolus of NS 1L given X1 over an hour.\n Response:\n SBP remained >100 the rest of the night.\n Plan:\n Monitor vs, temp and give NS bolus prn SBP <80.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658280,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp. failure, and is now being treated for\n influenza/ARDS.\n Events:\n Spiked to 102.5 (no cultures as pt was pan cultured on )\n 1 L NS bolus hypotension\n Restarted on levophed\n TF initiated\n RUQ US to rule out cholecystitis\n K of 3.5 repleted w/ 40mgq PO K\n Sepsis without organ dysfunction\n Assessment:\n T max 102.5, hypotensive to 80\ns systolic, no growth to date in all\n BCs.\n Action:\n ID consulted\n Response:\n No increase in antimicrobial coverage\n Plan:\n Monitor hemodynamic status and support as necessary w/ pressor and\n volume\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\n secretions.\n Action:\n Multiple vent changes made, remains on CPAP as pts own rate and volumes\n coincide w/ ARDS net protocol\n Response:\n ABGs remain largely unchanged PaO2 slightly improved, pt continues to\n deny any SOB\n Plan:\n Cont to monitor resp status and wean vent support as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658273,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for\n influenza/ARDS.\n Events:\n Spiked to 102.5 (no cultures as pt was pan cultured on )\n K of 3.5 repleted w/ 40mgq PO K\n 1 L NS bolus hypotension\n Restarted on levophed\n TF initiated\n RUQ US to rule out\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658274,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for\n influenza/ARDS.\n Events:\n Spiked to 102.5 (no cultures as pt was pan cultured on )\n K of 3.5 repleted w/ 40mgq PO K\n 1 L NS bolus hypotension\n Restarted on levophed\n TF initiated\n RUQ US to rule out cholecystites\n Sepsis without organ dysfunction\n Assessment:\n Tmax 102.5, hypotensive to 80\ns systolic, no growth to date in all BCs.\n Action:\n ID consulted\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658420,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains on CPAP/PSV, no changes made this shift.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1400\n pt vomitted contrast, orally suctioned for copious amounts of think\n yellow secretions.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658576,
"text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt increasingly more tachypneic this AM, switched back to A/C\n ventilation to rest w/ PIP/Pplat = 22/19, ETT advanced per CXR and ICU\n team.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: continue to attempt to wean as tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658717,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 8 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Frequent alarms (High pressure, High min.\n ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658769,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Sepsis without organ dysfunction\n Assessment:\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\n 80s-100. Spiked fecer to 101.3. This AM K 3.7 and Ph 2.5\n Action:\n Given 500 cc NS bolus, given Tylenol 0nce, 2 sets of bld cx, urine cx,\n and stool cx sent. Continued on antibiotics as ordered. KCL 20 meq IV\n given.\n Response:\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\n above 10.\n Plan:\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\n ordered, bolus fluids as needed. Monitor lytes and replete as needed,\n Ph to be repleted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\n at upper lobes and diminished at bases. Was observed to be very\n restless and trying to jump out of bed.\n Action:\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\n increased to 4 mg/hr.\n Response:\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\n strong productive cough.\n Plan:\n Wean vent as tolerated, suction frequently PRN.\n"
},
{
"category": "Social Work",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 658909,
"text": "Progress Note:\n This worker met with Ms. who reported having had a\nmelt down\n last night,\n apparently precipitated by talking with one of the\n residents re her husband\ns current medical status, which she is now\n feeling may be terminal. She spoke with her parents this AM and\n suggested that they might want to come to ; they live in\n . Although there have been two previous major medical\n events\nhis BMT and ICU admission in AZ\nshe seems to be feeling that\n this admission is the most foreboding because doctors cannot identify\n the source of her husband's infection. Ms. said that her sons\n still do not want to come to the , but she is beginning to wonder\n if she should insist. Friends and family members (sisters and\n sister-in-law) are providing support. She was able to contact her\n husband\ns business associates whom she reports are fine with their not\n being paid at this time.\n Assessment:\n Although clearly and understandably stressed, Ms. appeared more\n in control this AM than she reported being last night. Pt is anxious to\n speak with Dr. for further medical information and status.\n Plan:\n 1. This worker will continue to meet with pt for support during\n Mr. \ns stay in the .\n Page \n"
},
{
"category": "Respiratory ",
"chartdate": "2181-01-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 657904,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt intubated this am for impending resp failure and hypoxia.\n fio2 has been slowly weaned throughout the shift and currently remains\n at 70%\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658153,
"text": "FULL CODE\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658154,
"text": "FULL CODE\n CC: Respiratory failure influenza B/PNA\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658635,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fent and versed drips. Remained\n on AC overnight.\n Sepsis without organ dysfunction\n Assessment:\n BP started dropping to 80s then to high 70s, UO 30-40 cc/hr, CVP 13-14.\n Action:\n Levophed resumed at 0.01 mcg.kg/min, continues on antibiotics as\n ordered.\n Response:\n Pt with low grade fever overnight. T max 100.1, given Tylenol once as\n pt had been cultured (urine and sputum) within the past 24hrs.\n Plan:\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\n ordered, wean levophed off as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is sedated and intubated on AC for ARDS. Lung sounds rhonchi at\n upper lobes and diminished at bases..\n Action:\n Suctioned frequently for thick yellowish secretions. Remains on\n Fentanyl 50 mcg/hr and versed 2 mg/hr.\n Response:\n Present vent setting AC 20, 400, 50%, PEEP 8.\n Plan:\n Wean vent as tolerated, suction PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658570,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 101 oral, appeared to have aspirated his tube feedings, LS clear\n in the apices, bronchial on the L base and diminished in the R base, he\n has been coughing through the day, his sputum is thick and yellow.\n Remains off of pressors.\n Action:\n Sputum sent for clx and leginella, his tube feedings were stopped for\n now due to his aspiration. His sputum is MSSA so the linazolid was\n d/ced and he is now on naffcillin, he will need Tamaflu for 2 more\n days. He had a thoracentesis done, they removed ~600cc of serous fluid\n and this was sent for clx and chemistries. He was changed back to A/C\n since his rate was in the 30s and it was felt that he needed to rest.\n Response:\n Cont to cough despite an increase in his sedation, yellow secreations,\n febrile, WBC still elevated.\n Plan:\n Cont to follow temp, high aspiration risk - will need to discuss food\n in the near future, 2 more days of Tamaflu after today, f/u with clx\n results.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658713,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.5, conts to have a lg amount of secretions friom his ETT and\n the back of his mouth\n Action:\n Conts on abx, started on afrin for a sinusits, conts with frequent\n coughing and suctioning, given versed and fent boluses to try and stop\n the coughing\n Response:\n Still conts to cough, no high spike today\n Plan:\n Cont abx, follow temp, flx if spikes, afrin for 3 days.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on A/C, conts to have frequent coughing spells\n Action:\n His FI02 was decreased to 40%, we tried to decrease his PEEP to 5 but\n he started to cough and desaturated\n Response:\n 02 SAT has been in the mid 90s, his PEEP was put back up to 8\n Plan:\n Cont to try and wean the vent as he tolerates\n Sepsis without organ dysfunction\n Assessment:\n Pt had one episode of hypotension to the 80s after a fent and vesed\n bolus, CVP 8 at that time, it was 12 earlier in the day, u/o has been\n 30-70cc/hr of amber colored urine, t max 100.5.\n Action:\n Given a 500cc NS bolus\n Response:\n His BP did come back up to the 90s-100s\n Plan:\n Cont to follow VS, u/o, temp curve, cont abx\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658908,
"text": "Chief Complaint: This is a 53 year-old male with a history of hodkin's\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\n pneumonia, S. aureus superinfections, and ARDS.\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n \n -Weaned Fi02 from 50->40%\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\n not given\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\n contrast (unable to obtain peripheral access). However, there is no\n change in size of multiple regions of consolidation bilaterally.\n Further, there is no change in distribution and appearance of\n air-bronchograms that would suggest a change in the underlying\n consolidation, or the presence of a new space-occupying lesion.\n Persistent pleural effusions\n -RUQ U/S done\n -spoke to his wife about how mr. was doing. She was very\n anxious.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:35 PM\n Cefipime - 06:56 PM\n Nafcillin - 10:32 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:44 PM\n Fentanyl - 10:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.6\nC (97.8\n HR: 88 (77 - 107) bpm\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\n RR: 24 (20 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (10 - 24)mmHg\n Total In:\n 5,336 mL\n 499 mL\n PO:\n TF:\n IVF:\n 3,176 mL\n 170 mL\n Blood products:\n Total out:\n 1,400 mL\n 620 mL\n Urine:\n 1,400 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,936 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 652 (652 - 652) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 623 K/uL\n 7.7 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 23 mg/dL\n 102 mEq/L\n 134 mEq/L\n 23.9 %\n 25.6 K/uL\n [image002.jpg]\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n Plt\n 293\n 334\n 439\n \n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n TCO2\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n 151\n 131\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\n and oxygenation stable on AC settings. He is on day 8 of\n antimicrobial therapy with cefepime, he received six days of\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\n was stopped and nafcillin started (now day 4) after his staph was\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\n re-expansion after the procedure, suggesting that it is freely\n flowing. FiO2 40% from 50%.\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS so will attempt PS today\n - Has completed course of oseltamavir\n - continue nafcillin but can d/c cefepime considering no clear source\n of GNR infection\n - F/U cultures\n - diuresis with lasix drip today to decrease total body fluid and\n maximize chance of successful extubation\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\n drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin and saline nasal washes for sinus disease\n - Continue nafcillin\n - consider pulling central line, particularly if any blood cx are\n positive\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Attempted to place\n Duboff in post-pyloric position but appears to remain in the stomach\n despite raglan and mechanical manipulation. Will consult radiology\n regarding advancing tube.\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:54 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: hep sc, PPI\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659028,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659127,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\n following commands, writing on paper to communicate. T max 100.1po.\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\n abd and back appears improved micu md staff who saw this pt\n yesterday.\n Action:\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\n scant amts thick yellow sputum, small amts blood tinged sputum in back\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\n pending.\n Response:\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\n extubated today. ett retaped and repositioned to left side of mouth at\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\n and versed drips restarted and titrated up to comfort but pt still\n easily arousable and following commands. Continues to diurese well\n approx 3.9 liters negative since mn. 7 liters + los. Cvp approx .\n Plan:\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\n around 4. Follow up with 5pm lab results and replete lytes prn.\n Continue to monitor rash on abd and back.\n Sepsis without organ dysfunction\n Assessment:\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\n Also + influenza.\n Action:\n Continues with iv nafcillin\n Response:\n Remains with low grade temp, currently afebrile.\n Plan:\n Continue nafcillin, follow up with bld culture results. Monitor temps.\n Social: pt\ns wife up to visit pt in late am and most of day.pt\ns wife\n spoke with Dr. re: pt\ns update and plan of care. Pt\ns twin sons\n and also visited in the early evening. Pt\ns requested\n to also speak with Dr. for an update. Dr. spoke to them\n to give them an update, but they requested an update from Dr. .\n Dr. paged Dr. and plan is for Dr. to speak to pt\n later this evening after 7:30pm. Wife and are visiting\n in room and waiting room. social worker has been following wife\n and pt for support and spoke to them yesterday. Wife declined need to\n speak to today. continue to provide emotional support to\n pt/family prn.\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658102,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a possible PNA.\n Events:\n No growth to date on BCs, sputum or urine cultures\n Multiple vent changes made currently on\nARDS net\n settings\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear upper lobes dimished @ bases, suctioned for scant amounts thin\n yellow secretions, lightly sedated on fent/midaz and denies any\n subjective SOB\n Action:\n Multiple vent changes made, placed on ARDs settings some question\n of a worsening chest film, FI02 weaned to 50%\n Response:\n Most recent ABG on 50% is pending @ this time, appears comfortable w/\n vent, maintaing sats 97- 100%\n Plan:\n Cont to monitor resp status and wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n WBC count stable @ 12, Temp 100\n 100.9, hemodynamically stable, BUN/CR\n are within normal limits however U/O ~30cc/hr\n Action:\n Remains on cefepime/linezolid/\n Response:\n All vital signs within normal limits\n Plan:\n Monitor hemodynamic status, cont broad spectrum abx and , \n require maintainence fluids.\n"
},
{
"category": "General",
"chartdate": "2181-01-31 00:00:00.000",
"description": "ICU Event Note",
"row_id": 658254,
"text": "Clinician: Attending\n wife in for visit. She was updated in full on his clinical\n course with ARDS secondary to influenza +/- bacterial superinfection\n leading to hypoxemic respiratory failure. In addition he has\n intermittent hypotension and concern for acalculous cholecystitis and\n antibiotic resistant bacteria leading to sepsis.\n All questions were answered and plans for visit with her twin sons\n ) were made.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658574,
"text": "Chief Complaint: Respiratory failure, ARDS\n 24 Hour Events:\n - FEVER - 101.1\nF - 09:00 PM\n -OFF PRESSORS at 6:00 pm\n -CT torso w/o abcess or drainable collection\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\n -Thoracentesis deferred as minimal fluid on echo\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 12:30 AM\n Cefipime - 05:56 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 75 (75 - 117) bpm\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\n RR: 19 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (13 - 334)mmHg\n Total In:\n 1,855 mL\n 941 mL\n PO:\n TF:\n 917 mL\n 382 mL\n IVF:\n 878 mL\n 514 mL\n Blood products:\n Total out:\n 1,520 mL\n 218 mL\n Urine:\n 1,520 mL\n 218 mL\n NG:\n Stool:\n Drains:\n Balance:\n 335 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 370 (370 - 542) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/41/85./25/1\n Ve: 8.9 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : few)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 439 K/uL\n 8.3 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 104 mEq/L\n 133 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n WBC\n 15.8\n 20.4\n 19.2\n Hct\n 28.1\n 26.6\n 26.3\n Plt\n 293\n 334\n 439\n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 25\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL, ALT\n 70*, AST 75*, AP 385*, LDH 176, T Bil 0.8\n Imaging:\n CT Torso:\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\n greater\n than right, with scattered patchy opacities seen medially within the\n upper lobes. Interval increase in bilateral pleural effusions, now\n moderate.\n 2. Prominence of the esophagus, which is diffusely filled with oral\n contrast\n material, consistent with extensive gastroesophageal reflux disease.\n Given the degree of contrast reflux into the esophagus, which is\n marked, the patient is felt to be a very high risk for aspiration.\n 3. No acute inflammatory process or abnormal fluid collection is seen\n in the\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\n fluid.\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\n Microbiology: Sputum:\n : Culture with coag + staph\n Gram stain (-)\n : Culture preliminary negative, gram\n stain (-)\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\n known influenza B as well as staph aureus in sputums. Presumably, flu\n with bacterial superinfection is the etiology of his ARDS. The patient\n was on AC overnight but was switched back to CPAP this AM. Since then,\n he has been pulling lower tidal volumes than previously (<400) and more\n tachypneic. We will place him back on AC to decrease work of breathing\n while we continue to treat his pneumonia and support him through his\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\n and oseltamavir.\n -F/U cultures, obtain viral cultures per ID recommendation\n - Continue current antimicrobials pending culture data\n -IP will attempt to perform diagnostic thoracentesis today as ICU team\n unable to safely do at bedside\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though this should be\n appropriately covered by his antibiotics.\n -Continue linezolid/cefepime/oseltamavir pending culture data\n -obtain pleural fluid to rule out complicated effusion\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE today to evaluate for effusion/tamponade\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: Pt with noted aspiration event this AM, presumably due to\n history of irradiation, we will hold tube feeds for now and swallow\n study once extubated.\n 6) Access: 2 PIVs; right IJ\n 7) PPx: hep sc, PPI\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658632,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fent and versed drips. Remained\n on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains on the vent. ARDS protocol with low tidal volumes\n maintained. Lungs diminished at both bases. Clear breath sounds right\n upper lobe and coarse rhonchi on the left upper lobe. Suctioned for\n thick white secretions.\n Action:\n Seems to be requiring less suctioning tonight than previously\n described. Suctioned orally and nasally for large amts secretions.\n Response:\n Stable ABG on the AC overnight.\n Plan:\n Plan to switch to PSV in AM. Will need to repeat ABG omce on PSV for\n one hour.\n Sepsis without organ dysfunction\n Assessment:\n Remains off norepinephrine with goal MAP>60 most of the night. UO\n adequatevia foley. CVP 13-14.\n Action:\n Continues on antibiotics, Cefipime and Linezolid as ordered.\n Response:\n Pt with low grade fever overnight. Given Tylenol once as pt had been\n cultured in past 24hr.\n Plan:\n Will need to be cultured if spikes temp again. Follow vital signs\n closely and try to keep pt off pressors if possible.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658896,
"text": "Chief Complaint: This is a 53 year-old male with a history of hodkin's\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\n pneumonia, S. aureus superinfections, and ARDS.\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n \n -Weaned Fi02 from 50->40%\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\n not given\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\n contrast (unable to obtain peripheral access). However, there is no\n change in size of multiple regions of consolidation bilaterally.\n Further, there is no change in distribution and appearance of\n air-bronchograms that would suggest a change in the underlying\n consolidation, or the presence of a new space-occupying lesion.\n Persistent pleural effusions\n -RUQ U/S done\n -spoke to his wife about how mr. was doing. She was very\n anxious.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:35 PM\n Cefipime - 06:56 PM\n Nafcillin - 10:32 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:44 PM\n Fentanyl - 10:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.6\nC (97.8\n HR: 88 (77 - 107) bpm\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\n RR: 24 (20 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (10 - 24)mmHg\n Total In:\n 5,336 mL\n 499 mL\n PO:\n TF:\n IVF:\n 3,176 mL\n 170 mL\n Blood products:\n Total out:\n 1,400 mL\n 620 mL\n Urine:\n 1,400 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,936 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 652 (652 - 652) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 623 K/uL\n 7.7 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 23 mg/dL\n 102 mEq/L\n 134 mEq/L\n 23.9 %\n 25.6 K/uL\n [image002.jpg]\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n Plt\n 293\n 334\n 439\n \n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n TCO2\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n 151\n 131\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\n aureus superinfections, and ARDS.\n #) Hypoxic Respiratory failure/Influenza Pneumonia with secondary\n bacterial pneumonia: The patient was initially intubated for hypoxic\n respiratory failure. Has known influenza B as well as staph aureus in\n sputums presumably causing ARDS. Ventilation and oxygenation stable on\n AC settings. He is on day 7 of antimicrobial therapy with cefepime,\n he received six days of vancomycin/linezolid, he is on day six of\n oseltamavir. His linezolid was stopped and nafcillin started after his\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\n and lung reexpansion after the procedure would suggest this is freely\n flowing.\n -F/U cultures\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\n duration of nafcillin therapy in this very sick patient with ID who is\n following\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though this should be\n appropriately covered by his antibiotics. Hypotension presumably due\n to continued SIRs driving process (active infection vs ARDS).\n -Afrin and saline nasal washes for sinus disease\n -Continue nafcillin/cefepime/oseltamavir pending culture data\n -F/U cultures and culture if spikes\n -F/U ID reccs\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\n history of irradiation, nevertheless he needs nutrition. We will speak\n to GI re: post-pyloric feeding tube and start PPN in the interim.\n 6) Access: 2 PIVs; right IJ\n 7) PPx: hep sc, PPI\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:54 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: hep sc, PPI\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-01-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658140,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains intubated on full vent support. O2 sat remained\n stable through the night on 50%. Plan to wean 02 and ventilatory\n support as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658712,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.5, conts to have a lg amount of secretions friom his ETT and\n the back of his mouth\n Action:\n Conts on abx, started on afrin for a sinusits, conts with frequent\n suctioning\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659661,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n CNS: Remains alert and oriented x3 and can get out of bed with the\n assist of persons. Complained that he was having difficulty\n sleeping and was given a one time dose of lorazepam 1mg IV with good\n effect.\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\n seeing that he has been aggressively Diuresed. Has maintained\n normotensive blood pressures ranging SBP 110\n 130\ns. Right double\n lumen basilic PICC placed yesterday evening and OK for use. Central\n line D/c\nd this am without difficulty and occlusive dsg to site at\n present.\n RESP: Continues on 3l/min with sats in the mid to upper 90\ns. Denies\n any SOB or DOE. LS clear with minimally diminished bases.\n GU: Remains with urinary catheter and with good output. See flow chart\n for numbers.\n GI: Dobhoff now in stomach. Noted that it was longer than previously.\n KUB done and confirmed in stomach. TF ok to go and continues at\n 10cc/hr. tolerated diet as recommended last pm without difficulty. Will\n re-evaluated to today. Had a small soft BM last pm.\n INTEG: Skin remains unremarkable at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659490,
"text": "Chief Complaint: PNA, s/p resp failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:10 AM\n ARTERIAL LINE - STOP 04:00 PM\n -extubated in a.m. and did well\n -was c/o nausea intermittently -> concerning for opiate or benzo\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\n iv prn.\n Allergies:\n Cefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:32 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:30 AM\n Fentanyl - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.9\nC (96.7\n HR: 94 (91 - 114) bpm\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\n RR: 24 (14 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (12 - 18)mmHg\n Total In:\n 1,308 mL\n 288 mL\n PO:\n TF:\n 13 mL\n IVF:\n 547 mL\n 228 mL\n Blood products:\n Total out:\n 5,035 mL\n 1,100 mL\n Urine:\n 5,035 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,727 mL\n -813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 96%\n ABG: ///23/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : L\n >R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 896 K/uL\n 7.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 24.5 %\n 22.0 K/uL\n [image002.jpg]\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n WBC\n 24.7\n 25.6\n 26.7\n 23.6\n 22.0\n Hct\n 24.9\n 23.9\n 23.9\n 24.7\n 24.5\n Plt\n 81\n 896\n Cr\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 151\n 131\n 144\n 135\n 128\n 115\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659491,
"text": "Chief Complaint: PNA, s/p resp failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:10 AM\n ARTERIAL LINE - STOP 04:00 PM\n -extubated in a.m. and did well\n -was c/o nausea intermittently -> concerning for opiate or benzo\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\n iv prn.\n Allergies:\n Cefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:32 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:30 AM\n Fentanyl - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.9\nC (96.7\n HR: 94 (91 - 114) bpm\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\n RR: 24 (14 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (12 - 18)mmHg\n Total In:\n 1,308 mL\n 288 mL\n PO:\n TF:\n 13 mL\n IVF:\n 547 mL\n 228 mL\n Blood products:\n Total out:\n 5,035 mL\n 1,100 mL\n Urine:\n 5,035 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,727 mL\n -813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 96%\n ABG: ///23/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : L\n >R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 896 K/uL\n 7.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 24.5 %\n 22.0 K/uL\n [image002.jpg]\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n WBC\n 24.7\n 25.6\n 26.7\n 23.6\n 22.0\n Hct\n 24.9\n 23.9\n 23.9\n 24.7\n 24.5\n Plt\n 81\n 896\n Cr\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 151\n 131\n 144\n 135\n 128\n 115\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% and on PS 5/5 but\n blood gas this noon 7.52/41/64. This am, did well on SBT (although had\n some mucous plugging around 7a).\n - Has completed course of oseltamavir\n - continue nafcillin day 6 today- plan for 14 D course\n - F/U cultures\n - extubate this am. Will start Incentive spirometry\n -monitor diuresis and consider bolus lasix PRN. D/c diamox\n -will need speech and swallow eval but will hold off until tomorrow\n -of note, since pt has been on fent/versed for sedation for >1wk, may\n have benzo withdrawl. Will consided valium or versed PRN\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 14 D course\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN. If stable tomorrow, will likely pull CVL.\n - F/U cultures and culture if spikes\n - F/U ID recs- they rec thoracentesis but do not think this is\n medically necessary for now.\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will restart TF today after extubation. Cont TPN for today\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now\n #) Comm: With wife\n ICU \n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659605,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 4l/m nc with rr in the high 20\ns to low 30\ns. lungs\n essentially clear on auscultation with crackles bil at the bases. Neg\n fluid balance for this shift. Wbc has dropped to 22.\n Action:\n Fluid balance followed closely as well as his hemodynamics. Pt using\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\n Receiving nafcillin as ordered . resp status monitored closely. Speech\n and swallow study completed. Physical therapy has been consulted. Tube\n fdgs restarted via dobhoff tube since pt\ns nutritional status is most\n certainly not adequate. Oob to chair with assist of 2 and tolerated\n activity well. Ic consulted to place picc line since infectious dx\n consult team is recommending 21 day course of nafcillin. Post\n completion of speech andswallow study diet advancedto low sodium/heart\n healthy soft consistency , thin liqs ensure pudding with ea. Meal\n give all pills via dobhoff\n Response:\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\n and for los pos 1.6 liters.\n Plan:\n Will maintain aspiration precautions. Continue to follow fluid balance\n and resp status. Follow culture data. Pt to have picc line placed for\n 21 day course of nafcillin and once access is obtained will then d/cri\n j triple lumen. Increase pt\ns level of activity as he tolerates. If\n stable overnoc will transfer to medical floor bed tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659755,
"text": "Chief Complaint: s/p resp failure\n 24 Hour Events:\n PICC LINE - START 09:29 PM\n MULTI LUMEN - STOP 06:00 AM\n -PICC placed and IJ d'c'd\n -KUB checked to evaluate dobhoff\n -speech and swallow bedside eval passed with pt cleared to take thin\n liquids and MOIST soft solids.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Nafcillin - 04:55 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 03:42 PM\n Lorazepam (Ativan) - 01:10 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\n occassional nausea. Tolerated dinner last night well.\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 93 (92 - 109) bpm\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\n RR: 26 (22 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 14 (11 - 15)mmHg\n Total In:\n 1,693 mL\n 243 mL\n PO:\n 960 mL\n TF:\n 83 mL\n 72 mL\n IVF:\n 590 mL\n 172 mL\n Blood products:\n Total out:\n 3,330 mL\n 800 mL\n Urine:\n 3,330 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,637 mL\n -557 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.48/31/74/23/0\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at left base )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 948 K/uL\n 8.2 g/dL\n 113 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.3 %\n 20.4 K/uL\n [image002.jpg]\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n 08:09 AM\n 03:27 AM\n WBC\n 26.7\n 23.6\n 22.0\n 20.4\n Hct\n 23.9\n 24.7\n 24.5\n 25.3\n Plt\n 48\n Cr\n 0.7\n 0.8\n 0.8\n 1.0\n TCO2\n 28\n 31\n 35\n 24\n 24\n Glucose\n 144\n 135\n 128\n 115\n 113\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. Successfully extubated \n - Has completed course of oseltamavir\n - continue nafcillin - plan for 21 D course today abx from when\n linezolid was started \n -monitor diuresis and consider bolus lasix PRN.\n - speech and swallow eval clears for meds, thin liquids and soft\n solids PO\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\n consider fentanyl or ativan PRN\n -Incentive spirometry,\n -PT consulted\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam. WBC now trending down to 22\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 21 D course\n -PICC in place for ABX\n - F/U ID recs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: regular, soft diet\n #) Access: PICC in place\n #) PPx: hep sc, PPI\n #) Dispo: c/o floor today\n #) Comm: With wife\n ICU \n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 09:29 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659461,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Obtained pt on NC 3L, reports breathing is comfortable, productive\n cough, crackles at bases, using IS frequently without queing, pt with\n generalized edema, had been on lasix gtt prior to extubation, now\n autodiuresing, pt reporting abd pain and nausea at times\n Action:\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\n with HO ? scale overnight, monitoring for signs of withdrawal\n overnight, no scale ordered, adm fent and ativan x2 with good\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\n Response:\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\n continues to have nausea and abd pain at times though no other signs of\n withdrawl\n Plan:\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659754,
"text": "Chief Complaint: s/p resp failure\n 24 Hour Events:\n PICC LINE - START 09:29 PM\n MULTI LUMEN - STOP 06:00 AM\n -PICC placed and IJ d'c'd\n -KUB checked to evaluate dobhoff\n -speech and swallow bedside eval passed with pt cleared to take thin\n liquids and MOIST soft solids.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Nafcillin - 04:55 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 03:42 PM\n Lorazepam (Ativan) - 01:10 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\n occassional nausea. Tolerated dinner last night well.\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 93 (92 - 109) bpm\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\n RR: 26 (22 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 14 (11 - 15)mmHg\n Total In:\n 1,693 mL\n 243 mL\n PO:\n 960 mL\n TF:\n 83 mL\n 72 mL\n IVF:\n 590 mL\n 172 mL\n Blood products:\n Total out:\n 3,330 mL\n 800 mL\n Urine:\n 3,330 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,637 mL\n -557 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.48/31/74/23/0\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at left base )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 948 K/uL\n 8.2 g/dL\n 113 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.3 %\n 20.4 K/uL\n [image002.jpg]\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n 08:09 AM\n 03:27 AM\n WBC\n 26.7\n 23.6\n 22.0\n 20.4\n Hct\n 23.9\n 24.7\n 24.5\n 25.3\n Plt\n 48\n Cr\n 0.7\n 0.8\n 0.8\n 1.0\n TCO2\n 28\n 31\n 35\n 24\n 24\n Glucose\n 144\n 135\n 128\n 115\n 113\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. Successfully extubated \n - Has completed course of oseltamavir\n - continue nafcillin - plan for 21 D course today abx from when\n linezolid was started \n -monitor diuresis and consider bolus lasix PRN.\n - speech and swallow eval today\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\n consider fentanyl or ativan PRN\n -Incentive spirometry,\n -PT today and OOB to chair\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam. WBC now trending down to 22\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 21 D course\n -pull CVL today if can get PICC\n - F/U ID recs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Getting s/s today. If passes, d/c TF\n #) Access: 2 PIVs; right IJ\n trying to get PICC today\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now- consider PM c/o\n #) Comm: With wife\n ICU \n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 09:29 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\n c/b MSSA pneumonia. Much improved, tolerating POs, OOB, PICC placed,\n passed S+S.\n Exam notable for Tm 99.2 BP 110/65 HR 95 RR 24-30 with sat 97 on RA.\n TBB -1L/8h. Few rales. RRR s1s2. Soft +BS. Trace edema. Labs notable\n for WBC 23K, HCT 24, K+ 4.5, Cr 1.0. CXR B ASD, stable to sl worse.\n Agree with plan to discontinue low dose lasix given slight bump in\n creatinine. Will continue naf for MSSA pneumonia x 12/21 days total via\n PICC. Will mobilize OOB to chair and continue PT consult. Wean oxygen\n to off, ADAT, may need to d/c tube if it remains clogged. Above d/w\n wife and PCP. of plan as outlined above.\n Total time: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659419,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Obtained pt on NC 3L, reports breathing is comfortable, productive\n cough, crackles at bases, using IS frequently without queing, pt with\n generalized edema, had been on lasix gtt prior to extubation, now\n autodiuresing, pt reporting abd pain and nausea at times\n Action:\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\n with HO ? scale overnight, monitoring for signs of withdrawal\n overnight, no scale ordered, adm fent and ativan x2 with good\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\n Response:\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\n continues to have nausea and abd pain at times though no other signs of\n withdrawl\n Plan:\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659420,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Obtained pt on NC 3L, reports breathing is comfortable, productive\n cough, crackles at bases, using IS frequently without queing, pt with\n generalized edema, had been on lasix gtt prior to extubation, now\n autodiuresing, pt reporting abd pain and nausea at times\n Action:\n NC increased to 4L while pt sleeping, for sats around 93%, discussing\n with HO ? scale overnight, monitoring for signs of withdrawal\n overnight, no scale ordered, adm fent and ativan x2 with good\n effect, zofran x1 with some relief of nausea, monitoring u/o overnight\n Response:\n Pt continues to have copious u/o, 120-220ml/hr, resp status stable,\n continues to have nausea and abd pain at times though no other signs of\n withdrawl\n Plan:\n Continue IS, continue supplemental O2, ?c/o to floor, s/w in am\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658318,
"text": "FULL CODE\n CC: Respiratory failure influenza B/PNA\n Sepsis without organ dysfunction\n Assessment:\n Pt febrile to 101.7, BP\ns declining, CVP=5. u/o WNL, pt arouses to\n voice and follows commands\n Action:\n Pan cultured, NS 1L bolus x2 with minimal improvement in BP. Started on\n Levophed, initially .1mcg, Tylenol 650mg x1\n Response:\n Able to wean levo to .02mcg for several hours, to off at 05:30 but ABP\n slowly drifting down. T=98.9\n Plan:\n Monitor fever curve, maintain CVP~12, IV abx, pressor support prn.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of patient on CMV 50%/400/24/8. LS clear upper, dim at\n bases but maintaining sat >95%. Occasionally coughing , minimal\n secretions\n Action:\n RT placed on humidified air. CPAP trial started at 0600\n Response:\n Able to suction intermittently for mod amts thin, tan secretions.\n Currently maintaining sat at 97% on CPAP with improved HR and more\n comfortable appearance.\n Plan:\n Obtain abg. Sxn prn, iv abx/tamilflu\n Wife telephoned in for an update twice on this shift. She will be in\n to visit in the am.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658319,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Events:\n No growth to date on BCs, sputum or urine cultures\n Multiple vent changes made currently on\nARDS net\n settings\n Sepsis without organ dysfunction\n Assessment:\n Pt. spiked temp again yesterday, however, has continued with low-grade\n temp throughout this shift. No growth to date in all BCs, urine and\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\n weaned throughout the shift.\n Action:\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\n Response:\n Pt. remains with low-grade temp. Hemodynamically stable throughout\n shift.\n Plan:\n Monitor hemodynamic status and support as necessary w/ pressor and\n volume. Continue antibiotics as ordered/\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\n secretions. Remains on vent.\n Action:\n Multiple vent changes made, remains on CPAP as pts own rate and volumes\n coincide w/ ARDS net protocol\n Response:\n ABGs remain largely unchanged PaO2 slightly improved, pt continues to\n deny any SOB\n Plan:\n Cont to monitor resp status and wean vent support as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658375,
"text": "Chief Complaint: Respiratory Failure\n Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 102.5\nF - 12:00 PM\n ID Consult--Flagyl added\n RUQ U/S with no evidence of cholecystitis\n fevers persist\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 11:01 PM\n Cefipime - 04:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:16 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.2\nC (99\n HR: 92 (75 - 100) bpm\n BP: 137/59(82) {89/45(60) - 172/88(118)} mmHg\n RR: 22 (15 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 334 (4 - 334)mmHg\n Total In:\n 2,942 mL\n 752 mL\n PO:\n TF:\n 167 mL\n 389 mL\n IVF:\n 2,445 mL\n 303 mL\n Blood products:\n Total out:\n 1,615 mL\n 640 mL\n Urine:\n 1,615 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,327 mL\n 112 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 460 (435 - 465) mL\n PS : 10 cmH2O\n RR (Spontaneous): 20\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 19 cmH2O\n SpO2: 98%\n ABG: 7.38/40/94./24/0\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 334 K/uL\n 112 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 103 mEq/L\n 133 mEq/L\n 26.6 %\n 20.4 K/uL\n [image002.jpg]\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n WBC\n 12.3\n 15.8\n 20.4\n Hct\n 28.9\n 28.1\n 26.6\n Plt\n \n Cr\n 1.0\n 0.9\n 0.8\n TCO2\n 24\n 21\n 25\n 23\n 24\n 23\n 25\n Glucose\n 96\n 122\n 112\n Other labs: PT / PTT / INR:13.5/35.5/1.2, ALT / AST:67/64, Alk Phos / T\n Bili:381/0.9, Amylase / Lipase:/13, Differential-Neuts:85.9 %,\n Lymph:5.3 %, Mono:8.1 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR__ETT and IJ catheter in good position. He does have\n persistent and significant bilateral plural effusions and likely\n consolidations\n Microbiology: Sputum-\n --S. Aureus\n Assessment and Plan\n 53 yo male with admission with influenza with a history of Hodgkin\n Disease and now subsequently complicated by ARDS and hypoxemic\n respiratory failure now complicated by persistent sepsis. He has\n continued good tolerance of PSV support with FIO2 wean oxygenation has\n remained reasonably stable. The issue has been one of continued fevers\n and hypotension despite antibiotics in place. In addition he has had\n significant rise in WBC count all arguing for untreated bacterial\n infection, although, cultures have been negative to date. LFT's have\n improved in this setting and may be consistent with mild intrahepatic\n cholestasis.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n -Cefepime/Linezolid\n -He has GPC\ns noted in sputum and suggestion of S. Aureus involving\n pulmonary\n -Continue with ABX and raise issue of alternative coverage based up on\n culture and imaging findings.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -would favor return to A/C support to maintain adequate ventilatory\n support if worsening\n -return to A/C support if need for further imaging needed as with\n increased sedation will be needed\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n -Levophed continues\n -WBC is rising and persistent fevers seen\n -Concern for possible empyema and pulmonary cavitary lesions\n -Catheter placed in the setting of fevers and fevers have continued\n -No cultures positive\n -Sinusitis is somewhat unilikely as is relatively early in course but\n is possible\n -Pulmonary abscess is possible and of concern\n -U/S negative but intra-abdominal source is possible with focal\n collection\n -DVT is possible but will be evaluated with LENI\n -ECHO to eval for possible\n -No evidence of rash\nwill follow up on diff and consider possible drug\n fever\n -Will pursue further interventions as indicated based upon findings\n -No change in ABX and will pursue evaluation given hypotension, fever,\n despite antibiotics Rx\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:23 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 06:27 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 70 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658827,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt conts to have a fever, t max has been 100.4, LS coarse throughout,\n suctioning tan sputum from his ETT, he has been coughing less today.\n Action:\n To have a chest CT\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658511,
"text": "Chief Complaint: Respiratory failure, ARDS\n 24 Hour Events:\n FEVER - 101.1\nF - 09:00 PM\n -CT torso showed mildly decreased dense bilateral lower lobe\n consolidation, increase in bilateral pleural effusions, significant\n contrast reflux in esophagus concerning for high aspiration risk, but\n not abscess.\n -CT sinus wet read is paranasal sinus dz though cannot differentiate\n infection from tissue thickening\n -Patient prepped for bedside diagnostic thoracentesis but bedside\n ultrasound demonstrated less fluid than seen on CT so tap deferred\n -didn't get ECHO b/c of scheduling problem but should get on \n -kept on PS but put on AC for and kept on that overnight;\n put back on PS at 10/8 at 4a.m. and ABG written for 7a.m.\n -pressors stopped at 6pm\n -ID reccs -> cont oseltamavir, linezolid, cefepime; check sputum cx,\n sputum viral cx, legionella cx; send cx from TLC and peripherally if\n spikes\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 12:30 AM\n Cefipime - 05:56 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 75 (75 - 117) bpm\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\n RR: 19 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (13 - 334)mmHg\n Total In:\n 1,855 mL\n 941 mL\n PO:\n TF:\n 917 mL\n 382 mL\n IVF:\n 878 mL\n 514 mL\n Blood products:\n Total out:\n 1,520 mL\n 218 mL\n Urine:\n 1,520 mL\n 218 mL\n NG:\n Stool:\n Drains:\n Balance:\n 335 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 370 (370 - 542) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/41/85./25/1\n Ve: 8.9 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : few)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 439 K/uL\n 8.3 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 104 mEq/L\n 133 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n WBC\n 15.8\n 20.4\n 19.2\n Hct\n 28.1\n 26.6\n 26.3\n Plt\n 293\n 334\n 439\n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 25\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\n Imaging: CT Torso:\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\n greater\n than right, with scattered patchy opacities seen medially within the\n upper lobes. Interval increase in bilateral pleural effusions, now\n moderate.\n 2. Prominence of the esophagus, which is diffusely filled with oral\n contrast\n material, consistent with extensive gastroesophageal reflux disease.\n Given the degree of contrast reflux into the esophagus, which is\n marked, the patient is felt to be a very high risk for aspiration.\n 3. No acute inflammatory process or abnormal fluid collection is seen\n in the\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\n fluid.\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\n Microbiology: Sputum:\n : Culture with coag + staph\n Gram stain (-)\n : Culture preliminary negative, gram\n stain (-)\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\n to infectious process/ ARDS. Patient with known influenza and with\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\n likely flu but given staph aureus in respiratory culture there is\n evidence for bacterial superinfection. He is continuing to maintain\n good ventilation and adequate oxygenation on pressure support.\n Potentially concerning to allow ARDS patient off protocol due to\n ability to exceed low lung volumes but he seems more comfortable on PS\n and tidal volumes are relatively low (450-475) decreasing concern for\n barotrauma.\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\n -F/U cultures\n - Continue oseltamavir for influenza B\n 2) SIRS/ Hypotension/Fevers: This patient\ns fever is not as concerning\n in and of itself given influenza can often cause persistent fever.\n Still, with persistent white count and his leukocytosis recurring it is\n very concerning that we are not adequately covering an infectious\n process. Blood cultures remain negative and RUQ U/S not suggestive of\n choleycystitis. Major concern now if for a drainable collection as his\n broad spectrum antibiotics should cover most common organisms.\n -Continue current antimicrobial regimen\n -CT scan of torso and sinuses looking for possible closed space\n infection and to better evaluate possible effusions vs atelectasis in\n lungs\n -Echo to evaluate for other causes of hypotension give patient has hx\n of pericarditis and could potentially have some restrictive pathology\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE per above\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin, LMW Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2181-02-01 00:00:00.000",
"description": "ICU Event Note",
"row_id": 658454,
"text": "Clinician: Attending\n With ultrasound patient does have clear pleural effusion. We were,\n unable, however--to identify a pocket > 2.5 cm in depth despite\n multiple attempts at positioning to allow safe thoracentesis needle\n passage.\n Given concerns for risk of thoracentesis and pneumothorax in the\n setting of significant lung disease and ARDS will defer for IP\n evaluation for attmpt.\n Total time spent: 10 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658537,
"text": "Chief Complaint: ARDS\n SEPSIS\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.1\nF - 09:00 PM\n -Pressors weaned to off yesterday\n -Patient wtih A/C support overnight and return to PSV support this\n morning\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 12:30 AM\n Cefipime - 09:53 AM\n Infusions:\n Fentanyl - 35 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Midazolam (Versed) - 09:30 AM\n Fentanyl - 09:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Genitourinary: Foley\n Flowsheet Data as of 10:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.3\n HR: 86 (75 - 117) bpm\n BP: 138/65(86) {85/46(60) - 198/111(140)} mmHg\n RR: 28 (16 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (12 - 332)mmHg\n Total In:\n 1,855 mL\n 1,265 mL\n PO:\n TF:\n 917 mL\n 514 mL\n IVF:\n 878 mL\n 661 mL\n Blood products:\n Total out:\n 1,520 mL\n 378 mL\n Urine:\n 1,520 mL\n 378 mL\n NG:\n Stool:\n Drains:\n Balance:\n 335 mL\n 887 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 400 (400 - 542) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/41/85./25/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 439 K/uL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 104 mEq/L\n 133 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n WBC\n 15.8\n 20.4\n 19.2\n Hct\n 28.1\n 26.6\n 26.3\n Plt\n 293\n 334\n 439\n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 25\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n Other labs: PT / PTT / INR:13.1/35.9/1.1, ALT / AST:70/75, Alk Phos / T\n Bili:385/0.8, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:176 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\n Fluid analysis / Other labs: AG-4\n Imaging: CT--Inrease in bilateral pleural effusions, no abdominal\n process to suggest focus of infection.\n CT Sinus---Mild thickening of Mucosa\n CXR-\n ETT at 8 cm above carina\n OGT past diaphragm\n CVL in good position\n Improved bilateral pleural effusions\n Microbiology: -_Sputum-Staph\n -GS--Pending\n Assessment and Plan\n 53 yo male with admission with influenza and S. Aureus pnumonia\n complicated by ARDS and with persistent fevers at 7 days into course\n search for alternative sources has been extensive but unrevealing to\n date. His bilateral effusions appear to have diminished slightly. He\n has minimal sinusitis.\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n -Cefepime/Linezolid\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)-Concern for possible\n aspiration event and will need to confirm that ETT is in good position.\n -Advance ETT this morning 3 cm\n -Continue with A/C mode of support this morning\n -Maintain adequate PEEP\n SEPSIS WITHOUT ORGAN DYSFUNCTION-\n -Continue with Cefepime/Linezolid\n ICU Care\n Nutrition: NPO given concern for aspiration\nwith \n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: Wife updated in full in regards to plan for\n the day and the slight improvement from yesterday to today.\n Explanation of thoracentesis procedure provided in detail and timing\n for intervention with IP supervision today in the setting of difficult\n to identify safe pocket for thoracentesis.\n Code status: Full code\n Disposition :ICU\n Total time spent: 48 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658614,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658517,
"text": "Chief Complaint: Respiratory failure, ARDS\n 24 Hour Events:\n - FEVER - 101.1\nF - 09:00 PM\n -OFF PRESSORS at 6:00 pm\n -CT torso w/o abcess or drainable collection\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\n -Thoracentesis deferred as minimal fluid on echo\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 12:30 AM\n Cefipime - 05:56 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 75 (75 - 117) bpm\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\n RR: 19 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (13 - 334)mmHg\n Total In:\n 1,855 mL\n 941 mL\n PO:\n TF:\n 917 mL\n 382 mL\n IVF:\n 878 mL\n 514 mL\n Blood products:\n Total out:\n 1,520 mL\n 218 mL\n Urine:\n 1,520 mL\n 218 mL\n NG:\n Stool:\n Drains:\n Balance:\n 335 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 370 (370 - 542) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/41/85./25/1\n Ve: 8.9 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : few)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 439 K/uL\n 8.3 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 104 mEq/L\n 133 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n WBC\n 15.8\n 20.4\n 19.2\n Hct\n 28.1\n 26.6\n 26.3\n Plt\n 293\n 334\n 439\n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 25\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL\n Imaging:\n CT Torso:\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\n greater\n than right, with scattered patchy opacities seen medially within the\n upper lobes. Interval increase in bilateral pleural effusions, now\n moderate.\n 2. Prominence of the esophagus, which is diffusely filled with oral\n contrast\n material, consistent with extensive gastroesophageal reflux disease.\n Given the degree of contrast reflux into the esophagus, which is\n marked, the patient is felt to be a very high risk for aspiration.\n 3. No acute inflammatory process or abnormal fluid collection is seen\n in the\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\n fluid.\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\n Microbiology: Sputum:\n : Culture with coag + staph\n Gram stain (-)\n : Culture preliminary negative, gram\n stain (-)\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\n to infectious process/ ARDS. Patient with known influenza and with\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\n likely flu but given staph aureus in respiratory culture there is\n evidence for bacterial superinfection. He is continuing to maintain\n good ventilation and adequate oxygenation on pressure support.\n Potentially concerning to allow ARDS patient off protocol due to\n ability to exceed low lung volumes but he seems more comfortable on PS\n and tidal volumes are relatively low (450-475) decreasing concern for\n barotrauma.\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\n -F/U cultures\n - Continue oseltamavir for influenza B\n 2) SIRS/ Hypotension/Fevers: This patient\ns fever is not as concerning\n in and of itself given influenza can often cause persistent fever.\n Still, with persistent white count and his leukocytosis recurring it is\n very concerning that we are not adequately covering an infectious\n process. Blood cultures remain negative and RUQ U/S not suggestive of\n choleycystitis. Major concern now if for a drainable collection as his\n broad spectrum antibiotics should cover most common organisms.\n -Continue current antimicrobial regimen\n -CT scan of torso and sinuses looking for possible closed space\n infection and to better evaluate possible effusions vs atelectasis n\n lungs\n -Echo to evaluate for other causes of hypotension give patient has hx\n of pericarditis and could potentially have some restrictive pathology\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE per above\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658688,
"text": "Chief Complaint: Hypoxic respiratory failure\n 24 Hour Events:\n THORACENTESIS - At 12:36 PM\n FEVER - 102.3\nF - 04:00 PM\n -Restarted on norepinephrine overnight for hypotension\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:20 PM\n Linezolid - 12:35 PM\n Nafcillin - 04:12 AM\n Cefipime - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:43 PM\n Fentanyl - 02:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100\n HR: 90 (72 - 113) bpm\n BP: 124/87(100) {79/44(56) - 161/87(100)} mmHg\n RR: 22 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 13 (11 - 23)mmHg\n Total In:\n 2,076 mL\n 344 mL\n PO:\n TF:\n 514 mL\n IVF:\n 1,383 mL\n 344 mL\n Blood products:\n Total out:\n 818 mL\n 360 mL\n Urine:\n 818 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,258 mL\n -16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 31.5 cmH2O/mL\n SpO2: 96%\n ABG: ///24/\n Ve: 7.5 L/min\n Physical Examination\n General Appearance: Thin, ill appearing\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : at apices, Diminished: more diminished on\n right)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: verbal stimuli, Movement: purposeful\n Labs / Radiology\n 509 K/uL\n 8.1 g/dL\n 118 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 131 mEq/L\n 24.7 %\n 22.4 K/uL\n [image002.jpg]\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n Plt\n 293\n 334\n 439\n 509\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:84/80, Alk Phos / T\n Bili:419/1.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:193 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: Pleural fluid:\n WBC 6900*\n -PMN 68* -Lymphs 1* -Monos 0-Eos 3*-Mesos 13*-Macros 15*\n RBC 2275*\n Imaging: CXR from :\n IMPRESSION: Persistent bibasilar retrocardiac opacities, which may be\n due to pneumonia in the appropriate clinical setting. Bilateral areas\n of radiation fibrosis in the upper lobes without change.\n Microbiology: GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ):\n OROPHARYNGEAL FLORA ABSENT.\n STAPH AUREUS COAG +. SPARSE GROWTH.\n Staphylococcus species may develop resistance during prolonged\n therapy with quinolones. Therefore, isolates that are initially\n susceptible may become resistant within three to four days after\n initiation of therapy. Testing of repeat isolates may be\n warranted.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STAPH AUREUS COAG +\n |\n CLINDAMYCIN----------- =>8 R\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- 0.25 S\n OXACILLIN------------- 0.5 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\n aureus superinfections, and ARDS.\n 1) Respiratory failure/Influenza Pneumonia with secondary bacterial\n pneumonia: The patient was initially intubated for hypoxic respiratory\n failure. Has known influenza B as well as staph aureus in sputums\n presumably causing ARDS. Ventilation and oxygenation stable on AC\n settings. He is on day 7 of antimicrobial therapy with cefepime, he\n received six days of vancomycin/linezolid, he is on day six of\n oseltamavir. His linezolid was stopped and nafcillin started after his\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\n and lung reexpansion after the procedure would suggest this is freely\n flowing.\n -F/U cultures\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\n duration of nafcillin therapy in this very sick patient with ID who is\n following\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though this should be\n appropriately covered by his antibiotics. Hypotension presumably due\n to continued SIRs driving process (active infection vs ARDS).\n -Afrin and saline nasal washes for sinus disease\n -Continue nafcillin/cefepime/oseltamavir pending culture data\n -F/U cultures and culture if spikes\n -F/U ID reccs\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\n history of irradiation, nevertheless he needs nutrition. We will speak\n to GI re: post-pyloric feeding tube and start PPN in the interim.\n 6) Access: 2 PIVs; right IJ\n 7) PPx: hep sc, PPI\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658994,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Plan to extubate\n Comments: rsbi 74\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658947,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.4, coarse LS on the L, conts on Nafcillian, he has developed\n a rash on his abd and back, he has yellow sputum from his ETT and a lg\n amount of secretions from the back of his throat. He is more alert\n today, writing, though somewhat illegibly, able to tell us some of his\n needs. He is 13 liters pos.\n Action:\n Placed on PSV 5 PEEP 8, his PEEP was decreased to 5 this afternoon,\n started on a lasix gtt, weaned his fent to 75 mcg/hr and his midaz to 4\n mg/hr\n Response:\n Tolerating the PSV, he had had > 1 liter off from the lasix so far, his\n CVP was 18-20 this morning and now it is and his BP has been stable\n in the 110-120s this afternoon.\n Plan:\n Let him stay on PSV overnight if he tolerates this, cont with the lasix\n gtt as his BP and CVP allow, follow his lytes, follow his rash\n there\n is concern that the rash is from the nafacillin but this is a good\n antibiotic for his staph pneumonia, cont to wean the fent and versed.\n He went to radiology this afternoon to place a NG tube in his\n jejunum, the was done, he will be able to be started on TF this\n evening, his TPN will cont until his TF is up to his goal.\n His wife was very anxious today, she spent much of the morning and\n part of the afternoon here, she did feel better after talking to the\n attending, and is relieved to hear that he is doing better. His\n parents will be in to see him tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658677,
"text": "Chief Complaint: Hypoxic respiratory failure\n 24 Hour Events:\n THORACENTESIS - At 12:36 PM\n FEVER - 102.3\nF - 04:00 PM\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:20 PM\n Linezolid - 12:35 PM\n Nafcillin - 04:12 AM\n Cefipime - 06:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:43 PM\n Fentanyl - 02:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100\n HR: 90 (72 - 113) bpm\n BP: 124/87(100) {79/44(56) - 161/87(100)} mmHg\n RR: 22 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 13 (11 - 23)mmHg\n Total In:\n 2,076 mL\n 344 mL\n PO:\n TF:\n 514 mL\n IVF:\n 1,383 mL\n 344 mL\n Blood products:\n Total out:\n 818 mL\n 360 mL\n Urine:\n 818 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,258 mL\n -16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 31.5 cmH2O/mL\n SpO2: 96%\n ABG: ///24/\n Ve: 7.5 L/min\n Physical Examination\n General Appearance: Thin, ill appearing\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : at apices, Diminished: more diminished on\n right)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 509 K/uL\n 8.1 g/dL\n 118 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 131 mEq/L\n 24.7 %\n 22.4 K/uL\n [image002.jpg]\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n Plt\n 293\n 334\n 439\n 509\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n TCO2\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:84/80, Alk Phos / T\n Bili:419/1.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:193 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: Pleural fluid:\n WBC 6900*\n -PMN 68*\n -Lymphs 1*\n -Monos 0\n -Eos 3*\n -Mesos 13*\n -Macros 15*\n RBC 2275*\n Imaging: CXR from :\n IMPRESSION: Persistent bibasilar retrocardiac opacities, which may be\n due to pneumonia in the appropriate clinical setting. Bilateral areas\n of radiation\n fibrosis in the upper lobes without change.\n Microbiology: GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ):\n OROPHARYNGEAL FLORA ABSENT.\n STAPH AUREUS COAG +. SPARSE GROWTH.\n Staphylococcus species may develop resistance during prolonged\n therapy with quinolones. Therefore, isolates that are\n initially\n susceptible may become resistant within three to four days\n after\n initiation of therapy. Testing of repeat isolates may be\n warranted.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STAPH AUREUS COAG +\n |\n CLINDAMYCIN----------- =>8 R\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- 0.25 S\n OXACILLIN------------- 0.5 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\n known influenza B as well as staph aureus in sputums. Presumably, flu\n with bacterial superinfection is the etiology of his ARDS. The patient\n was on AC overnight but was switched back to CPAP this AM. Since then,\n he has been pulling lower tidal volumes than previously (<400) and more\n tachypneic. We will place him back on AC to decrease work of breathing\n while we continue to treat his pneumonia and support him through his\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\n and oseltamavir.\n -F/U cultures, obtain viral cultures per ID recommendation\n - Continue current antimicrobials pending culture data\n -IP will attempt to perform diagnostic thoracentesis today as ICU team\n unable to safely do at bedside\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though this should be\n appropriately covered by his antibiotics.\n -Continue linezolid/cefepime/oseltamavir pending culture data\n -obtain pleural fluid to rule out complicated effusion\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE today to evaluate for effusion/tamponade\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: Pt with noted aspiration event this AM, presumably due to\n history of irradiation, we will hold tube feeds for now and swallow\n study once extubated.\n 6) Access: 2 PIVs; right IJ\n 7) PPx: hep sc, PPI\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658746,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Sepsis without organ dysfunction\n Assessment:\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\n 80s-100. Spiked fecer to 101.3.\n Action:\n Given 500 cc NS bolus, given Tylenol 0nce, 2 sets of bld cx, urine cx,\n and stool cx sent. continued on antibiotics as ordered.\n Response:\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\n above 12.\n Plan:\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\n ordered, bolus fluids as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\n at upper lobes and diminished at bases. Was observed to be very\n restless and trying to jump out of bed.\n Action:\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\n increased to 4 mg/hr.\n Response:\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\n strong productive cough.\n Plan:\n Wean vent as tolerated, suction frequently PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659103,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n Family meeting with Dr. and re: pt's course and\n prognosis. Very helpful for wife to hear positive steps we are taking\n with him.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:23 PM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Fentanyl - 03:22 PM\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 07:44 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt denies Pain, nausea. States has some mild SOB\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.7\nC (98.1\n HR: 88 (85 - 121) bpm\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\n RR: 19 (19 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 8 (6 - 22)mmHg\n Total In:\n 1,897 mL\n 512 mL\n PO:\n TF:\n IVF:\n 889 mL\n 184 mL\n Blood products:\n Total out:\n 4,615 mL\n 1,810 mL\n Urine:\n 4,615 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,718 mL\n -1,298 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 388 (347 - 453) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.44/40/76./31/2\n Ve: 7.5 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n slight at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 714 K/uL\n 7.8 g/dL\n 144 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 23.9 %\n 26.7 K/uL\n [image002.jpg]\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n WBC\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n 26.7\n Hct\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n 23.9\n Plt\n \n Cr\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n 0.7\n TCO2\n 25\n 28\n 28\n 28\n Glucose\n 112\n 149\n 118\n 151\n 131\n 144\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% today and on PS 5/5\n but blood gas this noon 7.52/41/64\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS. Trying to wean PS daily but did not tolerate today.\n Will try again tomorrow.\n - Has completed course of oseltamavir\n - continue nafcillin day 5 today\n - F/U cultures\n - lasix gtt stopped today contraction alkylosis. Consider lasix\n boluses for CVP >4. Started Diamox 500 TID \n -added cefepime to allergy list given likely elevation LFT\ns with this.\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will give TF until early am for possible am extubation\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:42 PM 42 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\n c/b MSSA pneumonia. Improving with lasix, fevers and rash decreasing.\n Exam notable for Tm 100.4 BP 118/58 HR 90 RR 24 with sat 96 on PSV 5/5,\n 7.52/37/70 -3+L/24h. Rash on anterior chest improved, lungs clearer.\n RRR s1s2. Soft +BS. Trace edema. Labs notable for WBC 26K, HCT 23, K+\n 3.6, Cr 0.7. CXR .\n Agree with plan to continue PSV, lasix gtt and diamox for component of\n metabolic alkalosis while transitioning to bolus sedation. SBT now;\n appears close to extubation. Will continue naf for MSSA pneumonia x 14\n days total. Fever / rash better, will add cefepime to allergy list.\n +BM, will continue TPN and initiate Doboff feeds if not extubated.\n Above d/w wife and PCP. of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:25 ------\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659575,
"text": "Chief Complaint: PNA, s/p resp failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:10 AM\n ARTERIAL LINE - STOP 04:00 PM\n -extubated in a.m. and did well\n -was c/o nausea intermittently -> concerning for opiate or benzo\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\n iv prn.\n Allergies:\n Cefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:32 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:30 AM\n Fentanyl - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.9\nC (96.7\n HR: 94 (91 - 114) bpm\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\n RR: 24 (14 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (12 - 18)mmHg\n Total In:\n 1,308 mL\n 288 mL\n PO:\n TF:\n 13 mL\n IVF:\n 547 mL\n 228 mL\n Blood products:\n Total out:\n 5,035 mL\n 1,100 mL\n Urine:\n 5,035 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,727 mL\n -813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 96%\n ABG: ///23/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: crackles :\n L >R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 896 K/uL\n 7.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 24.5 %\n 22.0 K/uL\n [image002.jpg]\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n WBC\n 24.7\n 25.6\n 26.7\n 23.6\n 22.0\n Hct\n 24.9\n 23.9\n 23.9\n 24.7\n 24.5\n Plt\n 81\n 896\n Cr\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 151\n 131\n 144\n 135\n 128\n 115\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. Successfully extubated \n - Has completed course of oseltamavir\n - continue nafcillin - plan for 21 D course today abx from when\n linezolid was started \n -monitor diuresis and consider bolus lasix PRN.\n - speech and swallow eval today\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\n consider fentanyl or ativan PRN\n -Incentive spirometry,\n -PT today and OOB to chair\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam. WBC now trending down to 22\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 21 D course\n -pull CVL today if can get PICC\n - F/U ID recs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Getting s/s today. If passes, d/c TF\n #) Access: 2 PIVs; right IJ\n trying to get PICC today\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now- consider PM c/o\n #) Comm: With wife\n ICU \n Nutrition: diet pending speech and swallow eval today\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor possibly in afternoon\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\n c/b MSSA pneumonia. Extubated yesterday, on NC but still tachypnic.\n Exam notable for Tm 99.2 BP 110/65 HR 95 RR 24-30 with sat 93 on 4L NC.\n TBB -1.5L/8h. Scattered rales. RRR s1s2. Soft +BS. Trace edema. Labs\n notable for WBC 23K, HCT 24, K+ 4.5, Cr 0.8. CXR B ASD, stable to sl\n worse.\n Agree with plan to continue lasix bolus PRN for goal negative and CVP\n <4. Will continue naf for MSSA pneumonia x 12/21 days total. Will d/c\n CVL and place PICC for duration of therapy. Will mobilize OOB to chair\n and get PT consult. Wean oxygen to off, S+S eval, ADAT post evaluation.\n Given recent benzo/narcotic use, will continue low dose ativan and\n fentanyl PRN. Will continue TPN and initiate Doboff feeds today. Above\n d/w wife and PCP. of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:03 ------\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658801,
"text": "Chief Complaint: This is a 53 year-old male with a history of hodkin's\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\n pneumonia, S. aureus superinfections, and ARDS.\n 24 Hour Events:\n BLOOD CULTURED - At 10:03 PM\n 2 sets of bld cx\n URINE CULTURE - At 10:03 PM\n STOOL CULTURE - At 02:45 AM\n - ID rec to d/c cefepime but keeping for now as pt not clinically\n improving\n -Tried to place doppoff but first ended up in lungs. In stomach on\n second try. Will monitor to see if it can move post pyloric over the\n next day or so to safely start tube feeds\n - Afrin and NS nasal washes started for 3 days duration\n - No new cx data\n -Attempted to wean FiO2 but unable and remains on 50%\n - blood and urine cx ordered around 10p for T 101\n - Pt coughing throughout day and intermittently bolused with sedatives.\n - Bolused 500cc in afternoon for low BP. Map again low 60's in evening\n sedation.\n - PPN ordered\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:35 PM\n Nafcillin - 04:04 AM\n Cefipime - 06:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:37 PM\n Fentanyl - 10:07 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 75 (71 - 122) bpm\n BP: 93/54(67) {71/45(55) - 191/86(121)} mmHg\n RR: 21 (20 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (8 - 34)mmHg\n Total In:\n 1,648 mL\n 1,934 mL\n PO:\n TF:\n IVF:\n 1,528 mL\n 1,884 mL\n Blood products:\n Total out:\n 1,080 mL\n 110 mL\n Urine:\n 1,080 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 568 mL\n 1,824 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 283 (283 - 283) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 94\n PIP: 18 cmH2O\n Plateau: 20 cmH2O\n Compliance: 34.8 cmH2O/mL\n SpO2: 98%\n ABG: ///24/\n Ve: 8.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 519 K/uL\n 7.9 g/dL\n 151 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 103 mEq/L\n 135 mEq/L\n 24.9 %\n 24.7 K/uL\n [image002.jpg]\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n 24.7\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n 24.9\n Plt\n 293\n 334\n 439\n 509\n 519\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 1.0\n TCO2\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n 151\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:66/54, Alk Phos / T\n Bili:326/1.2, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:170 IU/L, Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia, S.\n aureus superinfections, and ARDS.\n 1) Respiratory failure/Influenza Pneumonia with secondary bacterial\n pneumonia: The patient was initially intubated for hypoxic respiratory\n failure. Has known influenza B as well as staph aureus in sputums\n presumably causing ARDS. Ventilation and oxygenation stable on AC\n settings. He is on day 7 of antimicrobial therapy with cefepime, he\n received six days of vancomycin/linezolid, he is on day six of\n oseltamavir. His linezolid was stopped and nafcillin started after his\n staph was cultured as MSSA. Thoracentesis showed exudative effusion\n and lung reexpansion after the procedure would suggest this is freely\n flowing.\n -F/U cultures\n - Continue oseltamavir through tomorrow as well as cefepime, discuss\n duration of nafcillin therapy in this very sick patient with ID who is\n following\n 2) Leukocytosis/Fevers/Hypotension: Imaging failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though this should be\n appropriately covered by his antibiotics. Hypotension presumably due\n to continued SIRs driving process (active infection vs ARDS).\n -Afrin and saline nasal washes for sinus disease\n -Continue nafcillin/cefepime/oseltamavir pending culture data\n -F/U cultures and culture if spikes\n -F/U ID reccs\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: Pt with noted aspiration event yesterday, presumably due to\n history of irradiation, nevertheless he needs nutrition. We will speak\n to GI re: post-pyloric feeding tube and start PPN in the interim.\n 6) Access: 2 PIVs; right IJ\n 7) PPx: hep sc, PPI\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 658815,
"text": "Chief Complaint: Respiratory Failure\n ARDS\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 10:03 PM\n 2 sets of bld cx\n URINE CULTURE - At 10:03 PM\n STOOL CULTURE - At 02:45 AM\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:35 PM\n Cefipime - 06:00 AM\n Nafcillin - 10:08 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 04:37 PM\n Fentanyl - 10:07 PM\n Heparin Sodium (Prophylaxis) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 87 (71 - 122) bpm\n BP: 110/61(77) {71/45(55) - 191/86(121)} mmHg\n RR: 24 (20 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 13 (8 - 34)mmHg\n Total In:\n 1,648 mL\n 2,680 mL\n PO:\n TF:\n IVF:\n 1,528 mL\n 2,043 mL\n Blood products:\n Total out:\n 1,080 mL\n 390 mL\n Urine:\n 1,080 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 568 mL\n 2,290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 283 (283 - 283) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 94\n PIP: 18 cmH2O\n Plateau: 20 cmH2O\n Compliance: 34.8 cmH2O/mL\n SpO2: 98%\n ABG: ///24/\n Ve: 8.6 L/min\n Physical Examination\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 519 K/uL\n 151 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 103 mEq/L\n 135 mEq/L\n 24.9 %\n 24.7 K/uL\n [image002.jpg]\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n 24.7\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n 24.9\n Plt\n 293\n 334\n 439\n 509\n 519\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 1.0\n TCO2\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n 151\n Other labs: PT / PTT / INR:13.0/29.8/1.1, ALT / AST:66/54, Alk Phos / T\n Bili:326/1.2, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:170 IU/L, Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR--ETT at 5cm, CVL in good position, OGT in stomach\n Assessment and Plan\n 53 yo male admit with influenza B and MSSA superinfection with severe\n hypoxemic respiratory failure and ARDS. He has had extensive\n evaluation for alternative source of infection and WBC count elevation\n but has been unrevealing to date. In this setting have had continued\n elevation in WBC count but has been able to maintain pressure off\n pressors.\n 1)Respiratory Failure-_Acute-\n -Will continue with A/C support and lung protective strategy for\n ventilation\n -Wean FIO2 as possible today\n -Maintain PEEP and only move to wean if able to maintain stable PO2 at\n decreased PEEP\n -Tamiflu\n 2) PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)-\n -Nafcillin/Cefepime continuing\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\nConcerning continued rise in WBC\n count.\n -C. Diff is of concern\n -Evidence of alternative source not clearly seen\n -Will need to consider ID input\n -Cefepime/Nafcillin/Taimflu continuing\n -CT for chest as concern for necrotizing abscess is of concern\n -If unrevealing would consider line changes as next intervention if\n persistent fever, leukocytosis seen\n -Will pre-hydrate with fluids and Mucomyst\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 07:45 AM 166 mL/hour\n today\nwe have OGT inplace and are looking for post pyloric feeding\n given significant risk of recurrent aspiration events. If unable to\n achieve with placement and Reglan will have to ask IR for assistance in\n achieving adequate positioning\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659096,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\n following commands, writing on paper to communicate. T max 100.1po.\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\n abd and back appears improved micu md staff who saw this pt\n yesterday.\n Action:\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\n scant amts thick yellow sputum, small amts blood tinged sputum in back\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\n pending.\n Response:\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\n extubated today. ett retaped and repositioned to left side of mouth at\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\n and versed drips restarted and titrated up to comfort but pt still\n easily arousable and following commands.\n Plan:\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\n around 4. Follow up with 5pm lab results and replete lytes prn.\n Continue to monitor rash on abd and back.\n Sepsis without organ dysfunction\n Assessment:\n T max 100.1po. sbp stable in 100s-140s.\n Action:\n Continues with iv nafcillin\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659099,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\n following commands, writing on paper to communicate. T max 100.1po.\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\n abd and back appears improved micu md staff who saw this pt\n yesterday.\n Action:\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\n scant amts thick yellow sputum, small amts blood tinged sputum in back\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\n pending.\n Response:\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\n extubated today. ett retaped and repositioned to left side of mouth at\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\n and versed drips restarted and titrated up to comfort but pt still\n easily arousable and following commands.\n Plan:\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\n around 4. Follow up with 5pm lab results and replete lytes prn.\n Continue to monitor rash on abd and back.\n Sepsis without organ dysfunction\n Assessment:\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\n Also + infuluenza.\n Action:\n Continues with iv nafcillin\n Response:\n Remains with low grade temp, currently afebrile.\n Plan:\n Continue nafcillin, follow up with bld culture results. Monitor temps.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659101,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n Family meeting with Dr. and re: pt's course and\n prognosis. Very helpful for wife to hear positive steps we are taking\n with him.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:23 PM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Fentanyl - 03:22 PM\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 07:44 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt denies Pain, nausea. States has some mild SOB\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.7\nC (98.1\n HR: 88 (85 - 121) bpm\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\n RR: 19 (19 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 8 (6 - 22)mmHg\n Total In:\n 1,897 mL\n 512 mL\n PO:\n TF:\n IVF:\n 889 mL\n 184 mL\n Blood products:\n Total out:\n 4,615 mL\n 1,810 mL\n Urine:\n 4,615 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,718 mL\n -1,298 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 388 (347 - 453) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.44/40/76./31/2\n Ve: 7.5 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n slight at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 714 K/uL\n 7.8 g/dL\n 144 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 23.9 %\n 26.7 K/uL\n [image002.jpg]\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n WBC\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n 26.7\n Hct\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n 23.9\n Plt\n \n Cr\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n 0.7\n TCO2\n 25\n 28\n 28\n 28\n Glucose\n 112\n 149\n 118\n 151\n 131\n 144\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% today and on PS 5/5\n but blood gas this noon 7.52/41/64\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS. Trying to wean PS daily but did not tolerate today.\n Will try again tomorrow.\n - Has completed course of oseltamavir\n - continue nafcillin day 5 today\n - F/U cultures\n - lasix gtt stopped today contraction alkylosis. Consider lasix\n boluses for CVP >4. Started Diamox 500 TID \n -added cefepime to allergy list given likely elevation LFT\ns with this.\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will give TF until early am for possible am extubation\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:42 PM 42 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659556,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 4l/m nc with rr in the high 20\ns to low 30\ns. lungs\n essentially clear on auscultation with crackles bil at the bases. Neg\n fluid balance for this shift. Wbc has dropped to 22.\n Action:\n Fluid balance followed closely as well as his hemodynamics. Pt using\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\n Receiving nafcillin as ordered . resp status monitored closely. Speech\n and swallow study completed. Physical therapy has been consulted. Tube\n fdgs restarted via dobhoff tube since pt\ns nutritional status is most\n certainly not adequate. Oob to chair with assist of 2 and tolerated\n activity well. Ic consulted to place picc line since infectious dx\n consult team is recommending 21 day course of nafcillin.\n Response:\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\n and for los pos 1.6 liters.\n Plan:\n Will maintain aspiration precautions. Continue to follow fluid balance\n and resp status. Follow culture data. Pt to have picc line placed for\n 21 day course of nafcillin and once access is obtained will then d/cri\n j triple lumen. Increase pt\ns level of activity as he tolerates. If\n stable overnoc will transfer to medical floor bed tomorrow.\n"
},
{
"category": "Rehab Services",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 659561,
"text": "TITLE: Bedside Swallow Evaluation\n Patient was seen for bedside swallow evaluation. Please see full\n evaluation in OMR or paper chart for details and recommendations.\n"
},
{
"category": "Nutrition",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 659571,
"text": "Objective\n Pertinent medications: Noted.\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 04:20 AM\n Glucose Finger Stick\n 144\n 06:00 PM\n BUN\n 21 mg/dL\n 04:20 AM\n Creatinine\n 0.8 mg/dL\n 02:50 AM\n Sodium\n 136 mEq/L\n 04:20 AM\n Potassium\n 4.5 mEq/L\n 04:20 AM\n Chloride\n 103 mEq/L\n 04:20 AM\n TCO2\n 23 mEq/L\n 04:20 AM\n PO2 (arterial)\n 74 mm Hg\n 08:09 AM\n PCO2 (arterial)\n 31 mm Hg\n 08:09 AM\n pH (arterial)\n 7.48 units\n 08:09 AM\n pH (urine)\n 6.0 units\n 09:54 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 08:09 AM\n Albumin\n 2.4 g/dL\n 03:19 AM\n Calcium non-ionized\n 8.2 mg/dL\n 02:50 AM\n Phosphorus\n 3.4 mg/dL\n 02:50 AM\n Magnesium\n 2.6 mg/dL\n 04:20 AM\n ALT\n 46 IU/L\n 04:20 AM\n Alkaline Phosphate\n 282 IU/L\n 04:20 AM\n AST\n 39 IU/L\n 04:20 AM\n Total Bilirubin\n 0.6 mg/dL\n 04:20 AM\n WBC\n 22.0 K/uL\n 04:20 AM\n Hgb\n 7.7 g/dL\n 04:20 AM\n Hematocrit\n 24.5 %\n 04:20 AM\n Current diet order / nutrition support: Regular/Soft/Thin with Ensure\n Pudding TID\n TF: Replete with Fiber at goal 75mL/hr via PPFT.\n Assessment of Nutritional Status/Plan:\n Specifics:\n Passed swallow eval today. TF started & currently at 10mL/hr. Recommend\n continue with TF until able to tolerate adequate po intake. Adjust free\n water flushes per hydration. Monitor & replete lytes PRN. Will adjust\n TF goal rate per po intake.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659573,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 4l/m nc with rr in the high 20\ns to low 30\ns. lungs\n essentially clear on auscultation with crackles bil at the bases. Neg\n fluid balance for this shift. Wbc has dropped to 22.\n Action:\n Fluid balance followed closely as well as his hemodynamics. Pt using\n incentive spirometry q 1 hrs. c&r mod amts of thick white sputum.\n Receiving nafcillin as ordered . resp status monitored closely. Speech\n and swallow study completed. Physical therapy has been consulted. Tube\n fdgs restarted via dobhoff tube since pt\ns nutritional status is most\n certainly not adequate. Oob to chair with assist of 2 and tolerated\n activity well. Ic consulted to place picc line since infectious dx\n consult team is recommending 21 day course of nafcillin. Post\n completion of speech andswallow study diet advancedto low sodium/heart\n healthy soft consistency , thin liqs ensure pudding with ea. Meal\n give all pills via dobhoff\n Response:\n Stable resp status. Autodiuresing with neg fluid balance for 12 hrs\n and for los pos 1.6 liters.\n Plan:\n Will maintain aspiration precautions. Continue to follow fluid balance\n and resp status. Follow culture data. Pt to have picc line placed for\n 21 day course of nafcillin and once access is obtained will then d/cri\n j triple lumen. Increase pt\ns level of activity as he tolerates. If\n stable overnoc will transfer to medical floor bed tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658646,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fent and versed drips. Remained\n on AC overnight.\n Sepsis without organ dysfunction\n Assessment:\n BP started dropping to 80s then to high 70s, UO 30-40 cc/hr, CVP 13-14.\n Action:\n Levophed resumed at 0.01 mcg.kg/min then weaned down to 0.001, then\n stopped at 0630, continues on antibiotics as ordered.\n Response:\n Pt with low grade fever overnight. T max 100.1, given Tylenol once as\n pt had been cultured (urine and sputum) within the past 24hrs.\n Plan:\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\n ordered, wean levophed off as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is sedated and intubated on AC for ARDS. Lung sounds rhonchi at\n upper lobes and diminished at bases..\n Action:\n Suctioned frequently for thick yellowish secretions. Remains on\n Fentanyl 50 mcg/hr and versed 2 mg/hr.\n Response:\n Present vent setting AC 20, 400, 50%, PEEP 8.\n Plan:\n Wean vent as tolerated, suction PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658784,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Sepsis without organ dysfunction\n Assessment:\n BP dropped to 80s and CVP dropped to 8-10, UO > 30-40 cc/hr, HR\n 80s-100. Spiked fecer to 101.3. This AM K 3.7 and Ph 2.5\n Action:\n Given 500 cc NS bolus x3, given Tylenol 0nce, 2 sets of bld cx, urine\n cx, and stool cx sent. Continued on antibiotics as ordered. KCL 20 meq\n IV given and Neutraphos will be given.\n Response:\n Pt spiked fever overnight, BP improved to MAP above 60, CVP improved to\n above 10.\n Plan:\n Monitor for any spikes in fever, cx as needed, continue antibiotics as\n ordered, bolus fluids as needed. Monitor lytes and replete as needed,\n Ph to be repleted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is still sedated and intubated on AC for ARDS. Lung sounds rhonchi\n at upper lobes and diminished at bases. Was observed to be very\n restless and trying to jump out of bed.\n Action:\n Suctioned frequently for excessive thick yellowish secretions. Fentanyl\n bolus given and Fentanyl drip increased to 75 mcg/hr and versed\n increased to 4 mg/hr.\n Response:\n Present vent setting AC 20, 400, 50%, PEEP 8, coughing frequently\n strong productive cough.\n Plan:\n Wean vent as tolerated, suction frequently PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 658939,
"text": "Chief Complaint: This is a 53 year-old male with a history of hodkin's\n s/p BMT in 93, h/o pericarditis, hypothyroidism, now with influenza B\n pneumonia, S. aureus superinfections, and ARDS.\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n \n -Weaned Fi02 from 50->40%\n -Prehydrated with sodium bicarb prior to CT though contrast ultimately\n not given\n -Chest CT wet read: Evaluation for abscess limited in absence of IV\n contrast (unable to obtain peripheral access). However, there is no\n change in size of multiple regions of consolidation bilaterally.\n Further, there is no change in distribution and appearance of\n air-bronchograms that would suggest a change in the underlying\n consolidation, or the presence of a new space-occupying lesion.\n Persistent pleural effusions\n -RUQ U/S done\n -spoke to his wife about how mr. was doing. She was very\n anxious.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:35 PM\n Cefipime - 06:56 PM\n Nafcillin - 10:32 PM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:44 PM\n Fentanyl - 10:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.6\nC (97.8\n HR: 88 (77 - 107) bpm\n BP: 118/58(76) {81/44(55) - 163/76(101)} mmHg\n RR: 24 (20 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (10 - 24)mmHg\n Total In:\n 5,336 mL\n 499 mL\n PO:\n TF:\n IVF:\n 3,176 mL\n 170 mL\n Blood products:\n Total out:\n 1,400 mL\n 620 mL\n Urine:\n 1,400 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,936 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 652 (652 - 652) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 623 K/uL\n 7.7 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 23 mg/dL\n 102 mEq/L\n 134 mEq/L\n 23.9 %\n 25.6 K/uL\n [image002.jpg]\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n WBC\n 15.8\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n Hct\n 28.1\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n Plt\n 293\n 334\n 439\n \n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n TCO2\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n 118\n 151\n 131\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:57/47, Alk Phos / T\n Bili:276/0.5, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:184 IU/L, Ca++:7.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\n and oxygenation stable on AC settings. He is on day 8 of\n antimicrobial therapy with cefepime, he received six days of\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\n was stopped and nafcillin started (now day 4) after his staph was\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\n re-expansion after the procedure, suggesting that it is freely\n flowing. FiO2 40% from 50%.\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS so will attempt PS today\n - Has completed course of oseltamavir\n - continue nafcillin but can d/c cefepime considering no clear source\n of GNR infection\n - F/U cultures\n - diuresis with lasix drip today to decrease total body fluid and\n maximize chance of successful extubation\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\n drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin and saline nasal washes for sinus disease\n - Continue nafcillin\n - consider pulling central line, particularly if any blood cx are\n positive\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Attempted to place\n Duboff in post-pyloric position but appears to remain in the stomach\n despite raglan and mechanical manipulation. Will consult radiology\n regarding advancing tube.\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:54 PM 42 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: hep sc, PPI\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 53M HD, BMT, pericarditis, p/w influenza B\n c/b MSSA pneumonia. CT chest\n Exam notable for Tm 101.4 BP 118/58 HR 90 RR 24 with sat 96 on 400x24\n 0.4 PEEP 8. Rash on anterior chest. Labs notable for WBC 25K, HCT 23,\n K+ 3.6, Cr 0.8. CT with dependent ASD, effusions.\n Agree with plan to transition to PSV and initiate gentle diuresis with\n lasix gtt while weaning sedation. Will d/c cefepime and continue naf\n for now. Will check cultures, diff, eos, amylase and lipase for ongoing\n fevers. +BM, will continue TPN and d/w IR re advancing Doboff. Case d/w\n wife and PCP in detail x50min. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 100 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:38 ------\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659206,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient with CAP and know influenza B, currently being treated with\n Nafcillin MSSA growth. Did suffer hypoxic respiratory failure on\n this admission with subsequent intubation.\n Action:\n Remains mechanically ventilated on PS 5/5 with sedation of fent/midaz\n at 50mg and 2mg respectively. Sedation has been weaned from fent/midaz\n 75/3 to previously mentioned settings. Suctioned for small amount of\n thick pale yellow secretions with strong cough. He is s/p thoracentesis\n with exudative effusion and lung re-expansion.\n Response:\n Tolerating vent settings well and will probably be extubated this am.\n Remains afebrile during shift, WBC trending down slowly now 23.6.\n Plan:\n Continue with antibiotic management as ordered f/u labs and cultures.\n Has been NPO since midnight Tube feeding off as ordered. TPN in\n progress. Does have a h/s of NHL with esophageal strictures so Dobhuff\n was placed on \n Started on diamox for metabolic alkalosis. Now s/p Lasix infusion for\n fluid excess more than 9l. Infusion stopped yesterday eventing with\n patient maintaining CVP greater than 14mmHg throughout the shift. No\n further diuresing done overnight, has maintained adequate urinary\n output.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659682,
"text": "Chief Complaint: s/p resp failure\n 24 Hour Events:\n PICC LINE - START 09:29 PM\n MULTI LUMEN - STOP 06:00 AM\n -PICC placed and IJ d'c'd\n -KUB checked to evaluate dobhoff\n -speech and swallow bedside eval passed with pt cleared to take thin\n liquids and MOIST soft solids.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Nafcillin - 04:55 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 03:42 PM\n Lorazepam (Ativan) - 01:10 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, SOB, CP, HA, abd pain. States\n occassional nausea. Tolerated dinner last night well.\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 93 (92 - 109) bpm\n BP: 123/67(81) {112/55(72) - 160/73(94)} mmHg\n RR: 26 (22 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 14 (11 - 15)mmHg\n Total In:\n 1,693 mL\n 243 mL\n PO:\n 960 mL\n TF:\n 83 mL\n 72 mL\n IVF:\n 590 mL\n 172 mL\n Blood products:\n Total out:\n 3,330 mL\n 800 mL\n Urine:\n 3,330 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,637 mL\n -557 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.48/31/74/23/0\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at left base )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 948 K/uL\n 8.2 g/dL\n 113 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.3 %\n 20.4 K/uL\n [image002.jpg]\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n 08:09 AM\n 03:27 AM\n WBC\n 26.7\n 23.6\n 22.0\n 20.4\n Hct\n 23.9\n 24.7\n 24.5\n 25.3\n Plt\n 48\n Cr\n 0.7\n 0.8\n 0.8\n 1.0\n TCO2\n 28\n 31\n 35\n 24\n 24\n Glucose\n 144\n 135\n 128\n 115\n 113\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:51/41, Alk Phos / T\n Bili:281/0.5, Amylase / Lipase:/13, Differential-Neuts:80.8 %,\n Lymph:11.6 %, Mono:4.4 %, Eos:2.6 %, Lactic Acid:0.9 mmol/L,\n Albumin:2.4 g/dL, LDH:262 IU/L, Ca++:8.2 mg/dL, Mg++:2.5 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. Successfully extubated \n - Has completed course of oseltamavir\n - continue nafcillin - plan for 21 D course today abx from when\n linezolid was started \n -monitor diuresis and consider bolus lasix PRN.\n - speech and swallow eval today\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\n consider fentanyl or ativan PRN\n -Incentive spirometry,\n -PT today and OOB to chair\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam. WBC now trending down to 22\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 21 D course\n -pull CVL today if can get PICC\n - F/U ID recs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Getting s/s today. If passes, d/c TF\n #) Access: 2 PIVs; right IJ\n trying to get PICC today\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now- consider PM c/o\n #) Comm: With wife\n ICU \n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 10 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 09:29 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659712,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n CNS: Remains alert and oriented x3 and can get out of bed with the\n assist of persons. Complained that he was having difficulty\n sleeping and was given a one time dose of lorazepam 1mg IV with good\n effect.\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\n seeing that he has been aggressively Diuresed. Has maintained\n normotensive blood pressures ranging SBP 110\n 130\ns. Right double\n lumen basilic PICC placed yesterday evening and OK for use. Central\n line D/c\nd this am without difficulty and occlusive dsg to site at\n present.\n RESP: Continues on 3l/min with sats in the mid to upper 90\ns. Denies\n any SOB or DOE. LS clear with minimally diminished bases.\n GU: Remains with urinary catheter and with good output. See flow chart\n for numbers.\n GI: Dobhoff fdg tube clooged this am without successful attempts to\n unclog with sodium bicarb and viokase. Pt tolerating heart healthy soft\n moist diet with good appetite. Will crush pt\ns pills and administer\n with pureed ood such as applesauce. Will follow pt\ns nutritionl intake\n and if poor will reinsert dobhoff fdgtube for nutritional support\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 71 Inch\n Admission weight:\n 71 kg\n Daily weight:\n Allergies/Reactions:\n Cefepime\n Rash;\n Precautions: Droplet\n PMH:\n CV-PMH:\n Additional history: pericarditis, pericardial effusion,myelodysplasia.\n GERD, high cholestrol,hypothyroidism\n Surgery / Procedure and date: s/p BMT in for myelodysplasia\n s/p splenectomy in \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:68\n Temperature:\n 98.8\n Arterial BP:\n S:99\n D:62\n Respiratory rate:\n 34 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 303 mL\n 24h total out:\n 980 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:27 AM\n Potassium:\n 4.2 mEq/L\n 03:27 AM\n Chloride:\n 105 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 17 mg/dL\n 03:27 AM\n Creatinine:\n 1.0 mg/dL\n 03:27 AM\n Glucose:\n 113 mg/dL\n 03:27 AM\n Hematocrit:\n 25.3 %\n 03:27 AM\n Finger Stick Glucose:\n 144\n 06:00 PM\n Valuables / Signature\n Patient valuables: blackberry\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: no\n Transferred from: 410\n Transferred to: 1165 \n Date & time of Transfer: \n INTEG: Skin remains unremarkable at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659713,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n CNS: Remains alert and oriented x3 and can get out of bed with the\n assist of persons. Complained that he was having difficulty\n sleeping and was given a one time dose of lorazepam 1mg IV with good\n effect.\n CVS: Monitoring in ST with SR while at rest. It is a bit concerning\n seeing that he has been aggressively Diuresed. Has maintained\n normotensive blood pressures ranging SBP 110\n 130\ns. Right double\n lumen basilic PICC placed yesterday evening and OK for use. Central\n line D/c\nd this am without difficulty and occlusive dsg to site at\n present.\n RESP: Continues on 3l/min with sats in the mid to upper 90\ns. Denies\n any SOB or DOE. LS clear with minimally diminished bases.\n GU: Remains with urinary catheter and with good output. See flow chart\n for numbers.\n GI: Dobhoff fdg tube clooged this am without successful attempts to\n unclog with sodium bicarb and viokase. Pt tolerating heart healthy soft\n moist diet with good appetite. Will crush pt\ns pills and administer\n with pureed ood such as applesauce. Will follow pt\ns nutritionl intake\n and if poor will reinsert dobhoff fdgtube for nutritional support\n Demographics\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658858,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Vigorous inspiratory efforts, Frequent alarms\n (High rate, High min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1730\n no complications\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2181-02-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 658921,
"text": "Objective\n Pertinent medications: Noted.\n Labs:\n Value\n Date\n Glucose\n 131 mg/dL\n 04:17 AM\n BUN\n 23 mg/dL\n 04:17 AM\n Creatinine\n 0.8 mg/dL\n 04:17 AM\n Sodium\n 134 mEq/L\n 04:17 AM\n Potassium\n 3.6 mEq/L\n 04:17 AM\n Chloride\n 102 mEq/L\n 04:17 AM\n TCO2\n 25 mEq/L\n 04:17 AM\n PO2 (arterial)\n 76. mm Hg\n 12:05 PM\n PCO2 (arterial)\n 40 mm Hg\n 12:05 PM\n pH (arterial)\n 7.44 units\n 12:05 PM\n pH (urine)\n 6.0 units\n 09:54 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 12:05 PM\n Albumin\n 2.4 g/dL\n 03:19 AM\n Calcium non-ionized\n 7.5 mg/dL\n 04:17 AM\n Phosphorus\n 2.7 mg/dL\n 04:17 AM\n Magnesium\n 2.4 mg/dL\n 04:17 AM\n ALT\n 57 IU/L\n 04:17 AM\n Alkaline Phosphate\n 276 IU/L\n 04:17 AM\n AST\n 47 IU/L\n 04:17 AM\n Total Bilirubin\n 0.5 mg/dL\n 04:17 AM\n WBC\n 25.6 K/uL\n 04:17 AM\n Hgb\n 7.7 g/dL\n 04:17 AM\n Hematocrit\n 23.9 %\n 04:17 AM\n Current diet order / nutrition support: NPO/TPN: Day /Starter STD w/\n nonstd lytes ()\n Assessment of Nutritional Status\n Specifics:\n On TPN now d/t aspiration event & inability to advance dobhoff as PPFT\n pending IR c/s for placement. ? if patient with an obstruction or a\n stricture at lower stomach. Please check triglyceride as lipids in TPN\n is contraindicated if >400mg/dl. Start RISS to assess glucose\n tolerance.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Consider KUB to R/O obstruction\n 2. TPN today: 1500mL(200g Dex/105g AA/35g Fat) with nonstd lytes\n in mEq: 50 NaCl, 55 NaPO4, 30 KCl, 30 KAc, 5 MgSO4, 10 CaGlu, 15 units\n insulin.\n 3. Start RISS; check FSBG Q 6hrs\n 4. Check Triglycerides with am labs\n 5. check chem. 10 daily\n 6. Advance toward goal TPN per FSBG: Goal TPN: 1750mL(298g\n Dex/105g AA/35g Fat)\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659300,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt initially intubated for hypoxic resp failure. Has known influenza\n bas well as a secondary bacterial pneumonia from staph aureus in\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\n for mssa that grew . thoracentesis to r lung shwed exudative\n effusion and lung re-expansion after procedure.tolerated spontaneous\n breathing trial after aggressive diuresis initially with lasix gtt and\n then with diamox. Post extubation pt c/o nausea.pt has been on\n fentanyul/versed gtts for > 1 week and concern is that pt may be\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\n with rhonchi bil on auscultation and crackles at the bases.\n Action:\n Fluid balance followed closely. Pt extubated this am and then able to\n be weaned to 4l/m nc. Diamox d/c\nd. pt medicated with 4 mg iv zofran\n with no relief. Was then given 10 mg ivp compazine with no effect. With\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Reps\n status monitored closely. Pt kept npo for now in the setting of\n continued nausea but will have speech and swallow study in the am if\n stable overnoc from resp standpoint.\n Response:\n Successful extubation with pt tolerating minimal amts of supplemental\n o2. pt still having adequate hourly uo off lasix and Fentanyl gtts.\n Pt\ns flid alnce neg 1.7 liters for 23 hrs but still overall positive\n for los.\n Plan:\n Continue to follow fluid balance and bolus with lasix as needed.\n Continue to monitor resp status closely and if pt has increasing resp\n distress notify medical team. Administer nafcillin as ordered.\n Continue to moitor fro signs if narcotic/benzo withdrawal and medicate\n with ativan and Fentanyl as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659545,
"text": "Chief Complaint: PNA, s/p resp failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:10 AM\n ARTERIAL LINE - STOP 04:00 PM\n -extubated in a.m. and did well\n -was c/o nausea intermittently -> concerning for opiate or benzo\n withdrawal so received boluses of ativan 1mg iv and fentanyl 25-50 mcg\n iv prn.\n Allergies:\n Cefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:32 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:30 AM\n Fentanyl - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.9\nC (96.7\n HR: 94 (91 - 114) bpm\n BP: 116/58(72) {105/55(67) - 144/69(87)} mmHg\n RR: 24 (14 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (12 - 18)mmHg\n Total In:\n 1,308 mL\n 288 mL\n PO:\n TF:\n 13 mL\n IVF:\n 547 mL\n 228 mL\n Blood products:\n Total out:\n 5,035 mL\n 1,100 mL\n Urine:\n 5,035 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,727 mL\n -813 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n SpO2: 96%\n ABG: ///23/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: No acute distress, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: crackles :\n L >R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 896 K/uL\n 7.7 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 24.5 %\n 22.0 K/uL\n [image002.jpg]\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n 04:20 AM\n WBC\n 24.7\n 25.6\n 26.7\n 23.6\n 22.0\n Hct\n 24.9\n 23.9\n 23.9\n 24.7\n 24.5\n Plt\n 81\n 896\n Cr\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 151\n 131\n 144\n 135\n 128\n 115\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:46/39, Alk Phos / T\n Bili:282/0.6, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:223 IU/L, Ca++:8.2 mg/dL, Mg++:2.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. Successfully extubated \n - Has completed course of oseltamavir\n - continue nafcillin - plan for 21 D course today abx from when\n linezolid was started \n -monitor diuresis and consider bolus lasix PRN.\n - speech and swallow eval today\n -may have benzo or narc withdrawl- nausea may be sx of this. Will\n consider fentanyl or ativan PRN\n -Incentive spirometry,\n -PT today and OOB to chair\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam. WBC now trending down to 22\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 21 D course\n -pull CVL today if can get PICC\n - F/U ID recs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Getting s/s today. If passes, d/c TF\n #) Access: 2 PIVs; right IJ\n trying to get PICC today\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now- consider PM c/o\n #) Comm: With wife\n ICU \n Nutrition: diet pending speech and swallow eval today\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor possibly in afternoon\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659550,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659194,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to extubate in am\n Comments: rsbi 71\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659045,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n Family meeting with Dr. and re: pt's course and\n prognosis. Very helpful for wife to hear positive steps we are taking\n with him.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:23 PM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Fentanyl - 03:22 PM\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 07:44 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt denies Pain, nausea. States has some mild SOB\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.7\nC (98.1\n HR: 88 (85 - 121) bpm\n BP: 95/70(80) {92/50(68) - 187/85(120)} mmHg\n RR: 19 (19 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 8 (6 - 22)mmHg\n Total In:\n 1,897 mL\n 512 mL\n PO:\n TF:\n IVF:\n 889 mL\n 184 mL\n Blood products:\n Total out:\n 4,615 mL\n 1,810 mL\n Urine:\n 4,615 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,718 mL\n -1,298 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 388 (347 - 453) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 74\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.44/40/76./31/2\n Ve: 7.5 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n slight at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 714 K/uL\n 7.8 g/dL\n 144 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 23.9 %\n 26.7 K/uL\n [image002.jpg]\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n WBC\n 20.4\n 19.2\n 22.4\n 24.7\n 25.6\n 26.7\n Hct\n 26.6\n 26.3\n 24.7\n 24.9\n 23.9\n 23.9\n Plt\n \n Cr\n 0.8\n 0.9\n 0.8\n 1.0\n 0.8\n 0.7\n TCO2\n 25\n 28\n 28\n 28\n Glucose\n 112\n 149\n 118\n 151\n 131\n 144\n Other labs: PT / PTT / INR:12.4/27.0/1.0, ALT / AST:49/44, Alk Phos / T\n Bili:251/0.5, Amylase / Lipase:/13, Differential-Neuts:87.6 %,\n Lymph:5.8 %, Mono:3.7 %, Eos:2.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:7.5 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. Ventilation\n and oxygenation stable on AC settings. He is on day 8 of\n antimicrobial therapy with cefepime, he received six days of\n vancomycin/linezolid, he is on day seven of oseltamavir. His linezolid\n was stopped and nafcillin started (now day 4) after his staph was\n cultured as MSSA. Thoracentesis showed exudative effusion and lung\n re-expansion after the procedure, suggesting that it is freely\n flowing. FiO2 40% from 50%.\n - Hypoxia appears more consistent with pneumonia/lobar consolidation\n instead of ARDS so will attempt PS today\n - Has completed course of oseltamavir\n - continue nafcillin but can d/c cefepime considering no clear source\n of GNR infection\n - F/U cultures\n - diuresis with lasix drip today to decrease total body fluid and\n maximize chance of successful extubation\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or a\n drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin and saline nasal washes for sinus disease\n - Continue nafcillin\n - consider pulling central line, particularly if any blood cx are\n positive\n - F/U cultures and culture if spikes\n - F/U ID reccs\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to reveal\n a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Attempted to place\n Duboff in post-pyloric position but appears to remain in the stomach\n despite raglan and mechanical manipulation. Will consult radiology\n regarding advancing tube.\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU until respiratory status improves\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:42 PM 42 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659295,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt initially intubated for hypoxic resp failure. Has known influenza\n bas well as a secondary bacterial pneumonia from staph aureus in\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\n for mssa that grew . thoracentesis to r lung shwed exudative\n effusion and lung re-expansion after procedure.tolerated spontaneous\n breathing trial after aggressive diuresis initially with lasix gtt and\n then with diamox. Post extubation pt c/o nausea\n Action:\n Fluid balance followed closely. Pt extubated this am and then able to\n be weaned to 4l/m nc. Diamox d/c\nd. pt medicated with 4 mg iv zofran.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659297,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt initially intubated for hypoxic resp failure. Has known influenza\n bas well as a secondary bacterial pneumonia from staph aureus in\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\n for mssa that grew . thoracentesis to r lung shwed exudative\n effusion and lung re-expansion after procedure.tolerated spontaneous\n breathing trial after aggressive diuresis initially with lasix gtt and\n then with diamox. Post extubation pt c/o nausea.pt has been on\n fentanyul/versed gtts for > 1 week and concern is that pt may be\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\n with rhonchi bil on auscultation and crackles at the bases.\n Action:\n Fluid balance followed closely. Pt extubated this am and then able to\n be weaned to 4l/m nc. Diamox d/c\nd. pt medicated with 4 mg iv zofran\n with no relief. Was then given 10 mg ivp compazine with no effect. With\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Reps\n status monitored closely. Pt kept npo for now in the setting of\n continued nausea but will have speech and swallow study in the am if\n stable overnoc from resp standpoint.\n Response:\n Successful extubation with pt toleratinf min\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658419,
"text": "Chief Complaint: Hypoxia/ARDS\n 24 Hour Events:\n FEVER - 102.5\nF - 12:00 PM\n -put back on Levo in afternoon hypotension then weaned back in\n evening - on 0.1 at 9p\n - ID consulted- d/c azithro and flagyl. ? Rpt Chest CT possibly in a\n couple days. Still on linezolid, cefepime, tamiflu, course still to be\n determined\n - TF were started per nutrition recs\n -d/c statin elevated LFTs\n -lipase 13\n -f/u on RUQ u/s - prelims are mildly distended gallbladder with sludge,\n no secondary signs of cholecystitis, no ductal dilation, right pleural\n effusion\n -bowel regimen ordered\n -EKG and pulsus checked - no sign of pericardial disease - no TTE\n -Vent on PS with FiO2 50%\n -Fungal Blood culture ordered\n - BNP 574\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 AM\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 11:01 PM\n Cefipime - 04:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:09 AM\n Heparin Sodium (Prophylaxis) - 11:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 37.7\nC (99.8\n HR: 92 (75 - 106) bpm\n BP: 111/49(67) {89/45(60) - 172/88(118)} mmHg\n RR: 23 (15 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (4 - 14)mmHg\n Total In:\n 2,942 mL\n 487 mL\n PO:\n TF:\n 167 mL\n 246 mL\n IVF:\n 2,445 mL\n 241 mL\n Blood products:\n Total out:\n 1,615 mL\n 440 mL\n Urine:\n 1,615 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,327 mL\n 47 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 465 (435 - 465) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 19 cmH2O\n SpO2: 99%\n ABG: 7.38/40/94./24/0\n Ve: 8.7 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Thin, appears unwell\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 334 K/uL\n 8.8 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 103 mEq/L\n 133 mEq/L\n 26.6 %\n 20.4 K/uL\n [image002.jpg]\n 03:08 PM\n 11:32 PM\n 03:19 AM\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n WBC\n 12.3\n 15.8\n 20.4\n Hct\n 28.9\n 28.1\n 26.6\n Plt\n \n Cr\n 1.0\n 0.9\n 0.8\n TCO2\n 24\n 21\n 25\n 23\n 24\n 23\n 25\n Glucose\n 96\n 122\n 112\n Other labs: PT / PTT / INR:13.5/35.5/1.2, ALT / AST:67/64, Alk Phos / T\n Bili:381/0.9, Amylase / Lipase:/13, Differential-Neuts:85.9 %,\n Lymph:5.3 %, Mono:8.1 %, Eos:0.6 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.1 mg/dL\n RUQ U/S: Sludge but no pericholeycystic fluid.\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory presumed due\n to infectious process/ ARDS. Patient with known influenza and with\n PaO2/FiO2<200 he does meet criteria for ARDS. Initial insult was most\n likely flu but given staph aureus in respiratory culture there is\n evidence for bacterial superinfection. He is continuing to maintain\n good ventilation and adequate oxygenation on pressure support.\n Potentially concerning to allow ARDS patient off protocol due to\n ability to exceed low lung volumes but he seems more comfortable on PS\n and tidal volumes are relatively low (450-475) decreasing concern for\n barotrauma.\n - On day 5 of linezolid (or vanc), cefepime and oseltamavir.\n -F/U cultures\n - Continue oseltamavir for influenza B\n 2) SIRS/ Hypotension/Fevers: This patient\ns fever is not as concerning\n in and of itself given influenza can often cause persistent fever.\n Still, with persistent white count and his leukocytosis recurring it is\n very concerning that we are not adequately covering an infectious\n process. Blood cultures remain negative and RUQ U/S not suggestive of\n choleycystitis. Major concern now if for a drainable collection as his\n broad spectrum antibiotics should cover most common organisms.\n -Continue current antimicrobial regimen\n -CT scan of torso and sinuses looking for possible closed space\n infection and to better evaluate possible effusions vs atelectasis in\n lungs\n -Echo to evaluate for other causes of hypotension give patient has hx\n of pericarditis and could potentially have some restrictive pathology\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE per above\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n ICU \n Nutrition:\n Replete with Fiber (Full) - 04:15 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 06:27 AM\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer: PPI\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659035,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Remained afebrile overnight. LS clear throughout conts on Nafcillian,\n he has developed a rash on his abd and back, he has yellow sputum from\n his ETT and a lg amount of secretions from the back of his throat. He\n is more alert today, writing, though somewhat illegibly, able to tell\n us some of his needs. He is 13 liters pos.\n Action:\n Placed on PSV 5 PEEP 8, his PEEP was decreased to 5 last evening,\n started on a lasix gtt secondary to positive fluid status. Continues on\n sedation fent/midaz at 75mg and 4mg respectively.\n Response:\n Tolerating the PSV with any distress overnight. Diuresing well on lasix\n gtt at 2mg/hr, his CVP is 14-16mmHgand maintaing SBP greater than 120\n throughout. Unable to tell whether rash has gotten any worse since I\n have nothing to compare with. However, it is diffuse.\n Plan:\n Cont with the lasix gtt as his BP and CVP allow, follow his lytes,\n follow his rash\n there is concern that the rash is from the nafacillin\n but this is a good antibiotic for his staph pneumonia, cont to wean the\n fent and versed.\n Went to radiology in afternoon of a NG tube in his\n jejunum. Order for TF written, however unable to start feed last pm\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659188,
"text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient with CAP and know influenza B, currently being treated with\n Nafcillin MSSA growth. Did suffer hypoxic respiratory failure on\n this admission with subsequent intubation.\n Action:\n Remains mechanically ventilated on PS 5/5 with sedation of fent/midaz\n at 50mg and 2mg respectively. Sedation has been weaned from fent/midaz\n 75/3 to previously mentioned settings. Suctioned for small amount of\n thick pale yellow secretions with strong cough. He is s/p thoracentesis\n with exudative effusion and lung re-expansion.\n Response:\n Tolerating vent settings well and will probably be extubated this am.\n Remains afebrile during shift, WBC trending down slowly now 23.6.\n Plan:\n Continue with antibiotic management as ordered f/u labs and cultures.\n Has been NPO since midnight Tube feeding off as ordered. TPN in\n progress. Does have a h/s of NHL with esophageal strictures so Dobhuff\n was placed on \n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658327,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Events:\n No growth to date on BCs, sputum or urine cultures\n Multiple vent changes made currently on\nARDS net\n settings\n Sepsis without organ dysfunction\n Assessment:\n Pt. spiked temp again yesterday, however, has continued with low-grade\n temp throughout this shift. No growth to date in all BCs, urine and\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\n weaned throughout the shift. Was able to wean gtt off for most of shift\n but BP slowly dropped. Back on at 0400.\n Action:\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\n Levophed gtt on to maintain MAP >60.\n Response:\n Pt. remains with low-grade temp. SBP high 90\ns to 130\ns. Good UO.\n Plan:\n Monitor hemodynamic status and support as necessary w/ pressor and\n volume. Continue antibiotics as ordered/\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\n secretions. Remains on vent. CPAP 50%/. Last gas 7.38/40/94. Sats\n >97%. Sedated on fent/versed.\n Action:\n Pt. kept on CPAP as pts own rate and volumes coincide w/ ARDS net\n protocol. Suctioned Q4h and prn.\n Response:\n Pt. remains stable on these vent settings. Also appears comfortable on\n sedation. Does arouse easily and nod head to questions asked.\n Plan:\n Cont to monitor resp status and wean vent support as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659137,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza. Pt\n remains intubated on low dose sedation, fentanyl and versed drips.\n Remained on AC overnight. Weaned to psv early in the am: 5 ps/5 peep.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remained on psv in am on 5 ps/5 peep, 40% fio2. lungs cta, awake,\n following commands, writing on paper to communicate. T max 100.1po.\n diuresing well from lasix >200cc/hr with cvp 8 in am. Am k 3.6. rash on\n abd and back appears improved micu md staff who saw this pt\n yesterday.\n Action:\n Am abg: 7.52/37/70 after a few hours on above settings. Suctioned for\n scant amts thick yellow sputum, small amts blood tinged sputum in back\n of throat via yankaeur. Fentanyl and versed drips weaned down and shut\n off for an hour and pt given an sbt for 1.5 hours: repeat abg:\n 7.52/41/64. lasix drip increased to 3mg/hr with goal of cvp to be down\n to 4. iv diamox also started. K repleted with 60 meq iv kcl. 5pm labs\n pending.\n Response:\n Pt placed back on 5 ps, 5 peep, remains on 40% fi02 d/t not able to be\n extubated today. ett retaped and repositioned to left side of mouth at\n 25cm at lip. Pt coughing a lot after off sedation for an hour. Fentanyl\n and versed drips restarted and titrated up to comfort but pt still\n easily arousable and following commands. Continues to diurese well\n approx 3.9 liters negative since mn. 7 liters + los. Cvp approx .\n Plan:\n Continue psv: 5 ps, 5 peep on 40% fi02. continue diamox. Cvp goal\n around 4. Follow up with 5pm lab results and replete lytes prn.\n Continue to monitor rash on abd and back.\n Sepsis without organ dysfunction\n Assessment:\n T max 100.1po. sbp stable in 100s-140s. stool and urine cx all\n negative to date. Blood cx from pending. Sputum cx + for s. aureus.\n Also + influenza.\n Action:\n Continues with iv nafcillin\n Response:\n Remains with low grade temp, currently afebrile.\n Plan:\n Continue nafcillin, follow up with bld culture results. Monitor temps.\n Social: pt\ns wife up to visit pt in late am and most of day.pt\ns wife\n spoke with Dr. re: pt\ns update and plan of care. Pt\ns twin sons\n and also visited in the early evening. Pt\ns requested\n to also speak with Dr. for an update. Dr. spoke to them\n to give them an update, but they requested an update from Dr. .\n Dr. paged Dr. and plan is for Dr. to speak to pt\n later this evening after 7:30pm. Wife and are visiting\n in room and waiting room. social worker has been following wife\n and pt for support and spoke to them yesterday. Wife declined need to\n speak to today. continue to provide emotional support to\n pt/family prn.\n ------ Protected Section ------\n Pt receiving tpn via tlcl and tube feedings replete with fiber via\n dobhoff ngtube confirmed to be postpyloric by radiology yesterday\n . tube feeding started at 14:30 at 10cc/hr and increased to\n 20cc/hr at 18:30. continue to increase rate by 10ml q4hr. stop feedings\n in am in prep for possible extubation tomorrow.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:27 ------\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659293,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659265,
"text": "Chief Complaint: resp failure\n 24 Hour Events:\n - pt failed. ABG 7.52/41/64\n -resumed TF until midnight.\n -lasix gtt turned off in afternoon as CVP down to 4\n - diamox TID started\n -KCL repleted\n -TPN reordered\n -Afrin d/c'd\n -added cefepime to allergy list given rash\n - plan for extubation during rounds in am. Respiratory aware.\n History obtained from Patient\n Allergies:\n History obtained from PatientCefepime\n Rash;\n Last dose of Antibiotics:\n Cefipime - 08:30 AM\n Nafcillin - 04:15 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:44 AM\n Heparin Sodium (Prophylaxis) - 03:46 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt very anxious having trouble breathing with ?\n muscous plug this am. Denies pain.\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.1\nC (98.8\n HR: 104 (81 - 116) bpm\n BP: 148/70(98) {99/49(65) - 175/86(117)} mmHg\n RR: 22 (18 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 19 (4 - 19)mmHg\n Total In:\n 2,153 mL\n 522 mL\n PO:\n TF:\n 150 mL\n 13 mL\n IVF:\n 979 mL\n 207 mL\n Blood products:\n Total out:\n 6,100 mL\n 1,255 mL\n Urine:\n 6,100 mL\n 1,255 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,947 mL\n -733 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 711 (289 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 71\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.42/36/60/24/0\n Ve: 14.4 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\n Labs / Radiology\n 781 K/uL\n 7.9 g/dL\n 128 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 101 mEq/L\n 133 mEq/L\n 24.7 %\n 23.6 K/uL\n [image002.jpg]\n 04:29 AM\n 02:36 AM\n 04:17 AM\n 12:05 PM\n 03:05 AM\n 08:23 AM\n 12:58 PM\n 04:13 PM\n 02:50 AM\n 06:12 AM\n WBC\n 22.4\n 24.7\n 25.6\n 26.7\n 23.6\n Hct\n 24.7\n 24.9\n 23.9\n 23.9\n 24.7\n Plt\n 14\n 781\n Cr\n 0.8\n 1.0\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 28\n 31\n 35\n 24\n Glucose\n 118\n 151\n 131\n 144\n 135\n 128\n Other labs: PT / PTT / INR:12.9/37.3/1.1, ALT / AST:54/50, Alk Phos / T\n Bili:299/0.4, Amylase / Lipase:/13, Differential-Neuts:84.9 %,\n Lymph:9.0 %, Mono:3.4 %, Eos:2.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:233 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, now with influenza B pneumonia and S.\n aureus superinfections.\n #) Hypoxic Respiratory failure: He was initially intubated for\n hypoxic respiratory failure. Has known influenza B as well as\n secondary bacterial pneumonia from staph aureus in sputum. s/p 7 D\n tamiflu tx. Cefepime (d/c )/linezolid used originally. Linezolid\n changed to Nafcillin when MSSA grew . Thoracentesis showed\n exudative effusion and lung re-expansion after the procedure,\n suggesting that it is freely flowing. FiO2 40% and on PS 5/5 but\n blood gas this noon 7.52/41/64. This am, did well on (although had\n some mucous plugging around 7a).\n - Has completed course of oseltamavir\n - continue nafcillin day 6 today- plan for 14 D course\n - F/U cultures\n - extubate this am. Will start Incentive spirometry\n -monitor diuresis and consider bolus lasix PRN. D/c diamox\n -will need speech and swallow eval but will hold off until tomorrow\n -of note, since pt has been on fent/versed for sedation for >1wk, may\n have benzo withdrawl. Will consided valium or versed PRN\n #) Sepsis: Patient met SIRS criteria with fever and leukocytosis and\n also had known source of infection. No longer requiring pressors.\n #) Leukocytosis: Imaging failed to reveal a closed space infection or\n a drainable abscess. The presumed etiology of his fevers is pneumonia\n and possibly sinusitis vs cholecystitis, but no clear source on CT\n torso and sinus. Repeated CT chest on but no evidence of abscess\n on exam.\n - Afrin 3 D course finished . Cont saline nasal washes for sinus\n disease\n - Continue nafcillin for 14 D course\n - consider pulling central line if any blood cx are positive. Keep now\n for TPN. If stable tomorrow, will likely pull CVL.\n - F/U cultures and culture if spikes\n - F/U ID recs- they rec thoracentesis but do not think this is\n medically necessary for now.\n #) Hx of Hodgkin\ns Lymphoma/pericardial disease: Echo failed to\n reveal a pericardial effusion.\n #) Hypothyroidism: Continue home levothyroxine.\n #) FEN: Pt with noted aspiration event on , presumably due to\n history of irradiation and esophageal stricture. Has Doppoff in place\n now. Will restart TF today after extubation. Cont TPN for today\n #) Access: 2 PIVs; right IJ\n #) PPx: hep sc, PPI\n #) Dispo: ICU for now\n #) Comm: With wife\n ICU \n Nutrition:\n TPN without Lipids - 06:01 PM 42 mL/hour\n Restart TF today after extubation\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659278,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658471,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Norepi shut off at 1800 last evening. Continues on Linezolid and\n cefipime IV.\n Pt remains intubated on low dose sedation, fent and versed drips.\n Remained on AC overnight with the plan to switch to PSV in AM.\n Plan for cardiac echo today. Pt may also go to IR for drainage of\n pleural effusions.\n Pt\ns wife is contact person and has been updated by team overnight. She\n wants to speak to Attending today before any invasive procedures are\n done. Visitors are limited to a few people written on a paper at the\n front desk. She was upset that his co-workers were let in to visit on\n .\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 658556,
"text": "Chief Complaint: Respiratory failure, ARDS\n 24 Hour Events:\n - FEVER - 101.1\nF - 09:00 PM\n -OFF PRESSORS at 6:00 pm\n -CT torso w/o abcess or drainable collection\n -CT sinus w/ paranasal sinusitis bilaterally (prelim)\n -Thoracentesis deferred as minimal fluid on echo\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 08:56 PM\n Metronidazole - 12:20 PM\n Linezolid - 12:30 AM\n Cefipime - 05:56 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.4\nC (99.3\n HR: 75 (75 - 117) bpm\n BP: 88/48(62) {85/46(60) - 198/111(140)} mmHg\n RR: 19 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 16 (13 - 334)mmHg\n Total In:\n 1,855 mL\n 941 mL\n PO:\n TF:\n 917 mL\n 382 mL\n IVF:\n 878 mL\n 514 mL\n Blood products:\n Total out:\n 1,520 mL\n 218 mL\n Urine:\n 1,520 mL\n 218 mL\n NG:\n Stool:\n Drains:\n Balance:\n 335 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 500) mL\n Vt (Spontaneous): 370 (370 - 542) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/41/85./25/1\n Ve: 8.9 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : few)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 439 K/uL\n 8.3 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 104 mEq/L\n 133 mEq/L\n 26.3 %\n 19.2 K/uL\n [image002.jpg]\n 04:01 AM\n 01:00 PM\n 04:13 PM\n 03:59 AM\n 07:11 AM\n 12:36 PM\n 03:42 AM\n 02:27 AM\n 04:03 AM\n 06:25 AM\n WBC\n 15.8\n 20.4\n 19.2\n Hct\n 28.1\n 26.6\n 26.3\n Plt\n 293\n 334\n 439\n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 25\n 23\n 24\n 23\n 25\n 28\n 28\n Glucose\n 122\n 112\n 149\n Other labs: PT / PTT / INR:13.1/35.9/1.1, Differential-Neuts:84.9 %,\n Lymph:6.7 %, Mono:6.1 %, Eos:2.1 %, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.0 mg/dL, ALT\n 70*, AST 75*, AP 385*, LDH 176, T Bil 0.8\n Imaging:\n CT Torso:\n 1. Mildly decreased dense bilateral lower lobe consolidation, left\n greater\n than right, with scattered patchy opacities seen medially within the\n upper lobes. Interval increase in bilateral pleural effusions, now\n moderate.\n 2. Prominence of the esophagus, which is diffusely filled with oral\n contrast\n material, consistent with extensive gastroesophageal reflux disease.\n Given the degree of contrast reflux into the esophagus, which is\n marked, the patient is felt to be a very high risk for aspiration.\n 3. No acute inflammatory process or abnormal fluid collection is seen\n in the\n abdomen or pelvis. Mild perirenal edema bilaterally with trace free\n fluid.\n CT Sinus (per verbal report): Paranasal sinusitis bilaterally\n Microbiology: Sputum:\n : Culture with coag + staph\n Gram stain (-)\n : Culture preliminary negative, gram\n stain (-)\n Assessment and Plan\n This is a 53 year-old male with a history of hodkin's s/p BMT in 93,\n h/o pericarditis, hypothyroidism, admitted with influenza B now with\n worsening hypoxia and respiratory distress and CT concerning for\n multilobar PNA.\n 1) Respiratory failure: Patient with hypoxic respiratory failure. Has\n known influenza B as well as staph aureus in sputums. Presumably, flu\n with bacterial superinfection is the etiology of his ARDS. The patient\n was on AC overnight but was switched back to CPAP this AM. Since then,\n he has been pulling lower tidal volumes than previously (<400) and more\n tachypneic. We will place him back on AC to decrease work of breathing\n while we continue to treat his pneumonia and support him through his\n ARDS. He is on day 6 of antimicrobial therapy with linezolid, cefepime\n and oseltamavir.\n -F/U cultures, obtain viral cultures per ID recommendation\n - Continue current antimicrobials pending culture data\n -IP will attempt to perform diagnostic thoracentesis today as couldn\n be done at bedside.\n 2) Leukocytosis/Fevers: Imaging yesterday failed to reveal a closed\n space infection or a drainable abcess. The presumed etiology of his\n fevers is pneumonia and possibly sinusitis though his\n -Continue current antimicrobial regimen\n -CT scan of torso and sinuses looking for possible closed space\n infection and to better evaluate possible effusions vs atelectasis n\n lungs\n -Echo to evaluate for other causes of hypotension give patient has hx\n of pericarditis and could potentially have some restrictive pathology\n 3) Hx of Hodgkin\ns Lymphoma/pericardial disease: Particularly given\n current concern for effusion there is a possibility of post radiation\n serositis in the chest or possibility of effusion.\n -TTE per above\n 4) Hypothyroidism: Continue home levothyroxine.\n 5) FEN: NPO for now, given potential for prolonged intubation will\n initiate nutrtition consult to start tube feeds\n 6) Access: 2 PIVs; right IJ (pulled back yesterday and more\n appropriately sited on follow up scans)\n 7) PPx: hep sc, ppi as outpt\n 8 Code: FULL (confirmed with patient)\n 8) Dispo: ICU until respiratory status improves\n 9) Comm: With wife\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:05 AM\n Arterial Line - 09:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659338,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Plug\n Sputum source/amount: Suctioned / Small\n Comments:\n Comments: Pt extubated this shift to 50% cool aerosol with good cuff\n leak noted. PT coughing and raising most secretions on own. Pt now\n wearing 3L NC with spo2 99-100%. Incentive spirometer at bedside and\n encouraged pt to use device every hr W/A. Will cont to follow as\n needed.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659341,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic respiratory failure, and is now being treated for\n influenza and a probable PNA with SEPSIS.\n Sputum growth to date positive for s. aureus. Pt also +influenza.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt initially intubated for hypoxic resp failure. Has known influenza\n bas well as a secondary bacterial pneumonia from staph aureus in\n sputum. Pt is s/p 7 day tamiflu tx. Now being treated with nafcillin\n for mssa that grew . thoracentesis to r lung showed exudative\n effusion and lung re-expansion after procedure. tolerated spontaneous\n breathing trial after aggressive diuresis initially with lasix gtt and\n then with diamox. Post extubation pt c/o nausea.pt had been on\n fentanyul/versed gtts for > 1 week and concern is that pt may be\n exoeriencing beginning signs of benzo.narcotic withdrawal. Lung sounds\n with rhonchi bil on auscultation and crackles at the bases.\n Action:\n Fluid balance followed closely. Pt extubated this am and then able to\n be weaned to 4l/m nc. Diamox d/c\nd. pt medicated with 4 mg iv zofran\n with no relief. Was then given 10 mg ivp compazine with no effect. With\n conxern for drug withdrawal pt was then medicated with 1 mg iv ativan\n and 50mcg iv Fentanyl. Pt instructed to use incentive spirometry. Resp\n status monitored closely. Pt kept npo for now in the setting of\n continued nausea but will have speech and swallow study in the am if\n stable overnoc from resp standpoint.\n Response:\n Successful extubation with pt tolerating minimal amts of supplemental\n o2. pt still having adequate hourly uo off lasix gtt and diamox. Pt\ns fluid balance neg 2.9 liters for 24 hrs but still overall positive\n for los.\n Plan:\n Continue to follow fluid balance and bolus with lasix as needed.\n Continue to monitor resp status closely and if pt has increasing resp\n distress notify medical team. Administer nafcillin as ordered.\n Continue to monitor for signs of narcotic/benzo withdrawal and\n medicate with ativan and Fentanyl as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658317,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Events:\n No growth to date on BCs, sputum or urine cultures\n Multiple vent changes made currently on\nARDS net\n settings\n"
},
{
"category": "Nursing",
"chartdate": "2181-02-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658320,
"text": "53 y/o M w/ a distant history of hodgkins disease s/p BMT in the 90\n who presented w/ influenza B and worsening hypoxia. Intubated on\n for hypoxic resp failure, and is now being treated for influenza\n as well as a probable PNA with SEPSIS.\n Events:\n No growth to date on BCs, sputum or urine cultures\n Multiple vent changes made currently on\nARDS net\n settings\n Sepsis without organ dysfunction\n Assessment:\n Pt. spiked temp again yesterday, however, has continued with low-grade\n temp throughout this shift. No growth to date in all BCs, urine and\n sputum cultures. ID consulted and in to see pt. yesterday. Antibiotic\n regime changed. Pt. received on levophed to maintain MAPS >60. Gtt\n weaned throughout the shift.\n Action:\n IV antibiotics admin as ordered. Hemodynamics monitored closely.\n Response:\n Pt. remains with low-grade temp. Hemodynamically stable throughout\n shift.\n Plan:\n Monitor hemodynamic status and support as necessary w/ pressor and\n volume. Continue antibiotics as ordered/\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout, suctioned for moderate amounts thin yellow\n secretions. Remains on vent. CPAP 50%/. Last gas 7.38/40/94. Sats\n >97%. Sedated on fent/versed.\n Action:\n Pt. kept on CPAP as pts own rate and volumes coincide w/ ARDS net\n protocol. Suctioned Q4h and prn.\n Response:\n Pt. remains stable on these vent settings. Also appears comfortable on\n sedation. Does arouse easily and nod head to questions asked.\n Plan:\n Cont to monitor resp status and wean vent support as tolerated.\n"
},
{
"category": "Social Work",
"chartdate": "2181-02-02 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 658544,
"text": "Family Information\n Next of : , (Wife)\n Health Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record\n Family Spokesperson designated: , (Wife) Phone:\n ; Other Phone: \n Communication or visitation restriction: Restriction on visitors. \n wife has given nursing a list of people who can see him.\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: First admission; he\n was last hospitalized in AZ approximately two years with what his wife\n reports as similar symptoms.\n Past psychiatric history: None known.\n Past addictions history: None known.\n Employment status: Employed\n Legal involvement: None known.\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: This worker met with pt's wife in response\n to RN concerns about her level of stress. Her 53 y/o husband was\n admitted with what had initially been flu symptoms. Recently, one of\n her 18 y/o twin sons had the flu is apparently concerned that he might\n have caused his father's illness. At this time, they have not seen the\n pt, nor does their mother want them to see him unless they are pushing\n the\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
}
] |
9,364 | 150,732 | 53 y/o male with ESLD due to Hep C/ETOH cirrhosis and HCC now with diuretic resistant ascites who presents for liver transplant. Of note he was called in several times previously over the last few weeks. He was taken to the OR on by Drs and who performed an orthotopic liver transplant with duct-to-duct anastomosis. The patient tolerated the procedure well and was transferred to the SICU, stable, intubated. He received protocol induction immunosuppression which included Solumedrol, and Cellcept, and started Prograf on pos op day 1. He was extubated on POD 1. In the post op period he required transfusion of 5 units RBCs and 3 units platelets. Over the course of the hospitalization the platelet count increased and the HCT remained stable. He was transferred out of the SICU on POD 3. evaluation of the liver revealed normal vasculature except the right hepatic artery. This was possibly a technical difficulty due to large abdominal size. A repeat U/S done on showed all patent vasculature including the RHA. There was some concern due to velocities in the main portal vein ranging from 109 to 149 cm/sec, which was similar to the previous study. An MR was initially suggestive of a Portal Vein stenosis and the patient was initiated on a heparin drip. Portal venography was performed on showing discrepancy in size between the native and donor portal veins with relative stenosis, but no significant pressure gradient across the anastomosis. No interventions were performed after discussion with Dr. . Drain Bili measured on was 8.1. The patient had one remaining JP at the time of this test which was putting out about 1-1.2 liters of ascitic fluid tinged with bile daily. Liver enzymes (AST and ALT) which had briefly elevated at the time of the portal venography trended back to normal. Alk phos remained slightly elevated in addition to serum bilirubin of 5.9. On , an ERCP was performed for concern for bile leak as the JP bili was 25.7. This revealed biliary narrowing at the site of duct to duct anastomosis. No extravasation of contrast was noted - high pressure cholangiogram was not obtained given recent transplant. A biliary sphincterotomy was performed and a biliary stent was inserted. Recommendations included repeating an ERCP in 2 months. LFTs trended down and the JP drainage decreased. A CT without iv contrast was performed on to assess for a perihepatic collection. A collection was noted and this was drained in CT for 260cc of serosanguinous fluid. A pigtail drain was left in place. Culture of this fluid was negative. The perihepatic drain and JP were left in place at time of discharge from the hospital. VNA services were arranged to assist with this at home. The JP drainage was ~700-1400cc/day. On (pod 9), the apex area of the incision was opened due to inadequete approximation of the incision and fluid noted at the site. A gram stain and culture were submitted and he was started on Ancef. Gram stain had 1+pmns without growth on the culture. Two 2x2 gauzes were placed at the apex. Immunosuppression consited of cellcept, prednisone and prograf titrated to 2mg . consult was obtain for assist with insulin management of hyperglycemia. Initially, he was on an insulin drip in the SICU, but this was switched to humalog sliding scale and glargine insulin. He did well with insulin teaching and experienced no low blood sugars. He was ambulatory, vital signs were stable and he was tolerating a regular diet when discharged home. | TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were obtained, including dynamic imaging performed prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. Pre- procedural non-contrast scan of the abdomen was performed, again demonstrating a perihepatic fluid collection. AP chest radiograph compared to shows replacement of the right IJ central venous catheter, which terminates at the confluence of the superior vena cava and brachiocephalic vein. IMPRESSION: Normal post-operative appearance of liver transplant without patent vasculature. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Unchanged small right pleural effusion and mild atelectasis of the right lung base. MRI OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is status post liver transplant. DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal vein are patent with hepatopetal flow. The stenosis is located 2.1 cm from the portal vein branch into the right and left portal veins, and 2.1 cm from the portosplenic confluence. The remaining hepatic vasculature is patent. (Over) 4:37 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # CT GUIDANCE DRAINAGE Reason: NEEDS TO BE DRAINED. 4:37 PM CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # CT GUIDANCE DRAINAGE Reason: NEEDS TO BE DRAINED. A newly inserted Swan-Ganz catheter over the right internal jugular vein is in standard position. The hepatic veins and inferior vena cava are patent. The right middle and left hepatic veins as well as the inferior vena cava are patent with normal waveforms. The main, left, and right hepatic arteries are patent with normal waveforms. Small right pleural effusion and ascites as described. The bladder, distal ureters, the rectum, and sigmoid colon are normal. No (Over) 11:14 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: assess for fluid collection or abscesses Admitting Diagnosis: END STAGE LIVER FAILURE FINAL REPORT (Cont) abscess cavity or hematoma. COMPARISON: Liver Doppler ultrasound . The impression should state normal postoperative appearance of the liver transplant with patent vasculature and no evidence of biliary ductal dilatation. IMPRESSION: Discrepancy in size between the native and donor portal veins with relative stenosis, but no significant pressure gradient across the anastomosis. The imaged aorta is of normal caliber. Placed on A/C, ABG slight resp. Resp Care,Pt. PT WEANED OFF OF NEO. JP'S PATENT - MOD AMT OF SEROUS DRAINAGE OUT. MD aware.ENDO: BS elevated. HOLDING HEPARIN PER DR. . CONDITION UPDATEVSS. Wean from neo gtt as tolerated. SICU NN: SEE CAREVUE FOR SPECIFICS. Dr. and Dr. notified of values. U/O ADEQUATE (SEE FLOWSHEETS). ENC IS, C/DB. WEANED OFF PPF. SVO2 AND CO WITHIN PT BASELINE. CONDITION UPDATEPT A/O X3. Turn/reposition as tolerated ? AFEBRILE. See carevue. Pt denies nausea. Medial JP and Lateral JP both patent and draining sanquinous fluild. RSR. Sinus rhythm. Sinus rhythm. Sinus rhythm. LUNGS CTA BILAT. U/O QS VIA FOLEY. BP WNL ON LOPRESSOR ATC. MD aware. POSSIBLE O.R. See carevue for details. IF HCT DROPS. + BS. REPEAT HCT 28.8. ADVANCED TO CLR DIET TODAY. USING IS.CV: NSR HR 70-80. PA PRESSURES UNCHANGED FROM PT BASELINE. admitted from OR intubated #8ET.BS equal. Sinus rhythm and occasional ventricular ectopy. TWO JP'S WITH SMALL AMT SEROSANG OUTPUT. RN admission noteSee Carevue for data & specifics. TOL CLEAR LIQUIDS. Pt able to cough up secretions. PO'S WELL. CVP 3-7. VSS. P.M. HCT PENDING. CVP 4-10. LS clear bilaterally,decreased at bases. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES. LUNGS CLEAR, DIMINISHED AT BASES. PAP 37-28/25. FOLEY ADEQUATE URINE OUTPUT. ORIG SURGICAL INCISION INTACT - MOD S/S DRAINAGE NOTED. LOWGRADE TEMP. Pt HCT stable at present, continue to follow HCTs.GI-Pt NPO, ok for sips with meds. SVO2 76-80. ABD OBESE. ABD OBESE. JP'S PUTTING OUT MIN SEROUS DRAINAGE, MOD AMT OF SEROUS DRAINAGE NOTED AROUND INSERTION SITE. PATIENT ALERT AND ORIENTED X 3. OOB today. LOW GRADE TEMP, PRESENTLY TEMP 98.8. PAIN/COMFORT. 4L NC. Wean from vent to extubate. ENCOURAGE TURN/COUGH/DEEP BREATHE. PROVIDE EMOTIONAL SUPPORT TO PT. FOLLOW PA NUMBERS. CO 7.8-12. SICU TEAM AND TRANSPLANT TEAMS AWARE. Currently 110s. NOT WEDGING SECONDARY TO LOW PLTS. CVP readings remain low 0-2 ?accuracy of readings. ? PA NUMBERS ACCEPTABLE; PAS 37 TO 45, CO 10 TO 14. PT WEANED SUCCESSFULLY TO CPAP - EXTUBATED AT 18:00 W/O INCIDENT. MONITORING HCT AND LFTS.GI: OBESE ABDOMEN. CVP CONT TO BE LOW HOWEVER PRESSURE LABILE, 3 -10. PT GIVEN 1UNIT OF PRBC'S THIS AM PER DR. ORDERS. SBP 140-160. MONITOR DRAIN OUTPUT. Compared tothe previous tracing of ventricular ectopy is absent. MAE EQUALLY. Non-diagnostic Q waves in leads II, III and aVF. 7pm-7am Nursing NoteSee CareVue for objective data and trends:NEURO-Pt alert and oriented X 3, follows commands appropriately.RESP-LS are coarse to clear and diminished at bases. Non-specific ST-T wavechanges. change PA line over to central IV access. JP X2 DRAINING AROUND INSERTION SITE, SM AMTS SER/SANG IN JP BULBS. O2 SAT ACCEPTABLE ON 4L NP. Abdomen is obese with positive bowel sounds. AS SHIFT PROGRESSED CVP DECREASING, PA READINGS LOWER, PT GIVEN MULT FLUID BOLUSES W/ MOD EFFECT MD'S ORDERS. Monitor recalibrated and now in 70s. MOD AMT OF SUCTIONING FOR THICK TAN SECRETIONS. | 29 | [
{
"category": "Radiology",
"chartdate": "2139-08-10 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1021204,
"text": " 10:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: blood flow\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o liver transplant\n REASON FOR THIS EXAMINATION:\n blood flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 5:26 PM\n No flow identified in the right hepatic artery otherwise patent vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with recent liver transplant.\n\n COMPARISON: Liver Doppler ultrasound .\n\n FINDINGS: The liver shows no focal or textural abnormality. There is no\n biliary dilatation and the common duct measures 0.5 cm. There is no ascites\n seen and no perihepatic collections are identified.\n\n DOPPLER EXAMINATION: The main portal vein, right portal vein and left portal\n vein are patent with hepatopetal flow. Appropriate waveforms are identified\n in the main hepatic artery and the left hepatic artery. No flow was\n documented in the right hepatic artery but this may be due to technical\n factors. Appropriate flow is seen in the IVC and the hepatic veins.\n\n IMPRESSION:\n 1. No flow detected in the right hepatic artery. This finding may be due to\n technical difficulties. A repeat ultrasound is suggested. The remaining\n hepatic vasculature is patent.\n 2. No biliary dilatation. No fluid collection is identified.\n\n These findings were discussed with Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-10 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1021205,
"text": ", J. SICU-A 10:23 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: blood flow\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o liver transplant\n REASON FOR THIS EXAMINATION:\n blood flow\n ______________________________________________________________________________\n PFI REPORT\n No flow identified in the right hepatic artery otherwise patent vasculature.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-14 00:00:00.000",
"description": "MRI ABDOMEN W/O & W/CONTRAST",
"row_id": 1021985,
"text": " 3:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess liver transplant vasculature specifically the portal\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: MAGNEVIST Amt: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTS. US showed high portal vein velocity. Unable to get CTA given\n iodine allergy\n REASON FOR THIS EXAMINATION:\n assess liver transplant vasculature specifically the portal vein\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant on for hepatitis C/HCC\n cirrhosis. Elevated LFTs. Ultrasound demonstrated high portal vein velocity.\n Iodine allergy. Assess liver transplant vasculature, specifically portal\n vein.\n\n COMPARISON: Liver ultrasound and Doppler of .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were\n obtained, including dynamic imaging performed prior to, during, and after the\n uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\n Multiplanar 2D and 3D reformatted images and subtraction images were generated\n and reviewed on an independent workstation.\n\n MRI OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The patient is status post\n liver transplant. The hepatic artery is patent, with patency of branches in\n the right and left lobes of the liver seen. The portal vein is patent,\n however, there is a severe stricture at the presumed anastomotic site, where\n the portal vein passes just posterior to the hepatic artery crossing\n anteriorly. This finding is perhaps best demonstrated on reformatted images\n (series 282, image 25). Proximal and distal to this severe focal stenosis,\n the portal venous caliber is normal to large. The hepatic veins and inferior\n vena cava are patent.\n\n No focal liver lesions are seen. There is no intra- or extra-hepatic biliary\n ductal dilatation. A choledochocholedocho anastomosis is seen (4:19). The\n spleen is large, measuring 18.9 cm in craniocaudad dimension. There is a\n wedge-shaped infarct measuring 2.5 cm in the posterior aspect of the spleen,\n and a second possible 7-mm infarct in the anterior spleen. The pancreas and\n adrenal glands are unremarkable. The kidneys enhance symmetrically and\n excrete normally. There is a 1-cm cyst in the interpolar region of the right\n kidney.\n\n The imaged aorta is of normal caliber. No lymphadenopathy is appreciated.\n There is a small right pleural effusion and small amounts of ascites within\n the abdomen. There are couple of foci of fluid within the abdomen for which\n followup will be necessary to determine if these are static or dynamic\n collections. One such focus of fluid measures 2.5 cm posterior to the spleen.\n Another such collection is medial to the native IVC, measuring 3.7 x 2.1 cm.\n (Over)\n\n 3:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess liver transplant vasculature specifically the portal\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: MAGNEVIST Amt: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar reformatted images were essential in the delineation of the portal\n venous stenosis and other findings described.\n\n IMPRESSION:\n\n 1. Severe portal vein stenosis, likely at the anastomosis. The stenosis is\n located 2.1 cm from the portal vein branch into the right and left portal\n veins, and 2.1 cm from the portosplenic confluence.\n\n 2. Patent hepatic artery and hepatic veins.\n\n 3. Splenomegaly with two small probable splenic infarcts.\n\n 4. Small right pleural effusion and ascites as described.\n\n Findings were discussed with Dr. on the surgical service at the\n conclusion of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-14 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1021906,
"text": ", J. FA10 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please assess liver transplant arterial/venous flow, assess\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n please assess liver transplant arterial/venous flow, assess for ductal\n dilatation\n ______________________________________________________________________________\n PFI REPORT\n Patent hepatic vasculature including the right hepatic artery. No biliary\n ductal dilation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-14 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1021905,
"text": " 8:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please assess liver transplant arterial/venous flow, assess\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant for HCV/HCC cirrhosis now with\n elevated LFTs\n REASON FOR THIS EXAMINATION:\n please assess liver transplant arterial/venous flow, assess for ductal\n dilatation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn FRI 4:33 PM\n Patent hepatic vasculature including the right hepatic artery. No biliary\n ductal dilation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man status post liver transplant on for\n hepatitis C/HCC cirrhosis, now with elevated LFTs.\n\n COMPARISON: Doppler ultrasound from .\n\n FINDINGS: No hepatic parenchymal abnormalities are appreciated. There are no\n perihepatic fluid collections. There is no biliary ductal dilation.\n\n The main, right anterior, right posterior and left portal veins are patent\n with appropriate waveforms. Velocities in the main portal vein range from 109\n to 149 cm/sec, similar to the previous study. The right middle and left\n hepatic veins as well as the inferior vena cava are patent with normal\n waveforms. The main, left, and right hepatic arteries are patent with normal\n waveforms.\n\n IMPRESSION:\n 1. Patent hepatic vasculature, including the right hepatic artery, which was\n not seen on the prior study.\n\n 2. No evidence of biliary ductal dilation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1021401,
"text": " 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: catheter location\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p rewiring of cvl\n REASON FOR THIS EXAMINATION:\n catheter location\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg TUE 2:52 PM\n Replacement of right IJ central venous catheter, which terminates at the\n confluence of the SVC and brachiocephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 53-year-old male status post rewiring of central venous\n line. Evaluate catheter location.\n\n AP chest radiograph compared to shows replacement of the right IJ\n central venous catheter, which terminates at the confluence of the superior\n vena cava and brachiocephalic vein. There is no pneumothorax. Since the last\n exam, the patient has been extubated. Small right pleural effusion is\n slightly increased in size. The cardiomediastinal contour is unchanged. Post-\n surgical changes related to median sternotomy and CABG are present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1021402,
"text": ", J. SICU-A 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: catheter location\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p rewiring of cvl\n REASON FOR THIS EXAMINATION:\n catheter location\n ______________________________________________________________________________\n PFI REPORT\n Replacement of right IJ central venous catheter, which terminates at the\n confluence of the SVC and brachiocephalic vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-20 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1022889,
"text": " 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant, continues with large volume drain output\n REASON FOR THIS EXAMINATION:\n assess for fluid collection or abscesses\n CONTRAINDICATIONS for IV CONTRAST:\n iodine allergy\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:49 PM\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\n fluid characteristics. No hematoma or abscess.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with liver transplant and continued large volume\n drain output. Please evaluate for fluid collection or abscess.\n\n Comparison is made to the MR of the abdomen performed on .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis after administration of the oral contrast. No IV contrast was used.\n Sagittal and coronal reformatted images were then obtained.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Unchanged small right pleural effusion\n and mild atelectasis of the right lung base.\n\n There is a new large fluid collection at the gastrohepatic ligament measuring\n 10.2 x 5.8 cm, which based on its Hounsfield units (4 ) is relatively simple\n fluid rather than being a hematoma or abcess. No hematocrit effect is noted\n within this collection. The surgical clips are noted adjacent to the IVC and\n the portal vein. The patient is status post liver transplant. The drain\n anterior to the right lobe of the liver terminates in the right lower quadrant\n area. The biliary drain is also in place.\n\n The enlarged spleen measures 18 cm. Multiple dilated tortuous vessels are not\n adjacent to the spleen suggesting the presence of varicosities setting of\n portal hypertension. Small amount of fluid is noted in both anterior pararenal\n spaces and perihepatic and perisplenic spaces and in the pelvis. The adrenal\n glands, kidneys, and pancreas have normal appearance. The stomach, duodenum\n and loops of small bowel and large bowel have normal appearance.\n\n The bladder, distal ureters, the rectum, and sigmoid colon are normal. Small\n amount of fluid is noted within the pelvis. No pathologically enlarged\n pelvic, inguinal, mesenteric, or retroperitoneum nodes are noted. The aorta is\n moderately calcified with no aneurysm or stenosis.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Enlarging 10.2 x 5.8 cm fluid collection in the gastrohepatic ligament. No\n (Over)\n\n 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n abscess cavity or hematoma.\n\n 2. Status post liver transplant with signs of prior portal hypertension with\n splenomegaly and multiple perisplenic collaterals.\n\n 3. Small amount of fluid in perihepatic, perisplenic spaces and within the\n pelvis.\n\n Findings were discussed with Dr at the time of dictataion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-20 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1022890,
"text": ", J. FA10 11:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection or abscesses\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant, continues with large volume drain output\n REASON FOR THIS EXAMINATION:\n assess for fluid collection or abscesses\n CONTRAINDICATIONS for IV CONTRAST:\n iodine allergy\n ______________________________________________________________________________\n PFI REPORT\n 10 x 6 cm fluid collection in the gastrohepatic ligament which has simple\n fluid characteristics. No hematoma or abscess.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-07 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1020840,
"text": " 3:14 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE LIVER FAILURE\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with HCV cirrhosis to undergo transplant today\n REASON FOR THIS EXAMINATION:\n For Pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Preoperative evaluation.\n\n COMPARISON: .\n\n IMPRESSION: No relevant changes as compared to the previous examination.\n Mild cardiomegaly, without overhydration. No pleural effusion, no focal\n parenchymal opacity suggestive of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1020885,
"text": " 4:31 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new r ij cvl/paline\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with liver txp\n REASON FOR THIS EXAMINATION:\n new r ij cvl/paline\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant.\n\n COMPARISON: .\n\n FINDINGS: Status post liver transplant. There is a newly inserted\n endotracheal tube located 4 cm above the carina. A newly inserted Swan-Ganz\n catheter over the right internal jugular vein is in standard position. The\n course of the catheter is unremarkable, there are no signs of complications,\n no evidence of pneumothorax. A small pneumothorax, however, is seen in the\n left lung. The apical gap of the pneumothorax averages 8-10 mm. There are no\n signs of tension. Except for small areas of retrocardiac atelectasis, there\n are no other parenchymal abnormalities. The size of the cardiac silhouette is\n unchanged. No pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-08 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1020906,
"text": " 7:45 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: SP LIVER TX EVAL FOR FLOW\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM\n\n There is a transcription error in the impression. The impression should state\n normal postoperative appearance of the liver transplant with patent\n vasculature and no evidence of biliary ductal dilatation.\n\n\n\n 7:45 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: SP LIVER TX EVAL FOR FLOW\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man pod 0 s/p liver txp\n REASON FOR THIS EXAMINATION:\n please assess vasculature / flow / biliary tree doppler\n ______________________________________________________________________________\n FINAL REPORT\n LIVER, GALLBLADDER ULTRASOUND\n\n INDICATION: 53-year-old man post-liver transplant.\n\n The liver transplant appears unremarkable, without evidence of peritransplant\n fluid collection. There is no intrahepatic biliary ductal dilatation.\n\n Doppler examination demonstrates normal color flow and waveforms in the\n hepatic arteries, veins and portal veins, as well as IVC.\n\n Common duct measures 5 mm.\n\n IMPRESSION: Normal post-operative appearance of liver transplant without\n patent vasculature.\n\n Findings were discussed with Dr. at 3 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-19 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1022987,
"text": " 12:27 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p OLTX, with bile leak.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: Patient is a 53-year-old male status post liver\n transplant, presenting with biliary leak status post ERCP , for review\n of ERCP images.\n\n EXAMINATION: 33 single spot fluoroscopic images from ERCP reviewed.\n\n FINDINGS: 33 single spot fluoroscopic images obtained by gastroenterologist\n without radiologist present reviewed. Surgical hardware from liver transplant\n noted in fluoroscopic images. There is a 10-mm long single smooth stricture\n present in the middle third of the common bile duct, likely at the site of the\n duct-to-duct anastomosis. There is some mild post-obstructive dilitation of\n the biliary tree. The visualized biliary tree is otherwise unremarkable. There\n is interval placement of a common bile duct biliary stent.\n\n IMPRESSION: Common bile duct stricture at site of anastomosis status post\n stenting.\n\n Please refer to ERCP report on for full report, findings, and\n recommendations.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-15 00:00:00.000",
"description": "PERC PORTAL VEIN CATH",
"row_id": 1022099,
"text": " 12:01 PM\n PORTAL VENOGRAPHY Clip # \n Reason: Pt needs portal stent for stenosis\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: VISAPAQUE Amt: 80\n ********************************* CPT Codes ********************************\n * PERC PORTAL VEIN CATH INJ SINUS TRACT, THERAPUTIC *\n * -51 MULTI-PROCEDURE SAME DAY PERC TRANHEP PORTOGRAPHY WITH *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant with rising bili, CT showing stenosis at\n portal anastomosis.\n REASON FOR THIS EXAMINATION:\n Pt needs portal stent for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n PORTOGRAM WITH PRESSURES\n\n INDICATION: Seven days after liver transplant with increasing LFTs and\n suggestion of a portal venous anastomosis stenosis by MRV.\n\n Details of the procedure and possible complications were explained to the\n patient and informed consent was obtained.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist,\n was present for the entire procedure.\n\n TECHNIQUE AND FINDINGS: Using sterile technique, local anesthesia and\n conscious sedation, the peripheral portal branch in the right lobe of the\n liver was accessed with a 21-gauge needle and an Accustick sheath was placed\n over the wire using Seldinger technique. The catheter and the wire were then\n placed through the sheath and advanced into the splenic vein under\n fluoroscopic guidance. Portogram was performed in several projections. A\n pressure gradient was then measured across the portal vein anastomosis. There\n is some discrepancy in size of the donor and native portal veins with relative\n stenosis at their anastomosis, which is not hemodynamically significant. There\n is a very brisk flow through the anastomosis and the pressure gradient across\n the anastomosis was 3 mmHg.\n\n The findings were discussed with Dr. and it was decided not to perform\n any interventions at this time. The catheter was removed. The liver\n parenchymal tract was embolized with two Gelfoam pledgets through the sheath\n and the sheath removed.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Discrepancy in size between the native and donor portal veins\n with relative stenosis, but no significant pressure gradient across the\n anastomosis. No interventions performed after discussion with Dr. .\n\n\n (Over)\n\n 12:01 PM\n PORTAL VENOGRAPHY Clip # \n Reason: Pt needs portal stent for stenosis\n Admitting Diagnosis: END STAGE LIVER FAILURE\n Contrast: VISAPAQUE Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-08-20 00:00:00.000",
"description": "CT PERITINEAL DRAIN EXCLUDING APPENDICEAL",
"row_id": 1022948,
"text": " 4:37 PM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ********************************* CPT Codes ********************************\n * CT PERITINEAL DRAIN EXCLUDING APPEND -79 UNRELATED PROCEDURE/SERVICE DURI *\n * CT GUIDANCE DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p liver transplant and now with a new subhepatic fluid\n collection\n REASON FOR THIS EXAMINATION:\n NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE. SEND SAMPLE FOR\n GRAM STAIN AND CULTURE AND FOR TOTAL BILI\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man status post liver transplant, now with new\n subhepatic fluid collection.\n\n PROCEDURE:\n The risks, benefits, and alternatives, including intravenous moderate\n sedation, were explained to the patient who gave her an informed consent.\n\n A pre-procedural timeout was performed using two patient identifiers.\n\n The patient received intravenous moderate sedation (150 mcg of fentanyl, 3 mg\n of Versed), during the procedure. There was continuous monitoring by\n radiology nursing staff for a total intra-service time of 35 minutes.\n\n Pre- procedural non-contrast scan of the abdomen was performed, again\n demonstrating a perihepatic fluid collection. After review of the scan, a\n suitable site for catheter placement was chosen. The overlying skin was\n prepped and draped in usual sterile fashion. 10% lidocaine was given in the\n subcutaneous tissues as local anesthetic. Under CT guidance, an 8 French\n catheter was advanced into the collection. Approximately 260 cc of\n serosanguineous fluid was aspirated. The catheter was connected to a drainage\n bag and securely fastened to the skin using a StatLock device. A sterile\n dressing was applied. The patient tolerated the procedure, without immediate\n post-procedural complications.\n\n Samples were sent to the lab for bilirubin and amylase as well as gram stain\n and culture.\n\n Dr. , the attending physician, present for and performed the\n entire procedure.\n\n IMPRESSION: Successful placement of catheter into perihepatic fluid\n collection.\n\n\n (Over)\n\n 4:37 PM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; -79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE\n Reason: NEEDS TO BE DRAINED. PLEASE PLACE AND LEAVE DRAIN IN PLACE.\n Admitting Diagnosis: END STAGE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2139-08-09 00:00:00.000",
"description": "Report",
"row_id": 134749,
"text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-08-08 00:00:00.000",
"description": "Report",
"row_id": 134750,
"text": "Sinus rhythm. Small non-diagnostic Q waves in the inferolateral leads.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof there is no significant diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-08-04 00:00:00.000",
"description": "Report",
"row_id": 134751,
"text": "Sinus rhythm. Non-diagnostic Q waves in leads II, III and aVF. Compared to\nthe previous tracing of ventricular ectopy is absent. Otherwise,\nno diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-08-03 00:00:00.000",
"description": "Report",
"row_id": 134752,
"text": "Sinus rhythm and occasional ventricular ectopy. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the recording is of\nimproved technical quality. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-08 00:00:00.000",
"description": "Report",
"row_id": 1385972,
"text": "CONDITION UPDATE\nVSS. LOWGRADE TEMP. AS SHIFT PROGRESSED CVP DECREASING, PA READINGS LOWER, PT GIVEN MULT FLUID BOLUSES W/ MOD EFFECT MD'S ORDERS. PT WEANED OFF OF NEO. WEANED OFF PPF. LUNGS COARSE THROUGHOUT. MOD AMT OF SUCTIONING FOR THICK TAN SECRETIONS. ABD OBESE. NO BOWEL SOUNDS AUSCULTATED. ORIG SURGICAL INCISION INTACT - MOD S/S DRAINAGE NOTED. JP'S PATENT - MOD AMT OF SEROUS DRAINAGE OUT. U/O ADEQUATE (SEE FLOWSHEETS). PT WEANED SUCCESSFULLY TO CPAP - EXTUBATED AT 18:00 W/O INCIDENT. PT REMAINS ON INSULIN DRIP - BSUGARS SOMEWHAT LABILE - INSULIN PROTOCOL FOLLOWED. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE W/ EFFECT.\nCONT CURRENT ICU CARE AND ASSESSMENTS. MONITOR FOR S/S OF BLEEDING/INFECTION/REJECTION. AGGRESSIVE PULMONARY TOILET. PAIN MANAGEMENT. PT AND FAMILY TEACHING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-09 00:00:00.000",
"description": "Report",
"row_id": 1385973,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt alert and oriented X 3, follows commands appropriately.\nRESP-LS are coarse to clear and diminished at bases. Pt able to cough up secretions. Pt weaned to nasal cannula at 6 liters O2 and pt's pox 96-98%.\nCV/Heme-Pt's HR 90s, NSR. CVP readings remain low 0-2 ?accuracy of readings. Pt given 2 units PRBC and 1 unit of platelets for HCT of 24.1 and PLTs 50. BPs running 110's/50s initially and now up to 130s/60s after transfusion. PA pressures low at start of shift but improved post transfusions as well Cardiac output trended up from 7 to during blood transfusion, Dr. aware of elevated C.O.(see flowsheet for specifics) Awaiting lab results post transfusion.\nGI-abdomen is obese, bowel sounds heard on auscultation. Pt taking small sips of water without difficulty. Pt denies nausea. No bowel movement overnight.\nGU-urine icteric in color, putting out 35-60cc of urine per hour.\nENDO-insulin drip continues-Blood sugars running 104-130s.\nPLAN-plan to change out PA catheter line today if pt remians stable. Monitor labs closely, follow HCT and platelet levels. Turn/reposition as tolerated ? OOB today. Monitor urine output closely.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-10 00:00:00.000",
"description": "Report",
"row_id": 1385976,
"text": "7pm-7am nursing note\nsee CareVue for objective data and trends:\nNeuro-pt is alert and oriented X 3, MAE, follows commands appropriately.\nResp-Pt on 4 liters via NC and maintaining pox at 96-98%. LS clear bilaterally,decreased at bases. Pt with productive cough, bringing up small amounts of white sputum.\nCV/heme-Pt HR 70s-80s in NSR. Pt BP 130s-140s/60s. PA pressures running 30-40s/. CVP 3-7. Pt HCT stable at present, continue to follow HCTs.\nGI-Pt NPO, ok for sips with meds. Abdomen is obese with positive bowel sounds. Pt c/o abdominal discomfort and getting morphine 2mg for pain with fair effect. Abdomen with surgical dressing and medial and lateral JP drains.\nGU-Pt urine output at has been >100cc/hr.\nPLAN-Follow HCTs, if HCT drops Dr. to consider pt going back to OR to explore abdomen. Follow LFTs as well as pt's levels have been trending up. ? change PA line over to central IV access.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-10 00:00:00.000",
"description": "Report",
"row_id": 1385977,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: A&OX3. MAE, WEAK. C/O INCISIONAL PAIN, RECIEVING 2MG MORPHINE W/EFFECT.\nRESP: SAT'S 97-99% 4L NC. LUNGS CLEAR, DIMINISHED AT BASES. PRODUCTIVE COUGH BRINGING UP SCANT/SMALL AMTS THICK WHITE SECRETIONS, USING YANKEUR APPROPRIATELY. USING IS.\nCV: NSR HR 70-80. SBP 140-160. CVP 4-10. RECIEVED 1UNIT PLATELETTES IN AM, GOAL TO MAINTAIN PLT LEVEL >50. SWAN TO REMAIN IN PER DR WHO SPOKE W/TRANSPLANT TEAM, AWARE THAT NUMBERS VARY GREATLY AT TIMES. PAP 37-28/25. SVO2 76-80. CO 7.8-12. MONITORING HCT AND LFTS.\nGI: OBESE ABDOMEN. + BS. NO BM. ADVANCED TO CLR DIET TODAY. PO'S WELL. LIVER US DONE AT BS, ORDERED TO MONITOR AV FLOW.\nENDO: INSULIN GTT, TITRATING ACCORDING TO SCALE.\nGU: FOLEY PATENT, ADEQUATE CYU.\nSKIN: TRANSPLANT INCISION C/D/I. JP X2 DRAINING AROUND INSERTION SITE, SM AMTS SER/SANG IN JP BULBS. ECCYMOSIS AROUND SWAN-GANZ SITE ON NECK, TEAMS AWARE; ALSO SM AREA OF ECCYMOSIS NOTED ON LEFT SIDE OF NECK AS WELL.\nSOCIAL: FAMILY INTO VISIT. SISTER AND NEPHEW CALLED.\n\nPOC: MONITOR HCT, LFT'S. PLT >50. FOLLOW PA NUMBERS. ENC IS, C/DB. MONITOR DRAIN OUTPUT. PAIN/COMFORT. PROVIDE EMOTIONAL SUPPORT TO PT. HO AWARE OF ABOVE, NOTIFY W/ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-09 00:00:00.000",
"description": "Report",
"row_id": 1385974,
"text": "addendum to 7p-7am nursing note\nPt's repeat HCT, post 2 units of PRBCs only bumped to 25 (from 24.1) Dr aware. Pt given an additional 2 units PRBCs and an additional unit of platelets. Subsequent HCT level came back at 26.5 and platelets at 55. Dr. and Dr. notified of values. Further plan pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-09 00:00:00.000",
"description": "Report",
"row_id": 1385975,
"text": "CONDITION UPDATE\nPT A/O X3. VSS. LOW GRADE TEMP, PRESENTLY TEMP 98.8. SBP 102 TO 136. PA NUMBERS ACCEPTABLE; PAS 37 TO 45, CO 10 TO 14. CVP CONT TO BE LOW HOWEVER PRESSURE LABILE, 3 -10. SICU TEAM AND TRANSPLANT TEAMS AWARE. PT GIVEN 1UNIT OF PRBC'S THIS AM PER DR. ORDERS. REPEAT HCT 28.8. P.M. HCT PENDING. LUNGS CTA BILAT. O2 SAT ACCEPTABLE ON 4L NP. ABD OBESE. SURGICAL DRSG - OLD S/S STAINING. JP'S PUTTING OUT MIN SEROUS DRAINAGE, MOD AMT OF SEROUS DRAINAGE NOTED AROUND INSERTION SITE. U/O QS VIA FOLEY. PT C/O INCISIONAL PAIN - MEDICATED W/ MORPHINE MD'S ORDERS W/ EFFECT. CONT ON INSULIN DRIP.\nMONITOR FOR S/S OF BLEEDING. SERIAL LABS AS ORDERED. MONITOR FOR S/S OF INFECTION. ENCOURAGE TURN/COUGH/DEEP BREATHE. PAIN MANAGEMENT. PT/FAMILY TEACHING. POSSIBLE O.R. IF HCT DROPS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-08 00:00:00.000",
"description": "Report",
"row_id": 1385969,
"text": "Resp Care,\nPt. admitted from OR intubated #8ET.BS equal. Placed on A/C, ABG slight resp. acidosis. See carevue. No RSBI due to OR procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-08 00:00:00.000",
"description": "Report",
"row_id": 1385970,
"text": "RN admission note\nSee Carevue for data & specifics. See chart and FHP for HPI and medical history.\n\n53 yo male with hx of HCV/ETOH cirrhosis and hepatocellular carcinoma was received from the OR s/p liver transplant. No complications during case, per OR report.\n\nNEURO: pt sedated on ppf, MAE, does not follow commands, open eyes to loud stimuli, withdraws to pain, PERRL. Pt appeared to be in pain as assessed by vital signs and grimace. IV morphine given with positive result.\n\nCV: ST in 130s when arrived. Currently 110s. No ectopy. Episodes of hypotension to 70s systolic, 500 cc bolus x 1 given and neo gtt started, currently at 0.6 , MD aware. SV02 initially in 40s and 30s. MD aware. Monitor recalibrated and now in 70s. Wedge not done d/t elevated INR. CVP 6-8.\n\nRESP: Ventilated on AC. Initially put on 50% Fi02 but PA02 low, so increased to 100% then weaned to 70% and 50% with ABGs improving with each vent change.\n\nGI: NGT to suction, draining bilious fluid. Medial JP and Lateral JP both patent and draining sanquinous fluild. Abdominal dsg intact.\n\nGU: Foley draining clear urine but output slowly decreasing. MD aware.\n\nENDO: BS elevated. Insulin gtt started.\n\nSOCIAL: Nephew called for an update.\n\nPLAN: Continue to monitor VS closely. Monitor lab values closely and tx abnormal values as ordered. Wean from neo gtt as tolerated. Wean from vent to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-08 00:00:00.000",
"description": "Report",
"row_id": 1385971,
"text": "resp care - Pt was extubated without incident and placed on cool aerosol. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-08-11 00:00:00.000",
"description": "Report",
"row_id": 1385978,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT ALERT AND ORIENTED X 3. MAE EQUALLY. NO NEURO DEFICITS. 4L NC. LUNGS CLEAR. RSR. BP WNL ON LOPRESSOR ATC. AFEBRILE. CCO SWAN IN PLACE VIA CATHETER. PA PRESSURES UNCHANGED FROM PT BASELINE. NOT WEDGING SECONDARY TO LOW PLTS. SVO2 AND CO WITHIN PT BASELINE. STRONG PEDAL PULSES PALPABLE. LARGE OBESE ABDOMEN, SOFT, WITH BOWEL SOUNDS PRESENT, HYPOACTIVE AT TIMES. TOL CLEAR LIQUIDS. INCISION WITH DSD , NO DRAINAGE. TWO JP'S WITH SMALL AMT SEROSANG OUTPUT. FOLEY ADEQUATE URINE OUTPUT. MORPHINE SULFATE FOR PAIN. PNEUMO BOOTS. HOLDING HEPARIN PER DR. . PLAN: FOLLOW HCT'S AND PLTS, ?DC SWAN AND CHANGE TO CVL OVER WIRE TODAY, ?DC RICC LINE, MONITOR HEPATIC FUNCTION, IMMUNOSUPRESSIVES AS ORDERED, ?OOB, PAIN CONTROL.\n"
}
] |
56,960 | 149,518 | Right bundle-branch block.Non-specific ST-T wave changes. Right axis deviation. Sinus tachycardia with right bundle-branch block and secondary ST-T waveabnormalities. Compared to the previous tracing of right axis deviation is new. Sinus tachycardia. | 2 | [
{
"category": "ECG",
"chartdate": "2118-03-21 00:00:00.000",
"description": "Report",
"row_id": 222251,
"text": "Sinus tachycardia with right bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-21 00:00:00.000",
"description": "Report",
"row_id": 222250,
"text": "Sinus tachycardia. Right axis deviation. Right bundle-branch block.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nright axis deviation is new.\n\n"
}
] |
|
11,505 | 106,933 | 1)Chemical pneumonitis due to chlorine. Pt presented to ED with unresponsiveness and was intubated for airway protection and difficulty breathing. A toxicology consult was obtained and pt was treated with a course of steroids as per their recommendations. After 5 days of mechanical ventillation pt was extubated without difficulty. There was a minor component of reactive airway disease and so pt was given tiotropium and Advair. Because he has no history of COPD and was previously without respiratory compromise, tiotropium was discontinued. As he continued to have mild wheeze, Advair was continued with instrution to discontinue after one more week. 2)Possible aspiration pneumonia in addition to pneumonitis: On arrival to the MICU, there was concern that the pt may have developed an aspiration pneumonia in the setting of decreased consciousness. He was treated with 7 day course of antibiotics. | BS rhonchi, occ wheeze; no change with MDI's. Trivial mitral regurgitation is seen. LS dimished throughout, exp wheeze resolved throughout shift w/ administration of albuterol/Qvar. Normal ascending aortadiameter. There is a trivial/physiologicpericardial effusion. recieving antibx. Denies any discomfort.Resp: Remains on Time Cycled Pressure Controled Ventilation, PEEP dropped from 12 to 10, RR 28 -30. a febrile and continued on ceftriaxone iv. Compared to the previous tracing of nosignificant diagnostic change.TRACING #1 Neb treatment given.Cv: 1st degree av block, without any ectopy, SBP 110-120's, monitoring via lt radial aline. now suctioning increased tan thin sputum.+temp. resp careremains intubated/vented in spontaneous mode. BS clear upper and diminished at the bases. Left ventricular function.Height: (in) 68Weight (lb): 170BSA (m2): 1.91 m2BP (mm Hg): 167/59HR (bpm): 67Status: InpatientDate/Time: at 14:56Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. psv weaned to however pt with pronounced insp/expir wheezing and active exhalation. No other significant events.Review of Systems:Neuro: Lightly sedated on propofol, arouse to voice, able to track and follows commands. Suctioned for moderate-copious amounts of thin tan secretions.GU/GI: NPO, abd firm/nt/nd, +BS, -BM, patent foley draining >75cc clear yellow (occasional clots).Access: 18G R AC, 18 G L hand, L a-line, all ports flush appropriately.Plan: Cont to monitor/maintain heme/resp status. No c/o discomfort.CV: 1st deg AV block (PR .23), w/ no appreciable ventricular ectopy, art waveform dampened unable to get accurate pressure even with repositioning NBP 120's -140s. Lung sounds bilat I/E wheeze R>L with bibasilar rales; mod th off white sput. RESPIRATORY CARE:Pt remains intubated, vent supported. The mitral valve leaflets are mildlythickened. Please refer to carevue for objective data.Resp: Intubated 7.5 ETT 22 @ lip, Remains on 40% 12PS PEEP 5, RR 27-32, wheeze's persist despite albuterol/qvar nebs. Wean vent support, re-evaluate possibility of extubation in AM. Borderline first degree A-V block. Surface ecco performed @ bedside. Resp Care Note:Pt received from West ER intub with OETT and placed on mech vent as per Carevue. Please refer to carevue for objective data.GU/GI: NPO, abd firm/NT/ND, +BS, Patent foley draining >100cc/hr, urine became pink after pt recieved heparin SC/plavix po and has since resolved. Rest overnight, wean vent support and extubate @ earliest opportunity. Team does not suspect low airway compliance r/t Chlorine gas inhalation, as CXR inidicative for RUL infiltrates (probable aspiration).CV: 1st deg AV block (PR .23), no appreciable ventricular ectopy, ABP 120's-140 systolic. Trivial MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Tricuspid valve not well visualized.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Suboptimal image quality. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded. new sepsis.Continue to monitor respiratory and hemodynamic status. BS's diminished, sxing thick pale tan secretions. Plan to continue weaning vent support as pt can tolerate. BS tight with insp and expir wheezes. RESP: BS'S RHONCHEROUS THROUGHOUT AND SOME WHEEZING NOTED EARLIER. LAST ABG WAS BETTER.GI: TO BE STARTED ON TF'INGS. BS coarse wheezes, MDI's as ordered. UPDATED.PLAN: RECHECK ABG'S AND K+ LATER D/T DIURESIS. GIVEN ATIVAN 1MG AND FENT 100MCQS IVP X1, BUT PT. BP IMPROVED WITH SEDATION.ID: CONT. TRIES TO REACH FOR TUBE.EARLIER ABLE TO WRITE AND ALERT AND MOUTHING WORDS.CV: HYPERTENSIVE TO 160'S WITH AGITATION. tube feeds d/ced. DOES REQUIRE AN OCCASS BOLUS. NSG.NOTES 1900-0700HRSA case of chloride gas inhalation,intubated and ventillated.Neuro:Sedated with propofol 22.6mcg/kg/hr which titrated to 15.07mcg as pt sedated well and HR remains 42-50/min.responding to call and pain.easily arousable.Resp:Intubated and ventillated,mode CPAP+PS,PEEP 5,Psupp 12,fio2 50%.blood gas done 7.4/43/150/2/28.suctioned small thick yellow secretions.sats >95% RR 10-16/min.coarse on auscultation.CVS:HR 42-50/min when sleeping and >50's when awake.Sinus brady.no PVC'noted.BP 120-145/40-68 MM OF HG.GI/GU:Abdomen soft ,bowel sounds present, sump OGT in place,started on feed Nutren pulmonary 10 ml/hr and then advanced to 20ml/hr after 4 hours,feed started as MD and orders to be put in.nil residue.on foley cath,UO adequate ,clear yellow urine.Integu:skin impaired,blister on left upper leg ,open to air.both hands restrained,circulation adequate.pulse present.T max 97.bath given and repositioned.all hygenic needs attended.IV access:two PIV'S ;one on each hand,patent,dressing intact.site looks clean.A line on Left radial,patent,BP monitoring.dressing ,pressure kit and saline changed.Endo:on sliding scale insulin.Social:no family visit or phone call this shift.full codePlan:wean off .advance tube feed if tolerating to acheieve goal rate of 40ml/hr. Resp Care,Pt. goal for today to diurese and wean to extubate.neuro: pt very alet and able to write messages on 15 mcg/kg/hr propofol. extubated at 1630 with improved gag off propophol. BS's coarse with, exp wheezes. PLACED ON PS OF , BUT AFTER HRS PT. LS range from exp wheezes to course throughout. but urine output only 20-30cc/hr Plan; cont to support as pt is very bronchospastic, inhalers as ordered. failed wean of psv earlier with increased wheezing,and access muscle use. GU; foley in place and draining well. SUCTIONED FOR COPIOUS TO MOD. Post extubation vitals HR 67, BP 156/80, RR 19 and non labored, SpO2 95 % on 0.5 via OFM. able to cough and talk and oriented x3. IPS wean as tol. ABG showed pH 7.26/55/, trouble with rising PIP's during fluid bolus, changed over to PCV Peep of 12cm,inspiratory pressure of 37, generating TV 400-480cc minute ventilation of 9liters/min. on D5w @ 180cc/hr. resp careremains intubated/vented in spontaneous mode. ABG slightly improve to pH 7.28. bronchodilators q4 and q2 as needed. remains intubated overnoc on IPS 12. BOTH HAVE IMPROVED WITH DIURESIS. hypernatremia tx with d5w at 75 cc/hr as pt is npo for extubation and flushes of 50 cc/q4h held.resp: secretions ranging yellow to white frothy and blood tinged.pt coughing. c/w frequent secretions although less tan than yesterday. AMTS OF THICK YELLOW SECRETIONS Q1-2HRS. 88 yr old pt post chlorine inhalation. may need to repeat lytes this pm. ID: hypothermic to 95 orally, placed on bair hugger, blood culture x1 urine sent. | 24 | [
{
"category": "Echo",
"chartdate": "2175-08-03 00:00:00.000",
"description": "Report",
"row_id": 99933,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 167/59\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 14:56\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Aortic valve not well seen. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nSuboptimal image quality. The left atrium is normal in size. Left ventricular\nwall thickness, cavity size, and systolic function are normal (LVEF>55%). Due\nto suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. There is no ventricular septal defect. Right ventricular\nchamber size and free wall motion are normal. The aortic valve is not well\nseen. There is no aortic valve stenosis. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. There is a trivial/physiologic\npericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-08-01 00:00:00.000",
"description": "Report",
"row_id": 283073,
"text": "Sinus rhythm. Borderline first degree A-V block. ST junctional depressions\nwhich are non-specific. Compared to the previous tracing of no\nsignificant diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2175-08-02 00:00:00.000",
"description": "Report",
"row_id": 283072,
"text": "Baseline artifact. Sinus bradycardia. Compared to tracing #1 no significant\ndiagnostic change.\nTRACING #2\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-03 00:00:00.000",
"description": "Report",
"row_id": 1413155,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Weaned vent support from PCV to AC without event. BS's diminished, sxing thick pale tan secretions. Administering MDI's as ordered, see flowsheet for times and further pt data. Plan to continue weaning vent support as pt can tolerate. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-03 00:00:00.000",
"description": "Report",
"row_id": 1413156,
"text": "NPN M/SICU ICU DAY 2 (0700 -1900)\n\nEvents: Failed SBT this AM, became wheezy throughout all lung fields tachypneic, Co2 rose, pt tongued out OG tube which was replaced & confirmed by cxr, PS increased from to PS 12 PEEP 5, propofol restarted. Abx tx started. Surface ecco performed @ bedside. Pt rested comfortably for remainder of shift.\n\nReview of Systems;\n\nNeuro: Lightly sedated on propofol, opens eyes and nods head appropriately to questions, able to track and follow commands, MAE. No c/o discomfort.\n\nCV: 1st deg AV block (PR .23), w/ no appreciable ventricular ectopy, art waveform dampened unable to get accurate pressure even with repositioning NBP 120's -140s. Tmax 99.2. Please refer to carevue for objective data.\n\nResp: Intubated 7.5 ETT 22 @ lip, Remains on 40% 12PS PEEP 5, RR 27-32, wheeze's persist despite albuterol/qvar nebs. Suctioned for moderate-copious amounts of thin tan secretions.\n\nGU/GI: NPO, abd firm/nt/nd, +BS, -BM, patent foley draining >75cc clear yellow (occasional clots).\n\nAccess: 18G R AC, 18 G L hand, L a-line, all ports flush appropriately.\n\nPlan: Cont to monitor/maintain heme/resp status. Wean vent support, re-evaluate possibility of extubation in AM. Cont abx tx. Update family on POC as it develops.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-03 00:00:00.000",
"description": "Report",
"row_id": 1413157,
"text": "resp care\nremains intubated/vented in spontaneous mode. psv weaned to however pt with pronounced insp/expir wheezing and active exhalation. increased to , given combivent q4h and receiving inhaled steroid . now suctioning increased tan thin sputum.+temp. wheezing persists but pt denies any sob. unable to wean despite good rsbi, increased wheezing and sputum production.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-04 00:00:00.000",
"description": "Report",
"row_id": 1413158,
"text": "Nursing progress notes (0410)\nReview carevue for all other additional data\n\nAllergy: Iodine, iodine containing\ncode: full\n\n88 yo male with h/o CAD,s/p CABG, HTN and multiple urologic procedure,admitted to MICU with episode of unresponsives in seting of chlorine exposure and respiratory disress, pneumonia and failed SBT on . No significant events overnight.\n\nNeuro: Lightly sedated with propofol and increased the dose to 22mic/kg/min to keep him comfortable with ETT.Eyes opens spontaneously and following commands. Bilateral wrist restraints are in place for safety.\n\nResp: Vent mode changed to A/C to rest overnight, and plan to wean sedation and to do RSBI and SBT in am. Bilateral lung sounds coarse and exp wheeze, copius secreation with suction. Neb treatment given.\n\nCv: 1st degree av block, without any ectopy, SBP 110-120's, monitoring via lt radial aline. a febrile and continued on ceftriaxone iv. AM labs pending.\n\nGu/Gi: NPO, abd firm, BS present and no BM this shift. UO 30-120ml/hr via foley's catheter.\n\nSkin: Intact\nsocial; no call from family overnight\n\nPlan: wean sedation, SBT and ?possible extubation, patient with increased secreation and exp wheeze. ? to start TF if no extubation today. monitor temp curves and labs and continue antibiotics.\nEmotional support to patient and family and routine ICU care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-02 00:00:00.000",
"description": "Report",
"row_id": 1413151,
"text": "Resp Care Note:\n\nPt received from West ER intub with OETT and placed on mech vent as per Carevue. Lung sounds bilat I/E wheeze R>L with bibasilar rales; mod th off white sput. MDI given as per order and with good result. Pt initially with elevated PIPs. Attempted decreasing Vt and increase rate which resulted in autoPeep switched to PCV which resulted in lower PIP. Most recent ABG show slow improvement, may require more vent \"tweaking\" to optimize gas exchange today. Cont mech vent support/bronchodilators/inhaled steroids.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-02 00:00:00.000",
"description": "Report",
"row_id": 1413152,
"text": "NPN M/SICU ICU day 1 (0700 - 1900)\n\nEvents: A-line placed, Hypothermia/hypotension resloved, propofol weaned to 20mcg/kg/min from 45. PCP updated on current status. No other significant events.\n\nReview of Systems:\n\nNeuro: Lightly sedated on propofol, arouse to voice, able to track and follows commands. MAE. PEARL. Denies any discomfort.\n\nResp: Remains on Time Cycled Pressure Controled Ventilation, PEEP dropped from 12 to 10, RR 28 -30. Most recent ABG 7.36/41/121. LS dimished throughout, exp wheeze resolved throughout shift w/ administration of albuterol/Qvar. Team does not suspect low airway compliance r/t Chlorine gas inhalation, as CXR inidicative for RUL infiltrates (probable aspiration).\n\nCV: 1st deg AV block (PR .23), no appreciable ventricular ectopy, ABP 120's-140 systolic. T-max 99.9 not currently on prophylactic abx (team aware of rising temp). Please refer to carevue for objective data.\n\nGU/GI: NPO, abd firm/NT/ND, +BS, Patent foley draining >100cc/hr, urine became pink after pt recieved heparin SC/plavix po and has since resolved. Fluid Status +2.2 liters for LOS.\n\nAccess: 18G R AC, 18 G L hand, L radial A-line all ports flush appropriately.\n\nPlan: Monitor/maintain heme/resp status. Rest overnight, wean vent support and extubate @ earliest opportunity. Monitor rising temp, possible initiation of abx therapy. Update pt on POC as it develops.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-02 00:00:00.000",
"description": "Report",
"row_id": 1413153,
"text": "BS rhonchi, occ wheeze; no change with MDI's. Able to wean PEEP to 10 and will continue to wean as tolerated. Slight temp, ? new sepsis.\nContinue to monitor respiratory and hemodynamic status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-03 00:00:00.000",
"description": "Report",
"row_id": 1413154,
"text": "MICU Nursing Progress Note\n Respiratory: intubated and vented with settings of PCV PEEP 10cm, TV range 450-500cc RR 30, FIO240% this am weaned to A/C 450 x 20 breaths and 10cm PEEP ABG 7,38/44/99 will cont to wean with hopes of extubating this am. suctioned q3-4 hr for thick pink to tan sputum spec sent for culture. BS clear upper and diminished at the bases.\n Cardiac: HR 58-64 1st degree block. BP stable 110-120/60's\n neuro: sedated on propofol at 20mcg/kg/hr pt will respond to his name will answer to yes/no questions with nodding of head. is following commands. MAE, helping with turning in bed.\n GU foley in place, occasional clots passed, urine from yellow to pink.\n GI: NPO, abd firm with hypoactive BS, no stool,\n ID: low grade temp most of night, fully cultured, not on any antibx awaiting cultures..\n Plan: cont with vent wean as tolerated, extubate if possible. follow temp and awaiting culture results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-06 00:00:00.000",
"description": "Report",
"row_id": 1413169,
"text": "uneventful day:\n\nneuro: A&O x3 weak but oob to chair and commode with 1 assist .\n\ncard: d/ced a line. sys bp 130-165. nr 50' with sleep and up to 70 nsr no ectopy\n\nresp: pt progressed from 50% face tent to 3l nc. resp status improved with IS. copius amts yellow sputum. recieving antibx. pt developes wheeze with exertion and has good response to inhalers and uses inhalers at home\n\ngi: hem neg lg bm on commode. good appetite. this am pt seemed to have more congested cough after taking po liquids and does better with soft foods.\n\ngu: bun 25 creat 1.5 and output adequate. hx kidney stones.\n\nskin: noted blister on lt lower back to have skin test for poss herpes\nand sseveral scratch marks on back\n\nplan: prob call out soon. resp monitoring and increase strength\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-07 00:00:00.000",
"description": "Report",
"row_id": 1413170,
"text": "NPN 1900 - 0700\n\nNEURO: AXOX3, PLEASANT AND COOPERTIVE. NO C/O\n\nRESP: LOOSE COUGH W/ YELLOW SECRETIONS.ON 4 L NC , DOE MAINT SATS 96-99%\n\nC/V: SR -ST NO ECOTPY BP STABLE.\n\nF/E/N: UO ~ 50-60CC HR TOL PO'S.NO STOOL OVERNOC.\n\nPLAN: BE C/O TO FLOOR TODAY IF REMAINS STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-02 00:00:00.000",
"description": "Report",
"row_id": 1413150,
"text": "MICU Nursing Progress Note\n pt is an 88y/o gentleman who had been working on a leak near pool filter in small enclosed room,family found pt to be confused and heavy smell of chlorine gas.. placed in shower and pt became unresponsive\nEMT's called, in the ew pt was unresponsive, intubated for airway precautions.\n Respiratory: intubated on the vent with settings of A/C 450cc x 18 PEEP of 12cm. ABG showed pH 7.26/55/, trouble with rising PIP's during fluid bolus, changed over to PCV Peep of 12cm,inspiratory pressure of 37, generating TV 400-480cc minute ventilation of 9liters/min. RR 30. ABG slightly improve to pH 7.28. BS tight with insp and expir wheezes. on albuterol and added comivent inhaler cont to have wheezes and diminished bs throughout all lung fields.\n Cardiac: HR 50's SB, no VEA, BP has ranged from low of 86 to high of 100/ did receive one fluid bolus of LR 500cc ... ?poor complaince after fluid bolus.\n Electrolytes: serum calcium 5.7 repleted. magnesium 1.7, sodium 149, will treat with 2liters of free water. on D5w @ 180cc/hr.\n ID: hypothermic to 95 orally, placed on bair hugger, blood culture x1 urine sent. not on antibx at present.\n GU; foley in place and draining well. but urine output only 20-30cc/hr\n Plan; cont to support as pt is very bronchospastic, inhalers as ordered. pt is hypothermic,bradycardic,hypotensive, ?thyroid labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-04 00:00:00.000",
"description": "Report",
"row_id": 1413159,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Rested overnight on AC. BS's coarse with, exp wheezes. Administering MDI's as ordered. Sxing copious yellow secretions. RSBI=88 this am. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413165,
"text": "88 yr old pt post chlorine inhalation. goal for today to diurese and wean to extubate.\n\nneuro: pt very alet and able to write messages on 15 mcg/kg/hr propofol. increased to 9 cc= 16+ mcg/kg/min for pt attempting to pull on et tube and biting et tube. ablo to MAE and good ROM.\n\ncard: hr drops to 40's with sleep but up when aroused. range 45-60 /min no pvcs notedbp 130-160 sys range. lasix 40 mg given at 1200 to diurese with good response at 1330 1000 cc+ output. just prior to lasix output dropped off to 20 cc/hr. hypernatremia tx with d5w at 75 cc/hr as pt is npo for extubation and flushes of 50 cc/q4h held.\n\nresp: secretions ranging yellow to white frothy and blood tinged.\npt coughing. LS range from exp wheezes to course throughout. blood gas after lasix is good except o2 80%. on 50% o2.\n\ngi/gu no bm today tube feeding off at 1200 for poss extubation . tolerated 20 cc/ hr and md requested 50 cc h2o flush q 4h but did not order. bs present. foley urine slightly brown tinged ? medication effects. GAG reflex is poor and will need to eval with propophol turned off prior to extubation\n\nskin NO breakdown,\n\niv access: 1 PIV both \n\nsocial: family called on phone and updated.\n\nendo: covered glucose as ordered, day 3 of 4 steroids administration.\n\nplan: poss extubate if gag and gas ok. resume tf if not extubated\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413166,
"text": "Respiratory Care\nPt extubated today at 1630. Post extubation vitals HR 67, BP 156/80, RR 19 and non labored, SpO2 95 % on 0.5 via OFM. No stridor was noted and lung sounds had slight exp wheeze in the RUL and clear else where. Pt has a strong cough and is able to speak. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413167,
"text": "extubated at 1630 with improved gag off propophol. able to cough and talk and oriented x3. cxr post done as soft tissue swelling on lt neck noted post extubation. tube feeds d/ced. pt had 2400 cc response to lasix given at 1200 and vital are stable. may need to repeat lytes this pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-06 00:00:00.000",
"description": "Report",
"row_id": 1413168,
"text": "NPN 1900-0700\nNeuro: Alert, oriented x3, denied any pain or discomfort.\n\nResp: Breathing regularly on FT 50%, RR 18-28, Sat 95-100%, LS CTA, coughing and expectorating moderate amount of thick yellowish secretions, which he spits in the kidney basin and sometimes suctioned by yanker, CPT done frequently, receiving resp. puffs.\n\nCV: SB-NSR HR 57-69, BP 119-159/59-104, with A-line and 2 PIV lines on ceftriaxone IV.\n\nGI/GU: NPO, yet tolerated meds with little water very well, abdomen soft, BS present, no BM during the night, with Foley cath drained adequate U/O.\n\nInteg: T max 98.2, covered with 2 units Humalogue insulin for FS 125 as per sliding scale.\n\nSocial: Full code, no contact from family over night.\n\nPlan: Monitor respiratory status and wean O2 as tolerated, perform CPT and continie resp tx, continue antibiotics, monitor FS and cover with insulin per sliding scale, consider nutrition, if stable, possible C/O of ICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-04 00:00:00.000",
"description": "Report",
"row_id": 1413160,
"text": "RESP: BS'S RHONCHEROUS THROUGHOUT AND SOME WHEEZING NOTED EARLIER. SUCTIONED FOR COPIOUS TO MOD. AMTS OF THICK YELLOW SECRETIONS Q1-2HRS. SECRETIONS HAVE DECREASED SINCE GIVING HIM LASIX. DESATED SEVERAL TIMES REQUIRING UPPING HIS FIO2 TO 50%. PLACED ON PS OF , BUT AFTER HRS PT. DECOMPENSATED AND PLACED BACK TO WHERE HE REMAINS. LAST ABG WAS BETTER.\nGI: TO BE STARTED ON TF'INGS. PASSING FLATUS. NO STOOL.\nRENAL: GIVEN 40MG LASIX IVP WITH EXCELLENT DIURESIS.\nENDOC: NA 147 K+ 4.8 THIS AM. BOTH HAVE IMPROVED WITH DIURESIS. SSI INSULIN GIVEN.\nNEURO: PROPOFOL OFF FOR A BRIEF PERIOD DURING PS TRIAL. GIVEN ATIVAN 1MG AND FENT 100MCQS IVP X1, BUT PT. BECAME MORE AGITATED AND PROPOFOL BACK ON. DOES REQUIRE AN OCCASS BOLUS. PT. TRIES TO REACH FOR TUBE.\nEARLIER ABLE TO WRITE AND ALERT AND MOUTHING WORDS.\nCV: HYPERTENSIVE TO 160'S WITH AGITATION. BP IMPROVED WITH SEDATION.\nID: CONT. ON ANTIBIOTICS. AFEBRILE.\nACCESS: NEW IV PLACED IN LEFT ANTECUB.\nSOCIAL: WIFE IN BY HO'S. SON ALSO IN AS WELL AS HIS PCP. UPDATED.\nPLAN: RECHECK ABG'S AND K+ LATER D/T DIURESIS. CONT. ON PS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-04 00:00:00.000",
"description": "Report",
"row_id": 1413161,
"text": "resp care\nremains intubated/vented in spontaneous mode. failed wean of psv earlier with increased wheezing,and access muscle use. c/w frequent secretions although less tan than yesterday. bronchodilators q4 and q2 as needed. reassess daily for wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413162,
"text": "blister on Left lower back present,open to air.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413163,
"text": "NSG.NOTES 1900-0700HRS\n\nA case of chloride gas inhalation,intubated and ventillated.\n\nNeuro:Sedated with propofol 22.6mcg/kg/hr which titrated to 15.07mcg as pt sedated well and HR remains 42-50/min.responding to call and pain.easily arousable.\n\nResp:Intubated and ventillated,mode CPAP+PS,PEEP 5,Psupp 12,fio2 50%.blood gas done 7.4/43/150/2/28.suctioned small thick yellow secretions.sats >95% RR 10-16/min.coarse on auscultation.\n\nCVS:HR 42-50/min when sleeping and >50's when awake.Sinus brady.no PVC'noted.BP 120-145/40-68 MM OF HG.\n\nGI/GU:Abdomen soft ,bowel sounds present, sump OGT in place,started on feed Nutren pulmonary 10 ml/hr and then advanced to 20ml/hr after 4 hours,feed started as MD and orders to be put in.nil residue.\non foley cath,UO adequate ,clear yellow urine.\n\nIntegu:skin impaired,blister on left upper leg ,open to air.both hands restrained,circulation adequate.pulse present.T max 97.bath given and repositioned.all hygenic needs attended.\n\nIV access:two PIV'S ;one on each hand,patent,dressing intact.site looks clean.A line on Left radial,patent,BP monitoring.dressing ,pressure kit and saline changed.\n\nEndo:on sliding scale insulin.\n\nSocial:no family visit or phone call this shift.full code\n\nPlan:wean off .advance tube feed if tolerating to acheieve goal rate of 40ml/hr.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-08-05 00:00:00.000",
"description": "Report",
"row_id": 1413164,
"text": "Resp Care,\nPt. remains intubated overnoc on IPS 12. VT 500 RR 18. BS coarse wheezes, MDI's as ordered. Suctioned for moderate amount thick yellow sputum. ABG acceptable, RSBI 52 this am. Cont. IPS wean as tol.\n"
}
] |
25,210 | 197,950 | The patient is an 82-year-old woman with a history of nonischemic cardiomyopathy, CHF, who presents to the CCU status post an episode of V tach, status post multiple shocks that were unable to resolve the V tach, status post EP study without inducibility of the rhythm, although the patient was found to have an infra HIS block resulting in a DDD pacer being placed. The patient received boluses of Amiodarone 150 mg times one and was loaded on IV Amiodarone for the V tach. 1. CARDIOLOGY: Rhythm/V tach: After the load of 1 mg per minute and vagal bang down broke into normal sinus rhythm. The Amiodarone was initially decreased to 0.5 mg per minute. She was converted to Amiodarone 400 mg p.o. q.d. and the Amiodarone was discontinued after the patient had been loaded sufficiently. The patient was started on low-dose of beta blocker 25 p.o. b.i.d. The patient had a run of sustained V tach on at approximately 4:00 p.m. and was given IV 2.5 Lopressor and the rhythm spontaneously reverted back to normal sinus rhythm. She had a 50 plus beat run of V tach at 8:55 a.m. on , again nonsymptomatic and then the ectopy tended to decrease, having three to four beats of NSVT on and four beats on . The Lopressor was converted to Toprol XL 50 mg q.d. at discharge. Of note, the patient received Amiodarone 400 mg b.i.d. for one week and then was transitioned to 400 q.d. | Mild tricuspid [1+]regurgitation is seen. Left ventricular function.Height: (in) 62Weight (lb): 143BSA (m2): 1.66 m2BP (mm Hg): 103/41HR (bpm): 73Status: InpatientDate/Time: at 16:02Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Right ventricular systolic functionappears depressed.AORTA: The aortic root is normal in diameter. CARDIAC ECHO DONE WITH (-) EFFUSION AND TAMPONADE. There is mild mitral annular calcification. Abd soft distended, +BS, -BM.GU: Pt has f/c with marginal u/o. PATIENT/TEST INFORMATION:Indication: r/o effusion.BP (mm Hg): 105/71HR (bpm): 75Status: InpatientDate/Time: at 06:06Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Left ventricular wall thicknesses are normal. R fem hematoma ecchymotic, but stable. TRANSCUTANEOUS PADS LEFT IN PLACE. Left ventricular wall thicknesses arenormal. ABD SOFT WITH (+) BSS. +BruitResp: Pt on 2L via NC, BS clear in upper airway, fine rales in bases. The heart size is at the upper limits of normal. Pt on 2Lnc with sats 95-98.GI=abd soft and slightly distended. There are focal calcificationsin the aortic root.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolichypertension. The leftventricular cavity is moderately dilated. "O-MS: A/O/X/3. Radial pulses 3+ and equal bilat. Tolerating Lopressor dose. Right ventricular systolic functionappears depressed. There is nomitral valve prolapse. PA AND LATERAL CHEST: Permanent pacemaker is present, with leads terminating in the right atrium and right ventricle. Probable sinus rhythm with ventricular pacing witha typical precordial progression for right ventricular pacing. Biapical thickening is noted. RIGHT GROIN SITE ECCYMOTIC WITH HEMATOMA. The left ventricular cavity isdilated. The left ventricular cavity is moderately dilated. There is no significant mitral stenosis.Moderate to severe (3+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The aortic valve leaflets (3) are mildly thickened but notstenotic. Hematoma Right fem/groin.Lungs= normal resp with no SOB. Acatheter or pacing wire is seen in the right atrium and/or right ventricle.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. DENIES SOB.GU/GI: FOLEY IN PLACE. (+)CSM. PULSES 2+ PALPABLE THROUGHOUT. Ventricular tachycardia. Since the previous tracing of nosignificant change. Right groin stable with no noted expansion.Anticipate call out to floor, refer to transfer note for detailed note. pedal pulses 1+ bilat. There is systolic anterior motion of the mitral valveleaflets. Since the previous tracing of nosignificant change.TRACING #2 LYTES WNLS. COLOR PALE AND DIAPHORETIC. The right common, superficial and deep femoral arteries are patent, and the peak velocities at these levels are 97, 91 and 88 cm/sec, respectively. Right AC perph iv patent, left lower arm perph iv patent. Rightventricular chamber size is normal. Rightventricular chamber size is normal. The leftventricular cavity is dilated. cough intact. Moderate to severe (3+) mitral regurgitation is seen. (+)BRUIT. pt taking po amio and metoprolol. IMPRESSION: Satisfactory positioning of pacemaker. There is mild pulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. Follow-up duplex ultrasonographic examination showed absence of flow in the pseudoaneurysm and normal patency and waveforms in the right common femoral artery. SINCE ADMISSION PT 3LS(+). Pacer rhythmventricular premature complexSince last ECG, no significant change BP STABLE AND PT ALERT. pt reports positive flatus. GIVEN SMALL SIP OF H2O OVERNIGHT.ID: AFBERILE. There is systolic anterior motionof the mitral valve leaflets. DDD PACER PLACED SUCCESFULLY BUT UNABLE TO REPRODUCE VT. PT LATER ADMITTED TO FLOOR WHERE DOING FINE UNTIL AROUND MN WHEN PT WHEN INTO VT WITH A RATE OF 170S TO 200S. Small pleural effusions are evident bilaterally. Thetricuspid valve supporting structures are normal. OLIGURIC. 7p-11pNeuro= pt A&O x3. There is severe global left ventricularhypokinesis.MITRAL VALVE: The mitral valve leaflets are mildly thickened.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Conclusions:Left ventricular wall thicknesses are normal. Pt c/o pain in L shoulder secondary to pacer placement, relieved with percocet.Cardiac: Pt remains AV paced with occ , pt had 8 beat run of NSVT; pt able to feel palpatations with VT. Pts HR 60's-70's BP in low 100's sys, with MAP >60. PREVIOULSY EXPANDING ON FLOORS BUT SINCE HAS BEEN STABLE. There is severeglobal left ventricular hypokinesis (ejection fraction approximately 20percent). CONCLUSION: Right groin pseudoaneurysm, with circulating portion measuring 1.2 x 1.6 cm, and connected to the higher portion of the right common femoral artery through a narrow neck. The needle was removed. There is severe global left ventricular hypokinesis. BUN/CREAT 24/0.9. IMPRESSION: Appropriately positioned pacing leads. CONCLUSION: 1. OBEYS AND FOLLOW COMMANDS APPROPRIATELY.MAES ON BED.CV: ARRIVING IN VT. BP DOWN INTO 80S POST AMIO LOAD FROM 100S SYS. Compared to the previous tracing no significant change.TRACING #3 The tricuspidvalve leaflets are mildly thickened. Sinus rhythm with ventricular pacing. The mitral valve leaflets are mildly thickened. APPEARING GREY AND SWEATY AGAIN. BP TREATED W/ 250CC BOLUS AND REPSONDANT. Informed consent was obtained and the right groin was sterilely prepped. A superficial hematoma is seen, located anteriorly to the right common femoral artery, with a circulating portion measured at 1.23 x 1.59 cm. SINCE BPS 90S TO 100S AND HR 60S TO 70S AVPACED. CKS ELEVATED IN 900S.RESP: LS WITH BIBASILAR CRACKLES. The mitral valveleaflets are mildly thickened. There is severe global leftventricular hypokinesis. (-) FOR PULSES PARADOX. This circulating hematoma or pseudoaneurysm is connected to the higher portion of the right common femoral artery through a narrow neck that shows to-and-fro flow pattern. grips strong and equal bilat. pt follows commands.CV=pt continues to be AV paced, Rate 70s-80s with frequent pvc's. PACER SITE CDI. LATER TOWARDS MORNING BP SPONTANEOUSLY DROPPING INTO 60S. A-V sequential paced rhythm. There ismild thickening of the mitral valve chordae. Pt amio gtt dc'd and started on po amio, and a low dose lopressor to help prevent VT. Pt has defib at bedside. | 18 | [
{
"category": "Radiology",
"chartdate": "2140-03-04 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 787606,
"text": " 9:00 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: check lead placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new pacemaker\n REASON FOR THIS EXAMINATION:\n check lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check lead placement, new pace maker.\n\n SINGLE VIEW CHEST: A left sided pace maker power pack is in place and the\n dual chamber pacing leads are in appropriate position. The heart size is at\n the upper limits of normal. No infiltrates identified and there are no\n pleural effusions. The question of prominence of the upper zone vessels may\n be due to technical factors.\n\n IMPRESSION: Appropriately positioned pacing leads.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-03-04 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 787649,
"text": " 2:57 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: RT GROIN BRUIT S/P EP STUDY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right groin bruit in an 82-year-old woman with recent cardiac\n catheterization for electrophysiologic study.\n\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\n examinations were performed at the level of the arteries and veins of the\n right groin.\n\n A superficial hematoma is seen, located anteriorly to the right common femoral\n artery, with a circulating portion measured at 1.23 x 1.59 cm. This\n circulating hematoma or pseudoaneurysm is connected to the higher portion of\n the right common femoral artery through a narrow neck that shows to-and-fro\n flow pattern.\n The right common, superficial and deep femoral arteries are patent, and the\n peak velocities at these levels are 97, 91 and 88 cm/sec, respectively.\n\n CONCLUSION: Right groin pseudoaneurysm, with circulating portion measuring 1.2\n x 1.6 cm, and connected to the higher portion of the right common femoral\n artery through a narrow neck.\n Close surveillance is recommended, with follow-up color Doppler ultrasound\n examination scheduled in three days from now.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-03-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 787872,
"text": " 8:31 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pacemaker\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new pacemaker\n\n REASON FOR THIS EXAMINATION:\n eval pacemaker\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pacemaker placement.\n\n PA AND LATERAL CHEST: Permanent pacemaker is present, with leads terminating\n in the right atrium and right ventricle. No pneumothorax is identified.\n\n The heart is enlarged, and there is upper zone vascular redistribution.\n Numerous thickened septal lines are present. Small pleural effusions are\n evident bilaterally. Biapical thickening is noted.\n\n IMPRESSION: Satisfactory positioning of pacemaker.\n\n Congestive heart failure pattern with interstitial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-03-07 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 787804,
"text": " 1:53 PM\n ART DUP EXT LO UNI;F/U; THROMBIN INJ PSEUDOANERYSM RIGHT Clip # \n GUID FOR PSEUDOANUREYSM (INJECTION)\n Reason: evaluate pseudoaneurysm on R, please compare to previous stu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with rt groin bruit s/p ep study\n\n REASON FOR THIS EXAMINATION:\n evaluate pseudoaneurysm on R, please compare to previous study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Surveillance of a right common femoral artery pseudoaneurysm post\n cardiac catheterization.\n\n TECHNIQUE AND FINDINGS: scale, color Doppler and spectral Doppler\n examinations was performed at the level of the arteries and veins of the right\n groin.\n\n The pseudoaneurysm is still present, with flow circulating within it, and its\n dimensions are slightly increased as compared to three days ago (1.87 x 2.25\n cm today).\n\n Decision was made to occlude the pseudoaneurysm by percutaneous thrombin\n injection. Informed consent was obtained and the right groin was sterilely\n prepped. Under real-time ultrasound and color Doppler guidance, a 21 gauge\n needle was advanced until its tip reached the pseudoaneurysm. 400 units of\n thrombin were injected, resulting in immediate cessation of flow within the\n pseudoaneurym. The needle was removed.\n\n Follow-up duplex ultrasonographic examination showed absence of flow in the\n pseudoaneurysm and normal patency and waveforms in the right common femoral\n artery.\n\n CONCLUSION:\n 1. Follow-up examination of a right common femoral artery pseudoaneurysm,\n with mild increase in diameter since three days ago.\n 2. Successful occlusion of this aneurysm by percutaneous injection of 400\n units of thrombin under color Doppler ultrasound guidance.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-03-05 00:00:00.000",
"description": "Report",
"row_id": 1591252,
"text": "CCU Nursing Progress Note 1900-0700: Stable VT arres\nVSS overnight. Unevenfut night. Complaining of right shoulder pain at inscional site. Given 2 percs for pain with good effect. Sleeping most of night. Tolerating Lopressor dose. Right groin stable with no noted expansion.\n\nAnticipate call out to floor, refer to transfer note for detailed note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 1591249,
"text": "CCU NURSING PROGRESS NOTE 1900-0700: VT\nHPI: IN BREIF 82 YO WHO PRESENTED ON IN STABLE VT AT OSH. AFTER MANY ATTEMPTS OF CARDIOVERSION PT CONVERTING AFTER AMIO LOAD TO NSR WITH BBB AND AV CONDUCTION DELAY. ON TRANSFERED TO EPS LAB FOR PACER PLACEMENT AND POSSIBLE ABLATION. DDD PACER PLACED SUCCESFULLY BUT UNABLE TO REPRODUCE VT. PT LATER ADMITTED TO FLOOR WHERE DOING FINE UNTIL AROUND MN WHEN PT WHEN INTO VT WITH A RATE OF 170S TO 200S. BP STABLE AND PT ALERT. NOT CV AT TIME. AMIO LOAD STARTED AND TRANSFERED TO CCU.\n\nSEE FHP FOR ALLERGIES AND PMH\n\nS-\"I FEEL HOT AND SWEATY.\"\n\nO-MS: A/O/X/3. VERY PLEASANT. OBEYS AND FOLLOW COMMANDS APPROPRIATELY.\nMAES ON BED.\n\nCV: ARRIVING IN VT. BP DOWN INTO 80S POST AMIO LOAD FROM 100S SYS. COLOR PALE AND DIAPHORETIC. GTT STARTED AT 1230 AT 1MG/MIN. BP TREATED W/ 250CC BOLUS AND REPSONDANT. PT SELF CONVERTING 15MIN POST CONTINUOUS INFUSION. LATER TOWARDS MORNING BP SPONTANEOUSLY DROPPING INTO 60S. APPEARING GREY AND SWEATY AGAIN. STATES NOT \"FEELING WELL.\"\nTOTAL OF 3 250CC NS BOLUSES GIVEN BEFORE PT RESPONDING. (-) FOR PULSES PARADOX. CARDIAC ECHO DONE WITH (-) EFFUSION AND TAMPONADE. SINCE BPS 90S TO 100S AND HR 60S TO 70S AVPACED. OCCASIONAL PVCS. LYTES WNLS. RIGHT GROIN SITE ECCYMOTIC WITH HEMATOMA. PREVIOULSY EXPANDING ON FLOORS BUT SINCE HAS BEEN STABLE. AREA SOFT. (+)BRUIT. PULSES 2+ PALPABLE THROUGHOUT. (+)CSM. AMIO GTT AT 1MG/MIN TILL FURTHER NOTICE THIS AM. LEFT GROIN CDI WITH NO HEMATOMA OR ECCYMOSIS. TRANSCUTANEOUS PADS LEFT IN PLACE. PACER SITE CDI. SLING REMOVED AND PT INSTRUCTED TO KEEP ARM IN PLACE. CKS ELEVATED IN 900S.\n\nRESP: LS WITH BIBASILAR CRACKLES. O2SATS 94-96% ON 3LNP. DENIES SOB.\n\nGU/GI: FOLEY IN PLACE. OLIGURIC. HUO 15-20CC/HR. URINE YELLOW AND SLIGHTLY CONCENTRATED. CCU TEAM AWARE. BUN/CREAT 24/0.9. SINCE ADMISSION PT 3LS(+). ABD SOFT WITH (+) BSS. NPO. GIVEN SMALL SIP OF H2O OVERNIGHT.\n\nID: AFBERILE. NO ISSUES. CONTINUE KEFZOL TIMES FOUR DOSES POST PACER.\n\nSOC: LIVES ALONE WITH VERY SUPPORTIVE SIGNIFICANT OTHER. HAS ONE SON WHO LIVE IN MA. FAMILY AND SO NOT AWARE EVENTS OVERNIGHT. PT WANTING TO WAIT TILL MORNING TO NOTIFY.\n\nA/P:S/P EPS WITH STABLE VT ARREST\nU/S OF RIGHT GROIN TODAY\nPOSSIBLE FORMAL CARDIAC ECHO\nPOSSIBLE RETURN TO EPS LAB\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 1591250,
"text": "CCU Nursing Progress Note\nNeuro: Pt A&O x3. Pt remains on bedrest secondary to R fem hematoma. Pt able to be at 30 degree angle. Pt c/o pain in L shoulder secondary to pacer placement, relieved with percocet.\n\nCardiac: Pt remains AV paced with occ , pt had 8 beat run of NSVT; pt able to feel palpatations with VT. Pts HR 60's-70's BP in low 100's sys, with MAP >60. Pt amio gtt dc'd and started on po amio, and a low dose lopressor to help prevent VT. Pt has defib at bedside. R fem hematoma ecchymotic, but stable. +Bruit\n\nResp: Pt on 2L via NC, BS clear in upper airway, fine rales in bases. O2 sat 98%.\n\nGI: Pt tolerating cardiac/low Na diet. Abd soft distended, +BS, -BM.\n\nGU: Pt has f/c with marginal u/o. Amber in color.\n\nID: Afebrile on cefzolin x4 s/p pacer placement.\n\nPt due to have echo and R fem ultrasound.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 1591251,
"text": "7p-11p\nNeuro= pt A&O x3. PERRLA at 3mm. grips strong and equal bilat. pt follows commands.\n\nCV=pt continues to be AV paced, Rate 70s-80s with frequent pvc's. pt taking po amio and metoprolol. Radial pulses 3+ and equal bilat. pedal pulses 1+ bilat. Right AC perph iv patent, left lower arm perph iv patent. Hematoma Right fem/groin.\n\nLungs= normal resp with no SOB. clear throughout. cough intact. Pt on 2Lnc with sats 95-98.\n\nGI=abd soft and slightly distended. bowel sounds hypoactive in all four quadrants. pt reports positive flatus. Pt reports last bm was and she normally has one to two bm's per day.\n\nGU=clear yellow urine via foley cathetar. Amts greater than 50cc per hour.\n\nendo= no issues.\n\nID= pt afebrile.\n\nsoc= pt states \"i'm lonely, I haven't been able to talk with my family today.\" pt has one son, grandchildren and en. Pt has significant other of 5 years. This RN remained in room to chat with pt for 45 min at which time pt stated \"I feel better now.\"\n\nPlan=continue to monitor HR. Possible transfer to floor tomorrow.\n"
},
{
"category": "Echo",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 71985,
"text": "PATIENT/TEST INFORMATION:\nIndication: Dilated cardiomyopathy. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 143\nBSA (m2): 1.66 m2\nBP (mm Hg): 103/41\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 16:02\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis. There is no resting left ventricular outflow tract\nobstruction. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. There is systolic anterior motion\nof the mitral valve leaflets. There is no significant mitral stenosis.\nModerate to severe (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\ntricuspid valve supporting structures are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. There is severe\nglobal left ventricular hypokinesis (ejection fraction approximately 20\npercent). No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed. The aortic valve leaflets (3) are mildly thickened but not\nstenotic. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. There is systolic anterior motion of the mitral valve\nleaflets. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 71986,
"text": "PATIENT/TEST INFORMATION:\nIndication: r/o effusion.\nBP (mm Hg): 105/71\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 06:06\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is dilated. There is severe global left ventricular\nhypokinesis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\ndilated. There is severe global left ventricular hypokinesis. The mitral valve\nleaflets are mildly thickened. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-09 00:00:00.000",
"description": "Report",
"row_id": 179478,
"text": "A-V sequential paced rhythm. Since the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-09 00:00:00.000",
"description": "Report",
"row_id": 179479,
"text": "Pacer rhythm\nventricular premature complex\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-05 00:00:00.000",
"description": "Report",
"row_id": 179704,
"text": "Technically difficult study. Probable sinus rhythm with ventricular pacing with\na typical precordial progression for right ventricular pacing. Since the\nprevious tracing of the heart rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 179705,
"text": "Paced rhythm. Compared to the previous tracing no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 179706,
"text": "Paced rhythm. Compared to the previous tracing paced rhythm is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-04 00:00:00.000",
"description": "Report",
"row_id": 179707,
"text": "Ventricular tachycardia. Lead V6 unsuitable for analysis. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-08 00:00:00.000",
"description": "Report",
"row_id": 179702,
"text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-03-06 00:00:00.000",
"description": "Report",
"row_id": 179703,
"text": "Sinus rhythm with ventricular pacing. Since the previous tracing of no\nsignificant change.\nTRACING #2\n\n"
}
] |
21,576 | 171,549 | 1. NEURO: CT imaging showed limited sinus disease, but marked diffuse cerebral edema. The neurological exam was remarkably non-focal. The question of edema secondary to infection (although she did not look toxic and had a negative Brudzinski) was addressed, as well as venous sinus thrombosis (secondary to a sinus infection), and metastatic processes. Neurosurgery was consulted in case intervention became necessary, and the patient was admitted to the ICU with neurochecks q 1 hr. Her HAART therapy on admission was continued with the addition of ampicillin, and urine, sputum, and blood cx's were sent. The patient was started on decadron 6q4, and ID was consulted. On , the patient continued to have frontal and parietal signs, along with papilledema. MRI revealed diffuse T2 signal abnormality and 8mm downward displacement of cerebellar tonsils. IV decadron continued at 6Q6. Patient's headache improved significantly on decadron, and she was ultimately transferred to the general neurology floor on . Given the high level of concern for CNS infection, and after discussion with ID and neurosurgery, it was decided that an LP was necessary. A repeat MRI was performed first, and showed no progression of edema and no change in the level of the cerebellar tonsils. Ms. to the procedure, and the LP on revealed OP 30, 11 wbc (lympho) 0 rbc protein 50 glucose 96. Crypto negative, HSV negative. Gram stain was negative for bacteria or poly's. CSF bacterial and fungal cultures were negative. Pending CSF labs include: EEE, WNV, AFB culture. CSF viral load was 1350 despite peripheral load of 424. There was some concern that this represented HIV meningoencephalitis, but was not thought to be a definite explanation for her cerebral edema. The Infectious Disease team has been closely involved with her case, as well as her PCP . and Dr. . During the course of the admission Ms. neurologic exam remained non-focal, with some mild difficulties with executive function. Her repeat MRI on showed improvement in the edema and white matter changes. Her decadron was slowly weaned so that she was off the medication by . See below for details of ID tests that were performed. Ultimately, no definitive etiology was found for her cerebral edema, although it is suspected to have been infectious in nature (HIV versus other infection). 2. ID: Infectious disease consulted while patient in the emergency room. Following tests were sent on : HCV Ab, Cryptococcal Ag negative, VZV IgG positive, CMV IgG positive and IgM negative, EBV IgG positive and IgM negative, Toxo Ab negative, Lyme serology negative, RPR negative, Mycoplasma Ab negative for acute infection. Pending studies include WNV serology, EEE serology. Ophthalmology was consulted on and found no evidence of CMV, toxoplasmosis, PC choroidopathy, or lymphoma. Due to concern for HIV mengingoencephalitis, her HAART therapy was adjusted to include medications with better CNS penetration. Her new regimen included tenofovir 300 mg daily, abacavir 600 mg po daily, lamivudine 300 mg daily, and kaletra 3 caps . Abacavir has a risk of rash but this did not occur during the admission. She was diagnosed with oral thrush on and began a 2 week course of diflucan. Ms. had a wbc of 9 on admission, wbc of 17 on the day of LP, and peak wbc of 28.5 on , all with neutrophilia. The pattern was that her wbc rose as expected after initiation of steroids, but continued to rise after steroid taper. She had multiple cultures of blood and urine sent, all of which were negative, and chest x-rays were negative as well. She was never febrile. No clear source for the wbc could be identified, ultimately, but it has been coming down to a most recent level of 23.5 on . 3. PSYCH: Unfortunately, although Ms. had been doing quite well neurologically after her steroid wean, she became progressively more anxious and agitated during the weekend of , and by the morning of was reporting hearing voices, obsessing about the Bible, and wandering about agitatedly. She said she had not slept at all the night before. Psychiatry was consulted and thought this could be related to a steroid psychosis, although its coincidence with the wean of the steroids was a bit atypical. The patient had no prior history of psychiatric illness, except some mild depression. Her agitation improved during the course of the day on , and she slept through the night after receiving Seroquel 50 mg. On Ms. was much calmer, although she was still a bit guarded and suspicious. A repeat MRI was obtained to ensure that her behavioral changes were not related to herniation with injury to basal forebrain structures, but the MRI was actually improved. On the morning of Ms. again became acutely psychotic, now reporting that she heard a voice commanding her to harm herself, randomly calling relatives and telling them "you're Satan", and repeatedly shouting for . She attempted to leave the hospital and a "Code Purple" was called, as the patient was in danger of harming herself. She was moved to a private room near the nurses' station with security posted outside her room. Over the course of the morning she calmed down but was refusing all medications. Her psychosis seemed to wax and wane over the course of the day. An EEG was obtained due to concern for temporal lobe epilepsy and revealed no epileptiform activity. She was placed on Seroquel 100 mg qHS, which she refused. The Psychiatry team was consulted and were closely involved with her care during the day. It was decided that she would be safest on an inpatient psychiatric (med-psych preferably given her complex history), and arrangements for transfer were begun. However, there was significant difficulty in finding a bed for her either at or at or . Given her complicated prior medical issues, we felt it most important that she remain here if possible. She calmed down significantly and was much more lucid later in the day, and hence she remained on the neurology floor for another day. On she was quite calm and seemed to be doing well during the day, but that night she awoke with nightmares and began walking outside her room and screaming. Due to concern about safety of other patients a Code Purple was called and she was briefly placed in restraints. By the morning she was again more calm and lucid, but understood that for her safety it would be necessary for her to move to the psychiatry service. | Sinus rhythm with sinus arrhythmiaProminent U waves suggested - are nonspecific and baseline artifact in leadsV1-V3 makes assessment difficultOtherwise probably normal ECGNo previous tracing available for comparison Nevertheless, the findings are likely in part due to cerebral/cerebellar edema. FINDINGS: The sagittal sinus, straight sinus, transverse sinus, and vein of are all show normal signal without evidence of thrombosis. The left posterior (Over) 8:04 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # MRA BRAIN W/O CONTRAST Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel Contrast: MAGNEVIST Amt: 14 FINAL REPORT (Cont) inferior cerebellar artery is not visualized. SYMPTOMS PERSISTED AND PT CAME TO ED , TREATED WITH COMPAZINE, PERCOCET AND IVF AND D/C HOME. This is likely secondary to cerebellar edema, and though the amount has progressed since the prior MR of the cervical spine from , the supracerebellar cistern remains patent. FINDINGS: The distal right vertebral artery is diminutive, and largely ends at the posterior inferior cerebellar artery on the right. Assess for herniation or venous thrombosis. PT DENIES CHEST PAIN, DIZZINESS, SOB. PT EMPIRICALLY STARTED ON ACYCLOVIR, CEFTRIAXONE AND DECADRON. Diffuse sulcal narrowing without shift of normally midline structures. Both superior cerebellar and anterior inferior cerebellar arteries are visualized and are normal in caliber. HEAD CT DONE SHOWED CEREBRAL EDEMA (UNKNOWN ETIOLOGY SEE RADIOLOGY REPORT FOR FULL DETAILS), MRI ALSO COMPLETED (RESULTS REMAIN PENDING). SYMPTOMS WORSENED AND PT RETURNED TO ED . PT DENIES SOB.GI/GU: ABD SOFT, NONTENDER + BOWEL SOUNDS. Both internal jugular veins are patent. Both internal carotid arteries demonstrate normal signal and caliber. LUNGS CTA WITH NON PRODUCTIVE COUGH. Both anterior cerebral and middle cerebral arteries proximally are normal in caliber without aneurysmal dilatation. PT TREATED FOR SINUSITIS WITH LEVOQUIN AND ZOMIG FOR MIGRAINES. This is increased since the limited assessment on the cervical spine MR , but the supracerebellar cistern remains visible. Diffuse abnormal T2 signal within the white matter and some areas of matter, associated with sulcal effacement. MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: There is downward protrusion of the cerebellar tonsils, measuring approximately 8 mm. The majority of the sulci over both cerebral convexities are effaced but both lateral ventricles are likely normal in size. A form of reversible leukoencephalopathy is also possible. Both posterior cerebral arteries are normal in caliber without aneurysmal dilatation. MRV: No definite evidence of venous sinus thrombosis. Headache, nausea, vomiting, and abnormal CT scan with evidence of intracranial edema. The right posterior communicating artery is normal. PT DENIES N/V. The basilar artery is slightly small, but otherwise, unremarkable. TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the brain including diffusion-weighted imaging, before and following administration of gadolinium. PRESENTED TO WITH C/O N/V, HA, DIZZINESS, MALAISE X 12 DAYS. Imaging findings are most consistent with brain edema that may be related to an infectious or inflammatory condition, although, clinical correlation is necessary. FINAL REPORT INDICATIONS: HIV. Worsening downward displacement of cerebellar tonsils. The greatest abnormality is located within white matter, but there is also blurring and indistinction of matter margins, most pronounced in the right frontal lobe. Assessment of the T2 and FLAIR sequences shows large areas of abnormal T2 signal hyperintensity within both frontal lobes, both parietal lobes, and both temporal lobes. The anterior communicating artery is not definitely visualized. + PROTECTIVE REFLEXES, PT C/O HA TREATED WITH TYLENOL 650 MG PO. Normal MRA and MRV. MICU NURSING ADMIT NOTE:SEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.38 Y.O. PT SEEN IN CLINIC ON WITH SIMILAR SYMPTOMS, SINUS TENDERNESS, FEVER AND NASAL DRAINAGE. PT SENT TO MICU FOR FURTHER MANAGEMENT.NEURO: PT ALERT, ORIENTED X 3. PT VOIDING IN COMMODE + MENSTRUAL CYCLE.ENDOCRINE: CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI AS ORDERED.ID: PT WITH X 2. COMPARISON: MRI of the cervical spine from . 8:04 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # MRA BRAIN W/O CONTRAST Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel Contrast: MAGNEVIST Amt: 14 MEDICAL CONDITION: 38 year old woman with HIV and HA, nausea, vomiting; REASON FOR THIS EXAMINATION: eval: abn CT with edema, ?herniation; please do mra/v as well to r/o venous sinus thrombosis WET READ: MRSg FRI 12:01 AM Diffuse T2/FLAIR hyperintensity in subcortical white matter. - EDEMA + PULSES.PULM: PT REMAINS ON RA SATS 95-100%. Findings are not typical for PML, though it is possible. PUPILS EQUAL/REACTIVE. Meningitis also cannot be excluded. PT REPORTS A SUPPORTIVE FAMILY.PLAN: FOLLOW CULTURES, CONT IV DECADRON, CONT ANTIBIOTICS, CONT FREQUENT NEURO CHECKS, CONT BEDREST RESTRICTIONS, FOLLOW VIRAL STUDIES, WILL CONT TO MONITOR. BLOOD AND URINE CULTURES PENDING. ALSO GIVEN MORPHINE 4 MG FOR C/O HA. PT REMAINS ON Q 1 HOUR NEURO CHECKS AND BEDREST.CV: TMAX 99.5 BP 110-140/50-70 HR 80-90 NSR NO ECTOPY NOTED. Differential diagnosis includes HIV encephalopathy, viral encephalitis such as CMV, PML, other infectious etiology. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2107-10-07 00:00:00.000",
"description": "Report",
"row_id": 1545815,
"text": "MICU NURSING ADMIT NOTE:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\n38 Y.O. FEMALE WITH HIV DX (CD4 555)AND MIGRAINES DX . PRESENTED TO WITH C/O N/V, HA, DIZZINESS, MALAISE X 12 DAYS. PT SEEN IN CLINIC ON WITH SIMILAR SYMPTOMS, SINUS TENDERNESS, FEVER AND NASAL DRAINAGE. PT TREATED FOR SINUSITIS WITH LEVOQUIN AND ZOMIG FOR MIGRAINES. SYMPTOMS PERSISTED AND PT CAME TO ED , TREATED WITH COMPAZINE, PERCOCET AND IVF AND D/C HOME. SYMPTOMS WORSENED AND PT RETURNED TO ED . HEAD CT DONE SHOWED CEREBRAL EDEMA (UNKNOWN ETIOLOGY SEE RADIOLOGY REPORT FOR FULL DETAILS), MRI ALSO COMPLETED (RESULTS REMAIN PENDING). BLOOD AND URINE CULTURES SENT. PT EMPIRICALLY STARTED ON ACYCLOVIR, CEFTRIAXONE AND DECADRON. ALSO GIVEN MORPHINE 4 MG FOR C/O HA. PT BEING FOLLOWED BY ID AND SEVERAL VIRAL STUDY LABS SENT OUT PER ID REQUEST. PT SENT TO MICU FOR FURTHER MANAGEMENT.\n\nNEURO: PT ALERT, ORIENTED X 3. PUPILS EQUAL/REACTIVE. MAE. FOLLOWS COMMANDS. + PROTECTIVE REFLEXES, PT C/O HA TREATED WITH TYLENOL 650 MG PO. PT REMAINS ON Q 1 HOUR NEURO CHECKS AND BEDREST.\n\nCV: TMAX 99.5 BP 110-140/50-70 HR 80-90 NSR NO ECTOPY NOTED. PT DENIES CHEST PAIN, DIZZINESS, SOB. - EDEMA + PULSES.\n\nPULM: PT REMAINS ON RA SATS 95-100%. LUNGS CTA WITH NON PRODUCTIVE COUGH. PT DENIES SOB.\n\nGI/GU: ABD SOFT, NONTENDER + BOWEL SOUNDS. TOLERATING POs WITHOUT DIFFICULTY. PT DENIES N/V. - BM OVERNIGHT. PT VOIDING IN COMMODE + MENSTRUAL CYCLE.\n\nENDOCRINE: CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI AS ORDERED.\n\nID: PT WITH X 2. BLOOD AND URINE CULTURES PENDING. ID FOLLOWING PATIENT ALL VIRAL STUDIES PENDING. PT REMAINS ON AMPICILLIN, ACYCLOVIR, CEFTRIAXONE, AND ANTIRETROVIRAL MEDS.\n\nSOCIAL: PT CURRENTLY LIVES WITH SON'S FATHER AND SON WHO HAS CP AND IS HIV +, ALSO HAS A DAUGHTER THAT IS IN COLLEGE. PT MOTHER AND FATHER IN TO SEE PATIENT. PT REPORTS A SUPPORTIVE FAMILY.\n\nPLAN: FOLLOW CULTURES, CONT IV DECADRON, CONT ANTIBIOTICS, CONT FREQUENT NEURO CHECKS, CONT BEDREST RESTRICTIONS, FOLLOW VIRAL STUDIES, WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-07 00:00:00.000",
"description": "Report",
"row_id": 1545816,
"text": "see nsg transfer note\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-06 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 885877,
"text": " 8:04 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with HIV and HA, nausea, vomiting;\n REASON FOR THIS EXAMINATION:\n eval: abn CT with edema, ?herniation; please do mra/v as well to r/o venous\n sinus thrombosis\n ______________________________________________________________________________\n WET READ: MRSg FRI 12:01 AM\n Diffuse T2/FLAIR hyperintensity in subcortical white matter. No abnormal\n enhancement identified in these areas, and no abnormal meningeal enhancement\n or extraaxial fluid collections are identified. Diffuse sulcal narrowing\n without shift of normally midline structures. No hydrocephalus. MRV: No\n definite evidence of venous sinus thrombosis.\n\n Differential diagnosis includes HIV encephalopathy, viral encephalitis such as\n CMV, PML, other infectious etiology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: HIV. Headache, nausea, vomiting, and abnormal CT scan with\n evidence of intracranial edema. Assess for herniation or venous thrombosis.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted imaging of the brain including\n diffusion-weighted imaging, before and following administration of gadolinium.\n\n COMPARISON: MRI of the cervical spine from .\n\n MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: There is downward protrusion of\n the cerebellar tonsils, measuring approximately 8 mm. This is increased since\n the limited assessment on the cervical spine MR , but the\n supracerebellar cistern remains visible. Nevertheless, the findings are\n likely in part due to cerebral/cerebellar edema. Assessment of the T2 and\n FLAIR sequences shows large areas of abnormal T2 signal hyperintensity within\n both frontal lobes, both parietal lobes, and both temporal lobes. The\n greatest abnormality is located within white matter, but there is also\n blurring and indistinction of matter margins, most pronounced in the\n right frontal lobe. There are no areas of abnormal enhancement within the\n brain parenchyma or leptomeninges. No signal abnormality is seen on\n diffusion-weighted imaging. There is no evidence of intracranial hemorrhage.\n The majority of the sulci over both cerebral convexities are effaced but both\n lateral ventricles are likely normal in size.\n\n BRAIN MRA:\n\n TECHNIQUE: 3D time-of-flight imaging of the circle of and its major\n branches with multiplanar reconstructions.\n\n FINDINGS: The distal right vertebral artery is diminutive, and largely ends\n at the posterior inferior cerebellar artery on the right. The left posterior\n (Over)\n\n 8:04 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval: abn CT with edema, ?herniation; please do mra/v as wel\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inferior cerebellar artery is not visualized. Both superior cerebellar and\n anterior inferior cerebellar arteries are visualized and are normal in\n caliber. The basilar artery is slightly small, but otherwise, unremarkable.\n Both posterior cerebral arteries are normal in caliber without aneurysmal\n dilatation. The right posterior communicating artery is normal. The left is\n not definitely visualized. Both internal carotid arteries demonstrate normal\n signal and caliber. Both anterior cerebral and middle cerebral arteries\n proximally are normal in caliber without aneurysmal dilatation. The anterior\n communicating artery is not definitely visualized.\n\n MRV OF THE BRAIN:\n\n TECHNIQUE: Sagittal 2D time-of-flight imaging through the brain and venous\n sinuses.\n\n FINDINGS: The sagittal sinus, straight sinus, transverse sinus, and vein of\n are all show normal signal without evidence of thrombosis. Both\n internal jugular veins are patent.\n\n IMPRESSION:\n 1. Diffuse abnormal T2 signal within the white matter and some areas of \n matter, associated with sulcal effacement. Imaging findings are most\n consistent with brain edema that may be related to an infectious or\n inflammatory condition, although, clinical correlation is necessary. A form of\n reversible leukoencephalopathy is also possible. Findings are not typical for\n PML, though it is possible. Meningitis also cannot be excluded.\n 2. Worsening downward displacement of cerebellar tonsils. This is likely\n secondary to cerebellar edema, and though the amount has progressed since the\n prior MR of the cervical spine from , the supracerebellar cistern\n remains patent.\n 3. Normal MRA and MRV.\n\n Results were discussed with Dr. at 11:50 a.m. on .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-10 00:00:00.000",
"description": "Report",
"row_id": 258761,
"text": "Sinus rhythm with sinus arrhythmia\nProminent U waves suggested - are nonspecific and baseline artifact in leads\nV1-V3 makes assessment difficult\nOtherwise probably normal ECG\nNo previous tracing available for comparison\n\n"
}
] |
78,301 | 108,493 | The patient was admitted to the vascular surgery service on to manage his aortic dissection. Upon admission, the patient was started on nitro and esmolol drips to keep his MAP < 70. He was closely monitored in the ICU. As the patient started to tolerate po intake, he was transitioned to oral anti-hypertensive medications. He was kept on a regimen of atenolol, hydralazine, and lisinopril which was very effective in keeping his blood pressure low. Once on po blood pressure regimen, the patient was transferred to the floor. On HD 3, patient had worsening abdominal pain and nausea in the morning. A CTA was performed that showed stable aortic dissection and no signs of impending rupture. As such, patient continued to be managed medically with strict blood pressure control. His diet was advanced to regular and was well tolerated. Physical therapy worked with the patient and determined that he was safe for home, but recommended physical therapy at home. Patient is a Jehovah's witness and as such is not a good surgical candidate. This fact was discussed with the patient and he understood all the issues. At the time of discharge, patient was feeling well. He was afebrile with stable vital signs, pain was well controlled, and he was tolerating regular diet. He will be sent home with new BP medications for strict blood pressure control and will follow up with Dr. in clinic. | Perfusion of entire false lumen, unchanged from . Decreased perfusion of right kidney relative to left kidney although R renal artery originates from true lumen and is patent. Mesenteric and renal arteries originate from true lumen. As described above, the right kidney is hypoperfused relative to the left kidney. Decreased perfusion of the right kidney relative to the left kidney, although the right renal artery originates from the true lumen and is patent. A small pericardial effusion is seen. Airways are patent to the level of subsegmental bronchi bilaterally. Perfusion of the entire false lumen is unchanged from . Prominent limb lead QRS voltage suggests left ventricularhypertrophy. RSR' pattern in lead V1. Mesenteric and renal arteries originate from the true lumen. The intramural hematoma at the level of the aortic arch is stable. Small bilateral pleural effusions and associated compressive atelectasis are new from . A 1.3 cm hypodensity (2:81) is a cyst. RSR' pattern in lead V1 may be normal variant. Extends to right superficial femoral and deep femoral arteries and to Left external iliac, possibly to left common femoral (artifact from L THR limits eval). Compression fractures of L1 and L2, stable from . Type B dissection originating just distal to L subclav. The rectum and sigmoid colon are normal. The celiac trunk, SMA, and renal arteries originate from the true lumen. Small pleural effusions and associated compressive atelectasis are new from . Low lateral precordial leadQRS voltage. Diverticula are seen throughout the sigmoid colon without inflammatory changes. The entire false lumen is perfused, unchanged from the prior study. Sinus rhythm. Sinus rhythm. Status post left total hip arthroplasty. Prostatic seeds are in place bilaterally. Prominent limb lead QRS voltagesuggests left ventricular hypertrophy. Stable compression fractures of L1 and L2. originates from false lumen. IMPRESSION: 1. There is decreased perfusion of the right kidney relative to the left kidney, although the right renal artery originates from the true lumen. A left adominal wall lipoma measures 1.5cm. Small bilateral pleural effusions and associated compressive atelectasis (Over) 7:15 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: please assess for progression of dissection, initial scan wi Admitting Diagnosis: TYPE B AORTIC DISSECTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) are new from . Compression fractures of L1 and L2 are stable from . Low laterallimb lead QRS voltage is non-specific. The originates from the false lumen. Stable from with no extention of dissection. Inferolateral lead T wave changes. The dissection course is stable from . The small and large bowels are normal in course and caliber. There is apparent fusion of the L5 and S1 vertebral bodies. Since the previous tracing of the samedate probably no significant change.TRACING #2 Type B aortic dissection as described above. A Foley catheter is in place. A right abdominal wall lipoma measures 3.8 x 5.2cm. (Over) 7:15 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: please assess for progression of dissection, initial scan wi Admitting Diagnosis: TYPE B AORTIC DISSECTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Calcifications and possible stenosis at the celiac artery origin are noted with a widely patent celiac artery just beyond the origin. Dissection is stable since with no evidence of extension. The spleen, pancreas, and bilateral adrenal glands are normal. CT ABDOMEN: The liver is normal. CT PELVIS: Left total hip arthroplasty limits evaluation of details at the pelvis. No contraindications for IV contrast WET READ: 10:41 AM 1. 4. 4. 2. 2. The originates from the false lumen with no perfusion over a 5 mm segment just distal to the origin of the , but the is very well perfused distally. 3. 3. Multilevel degenerative change is noted with loss of disc space height at multiple levels. The dissection does not extend into the mesenteric, renal, or internal iliac arteries. Thyroid is unremarkable without nodules. TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic symphysis were displayed with 2.5-mm slice thickness with 75 mL Optiray intravenous contrast. 5. 5. Findings are non-specific.No previous tracing available for comparison.TRACING #1 COMPARISON: Outside CT . No pathologically enlarged mediastinal, axillary or hilar lymph nodes are present. The largest aortic diameter is 4.5 cm, just above the diaphragm. CT ANGIOGRAM: A type B aortic dissection originates just distal to the left subclavian takeoff and extends to the right superficial and right deep femoral arteries and definitely to the left external iliac artery and possibly into the left common femoral artery, although complete evaluation is limited due to artifact from left hip arthroplasty. Coronal and sagittal reformats were displayed with 5-mm slice thickness. 6. 6. No mesenteric or retroperitoneal lymphadenopathy. Now wit abdominal pain and vomiting REASON FOR THIS EXAMINATION: please assess for progression of dissection, initial scan with mesenteric and renal vessels off true lumen except for . The heart is enlarged. | 3 | [
{
"category": "Radiology",
"chartdate": "2171-04-18 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1184482,
"text": " 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with type B descending aortic dissection, from OSH with scan\n from 48 hours ago. Now wit abdominal pain and vomiting\n REASON FOR THIS EXAMINATION:\n please assess for progression of dissection, initial scan with mesenteric and\n renal vessels off true lumen except for . Assess for change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:41 AM\n 1. Type B dissection originating just distal to L subclav. Extends to right\n superficial femoral and deep femoral arteries and to Left external iliac,\n possibly to left common femoral (artifact from L THR limits eval). Stable from\n with no extention of dissection.\n 2. Mesenteric and renal arteries originate from true lumen. originates\n from false lumen.\n 3. Decreased perfusion of right kidney relative to left kidney although R\n renal artery originates from true lumen and is patent.\n 4. Perfusion of entire false lumen, unchanged from .\n 5. Small pleural effusions and associated compressive atelectasis are new from\n .\n 6. Compression fractures of L1 and L2, stable from .\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain and vomiting, type B aortic dissection, evaluate\n for interval change.\n\n COMPARISON: Outside CT .\n\n TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic\n symphysis were displayed with 2.5-mm slice thickness with 75 mL Optiray\n intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm\n slice thickness.\n\n CT ANGIOGRAM: A type B aortic dissection originates just distal to the left\n subclavian takeoff and extends to the right superficial and right deep femoral\n arteries and definitely to the left external iliac artery and possibly into\n the left common femoral artery, although complete evaluation is limited due to\n artifact from left hip arthroplasty. The dissection does not extend into the\n mesenteric, renal, or internal iliac arteries. The dissection course is stable\n from . The largest aortic diameter is 4.5 cm, just above the diaphragm.\n The entire false lumen is perfused, unchanged from the prior study.\n\n The celiac trunk, SMA, and renal arteries originate from the true lumen. The\n originates from the false lumen with no perfusion over a 5 mm segment just\n distal to the origin of the , but the is very well perfused distally.\n (Over)\n\n 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Calcifications and possible stenosis at the celiac artery origin are noted\n with a widely patent celiac artery just beyond the origin. There is decreased\n perfusion of the right kidney relative to the left kidney, although the right\n renal artery originates from the true lumen. The intramural hematoma at the\n level of the aortic arch is stable.\n\n CT CHEST: Contrast bolus timing is not optimized to evaluate for pulmonary\n embolism, but there is no large central PE. No pathologically enlarged\n mediastinal, axillary or hilar lymph nodes are present. The heart is\n enlarged. A small pericardial effusion is seen. Small bilateral pleural\n effusions and associated compressive atelectasis are new from .\n Thyroid is unremarkable without nodules. Airways are patent to the level of\n subsegmental bronchi bilaterally.\n\n CT ABDOMEN: The liver is normal. A 1.3 cm hypodensity (2:81) is a cyst.\n Hyperdensity of the gallbladder is due to vicarious excretion of contrast. The\n spleen, pancreas, and bilateral adrenal glands are normal. As described\n above, the right kidney is hypoperfused relative to the left kidney. The\n small and large bowels are normal in course and caliber. No free air and no\n free fluid. No mesenteric or retroperitoneal lymphadenopathy. A right\n abdominal wall lipoma measures 3.8 x 5.2cm. A left adominal wall lipoma\n measures 1.5cm.\n\n CT PELVIS: Left total hip arthroplasty limits evaluation of details at the\n pelvis. A Foley catheter is in place. The rectum and sigmoid colon are\n normal. Diverticula are seen throughout the sigmoid colon without\n inflammatory changes. Prostatic seeds are in place bilaterally. No free\n fluid and no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No lytic or sclerotic lesion suspicious for malignancy is seen.\n Multilevel degenerative change is noted with loss of disc space height at\n multiple levels. Compression fractures of L1 and L2 are stable from .\n There is apparent fusion of the L5 and S1 vertebral bodies. Status post left\n total hip arthroplasty.\n\n IMPRESSION:\n 1. Type B aortic dissection as described above. Dissection is stable since\n with no evidence of extension.\n 2. Mesenteric and renal arteries originate from the true lumen. The \n originates from the false lumen.\n 3. Decreased perfusion of the right kidney relative to the left kidney,\n although the right renal artery originates from the true lumen and is patent.\n 4. Perfusion of the entire false lumen is unchanged from .\n 5. Small bilateral pleural effusions and associated compressive atelectasis\n (Over)\n\n 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: please assess for progression of dissection, initial scan wi\n Admitting Diagnosis: TYPE B AORTIC DISSECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are new from .\n 6. Stable compression fractures of L1 and L2.\n\n Findings discussed with Dr. by phone, 9:20 a.m. .\n\n"
},
{
"category": "ECG",
"chartdate": "2171-04-16 00:00:00.000",
"description": "Report",
"row_id": 255124,
"text": "Sinus rhythm. Prominent limb lead QRS voltage suggests left ventricular\nhypertrophy. RSR' pattern in lead V1 may be normal variant. Low lateral\nlimb lead QRS voltage is non-specific. Since the previous tracing of the same\ndate probably no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2171-04-16 00:00:00.000",
"description": "Report",
"row_id": 255125,
"text": "Sinus rhythm. RSR' pattern in lead V1. Prominent limb lead QRS voltage\nsuggests left ventricular hypertrophy. Low lateral precordial lead\nQRS voltage. Inferolateral lead T wave changes. Findings are non-specific.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
4,857 | 118,301 | 75F with hx HTN admitted with ant NSTEMI and found to have 3VD at , transferred for high risk cath: s/p stent to LAD and LCx-OM1 on . Pt was started on Metoprolol 25 mg PO BID (switched to carvedilol 6.25mg PO bid the next morning), ASA 325 mg PO qD, Plavix 75 mg PO qD (loaded with 300 mg in cath lab), captopril 6.25 mg PO TID (gradually increased to 25mg PO tid), and atorvastatin 80mg PO qD. Given EF of % and global HK, considered anti-coagulation with heparin or coumadin, but did not do so due to bleeding during hospital stay. OSH reported vaginal bleeding after starting integrillin. Pelvic U/S was normal, and pt refused pelvic exam. Since admission to CCU, has been guiac positive on all stools. Hct has been stable, and pt was told to f/u with PCP for outpatient colonoscopy. Initial and CXR consistent with pulmonary edema with bilateral pleural effusions. Ms. experienced episodes of a-fib in cath lab, and continued to flip between sinus and afib in the CCU until converting back to sinus during the evening of . Pt was in ARF on admission to CCU, with Cr 1.4, and 2.2 on transfer from OSH. Baseline 1.1. She was treated with mucomyst and bicarbonate IVF, and monitored closely. She gradually recovered, with creatinine dropping to 1.2 by discharge. Urine cultured Alpha strep and lactobacillus at OSH, pt admitted on Ciprofloxacin. Changed to 7 days of levofloxacin 250mg PO qd for better alpha strep coverage. Ms. pre-existing hypertension continued to be managed with the use of beta blockers and ACEIs. An atypical CBC differential at OSH led to a new diagnosis of CLL. Heme Onc consulted, and reported the following: "Impression: The patient may have very early CLL. Her increased retics, LDH, and bilirubin may indicate the presence of hemolysis. Plan includes ordering flow studies on her lymphocytes along with Coombs testing. If this is stage zero CLL, no treatment is indicated at the present time, although Coombs positive hemolytic anemia, if present, may need treatment." Flow cytometry supported this dx, with CD519+, CD23+, FMC7-, and CD20dim. | Compared to the previous tracingof atrial fibrillation is now present.TRACING #1 Normal ascending aorta diameter. Left ventricular wall thicknesses arenormal. There is a latetransition consistent with possible prior anterior myocardial infarction.Diffuse non-specific ST-T wave changes. Left atrial abnormality. Sinus rhythm with atrial ectopy. The aorta is calcified. The aorta is calcified. Mild (1+) mitralregurgitation is seen. Atrial ectopic beats. Sinus arrhythmia. There is again noted perihilar haziness and bilateral pleural effusions (left greater than right). Non-specificinferior ST-T wave changes. Non-specificinferior ST-T wave changes. Severelydepressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - hypo; basal inferior - hypo; mid inferior - hypo; basalinferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; lateralapex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. IMPRESSION: Findings consistent with CHF with interstitial edema and bilateral pleural effusions (left greater than right). There is slight perihilar haziness of the pulmonary vascularity and septal lines. ST segmentdepression in leads V3-V6 - consider anterolateral ischemia. Right pleuraleffusion.Conclusions:The left atrium is normal in size. Diffuse non-specific ST-T wave changes. Compared to the previous tracing there ismore atrial ectopy.TRACING #2 Sinus rhythm. Sinus rhythm. P-R interval 0.12. Thereis a late transition with inverted T waves in the anterior and anterolateralleads consistent with prior anterior myocardial infarction. The QTc interval isprolonged. Sinus rhythm with atrial ectopy and atrial tachycardia. Compared to the previous tracing of therhythm is now sinus.TRACING #2 Question of CHF. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Late transitionwith anterior and anterolateral ST-T wave changes consistent with possibleprior anterior myocardial infarction. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). There is a late transition with anterior and anterolateralST-T wave changes consistent with possible prior anterior myocardialinfarction. No AR.MITRAL VALVE: Normal mitral valve leaflets. Compared to the previous tracing of the ST segment depressions are less prominent.TRACING #1 These findings most likely represent CHF. The left ventricular cavity size is normal. Normal LV cavity size. FINDINGS: The heart is of normal size. FINDINGS: The heart is of normal size. Prolonged QTc interval. IMPRESSION: Persistent pulmonary edema and bilateral pleural effusions (left greater than right). Resting regional wall motionabnormalities include anteroseptal, apical, inferior and inferolateral severehypokinesis/akinesis. TECHNIQUE: AP portable single view of the chest. Shortness of breath. TECHNIQUE: PA and lateral views of the chest. No AS. No AS. Right ventricularchamber size and free wall motion are normal. The mediastinal and hilar contours are stable when compared to prior study. Atrial fibrillation with a rapid ventricular response. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 64Weight (lb): 121BSA (m2): 1.58 m2BP (mm Hg): 117/69HR (bpm): 88Status: InpatientDate/Time: at 10:40Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The mitral valve leaflets are structurally normal. QTc interval is prolonged. Overall left ventricularsystolic function is severely depressed. Diffuse non-specific ST-T wave changes.Compared to the previous tracing of there is no diagnostic change.TRACING #2 Pre- operative evaluation. P-R interval 120 milliseconds. No AR. No previous tracingavailable for comparison.TRACING #1 The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aorticregurgitation. No aortic regurgitation isseen. Antegrade flow is seen in both vertebral arteries. FINDINGS: Duplex evaluation of bilateral extracranial internal carotid arteries and vertebral arteries was performed, which demonstrates peak velocities on the right to be 149, 50, 58 cm per second, and on the left to be 149, 65, and 112 cm per second, corresponding to ICA to CCA ratio of 2.61 on the right and 2.9 on the left. The apex is not fully visualized. There is no pericardial effusion. There are also bilateral pleural effusions (left greater than right). COMPARISON: Comparison is made to . There is no aortic valve stenosis. There is also septal lines consistent with pulmonary edema. No significant plaque formation is demonstrated. There is no evidence of pneumothorax. IMPRESSION: 40-59% stenosis, bilateral internal carotid arteries, more towards 59%. 11:15 AM CHEST (PRE-OP PA & LAT) Clip # Reason: CORONARY ARTERY DISEASE Admitting Diagnosis: CORONARY ARTERY DISEASE MEDICAL CONDITION: 75 year old woman with CAD/Low EF REASON FOR THIS EXAMINATION: Pre Op FINAL REPORT INDICATION: 75-year-old woman with CAD and low ejection fraction. 7:16 AM CHEST (PORTABLE AP) Clip # Reason: ?CHF Admitting Diagnosis: CORONARY ARTERY DISEASE MEDICAL CONDITION: 75 year old woman with hx CHF REASON FOR THIS EXAMINATION: ?CHF FINAL REPORT INDICATION: 75-year-old woman with history of CHF. | 10 | [
{
"category": "Echo",
"chartdate": "2174-07-13 00:00:00.000",
"description": "Report",
"row_id": 69614,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 121\nBSA (m2): 1.58 m2\nBP (mm Hg): 117/69\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 10:40\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo; septal apex - hypo; lateral\napex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural\neffusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is severely depressed. Resting regional wall motion\nabnormalities include anteroseptal, apical, inferior and inferolateral severe\nhypokinesis/akinesis. The apex is not fully visualized. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871153,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hx CHF\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with history of CHF. Shortness of breath.\n Question of CHF.\n\n COMPARISON: Comparison is made to .\n\n TECHNIQUE: AP portable single view of the chest.\n\n FINDINGS: The heart is of normal size. The aorta is calcified. The\n mediastinal and hilar contours are stable when compared to prior study. There\n is again noted perihilar haziness and bilateral pleural effusions (left\n greater than right). There is also septal lines consistent with pulmonary\n edema.\n\n IMPRESSION: Persistent pulmonary edema and bilateral pleural effusions (left\n greater than right).\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-13 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 870929,
"text": " 10:03 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o carotid stenosis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe CAD; pre op CABG\n REASON FOR THIS EXAMINATION:\n r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preoperative CABG surgery.\n\n FINDINGS: Duplex evaluation of bilateral extracranial internal carotid\n arteries and vertebral arteries was performed, which demonstrates peak\n velocities on the right to be 149, 50, 58 cm per second, and on the left to be\n 149, 65, and 112 cm per second, corresponding to ICA to CCA ratio of 2.61 on\n the right and 2.9 on the left. No significant plaque formation is\n demonstrated. Antegrade flow is seen in both vertebral arteries.\n\n IMPRESSION: 40-59% stenosis, bilateral internal carotid arteries, more\n towards 59%.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-07-13 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 870940,
"text": " 11:15 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD/Low EF\n REASON FOR THIS EXAMINATION:\n Pre Op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with CAD and low ejection fraction. Pre-\n operative evaluation.\n\n TECHNIQUE: PA and lateral views of the chest.\n\n FINDINGS: The heart is of normal size. The aorta is calcified. There is\n slight perihilar haziness of the pulmonary vascularity and septal lines. There\n are also bilateral pleural effusions (left greater than right). These findings\n most likely represent CHF. There is no evidence of pneumothorax.\n\n IMPRESSION: Findings consistent with CHF with interstitial edema and\n bilateral pleural effusions (left greater than right).\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-15 00:00:00.000",
"description": "Report",
"row_id": 163334,
"text": "Sinus rhythm. P-R interval 120 milliseconds. QTc interval is prolonged. There\nis a late transition with inverted T waves in the anterior and anterolateral\nleads consistent with prior anterior myocardial infarction. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of the\nrhythm is now sinus.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-14 00:00:00.000",
"description": "Report",
"row_id": 163335,
"text": "Atrial fibrillation with a rapid ventricular response. There is a late\ntransition consistent with possible prior anterior myocardial infarction.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof atrial fibrillation is now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-13 00:00:00.000",
"description": "Report",
"row_id": 163551,
"text": "Sinus rhythm with atrial ectopy. P-R interval 0.12. Late transition\nwith anterior and anterolateral ST-T wave changes consistent with possible\nprior anterior myocardial infarction. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing of there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-13 00:00:00.000",
"description": "Report",
"row_id": 163552,
"text": "Sinus rhythm with atrial ectopy and atrial tachycardia. The QTc interval is\nprolonged. There is a late transition with anterior and anterolateral\nST-T wave changes consistent with possible prior anterior myocardial\ninfarction. Diffuse non-specific ST-T wave changes. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-16 00:00:00.000",
"description": "Report",
"row_id": 163332,
"text": "Sinus rhythm. Atrial ectopic beats. Compared to the previous tracing there is\nmore atrial ectopy.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2174-07-15 00:00:00.000",
"description": "Report",
"row_id": 163333,
"text": "Sinus arrhythmia. Prolonged QTc interval. Left atrial abnormality. ST segment\ndepression in leads V3-V6 - consider anterolateral ischemia. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of \nthe ST segment depressions are less prominent.\nTRACING #1\n\n"
}
] |
99,785 | 120,655 | There is mild-to-moderate loss of height of the L1 vertebral body with irregularity of the endplates, anterior and posterior osteophytes and Schmorl's nodes and marrow edema in the superior portion of L1. Cardiac silhouette is unchanged and there is again evidence of bilateral pleural effusions with compressive atelectasis at the bases. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and temporal lobes and extending into the suprasellar, prepontine and interpeduncular cisterns with indentation on the pons. There is redemonstration of the bilateral subarachnoid hemorrhage noted in both frontotemporal regions and layering within the Sylvian fissure, suprasellar cisterns, and interpeduncular cisterns, volume and distribution appears relatively stable compared to prior study. Persistent moderate right and small left pleural effusion as well as bibasilar retrocardiac opacities. FINDINGS: Limited examination due to subcutaneous edema. Moderate loss of height T12 vertebral body with Schmorl's nodes, likely chronic. Minimal increase of the intraventricular hemorrhage layering in the occipital horns. Minimal increase in the intraventricular hemorrhage layering in the occipital horns. Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's node with an acute component of marrow edema in the L1 vertebral body. There is edema within the inferior left frontal lobe, compatible with contusion. FINDINGS: Since , there is minimal increase of the intraventricular hemorrhage layering in the occipital horns. There is a possibile small subdural hematoma overlying the right frontal convexity; however, this may simply represent bridging cortical veins. At T7-T8, disc desiccation, small Schmorl's nodes and mild bulge along with a more focal component of disc protrusion/extrusion on the right side is seen to indent the ventral cord with deformity. Increased retrocardiac density concerning for atelectasis or concomitant consolidation and minimal left pleural effusions are unchanged. Otherwise, the left frontal lobe contusion and multifocal intraparenchymal hemorrhage, subdural hemorrhage along the falx and the multifocal subarachnoid hemorrhage including in the prepontine cistern indenting the pons are unchanged. While part of this may be related to pulsation artifacts, presence of hemorrhagic components cannot be completely excluded given the presence of subarachnoid and intraventricular hemorrhage, on the concurrent CT head. Bilateral pleural effusions are noted. Bilateral pleural effusions and distended gall bladder -correlate with dedicated imaging. Grayscale and Doppler son of bilateral common femoral, femoral and popliteal veins were performed. Within that limitation, the cardiomediastinal and hilar contours appear within normal limits. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is redemonstrated, as is a contusion involving the left inferior frontal lobe. def of T12 and L1; small disc extrusion on the right side at T7/8 indenting the thecal sac. Multilevel degenerative changes are noted in the form of disc desiccation, narrowing of the disc space, disc osteophyte complexes and facet degenerative changes indenting the ventral thecal sac resulting in mild canal stenosis. FINDINGS: There is diffuse osteopenia. Partially imaged is a comminuted distal femoral fracture with evidence of lipohemarthrosis. There is a diffuse osteopenia. BILATERAL HIPS, TWO VIEWS EACH INCLUDING A VIEW WITH TRACTION: Comminuted right intertrochanteric fracture is identified with minimal displacement. Underlying this fracture is a tiny focus of pneumocephalus. A small step-off is seen at the roof of the right sphenoid sinus which may represent a neurovascular channel or a small nondisplaced fracture. There are bilateral pleural effusions, with associated bibasilar dependent consolidations most likely reflecting atelectasis. A displaced nasal bone fracture is identified. Likely chronic compression deformity of L1 is noted, as described above. Small foci of pneumocephalus posterior to the right frontal sinus. Small foci of pneumocephalus posterior to the right frontal sinus. Small foci of pneumocephalus posterior to the right frontal sinus. Please see seperately reported thoracic spine CT for comments regarding the low thoracic spine. Left retrocardiac atelectasis has developed in the interim, associated with small amount of pleural effusion. In the lower lumbar spine there is facet arthropathy. Partially imaged comminuted fracture of distal right femur with associated lipohemarthrosis. Evaluation of left ankle is somewhat suboptimal, with degenerative changes of the tibiotalar joint present. Compression deformities involving the T11, T12, and L1 vertebral bodies. Compression deformities involving the T11, T12, and L1 vertebral bodies. Compression deformities involving the T11, T12, and L1 vertebral bodies. There is mild atherosclerosis. There is additional compression deformity at L1, also without specific evidence of acuity, and with marked degenerative osteophyte formation at T12-L1 suggesting chronicity. Bilateral complex supracondylar fractures. bilateral comminuted, angulated and slightly impacted distal femur fractures. There is hematoma at the fracture site. RIGHT: There is a comminuted impacted angulated fracture of the femoral neck and intertrochanteric fracture with varus angulation. FINDINGS: There is subtle loss of height involving the posterior aspect of the T3 vertebral body, with associated irregularity/buckling of the posterior cortex. There is associated soft tissue hematoma and joint effusion. There is diffuse osteopenia which limits the sensitivity for detection of subtle fractures. Another fracture is seen on the medial wall of the right sphenoid sinus with slight displacement of the inferior fragment laterally into the sinus. Nonspecific fat stranding about the rectum; correlate clinically. Marked associated degenerative change at T12-L1 with anterior osteophyte formation and a prominent L1 superior enplate Schmorl's node favor chronicity. There is bilateral lipohemarthrosis of the knees. expected soft tissue changes with bilateral lipohemarthoses of the knees. Multilevel degenerative change is present, with posterior disc-osteophyte complexes noted at T6-7 and T7-8 effacing the thecal sac at these levels. Severe osteopenia. Another fracture is seen through the posterior margin of the left side of sphenoid sinus which extends into the sphenoid septations and nasal septum. See subsequent MRI Mild degenerative change at L3-S1, without apparent critical canal stenosis. There are some irregular lucencies noted within the (Over) 6:19 PM CT T-SPINE W/O CONTRAST Clip # Reason: please perfor CT of thoracic and lumbar spine to evaluate fo Admitting Diagnosis: BILATERAL FEMORAL FRACTURES FINAL REPORT (Cont) vertebral body, though no discrete fracture line is identified, and these lucencies may reflect a combination osteopenia and a superior endplate Schmorl's node. | 31 | [
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1207422,
"text": " 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall w/ known SAH/SDH.\n REASON FOR THIS EXAMINATION:\n evaluate for progression of SAH/SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:41 PM\n No significant change compared to study performed approximately 12 hours\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\n Extensive facial fractures with blood in the paranasal sinuses was better\n characterized on prior dedicated facial bones CT. There is again no midline\n shift or evidence of central brain herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall. Evaluate for progression of\n intracranial hemorrhage.\n\n COMPARISON: at 05:46 hours.\n\n NON-CONTRAST HEAD CT:\n\n There is little change from prior study. A large right frontal subgaleal\n hematoma/contusion is identified, with underlying facial fractures and\n hemorrhage in the paranasal sinuses, better characterized on recent dedicated\n facial bone CT.\n\n Intracranially, there is extensive subarachnoid hemorrhage identified,\n throughout the basal cisterns, about the bilateral frontal lobes, and in the\n sylvian fissures. Intraventricular blood is also identified layering in the\n occipital horns of the lateral ventricles. Subdural blood is seen over the\n left frontal lobe, as well as along the falx posteriorly at the vertex. There\n is edema within the inferior left frontal lobe, compatible with contusion.\n There is no shift of midline structures or evidence of central brain\n herniation. The basal cisterns remain patent, and the ventricles are\n unchanged in size. There is no CT evidence of acute territorial infarct.\n\n IMPRESSION: No significant change compared to study performed approximately\n 12 hours prior. Multifocal subarachnoid, subdural, or intraventricular\n hemorrhage is redemonstrated, as is a contusion involving the left inferior\n frontal lobe. Extensive facial fractures with blood in the paranasal sinuses\n was better characterized on prior dedicated facial bones CT. There is again\n no midline shift or evidence of central brain herniation.\n\n (Over)\n\n 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1207423,
"text": ", J. TSICU 5:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of SAH/SDH\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall w/ known SAH/SDH.\n REASON FOR THIS EXAMINATION:\n evaluate for progression of SAH/SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to study performed approximately 12 hours\n prior. Multifocal subarachnoid, subdural, or intraventricular hemorrhage is\n redemonstrated, as is a contusion involving the left inferior frontal lobe.\n Extensive facial fractures with blood in the paranasal sinuses was better\n characterized on prior dedicated facial bones CT. There is again no midline\n shift or evidence of central brain herniation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-10 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1207627,
"text": " 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH, T2/T3 fractures, bilateral\n hip fractures s/p hemiarthroplasty on left, TFN on right now with T3 fracture\n and inability to move upper or lower extremities\n REASON FOR THIS EXAMINATION:\n please evaluate for spinal cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SAT 8:08 PM\n Marrow edema in t2 and t3 from injury.\n Comp. def of T12 and L1; small disc extrusion on the right side at T7/8\n indenting the thecal sac.\n\n Diffusely altered signal intensity in the thecal sac, may relate to pulsation\n artifacts; however, blood products cannot be completely excluded given the\n presence of subarachnoid and intraventricular hemorrhage on the prior CT head\n study.\n Vague areas of increased signal intensity in the thoracic cord, nature of\n which is uncertain. Attention on followup can be considered.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, with loss of consciousness, diffuse multifocal\n intracranial hemorrhage, T2 and T3 fractures, inability to move upper and\n lower extremities, to evaluate for spinal cord injury.\n\n COMPARISON: CT of the T-spine done on .\n\n TECHNIQUE: MR T AND L SPINE WITHOUT CONTRAST\n\n FINDINGS:\n\n MR T SPINE WITHOUT CONTRAST:\n\n\n The numbering used for the present study is shown on series 7, image 9.\n There is diffuse hypointense signal of the marrow which needs correlation with\n hematology labs for anaemia, systemic disease or infiltrative disorders.\n\n There is kyphosis in the lower cervical and upper thoracic regions. Areas of\n marrow edema are noted at T2 and T3 vertebral bodies along the endplates and\n extending into the vertebral body and may relate to recent trauma.\n\n There is moderate-to-severe loss of height of the T12 vertebral body and mild\n loss of height of the T11 vertebral body.\n\n Disc desiccation is noted at multiple levels along with degenerative changes\n in the facets.\n\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n At T3, there is mild anterior displacement of the vertebral body with\n irregularity of the posterior cortex, which is seen to efface the ventral CSF\n space and indent the ventral surface of the cord with some degree of deformity\n on the cord.\n\n At T6-T7, mild bulge and small central protrusion are noted, effacing the\n ventral CSF space and indenting the ventral surface of the cord.\n\n At T7-T8, disc desiccation, small Schmorl's nodes and mild bulge along with a\n more focal component of disc protrusion/extrusion on the right side is seen to\n indent the ventral cord with deformity.\n\n At T8-T9, T9-T10 and T10-T11 levels, no disc herniation to the canal is noted.\n\n At T11-T12, Schmorl's nodes are noted, causing indentation on the adjacent\n endplates. No disc herniation into the canal.\n\n There are areas of altered signal intensity diffusely on the posterior thecal\n sac, assessment of which is limited. While part of this may be related to\n pulsation artifacts, presence of hemorrhagic components cannot be completely\n excluded given the presence of subarachnoid and intraventricular hemorrhage,\n on the concurrent CT head. No pre- or para-vertebral soft tissue swelling or\n masses are noted.\n\n Areas of signal intensity in the cord are of uncertain significance and\n attention on followup can be considered for better assessment. Axial images\n are limited due to artifacts.\n\n Bilateral pleural effusions are noted. Distended gallbladder incompletely\n imaged.\n\n MR OF THE LUMBAR SPINE:\n\n Numbering used for the present study is shown on series 13, image 11.\n\n The lumbar vertebral bodies are normal in height, signal intensity, and\n alignment from L2-L5. There is mild-to-moderate loss of height of the L1\n vertebral body with irregularity of the endplates, anterior and posterior\n osteophytes and Schmorl's nodes and marrow edema in the superior portion of\n L1.\n\n Disc desiccation and facet degenerative changes are noted at all levels.\n Minimal indentation on the ventral thecal sac is noted from the disc bulges.\n Mild foraminal narrowing is noted at L4 and L5 levels. No definite\n compression on the nerves is noted.\n\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The spinal cord ends atL1-2 level; the roots of the cauda equina are\n unremarkable.\n No pre- or para-vertebral soft tissue swelling or masses are noted.\n\n There is atrophy of the paraspinal muscles with fat infiltration.\n\n IMPRESSION:\n\n Limited due to motion-related artifacts.\n\n 1. Areas of marrow edema in the T2 and T3 vertebral bodies, with mild contour\n irregularity of the posterior cortex of T3 which is seen to indent the ventral\n thecal sac and the ventral surface of the cord. Osseous details are better\n assessed on the prior CT.\n\n Mild diffuse disc bulge, with small-to-moderate sized disc extrusion, on the\n right side deforming the right side of the cord at T7/8.\n Small central protrusion at T6-T7 level indenting the ventral thecal sac and\n ventral cord.\n\n Moderate loss of height T12 vertebral body with Schmorl's nodes, likely\n chronic.\n\n Mild-to-moderate loss of height of the L1 vertebral body, with a Schmorl's\n node with an acute component of marrow edema in the L1 vertebral body.\n\n Multilevel disc and facet degenerative changes in the lumbar spine with mild\n foraminal narrowing at L4 and L5 levels.\n\n 2. Diffusely altered signal intensity in the thecal sac, may relate to\n pulsation artifacts; however, blood products cannot be completely excluded\n given the presence of subarachnoid and intraventricular hemorrhage on the\n prior CT head study.\n\n 3. Vague areas of increased signal intensity in the thoracic cord, nature of\n which is uncertain. Assessment of cord lesions is limited due to artifacts.\n Attention on followup can be considered.\n\n\n 4. Diffuse hypointense signal of the marrow- correlate with hematology labs.\n\n 5. Bilateral pleural effusions and distended gall bladder -correlate with\n dedicated imaging.\n (Over)\n\n 3:12 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: please evaluate for spinal cord injury\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-12 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1207923,
"text": " 9:13 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: dvt\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with tachcardia\n REASON FOR THIS EXAMINATION:\n dvt\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE EXAMINATION: 72-year-old woman with tachycardia, to rule out\n DVT.\n\n COMPARISON: No comparisons are available.\n\n FINDINGS:\n Limited examination due to subcutaneous edema.\n Grayscale and Doppler son of bilateral common femoral, femoral and\n popliteal veins were performed. There is normal compressibility, flow and\n augmentation.\n The calf vesssles were not visualized.\n\n IMPRESSION: No evidence of DVT in right or left lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-14 00:00:00.000",
"description": "O ABDOMEN (SUPINE ONLY) IN O.R.",
"row_id": 1208234,
"text": " 12:29 AM\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb FRI 12:34 PM\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\n vertebra.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old woman status post trauma, undergoing IVC filter\n placement.\n\n COMPARISON: None.\n\n FINDINGS: A single intraoperative spot view of the abdomen shows an IVC\n filter in vertical orientation with its tip at the level of the lower\n one-third of the L1 vertebra. An NG tube is also seen.\n\n IMPRESSION: Vertically oriented IVC filter with the tip at the lower\n one-third of the L1 vertebra.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-14 00:00:00.000",
"description": "O ABDOMEN (SUPINE ONLY) IN O.R.",
"row_id": 1208235,
"text": ", J. TSICU 12:29 AM\n ABDOMEN (SUPINE ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n PFI REPORT\n Vertically oriented IVC filter with the tip at the lower one-third of the L1\n vertebra.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208079,
"text": " 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is status post intubation, to look for interval\n changes in the lung.\n\n TECHNIQUE: Supine portable semi-upright radiograph of chest.\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: Left subclavian line ends at mid SVC. Endotracheal tube ends\n approximately 3.1 cm above the carina. Orogastric tube is seen coursing below\n the diaphragm with distal end within the stomach and is adequately placed.\n Bilateral moderate pulmonary edema has minimally improved. Increased left\n retrocardiac density is no different from prior radiograph and may either\n represent a left lower lung atelectasis or a concomitant lung pneumonia.\n Minimal left pleural effusion has been stable.\n\n IMPRESSION: Since , there is minimal improvement in the\n moderate pulmonary edema. Increased retrocardiac density concerning for\n atelectasis or concomitant consolidation and minimal left pleural effusions\n are unchanged.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "LO HIP UNILAT MIN 2 VIEWS LEFT IN O.R.",
"row_id": 1207369,
"text": " 2:09 PM\n HIP UNILAT MIN 2 VIEWS LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN\n LOWER EXTREMITY WITHOUT RADIOLOGIST IN O.R.\n Reason: LEFT THR, FEMUR HRDWARE\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hip intraoperative studies .\n\n CLINICAL HISTORY: Patient with left total hip arthroplasty.\n\n FINDINGS: Multiple fluoroscopic images from the operating room demonstrate\n interval placement of a left hemiarthroplasty with a cemented femoral\n component. There are no signs for hardware-related complications. There is\n also a fracture involving the distal femoral metaphysis. This is fixated by a\n large fracture plate with mobile associated cortical screws. Please refer to\n the operative note for additional details. The total intraservice\n fluoroscopic time was 8.8 seconds.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "BO FEMUR (AP & LAT) BILAT IN O.R.",
"row_id": 1207310,
"text": " 10:23 AM\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILATClip # \n Reason: ORIF BILATERAL DISTAL FEMURS\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ORIF of bilateral distal femurs.\n\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\n radiologist present. Fourteen spot views were obtained. These demonstrate\n ORIF of bilateral distal femoral fractures with placement of bilateral lateral\n plates and screws. A total of 69.2 seconds of fluoroscopic time was used.\n Please refer to the operative note for further details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209311,
"text": " 9:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for intrapulmonary process\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with TBI and hx of MRSA pneumonia\n REASON FOR THIS EXAMINATION:\n please evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MRSA pneumonia.\n\n FINDINGS: In comparison with study of , the tracheostomy tube is in\n place. The left double-lumen tube is not appreciated at this time. Cardiac\n silhouette is unchanged and there is again evidence of bilateral pleural\n effusions with compressive atelectasis at the bases. Elevation of pulmonary\n venous pressure is again noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-07 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1207193,
"text": " 4:21 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old female status post fall.\n\n STUDY: Portable AP chest radiograph.\n\n COMPARISON: CT of the chest on at 12:36 p.m.\n\n FINDINGS: The endotracheal tube sits 2.5 cm above the carina. Right-sided\n central venous catheter tip sits in the lower SVC. The endogastric tube side\n port sits just below the GE junction. The patient is situated on a trauma\n board, limiting assessment for fine detail. Within that limitation, the\n cardiomediastinal and hilar contours appear within normal limits. The lungs\n are clear. There is no large pleural effusion or pneumothorax. Irregularity\n along multiple right posterior ribs and the right proximal humerus are most\n compatible with old injuries.\n\n IMPRESSION:\n 1. Lines and tubes as described above.\n 2. No evidence of acute intrathoracic injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-09 00:00:00.000",
"description": "MR CERVICAL SPINE W/O CONTRAST",
"row_id": 1207581,
"text": " 4:29 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please evaluate for c-spine bone, cord or ligamentous\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for c-spine bone, cord or ligamentous\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SAT 8:12 PM\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\n multifactorial degenerative changes, with assessment of details being\n significantly limited on the axial images, due to motion-related artifacts.\n\n Areas of altered signal intensity in the thecal sac may relate to blood\n products/pulsation artifacts or a combination of both given the presence of\n subarachnoid and intraventricular hemorrhage on prior CT head study.\n Correlate clinically. Please see important findings on the MR and\n L-spine performed as a separate study on the same day.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, with SAH and SDH and intraventricular\n hemorrhage, to evaluate for C-spine bone, cord or ligamentous lesions.\n\n COMPARISON: No prior C-spine studies.\n\n TECHNIQUE: MR of the cervical spine without contrast.\n\n FINDINGS:\n\n The cervical vertebral bodies are normal in height, signal intensity and\n alignment.\n Multilevel degenerative changes are noted in the form of disc desiccation,\n narrowing of the disc space, disc osteophyte complexes and facet degenerative\n changes indenting the ventral thecal sac resulting in mild canal stenosis.\n Most prominent changes are noted at C5-6 level. No pre- or para-vertebral\n soft tissue swelling or masses are noted. However, assessment is limited due\n to intubation.\n Vague areas of cord signal intensity are noted, inadequately assessed on the\n present study.\n Areas of altered signal intensity in the thecal sac may relate to pulsation\n artifacts versus blood products.\n\n Areas of marrow edema in T2 and T3 bodies- pl. see concurrent MR T spine\n study.\n Increased signal is noted in the mastoid air cells from fluid/mucosal\n thickening.\n\n IMPRESSION:\n (Over)\n\n 4:29 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please evaluate for c-spine bone, cord or ligamentous\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No obvious focus of marrow edema in the cervical vertebrae. Multilevel,\n multifactorial degenerative changes, with adequate assessment is significantly\n limited on the axial images, due to motion-related artifacts. Osseous details\n can be better assessed with CT if necessary.\n Vague areas of cord signal intensity are noted, inadequately assessed on the\n present study.\n Areas of altered signal intensity in the thecal sac may relate to blood\n products/pulsation artifacts or a combination of both given the presence of\n subarachnoid and intraventricular hemorrhage on prior CT head study.\n Correlate clinically.\n\n Please see important findings on the MR and L-spine performed as a\n separate study on the same day.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207894,
"text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p fall, w/ fever, increased sputum production, increased\n ventilatory requirements\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fall, fever.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained on .\n\n There is interval progression of pulmonary edema. The left lower lobe\n consolidation has increased and there are also bilateral pleural effusion\n noted. Findings are consistent with progression of pulmonary edema, effusions\n and potentially worsening of the left lower lobe infectious process.\n Supporting devices are in unchanged position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209426,
"text": " 2:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 72 year old woman with TBI, VAP with increased WOB, RR 30s w\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\n oxygen requirement.\n REASON FOR THIS EXAMINATION:\n 72 year old woman with TBI, VAP with increased WOB, RR 30s with increased\n oxygen requirement: assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Chest x-ray .\n\n FINDINGS: Tracheostomy tube remains in standard position. Persistent\n moderate right and small left pleural effusion as well as bibasilar\n retrocardiac opacities. No new or worsening lung or pleural abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1207657,
"text": " 8:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate stability of bleed\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with MS and head bleed\n REASON FOR THIS EXAMINATION:\n please evaluate stability of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 10:09 AM\n 1. Minimal increase in the intraventricular hemorrhage layering in the\n occipital horns.\n 2. Otherwise no change, including no new hemorrhage, no intracranial\n herniation and no midline shift.\n 3. Stable mild dilatation of the ventricles.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with MS and head bleed. Please evaluate\n change.\n\n TECHNIQUE: Axial images through the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: CT of the head from , and ,\n CT of the facial bones from .\n\n FINDINGS:\n\n Since , there is minimal increase of the intraventricular\n hemorrhage layering in the occipital horns. Otherwise, the left frontal lobe\n contusion and multifocal intraparenchymal hemorrhage, subdural hemorrhage\n along the falx and the multifocal subarachnoid hemorrhage including in the\n prepontine cistern indenting the pons are unchanged. There is stable minimal\n dilatation of the ventricles. There is no shift of midline structures and no\n herniation. The basilar cisterns are patent.\n\n On a facial bone CT from , multiple facial bone and sphenoid\n bone fractures are unchanged but better evaluated on this prior exam.\n\n IMPRESSION:\n 1. Minimal increase of the intraventricular hemorrhage layering in the\n occipital horns. Otherwise, no change of the intraparenchymal, subarachnoid\n and subdural hemorrhage.\n 2. No shift of midline structures and no intracranial herniation.\n 3. Stable minimal dilatation of the ventricles.\n (Over)\n\n 8:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate stability of bleed\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1207256,
"text": " 3:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with SAH/SDH s/p fall\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with subarachnoid hemorrhage/subdural hematoma after\n fall, please evaluate for interval change.\n\n COMPARISON: Comparison is made to outside hospital head CT performed\n .\n\n TECHNIQUE: Non-contrast axial images obtained through the brain. Coronal and\n sagittal reformations were provided.\n\n FINDINGS:\n\n There is redemonstration of the left extra-axial hematoma overlying the\n convexity of the left frontal lobe, slightly increased in size, measuring 8 mm\n on current study compared to 7 mm on prior study and without associated mass\n effect. There is a possibile small subdural hematoma overlying the right\n frontal convexity; however, this may simply represent bridging cortical veins.\n\n There is redemonstration of the bilateral subarachnoid hemorrhage noted in\n both frontotemporal regions and layering within the Sylvian fissure,\n suprasellar cisterns, and interpeduncular cisterns, volume and distribution\n appears relatively stable compared to prior study. Bilateral\n intraventricular hemorrhages are noted layering in the occipital horns, new\n compared to prior study.\n High-density material, likely blood is noted within the bilateral maxillary\n sinuses. Ventricles and sulci are prominent. No calvarial fracture\n identified, though there appears to be anterior maxillary sinus fractures as\n well as a displaced nasal bone fracture identified. These fractures may be\n better evaluated on the subsequent maxillofacial CT. The ethmoid air cells as\n well as sphenoid sinus demonstrate increased opacification with high-density\n fluid. A subgaleal hematoma overlys the right frontal bone.\n Small amount of gas is noted in the soft tissues of the left cheek.\n\n\n IMPRESSION:\n\n 1. Slightly increased small extra-axial hematoma overlying the left frontal\n lobe convexity and possible small secondary frontal hematoma noted on the\n right.\n 2. Stable bilateral subarachnoid hemorrhage layering around the bifrontal and\n temporal lobes and extending into the suprasellar, prepontine and\n interpeduncular cisterns with indentation on the pons.\n (Over)\n\n 3:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Likely anterior maxillary and nasal bone fractures better evaluated on\n subsequent maxillofacial CT. Opacification of the paranasal sinuses likely\n related to blood.\n 4. Subgaleal hematoma overlying the right frontal bone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1207257,
"text": " 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p fall with trauma to the face\n REASON FOR THIS EXAMINATION:\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\n with head CT*\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:48 PM\n PFI:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall with trauma to face, evaluate for facial\n fractures.\n\n COMPARISON: Head CT from at 05:46 a.m.\n\n TECHNIQUE: Routine MDCT study of the facial bones was performed with 1.25-mm\n slice thickness. Coronal and sagittal reconstructions were provided.\n\n FINDINGS: There are multiple fractures seen.\n\n There are two fractures through the frontal bone, one of which extends through\n the cribriform region and into the right ethmoidal air cells. Underlying this\n fracture is a tiny focus of pneumocephalus. A dural tear with a CSF leak\n cannot be excluded as the fracture line does extend through the posterior\n table.\n Another fracture is seen through the posterior margin of the left side of\n sphenoid sinus which extends into the sphenoid septations and nasal septum.\n The posterior fragments are overriding and again an underlying dural tear with\n CSF leak cannot be excluded. Another fracture is seen on the medial wall of\n the right sphenoid sinus with slight displacement of the inferior fragment\n laterally into the sinus. A small step-off is seen at the roof of the right\n sphenoid sinus which may represent a neurovascular channel or a small\n nondisplaced fracture.\n No fracture fragments are seen within the orbital cavity.\n Mastoid air cells are opacified, right greater than left, and there is fluid\n surrounding the right ossicular chain and therefore a fracture or dislocation\n cannot be excluded. Small amount of fluid is noted in the left mastoid air\n cells. Evaluation for T bone fractures is limited.\n There are multiple fractures noted involving the nasal bones, nasal septum and\n (Over)\n\n 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the bilateral maxillae with displacement of a few small fragments.\n\n A displaced nasal bone fracture is identified. There is high-density fluid\n throughout the paranasal sinuses, which most likely represents acute bleeding.\n There are scattered foci of soft tissue gas secondary to recent trauma. No\n osseous fragments are seen intracranially or within the orbital cavities. The\n bones are diffusely demineralized which makes identification of any additional\n fractures difficult to exclude.\n\n Areas of high attenuation are seen intracranially which represent subarachnoid\n and intraparenchymal hemorrhage. This is further characterized on concurrent\n head CT. A large right frontal subgaleal hematoma is seen without any\n radiodense foreign object embedded within. An ET tube and OG tube have been\n placed.\n\n IMPRESSION:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the right maxillary sinus and anterior wall of the left maxillary\n sinus and nasal bones . The bones are diffusely demineralized which makes\n identification of any additional fractures difficult to exclude.\n CTA can be considered for assessment of vascular structures and T bones.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n\n D/w Dr., Ortho by Dr. in the room on \n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1207258,
"text": ", J. TSICU 3:44 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?facial fractures *please obtain thin cuts to the face, if p\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p fall with trauma to the face\n REASON FOR THIS EXAMINATION:\n ?facial fractures *please obtain thin cuts to the face, if possible coordinate\n with head CT*\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Multiple maxillofacial fractures including the posterior sphenoid sinus,\n anterior and posterior frontal sinus, ethmoidal air cells, nasal bone, medial\n wall of the maxillary sinus and anterior wall of the left maxillary sinus.\n 2. Paranasal sinuses are filled with hyperdense material, likely blood.\n 3. Small foci of pneumocephalus posterior to the right frontal sinus. An\n underlying dural tear and CSF leak cannot be excluded.\n 4. Diffuse intracranial hemorrhage better characterized on concurrent head\n CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "RO HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.",
"row_id": 1207331,
"text": " 11:51 AM\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RIGHT HIP DHS\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with ORIF of the right hip with dynamic hip\n screw.\n\n FINDINGS: Fluoroscopic assistance was provided to the surgeon without the\n radiologist present. Twelve fluoroscopic spot views were obtained. Images\n demonstrate placement of markers into the femoral shaft and the femoral neck,\n followed by insertion of an intramedullary rod with dynamic hip screw fixation\n of a right intertrochanteric fracture. A total of 75.1 seconds of\n fluoroscopic time was used. Please refer to the operative note for further\n details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207822,
"text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with IPH, desat + fever\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n WET READ: MDAg SUN 9:43 PM\n 1. Increased retrocardiac opacity since could be atelectasis or\n infection. could be evaluated on with PA and lateral views if clinically\n feasible.\n 2. NG tube side port ends at GE junction and could be advanced.\n 3. Remainder of support devices in satisfactory position.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Desaturations in a patient with intraparenchymal\n hemorrhage.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is 3 cm above the carina. The right PICC line tip is at the\n cavoatrial junction. The left subclavian line is at the left brachiocephalic\n vein/SVC junction. The NG tube tip is in the stomach, but the side hole is at\n the gastroesophageal junction and should be advanced.\n\n Heart size and mediastinal contours are stable. There is interval development\n of interstitial pulmonary edema, mild. Left retrocardiac atelectasis has\n developed in the interim, associated with small amount of pleural effusion.\n Right pleural effusion is most likely present as well.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208604,
"text": " 9:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for intrapulmonary process\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with MS s/p TBI\n REASON FOR THIS EXAMINATION:\n please evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for intrapulmonary process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a technically\n limited examination given hardware overlaying the thorax. The patient has\n been extubated, the nasogastric tube has been removed. The left double-lumen\n catheter is in unchanged position. The size of the cardiac silhouette is\n unchanged, extensive retrocardiac atelectasis and presence of bilateral\n pleural effusions. The pre-existing signs of pulmonary edema might have\n minimally decreased in the interval. This increase, however, is not\n substantial. Otherwise, no relevant changes are seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208255,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72F wheelchair bound female w MS who tx from OSH after fall from\n wheelchair lift onto face (facial fxs, B femur fx, SAH, SDH) now s/p repair B/L\n femur fx's \n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with multiple medical\n problems, bedridden.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip, the left subclavian line and the NG tube are in unchanged\n position. Moderate pulmonary edema is unchanged as well as left lower lobe\n consolidation and bilateral pleural effusions. No definitive pneumothorax is\n seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-09 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 1207593,
"text": " 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n s/p repair, intubated, sedated\n REASON FOR THIS EXAMINATION:\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\n injury to obtain clearance of the thoracic and lumbar spines\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 9:22 PM\n 1. Findings concerning for acute fracture of the T3 vertebral body.\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\n not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While these may also be chronic, given the concurrent acute injury in the\n upper thoracic spine, it is difficult to exclude acute compression injury at\n these levels, and further evaluation with MRI of the thoracic spine can be\n considered.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall with bilateral hip fractures.\n The patient is intubated and sedated. Evaluate for thoracic spine fracture.\n\n COMPARISON: MR cervical spine performed the same day. No prior imaging of\n the thoracic spine is available for review.\n\n TECHNIQUE: MDCT imaging of the thoracic spine was performed without contrast.\n Multiplanar reformats are prepared and reviewed in bone and soft tissue\n algorithm.\n\n FINDINGS:\n\n There is subtle loss of height involving the posterior aspect of the T3\n vertebral body, with associated irregularity/buckling of the posterior cortex.\n The inferior aspect of the posterior cortex is displaced posteriorly by\n approximately 3 mm, likely causing associated thecal sac effacement. A subtle\n lucency is seen traversing the T3 vertebral body. These findings are\n suspicious for an acute fracture, as confirmed by marrow edema seen on\n concurrent cervical spine MRI. Of note, T2 fracture suggested by additional\n marrow edema seen at that level is not apparent by CT.\n\n From T4 through T10, vertebral body heights are preserved, and there is no\n evidence of fracture. The alignments are similarly normal. Multilevel\n degenerative change is present, with posterior disc-osteophyte complexes noted\n at T6-7 and T7-8 effacing the thecal sac at these levels.\n\n The T11 vertebral body demonstrates mild, less than 25%, superior end plate\n depression anteriorly. There are some irregular lucencies noted within the\n (Over)\n\n 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vertebral body, though no discrete fracture line is identified, and these\n lucencies may reflect a combination osteopenia and a superior endplate\n Schmorl's node. There is no adjacent soft tissue change to specifically\n suggest an acute injury.\n\n There is approximately 50% loss of height involving the anterior aspect of the\n T12 vertebral body, with some associated irregularity of the posterior cortex\n which can relate to buckling from injury , though again no acute fracture line\n or associated soft tissue change is seen.\n There is additional compression deformity at L1, also without specific\n evidence of acuity, and with marked degenerative osteophyte formation at\n T12-L1 suggesting chronicity.\n There is angulated appearance of the posterosuperior portions of T12 and L1\n vertebral bodies indenting the thecal sac.\n\n The included mediastinal structures are normal within the limits of a\n non-contrast evaluation. Right and left central lines terminate in the SVC.\n Nasogastric tube seen entering the stomach. The patient is intubated with an\n endotracheal tube terminating in the mid trachea. There is no adenopathy. A\n small amount of fluid is seen in the pericardial recess.\n\n There are bilateral pleural effusions, with associated bibasilar dependent\n consolidations most likely reflecting atelectasis. Remainder of the lung\n parenchyma included is well aerated.\n\n IMPRESSION:\n\n 1. Acute compression fracture of the T3 vertebral body, with buckling of the\n posterior cortex, the inferior aspect of which is displaced posteriorly by\n approximately 3 mm. Suspected T2 vertebral body fracture (seen on concurrent\n cervical spine MRI) is not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While as detailed above these may be chronic, given the concurrent acute\n injury in the upper thoracic spine, it is difficult to exclude an acute\n component. Further evaluation with MRI of the thoracic spine can be\n considered as clinically indicated.\n\n Discussed with Dr at 8pm by Dr via phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-07 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 1207198,
"text": " 5:05 PM\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \n ANKLE (AP, LAT & OBLIQUE) BILAT\n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with bilateral femoral head/neck fractures\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral femoral neck and head fractures.\n\n COMPARISON: CT torso performed at 12:36.\n\n BILATERAL HIPS, TWO VIEWS EACH INCLUDING A VIEW WITH TRACTION: Comminuted\n right intertrochanteric fracture is identified with minimal displacement. No\n dislocation is identified. On the left, there is a mildly displaced\n subcapital femoral neck fracture with mild superior displacement of the distal\n fracture fragment. No dislocation is present. After traction, the degree of\n displacement of both fractures appear improved. There are degenerative\n changes in both hips with joint space narrowing. There is diffuse osteopenia\n which limits the sensitivity for detection of subtle fractures. There is no\n diastasis of the pubic symphysis or sacroiliac joints. Dense material within\n the region of the bladder likely represents excreted contrast.\n\n RIGHT TIBIA AND FIBULA, TWO VIEWS, AND RIGHT ANKLE, THREE VIEWS: No acute\n fracture or dislocation is identified. The ankle mortise is preserved. The\n talar dome appears smooth. There is diffuse demineralization of the osseous\n structures which limits sensitivity for detection of subtle fractures. Soft\n tissue swelling is noted about the ankle and foot. Partially imaged is a\n comminuted distal femoral fracture with evidence of lipohemarthrosis. Soft\n tissue calcification within the anterior aspect of the knee is likely vascular\n in etiology.\n\n LEFT TIBIA AND FIBULA, TWO VIEWS, AND LEFT ANKLE, THREE VIEWS: No acute\n fracture or dislocation is identified. There is diffuse soft tissue swelling.\n Rounded calcifications within the anterior soft tissues of the knee and lower\n leg likely represent vascular calcifications. Evaluation of left ankle is\n somewhat suboptimal, with degenerative changes of the tibiotalar joint\n present. Degenerative changes of the mid foot and hindfoot are also\n visualized, without a significant joint effusion.\n\n IMPRESSION:\n 1. Bilateral femoral neck fractures.\n\n 2. Partially imaged comminuted fracture of distal right femur with associated\n lipohemarthrosis.\n\n 3. No acute fracture or dislocation within either tibia or fibula, or ankle.\n DFDdp\n (Over)\n\n 5:05 PM\n BILAT HIPS (AP,LAT & AP PELVIS); TIB/FIB (AP & LAT) BILAT Clip # \n ANKLE (AP, LAT & OBLIQUE) BILAT\n Reason: eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1207283,
"text": " 7:58 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval line placement\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with polytrauma, intubated\n REASON FOR THIS EXAMINATION:\n Eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with polytrauma, status post intubation.\n Evaluate line placement.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: Endotracheal tube is 3.0 cm above the carina.\n Nasogastric tube follows a normal course terminating in the left upper\n quadrant with last side port just below the GE junction. Left subclavian\n central venous catheter terminates just beyond the junction of the\n brachiocephalic and SVC. Right-sided PICC follows a normal course terminating\n in the distal SVC.\n\n There is bibasilar atelectasis, but lungs are elsewhere clear. There is no\n large pleural effusion or pneumothorax. Heart size is normal. Mediastinal\n silhouette, hilar contours and pulmonary vasculature are normal. There is no\n displaced rib fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-09 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 1207594,
"text": ", J. TSICU 6:19 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: please perfor CT of thoracic and lumbar spine to evaluate fo\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n s/p repair, intubated, sedated\n REASON FOR THIS EXAMINATION:\n please perfor CT of thoracic and lumbar spine to evaluate for signs of spinal\n injury to obtain clearance of the thoracic and lumbar spines\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Findings concerning for acute fracture of the T3 vertebral body.\n Suspected T2 vertebral body fracture seen on concurrent cervical spine MRI is\n not apparent by CT.\n\n 2. Compression deformities involving the T11, T12, and L1 vertebral bodies.\n While these may also be chronic, given the concurrent acute injury in the\n upper thoracic spine, it is difficult to exclude acute compression injury at\n these levels, and further evaluation with MRI of the thoracic spine can be\n considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-09 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 1207595,
"text": " 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for thoracic or lumbar processes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 7:56 PM\n No secure evidence of acute lumbar spine fracture. Compression deformities of\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\n fracture lines identified. These are most likely chronic. Bony canal appears\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\n Intrathecal detail is poorly assessed by CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post fall from wheelchair with\n bilateral hip fractures. Evaluate for fracture involving the lumbar spine.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT imaging of the lumbar spine was performed without contrast.\n Multiplanar reformats were prepared and reviewed in bone and soft tissue\n algorithm.\n\n FINDINGS:\n\n There is diffuse osteopenia.\n There is no obvious evidence of acute fracture involving the lumbar spine.\n The L1 - L5 vertebral bodies are preserved in alignment, and there is no\n prevertebral or paravertebral soft tissue change to suggest acute injury.\n\n There is superior endplate compression deformity involving L1, with 25-50%\n height loss of L1 anteriorly but preservation of the posterior cortex.\n Angulated postero-superior aspect of L1 is seen to indent the ventral thecal\n sac.\n Marked associated degenerative change at T12-L1 with anterior osteophyte\n formation and a prominent L1 superior enplate Schmorl's node favor chronicity.\n (However, small amount of marrow edema is noted adjacent to the Schmorl's node\n on susequent MRI).\n\n Milder degenerative change is seen in the lower lumbar spine, with additional\n disc space narrowing at L3-L4 and small posterior disc protrusions at L4-L5\n and L5-S1. There is however only minimal facet arthropathy, and no\n significant central canal or neural foraminal narrowing, however, intrathecal\n detail is poorly assessed by CT.\n\n There are no suspiciou/concerning lytic or sclerotic osseous lesions.\n There is excreted contrast within the renal collecting systems, reflecting\n prior contrast administration. There is mild atherosclerosis. There is no\n (Over)\n\n 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aneurysm or retroperitoneal adenopathy/mass identified.\n\n IMPRESSION:\n\n No definite acute fractures or malalignment involving the lumbar spine.\n Likely chronic compression deformity of L1 is noted, as described above. See\n subsequent MRI\n\n Mild degenerative change at L3-S1, without apparent critical canal stenosis.\n\n Please see seperately reported thoracic spine CT for comments regarding the\n low thoracic spine.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-09 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 1207596,
"text": ", J. TSICU 6:24 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for thoracic or lumbar processes\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 yF s/p fall from wheelchair with + LOC, SAH/SDH and bilateral hip fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for thoracic or lumbar processes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No secure evidence of acute lumbar spine fracture. Compression deformities of\n T12 and L1. Lack of associated soft tissue change, and there are no lucent\n fracture lines identified. These are most likely chronic. Bony canal appears\n widely patent, with mild disc protrusions seen in the lower lumbar spine.\n Intrathecal detail is poorly assessed by CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-10-07 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1207220,
"text": " 7:17 PM\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \n Reason: surgical planning\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with bilateral femoral neck and distal femur fx\n REASON FOR THIS EXAMINATION:\n surgical planning\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:06 AM\n\n comminuted right intertrochanteric proximal femur fracture with angulation of\n the femoral neck. left subcapital femoral neck fx with mild-moderate superior\n translation of the distal femur relative to the femoral head. bilateral\n comminuted, angulated and slightly impacted distal femur fractures. no pelvic\n fractures. expected soft tissue changes with bilateral lipohemarthoses of the\n knees. no large pelvic or retroperitoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral femoral neck and distal femur fracture for surgical\n planning.\n\n TECHNIQUE: CT of pelvis and bilateral femurs without IV contrast with coronal\n and sagittal reformatted images per protocol.\n\n COMPARISON: Bilateral hips radiograph .\n\n FINDINGS: There is a Foley catheter in the urinary bladder with suprapubic\n access. There is air within the urinary bladder presumably from catheter\n placement; however, correlate clinically. There is mild stranding about the\n rectum (3:47); nonspecific.\n\n There is a diffuse osteopenia. In the lower lumbar spine there is facet\n arthropathy. Degenerative changes are seen in the SI and hip joints\n bilaterally.\n\n RIGHT:\n\n There is a comminuted impacted angulated fracture of the femoral neck and\n intertrochanteric fracture with varus angulation. There is associated soft\n tissue hematoma and joint effusion.\n\n There is a supracondylar highly comminuted impacted fracture with marked\n angulation and distraction of fracture fragments. There is moderate\n angulation of major distal fracture fragments anterior and lateral with\n rotation. The right knee joint is incongruent. Fracture extends into the\n posterior aspect of the medial femoral condyle and intercondylar notch;\n involves the majority of the medial femoral condyle. The right proximal tibia\n appears intact.\n\n LEFT:\n (Over)\n\n 7:17 PM\n CT PELVIS W/O CONTRAST; CT LOW EXT W/O C BILAT Clip # \n Reason: surgical planning\n Admitting Diagnosis: BILATERAL FEMORAL FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a comminuted fracture of the femoral neck with varus angulation and\n impaction. There is associated joint effusion. There is a highly comminuted\n impacted supracondylar fracture with anterior angulation of major distal\n fracture fragment overriding and shortening the limp. There is hematoma at\n the fracture site. There is distraction of fracture fragments. The fracture\n line involves both medial and lateral condyle extending to the lateral condyle\n joint surface and medial trochlea.\n\n There is extensive hematoma in the subcutaneous soft tissue tracking along\n bilateral thighs. There is bilateral lipohemarthrosis of the knees.\n\n IMPRESSION:\n\n 1. Complex fracture of the right femoral neck and intertrochanteric region.\n 2. Complex fracture of the left femoral neck.\n 3. Bilateral complex supracondylar fractures.\n 4. Bilateral hemarthrosis of the knees.\n 5. Subcutaneous soft tissue hematoma tracking along bilateral thigh.\n 6. Severe osteopenia.\n 7. Degenerative changes in the lower lumbar spine, SI and hip joints.\n 8. Suprapubic Foley catheter in the urinary bladder and air in the urinary\n bladder, presumably from catheter placement; correlate clinically.\n 9. Nonspecific fat stranding about the rectum; correlate clinically.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-10-11 00:00:00.000",
"description": "Report",
"row_id": 248512,
"text": "Sinus tachycardia. Low limb lead voltage. Non-specific ST-T wave changes.\nCompared to the previous tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-10-08 00:00:00.000",
"description": "Report",
"row_id": 248513,
"text": "Sinus tachycardia. Non-specific ST-T wave changes are diffuse. No previous\ntracing available for comparison.\n\n"
}
] |
|
25,580 | 192,528 | Patient was transferred for emergent repair of ruptured AAA. For details of this, please see the previously dictated operative note. Post-operatively, the patient was brought to the ICU for monitoring. She remained intubated for 10 days secondary to her open abdomen and volume overload following resuscitation. Throughout this period, she was maintained on vancomycin, Levaquin and Flagyl for antibiotic prophylaxis, fearing a graft infection. On POD #10, she was brought back to the operating room for closure of her abdomen. For details of this, please see the previously dictated operative note. The patient then had a slow wean from mechanical ventilation and was intermittently diuresed with Lasix prn and Lasix gtt. She extubated on POD #20 without event. She did spike fevers and had a mildly elevated WBC (12 - 13) which prompted an infectious work-up which revealed an E. coli pneumonia and urinary tract infection. She was empirically begun on Zosyn while culture data was pending, and continued on Zosyn based on sensitivities. Ultimately, the patient was discharged to rehab on PODs #25 & 15 tolerating a regular diet, in adequate pain control, afebrile and with a normal white count. She has been working with physical therapy to regain her strength and motor function. | Resp Care,Pt. Afib-rate controlled.GI: Abdomen softly distended. Afib rate controlled. remains intubated on A/C overnoc. Bedside TEE done. Lungs CTAB.CV: Afebrile. See carevue for objective data.Remains sedated on proprofol/fentanyl gtts. Min amt of secretions. CONDITION UPDATEVSS. REMAINS IN AFIB RATE CONTROLLED. Cdif sent.GU: Diuresing. decreasing.GU: Foley to gravity. Assess CO and PAWP and need for continued fluid bolus'. Diuresing well.Labs: Hct stable. Lasix dose given as ordered. Chest PT done. JP'S TO WALL SUCTION - LG AMT OF S/S DRAINAGE OUT. Attempted RSBI, apnea. Enc C&DB. CO/CI CONT TO BE LOW - SICU TEAM AND ATTENDING DR AWARE. Pt & abg showed improvment today with some reduction in sputum noted. Denies pain.Resp: Lungs clear at the upper lobes bilat. AFEBRILE. ,rrtpt. decreased, plan for rsbi in am. BP stable. U/O QS VIA FOLEY. PCXR done this PM.Had an episiode of hypotension to systolic of 60's with turning to the right this AM requiring initiation of levophed. Dobutamine dc'd.See flowsheet for CO/CI/SVR data. Maintain current vent settings. CO , CO . CONT CURRENT ICU CARE AND ASSESSMENT. Plan: Pt. on Fri for closure (per Dr. Fent gtt for comfort Notify H.O. CI and CO running low even after 1U PRBC-may need to give more fluid or start nitro gtt. LYTES REPLETED PRN.ENDO: FS QID COVERAGE PER RISS. Cont wiht generalized 3+ pit edema.LS clear to coarse. DIAMOX WAS ADDED TO OFFSET ALREADY SL ELEVATED TCO2. JP's with seroserosang output.PLAN: Cont vent wean as pt tol. Plan to maintain at this time due to tachypnea with RSBI. PT APPEARS TO BE TOLERATING TF EVEN WITH HYPOACTIVE BOWEL SOUNDS. Tol TF at goal minmal residuals. Arrived on NEO for hypotension. 2200-PT LS /FEW SCATTERED EXP WHEEZES. MONITOR WBC'S/HCT/ABG'S/LYTES PRN. FOCUS: CONDITION UPDATED: SEE CAREVUE FOR SPECIFICSCONTINUES TO IMPROVE, AWAITING VICU BED,OOB TO CHAIR, TOLERATED WELL. Respiratory CarePt.continues on full vent.support t/o shift.Labile b/p at times.Vent.changes made as needed. HR UP TO 130 AND HTN 170'S WHEN ANXIOUS/UNDERSEDATED, SETTLES WITH HR 80-90'S AND SBP 95-120 WHEN COMFORTABLE. 2+ LE edema. Goal is to be 2L neg.Access: RIJ TLC, R rad a-line (positional).ID: T=100.4 oral, all antibx d/c'd yesterdayEndo: FS covered w/ RISSSkin: Abd incision pink w/ necrotic areas as previously noted. CONSOLIDATION IN TH LLL PER SICU TEAM. respiratory CareNo vent. BS hypoactive.GU: Foley to gravity. PLAN-- OR IN AM TO CLOSE ABDOMEN. GIVEN 20 IV LASIX X1 WITH GOOD DIURESIS. Pheripheral Edema +3. BS equal with coares rhonchi & wheezes thoughout. FOLEY TO CD QUANTITY SUFFFICIENT.ENDO- BS STABLE THIS SHIFT.ID- CONTINUES ON VANCO FLAGGYL AND LEVOFLOXICIN T 99.5POC- CONTINUE TO MONITOR-K AND ABG. Diurese, replete lytes. DP/PT pulses dopplerable. DP/PT pulses dopplerable. BS improve some post sxTrach was planed for today. pt had a bronch today lg amt. CXR done. care note - Pt. BS 105-207; RISS q6hr and NPH 10units . tube fdgs via ngt and tol well. pt was reintubated pre bronch today. Pt w/ +3 edema on BUE and BLE. ABG PENDING.GI/GU- NG TO LWS SMALL BILLIOUS DRAINAGE, OPEN ABD. Abdomen softly distended w/ +BS. Abdomen softly distended w/ +BS. HR 90s-120s AF with occ. abd binder intact and abd dsg changed. R TLC line intact and R radial a-line intact.Plan for possible bronch today. Respratory CareNo vent.changes needed overnight.abg's adequate.Plan:continue wean as tolerated CO-4.01 CI- 2.20 LASIX GIVEN TIMES TWO WITH GOOD DIURESIS. Resp. Adequate sedation w/ major care/procedures. Possible bronch today for LLL atelectasis on CXR.GI/GU: Abd. Cont RISS as well. HR 80-101 (A.fib). Lasix 20mg IV x1 ordered and given. amt of sputum today. Monitor BS; NPH . dsgs intact with scant serosang. Open abd wound w/ 2 JP's to sx, decreasing s/s drng. Good ABG'S.Will cont to moniotr resp status. Rhonchi improves post sx. Resp Care Note,Weaned down FIO2 for good ABG. Resp Care Note,Weaned pt 2 ^ peep.Temp 100. Resp CarePt intubated on A/C. open with transparent dsg intact- continues to ooze serosang. Weak but follows commands.CO/CI remain labile requiring fluid boluses prn. FOLLOWING COMMANDS.RESP: LS CLEAR. dsg intact.Plan for closure of abd. Pneumoboots on. Pt stable with present settings. Pt was bronch'd for a lot of secretions f/u CXR showed improvement. TOLERATING REG. support @ this time but continues to have pul. Respiratory Care Pt continues on CPAP/PSV 10/5 in NARD. L glass eye intact.CV: Tmax 101.1 and pan cx'd. JP's still to LWS and draining lge amts. K+ & MG+ repleted.Plan: continue with current plan of care per sicu/ vascular teams. Condition UpdateD: See carevue flowsheet for specificsPatient remains afebrile HR stable in afib with good rate control-pt was started on a small dose of lopressor which was well tolerated. Lungs have been clear and dim in the bases -CXR ordered for tomorrow. drainage in moderate amts. +++ EDEMA. +ATN per team. + PPP BILAT. Lungs are clear and diminished in the bases. Sx'd for scant amts whitish secretions. Simpleatheroma in aortic arch. Again, noted is interstitial edema and moderate bilateral pleural effusions. There are simple atheroma in the aortic arch. There is cardiomegaly, with a calcified, unfolded aorta. Again seen are mild-to-moderate bilateral pleural effusions. There is stable appearance of the heavily calcified thoracic aorta with unchanged appearance of wall thickening at the level of the aortic knob, which may represent chronic dissection or calcification of a thick pseudointima. Lines and tubes are unchanged in position with note again made of overdistention of the endotracheal tube cuff. The aorta is calcified. Left pleural effusion.Conclusions:1. Heart is probably not enlarged, although the aortic knob is markedly dilated and calcified. Heterogeneously echoic fluid collection in the right lower quadrant is incidentally noted. AP BEDSIDE CHEST: There are bilateral moderate-sized pleural effusions with associated basal atelectasis. Various lines and tubes are unchanged in position with note again made of overdistention of endotracheal tube cuff. IMPRESSION: Small-to-moderate bilateral pleural effusions. There is dextroscoliosis of the thoracic spine. There is an endotracheal tube with distal tip at the thoracic inlet. There is slight perihilar haziness and subtle interstitial pattern in the right lung, which may reflect a component of interstitial edema, and there is also a probable small right pleural effusion. | 100 | [
{
"category": "Nursing/other",
"chartdate": "2111-11-17 00:00:00.000",
"description": "Report",
"row_id": 1595844,
"text": "neuro: Pt remains sedated on propofol and fentanyl. Opens eyes to pain, unable to follow any directions. Appear to have abd/incisional pain with turning and repositioning.\nCV: low grade temp 100.4, HR 100-120's Afib with transient episodes of PVC's, Lytes repleated with noted improvement in ectopy. SBP 80-120's, Unable to wean off dobutamine. CVP 11-15, PAP 40's/20's. PAWP 19-20. CO , CO . Requiring significant amounts of fluid bolus' for continued hypotension. HCT 23.8, treated with 2u PRBC's\nRESP: lungs clear to dim at bases, No vent changes overnight. O2 sats >95%. Occasional suctioning of thin white secretions.\nGI: abd open with absent BS. NGT draining mod amounts of bilious drg.\nGU: foley draining 10-15cc of amber urine.\nENDO: blood sugars labile.\nPLAN: Cont to wean dobutamine. Assess CO and PAWP and need for continued fluid bolus'. Monitor pain and effectiveness of fentanyl gtt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-18 00:00:00.000",
"description": "Report",
"row_id": 1595850,
"text": "Abd wound washing/dressing to be done in AM MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-19 00:00:00.000",
"description": "Report",
"row_id": 1595851,
"text": "Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift, ABG acceptable. Attempted RSBI, apnea. Maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-25 00:00:00.000",
"description": "Report",
"row_id": 1595872,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Vent settings Vt 450, A/c 14, Fio2 40%, and Peep 5. Bs clear bilaterally. Sx'd for sm amounts of thick white secretions. RSBI 34. Abg this am reveals metabolic alkalosis. Plan: Pt. to return to OR for closure of Abd. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-25 00:00:00.000",
"description": "Report",
"row_id": 1595873,
"text": "Events:\n\nPt To OR for abd closure with mesh return to ICU neo for SBP 90, fluid boluses x2 for SBP and low CVP with good response, Sao2 drop 93, sx for thick yellow, Left upper lung grossly dim bronchial BS, CXR done atelectasis, L plueral effusion\n\nNeuro-sedated on Prop, fent gtt Right PERLA, left glass eye, MAEW\nCV-MP AFib neo gtt weaned to off, will restart lopressor when SBP stable, lasix drip d/c, generalized anasarca, cool extrem x4\nResp-AC rate 16, 60%, TV500, vent wean as tolerated\nFEN-TPN, BS covered with SS insulin, TF held, absent BS, NGT to Liwsx drg bilious green\nU/O >40cc/hr\nID-cont on ABX\nFamily-daughter , request aggressive attempts to wean from ventilator, reassurance given to daughter and all questions answered\n and fentanyl overnight, wean prop in AM, and plan for vent wean, monitor ABG, CBC, and lytes, cont ABX, TPN, prophylaxis protonix\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-25 00:00:00.000",
"description": "Report",
"row_id": 1595874,
"text": "Pt came back from OR on 100% O2. Chest Xray showed Left lung to be largely out with only LUL aerated. Pt sxed for a mod-lg amt. very thick yellow sputum (no plugs noted). Recruetment manuver used to try and open lung.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-17 00:00:00.000",
"description": "Report",
"row_id": 1595845,
"text": ",rrt\npt. tolerating current settings reasonably well, fio2 increased to .60 following am abg due to low pa02, b/l b.s. diminished/slight coarse, sx'ing minimal #'s tan thick/moist sputum, sats remained mid 90's with few drops to high 80's/low 90's, plan to do rsbi this am, will monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-17 00:00:00.000",
"description": "Report",
"row_id": 1595846,
"text": "See carevue for objective data.\n\nRemains sedated on proprofol/fentanyl gtts. No change in vent settings. Minimal secretions. ETT rotated. PCXR done this PM.\nHad an episiode of hypotension to systolic of 60's with turning to the right this AM requiring initiation of levophed. Dobutamine dc'd.\nSee flowsheet for CO/CI/SVR data. Bedside TEE done. Ventricles under filled-no thrombus/aneurysm MD. PCWP:15-10 CVP: \nMinimal urine output-team aware. PM lytes pending.\nJP's draining large amount of bloody drainage-2L this shift.HCT OK.\nHIT antibody sent for plts<100.\nAbd wound remains open and dressing intact.\n\nFamily in and updated on POC. Support provided.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-18 00:00:00.000",
"description": "Report",
"row_id": 1595847,
"text": ",rrt\nno changes made, sats in the high 90's t/o shift, sx'd min tan secretions,b/l b.s. decreased, plan for rsbi in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595906,
"text": "Addendum to NPN:\nPt's tongue w/ thrush; Nystatin oral suspension applied on tongue w/ swabs. Red rash under bilat arms/breasts and groin; miconazole powder applied. Cont to monitor rash.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595907,
"text": " 19/07\n NEURO A/O TALKS AROUND TUBE SEEMS TO UNDERSTAND AND HELPS WITH CARE GIVEN PAIN CONTROL WITH FENT DRIP PERIODS OF AGITATION ABLE TO BE TALKED DOWN OPENLY WANTS ETT OUT AND TO GO HOME\n RESP ETT CPAP 15/5 TOL WELL RSBI 87 IMPROVING TV 450 TO 500 SCANT SPUTUM RHONCHI THRUOUT CLEARS AFTER SUCTIONING\n HEART AF RATES 80 TO M MITRIAL AREA SYS POOR PULSES THRU OUT POS NVD WITH MILD HJR\n ABD DRESSING IN PLACE FOLEY CATH NO B/S\n PLAN WEAN VENT REMOVE TUBE GIVE EMOTIONAL SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-05 00:00:00.000",
"description": "Report",
"row_id": 1595908,
"text": "Respiratory Care\nPt.remains stable on PSV.no changes overnight.RSBI-88,abg's wnl.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-05 00:00:00.000",
"description": "Report",
"row_id": 1595909,
"text": "Nursing care note\nSee careview for specifics.\nSignificant event: Pt extubated at 1400 hours. Placed in 50% FM. O2 sats have remained 99-100%. No resp. distress. Encouraging C&DB.\n\nNeuro: Awake, oriented to person & place. Moves all extremities. Follows commands. Difficult to move BLE's d/t edema. Right pupil equal and reactive. Denies pain.\n\nResp: Lungs clear at the upper lobes bilat. Diminished bibasilar. Coughing/expectorating thick white sputum. RR 28-35.\n\nCV: Afebrile. Afib rate controlled. BP stable. All 4 extremities warm with palpable pulses.\n\nGI: Abdomen obese with positive BS. Rec's Impact with fiber at goal rate of 80cc/hr. Stooling. Cdif sent.\n\nGU: Diuresing. Lasix given to help mobilize fluid.\n\nSkin: Midline abdominal staples intact. Note small amount of eschar at mid pole. No drainage.\n\nPlan: Pulmonary toilet. Enc C&DB. OOB to recliner tomorrow if tolerates extubation. Provide support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-05 00:00:00.000",
"description": "Report",
"row_id": 1595910,
"text": "Pt & abg showed improvment today with some reduction in sputum noted. She was extubated @ about 1400pm today. She has a good productive and moist cough plan to continue Deep Breathing & coughing with pt\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-19 00:00:00.000",
"description": "Report",
"row_id": 1595852,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile and HR remains in afib with improved rate control ~80's very little ectopy noted overnight. Swan required re-floating x2 in order to obtain PCWP. Wedge 17-19. CVP 10-13. CI and CO running low even after 1U PRBC-may need to give more fluid or start nitro gtt. Patient making marginal amts of urine.\n Transplant team in at beginning of shift to remove packing from abd and re-explore belly. No ischemic bowel noted (during procedure pt was sedated with ppf and fentanyl gtts BP tolerated well did not require any pressors). JP's not draining as much as over the past couple of days but still dilute sanginous drg. Amino Acids started for nutrition.\n No vent changes made overnight. AM ABG unchanged from previous abg with paO2 80's. Min amt of secretions. Pt remains on fent gtt for comfort. Opens eyes and will open mouth on command but not nodding to questions or moving extremeties on command.\nPLAN:\n ? get cardiology on board\n ?fluid vs nitro gtt\n Return to OR ? on Fri for closure (per Dr. \n Fent gtt for comfort\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-19 00:00:00.000",
"description": "Report",
"row_id": 1595853,
"text": "CONDITION UPDATE\nVSS. AFEBRILE. REMAINS IN AFIB RATE CONTROLLED. CO/CI CONT TO BE LOW - SICU TEAM AND ATTENDING DR AWARE. UNABLE TO WEDGE SWAN - SICU TEAM AWARE. MAJORITY OF SHIFT PT ALERT. FOLLOWING SIMPLE COMMANDS. REMAINS ON FENT DRIP APPEARS TO HAVE GOOD PAIN MANAGEMENT. LUNGS COARSE THROUGHOUT. MIN SUCTIONING FOR THICK, TAN SPUTUM. ABD REMAINS OPEN. TRANSPARENT DRESSING INTACT. JP'S TO WALL SUCTION - LG AMT OF S/S DRAINAGE OUT. STARTED ON TPN. U/O QS VIA FOLEY. DIURESED W/ 10MG OF LASIX MD'S ORDERS W/ SM EFFECT. SOCIAL WORKEER IN AND SPOKE W/ FAMILY.\nCONT TO MONITOR FOR S/S OF BLEEDING. PAIN MANAGEMENT. PT/FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-20 00:00:00.000",
"description": "Report",
"row_id": 1595854,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made overnoc. Currently on A/C ventilation w/ PIP/Pplat = 26/20. BLBS slightly diminished, suctioned for small amounts of thick white secretions. SpO2 remained 90s. ETT secure/patent & in good position. No RSBI d/t apnea. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-01 00:00:00.000",
"description": "Report",
"row_id": 1595892,
"text": "Respiratory Care\nPt continues to be orally intubated and mechanically ventilated at this time. Currently on PSV 10/5/.50 with tidal volumes 350-500ccs and resp rate 15-30. BS: clear bilaterally. Suctioned for small amts of thick white secretions. Discussion with family about trach/peg today. Plan to attemp rsbi in am and possible extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-05 00:00:00.000",
"description": "Report",
"row_id": 1595911,
"text": " 19/07\n NEURO A/O RELAXED TALKATIVE MAE IN GOOD SPIRITS\n RESP FM TOL WELL MOBILIZING OWN SPUTUM CLEAR LUNGS\n HEART AF TOL WELL VSS PULSES POS 3 THRU OUT NVD REMAINS CVP WNL LASIX TO MOTIVATE FLUID SHIFT TOL WELL\n GI POS B/S STOOLING TOL T/F WELL ABD DRESSING IN PLACE D/I\n PLAN PROGRESSIVE AMBULATION P/T FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-06 00:00:00.000",
"description": "Report",
"row_id": 1595912,
"text": "Nursing care note\nSee careview for specifics\nNeuro: PERL Oriented x3. Follows commands. OOB to recliner. Tolerated well. Denies pain.\nResp: O2 sats 92-98% on 50% FT. Chest PT done. Expectorating thin white sputum. Lungs CTAB.\nCV: Afebrile. VSS. Afib-rate controlled.\nGI: Abdomen softly distended. TOlerating TF's at goal rate of 80cc/hour. Liquid stool ? decreasing.\nGU: Foley to gravity. Lasix dose given as ordered. Diuresing well.\nLabs: Hct stable. Glucoses marginally elevated. Covered with RISS in addition to NPH.\nSocial: Family at the bedside.\nPlan: ?transfer to floor tomorrow. Aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-09 00:00:00.000",
"description": "Report",
"row_id": 1595918,
"text": "SICU B NPN:\nNEURO: A&Ox3. Pleasant and cooperative. Denies any pain but complaining of \"stiff legs.\" Moving all extremities UE>LE.\nCV: Afeb. HR 80s-90s AF, no ectopy noted. BP stable via NIBP. 3+ edema to extremities. Palpable pedal pulses. CVP 4-6. R IJ TLC line intact with slight redness noted around insertion site, no swelling or drainage noted.\nRESP: On 4L NC with O2 Sat >92% but did desaturate to 87-88 x2 overnight- chest PT given with good results both times. Encouraged to cough and deep breathe and using Yankar to clear secretions. RR 20s-30s. LS coarse and diminished at bases.\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with small amts of loose brown stool draining. Taking pills without difficulty. No NPH insulin given at 2200 due to pt. not eating much and glucose on previous night dipped very low after receiving NPH. Dr. aware. Foley with clear yellow urine >40cc/hr.\nSKIN: Abd. incision site C/D/I with staples, no swelling or drainage. Dsg changed with small amt of serosang. drainage on old dsg. Yeast rash to groin and folds- miconazole powder to affected areas.\nPlan to transfer to VICU when bed avail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-09 00:00:00.000",
"description": "Report",
"row_id": 1595919,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFICS\nCONTINUES TO IMPROVE, AWAITING VICU BED,\nOOB TO CHAIR, TOLERATED WELL. NEEDS AGGRESSIVE PT AS LOWER EXTREMITIES ARE VERY WEAK.\nTOLERATING DIET, YET APPETIT POOR, ENCOURAGED TO TAKE POS AND ENRICHED WITH BOOST.\nCENTRAL LINE OUT, PHERIPHERAL IV PLACED.\nFAMILY SUPPORTIVE.\n REHAB SCREEN.\nWILL CALL WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-10 00:00:00.000",
"description": "Report",
"row_id": 1595920,
"text": "SICU B NPN:\nNEURO: A&Ox3 with periods of slight disorientation overnight but easily reoriented. MAE x4. Denies pain. R pupil 3mm and brisk. Given 1mg ativan for sleep but did not sleep all night.\nCV: Afeb. HR AF, no ectopy noted. BP stable. Skin warm and dry with weak but palpable pedal pulses bilaterally. 2+ LE edema. Started on warfarin 5mg po. Repleted with KCL po and MGSO4 IV.\nRESP: Weaned to 3L O2 with O2 Sat >92%. LS clear/coarse and diminished at bases. Intermitent non-productive cough. RR 20s-30s.\nGI/GU: Abd. softly distended with positive bowel sounds. Having continous loose stools in small amts, brown. Foley with clear yellow urine- continues on lasix.\nSKIN: Abd. incision with staples C/D/I- old dried blood around staples and area cleaned and dsg changed. Red yeast rash/excoriation to groin and buttocks area- barrier cream applied with miconazole powder.\nOTHER: Daughter to come in this am to visit. Pt. ready to transfer to floor when bed avail. Plan to get OOB to chair this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-01 00:00:00.000",
"description": "Report",
"row_id": 1595893,
"text": "NEURO; MAE, FOLLOWS COMMANDS, NODS APPROPRIATELY AND OCCAS MOUTHES WORDS, A&O TO PERSON, OCCAS WRITES NOTES\n\nCARDIOVASCULAR; HR 80'S-90'S A FIB, A LINE RT RADIAL WAVEFORM COMPLETELY DAMPENED, REMOVED AFTER NEW ALINE PLACED LEFT RADIAL, SYS 110-130'S, OCCAS DOWN TO 90'S, LASIX GTT PRESENTLY AT 5 MGM/HR, (GOAL IS 2 L/NEG IN 24 HRS AND PT IS > 1600 CC NEG THIS SHIFT), K LOW -REPLETED WITH 40 MEQ THIS PM, SHOULD RE-EVALUATE TONOC, MAG LEVEL 1.7-REPLETED, TEMP 99.0, REMAINS WITH EDEMA OF ALL EXTREMITIES, PULSES DOPPLERABLE BOTH FEET\nCVP 5-13\n\nRESPIR; LUNGS CLEAR THIS SHIFT, SUCTIONED FOR SMALL AMTS THICK LIGHT YELLOW SECRETIONS, 02 SAT 98-100%, REMAINS ON SAME VENT SETTINGS,\n\nGI; TUBE FEEDS AT GOAL (80C/HR), OFF FOR ONE HR FOR RESIDUALS > 60CC\n\nENDOCRINE; BS 173 THIS AM, SLIDING SCALE TIGHTENED, PM BS 117-123\n\nWOUND; ABD INCISION SEEN BY VASCULAR TODAY, SMALL NECROTIC AREA LOWER INCISION, SCANT SERO-SANGE DGE, DSD APPLIED, JP MINIMAL DGE, ? REMOVING TOMORROW\n\nPLAN;PULMONARY SUPPORT,? ATTEMPTING EXTUBATION, TRACH OPTION DISCUSSED BY SICU ATTENDING WITH PT AND DAUGHTER AND PT NODDED POSITIVELY TO CONSENTING TO PROCEDURE, WILL BE DISCUSSED FURTHER, ? FAMILY MEETING, SOCIAL WORKER IN WITH DAUGHTER AND UPDATED\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-02 00:00:00.000",
"description": "Report",
"row_id": 1595894,
"text": "Respiratory Care Note:\n Patient on PSV of overnight. RSBI this am =108. BS= bilat, decreased slightly over L lung. Suctioned for thick whitish sputum. ET resecured at 19-20 cm by lip after reviewing CXR. See Carevue flowsheet for specifics. Plan to maintain at this time due to tachypnea with RSBI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-02 00:00:00.000",
"description": "Report",
"row_id": 1595895,
"text": "cv:hr afib 88-109 . pt received lopressor dose at 2400 hr was 109 at the time and rate decreased to 80's after med.sbp decreased to 88 with mean in 50's requiring neo for ~ 3 hours. neo off at 2330. lasix drip off . pt is 2000cc negative for past 24 hours. fentanyl off for a few hours secondary to hypotension but pt became a bit agiated and nodding \"yes \" when questioned about pain so fentnyl restarted at 20 mics/ with good effect.\n\ngu: diuresed with lasix drip. 2000cc negative at 2400(goal) lasix drip off secondary to hypotension.\n\ngi: several large liquid stools, fecal bag placed.tolerating tube feed at goal Impact with fiber at 80 cc/hr.\n\nintegumentary: generalized edema.perinium red rash..nistatin powder ordered and applied. tongue has thrush nilstatin applied.JP # 1 d.c'd\n# 2 draining serous fluid very small amount.incision is approximated. staples. sm areas of reddnesss along incisional line.\n\nneuro: left eye open at all times. It is a prosthetic eye. pt opens r eye spontaneously and to command. nods appropriately.\n\nresp: cpap 50 % peep 5,ps 10 see careview for abg.o2 sats 98-100%. sx for thick yellow q 2-4 hours.breath sounds decreased l base .after retaping et tube tube breath sounds clear bilateral.\n\nnote: gall bladder us done at 0600. levothyroxine restarted. Tsh elevated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-23 00:00:00.000",
"description": "Report",
"row_id": 1595867,
"text": "Neuro: pt is alert MAE slightly on bed very edemitious. R pupil reactive L eye glass.\n\nPain: on 100mcg of fentanyl . Pt comfortable at rest.\n\nCV: AF 80-90's SBP 105-150 up to high of 170 when turned. Palp DP/PT. Pheripheral Edema +3. CVP 8-13.\n\nLungs: AC changed to CPAP at 1500 tolerating well at present. lungs coarse to slightly decreased in bases. upper lobes slighty clearer this PM.\n\nGI: ABD open and packed. NG LWS clamped then TF started at 1400 impact with fiber STR @ 10. BS hypoactive.\n\nGU: Foley to gravity. On 8mg lasix drip. goal to be negative by 2liters. currently > 1400.\n\nSkin: pt without pressure sores. ABD open dsg done by surgical team. TWO Jp\"s to suction slightly bloody drainage moderate amt.\n\nA Stable\nP monitor output closely maintain goal of 2 liters negative. monitor labs repleat lytes as indicated. send ABG on CPAP support resp as indicated. possible wound closure on thursday. skin and wound care as indicated. Adance TF as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-24 00:00:00.000",
"description": "Report",
"row_id": 1595868,
"text": "RESP CARE: Pt remains intubated/on vent on 16 PS all shiftSEE CAREVUE. Lungs coarse with wheezes. Sxd thick yellow/white sputum. RSBI-148.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-24 00:00:00.000",
"description": "Report",
"row_id": 1595869,
"text": "NURSING UPDATE\nCV:\n TMAX 100 PO. REMAINS IN AFIB. HR UP TO 130 AND HTN 170'S WHEN ANXIOUS/UNDERSEDATED, SETTLES WITH HR 80-90'S AND SBP 95-120 WHEN COMFORTABLE. DIURESING ON LASIX GTTS. FLUID BALANCE DOWN 1800CC YESTERDAY BUT WEIGHT DOWN 5KG, PT OOZING LARGE AMOUNT OF FLUID INTO BED. FENTANYL GTTS MAINTAINING ADEQUATE LEVEL OF PAIN RELIEF AND SEDATION.\n\nGI:\n TROPHIC TUBE FEEDS @ 10CC/H UNTIL 4AM, STOPPED PER REQUEST OF DR , PT POSSIBLY RETURN TO O.R. TODAY FOR CLOSURE OF INCISION, BUT PLAN REMAINS UNCLEAR AT THIS TIME. NUTRITION ALSO MAINTAINED WITH TPN. BOWEL SOUNDS HYPOACTIVE, NO BM. ABDOMEN OPEN LEAKING LARGE AMOUNT OF SEROUS FLUID BENEATH DRESSING, AND 150CC VIA JP'S TO LWS.\n\nPLAN:\n CLOSURE OF INCISION, DATE/TIME YET TO BE CONFIRMED BY DR .\n CONT TO DIURESE AS TOLERATED, STILL EDEMATOUS AND 20L POSITIVE LOS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-24 00:00:00.000",
"description": "Report",
"row_id": 1595870,
"text": "STATUS UPDATE\nDATA- SEE CAREVIEW FOR DETAILS\nN-ALERT RIGHT PUPIL REACTIVE TO LIGHT. MOVING ALL EXTREMITIES ON BED. ABLE TO FOLLOW COMANDS, IS ABLE TO NOD HEAD YES OR NO TO DIRECT QUESTIONS. ON FENTANYL FOR PAIN WITH GOOD EFFECT. ATIVAN 1 MG GIVEN DURING ET TUBE REPOSITIONING FOR ANXIETY WITH GOOD EFFECT.\n\n\nCV- A-FIB MOST OF SHIFT 90S-130'S WITHOUT ECTOPY SBP 100'S-130'S CVP 8-12. PERIPHERAL EDEMA + GOOD PALPABLE PULSES.\n\nRESP-CHANGED TO AC- FI02 40% 450 X 14WITH 8 OF PEEP\nSUCTIONED FOR SMALL AMOUNTS THICK WHITE SECRETIONS. LUNGS SOUNDS COARSE.NO VENT CHANGES OVERNIGHT.\n\nGI/GU- ABD OPEN- TRANSPARENT DRESSING DRAINAGE REINFORCED TIMES TWO- DRAINING SERO-SANG DRAINAGE.TWO JP DRAING TO LWS SERO-SANG DRAIAGE.\n TROPHIC TUBE FEEDS RESTARTED 5PM AT 10CC/HOUR. TPN AT 74 CC/HOUR.\nPATIENT TO HAVE SURGERY THIS10/29- ? WHEN TO START NPO.\n\nFOLEY TO GRAVITY DRAING LARGE AMOUNTS CLEAR YELLOW DRAINAGE. BUN 30 LASIX GTT DOWN TO 6MG/HOUR. NOW -1400\n\n\nPOC- CONTINUE TO MONITOR DIURESEIS,PAIN CONTROLL. PLAN-- OR IN AM TO CLOSE ABDOMEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-16 00:00:00.000",
"description": "Report",
"row_id": 1595840,
"text": "Pt arrived from OR at 2100, S/P AAA repair.\nNeuro: Sedated on propofol. R pupil 3mm brisk. L artificial. MAE when sedation off for neuro exam. Appears to respond to name but unable to follow any directions.\nCV: Initially on arrival Temp 91.2, bare hugger on and present Temp 95.9. HR 60-80's afib with occasional to frequent PVC's. Arrived on NEO for hypotension. Noted to be having increasing PVC's, labile pressures. CO=1.7. Dr. aware and started pt on dobutamine, noted improvement in SBP, CO 4, SVR 1600 from 2300. Attempting to wean neo. Extremities increasingly warm with bare hugger. Dopplerable pulses DP & PT, femoral pulses palpable.\nRESP: Several vent changes presently on AC, 550X14 peep 5, FIO2 50%. ABG much improved since admission.\nGI: abd open, JP draining large amounts of bloody drg.\nGU: foley draining just adequate amounts of clear yellow urine.\nENDO: blood sugars elevated, Treated with humalog insulin.\nPLAN: Attempt to wean neo, Frequent CO and assess tolerance of dobuamine, Frequent labs check for bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-16 00:00:00.000",
"description": "Report",
"row_id": 1595841,
"text": "Respiratory Care\nPt.continues on full vent.support t/o shift.Labile b/p at times.Vent.changes made as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-16 00:00:00.000",
"description": "Report",
"row_id": 1595842,
"text": "Pt had periods of of hypoxia this shift and PEEP was therefore increased from 5 to 8. Her vent settings were also changed to bring them closer to ARDSnet protocol. Plan is to keep her sedated to prevent abdominal breathing at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-29 00:00:00.000",
"description": "Report",
"row_id": 1595887,
"text": "FULL CODE Universal Precautions Allergy: Percocet\n\n\nNeuro: Awake, alert, nodding approp and mouthing words; becoming frustrated and angry w/ her son - mouthing \"take me home\", \"take out the tube (ETT)\", moving her hands to the tubes (unrestrained while family was at the bedside). Following commands, MAEx4 spont/command. R pupil 3mm/brisk.\n\nCV: HR=90-110s, afib, no ectopy. BP ranges from 100-150s/50-60s. +periph pulses, +edema, extrems warm. CVP=. Lopressor increased from 50mg to TID.\n\nResp: CAPA/PS 50%. Pt very adamant about getting the tube out. She was diaphoretic as she was working herself up. Repeatedly explained the weaning to her and since the hope is to extubate tomorrow, she was placed on CPAP/PS 5/5, but she continued to be agitated w/ RR=30, HR 110s, BP 180/. Med w/ ativan 2mg and she relaxed, but resp status did not improve - it worsened w/ 02sat down to 87%, RR remained hi 20s; RSBI 80s. ABG obtained just before placing her back on CPAP/PS - 7.48/40/43/31/5/84%. On now and RR remains 26-27, 02sat 95-100%, HR to 90s. Lungs fairly clear bilat, sx minimal tan secretions via ETT. CXR ordered for am. Lasix 20mg ordered - goal is 2L neg.\n\nGI/GU: abd firm/distended, +BS, +flatus. Attempted to use bedpan w/ no success. TF FS Impact w/ fiber at 80cc/hr (goal). Foley cath w/ amber urine - lasix 20mg ivp given this am and is now order. Goal is to be 2L neg.\n\nAccess: RIJ TLC, R rad a-line (positional).\n\nID: T=100.4 oral, all antibx d/c'd yesterday\n\nEndo: FS covered w/ RISS\n\nSkin: Abd incision pink w/ necrotic areas as previously noted. JPx2 w/ serous drainage.\n\nSocial: Family in to visit - updated on pt's status.\n\nPlan: Wean as tol. Lasix . Increase lopressor as ordered. Support family\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-29 00:00:00.000",
"description": "Report",
"row_id": 1595888,
"text": "Pt became very agitated with ETT today. Attempt made to wean pt's PEEP and PSV today but SpO2 and PaO2 dropped, pt sx'd for a moderate amount of thick secretions by RN, plan is to attempt more weaning tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-30 00:00:00.000",
"description": "Report",
"row_id": 1595889,
"text": "respiratory Care\nNo vent. changes overnight with stable resp.status.abg's adequate.Rsbi improving to 94 this am.Plan:continue to evaluate for extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-30 00:00:00.000",
"description": "Report",
"row_id": 1595890,
"text": "CONDITION UPDATE\n\\D. LOW GRADE TEMP AND SLIGHTLY DIAPHORETIC MUCH OF THE TIME.DR. AWARE.SR 90'S TO LOW 100'S REQUIRING INCREASE IN LOPRESSOR. BP STABLE 109-130/60-70.O2 SAT=99-100\n DESPITE IMPROVED OXYGENATION WITH DECREASE IN IPS=8,DECISION BY DR. TO DIURESE TODAY MORE VIGOROUSLY WITH LASIX DRIP WAS STARTED THIS PM. DIAMOX WAS ADDED TO OFFSET ALREADY SL ELEVATED TCO2. CVP STARTED 12 AND HAS DECREASED TO 7 WITH HUO=200ML.\n BY 1800 C-PAP WAS DECREASED TO 5 WITH IPS-8. AWAIT REPEAT ABG'S.SXED FOR SM TO MOD AMT WHITE THICK SECRETIONS FOR WHICH PT WAS STARED ON ROBITUSSIN TO BREAK-UP MORE OF THE ? CONSOLIDATION IN TH LLL PER SICU TEAM.\n DUE TO PT'S FRUSTRATION THAT LEADS TO ANXIETY AT TIMES,PT WAS STARTED ON ANTIANXIETY MED. FENTANYL WAS ALSO WEANED SLIGHTLY TODAY DUE TO PT'S DENIAL OF INCISIONAL PAIN EVEN WITH TURNING IN BED . PT CURRENTLY IS ON 30MCQ OF FENTANYL AND DENIES PAIN.PT IS ALERT AND AWAKE COMMUNICATING BY FORMING WORDS WITH HER LIPS.\n PT APPEARS TO BE TOLERATING TF EVEN WITH HYPOACTIVE BOWEL SOUNDS. ABD APPEARS DISTENDED FOR WHICH SHE WAS GIVEN A SUPPOSITORY AND HAD SM AMT OF LIQUID AND FORMED STOOL.? NEED FOR ANOTHER SUPP. TOMORROW.\n ABD INCISION INTACT WITH SM AREAS OF ? ECCYMOSIS THAT DRAINED A VERY SMALL AMT OF OLD BLOOD.\n DAUGHTER IN.LESS ANXIETY OVER HER MOM TODAY BECAUSE HER MOM APPEARS TO BE LESS ANXIOUS.UPDATE TO FAMILY WAS GIVEN\nA.MONITOR VS CLOSELY. IF PT IS DIURESED TOO QUICKLY AND DUE TO INCREASE IN LOPRESSOR DOSE,PT COULD HAVE A HYPOTENSIVE EPISODE.\n CHECK ABG ON C-PAP5 AND 8 IPS..? INCREASE IN VENT SETTINGS FOR OVERNITE.GOAL= TO BE NEG 1-2 LITERS IN THIS 24HR PERIOD.\nR.CONDITION IMPROVING\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-01 00:00:00.000",
"description": "Report",
"row_id": 1595891,
"text": "Condition Update B:\nPlease refer to creview and remarks for details.\n\nPt wide awake until 0400 after 50mcg bolus of fentanyl. Pt pleasant, copperative. Communicating via mouthing appropriately. OD 3mm and brisk reactive. OS with false eye intact. Daughter taking care of oer nsg report. Pt denies c/o pain/discomfort on fentanyl gtt.\n\nTmax 100.7, cuurently 99.2 po. Aline flat waveform, unable ot draw back from. Discussed with Dr. at . Following NIBP. While asleep SBP down to 90. HR down from 90's to 80's rate controlled afib. CVP down to 5-6. Cont wiht generalized 3+ pit edema.\n\nLS clear to coarse. Suctioned for thick white secretions. Vent rested over night as RR 35-40, and LS CTA. Discussed with Dr, . Vent changed to CPAP and PS on 50%. Morning ABG 7.46 42 79 31 5.Pox 98-100%.\n\nPt neg 850cc at MN. Titrated lasix gtt up, neg 500cc at 0500. CVP 10->5. Tol TF at goal minmal residuals. Abd soft distended. BS present. Med formed BM x one on evening shift. Treating gluose levels per RISS.\n\nNystatin S&S applied to tongue for thrush. Abd inc D&I with erythema and a few small blister/hematoma. JP's with seroserosang output.\n\nPLAN: Cont vent wean as pt tol. Titrate insulin gtt to assist with Goal 1-2L neg by MN. Culture pt for temp spike. Nystatin for thrush. Monitor skin. Call H.O. for changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-16 00:00:00.000",
"description": "Report",
"row_id": 1595843,
"text": "CONDITION UPDATE\nD.TEMP SLOWLY INCREASED THRU THE COURSE OF THE DAY.AF RATE 90'S TO LOW 100'S WITHOUT ECTOPY ON DOBUTAMINE 6MCQ MOST OF THE DAY. PT HAD ALSO RECEIVED 2 PC FOR HCT OF 24.MAINTANENCE FLUID REMAINED AT 150ML/HR.PCWP20,CO-4.98 AND PA=40/23. REPEAT HCT-27. HUO 18-24.\n DESPITE STABLE HCT THIS PM,SBP DROPPED TO 80'D AND PAS TO 30'S.FLUID BOLUS GIVEN WITH IMMEDIATE RESPONSE.REPEAT HCT AT THIS TIME INCREASED TO 28.WHILE VOLUME INFUSING SBP REMAINS ELEVATED DR. AWARE OF ABOVE.HUO CONTINUES TO DECREASE TO 15MLDESPITE MULTIPLE FLUID BOLUSES.DOBUTAMINE WEANED SLOWLY DOWN PER DR. FOR POSSIBLE CAUSE OF ELEVATED HR AND ECTOPY.\n PT INITIALLY WAS GIVEN MORPHINE PRN FOR PAIN ALONG WITH PROPOFOL(OFF PROPOFOL,PT CONFIRMED ABD PAIN).FENTANYL DRIP WAS STARTED AND TITRATED\nUP. PRN ATIVAN WAS ALSO STARTED IN ATTEMPTS TO WEAN OFF PROPOFOL DUE TO LOWER BP.PT TO BE SEDATED WELL ENOUGH FOR NO RESPIRATORY EFFORT ON PART OF PT.PO2 WAS LOW THIS AM REQUIRING VENT CHANGES.WITH THE CHANGES PT BEGAN TO USE HER ABD MUSCLES WITH RESPIRATIONS.THUS CURRENTLY PT REQUIRES 85 MCQ OF FENTANYL AND PROPOFOL DOWN TO 15MCQ.PT HAS RECEIVED A TOTAL OF 2MG ATIVAN.BY THIS PM PT APPEARS MORE COMFORTABLE ON VENTILATOR,NOT USING ABD.MUSCLES.\n THIS AM, PO2 DOWN TO 60'S .BREATH SOUNDS CLEAR AND SXED FOR MINIMAL SECRETIONS.WITH INCREASE OF PEEP TO 8,RR=22 AND TV DOWN TO 450.ONCE SEDATION FOR RESPIRATORY EFFORT REACHED,PO2 INCREASED TO 110.PH NORMAL WITH LACTIC ACID LEVEL AT 3.0\n JP'S CONTINUE TO DRAIN APPROX 100ML/HR OF RED DRAINAGE.ABD WOUND REMAINS COVERED WITH TRANSPARENT DSG.\n DAUGHTER AND SON IN. DAUGHTER IS AN OR NURSE AND UNDERSTANDS THE ONGOING GRAVITY OF HER MOM'S CONDITION.\nA.MAINTAIN MAP >60.CHECK WITH HO REGARDING FLUID BOLI. WEAN DOBUTAMINE MAINTAINING CI >2.0 REPEAT LABS THIS EVENING(SEE ORDERS.\nR.DESPITE REQUIREMENTS OF VOLUME,PT'S CONDITION REMAINS GUARDED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595903,
"text": "CONDITION UPDATE: SEE CARE VUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: ALERT. FOLLOWS SIMPLE COMMANDS. ABLE TO MOUTH WORDS/NODDING. APPROP TO MAKE NEEDS KNOWN. PERRL. MAE WITH PURPOSEFUL MOVEMENT. NO C/O PAIN. CONTINUES ON FENTANYL GTT WITH GOOD PAIN CONTROL.\n\nCARDIAC: HCT-30. AFIB-NO ECTOPY. HR-80-90'S. BP-100'S-140'S/60-70'S. CONTINUES ON LOPRESSOR WITH GOOD HR CONTROL. +RADIAL/PT/DP X2. CLS ON. HEPARIN SC.\n\nRESP: CONTINUES ON CPAP . ABG WITH ADAQUATE OXYGENATION. 2200-PT LS /FEW SCATTERED EXP WHEEZES. GIVEN 20 IV LASIX X1 WITH GOOD DIURESIS. LS-COARSE-DIMINISHED BIBASILAR. SX FOR SM/MOD AMTS OF THICK YELLOW SPUTUMN.\n\nGI: REMAINS NPO. TOLERATING TF WELL WITH NO RESIDUALS. ABD-SD, +BSX4,\nS, TENDERNESS AT INCISION SITE. ABD- INCISION STAPLES INTACT. DSD INTACT. ABD BINDER ON.\n\nGU: FOLEY WITH QS URINE. LYTES REPLETED PRN.\n\nENDO: FS QID COVERAGE PER RISS. STARTED ON NPH .\n\nSKIN: SKIN WDI. AXILLA/UNDER BREASTS/GROIN WITH RED RASH. NYSTATIN POWDER APPLIED.\n\nSOCIAL: SON CALLED OVERNIGHT UPDATED REGARDING POC.\n\nPLAN: MONITOR HEMODYNAMICS. WEAN VENT SETTINGS AS TOLERATED. PULMONARY HYGIENE. MONITOR WBC'S/HCT/ABG'S/LYTES PRN. TITRATE FENTAYL GTT PRN FOR PAIN. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595904,
"text": "Pt remains on PSV 15/5 with a lg. amt of sputum today. BS equal with coares rhonchi & wheezes thoughout. BS improve some post sx\nTrach was planed for today. but as yet has not taken place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595905,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Fentanyl gtt @ 20mcg/hr; pt appears to be comfortable. Denies any pain. Pt more alert today. Mouthing words and writing on clipboard. Right pupil 3mm; briskly reactive to light. Left glass eye in place. Pt following commands consistently. MAE. +gag/cough reflex. Tmax 98.9. HR 80-90s (A.fib). ABP 100-140s/50-70s. CVP 2-14. Pt w/ +3 generalized edema. Lasix 20mg IV x1 ordered and given. Goal is for pt to be negative 1Liter. DP/PT pulses dopplerable. Skin is warm and dry; pale. Lungs coarse. Suctioned frequently for moderate amount thick white/ yellow secretions. No vent changes; CPAP 50%, PEEP 5, PS 15. Plan for trach (to be done in the OR vs bedside); ?when. Pt w/ strong cough; nonproductive. O2 sat >/= 99%. RR 20-30s. CXR done. Abdomen softly distended w/ +BS. Impact w/ fiber at 80cc/hr via NGT (goal rate); minimal residual. No c/o nausea. BM x2 (soft/liquid brown stool). BS 105-207; RISS q6hr and NPH 10units . Dr. ordered to change foley catheter today d/t pt +E.coli UTI; 16 Fr. foley catheter placed. Urine clear yellow. Midline abdominal incision w/ staples intact; pink around incision site. No drainage noted; DSD changed x1. Pt T&R freq to maintain skin integrity. No skin breakdown noted. son and daughter visited; updated on pt's plan of care and status.\n Plan: Cont to monitor VS, I's and O's, labs. Cont to wean off vent as tolerated. If unable to wean off, trach in future. Titrate fentanyl gtt for comfort. Monitor BS; NPH . Update pt's family w/ plan of care. Cont ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-28 00:00:00.000",
"description": "Report",
"row_id": 1595883,
"text": "see careview for details\nfocus data update\n\nNEURO: FENTANYL GTT DECREASED, MOUTHING WORDS STATING SHE WANTS TO GO HOME, MAE'S, DIFFICULTY LIFTING EXTRIMITIES R/T EDEMA, PT ANXIOUS @ TIMES, RESPONSES WELL TO VERBAL REASSURANCE\n\nRESP: CPAP 8PEEP, 10 PS, POOR RISBEE THIS AM, WILL DIURESIS TODAY AND ATTEMPT VENT WEANING TOMMOROW, B/L BREATH SOUNDS COARSE, IMPROVED NOTED ON LEFT SIDE, ORALLY SX'D FOR SMALL AMT OF THICK WHITE SPUTUM\n\nCV: TMAX 100.1, IV LOPRSSOR CHANGED TO PO, REMAINS IN A-FIB WITHOUT ECTOPY, PITTING EDEMA CONTINUES ON EXTRIMITIES, 10 MG'S IVP LASIX GIVEN, A-LINE AND MULTI-LUMEN CENTRAL LINE PATENT\n\nGI: ABDOMINAL BINDER INTACT, NO DRAINAGE NOTED FROM INCSION, HOWEVER REDDEN, TF'S CHANGED TO FULL STRENGHT AND GRADUALLY INCREASED, BS ACTIVE, NGT FOR FEEDINGS, MINIMAL RESIDUAL NOTED\n\nGU: LASIX 40MG'S IVP GIVEN, CREATINE WNL, ADEQUATE HOURLY U/O\n\nA/P: CONTINUE EDUCATIONAL AND EMOTIONAL SUPPORT TO BOTH PATIENT AND FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-28 00:00:00.000",
"description": "Report",
"row_id": 1595884,
"text": "Respiratory Care:\nPt remains on PSV 10/8peep 50%. She seems uncomfortable this eve and\nher PaO2 has to 68 from 144 at AM gas with no changes. Has been grabbing at OET and was restrained. Few secretions...check CareVue\nfor details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-29 00:00:00.000",
"description": "Report",
"row_id": 1595885,
"text": "Respratory Care\nNo vent.changes needed overnight.abg's adequate.Plan:continue wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-29 00:00:00.000",
"description": "Report",
"row_id": 1595886,
"text": "focus hemodynmc\ndata: opens eyes to verbal stimuli. moves arms and legs on the bed. follows commands. tube fdgs via ngt and tol well. abd binder intact and abd dsg changed. incision line pink with ? necrotic areas near the midline incision. foley patent and ddraining yellow urine. on fentanyl gtt at 5omcg and resting comf. update to daughter.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-26 00:00:00.000",
"description": "Report",
"row_id": 1595877,
"text": "Xray improved some. pt had a bronch today lg amt. of secreations cleared not plugs noted. pt was reintubated pre bronch today. changing size from #7 to #7.5\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-15 00:00:00.000",
"description": "Report",
"row_id": 1595839,
"text": "Respiratory Care\nPt. form O.R.s/p leaking AAA repair.Pt. arrived intubated as documented,BBS+.Placed on vent.will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-03 00:00:00.000",
"description": "Report",
"row_id": 1595901,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice. Right pupil 3mm; briskly reactive (left fake eye in place). Pt mouths words, gestures, and writes on clipboard. Follows commands consistently. MAE. Appropriate behavior; calm. Fentanyl gtt @ 20mcg/hr. Pt c/o of abdominal/incisional pain w/ turning and repositioning, but appears comfortable once settled. Tmax 101.1; Tylenol 650mg given via NGT w/ +effect (pt pan cultured last night). HR 80-101 (A.fib). ABP 90-130s/50-80s. CVP 8-15. Pt w/ +3 edema on BUE and BLE. DP/PT pulses dopplerable. Hct this AM was 26.9; 1unit PRBC transfused. Hct needs to be rechecked post transfusion. Lungs clear, diminished at bases. Pt not extubated today d/t large amount of thick yellow/white secretions; frequently suctioned. RSBI this AM 100; repeat 94.3. Cont CPAP 50%, PEEP 5, PS 10. O2 sat >/= 99%. Abdomen softly distended w/ +BS. Impact w/ fiber restarted at 1200 @ 80cc/hr (goal rate); infusing via NGT w/ minimal residual. Large amount of liquid, brown stool in fecal incontinence bag this AM. FIB bag changed. Needs stool to be sent for C.diff. No c/o nausea, emesis. BS 84-138; NPH 10units ordered. Cont RISS as well. Midline abdominal incision w/ staples intact; pink around incision. No drainage noted; DSD changed x1. Abdominal binder on. Pt's tongue w/ thrush; Nystatin oral suspension given. Miconazole powder applied under bilat breasts and underarms d/t yeast infection. T&R freq to maintain skin integrity; no skin breakdown noted. son and daughter visited today; updated on pt's plan of care and status.\n Plan: Cont to monitor VS, I's and O's, labs. Monitor respiratory status; ?extubate tomorrow if secretions decrease and RSBI improves. Monitor BS. Titrate fentanyl gtt for comfort. Update pt and family w/ plan of care. Cont ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-04 00:00:00.000",
"description": "Report",
"row_id": 1595902,
"text": "Respiratory Care Note:\n Patient on increased PSV overnight with minute ventilation 11-15L, and RR 25-32. BS=bilat, coarse with occassional scattered wheezing noted. Suctioned for whitish sputum. CXR appears wetter. Patient receiving lasix. ET tube resecured. Noted skin breakdown beneath L nare- duoderm applied. RSBI done this am with result of >130. Patient left on PSV of 15/5, 50%.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-27 00:00:00.000",
"description": "Report",
"row_id": 1595878,
"text": "CONDITION UPDATE\nD: SEE CAREVUE FLOWSHEET FOR SPECIFICS\n PATIENT IMPROVED A LITTLE OVERNIGHT. TMAX 100.0-HOWEVER WBC UP TO 30 ON EVENING LABS-TRIPLE IV ANTIBIOTICS WERE RESTARTED PER REC. OF SURGICAL TEAM. HR A LITTLE TACHY IN AFIB WITH A RATE BTWN 90-110 FOR MOST OF THE NIGHT WITH MIN AMT OF ECTOPY NOTED-LOPRESSOR 7.5 IV GIVEN Q6 BUT AFTER DOSE BP NOTED TO DIP BOTH TIMES DOWN INTO THE 80'S-?DECREASE DOSE TO 5MG. NEO WAS WEANED OFF AND ABOUT AN HOUR AFTER TURNING IT OFF BP DIPPED INTO THE 70'S (AFTER AMBU'ING AND LAVAGING PT D/T DESATURATION) INSTEAD OF RESTARTING NEO 1L BOLLUS OF NS WAS GIVEN WITH GOOD EFFECT AND NEO GTT REMAINED OFF FOR REMAINDER OF THE SHIFT. PT MAKING ADEQUATE AMTS OF URINE AND BLADDER PRESSURES WERE CHECKED Q4 RUNNING 15-18.\n PPF GTT WAS ALSO TURNED OFF AND VENT WAS WEANED FROM AC DOWN TO CPAP -PULSE OXIMETRY ~94-96% BUT AM ABG LOOKS GREAT. SUCTIONED A FEW TIMES FOR A SMALL AMT OF THICK CLEAR/WHITE SECRETIONS. PT CONTINUES TO RECEIVE FENT GTT FOR COMFORT AND IS ALERT/FOLLOWS COMMANDS AND NODS A LITTLE YES/NO TO SOME QUESTIONS.\n TROPHIC TF INFUSING VIA NGT-RESIDUALS CHECKED <100 BUT UP TO 90CC AT ONE POINT. ABD INCISION WITH STAPES AND SOME REDNESS BUT MIN AMT OF DRG AND JP'S PUTTING OUT SEROSANG DRG.\n DTR CALLED FOR UPDATE\nPLAN:\n CONT TO WEAN VENT AS TOLERATED\n PULMONARY TOILET\n BLADDER PRESSURES Q4HRS\n FENT FOR PAIN\n NOTIFY H.O. WITH ANY CHANGES\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-27 00:00:00.000",
"description": "Report",
"row_id": 1595879,
"text": "Respiratory Care\nSwitched to PSV overnight and tolerated well.Abg's adequate on current settings.Plan:continue ps wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-27 00:00:00.000",
"description": "Report",
"row_id": 1595880,
"text": "Resp. care note - Pt. remaines intubated and vented, PEEP weaned to 5 cmH2O, tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-27 00:00:00.000",
"description": "Report",
"row_id": 1595881,
"text": "see careview dor details\nfocus data update\n\n\nNEURO: FENTANLY GTT DECREASED TO 75 MCG'S/HR, PT TRACKING, ABLE TO FOLLOW COMMANDS, MAE'S MINIMALLY\n\nRESP: VENT SETTING'S CHANGED PEEP 5, PS 10, DECREASED PO2 57, FIO2 INCREASED TO 50% ABG PENDING, IMPROVED , PT KEPT OFF LEFT SIDE MOST OF DAY, ORALLY SUCTIONED FOR THICK WHITE SECRETIONS, BITING ON ETT\n\nCV: WBC DECREASED, A-LINE CHANGED OVER WIRE, 500CC LR BOLUS X1, EXT'S CONTINUE TO WEEP SEROUS DRAINAGE, CVP 8-10,\n\nGI: NPO, TF HELD THIS AM FOR HIGH RESIDUAL, REGLAN STARTED TF RESUMED THIS PM, ABDOMINAL BINDER APPLIED, DSG CLEAN AND DRY, JP'S PATENT FOR SEROUS DRAINAGE, MTN TO SELF SUCTION, BS HYPOACTIVE\n\nGU: BLADDER PRESSURES 15-20, ADEQUATE HOURLY U/O\n\nA/P: CONTINUE TO LIGHTEN SEDATION, WEAN FROM VENT, CONTINUE EMOTIONAL AND EDUCATIONAL SUPPORT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-28 00:00:00.000",
"description": "Report",
"row_id": 1595882,
"text": "Respiratory Care\nPt.remains on PSV,peep increased to 8, md request for pa02-60's on .50.No further changes needed follow-up abg's reveal improved oxygenation.Plan:attempt further vent.weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-26 00:00:00.000",
"description": "Report",
"row_id": 1595875,
"text": "SICU B NPN:\nNEURO: Continues on fentanyl gtt at 100mcg/hr and propofol 20mcg/kg/min. Opens L eye to stimuli, no following of commands, moving UEs slightly in bed. L pupil 3mm and briskly reactive to light. L glass eye intact.\nCV: Tmax 101.7- pan cx'd but unable to get sputum yet due to no secretions. HR 90s-120s AF with occ. PACs. Recieved 1L fluid bolus x2 for decreased BP with some effect. Neo titrated to maintain MAP >60 and attempting to wean off. CVP 8-12. Repleted with 2G MGSO4 IV for level 1.8. A-line positional at times. Extremities cool to touch with palpable pulses. Generalized anasarca.\nRESP: Continues on ACV 500x16 FiO2 40% Peep +10 with adequate ABG. O2 Sat >95%. LS coarse and diminished at bases. Sx'd for scant thick yellow secretions. Possible bronch today for LLL atelectasis on CXR.\nGI/GU: Abd. dsgs intact with scant serosang. drainage noted on upper dsg. Two JP drains to bulb sxn with sersang. drainage. Abd. soft with absent bowel sounds. TPN continues at 74cc/hr. Fingersticks QID with 4u reg insulin given x2. NGT to continuous LWS with bilious drainage. Foley with amber clear urine 30-40cc/hr.\nSKIN: Red area to coccyx but skin intact. Pneumoboots and multipodus boots on. R TLC line intact and R radial a-line intact.\nPlan for possible bronch today. Attempting to wean neo off with fluid boluses for low BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-26 00:00:00.000",
"description": "Report",
"row_id": 1595876,
"text": "focus data update\nsee careview for details\n\nNEURO: SEDATED ON PROPOFOL, FENTANYL GTT FOR COMFORT, NO SPONTANEOUS MOVEMENT, AND PRESENTLY UNABLE TO FOLLOW COMMANDS\n\nRESP: VENT SETTINGS UNCHANGED, LLL BREATH SOUNDS DIMINISHED, REINTUBATED WITH 7.5 ETT FOR BRONCHOSCOPY, VECURONIUM,PROPOFOL AND FENTANYL BOLUS GIVEN, BRONCH CULTURE OBTAINED, TENACIOUS THICK WHITE SECRETIONS\n\nCV: NEO GTT INCREASED TO 2MCG/KG/MIN, LOPRESSOR GIVEN TO CONTROL HR, ICU TEAM AWARE. CVP 8-10, 500CC LR BOLUS GIVEN X1, EDEMANOUS AND WEEPING SEROUS FLUID FROM UPPER EXT'S, REPEAT K 5.2, RIJ MULTI-LUMEN PATENT, A-LINE PATENT NEO TITRATED FOR MAP >70, T MAX 100.7 PO,\n\nGI: NPO, ORAL THRUSH NOTED, RX WITH NYSTATIN S/S, NGT PATENT IMPACT WITH FIBER FEEDS STARTED, HELD DURING BRONCHOSCOPY, ABD DRESSING CHANGED MIDLINE INCISION REDDEN SMALL AMOUNT OF SEROUS/SANG DRG NOTED\n\nGU: CREATINE NORMAL, MARGINAL AND CONCETRATED HOURLY U/O NOTED\n\nA/P: HEMODYNAMIC STATUS LABILE, EMOTONAL AND EDUCATIONAL SUPPORT GIVEN TO FAMILY, SOCIAL SERVICES CONTACT AND WILL FOLLOW, DR. NOTIFIED OF NEED FOR EDUCATION AND SUPPORT TO FAMILY, STATES HE WILL F/U\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-20 00:00:00.000",
"description": "Report",
"row_id": 1595855,
"text": "neuro: Calm/coop on fentanyl gtt @125mcg, prn ativan 1mg before major nsg care. Pt becomes anxious, responds to voice, follows command. NV grossly intact.\nCV: afib, rate controlled, min VEA. CI 1.7 after lasix 10mg w/ 500cc diuresis. Lytes repleted. CVP 10-14. + perocardial rub @ apex, positional; no ST changes.\nresp: CMV, 50%, 8PEEP. Improving ABG's, PaO2>100. Dim bases, intermintently rhonchorous, scant white ET secretions.\nGI: silent gut, NG scant bile. Open abd wound w/ 2 JP's to sx, decreasing s/s drng. TPN at target.\nGU: U O/P 30-50cc/hr clear amber.\nEndo: BS labile\nDerm: mod anasarca. Skin grossly intact.\nID: WBC 5.2; cont on vanco, levofloxacin, metronidazole. Core temp 37.\nlabs: HIT neg; plates improving...95.\nPlan: d/c S/G cath. Diurese, replete lytes. ?delete heparin in TPN. vent...? PEEP/FIO2 wean. Follow pericardial rub if not improved after diuresis. Adequate sedation w/ major care/procedures.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-20 00:00:00.000",
"description": "Report",
"row_id": 1595856,
"text": "Resp Care\nPt remains intubated on A/C. Dropped PEEP from 8 to 6 and then to 5. Decreased FIO2 from 505 to 40%. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-20 00:00:00.000",
"description": "Report",
"row_id": 1595857,
"text": "Update note\nSHIFT A- PLEASE SEE CARE VIEW FOR SPECIFIC DATA.\n\nN- ALERT MOST OF SHIFT ABLE TO FOLLOW COMMANDS AND MOVES ALL EXTREMITIES. CONTINUES ON FENTANYL GTT AT 125 MCG'S /HOUR PATIENT APPEARS COMFORTABLE. RECIEVED TWO DOSES 1MG ATIVAN PRIOR TO CARE WHICH WAS EFFECTIVE WITH AGITATION.\n\nCV- AFIB WITH RARE TO OCCASIONAL PVC'S. CO-4.01 CI- 2.20 LASIX GIVEN TIMES TWO WITH GOOD DIURESIS. GOAL IS -500 - -1 LITER. CVP 6-8 B/P'S 100-120'S. SWAN IN RIJ -DO NOT WEDGE. K REPLETED TIMES ONE WITH 20 AND SECOND ONE WITH 40 K WAS3.7. K LEVEL TO BE REDRAWN TONIGHT. LUNGS CLEAR ALL FIELDS.\n\nRESP- CMV- FIO2 FROM 50 TO 40 PEEP WEENED FROM 8. NOW AT 5. 1700 BLOOD GAS PAC02 WAS 28 RATE DECREASED TO 20. ABG PENDING.\n\nGI/GU- NG TO LWS SMALL BILLIOUS DRAINAGE, OPEN ABD. WOUND 2 JP'S TO LWS DRAINING SEROSANGUINOUS DRAINAGE. TPN AT 73CC/HR. FOLEY TO CD QUANTITY SUFFFICIENT.\n\nENDO- BS STABLE THIS SHIFT.\n\nID- CONTINUES ON VANCO FLAGGYL AND LEVOFLOXICIN T 99.5\n\nPOC- CONTINUE TO MONITOR-K AND ABG. GOAL 500CC- I LITER NEGATIVE FOR TODAY. ABDOMINAL DRESSING NEED REINFORCEMENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-21 00:00:00.000",
"description": "Report",
"row_id": 1595858,
"text": "Resp Care Note,Weaned pt 2 ^ peep.Temp 100. HR-A-Fib with PVC'S.Sedated with fentanyl. Good ABG'S.Will cont to moniotr resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-21 00:00:00.000",
"description": "Report",
"row_id": 1595859,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.2\n\nNEURO: FENTANYL GTT WITH GOOD PAIN CONTROL. ATIVAN X1 FOR BATHING/REPOSITIONING. PT ANXIOUS AT TIMES. TIGHTLY FLEXING ARMS WHEN STIMULATED. FOLLOWING COMMANDS.\n\nRESP: LS CLEAR. VENT SETTINGS INCREASED SLIGHTLY AS PT'S PAO2 DECREASED TO 60'S. AC 50%, 20X450, PEEP 8 WITH CURRENT ABG: 7.36, 42, 95, 25, -1.\n\nCV: HR 80'S-110 AFIB. CVP ~12. ABP ~130/60. PA 40'S/20'S. BEING DIURESED WITH LASIX. FLUID BALANCE -380CC'S. MN-0500 + 163 CC'S. + PPP BILAT. +++ EDEMA. WT DOWN 2 KG'S FROM YESTERDAY. NO PERICARDIAL RUB AUSCULTATED THIS SHIFT.\n\nGI: NGT-LCWS WITH MINIMAL OUTPUT. ABDOMEN OPEN, COVERED WITH OPSITE, X2 JP'S. TROPHIC TUBE FEEDS ORDERED.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: FAMILY VISITED AND CALLED.\n\nR: REQUIRING SLIGHTLY MORE VENTALATOR SUPPORT, MILD DIURESIS, ABDOMEN REMAINS OPEN.\n\nP: CONTINUE CURRENT CLOSE MONITORING AND MANAGEMENT. PAIN CONTROL. GOAL MAP > 60. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-02 00:00:00.000",
"description": "Report",
"row_id": 1595896,
"text": "npn 0700-1500;\nNO VENT CHANGES MADE TODAY. PT WAS GOING TO GO FOR /PELVIC CT BUT WAS CANCELLED AFTER DISCUSSION WITH PRIMARY TEAM.\n\nNEURO; AOOX1.WAEKLY MAE TO COMMAND LT EYE FALSE,RT EYE 3MM,BSK.\n\nRESP; LUNGS COARSE WITH INTERMITTENT EXP WHEEZE, DIMINISHED AT BASES SUCTIONED FOR MOD AMOUNTS THICK WHITE SECRETIONS,,SATS 96-100%,RR 26-35. CONTINUEES ON CPAP WITH 10 PS AND 5 PEEP.\n\nCVS; TMAX 100.5 PO AFIB 103-89 GIVEN 25 MGS OF LOPRESSOR INSTEAD OF 50 MGS AS BP 103-110 BY ALINE TOL DOSE WITH NO DRAMATIC DROP IN BP.CURRENTLY 105-115/60 AT REST UP TO 140-160/80 WHEN COUGHING BUT SETTLES QUICKLY. CVP 13-9.\n\nGU; LASIX DRIP REMAINS OFF,PASSING 100-50 MLS/HR, K REPLETED.\n\nGI; TOLERATING T/F AT GOAL BELLY SOFT DISTENDED HYPOACTIVE BS. PASSING SMALL AMOUNTS OF GOLDENYELLOW LIQUID STOOL VA RECTAL BAG .\n\nENDO;COVERED ON RISS.\n\nINTEGRUM;BELLY WOUND UNCHANGED EDEMATOUS , MOIST RED PATCHES UNDER ARMS AND BREASTS,TREATED WITH NYSTATIN POWDER,THRUSH IN MOUTH. TREATED WITH NYSTASTIN.\n\nSOC; DAUGHTER INTO VISIT TEARFUL AT TIMES TALKED WITH LISW . LEFT WITH FRIEND WILL RETURN LATER THIS AFTERNOON.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-02 00:00:00.000",
"description": "Report",
"row_id": 1595897,
"text": "Respiratory Care\n\n Pt continues on CPAP/PSV 10/5 in NARD. B/S ess clear dim on L sx'd for mod thick white. No changes made today Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-03 00:00:00.000",
"description": "Report",
"row_id": 1595898,
"text": "Respiratory Care Note:\n Patient continues on PSV 10/5. She appears comfortable with good BS bilat. Suctioned for minimal white secretions. No change in respiratory status. It appears patient is becoming more responsive. Plan to maintain at this time. RSBI yesterday >105, will recheck this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-18 00:00:00.000",
"description": "Report",
"row_id": 1595848,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient's temp coming down to 99.4 from tmax of 100.9. HR at beginning of shift up to rate of 130's with frequent PVC's, labs were sent with no significant findings. HR settled down into the 90's with no intervention. Later in the shift PPF was turned off d/t pt heavily sedated, bed bath was given and pt was positioned on right side HR went up to 120-130 with freuqent PVC's and didn't settle out within an hour so PPF was restarted-HR still did not come down (at this time BP also higher so titrating down on levo gtt). SICU resident notified fluid bollus was given with little effect. Finally pt was repositioned back onto left side and rate came down ~100, second fluid bollus given. CVP all night running . Currently Levo gtt at .04mcg/kg/min with map maintained >60. PA numbers have remained stable but elevated with adequate CO>4 and CI>2. URine output still marginal. Heparin SC was held after discussing with Dr. results of HIT.\n While PPF was off pt appeared more alert, opened mouth on command and had more spontaneous movement. Fent gtt still at 100mcg/hr for pain.\n No vent change were made overnight and oxygenation much improved with am abg. PaO2 up from 78 to 140's. Pt has not been breathing much over the vent and has not been suctioned for much in way of secretions. Lungs are clear and diminished in the bases.\n Abd open and dressing required reinforcement d/t leaking of sanginous drg. JP's still to LWS and draining lge amts. No bowel sounds noted. NGT to LCWS. Pt receiving LR at 150 and not receiving any nutrition at this time. Pt to return to OR today for wash out. No plans to close belly at this time.\nPLAN:\n OR today\n Fent/PPF for sedation\n Levo to keep map>60\n F/U with HIT spec\n Call social worker to speak with family\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-18 00:00:00.000",
"description": "Report",
"row_id": 1595849,
"text": "See carevue for objective data.\n\nProprofol dc'd this AM with prn ativan for sedation with good results. MAP much improved after proprofol dc'd. Fentanyl gtt remains at 125 mcg/hr. Nods head slightly when asked questions. Weak but follows commands.\nCO/CI remain labile requiring fluid boluses prn. PCWP 15-17. CVP 7-11.\nPA #'s remain elevated as well. Levophed remains off. Body edema present. Less ectopy today-remains in AFIB.\nAbd wound leaking copious amts of sangious fluid around dressing.\nPlan this PM is to wash wound and re-dress. Awaiting MD's to arrive.\nAbd around dressing remains soft.\nUrine output marginal at best. +ATN per team. Will monitor.\nNo vent changes except FIO2 decreased to 50% from 60%. ? decrease PEEP to 5 in AM if PO2 adequate for venous return.\nTPN to be started soon-no order for today. NGT to LCWS-flushed X2 patent and draining bilious fluid.\n\nFamily in and updated on POC. Support/education provided by many members of the team.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-06 00:00:00.000",
"description": "Report",
"row_id": 1595913,
"text": "Pt remains off vent. support @ this time but continues to have pul. hygien issues. Her cough is productive of a mod-lg amt of thick yellow sputum. Percusion & vibration was started to Left & right sides\nwith bed in mild trendelinburg. deep breathing & coughing was also aggressively encouraged.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-03 00:00:00.000",
"description": "Report",
"row_id": 1595899,
"text": "SICU B NPN:\nNEURO: Continues on fentanyl gtt at 20mcg/hr. Opens eyes spontaneously, follows commands and nodding/mouthing words. Does nod head yes to pain and appears to be incisional. Fentanyl bolus 25mcg x2 for pain given. MAE in bed UE >LE. Not restrained and no attempts made to pull out ETT or lines. R pupil 3mm and briskly reactive to light. L glass eye intact.\nCV: Tmax 101.1 and pan cx'd. Tylenol given with last temp. 99.9 at 4am. Skin warm and dry with weak but palpable pedal pulses. HR 80s-100s AF, no ectopy noted. BP stable with MAPs >60.\nRESP: No vent changes made. LS coarse and diminished at bases. Sx'd for thick white secretions in moderate to large amts. Large amts of oral secretions also.\nGI/GU: Abd. softly distended with positive bowel sounds. Rectal bag intact with large amt of liquid-loose brown stool- heme negative. Impact with fiber continues at 80cc/hr via NGT. Requiring insulin with q6hr fingersticks. Foley with clear yellow urine >40cc/hr.\nSKIN: Thrush in mouth with nystatin swabs given. Abd. dsg intact with no drainage noted. Staples to site clean, dry and intact. Abd. binder in place. Pneumoboots on. Yeast rash to underarms, folds and groin with miconazole powder applied.\nOTHER: Daughter called and updated on pt's condition and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-03 00:00:00.000",
"description": "Report",
"row_id": 1595900,
"text": "Pt stable with present settings. Bs deminished in left base with coares rhonchi thoughout. Rhonchi improves post sx. Pt sxed for a lg amount of thick white and yellow sputum. No vent changes requested.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-06 00:00:00.000",
"description": "Report",
"row_id": 1595914,
"text": " 19/07\n PT A/O RELAXED NO PAIN OR DISCOMFORT NOTED SLEEPS SHORT NAPS UNDERSTANDS AND TRIES TO HELP WITH CARE\n RESP ON .50 FACE TENT TOL WELL SAT 92 TO 100 CLEAR FIELDS\n HEART AF RATES 78 TO 90 PULSES POS 3 THRU OUT VSS\n GI POS B/S NOTED TOL T/F WELL SOFT ABD\n PLAN PROGRESSIVE PT ROM REALITY BASED CARE FAMILY SUPPORT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-07 00:00:00.000",
"description": "Report",
"row_id": 1595915,
"text": "CONDITION UPDATE\nPT TRANSFER TO VICU. VSS, A&OX3, NO C/O PAIN. PLEASE SEE TRANSFER NOTED FOR DETAILS.\nPLAN:\n TRANSFER TO VICU \n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-08 00:00:00.000",
"description": "Report",
"row_id": 1595916,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt is alert and oriented x 3, but does get confused at times ? sundowning. She is easy to reorient. Otherwise, behavior is appropriate. She had no c/o pain throughout the noc. She is able to move all extremities w/ equal strength. Afebrile. Chronic afib. 02 sats 93-97% Cool mist face tent remains on to help loosen secretions. Robitussin also given q 6 hours. She is able to expectorate small to moderate amts of thick, white secretions using the yankaur independently. LS are coarse b/l. Foley is patent and draining adequate amts of clear urine. She tolerated liquids throughout the noc. Pt is incontenent of liquid, brown stool. FIB placed. Peri area is excoriated. double gaurd cream applied. Pt has a riss and am/pm nph for bs coverage. K+ & MG+ repleted.\n\nPlan: continue with current plan of care per sicu/ vascular teams. Xfer to VICU when bed is available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-12-08 00:00:00.000",
"description": "Report",
"row_id": 1595917,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.\nPATIENT DOING WELL TODAY, ALERT AND COOPERATIVE. TOLERATING REG. DIET SLOWLY, ENCOURAGED TO DRINK BOOST.\nOOB FOR ABOUT 1 HR, ANXIOUS TO GET BACK INTO BED.\nDIURESING SLOWLY WITH LASIX.\nSATS GOOD ON 4L NASAL PRONGS, ENCOURAGED TO TCDB.\nFOLEY WITH CLEAR YELLOW URINE.\nP: TO VICU WHEN BED AVAILABLE.\nWILL CALL HOW WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-25 00:00:00.000",
"description": "Report",
"row_id": 1595871,
"text": "SICUB NPN:\nNEURO: Intermittently agitated at times- ativan 1mg x2 with good effect. Right pupil 3mm and brisk. Moving all extremites in bed UE>LE. Follows commands and does not appear in to be in pain. Fentanyl gtt at 100mcg/hr.\nCV: Tmax 99.0. HR 70s-100s AF with occ. PACs. Occasional P waves noted. BP stable with MAPs >60. SBP up to 180s with turning and agitation. CVP 8-10. Receiving MGSO4 and KCL repletion. A-line positional at times and difficult to draw blood from.\nRESP: No vent changes - continues on ACV 450x14 FiO2 40% Peep +5, breathing over vent 4-6 breaths per minute. LS coarse and diminished at bases. Sx'd for scant amts whitish secretions. O2 Sat >95%.\nGI/GU: Abd. open with transparent dsg intact- continues to ooze serosang. drainage in moderate amts. TF shut off at 12am for planned OR today. 2 JP drains continue to LWS. TPN continues at 74cc/hr. Foley with clear yellow urine >100cc/hr- lasix gtt increased to 8mg/hr for goal negative 2L in 24hr (was -1500cc last 24hrs).\nSKIN: Coccyx red but skin intact. Abd. dsg intact.\nPlan for closure of abd. wound in OR today. Consents signed by daughter. TF off since MN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-21 00:00:00.000",
"description": "Report",
"row_id": 1595860,
"text": "Condition Update\nD: See carevue flowsheet for specifics\nPatient remains afebrile HR stable in afib with good rate control-pt was started on a small dose of lopressor which was well tolerated. Swan was changed over a wire to a multilumen which was then leaking after placement had been confirmed so a 2nd line was placed (over a wire). CVP still ~12 and pt was started on a lasix gtt to diurese to 1L negative by midnight but due to difficulty with access throughout the day that goal may not be achieved.\n In the second CXR done to confirm line placement left lung noted to be out. O2 sats at the time down to ~94-95%, lung sounds diminished on left. Pt was bronch'd for a lot of secretions f/u CXR showed improvement. PT still on AC PEEP increased to 12 after bronch otherwise settings unchanged 450x22 fio2 50%.\n Abd assessment unchanged. Pt was started on trophic feeds this am. Abd still open and leaking a lot of serosang drg from around dressing. Pt also receiving TPN for nutrition.\n Family has been at bedside throughout the day and has been updated as to todays events.\nPLAN:\n Return to OR on monday\n Wean PEEP tonight if abg adequate\n Lasix gtt to diurese to 1L negative by midnight.\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-21 00:00:00.000",
"description": "Report",
"row_id": 1595861,
"text": "Resp Care\nPt intubated on A/C. Pt bronched for large amt thick secretions. Increased PEEP from 8 to 12 due to increased fluid in right lung seen on latest X-ray. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-22 00:00:00.000",
"description": "Report",
"row_id": 1595862,
"text": "Resp Care Note,Weaned down FIO2 for good ABG. Sedated with fentanyl. Getting lasix.Suctioned for sml amts thick white secretions. Temp 100. Will cont to monitor resp status.Will try to wean peep today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-22 00:00:00.000",
"description": "Report",
"row_id": 1595863,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient remains afebrile-hemodynamically stable and tolerating diuresis well on lasix gtt. HR in afib with rate controlled in 80's on a small dose of lopressor. Goal is to keep SBP>100 and diurese to negative 2L by midnight. Currently close to 1L negative this afternoon. Lytes requiring frequent repleting.\n No vent changes were made today and still has not required much suctioning. Lungs have been clear and dim in the bases -CXR ordered for tomorrow.\n No change in abd exam, continues to leak lge amts of serosang drg from around transparent dressing. Tube feeds have remained off d/t lge residual overnight. TPN infusing-SSI tightened.\nPLAN:\n Cont to diurese with lasix gtt\n ? return to OR tomorrow for closure\n Notify H.O. of any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-22 00:00:00.000",
"description": "Report",
"row_id": 1595864,
"text": "Resp Care\nPt remains intubated on A/C. Dropped PEEP from 12 to 8 due to improved X-ray. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-23 00:00:00.000",
"description": "Report",
"row_id": 1595865,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. HR-A-Fib. Temp 100.8. Sedated with fentanyl. Getting lasix.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-23 00:00:00.000",
"description": "Report",
"row_id": 1595866,
"text": "D: neuro intact, anxiety @ times requires PRN ativan. minimal mov't of extremities due to fluid accumulation. VSS, low grade temps. Fluid overload, pt on lasix gtt with good u/o. No vent changes overnoc. NGT placed to wall suction and 200ml bilious drg returned. NGT left to LCWS. Oozing large am't serosang drg from around open abd wound from beneath opsite. Extra pads used to collect drg.\nA:Stable\nP:Diurese as ordered.\nEventual closure of wound in OR.\nSupport pt and family\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2111-11-17 00:00:00.000",
"description": "Report",
"row_id": 79454,
"text": "PATIENT/TEST INFORMATION:\nIndication: Ascending aortic aneurysm\nHeight: (in) 65\nWeight (lb): 175\nBSA (m2): 1.87 m2\nBP (mm Hg): 91/49\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 17:28\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function.\nHyperdynamic LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter. Simple\natheroma in aortic arch. Focal calcifications in aortic arch. Focal\ncalcifications in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. Echocardiographic results were reviewed with the\nhouseofficer caring for the patient. Left pleural effusion.\n\nConclusions:\n1. The left atrium is moderately dilated. The right atrium is dilated.\n2. The left ventricular cavity size is normal. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\n3. There are simple atheroma in the aortic arch. There are focal\ncalcifications in the aortic arch.\n4. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6. No aortic aneurysm is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885650,
"text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pleural effusions\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n assess pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm bronchoscopy; assess\n effusions.\n\n PORTABLE AP CHEST: Comparison is made to study dated .\n Endotracheal tube, nasogastric tube, and right IJ central venous catheter\n remain in stable, satisfactory position. Assessment is limited by patient\n rotation. Allowing for this, cardiac and mediastinal contours are likely\n unchanged. The aortic knob remains indistinct. In the interval, interstitial\n edema has improved and pleural effusions have decreased in size, with\n resolution of the right pleural effusion. There is a persistent small left\n pleural effusion as well as a left lower lobe atelectasis.\n\n IMPRESSION: Resolving congestive heart failure pattern. Persistent small left\n pleural effusion and left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885341,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for atelectasis\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n assess for atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm and line placement status post\n bronchoscopy.\n\n PORTABLE AP CHEST: Comparison is made to study, dated .\n\n FINDINGS: Endotracheal tube, nasogastric tube, and right IJ central venous\n catheter remaining stable, satisfactory position. No new central venous\n catheters are identified. Cardiac and mediastinal contours are unchanged.\n Again, noted is interstitial edema and moderate bilateral pleural effusions.\n Dense left retrocardiac density is consistent with atelectasis and appears\n unchanged.\n\n IMPRESSION: No significant interval change in pulmonary edema, small-to-\n moderate bilateral pleural effusions and left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885691,
"text": " 12:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p abd closure, decreased BS on L, eval tube placement and\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n s/p abd closure, decreased BS on L, eval tube placement and for pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured aneurysm and decreased breath sounds on the left.\n\n PORTABLE AP CHEST: Comparison is made to study performed 5 hours prior.\n Endotracheal tube terminates approximately 3.8 cm above the level of the\n carina. There is expansion of the tracheal contour, consistent with\n overinflation of the cuff. Right IJ central venous catheter and nasogastric\n tube remain in stable position. As before, there is atelectasis of the left\n lower lobe with associated volume loss and some shift of the heart and\n mediastinal structures. There appears to be an abrupt cutoff of the left\n lower lobe bronchus, finding consistent with obstructing mucous plug. There\n may be a small left pleural effusion. The right lung is grossly clear.\n\n IMPRESSION:\n 1. Apparent overdistention of the endotracheal tube cuff as above.\n 2. Left lower lobe collapse and abrupt occlusion of the left lower lobe\n bronchus. These findings are most consistent with an obstructing mucous plug.\n\n These findings were conveyed to Dr. at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884614,
"text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desat\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n\n REASON FOR THIS EXAMINATION:\n desat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with ruptured AAA and desaturation.\n\n COMPARISONS: Comparison is made to immediate postoperative radiograph from\n .\n\n TECHNIQUE: AP single view of the chest.\n\n There is an ET tube in good position. There is a Swan-Ganz catheter with the\n tip in the pulmonary artery trunk. The NG tube within the stomach. There are\n two drains into the abdomen. There are bibasilar atelectases. Left\n retrocardiac opacity could represent atelectasis Vs. consolidation Vs.\n aspiration. Severe scoliosis of the thoracic spine. The pulmonary\n vascularity is within normal limits without evidence of CHF. There are\n probable bilateral pleural effusions. There is no evidence of pneumothorax.\n The aorta is tortuous and calcified. The splenic artery is calcified. There\n are clips in the left axilla.\n\n IMPRESSION:\n 1. Bibasilar atelectases.\n 2. Left retrocardiac opacity could represent atelectasis, consolidation or\n aspiration. The shift of the mediastinum to the left suggests atelectasis.\n Clinical correlation recommended.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886853,
"text": " 9:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, spiking fevers\n REASON FOR THIS EXAMINATION:\n eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman status post repair of ruptured AAA, now spiking\n fevers. Please assess for pneumonia.\n\n TECHNIQUE: Single AP upright portable chest radiograph was obtained.\n\n COMPARISON: Supine AP portable chest radiograph, .\n\n FINDINGS: There is an endotracheal tube with tip approximately 3 cm above the\n carina. There is a nasogastric tube with tip within the stomach. The right\n internal jugular central catheter with tip in the SVC. There is stable\n appearance of the heavily calcified thoracic aorta with unchanged appearance\n of wall thickening at the level of the aortic knob, which may represent\n chronic dissection or calcification of a thick pseudointima. Again noted are\n small bilateral pleural effusions. Overall, there has been no significant\n interval change in appearance of the chest compared to .\n\n IMPRESSION: Tubes and lines in satisfactory position. Persistent small\n bilateral pleural effusions. Overall, no significant change in appearance of\n the chest compared to .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885867,
"text": " 4:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: exchange of ETT please eval position s/p bronch\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\n maneuver\n REASON FOR THIS EXAMINATION:\n exchange of ETT please eval position s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured AAA status post OR, exchange of endotracheal tube.\n\n COMPARISON: Radiograph dated at 5:21 a.m.\n\n SINGLE AP PORTABLE SUPINE VIEW OF THE CHEST: A right internal jugular\n catheter is unchanged. An NG tube was again demonstrated with distal tip\n terminating below the diaphragm below the lower margin of this film. Anterior\n abdominal midline staples are seen at the lower margin of the film. There is\n an endotracheal tube with distal tip at the thoracic inlet. The exam is\n otherwise not significantly changed compared to the prior study.\n\n IMPRESSION: ET tube in satisfactory position with no other significant\n interval change compared to the exam of 12 hours prior.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886214,
"text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: am chest xray to eval progression of lung process\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p\n recruitment maneuver\n REASON FOR THIS EXAMINATION:\n am chest xray to eval progression of lung process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:40 A.M., \n\n HISTORY: Ruptured aortic aneurysm.\n\n IMPRESSION: AP chest compared to and 20th.\n\n Left lower lobe collapse persists. Small bilateral pleural effusions are\n unchanged since while borderline pulmonary edema has improved.\n The heart is top normal size. ET tube, right internal jugular line, and\n nasogastric tube are in standard placements respectively. No pneumothorax.\n\n The thoracic aorta is heavily calcified. Thickening of the wall at the level\n of the aortic knob could be due to chronic dissection or calcification of a\n thick pseudointima, but is not changed acutely.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-12-02 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 886572,
"text": " 5:02 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval liver/gallbladder\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman w/ labile BPs and rising LFTS\n REASON FOR THIS EXAMINATION:\n eval liver/gallbladder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rising LFTs, evaluate liver and gallbladder.\n\n COMPARISON: None.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n RIGHT UPPER QUADRANT ULTRASOUND: Limited images of the liver are provided.\n The hepatic echotexture appears within normal limits. No definite masses are\n identified within the hepatic parenchyma.\n\n The gallbladder is distended and contains echogenic sludge. No definite\n shadowing gallstones are identified. There is no definite gallbladder wall\n thickening or edema. A small amount of fluid adjacent to the gallbladder on\n several images may be located within the adjacent bowel. The common hepatic\n duct is nondilated (measuring 2 mm). Visualization of the common bile duct is\n limited on the images provided from this examination, which was performed\n portably.\n\n The right kidney measures 10.9 cm. A simple cyst is seen within the\n interpolar region of the right kidney measuring 3.1 cm in diameter.\n\n Note is made of a heterogeneously echoic fluid collection in the right lower\n quadrant, which measures 12.9 x 4.5 cm.\n\n IMPRESSION:\n 1. Markedly dilated gallbladder containing sludge. No definite evidence of\n acute cholecystitis.\n\n 2. Heterogeneously echoic fluid collection in the right lower quadrant is\n incidentally noted. This measures 12.9 cm in diameter. The etiology is\n uncertain and this may be further evaluated with CT.\n\n 3. 3-cm simple cyst in the interpolar region of the right kidney.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885710,
"text": " 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: repeat - old film rotated. upright to eval for CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n FINAL ADDENDUM\n INDICATION: Status post bronchoscopy. Repeat chest x-ray requested due to\n rotation on prior film.\n\n The patient is similarly rotated on the current film as on the previous\n studies. Various lines and tubes are unchanged in position with note again\n made of overdistention of endotracheal tube cuff. There remains collapse of\n the left lower lobe. There is increasing opacity in the left hemithorax,\n difficult to assess due to the degree of rotation, which could be due to\n partially layering pleural fluid or increasing atelectasis within the left\n lung. Within the right lung, previously noted right pleural effusion appears\n slightly smaller, possibly due to positional differences. There is minimal\n perihilar haziness in the right lung, suggesting a component of mild perihilar\n edema.\n\n\n\n\n 2:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: repeat - old film rotated. upright to eval for CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt, had bronch\n\n REASON FOR THIS EXAMINATION:\n repeat - old film rotated. upright to eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF AT 14:41.\n\n Comparison is made to previous study of approximately one hour earlier.\n\n INDICATION: Evaluate for congestive heart failure.\n\n Lines and tubes are unchanged in position with note again made of\n overdistention of the endotracheal tube cuff. Again demonstrated is left\n lower lobe collapse with abrupt cut off of the left lower lobe bronchus\n suggesting mucus plugging. There is increasing hazy opacity in the left\n hemithorax extending to the level of the lower portion of the aortic knob,\n possibly due to increasing pleural fluid on this side. There is slight\n perihilar haziness and subtle interstitial pattern in the right lung, which\n may reflect a component of interstitial edema, and there is also a probable\n small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886921,
"text": " 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm process\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, spiking fevers\n\n REASON FOR THIS EXAMINATION:\n eval pulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Repair ruptured AAA. Fever.\n\n AP BEDSIDE CHEST: There are bilateral moderate-sized pleural effusions with\n associated basal atelectasis. I doubt the presence of consolidations although\n this cannot be assessed in the obscured left lower lobe. Heart is probably\n not enlarged, although the aortic knob is markedly dilated and calcified. No\n vascular congestion. Tubes and catheters satisfactorily positioned.\n Appearances unchanged from similar exam one day ago ().\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885768,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of collapse, need for bronch\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure.\n\n REASON FOR THIS EXAMINATION:\n question of collapse, need for bronch\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:21 A.M. ON :\n\n HISTORY: Ruptured aneurysm. Possible lobar collapse and the need for\n bronchoscopy.\n\n IMPRESSION: AP chest compared to and 19, :\n\n Left lower lobe remains collapsed, although volume loss indicated by leftward\n mediastinal shift is not quite as severe as it was on . Right lung\n volume is lower and new opacification in the right lower lung is concerning\n for either atelectasis or new pneumonia while mild interstitial edema is more\n pronounced and small bilateral pleural effusions have increased. ET tube,\n nasogastric tube, and a right internal jugular line are in standard placements\n respectively. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887215,
"text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrates, CHF\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p repair, tachypnic\n REASON FOR THIS EXAMINATION:\n eval infiltrates, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachypneic, evaluate infiltrate, CHF.\n\n CHEST, SINGLE AP VIEW.\n\n There is cardiomegaly, with a calcified, unfolded aorta. Parenchymal detail\n is difficult to assess due to overpenetration. In particular, it is difficult\n to assess for CHF. There is probable upper zone redistribution, without\n interstitial edema. There is increased retrocardiac opacity consistent with\n left lower lobe collapse and/or consolidation and a small left effusion. There\n is patchy opacity at the right base. Compared with , this appearance\n is probably unchanged. There has been interval removal of the ET tube. A\n right IJ central line is present, tip over distal SVC, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 885167,
"text": " 1:04 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt\n REASON FOR THIS EXAMINATION:\n eval line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: new line placement.\n\n FINDINGS: Single radiograph of the chest reveals moderate right pleural\n effusion. Left hemithorax opacity with mediastinal shift which could be due\n to positioning of the patient partially as well as volume loss. Subsequent\n radiograph taken on same day, , at 4:25 PM shows aerated left\n lung. The tubes are in satisfactory position.\n\n IMPRESSION: Moderate right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884344,
"text": " 9:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia, vol overload\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n REASON FOR THIS EXAMINATION:\n pneumonia, vol overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST , WITH NO PRIOR FILMS FOR COMPARISON.\n\n INDICATION: Ruptured AAA.\n\n An endotracheal tube terminates approximately 1.5 cm above the carina. A\n nasogastric tube terminates in the stomach, and a Swan-Ganz catheter\n terminates in the distal right pulmonary artery. There is no pneumothorax.\n\n There is widening of the mediastinum in the region of the aortic arch. The\n cardiac silhouette is upper limits of normal in size allowing for rotation and\n portable technique. There is bilateral perihilar haziness, and there are\n several septal lines within the lung periphery. Patchy opacities are noted in\n both lower lung zones and may relate to patchy atelectasis or aspiration.\n Small pleural effusions are present, blunting the left costophrenic sulcus and\n thickening the right minor fissure. Note is made of apparent left mastectomy\n and axillary lymph node dissection.\n\n IMPRESSION:\n 1. Low position of endotracheal tube, which could be withdrawn 1 to 2 cm for\n more optimal placement.\n 2. Widened mediastinum in region of aortic knob, which may be related to\n tortuosity and/or dilation of the structure.\n 3. Interstitial pulmonary edema.\n 4. Patchy bibasilar atelectasis versus aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 885144,
"text": " 9:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CVL placement\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA.\n\n REASON FOR THIS EXAMINATION:\n CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ruptured abdominal aortic aneurysm.\n\n Single portable chest radiograph demonstrates no change in the\n cardiomediastinal silhouette when compared to . Endotracheal tube\n is present with its tip at the clavicular heads. Right internal jugular\n central venous catheter is present with its tip in the SVC. Nasogastric tube\n is seen to course through the stomach and off the inferior aspect of the\n imaged field of view. There are small-to-moderate bilateral pleural\n effusions. The plate-like atelectasis in the right lower lung seen on the\n previous study has markedly improved. Assessment is slightly limited by\n patient positioning. There is dextroscoliosis of the thoracic spine. The\n aorta is calcified. Surgical clips project over the left axilla. The right\n internal jugular Swan-Ganz catheter has been removed.\n\n IMPRESSION:\n\n Small-to-moderate bilateral pleural effusions.\n\n Interval improvement in right mid lung atelectasis.\n\n Support lines as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885190,
"text": " 3:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 80 yo female sp broncoscopy\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA and new line plcmt\n\n REASON FOR THIS EXAMINATION:\n 80 yo female sp broncoscopy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ruptured abdominal aortic aneurysm.\n\n Single portable chest radiogram demonstrates an endotracheal tube with its tip\n at the clavicular head. A nasogastric tube courses through the stomach and\n below the inferior aspect of the imaged field of view. A right internal\n jugular central venous catheter is present with its tip in the superior vena\n cava. There is again evidence of volume loss in the left, although this is\n markedly improved when compared to the chest radiograph obtained three hours\n prior. Again seen are mild-to-moderate bilateral pleural effusions.\n Prominent vascular markings in the right lung likely represents mild fluid\n overload. Degenerative changes are present throughout the thoracic spine.\n\n Surgical clips project over the left axilla.\n\n IMPRESSION:\n\n Small-to-moderate bilateral pleural effusions, unchanged.\n\n Interval improvement of left-sided atelectasis and volume loss.\n\n Support lines as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885742,
"text": " 8:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess left lower lobe collapse, please perform x-ray at 9pm\n Admitting Diagnosis: S/P AAA REPAIR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rupt AAA s/p OR for abd closure, s/p recruitment\n maneuver\n REASON FOR THIS EXAMINATION:\n assess left lower lobe collapse, please perform x-ray at 9pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured abdominal aortic aneurysm, now with persistent left\n lower lobe collapse.\n\n PORTABLE AP CHEST: Comparison is made to study performed seven hours prior.\n There has been no interval change in the appearance of the chest. Endotracheal\n tube, nasogastric tube, and right IJ central venous catheter remain in stable\n position. Again, demonstrated is left lower lobe collapse with volume loss\n and shift of the heart and mediastinal structures. Interstitial edema has\n improved in the interval. There are persistent small bilateral pleural\n effusions.\n\n IMPRESSION: Persistent left lower lobe collapse, likely due to mucous\n plugging. Improving interstitial edema.\n\n"
}
] |
141 | 168,006 | There is a small amount of hyperattenuating fluid over the right parietal lobe which was seen previously and relates to subarachnoid hemorrhage. Again noted is a small right pleural effusion with pleural thickening/fluid noted in the right lower lateral hemithorax. TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT CONTRAST: There has been progression of a large infarct including the left-sided parietal, temporal and occipital lobes. There is hyperattenuating fluid overlying the tentorium which was seen previously and corresponds to a subdural hematoma which has not changed in appearance. Again noted is a right pleural effusion and effusion/pleural thickening along the lateral right pleura, which is unchanged. 3) Persistent small right pleural effusion and pleural thickening/fluid within the right lower lateral hemithorax. The ascending aorta is mildlydilated. Grayscale and Doppler images of the right and left common femoral, superficial femoral, greater saphenous, popliteal veins were obtained. There is edema associated with this area with mass effect and right-sided midline shift. There is moderate pulmonary artery systolichypertension.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is elongated. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve appears structurally normal with trivial mitralregurgitation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. CT ABDOMEN WITHOUT CONTRAST: There are moderate size bilateral pleural effusions. There are calcifications within the carotid bifurcations bilaterally. There is a stable amount of subarachnoid hemorrhage overlying the sulci of the left frontal lobe, left temporoparietal and right temporoparietal regions. There is moderatepulmonary artery systolic hypertension. TECHNIQUE: Noncontrast head CT. There is noaortic valve stenosis. This could be related to intrabladder hematoma, although other space occupying mass cannot be excluded. Retroperitoneal hematoma. CT PELVIS WITH CONTRAST: There is soft tissue stranding extending along the lateral conal fascia, psoas muscle and retroperitoneum. Left frontal lobe subarachnoid hemorrhage. FINDINGS: Again there is intraparenchymal hemorrhage in the anterior portion of the left temporal lobe. There is slight left ventricular enlargement with minimal upper zone redistribution which may be related to patient's positioning. There is fluid withn the sphenoid sinus and the right mastoid air cells. This may be due to asymmetric prostatic enlargement. There is opacification within the the right lung apex. Additionally there is fluid within the sphenoid sinus and ethmoid air cells without associated fractures of these sites appreciated. There is ill-defined opacity at the right lung base, of unknown chronicity. FINDINGS: There is hemorrhage seen in the left temporal pole. There is left neural foraminal narrowing at the left C2/3 and C3/4 levels. There also appears to be a small amount of left- sided uncal herniation which was present previously and has not changed in appearance. There is a small amount of blood within the occipital horns of the lateral ventricles. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets are mildly thickened. The prevertebral soft tissues cannot be assessed more inferiorly. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Comparison is made to previous lower extremity bilateral venous ultrasound dated . ABD FIRM AND DISTENDED WITH BOWEL SOUNDS.GU: FOLEY CATH CONT TO LEAK, U/O LOW. OGT to low intermittent sx draining brow, bilious liquid.ID: Remains afebrile.Access: Has triple lumen in L groin. Aspen collar intact.resp: remains intubated and vented with a/c 14/600/40%/5peep, min vol 8.7 L, sxn for small amts thick blood tinged secretions, breath sounds coarse.cv: HR 80-90 SR, no VEA, BP 160-170 IV NTG gtt initiated, titrate to goal BP 120-140,heme: transfused with second unit PRBC's, 1 bag plt, hct 24, post plt ct 124gu: foley leaking around catheter, foley replaced with #18, urine 40-60cc/hrid: cont clinda/levoflox, afebrile, wbc 1.8 this amsocial: NH called for update on status, no contact from family member or guardian, social work involvedPLAN: follow neuro exam, titrate NTG gtt to goal BP 120-140, follow coags, correct coagulopathy NTG D/C'D AND STARTED ON NIPRIDE, TITRATED UP TO 2.0 MCQ/KG, WEANING DOWN THIS AM TO 1.2MCQ'S. PT SX FOR MOD AMT'S OF THIN BLOOD TINGED SECRETIONS. CXR done after first attempt.F&E: K and Mg to be repleted once access is obtained.Heme: Hct. keep sbp 120/-140/ neuro check q 1 hr vit k 10 mg sc x3 daysinsulin gt titratefollow lactate, ivf TEMP MAX 99.2 PO.RESP: PT VERY TACHYPNEIC WITH RATES IN THE 30'S, PT VERY WHEEZY INSP/EXP. Patient remains on mechanical ventilation, transfused this morning for low Hct.BS diminished, not much secretion bloody catheter instead. SX FOR BLOODY SECRETIONS.GI: PT HAS OGT WHICH WAS PLACED DURING INTUBATION WHICH WAS PASSED THROUGH AN ETT. Pt sedated. micu npn 0700-1900review of systems:neuro: sedated with propofol gtt, am wake up, RR 30's grimacing, out of synch with ventilator, no spontaneous movement, resedated. HCT 20, IS PRESENTLY RECEIVING A UNIT OF PACKED CELLS.. PT HAS SMALL RETROPERITONEAL BLEED FROM LINE PLACEMENT EARLIER IN THE DAY.LACTIC ACID DOWN TO 6.5 FROM 15.PT REMAINS FULL CODE. remains sedated on Propofol 43mcg/kg gtt. HO notified and pronounced pt dead. patient does not follow commands.aspen collar in place.hems: transfused 2 units prbc's afer multilumen inserted. Add 1830p given 2 uffp inr 1.6, bc x2 sent, nasal swab for msra sent, given lopressor 5mg iv x1 sbp >150 KEEP BP 120-140 RANGE, TREAT WITH LOPRESSOR. Compared to the previous tracing of nosignificant change. R pupil is pinpoint and reactive, L has cataract-3mm. HR IN 70'S -80'S WITH NO ECTOPY.AFEBRILE, TAKING FEW SPONTANEOUS BREATHS OVER THE VENT.GI: PT HAS ORAL GT. Some inspiratory wheezes on exam. cerebral hemmorhagedkametabolic acidosisarfuti pna lt retrocardiac opacityincrease inrrhabdomyolysisp. post transfusion hct= 26.8.endo: following q 6 hr glucose and tx with sliding scale. On Nitroprusside at 1.2mcg/kg. O2 SAT'S HIGH 90'S TO 100%.NEURO: PT WELL SEDATED, PT AROUSES WITH PAINFUL STIMULI. grimacing and furrowing forehead when suctioned or attempts at mouth care. AT 2330 IT WAS DECIDED TO ELECTIVELY AND SEDATE PT IN ORDER TO OBTAIN ACCURATE CT SCAN AND CORRECT LOW PO2. sedation stopped this last pm for eval by neuro. Pt died comfortable on the morphine drip. | 30 | [
{
"category": "Radiology",
"chartdate": "2140-11-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 804020,
"text": " 7:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p fall. change in MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall. change in MS\n contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe SUN 10:01 AM\n L temp lobe hemorrhage. L frontal small SAH\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: 80 year old man status post fall with change in mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is hemorrhage seen in the left temporal pole. In addition,\n there is high attenuation material at the periphery of the left frontal lobe.\n There is no mass effect or shift of the normally midline structures. The\n ventricles and sulci are unremarkable. Again seen is deep white matter low\n attenuation, also seen in the subinsular regions. These are unchanged from\n the prior study.\n\n Bone windows demonstrate no fractures. The overall study is somewhat limited\n by motion artifact.\n\n IMPRESSION: Left temporal lobe contusion. Left frontal lobe subarachnoid\n hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804021,
"text": " 7:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p fall, hypoxic\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall, hypoxic\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and fall.\n\n FINDINGS: This study is limited by patient motion. There is prominence of\n the upper mediastinum which is likely secondary to the supine\n technique. There is ill-defined opacity at the right lung base, of unknown\n chronicity. There is miniaml patchy increased density in the left\n retrocardiac region. There is no evidence of pneumothorax or definite pleural\n effusion. There is no evidence of overt heart failure. There are fractures of\n the left 4th, 5th, and 6th ribs posterolaterally. One of these rib fractures\n demonstrates evidence of callus formation. Other of these fractures\n demonstrate distraction without callus formation.\n\n IMPRESSION: 1. Ill-defined density right lung base and left retrocardiac\n area, of unknown chronicity/etiology. An acute process in these areas cannot\n be excluded. PA and lateral chest radiograph would be helpful when possible.\n\n 2. Left 4th, 5th, and 6th posterior rib fractures. One of these fractures\n demonstrates callus formation; the other two demonstrate distraction without\n callus formation. These may all be chronic or subacute; given the history of\n fall, clinical correlation is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804311,
"text": " 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm L SC line placement, r/o PTX\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p L SC central line placement\n REASON FOR THIS EXAMINATION:\n confirm L SC line placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n For CV line placement.\n\n Tip of left subclavian CV line overlies proximal SVC. ETT is 3 cm above\n carina. Tip of NG tube is in distal antrum of stomach. No change in appearance\n of heart or lungs since prior film of same date.\n\n IMPRESSION: Lines and tubes as described and satisfactorily located. No\n pneumothorax or other change since prior film of same date.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-07 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 804115,
"text": " 9:03 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: HYPOXIA AND INCREASED RESP STATUS, EVAL FOR DVT\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with hypoxia and increased respiratory status, h/o of\n immobility in nursing home\n REASON FOR THIS EXAMINATION:\n Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, increased respiratory distress, history of immobility.\n Please evaluate for DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Comparison is made to previous\n lower extremity bilateral venous ultrasound dated . Grayscale and\n Doppler images of the right and left common femoral, superficial femoral,\n greater saphenous, popliteal veins were obtained. Normal flow,\n compressibility, and augmentation were present throughout. No intraluminal\n thrombus was identified.\n\n IMPRESSION: No evidence of lower extremity deep venous thrombosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-06 00:00:00.000",
"description": "C-SPINE, TRAUMA",
"row_id": 804041,
"text": " 11:11 AM\n C-SPINE, TRAUMA Clip # \n Reason: s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Change in mental status s[ fall.\n\n AP, LATERAL AND ODONTOID VIEWS OF THE CERVICAL SPINE: Imaging of the mid and\n lower cervical spine is suboptimal due to overlying soft tissue and humerus.\n There is no prevertebral soft tissue swelling at the C1 through C3 levels,\n although there appeared to be some increase in soft tissue in the posterior\n pharynx. The prevertebral soft tissues cannot be assessed more inferiorly.\n\n On the swimmer's view, there is a quesiton of cortical step-off at the\n posterior margin of the dens; this could be an artifact of limited bone detail\n on this view (the odontoid view shows no abnormality), although further\n evaluation is recommended.\n\n Evaluation of vertebral body alignment is limited. Degenerative change is\n noted.\n\n IMPRESSION: Nondiagnostic study, as detailed above. See above comments\n regarding the appearance of the dens on the swimmer's view. A CT of the\n cervical spine should be strongly considered based on these findings.\n\n These findings were discussed with the requesting physician, . , at\n approximately 12:05 p.m. on the date of study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804082,
"text": " 12:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for ETT placement\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with delta MA, metabolic acidosis, s/p head bleed s/p ETT\n placement.\n REASON FOR THIS EXAMINATION:\n Please assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change, metabolic acidosis, s/p head bleed and ETT\n placement.\n\n VIEWS: Semierect AP view compared with supine AP view from .\n\n FINDINGS: There has been interval placement of ETT with tip approximately 4\n cm above the carina. A NGT has also been placed with the tip below the\n diaphragm and extending off the inferior borders of the film. No pneumothorax\n is identified. The left lateral hemithorax is excluded from this film. There\n is slight left ventricular enlargement with minimal upper zone redistribution\n which may be related to patient's positioning. Again noted is a small right\n pleural effusion with pleural thickening/fluid noted in the right lower\n lateral hemithorax. Numerous rib fractures are again noted within the right\n posterior ribs. No pneumothorax is present.\n\n IMPRESSION:\n 1) Satisfactory placement of ETT and NGT.\n 2) Slight left ventricular enlargement and minimal upper zone redistribution,\n likely related to patient positioning, however minimal left ventricular\n failure cannot be excluded.\n 3) Persistent small right pleural effusion and pleural thickening/fluid\n within the right lower lateral hemithorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 804084,
"text": " 12:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for evolution of head bleed.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man found down with acute head bleed seen on head CT now\n with continued delta MS neuro exam\n REASON FOR THIS EXAMINATION:\n Please eval for evolution of head bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old man found down with an acute head bleed seen on prior\n CT now with continued mental status changes and nonfocal neural examination.\n Evaluate for progression of intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Again there is intraparenchymal hemorrhage in the anterior portion\n of the left temporal lobe. Better visualized is contusion of the inferior\n frontal lobes, greater on the left. There is a stable amount of subarachnoid\n hemorrhage overlying the sulci of the left frontal lobe, left temporoparietal\n and right temporoparietal regions. Additionally there is subarachnoid blood in\n the intrapeduncular cistern. There is a small amount of blood within the\n occipital horns of the lateral ventricles. While this is not commented upon in\n the prior study, there is motion limiting the evaluation on the previous\n study. Thin subdural CSF density collections have developed.\n\n Again seen is the white matter low attenuation in the subinsular and\n periventricular white matter, unchanged. There is no shift of normally midline\n structures. Ventricles are not dilated.\n\n BONE WINDOWS: There is a nondisplaced fracture through the right temporal\n bone, mastoid air cells and middle ear cavity. There is fluid within the right\n mastoid air cells. There is soft tissue density deep to the eardrum in the\n middle ear cavity which is most likely blood given the associated fracture.\n Additionally there is fluid within the sphenoid sinus and ethmoid air cells\n without associated fractures of these sites appreciated. These frontal\n sinuses, and upper portions of the maxillary sinuses and left mastoid air\n cells are free of fluid.\n\n IMPRESSION:\n\n 1) Given the differences in technique, there is no significant difference in\n the appearance of the brain parenchyma and its various hemorrhages since the\n prior study.\n 2) Fracture through the right mastoid air cells with fluid in the mastoid air\n cells in the middle ear cavity, presumably blood related to the patient's\n fracture. No other fractures are appreciated.\n\n (Over)\n\n 12:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for evolution of head bleed.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n These findings were telephoned to Dr. , physican caring for the\n patient at the time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-07 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 804085,
"text": " 1:00 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please eval for C-spine fracture.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status s/p fall and ?dens fracture on plain\n films\n REASON FOR THIS EXAMINATION:\n Please eval for C-spine fracture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Elderly man s/p fall, evaluate for cervical spine fracture.\n Questionable dens abnormality on plain films.\n\n TECHNIQUE: Axial images were performed through cervical spine with sagittal\n and coronal reformatted images.\n\n FINDINGS: On the sagittal reformatted series, images 20 and 22 there is a\n lucent line through the base of the dens. This does appear to violate the\n posterior cortex on image 20. There is no displacement. This is not well\n appreciated on the axial or coronal reformatted series, while this may be\n artifactual or a vascular groove, a nondisplaced dens fracture cannot be\n entirely excluded. There is some thickening of the prevertebral soft tissues\n anterior to this. No other area suspicious for cervical spine fracture is\n identified. There is cervical spondylosis in the mid cervical spine with\n endplate sclerosis and loss of disc height at the C3-4, C4-5 and C5-6 levels.\n There is normal alignment of the cervical vertebral bodies. No evidence of\n spinal canal compromise is apparent.\n\n There is fluid withn the sphenoid sinus and the right mastoid air cells. There\n is evidence of a skull fracture extending through the mastoid air cells\n accounting for the fluid within them. Additionally there is soft tissue\n density within the right middle ear canal, deep to the tympanic membrane. This\n may represent blood. No other fractures are appreciated.\n\n There is opacification within the the right lung apex. There are\n calcifications within the carotid bifurcations bilaterally.\n\n IMPRESSION:\n\n 1) Possible nondisplaced fracture through the dens of C2. v. artifact or\n vascular groove.\n 2) Right basilar skull fracture through the right mastoid air cells.\n Additionally there is soft tissues density within the middle ear cavity which\n could represent acute blood products.\n 3) Fluid within the sphenoid sinus without a fracture seen. However, the\n entire sphenoid sinus is not imaged.\n\n These findings were telephoned to Dr. , the physician caring for\n the patient at the time of the study.\n\n (Over)\n\n 1:00 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please eval for C-spine fracture.\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n NOTE: An MRI study of the cervical spine may be helpful in excluding edema in\n C2, which if present, would support the presence of a fracture. However, a\n negative result does not exclude a fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-07 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 804086,
"text": " 1:01 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please assess for mesenteric ischemia\n Admitting Diagnosis: DRA, SAH\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\n with guaiac positive stools.\n REASON FOR THIS EXAMINATION:\n Please assess for mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 80 year old man with altered mental status, 10. hematocrit drop,\n distended abdomen and quiac positive stools. The patient has a mildly elevated\n creatine. Evaluate for mesenteric ischemia or retroperitoneal hematoma.\n\n TECHNIQUE: Noncontrast images were obtained from the lung bases to the pubic\n symphysis. There are no prior studies for comparison.\n\n CT ABDOMEN WITHOUT CONTRAST: There are moderate size bilateral pleural\n effusions. There is dense consolidation at the right lung base with air\n bronchograms. This could represent aspiration vs pneumonia.\n\n Noncontrast images of the liver, gallbladder, pancreas, spleen, adrenals and\n kidneys are within normal limits. The upper bowel loops are unremarkable.\n\n CT PELVIS WITH CONTRAST: There is soft tissue stranding extending along the\n lateral conal fascia, psoas muscle and retroperitoneum. This extends to the\n left groin and can be seen with recent femoral puncture and bleeding. There is\n no large focal hematoma. The unopacified bowel loops are within normal\n limits. The bowel loops are not dilated and there is no evidence of wall\n thickening to suggest ischemia. There is a moderate amount of calcification at\n the origin of the celiac and SMA vessels. There is no calcification at the\n origin of the . There is a lobulated appearance to the prostate gland with\n the Foley catheter being deviated to the right as it enters the urinary\n bladder. This may be due to asymmetric prostatic enlargement.\n\n BONE WINDOWS: There are multiple bilateral fractures of the lower ribs. Each\n rib is broken in more than one place. This can result in a flail chest.\n Additionally there are fractures of the L1 and L2 right transverse processes.\n\n IMPRESSION:\n\n 1) Mild amount of stranding extending from the left groin up along the left\n psoas muscle consistent with a mild amount of retroperitoneal bleeding given\n the recent history of a line placement at this site.\n\n 2) No secondary signs of mesenteric ischemia.\n\n 3) Asymmetric appearance to the base of the bladder. This may be due to\n (Over)\n\n 1:01 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please assess for mesenteric ischemia\n Admitting Diagnosis: DRA, SAH\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n asymmetric hypertrophy of the prostate.\n\n 4) Multiple bilateral rib fractures and transverse process fractures. Has the\n patient had a recent cardiopulmonary resuscitation or trauma?\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-06 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 804022,
"text": " 7:54 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n FINDINGS: This study is limited by patient motion. This single AP view of\n the pelvis demonstrates no evidence of obvious fracture or dislocation. There\n is a left-sided femoral line in position with its distal tip within the left\n hemipelvis. There is no evidence of overt bone destruction or bone erosion.\n\n IMPRESSION: No obvious fracture on this limited study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 804252,
"text": " 10:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u L temporal contusion\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man w/ L temp contusion\n REASON FOR THIS EXAMINATION:\n f/u L temporal contusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old man status post fall with decreased mental status.\n Left temporal contusion.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT CONTRAST: There has been progression of a large infarct\n including the left-sided parietal, temporal and occipital lobes. This infarct\n is within the MCA distribution, and may be secondary to an internal carotid\n dissection at the time of the trauma. There is edema associated with this\n area with mass effect and right-sided midline shift. There has been complete\n effacement of the left lateral ventricles. There is also an area of infarct\n within the left temporal and frontal lobes which corresponds to the previous\n areas of contusion.\n\n No new evidence of intracranial hemorrhage when compared to the previous exam.\n There is increased intraparenchymal blood as well as well as a subdural\n hematoma within the left middle cranial fossa and the left temporal lobe.\n There is hyperattenuating fluid overlying the tentorium which was seen\n previously and corresponds to a subdural hematoma which has not changed in\n appearance. This blood is also seen tracking up the falx. There is a small\n amount of hyperattenuating fluid over the right parietal lobe which was seen\n previously and relates to subarachnoid hemorrhage. There also appears to be a\n small amount of left- sided uncal herniation which was present previously and\n has not changed in appearance.\n\n There is opacification of the bilateral mastoid air cells, and there is\n opacification within the right middle ear and fluid within the sphenoid sinus.\n\n IMPRESSION: Continued evolution of a large left middle cerebral artery\n infarction. Increased mass effect secondary to edema of this infarction with\n right-sided shift and effacement of the left lateral ventricles. No new\n hemorrhage when compared to the previous exam. These findings were called to\n the caring team at the time of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804301,
"text": " 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pnuemothorax\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p R SC central line attempt with arterial puncture\n REASON FOR THIS EXAMINATION:\n r/o pnuemothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right subclavian central line placement with arterial\n puncture. ? placement/pneumothorax.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The cardiomediastinal and hilar contours are stable.\n There is interval increase in diffuse interstitial opacification and the\n pulmonary vasculature appears more prominent than in the prior study. Again\n noted is a right pleural effusion and effusion/pleural thickening along the\n lateral right pleura, which is unchanged. The left CP angle is not included\n in the study, and a left effusion cannot be excluded. The ET and NG tubes\n remain unchanged in position. There is no pneumothorax. Numerous rib\n fractures are again noted.\n\n IMPRESSION:\n\n 1. No evidence of pneumothorax.\n 2. Interval increase in interstitial edema and prominence of the pulmonary\n vasculature in the setting of right effusion, consistent with slightly\n worsened heart failure.\n 3. Stable ET & NG tubes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-08 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 804260,
"text": " 11:41 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\n Admitting Diagnosis: DRA, SAH\n Field of view: 43\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with altered mental status, 10 pt Hct drop and distended belly\n with guaiac positive stools.\n REASON FOR THIS EXAMINATION:\n bleed? Will be there soon for head CT.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS\n\n INDICATION: Guaiac positive stools. Continued drop in hematocrit.\n Retroperitoneal hematoma.\n\n Comparison is made to the prior exam of one day earlier on .\n\n TECHNIQUE: Noncontrast images of the abdomen and pelvis were performed.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Multiple bilateral rib fractures and\n fractures of the L1 and L2 transverse processes are again noted. No\n pneumothoraces at the lung bases are seen. There is interval increase in size\n of small-moderate bilateral pleural effusions, left greater than right with\n adjacent basilar consolidation. An NG tube is seen with it's tip at the\n gastroduodenal junction. No free air seen. The liver, gallbladder, pancreas,\n spleen, adrenal glands, and kidneys are stable in appearance. Newly\n appreciated within the right lower quadrant, is a 5.9 x 4.3 cm fluid\n collection of increased density overlying and most probably related to the\n cecum.\n\n The previously appreciated increased thickening and stranding extending from\n the left groin to the retroperitoneum and lateral coronal fascia is slightly\n increased in the interval. The stomach and small bowel loops are\n unremarkable. Note is made of high density material within the large bowel\n lumen distal to the site of likely cecal hematoma. This high density extends\n throughout the colon and is most notable in the rectum and sigmoid. No oral\n contrast was administered.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The bladder contains high density fluid,\n and a balloon Foley catheter tip is seen displaced to the right and\n anteriorly.\n\n IMPRESSION: 1. Newly identified high density localized fluid collection\n related to the cecum measuring 5.9 x 4.3 cm. Increased density intraluminal\n material throughout the large bowel distal to this presumed cecal hematoma\n presumably relates to intraluminal blood products, as oral contrast was not\n administered.\n 2. Mild interval increase in amount of soft tissue stranding\n extending from the left groin and tracking through the retroperitoneum,\n (Over)\n\n 11:41 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: HCT DROP AND DISTENDED BELLY WITH GUAIAC POSITIVE STOOLS, EVAL FOR BLEED\n Admitting Diagnosis: DRA, SAH\n Field of view: 43\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n probably related to mild hemorrhage from left femoral line placement.\n 3. High density material within the bladder seen to displace the\n balloon Foley tip. This could be related to intrabladder hematoma, although\n other space occupying mass cannot be excluded. The appearance of this is\n unchanged from yesterday.\n 4. Interval mild increase in size of bilateral pleural\n effusions, left greater than right, with adjacent basilar consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-11-08 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 804270,
"text": " 1:09 PM\n MR CERVICAL SPINE Clip # \n Reason: w/ inversion recovery images. ? dens fx, r/o ligamentous i\n Admitting Diagnosis: DRA, SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with L temporal contusion s/p fall\n REASON FOR THIS EXAMINATION:\n w/ inversion recovery images. ? dens fx, r/o ligamentous injury s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left temporal contusions, S/P fall. Evaluate for dens fracture\n or ligamentous injury.\n\n TECHNIQUE: Sagittal T2, T1, inversion recovery, and axial gradient echo\n sequences.\n\n FINDINGS: Comparison is made to the C-spine CT from . No\n abnormal signal on inversion recovery sequences or T2 sequences are seen\n within the odontoid process. Nevertheless, a fracture cannot be excluded.\n There is increased T2 and inversion recovery signal intensity anterior to the\n vertebral bodies, which may reflect ligamentous injury. Prevertebral soft\n tissue swelling is present. Multilevel degenerative changes are present, with\n desiccation of intervertebral disks and loss of disk space height, most\n pronounced at C3/4, C4/5, and C5/6. There is also moderately severe anterior\n osteophyte formation at these levels. There is left neural foraminal\n narrowing at the left C2/3 and C3/4 levels.\n\n Also noted on the STIR sequences increased signal within the T4 vertebral\n body, which may represent a fracture.\n\n IMPRESSION: 1) No signal abnormality within the odontoid process.\n Nevertheless, a fracture at this level cannot be excluded.\n\n 2) Increased T2 and STIR signal intensity within the prevertebral soft tissue\n and the anterior longitudinal ligament. This may reflect a ligamentous\n injury.\n\n 3) Increased T2 signal intensity within the T4 vertebral body, with irregular\n marrow signal. Findings may represent a fracture.\n\n"
},
{
"category": "Echo",
"chartdate": "2140-11-07 00:00:00.000",
"description": "Report",
"row_id": 69871,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Valvular heart disease.\nBP (mm Hg): 181/75\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 13:24\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is moderate pulmonary artery systolic\nhypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thickness, cavity size,\nand systolic function are normal (LVEF>55%). The ascending aorta is mildly\ndilated. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. Trace aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared to previous report (study not available for review) from ,\nthe right ventricular systolic pressure has increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-07 00:00:00.000",
"description": "Report",
"row_id": 151559,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-11-06 00:00:00.000",
"description": "Report",
"row_id": 151560,
"text": "Sinus rhythm. Supraventriciular extrasystoles. Inferior/lateral ST-T wave\nchanges are non-specific. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-06 00:00:00.000",
"description": "Report",
"row_id": 1261991,
"text": "Admit note 80 yo black male NH resident found down at NH approx 1.5 hrs noted to have laceration on back of head lt side he was alert and oriented at that time. His o2 sat was 87% came into the ed disoriented and c collar not in place had lt lac head, labs glucose 393 anion gap 30, cpk 2135, phos 5.8. ekg elevated t waves v2-3 CT showed lt temporal hemorrhage with lt SAH small inr was elevated. Has rib fx, found to have UTI given 500mg levo iv WBC 15.6 cxr lt retrocardiac opacity\nPMH cardiopulm emboli, dementia, psychosis, syndrome of inappropirate antidiuretic hormone, urine incont. prostatic hypertrophy, htn, dm II, cva, lung abscess ribs removed, ? hepatitis B, +MRSA\nsocial etoh abuse, ivda, was homeless now in NH demented has (notified has not seen in awhile), , allergies nka\nNeuro arrived to floor garbled speech pearla 2mm brisk was not fc after few hrs would fc inconsistently tylenol and etoh levels neg\ncorneal reflex intact face symetrical, collar on logrolled\ncardiac K+ in er 3.4 tx ivf 40 kcl k+ 4.7, ST 100-110 without ectopy sbp 110/-160/, cpk 3827 mb 93\nresp 4lnp 7.26/27/77/-13/13 repeat 7.30/33/91/- lungs exp wheezes throughout RR 36-44\nGI abd snt bs + npo\ngu 0-30 q hr receiving iv boluses cr 1.6 bun 27\nendo bs 211-125 insulin drip titrated lactate 15.3 to 14\nid wbc 15.6 temp max 99.8 on levo and clinda a nasal swab sent msra bc x2 sent\naccess lt fem triple lumen line, lt aline radial\na. cerebral hemmorhage\ndka\nmetabolic acidosis\narf\nuti pna lt retrocardiac opacity\nincrease inr\nrhabdomyolysis\np. keep sbp 120/-140/ neuro check q 1 hr vit k 10 mg sc x3 days\ninsulin gt titrate\nfollow lactate, ivf\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1262002,
"text": "MICU NPN Update Code status:\nFamily met with Dr. and pt's primary care MD also discussed case with pt's guardian at length. Decision was made to withdraw aggressive care this afternoon. Plan is to extubate him after he has a morphine drip started and looks comfortable on this. If he looks stable he will be called out to the floor CMO. All meds are d/c'd as well as blood draws.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1262003,
"text": "MICU NPN Update:\nPt was extubated just a little before 8PM. Pt immediately dropped his sats and BP and by 8:30PM he was asystolic. Pt died comfortable on the morphine drip. HO notified and pronounced pt dead. He will notify family of the death.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-08 00:00:00.000",
"description": "Report",
"row_id": 1261997,
"text": "NPN 7a-7p\nNeuro: Pt. remains sedated on Propofol 43mcg/kg gtt. R pupil is pinpoint and reactive, L has cataract-3mm. Has mild reaction to painful stimuli, grimaces and flexes. Went for head ct today to evaluate bleed and look for cerebral edema. Pt. has C-2 fx. Also went to MRI to evaluate status of cervical spine, results pnd. Aspen collar in place.\nCV: HR 80's. On Nitroprusside at 1.2mcg/kg. SBP maintained at 130-140 most of the day. Was off Nipride briefly and SBP was 150.\nResp: Remains vented on 50% 600x18 5. Sx for small amount of prulent looking sputum, cx sent. Some inspiratory wheezes on exam. On levo for presumed pneumonia.\nGI: Had ct of abdomen which shows bleed in his cecum. Also has multiple old rib fx. Tube feedings on hold. No stool today. Started on sucralfate today. OGT to low intermittent sx draining brow, bilious liquid.\nID: Remains afebrile.\nAccess: Has triple lumen in L groin. R subclavin attempt was unsuccessful, team will try again. CXR done after first attempt.\nF&E: K and Mg to be repleted once access is obtained.\nHeme: Hct. 21. No overt signs of bleeding. FDP panel snet. Due for 2 u PRBC once line placed.\nSocial: Patients grand niece has been contact and she gave consent for line access. Pt. is DNR. Social work consulted. Spoke with director of nursing at nursing home regarding pt. status.\nSkin: Pt. has large bruise under R axilla which has not increased in size. Area outlined.\nAssessment: Pt. with multiple old rib fx, new SAH and stroke, blood in cecum. ? etiology of multiple injuries.\nPlan:\n-obtain access\n-transfuse 2u PRBC\n-Hct 4 hours post transfusion\n-Replete K and P04.\n-Follow neuro exam.\n-Sx prn\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1261998,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 600, A/c 18, Fio2 50%, and Peep 5. Pt sedated. Adequate O2 sats. Bs clear bilaterally. Sx'd for sm amounts of thick yellow sputum. No further vent changes made this shift. Unable to do RSBI this am. No spont effort. Plan: Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1261999,
"text": "PaO2 decreasing to 66. Fio2 increased to 60%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1262000,
"text": "CV goal sbp to be between 120 - 140. niprid increased to 3 mics over night in attemps to get sbp with in goal range.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-09 00:00:00.000",
"description": "Report",
"row_id": 1262001,
"text": "CV: hr 80-90 nsr No ectopy. goal sbp= 140-160..nipride increased overnight to 2.8 mics/kg/min to maintain this goal.\nGu: foley draining clear yellow urine.some leaking around foley contained by wrapping around catheter and penis. urine ouput is adequate..increase urine ouput after mannitol 100 mg given.\ngi: og tube draining bilious. bowel sounds present but hypoactive.no stool.\nneuro: patient is sedate. on propofol at 43 mics/kg/min. sedation stopped this last pm for eval by neuro. patient moved bioth legs on bed to painful stimuli.moved both hands on bed to paiful stimuli. grimacing and furrowing forehead when suctioned or attempts at mouth care. patient does not follow commands.aspen collar in place.\n\nhems: transfused 2 units prbc's afer multilumen inserted. post transfusion hct= 26.8.\nendo: following q 6 hr glucose and tx with sliding scale. 2 units reg for bs of 167 st 2400. this a.m. glucose =176 tx with 2 units reg at 0530.\nresp: abg ph=7.47/30/po2 =66 fio2 increased to 70 %. suctione dq 2-3 hours for small amounts thick yellow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-06 00:00:00.000",
"description": "Report",
"row_id": 1261992,
"text": "Add 1830p given 2 uffp inr 1.6, bc x2 sent, nasal swab for msra sent, given lopressor 5mg iv x1 sbp >150\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-07 00:00:00.000",
"description": "Report",
"row_id": 1261993,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT RECEIVED WITH CERVICAL COLLAR ON, PT MUMBLING AND CALLING OUT. UNABLE TO UNDERSTAND WHAT HE WANTED. MAE, FOLLOWS COMMANDS, PERLA, 2CM REACTING BRISKLY. HO ATTEMPTED NGT PLACEMENT HR DROPPED TO THE 50'S AND BECAME HYPOTENSIVE TO THE 70'S. AFTER THIS IT WAS THEN NOTICED THAT RIGHT PUPIL MUCH LARGER THAN THE LEFT, APPROX 5REACTING SLUGGISHLY AND LEFT 2 REACTIVE BRISKLY. PT HAD REPEAT CT SCAN WHICH SHOWED NO CHG IN BLEED, SKULL FX, QUESTIONABLE C2 FX. PT NOW HAS ASPEN COLLAR IN PLACE. PT CONT TO MAE, RESPONDS TO STIMULI, FOLLOWS SIMPLE COMMANDS. UNABLE TO VISUALIZE POST HEAD LACERATION DUE TO COLLAR AND HAIR.\nCV: PT'S HR NSR 70-80'S WITHOUT ECTOPY. SBP STABLE SEE FLOWSHEET FOR DATA. KEEP BP 120-140 RANGE, TREAT WITH LOPRESSOR. PRESENTLY ON 40MCQ OF PROPOFOL FOR SEDATION WHILE INTUBATED. TEMP MAX 99.2 PO.\nRESP: PT VERY TACHYPNEIC WITH RATES IN THE 30'S, PT VERY WHEEZY INSP/EXP. COARSE AT THE BASES. UNABLE TO COUGH AND RAISE SECRETIONS. SEVERAL ABG'S DRAWN DURING THE NIGHT. SEE FLOWSHEET. AT 2330 IT WAS DECIDED TO ELECTIVELY AND SEDATE PT IN ORDER TO OBTAIN ACCURATE CT SCAN AND CORRECT LOW PO2. 2345 PT AND CONFIRMED PLACEMENT BY CXR. SX FOR BLOODY SECRETIONS.\nGI: PT HAS OGT WHICH WAS PLACED DURING INTUBATION WHICH WAS PASSED THROUGH AN ETT. LWS DRAINING BROWN GUIAIC POS DRAINAGE.\nGU: FOLEY CATH DRAINING VERY SMALL AMT'S OF YELLOW FOUL SMELLING URINE WITH SEDIMENT. 8-60CC/HR. FOLEY LEAKING URINE AROUND CATH, INC FLUID IN BALLOON WHICH SEEMED TO HELP AT THIS TIME.\nENDO: PT IS ON INSULIN DRIP PRESENTLY AT 3UNITS, TITRATED ACCORDING TO FINGERSTICKS.\nPT 2UNITS FFP FOR ELEVATED INR. HCT 20, IS PRESENTLY RECEIVING A UNIT OF PACKED CELLS.. PT HAS SMALL RETROPERITONEAL BLEED FROM LINE PLACEMENT EARLIER IN THE DAY.\nLACTIC ACID DOWN TO 6.5 FROM 15.\nPT REMAINS FULL CODE. PT HAS LEFT FEMORAL TLC WHICH IS IN GREAT DANGER OF BECOMING INFECTED DUE TO LEAKAGE AROUND FOLEY. HO NOTIFIED OF THIS TO CHG THE SITE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-07 00:00:00.000",
"description": "Report",
"row_id": 1261994,
"text": "micu npn 0700-1900\n\nreview of systems:\nneuro: sedated with propofol gtt, am wake up, RR 30's grimacing, out of synch with ventilator, no spontaneous movement, resedated. Pupils right 3mm reactive, left pin point nonreact, -corneals, +cough/gag. Aspen collar intact.\n\nresp: remains intubated and vented with a/c 14/600/40%/5peep, min vol 8.7 L, sxn for small amts thick blood tinged secretions, breath sounds coarse.\n\ncv: HR 80-90 SR, no VEA, BP 160-170 IV NTG gtt initiated, titrate to goal BP 120-140,\n\nheme: transfused with second unit PRBC's, 1 bag plt, hct 24, post plt ct 124\n\ngu: foley leaking around catheter, foley replaced with #18, urine 40-60cc/hr\n\nid: cont clinda/levoflox, afebrile, wbc 1.8 this am\n\nsocial: NH called for update on status, no contact from family member or guardian, social work involved\n\nPLAN: follow neuro exam, titrate NTG gtt to goal BP 120-140, follow coags, correct coagulopathy\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-07 00:00:00.000",
"description": "Report",
"row_id": 1261995,
"text": "Patient remains on mechanical ventilation, transfused this morning for low Hct.BS diminished, not much secretion bloody catheter instead. CT Scan intra-parenchymal bleed @ (L) temporal lobe, no recent ABG maintaining good saturation will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-11-08 00:00:00.000",
"description": "Report",
"row_id": 1261996,
"text": "NURSING PROGRESS NOTE;\nPT REMAINS WELL SEDATED ON PROPOFOL. PT REMAINS /VENT ON A/C 600 X 18 +5 40%. ABG PO2 IN THE 70'S, FIO2 INC TO 70% THEN DROPPED TO 60% WHERE HE IS NOW. SEE FLOWSHEET FOR ABG'S. PT SX FOR MOD AMT'S OF THIN BLOOD TINGED SECRETIONS. LUNG SOUNDS COARSE WITH OCC WHEEZES BUT CLEAR WITH SX'ING. O2 SAT'S HIGH 90'S TO 100%.\nNEURO: PT WELL SEDATED, PT AROUSES WITH PAINFUL STIMULI. MOVES EXTREMETIES ON THE BED ONLY. PUPILS RIGHT LARGER THAN THE LEFT, LEFT NONREACTIVE. DOES NOT OPEN EYES UNLESS STRONGLY STIMULATING.\nCV: PT RECEIVED ON NTG TO KEEP BP 120-140, BP CONSISTENTLY IN THE 180'S. NTG D/C'D AND STARTED ON NIPRIDE, TITRATED UP TO 2.0 MCQ/KG, WEANING DOWN THIS AM TO 1.2MCQ'S. HR IN 70'S -80'S WITH NO ECTOPY.\nAFEBRILE, TAKING FEW SPONTANEOUS BREATHS OVER THE VENT.\nGI: PT HAS ORAL GT. LWS DRAINING BROWN/GREEN MATERIAL, GUIAIC POS. NO STOOL AT THIS TIME. ABD FIRM AND DISTENDED WITH BOWEL SOUNDS.\nGU: FOLEY CATH CONT TO LEAK, U/O LOW. URINE YELLOW WITH SEDIMENT.\nENDO: PT ON INSULIN DRIP TITRATED ACCORDING TO FINGERSTICKS. CHECKED Q 1/HR.\nSKIN: PT HAS SOME OPEN SCRAPS FROM WHEN HE FELL, BACITRACIN OINT APPLIED. PT'S TOES REQUIRED MUCH CLEANSING, GUAZE PLACED BETWEEN TO KEEP DRY AND PROMOTE HEALING. PT HAS ECHYMOTIC AREA UNDER RIGHT AXILLA EXTENDING DOWN RIGHT CHEST WALL. HO NOTIFIED.\nNO CALL RECEIVED BY NH/FAMILY.\nPT IS FULL CODE. ASPEN COLLAR ON.\n\n"
}
] |
|
90,776 | 181,396 | 80F history of HTN, arrythmia, PAD presented to OSH with ~16 hours of chest pain, found to have elevated troponin and EKG suggestive of inferior MI, then transferred to for further management. At , she went to the cath lab, where she had BMS to RCA x2 with restoration of flow. . # INFERIOR STEMI: Cath showed total occlusion of proximal RCA. Two BMS were placed in the proximal and mid RCA with restoration of flow. (The LMCA was normal. The LAD was normal and patent. Lcx was patent.) Pt was started on medical management with Plavix 75 mg daily, aspirin 325 mg daily, atorvastatin 80 mg daily. Echo was done in the morning that showed depressed RV function. Beta blocker, verapamil, spironolactone and ACEI were held given low blood pressure and RV infarction. Enzymes were trended and MB peaked at 215 in the morning (troponin peaked at 7.68). AM CXR was benign with no s/s of overload. On AM pt continued to have substernal chest pain, without radiation. MAPs also dropped to 50s, and she was bradycardic, so we increased her dopamine drip to 10; norepinephrine was added, as was aminophylline 150mg/day (only one dose was given). Pt also received 500 mL bolus NS which increased CVP from 10 to 16. The patient's sinus node seemed to recover on , as she went back into sinus rhythm without bradycardia, and this improved her hemodynamics considerably. Pressors were weaned. She was started on lisinopril. Metoprolol can be considered as an outpatient. . # PUMP: Post-cath ECHO showed significant depression of RV function and PCWP of 22. CVP on morning of was 10. Patient required 500mL bolus as her MAP was in the 50s AM, CVP found to be 16 after bolus, with MAP in 60s. Patient was started on Lasix 20mg PO daily prior to discharge. She was euvolumic on discharge. . # RHYTHM: On presentation, pt had bradycardia and an irregular rhythm suggestive of atrial fibrillation with bradycardia. After revascularization and removal of the temporary pacemaker, rhythm was sinus initially, but she did go back into atrial fibrillation over the next 24 hours. Pt was monitored on telemetry, and her HR and BP remained low post procedure (50s, MAP 50s-60s). She required BP support with dopamine and norepinephrine. Aminophylline 150mg x 1 dose was given. The patient's sinus node seemed to recover on , as she went back into sinus rhythm without bradycardia, and this improved her hemodynamics considerably. Pressors were weaned. We did not anticoagulate the patient given that she was in atrial fibrillation for less than 48 hours and in the setting of an acute STEMI. . # COPD: We continued home tiotropium and put the patient on albuterol PRN instead of home metoproterenol. . # PSEUDOGOUT: Patient developed pain in the right knee with swelling, warmth, and an effusion. Rheumatology consult was called. Joint aspirate was done, and result were consistent with CPPD arthropathy. Injection of 40 mg of depo-medrol was performed. Pain improved considerably, and mobility was no longer limited. She will follow up with rheumatology as an outpatient. . # HYPERTENSION: We held her home verapamil, spironolactone, and lisinopril and started lisinopril prior to discharge. . # HYPOTHYROIDISM: We continued her home levothyroxine. . ### TRANSITIONAL ISSUES: - Patient will call Dr. office the day following discharge to request a follow up appointment. - Patient's cardiologist may wish to consider adding metoprolol and/or increasing lisinopril. - Patient will call her PCP tomorrow to request a follow up appointment. - Patient should call rheumatology to make appt with Dr. (fellow) within 1-2 weeks after discharge (); patient was called on and asked to make this follow-up appointment because this had not been written in her discharge paperwork. | Prior anteroseptal myocardial infarction of indeterminate age.Borderline low voltage. Moderate regional LV systolic dysfunction. Poor anterior R wave progression is consistent with prioranteroseptal myocardial infarction. Q wavesin leads III and aVF are consistent with prior inferior wall myocardialinfarction. Baseline artifact marring interpretation of rhythm but probable low amplitudeP waves consistent with sinus tachycardia and ventricular premature complexes.Acute inferior wall myocardial infarction with evidence of persistentST segment elevations inferiorly and ST segment depressions in the high lateralleads. Previously described inferior ST segment elevations are mucghless apparent. Inferior myocardial infarction with ST segment elevtions,likely acute. Moderatetricuspid regurgitation. Myocardial infarction of indeterminate age. Acute inferior myocardial infarction with persistent ST segmentelevations inferiorly and ST segment depressions in the high lateral leads.Anteroseptal myocardial infarction of indeterminate age. Left axis deviation.Intraventricular conduction delay. Probable prior anteroseptal myocardialinfarction of indeterminate age. Mild tomoderate (+) mitral regurgitation is seen. There are Q waves in the inferior leads consistent with myocardialinfarction. Restingbradycardia (HR<60bpm).Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Anterior wall myocardial infarction, age indeterminate.Prolonged Q-T interval. There is a late transition with small R waves in the anteriorleads consistent with possible myocardial infarction. Non-specific inferolateral repolarization abnormalities areimproved in the lateral limb leads and flatter in the inferior and leftprecordial leads. Probable prior anteroseptal myocardial infarction ofindeterminate age. Consider anteroseptal myocardial infarction of indeterminate age.TRACING #3 Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No restingLVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; midinferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;septal apex - hypo; inferior apex - akinetic;RIGHT VENTRICLE: Dilated RV cavity. Moderate [2+] tricuspidregurgitation is seen. Unchanged moderate cardiomegaly with signs of minimal fluid overload and bilateral areas of atelectasis. Normal ascending aortadiameter. Acute inferior wallmyocardial infarction with ST segment elevation. Non-specific intraventricular conduction delay. Non-specific intraventricular conduction delay. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Right ventricular dilation and severe dysfunction. There are diffuse minimal degenerative changes noted. Mild-to-moderate mitralregurgitation. There is mild pulmonary artery systolic hypertension.There is no pericardial effusion.IMPRESSION: Regional wall motion abnormalities c/w inferior/RV myocardialinfarction. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. There is mild osteopenia. Mild pulmonary hypertension. STEMIHeight: (in) 64Weight (lb): 165BSA (m2): 1.80 m2BP (mm Hg): 117/54HR (bpm): 56Status: InpatientDate/Time: at 10:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Myocardial infarction. Inferiormyocardial infarction with ST segment elevation may represent acute myocardialinfarction. Left axis deviation with leftanterior fascicular block, Baseline artifact. Lung volumes are again low. Inferior myocardial infarction withpersistent ST segment elevations concerning for ongoing ischemia. Inferiormyocardial infarction with ST segment elevation may represent acutemyocardial infarction. Acute inferior wall myocardial infarction with ST segmentdepressions in high lateral leads. Moderate [2+] TR. There is most likely small suprapatellar effusion present. Compared to tracing #2 delayedR wave progression in leads V2-V3 persists. IMPRESSION: Mild cardiomegaly. Borderline lowvoltage. The right atrium is moderately dilated. Unchanged venous introduction sheath in the right internal jugular vein. Borderline low voltage. Low amplitude P waves. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Extensive baseline artifact precludes rhythm determination. Sinus tachycardia. Sinus rhythm with P-R interval prolongation. Extensive anterior wall myocardial infarction, age indeterminateHowever, there could be right-sided chest leads submitted.TRACING #2 Non-specific ST-T wavechanges. Left axisdeviation. Mild to moderate(+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Lung volumes are low. Suboptimal image quality - patient unable to cooperate. Compared totracing #3 R waves in leads V4-V6 are less pronounced.TRACING #4 Sinus rhythm. Sinus rhythm. Compared to the previous tracing of earlier the sameday clearly identified P waves are less easily identified.TRACING #3 Compared to the previous tracing of the rate is slower. Compared to the previous tracing of ST segment elevation inthe inferior leads is less but still persists. The right ventricular cavity is dilated with severe global free wallhypokinesis. Severe global RV free wall hypokinesis.Prominent moderator band/trabeculations are noted in the RV apex.AORTA: Normal aortic diameter at the sinus level. Mediastinal contour appears normal. A new right IJ line terminates in the high SVC. Left ventricular wallthickness, cavity size, and global systolic function are normal (LVEF>55%).There is moderate regional left ventricular systolic dysfunction with severehypokinesis to akinesis of the inferior, inferolateral, and inferoseptalwalls. FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusions. Bony structures intact, though high-riding right humeral head suggests chronic rotator cuff injury. Heart is mildly enlarged. FINDINGS: As compared to the previous radiograph, there is no relevant change. No AS. No visible pleural effusions. 7:13 AM CHEST (PORTABLE AP) Clip # Reason: New pleural effusion? CHF, AMI REASON FOR THIS EXAMINATION: r/o CHF No contraindications for IV contrast FINAL REPORT CHEST RADIOGRAPH PERFORMED ON COMPARISON: None. The heart is mildly enlarged. Compared to the previous tracing of earlier the same daythe inferior ST segment elevations may be slightly less prominent but remainconcerning for ongoing ischemia and the ventricular rate is faster.TRACING #1 SINGLE PORTABLE AP VIEW OF THE CHEST: In comparison to the prior exam, there is no significant change. No MVP. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Clinicalcorrelation is suggested. 9:47 PM KNEE (AP, LAT & OBLIQUE) RIGHT PORT Clip # Reason: chondrocalcinosis? | 15 | [
{
"category": "Echo",
"chartdate": "2114-08-08 00:00:00.000",
"description": "Report",
"row_id": 72622,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. STEMI\nHeight: (in) 64\nWeight (lb): 165\nBSA (m2): 1.80 m2\nBP (mm Hg): 117/54\nHR (bpm): 56\nStatus: Inpatient\nDate/Time: at 10:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. IVC dilated (>2.1cm)\nwith <50% decrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Moderate regional LV systolic dysfunction. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\ninferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;\nseptal apex - hypo; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\nProminent moderator band/trabeculations are noted in the RV apex.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Resting\nbradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. The\nestimated right atrial pressure is at least 15 mmHg. Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nThere is moderate regional left ventricular systolic dysfunction with severe\nhypokinesis to akinesis of the inferior, inferolateral, and inferoseptal\nwalls. The right ventricular cavity is dilated with severe global free wall\nhypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild to\nmoderate (+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Regional wall motion abnormalities c/w inferior/RV myocardial\ninfarction. Right ventricular dilation and severe dysfunction. Moderate\ntricuspid regurgitation. Mild pulmonary hypertension. Mild-to-moderate mitral\nregurgitation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-10 00:00:00.000",
"description": "Report",
"row_id": 171915,
"text": "Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left axis\ndeviation. There are Q waves in the inferior leads consistent with myocardial\ninfarction. There is a late transition with small R waves in the anterior\nleads consistent with possible myocardial infarction. Non-specific ST-T wave\nchanges. Compared to the previous tracing of ST segment elevation in\nthe inferior leads is less but still persists.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-09 00:00:00.000",
"description": "Report",
"row_id": 171916,
"text": "Sinus rhythm. Acute inferior myocardial infarction with persistent ST segment\nelevations inferiorly and ST segment depressions in the high lateral leads.\nAnteroseptal myocardial infarction of indeterminate age. Borderline low\nvoltage. Compared to the previous tracing of earlier the same day the\nventricular rate is slower and P waves are more easily identified.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-09 00:00:00.000",
"description": "Report",
"row_id": 171917,
"text": "Baseline artifact marring interpretation of rhythm but probable low amplitude\nP waves consistent with sinus tachycardia and ventricular premature complexes.\nAcute inferior wall myocardial infarction with evidence of persistent\nST segment elevations inferiorly and ST segment depressions in the high lateral\nleads. Prior anteroseptal myocardial infarction of indeterminate age.\nBorderline low voltage. Compared to the previous tracing of earlier the same\nday clearly identified P waves are less easily identified.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-08 00:00:00.000",
"description": "Report",
"row_id": 171918,
"text": "Sinus tachycardia. Acute inferior wall myocardial infarction with ST segment\ndepressions in high lateral leads. Probable prior anteroseptal myocardial\ninfarction of indeterminate age. Borderline low voltage. Compared to the\nprevious tracing of earlier the same day the ventricular response rate is\nmarkedly faster and the inferior ST segment elevations are more pronounced.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-08 00:00:00.000",
"description": "Report",
"row_id": 171919,
"text": "Accelerated junctional rhythm at 62 beats per minute. Left axis deviation.\nIntraventricular conduction delay. Inferior myocardial infarction with\npersistent ST segment elevations concerning for ongoing ischemia. Clinical\ncorrelation is suggested. Probable prior anteroseptal myocardial infarction of\nindeterminate age. Compared to the previous tracing of earlier the same day\nthe inferior ST segment elevations may be slightly less prominent but remain\nconcerning for ongoing ischemia and the ventricular rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-08 00:00:00.000",
"description": "Report",
"row_id": 171920,
"text": "Junctional rhythm. Inferior myocardial infarction with ST segment elevtions,\nlikely acute. Myocardial infarction of indeterminate age. Compared to\ntracing #3 R waves in leads V4-V6 are less pronounced.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-12 00:00:00.000",
"description": "Report",
"row_id": 171914,
"text": "Sinus rhythm with P-R interval prolongation. Left axis deviation with left\nanterior fascicular block, Baseline artifact. Low amplitude P waves. Q waves\nin leads III and aVF are consistent with prior inferior wall myocardial\ninfarction. Poor anterior R wave progression is consistent with prior\nanteroseptal myocardial infarction. Compared to the previous tracing of \nthe rate is slower. Non-specific inferolateral repolarization abnormalities are\nimproved in the lateral limb leads and flatter in the inferior and left\nprecordial leads. Previously described inferior ST segment elevations are mucgh\nless apparent.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-08 00:00:00.000",
"description": "Report",
"row_id": 172136,
"text": "Extensive baseline artifact precludes rhythm determination. Acute inferior wall\nmyocardial infarction with ST segment elevation. Compared to tracing #2 delayed\nR wave progression in leads V2-V3 persists. R waves awre now present in\nleads V4-V6. Consider anteroseptal myocardial infarction of indeterminate age.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-07 00:00:00.000",
"description": "Report",
"row_id": 172137,
"text": "Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\nmyocardial infarction with ST segment elevation may represent acute myocardial\ninfarction. Extensive anterior wall myocardial infarction, age indeterminate\nHowever, there could be right-sided chest leads submitted.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2114-08-07 00:00:00.000",
"description": "Report",
"row_id": 172138,
"text": "Junctional rhythm. Non-specific intraventricular conduction delay. Inferior\nmyocardial infarction with ST segment elevation may represent acute\nmyocardial infarction. Anterior wall myocardial infarction, age indeterminate.\nProlonged Q-T interval. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-10 00:00:00.000",
"description": "RP KNEE (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1255089,
"text": " 9:47 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: chondrocalcinosis?\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CPPD crystals in right knee\n REASON FOR THIS EXAMINATION:\n chondrocalcinosis?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with known CPPD crystal\n deposition in the right knee.\n\n COMPARISON: No prior studies available for comparison.\n\n Three views of the right knee were reviewed.\n\n There is no evidence of fracture, lytic or sclerotic lesions or dislocation.\n Linear calcifications in both lateral and medial menisci of the knee are\n noted, consistent with CPPD. There is mild osteopenia. There are diffuse\n minimal degenerative changes noted. There is most likely small suprapatellar\n effusion present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254799,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with inferior STEMI\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with inferior STEMI. Evaluate for interval\n change.\n\n COMPARISON: at 20:20.\n\n SINGLE PORTABLE AP VIEW OF THE CHEST: In comparison to the prior exam, there\n is no significant change. Heart is mildly enlarged. Lung volumes are again\n low. There is no overt sign of pneumonia or pulmonary edema. No large\n effusion or pneumothorax is seen. An opacity in the right middle lobe which\n silhouettes the heart border and may represent pneumonia in the correct\n clinical setting, however it is likely atelectasis given the low lung volumes.\n A new right IJ line terminates in the high SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254893,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New pleural effusion?\n Admitting Diagnosis: NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with Inferior MI s/p PCI with BMS\n REASON FOR THIS EXAMINATION:\n New pleural effusion?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pleural effusions.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No visible pleural effusions. Unchanged moderate cardiomegaly with\n signs of minimal fluid overload and bilateral areas of atelectasis. Unchanged\n venous introduction sheath in the right internal jugular vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254775,
"text": " 10:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80F with ? CHF, AMI\n REASON FOR THIS EXAMINATION:\n r/o CHF\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: None.\n\n CLINICAL HISTORY: 80-year-old female with CHF, question acute intrathoracic\n process.\n\n FINDINGS: AP portable upright chest radiograph obtained. The heart is mildly\n enlarged. Lung volumes are low. There is no overt sign of pneumonia or\n pulmonary edema. No large effusion or pneumothorax seen. Mediastinal contour\n appears normal. Bony structures intact, though high-riding right humeral head\n suggests chronic rotator cuff injury.\n\n IMPRESSION: Mild cardiomegaly. Otherwise, normal.\n\n\n"
}
] |
8,184 | 157,949 | Pursuant with management and plan the patient was admitted to the Trauma CICU where the oral maxillofacial surgery service was consulted for repair of this patient's fracture. The OMFS Service saw the patient shortly after his admission to the and their impression was that this 26 year-old patient should be started on intravenous Clindamycin at 600 mg q 8 hours. Also he should be given Peridex 15 cc swish and spit b.i.d. Pertaining to the operative management they suggested that the patient would require an open reduction and internal fixation of his LeFort 1 fracture. Consultation with ophthalmology was also recommended due to the patient's periorbital swelling. Pursuant to this recommendation, ophthalmology was consulted and on hospital day one they commented that there were no clinical signs of entrapment, although it was difficult to assess vision or voluntary mobility of the eyes due to the patient's mental status. There was no evidence of intraorbital injury per the examination by the ophthalmologist and no signs of compartment syndrome. Their recommendation was for lubrication to the eyes to prevent exposure injury. On hospital day two the OMFS Service commented that per their operative plan the patient would be taken to the Operating Room on hospital day three for open reduction and internal fixation of his facial fracture. Preoperative laboratories and workup were completed and the patient was cleared for this procedure. While in the CICU the patient remained intubated in light of his impending procedure and for protection of his airway in light of his facial fracture. The patient continued to be dosed with intravenous Clindamycin per the recommendation of the OMFS team and the patient continued to be afebrile with stable vital signs. On hospital day three the patient was taken to the Operating Room by the Oral Maxillofacial Surgery Service where an open reduction and internal fixation was performed on the patient's LeFort 1 fracture. This procedure was performed without complications with an estimated blood loss of 200 cc and an intraoperative urine output of 900 cc. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit in stable condition. On postoperative day one as the patient continued to do well and his mental status had continued to be awake, alert and the patient was extubated, the patient was transferred out of the Surgical Intensive Care Unit where his continuing complaints were mild swelling of his face bilaterally, which was being treated postoperatively with intravenous steroids. Cranial nerve examination postoperatively was intact as far as cranial nerve V in the V - II distribution and the patient was started on a po diet consisting of a blenderized diet. On postoperative day two the patient continued to have mild swelling of his face bilaterally, but his nerve examination remained intact and the patient was tolerating a reasonable po diet. On postoperative day three as the patient continued to do well and was cleared for discharge by the Oral Maxillofacial Surgery Service the patient was discharged with prescriptions for Clindamycin to continue until follow up with OMFS as well as appropriate pain medication consisting of Roxicet elixir. The patient's steroids were discontinued after discussion with the Oral Maxillofacial Surgery Service as the patient's swelling had decreased significantly and the intravenous steroids were no longer necessary to control postoperative swelling. | Pt requests to be suctioned.GI: Pt c/o nausea X1, resolved spontaneously. RUA IV infiltrated, pt with 2 patent #18 IVs in L arm.Resp: Pt changed to PSV this AM, tolerating well with adequate ABGs. Mouth/nose oozes serous type drainage.Endo-no issues,ID-temp. K 4.1/MG 1.7->REPLETEDR: STABLE ABG ON PSV. RETURNED INTUBATED/SEDATED/VENTED. Pt remains NPO, abd soft with good BS throughout.GU/renal: Good u/o via foley catheter. Pt to remain NPO, pepcid started for prophylaxis.GU/renal: Large u/o via foley catheter, brisk diuresis. Keep pt updated on plan of care, offer support, reassurance.R: As above, 2mg ativan IVP with fair-good effect. CONT FROM PREVIOUS NSG ENTRY..CV: MG 1.8-REPLETED. Back intact, collar care provided.Endo: RISS, no coverage required.ID: Low grade temps today, IV Clinda for facial fx.Social; father by anesthesia this AM for consent, aware pt is doing well and plans for OR this PM. PT C/O NAUSEA X1 AND RESOLVED WITHOUT MED. Pt was sedated and returned to . C/O FACIAL/JAW PAIN-->MEDICATED WITH MSO4 PRN WITH EFFECT. CV: SR no ectopy, BP stable via right radial aline.GU: >150/hr. CLEARS BILAT WITH SXN'NG. 7:52 AM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: s/p mvc. Pt appears calm and comofortable on MSO4 PRN and propofol gtt. Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BP stable via A-line. Pt arrived to without C-collar, placed disposible collar in ER and changed to J on arrival to SICU. WILL ATTEMPT TO CLEAR NECK TODAY PRIOR TO OR.CV: HD STABLE. Abd softly distended, hypoactive BS throughout. REC'D 1.5L IVF, 900U/O, 200EBL, AND CA/MG REPLETED. Pt given 2gm mag sulfate for mag 1.2; set of obscure labs this AM repeatd and WNL.Endo: SSI, no coverage requiredSkin: Multiple lacerations to face- deep chin lac on L side of face irrigated and sutured at bedside with other smaller check laceration, Lip lacs sutured in ER. CONT ON IV DECADRON FOR AIRWAY EDEMA.GI: ABD SOFT/DISTENDED WITH HYPO BS. Pt started on SC heparin.Resp: Pt remains intubatd for airway protection with #7 tube at 22 lip line. r/o acute process No contraindications for IV contrast WET READ: PSLa MON 8:48 AM aspiration vs. atelectasis, no acute abdominal process FINAL REPORT INDICATION: Status post MVC high speed. Pt with question of siezure activity when he became light, taken for stat head CT which was negative for bleed/contusion. Nursing Progress NoteS/ pt has been stable throughout the shift, has required suctioning q1 hour by his request for small to mod amts of thin tan sputum. NPNN: PT ALERT/APPROPRIATE/NEURO INTACT. Endo: BS 130's Skin: Grossly intact, sutures at chin/lip intact. CLINDA ATC.ENDO: GLUC 130'S NOT REQUIRING SS COVERAGE.SOC: BROTHER IN VISITING/UPDATED.A/ HD STABLE S/P ORIF FACIAL FX'S.P/ PLAN TO EXTUBATE IF NO AIRWAY EDEMA PRESENT. TLS films completed today, negative per Dr. and logroll precautions d/c'd. decreased, rel clear bilat. WBC 15.5/CLINDA ATC.ENDO: GLUC 132SOC: NO CONTACT WITH FAMILY OVERNIGHT.A/P: STABLE/AWAITING REDUCTION IN NECK SWELLING WITH ASSIST OF DECADRON, CLEAR NECK PRIOR TO OR TODAY. Pt is intubated at this time. TECHNIQUE: Helically acquired contiguous axial images were obtained from the thoracic inlet to the pubic symphysis after the administration of intravenous contrast. LUNGS CLEAR THROUGHOUT SL DIM AT BASES. Pulm:PS settings being tolerated well, lungs clear bilaterally, rr even/unlabored. Pt noted to have +u/a, repeat u/a and cultures sent this PM with MRSA screen. Pt tolerating MSO4 5mg Q2-4 hours PRN for jaw/facial pain.CV: Stable, HR 60-90, no VEA. intubated.o. Hct noted to have sl drop, likely dilutional rresult. Corneals and cough present, gag not checked due to facial fractures.CV: Stable, HR 80-100's, no ectopy noted. Pt remained stable and was vented on IMV. Propofol turned off for neuro exam this AM, has been off ever since with PRN morphine for pain.ROS:Neuro: Pt very calm and appropriate off of propofol today. Pt has been given MSO4 5mg x3 to keep pt comfortable.A/ pt to OR, will return here for post-op care. REMAINS SEDATED ON PROPOFUL OVERNIGHT.CV: NSR 70-120'S WITH COUGHING. K+4.0R: LUNGS OCC COURSE THROUGHOUT. SXN'D PER PT REQUEST FOR SCANT AMTS THICK YELLOW.GI: NPO. c/o pain occasionally, medicated with MS04 with good effect.Resp-no vent changes during night, pt. Pt remains on IMV, 12X700, 40% with 5PEEP, ABGs adequate.GI: OGT placed on arrival to ICU, to LWS with dk red/black drainage. REASON FOR THIS EXAMINATION: s/p mvc. OGT D/C'D IN OR/NOT REPLACED. Pt requesting frequent oral/ett suction with scant return, sats >97%. NPNEVENT: RETURNED FROM OR S/P ORIF OF FACIAL FX'S 8:45PM NASALLY INTUBATED WITH 6.5 ETT (SUTURED TO LEFT NARE). small laceration on left chin is dry, oovered with DSD. NO COMPLICATIONS REPORTED.N: LIGHTENED FROM PROPOFUL GTT AND FC'S CONSISTENTLY. Good ABG's.GI/GU=NPO, BS present, no stool or flatus. AddendumPt returned from OR withoutstabilization of his facial fractures, they were unable to nasally intubate him, decadron given and ordered q8. Please see carevue for further vent inqueries. Stable BP 130-150/sys. MEDICATED WITH MSO4 PRN FOR PAIN WITH EFFECT. Plan to wean and extubate once pt goes to OR. ETT retaped on arrival to SICU. Neuro: A&O, no deficits noted. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal glands and unopacified loops of bowel are normal. They appeared appropriately worried about pt. Continue sedation and pain control. LR WITH THIAMINE/FOLATE/MVI AT 50CC/HR.GU: BRISKLY AUTODIURESING CLEAR YELLOWHEME: HCT 34. LR decreased to 50cc/hr, pt still with good u/o. Will f/u with family, pt tomorrow.A: Stable s/p MVC with significant facial injuriesP: Keep pt intubated and sedated until taken to OR for repair of facial fractures. | 15 | [
{
"category": "Radiology",
"chartdate": "2107-01-17 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 780407,
"text": " 7:52 AM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: s/p mvc. r/o acute process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p high speed unrestrained mvc.\n REASON FOR THIS EXAMINATION:\n s/p mvc. r/o acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa MON 8:48 AM\n aspiration vs. atelectasis, no acute abdominal process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC high speed.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet to the pubic symphysis after the administration of intravenous\n contrast.\n\n CONTRAST: 150 cc of Optiray was administered per trauma protocol.\n\n CHEST CT WITH INTRAVENOUS CONTRAST: There is no significant axillary,\n mediastinal, or hilar lymphadenopathy. The heart and great vessels are normal\n in appearance. The airways are patent as well as the segmental bronchi\n bilaterally. An ET tube is present within the trachea. There are bilateral\n lower lobe consolidations. The remainder of the lungs are clear. There are\n no pleural effusions. There is no pericardial effusion.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n pancreas, adrenal glands and unopacified loops of bowel are normal. The\n kidneys enhance symmetrically and excrete normally. There is no significant\n abdominal adenopathy. There is no free fluid or free air within the abdomen.\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters and urinary\n bladder are unremarkable. The intrapelvic bowel loops are unremarkable.\n\n The osseous structures are normal. No fractures are identified.\n\n IMPRESSION:\n 1) There are increased opacities at the lung bases bilaterally consistent\n with probable aspiration or atelectasis.\n 2) No acute intraabdominal process is identified.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-17 00:00:00.000",
"description": "Report",
"row_id": 1370969,
"text": "SOCIAL WORK NOTE:\n\nNew trauma pt on T-SICU. Pt is s/p MVC as unrestrained driver of car vs. cement barrier. Pt is a 26 year old single Caucasian man who lives in with his father, . Pt has a brother and sister. Pt does landscaping work. He is not involved in a dating relationship. Pt transferred here from Hospital for management of facial fractures. Pt is intubated at this time. Pt's etoh level at time of testing at this hospital was 20 and was reportedly higher at OSH. Pt's tox screen at OSH was also + for marijuana.\n\nEarlier, Police were present but have since left hospital. This SW called Police () to clarify pt's legal status. Police officer I spoke with stated that pt was initially arrested but now released to his father's custody and will receive information by mail about citation related to accident (suspected of drunk driving by police). This does not affect his ability to have visitors or his discharge.\n\nThis SW met pt's father and brother, both named , to introduce self, offer support, and gather information. They were not unpleasant but not easily engaged. They appeared appropriately worried about pt. They said that pt drinks \"heavily but not alone\" and they did seem concerned about his substance use. This issue can be explored further later in pt's hospitalization. Family given contact information for this SW and I remain available as needed. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-17 00:00:00.000",
"description": "Report",
"row_id": 1370970,
"text": "SICU Admit note\nPt is a 26 yr old gentleman admitted to from an OSH s/p MVC. Pt was the driver of a single car accident, car vs. cement wall. Pt was initally awake and alert, taken to OSH where he was noted to have significant facial fractures, was intubated for airway protection and sent to . Pt's tox screen was + for ETOH and marijuana. On arrival, pt was placed into a C-collar for cervical protection, scans reviewed and pt brought to SICU for care.\nShortly after arrival to SICU, pt noted to have ?siezure activity, taken to stat head CT scan (was negative for bleed/contusion) and also had TLS films completed. Optho and OMFS in to eval pt, ?plan for OR to repair 1 fracture with R mildly medially displaced zygomatic-maxillary complex fractures when OMFS available.\n\nPMH: none\nMeds PTA: denies\n**Drinks <6 beers a day, social marijuana***\n\nROS\nNeuro: Pt brought to SICU chemically paralyzed and sedated. Pt with question of siezure activity when he became light, taken for stat head CT which was negative for bleed/contusion. Pt arrived to without C-collar, placed disposible collar in ER and changed to J on arrival to SICU. TLS films completed today, negative per Dr. and logroll precautions d/c'd. Pt with pupils 2mm and brisk most of day, pupils were dilated at 1430 this afternoon for Optho exam. No further siezure activity noted this PM, no dilantin required. Pt appears calm and comofortable on MSO4 PRN and propofol gtt. Corneals and cough present, gag not checked due to facial fractures.\n\nCV: Stable, HR 80-100's, no ectopy noted. BP stable, SBP 100-150's. Extremities warm and well perfused, easily palpable pulses. Pt arrived to SICU with 2 periph IVs in place, 3rd placed in SICU. A-line placed on arrival, also. Hct noted to have sl drop, likely dilutional rresult. Pt started on SC heparin.\n\nResp: Pt remains intubatd for airway protection with #7 tube at 22 lip line. ETT retaped on arrival to SICU. Lungs coarse throughout, dimished at bilateral bases. Pt with obvious aspiration of blood, suctioned Q1-2 hours for thick, thick dk red blood. Pt remains on IMV, 12X700, 40% with 5PEEP, ABGs adequate.\n\nGI: OGT placed on arrival to ICU, to LWS with dk red/black drainage. Abd softly distended, hypoactive BS throughout. Pt to remain NPO, pepcid started for prophylaxis.\n\nGU/renal: Large u/o via foley catheter, brisk diuresis. LR decreased to 50cc/hr, pt still with good u/o. Pt given 2gm mag sulfate for mag 1.2; set of obscure labs this AM repeatd and WNL.\n\nEndo: SSI, no coverage required\n\nSkin: Multiple lacerations to face- deep chin lac on L side of face irrigated and sutured at bedside with other smaller check laceration, Lip lacs sutured in ER. Small abrasions/laceration noted on medial apsect of R knee\n\nID: Pt on Clinda for facial fracture coverage. Pt noted to have +u/a, repeat u/a and cultures sent this PM with MRSA screen. Tmax 100.4.\n\nSocial: father and brother, both named , in to visit this PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-17 00:00:00.000",
"description": "Report",
"row_id": 1370971,
"text": "SICU Admit note\n(Continued)\n When pt arrived from ER, was under police custody. Pt is no longer under their custody now, does not require sitters or police guard. Social work consulted, also for pt's history of ETOH and Marijuana use. Will f/u with family, pt tomorrow.\n\nA: Stable s/p MVC with significant facial injuries\n\nP: Keep pt intubated and sedated until taken to OR for repair of facial fractures. Closely monitor resp status, WBCs, temp curve due to likely aspiration of blood. Closley observe pt for signs/symptoms of withdrawal due to ETOH and Marijuana use. Plan to wean and extubate once pt goes to OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-20 00:00:00.000",
"description": "Report",
"row_id": 1370981,
"text": "CONT FROM PREVIOUS NSG ENTRY..\nCV: MG 1.8-REPLETED. K+4.0\nR: LUNGS OCC COURSE THROUGHOUT. CLEARS BILAT WITH SXN'NG. REQUIRED SXN FOR SM AMTS THICK YELLOW SEC. WHEN AWAKE, PERSISTENTLY COUGHING WITH VERY SENSITIVE GAG REFLEX. SIMV 14X600, PEEP 5, 50%. CONT ON IV DECADRON FOR AIRWAY EDEMA.\nGI: ABD SOFT/DISTENDED WITH HYPO BS. OGT D/C'D IN OR (D/T MIN OUTPUT) RECEIVING LR @ 50CCHR WITH MVI/THIAMINE/FOLATE/KCL 40MEQ/L.\nGU: URINE OUTPUT CLEAR YELLOW 50-70CC/HR.\nHEME: HCT 30\nID: LOW GRADE TEMPS. WBC 16. CLINDA ATC.\nENDO: GLUC 130'S NOT REQUIRING SS COVERAGE.\nSOC: BROTHER IN VISITING/UPDATED.\nA/ HD STABLE S/P ORIF FACIAL FX'S.\nP/ PLAN TO EXTUBATE IF NO AIRWAY EDEMA PRESENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-20 00:00:00.000",
"description": "Report",
"row_id": 1370982,
"text": "SOCIAL WORK NOTE:\nPt likely to be able to transfer out to floor soon. This SW met with pt briefly this morning to offer support. Pt was drowsy. He engaged pleasantly but was not able to do so at length. Pt still needs f/u about etoh and marijuana use (+ at time of accident). This SW will continue to check-in or will refer to floor SW as necessary. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-18 00:00:00.000",
"description": "Report",
"row_id": 1370975,
"text": "Nursing Progress Note\nS/ pt has been stable throughout the shift, has required suctioning q1 hour by his request for small to mod amts of thin tan sputum. pt family in to visit, he is awake and alert and communicating by notes. pt moving all extrems equally. Consent was signed by his father with his knowledge. Pt has been given MSO4 5mg x3 to keep pt comfortable.\nA/ pt to OR, will return here for post-op care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-18 00:00:00.000",
"description": "Report",
"row_id": 1370976,
"text": "Addendum\nPt returned from OR withoutstabilization of his facial fractures, they were unable to nasally intubate him, decadron given and ordered q8. Pt was sedated and returned to . Pt remained stable and was vented on IMV. Pt family was notified by surgeon.\nA/P pt is to go to MRI for cervical neck clearance and to OR at 3PM\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-19 00:00:00.000",
"description": "Report",
"row_id": 1370977,
"text": "NPN\nN: PT ALERT/APPROPRIATE/NEURO INTACT. MEDICATED WITH MSO4 PRN FOR PAIN WITH EFFECT. C/O \"WANTING TO SLEEP\"--RESTLESS/AGITATED--> STARTED LOW DOSE PROPOFUL GTT OVERNIGHT. WILL ATTEMPT TO CLEAR NECK TODAY PRIOR TO OR.\nCV: HD STABLE. K 4.1/MG 1.7->REPLETED\nR: STABLE ABG ON PSV. LUNGS CLEAR THROUGHOUT SL DIM AT BASES. SXN'D PER PT REQUEST FOR SCANT AMTS THICK YELLOW.\nGI: NPO. OGT D/C'D IN OR/NOT REPLACED. PT C/O NAUSEA X1 AND RESOLVED WITHOUT MED. LR WITH THIAMINE/FOLATE/MVI AT 50CC/HR.\nGU: BRISKLY AUTODIURESING CLEAR YELLOW\nHEME: HCT 34. COAGS NL.\nID: AFEBRILE. WBC 15.5/CLINDA ATC.\nENDO: GLUC 132\nSOC: NO CONTACT WITH FAMILY OVERNIGHT.\nA/P: STABLE/AWAITING REDUCTION IN NECK SWELLING WITH ASSIST OF DECADRON, CLEAR NECK PRIOR TO OR TODAY. EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-19 00:00:00.000",
"description": "Report",
"row_id": 1370978,
"text": "D: Pls see careview assessment/data. Neuro: A&O, no deficits noted. Pt expressing anxiety, wanting to be \"knocked out\" until surgery. Pulm:PS settings being tolerated well, lungs clear bilaterally, rr even/unlabored. Pt requesting frequent oral/ett suction with scant return, sats >97%. CV: SR no ectopy, BP stable via right radial aline.\nGU: >150/hr. GI: No n/v, abd soft, +bs. Endo: BS 130's Skin: Grossly intact, sutures at chin/lip intact. scattered scrapes/lacs open to air. Peripheral pulses 4+. Surgical team in on rounds, please see orders.\n\nP: Continue full support. keep npo for surgery this afternoon, Ativan prn for anxiety. Keep pt updated on plan of care, offer support, reassurance.\n\nR: As above, 2mg ativan IVP with fair-good effect. Pt with call light in hand.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-19 00:00:00.000",
"description": "Report",
"row_id": 1370979,
"text": "D: Pt remains a&o, cooperative and calm. OR scheduled for approx 1530. Pt aware of and agreeable to same.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-20 00:00:00.000",
"description": "Report",
"row_id": 1370980,
"text": "NPN\nEVENT: RETURNED FROM OR S/P ORIF OF FACIAL FX'S 8:45PM NASALLY INTUBATED WITH 6.5 ETT (SUTURED TO LEFT NARE). REC'D 1.5L IVF, 900U/O, 200EBL, AND CA/MG REPLETED. RETURNED INTUBATED/SEDATED/VENTED. NO COMPLICATIONS REPORTED.\n\nN: LIGHTENED FROM PROPOFUL GTT AND FC'S CONSISTENTLY. C/O FACIAL/JAW PAIN-->MEDICATED WITH MSO4 PRN WITH EFFECT. ANXIOUS/AGITATED WITH NASAL ETT, PERSISTENTLY COUGHING/GAGGING->GIVEN ATIVAN 2MG X1 WITH EFFECT. REMAINS SEDATED ON PROPOFUL OVERNIGHT.\nCV: NSR 70-120'S WITH COUGHING. SBP 100-190/ HYPERTENSIVE TRANSIENTLY WITH COUGHING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-18 00:00:00.000",
"description": "Report",
"row_id": 1370972,
"text": " 7p-7a Nursing Progress Note\n\ns. Pt. intubated.\n\no. C-V=NSR 70-90's,no VEA. Stable BP 130-150/sys. Strong palpable pedal pulses. peripheral IV's only. Right radial A-line. LR at 50cc/hr.\n\nNeuro=Able to follow commands through Propofol at 20-30mcg/. Squeezes hands, shows fingers, wiggles toes, nods head yes/no. Opens eyes spontaneously and to commands. Gags on ETT, great strong cough. Pupils are PERLA, 3mm. c/o pain occasionally, medicated with MS04 with good effect.\n\nResp-no vent changes during night, pt. pre-op today. Continues on SIMV at 12/700/40%/5PEEP, 02 sats 98-100%. occasionally breathes over vent. Suctioned for thick brown secretions, BS clear but diminished, R>L. Good ABG's.\n\nGI/GU=NPO, BS present, no stool or flatus. NG tube draining coffee-brown secretions. Foley draining ~60cc/hr.\n\nSkin-laceration on right knee, dry crusty blood covers it. small laceration on left chin is dry, oovered with DSD. Mouth/nose oozes serous type drainage.\n\nEndo-no issues,\n\nID-temp. 100.8, on Clindamycin\n\nSocial-Dad called during evening, Dr. was to call him re:surgery.\n\nA.- stable night, sedated on Propofol and MS04.\n\nP.-Pre-op for later this evening. Continue sedation and pain control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-18 00:00:00.000",
"description": "Report",
"row_id": 1370973,
"text": "Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BS sl. decreased, rel clear bilat. Not req freq sx'ing by RT. Changed to PSV. ABG WNL. Plan to go back to OR for facial . Please see carevue for further vent inqueries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-01-18 00:00:00.000",
"description": "Report",
"row_id": 1370974,
"text": "SICU NPN\nPt remains intubated and vented in the SICU awaiting surgery for his facial fractures. Propofol turned off for neuro exam this AM, has been off ever since with PRN morphine for pain.\n\nROS:\nNeuro: Pt very calm and appropriate off of propofol today. Pt alert and oriented X3 by writing, asking appropriate questions. Pt follows commands, MAE with good strength. C-collar remains on, pt denies any neck pain/tenderness. Pt tolerating MSO4 5mg Q2-4 hours PRN for jaw/facial pain.\n\nCV: Stable, HR 60-90, no VEA. BP stable via A-line. Pulses easily palpable. RUA IV infiltrated, pt with 2 patent #18 IVs in L arm.\n\nResp: Pt changed to PSV this AM, tolerating well with adequate ABGs. RR 12-18, sats 100% all day. Pt requires suctioning Q2-3 hours for thick, yellowish rusty sputum. Pt requests to be suctioned.\n\nGI: Pt c/o nausea X1, resolved spontaneously. OGT draining small ammts green/dk red output. Pt remains NPO, abd soft with good BS throughout.\n\nGU/renal: Good u/o via foley catheter. Pt rec'd 10 MEq KCL this AM. LR at 50cc/hr.\n\nSkin: facial lacs approximated well with sutures, bacitracin ointment applied. R leg abrasion scabbed over. Back intact, collar care provided.\n\nEndo: RISS, no coverage required.\n\nID: Low grade temps today, IV Clinda for facial fx.\n\nSocial; father by anesthesia this AM for consent, aware pt is doing well and plans for OR this PM. No other family contact.\n\nA: Stable s/p MVC with facial fractures\n\nP: Send pt to OR this PM for repair of facial fractures, plan to return to SICU post-op for extubation and airway monitoring.\n"
}
] |
41,024 | 164,431 | This is a 71 yo female with complicated medical including a stroke ~ 30 years ago with residual aphasia and right hemiparesis, chronic SDH bilaterally, afib off AC due to SDH, seizure disorder, and recurrent cycles of UTI/urosepsis (moraxella bacterimia) and C.Diff infections, who had her dilantin discontinued on , and was noted to develop decreased level of alertness and confusion at her NH 2 days PTA. She was diagnosed with a UTI however did not improve after one day of treatment and was thus transferred to OSH, then . She was initially admitted to the medicine service, where CFTX was stopped. A neurology service was consulted to determine whether patient was in NCSE. Her initial exam showed that she does not follow commands, eyes closed, eyes midline, mumbles with pain, and retracts both legs and arms L>R to noxious stimuli. Because the initial EEG showed signs concerning for NCSE, she was transferred to Neurology service for further monitoring and treatment on . Her baseline state includes (confirmed with NH staff): Awake, alert, interacting with staff (maintains eye contact) and answers in one word, often with intelligible sounds without reproducibly following directions with dense right sided hemiparesis requiring full assisstance with transfers and ADLs. | Fosphenytoin level still subtherapeutic at beginning of shift Remains on continuous EEG NGT in place with placement confirmed by xray per sicu resident +lg semiformed stool (on PO flagyl for cdiff until ) Action: Fosphenytoin re-bolused Response: unsure if seizure activity per EEG Plan: Fosphenytoin level still subtherapeutic at beginning of shift Remains on continuous EEG NGT in place with placement confirmed by xray per sicu resident +lg semiformed stool (on PO flagyl for cdiff until ) Pt receiving IV Hydralazine d/t usual antihypertensives SR and unable to crush Action: Fosphenytoin re-bolused Response: unsure if seizure activity per EEG Plan: Q2hr neuro Cont EEG Withdrawing to pain on right Hx a-fib in NSR 70-80s. Withdrawing to pain on right Hx a-fib in NSR 70-80s. Follow LFT medication, unclear etiology.h/o Cdiff - on flagyl, PO vanco. Withdrawing to pain on right Hx a-fib in NSR/ST 90-100s. D/W resident and versed drip titrated up for sedation this time not for seizure activity Plan: Q2hr neuro Cont EEG Versed drip for seizure control (as well as ETT comfort) Will restart - amlodipine, verapamil, lisinopril, hydral prn. Lansoprazole Oral Disintegrating Tab 18. Lansoprazole Oral Disintegrating Tab 18. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Keppra/Dilantin administered MD order. Pneumococcal Vac Polyvalent 23. Pneumococcal Vac Polyvalent 23. Administer Keppra/Dilantin MD order. Administer Keppra/Dilantin MD order. Administer Keppra/Dilantin MD order. Follow 24hr EEG Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril, hydral prn. Follow 24hr EEG Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril, hydral prn. Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Endocrine: DM. Endocrine: DM. Endocrine: DM. Endocrine: DM. + UTI s/p rx w/ ceftriaxone. + UTI s/p rx w/ ceftriaxone. + UTI s/p rx w/ ceftriaxone. LENI today Lines / Tubes / Drains: NGT, PIV, Picc Fluids: KVO Consults: Neuro Billing Diagnosis: Status epilepticus, seizures DVT: SQH Stress ulcer: PPI VAP bundle: + Communication: Code status:FULL Disposition:SICU to floor Lines: PICC Line - 02:55 PM Total time spent: 31 min Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. Follow LFT medication, unclear etiology. prior admit for B chronic SDH and acute parafalcine SDH. prior admit for B chronic SDH and acute parafalcine SDH. prior admit for B chronic SDH and acute parafalcine SDH. LENI today Lines / Tubes / Drains: NGT, PIV, Picc Fluids: KVO Consults: Neuro Billing Diagnosis: Status epilepticus, seizures DVT: SQH Stress ulcer: PPI VAP bundle: + Communication: Code status:FULL Disposition:SICU to floor Lines: PICC Line - 02:55 PM Total time spent: Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Right upper and lower extremities withdraw to noxsious stimuli (baseline). Since the previous tracingof sinus tachycardia is absent and further ST-T wave changes are seen. Keppra/Dilantin administered MD order. Persistent bibasilar nodular opacities and atelectasis which is again (Over) 8:09 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: please eval for intra-abd process FINAL REPORT (Cont) nonspecific. Administer Keppra/Dilantin MD order. Endocrine: DM. Endocrine: DM. Endocrine: DM. IMPRESSION: Initial nasogastric tube below the diaphragm, though subsequent radiograph shows absence of nasogastric tube. Identified now is a right-sided PICC line seen to terminate overlying the SVC at the level 2 cm below the carina. UTI with ceftriaxone. UTI with ceftriaxone. UTI with ceftriaxone. Renal: Recurrent UTI. Renal: Recurrent UTI. Renal: Recurrent UTI. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Atelectasis and nodular opacities in the lung bases persist unchanged from . The first 10:12 p.m. shows a nasogastric tube ending below the diaphragm with its tip not completely evaluated. In the left adnexa, there is either a 3.9cm exophytic fibroid with calcification or enlarged ovary (2:78). The patient has been extubated. FINDINGS: Grayscale, color and Doppler son of bilateral common femoral, superficial femoral, popliteal and tibial veins were performed. | 58 | [
{
"category": "Nutrition",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 712504,
"text": "Subjective: patient intubated and sedated. Patient resides in a\n nursing home and takes a regular diet with nectar thick liquids.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 91.5 kg\n 91.3 kg ( 12:00 AM)\n 35.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 52.2 kg\n 175%\n 62 kg\n Diagnosis: Changes in Mental Status\n PMHx: 1. stroke 30 years ago (? location-images not available) with\n residual right hemiparesis, dysarthria, and difficulty to express\n herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n 17. B/L cataract surgery\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Versed, Lantus, RISS, heparin, ABx, KCl, Phos\n and Mag repletions, dextrose 5% with 1/2 normal saline @ 75mL/hr,\n others noted\n Labs:\n Value\n Date\n Glucose\n 171 mg/dL\n 02:14 AM\n Glucose Finger Stick\n 111\n 10:00 AM\n BUN\n 20 mg/dL\n 02:14 AM\n Creatinine\n 0.8 mg/dL\n 02:14 AM\n Sodium\n 142 mEq/L\n 02:14 AM\n Potassium\n 2.8 mEq/L\n 02:14 AM\n Chloride\n 108 mEq/L\n 02:14 AM\n TCO2\n 23 mEq/L\n 02:14 AM\n PO2 (arterial)\n 207 mm Hg\n 05:17 AM\n PCO2 (arterial)\n 36 mm Hg\n 05:17 AM\n pH (arterial)\n 7.44 units\n 05:17 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 05:17 AM\n Calcium non-ionized\n 8.7 mg/dL\n 02:14 AM\n Phosphorus\n 2.8 mg/dL\n 02:14 AM\n Magnesium\n 1.7 mg/dL\n 02:14 AM\n ALT\n 181 IU/L\n 02:14 AM\n Alkaline Phosphate\n 118 IU/L\n 02:14 AM\n AST\n 97 IU/L\n 02:14 AM\n Total Bilirubin\n 0.5 mg/dL\n 02:14 AM\n Phenytoin (Dilantin)\n 16.8 ug/mL\n 07:33 AM\n WBC\n 9.3 K/uL\n 02:14 AM\n Hgb\n 11.4 g/dL\n 02:14 AM\n Hematocrit\n 36.3 %\n 02:14 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Replete with Fiber @ 50mL/hr (1200kcals, 74g protein)\n GI: abd soft/obese, hyperactive bowel sounds, brown liquid stool\n Assessment of Nutritional Status\n Obese\n Estimated Nutritional Needs\n Calories: 1240-1430 (20-23 cal/kg)\n Protein: 62-81 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Excessive\n Estimation of current intake: Adequate\n Specifics:\n 71 y.o. Female with h/o stroke and seizure disorder transferred from\n outside hospital from nursing home with low grade fever, agitation and\n increased seizure activity. Patient is currently intubated, sedated,\n with NGT in place. Tube feeds were just started and current goal meets\n protein needs but is slightly low on calories. Recommend slightly\n increasing tube feeding goal to better meet needs. Noted K, Phos and\n mag all being repleted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend change tube feeding goal to Replete with Fiber @\n 55mL/hr (1320kcals, 82g protein).\n Continue with lyte repletions.\n Adjust H20 flushes as needed to maintain hydration.\n Followig - #\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712745,
"text": "Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG . Pt intubated for airway\n protection d/t start of Midazolam gtt for seizure control.\n Midazolam gtt weaned overnoc and at 2mg/hr this mornine\n Intubated on CMV w/ FIO2@ of 40% Peep 10 RR 15 x500.\n Copious oral secretions\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR/ST 90-100s. SBP improved. Given\n Antihypertensive meds this am\n Continuous EEG per Neuro med w/o seizures\n NPO w/ NS w/ 40kcl @100cchr. u/o borderline adequate. 5L\n positive\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level overnoc corrected for Albumin and\n supra-therapeutic in 20s. Goal 18-20\n Action:\n Midazolam gtt stopped in preparation of waking pt up for\n extubation\n TF put on hold\n LFTs remain elevated. Hepatitis panel sent\n Suctioned for some tan sputum via ETT. Sputum cx pending\n Dilantin level prior morning dose supra-therapuetic and\n Phosphenytoin decreased to 150mg IV Q8hrs\n Head CT d/c\nd per \n IVF d/c\n Neuro checks Q2hrs\n Bilateral Lenis performed to r/o DVT d/t Bilateral LE pedal\n edema R>L\n Son at BS to visit mother and able to update\n Response:\n Pt more alert t/o day but falls asleep. Agitated w/\n stimulation. Good gag/cough\n Extubated at 1500. O2 sats stable on Face tent w/ FIO@ at\n 70%\n Pt needs to be encouraged to cough up secretions. Oral\n suction PRN.\n Not following commands. Some words comprehensible but most\n not. Hx of being combative in past w/ LUE\n Tolerating testart of TF and u/o\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Pt may go to neuro step down vs floor if continues to\n progress\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712405,
"text": "Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Action:\n Fosphenytoin re-bolused\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712409,
"text": "Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour\n Action:\n Fosphenytoin re-bolused\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712419,
"text": "Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour\n Action:\n Fosphenytoin re-bolused\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Response:\n unsure if seizure activity per EEG\n Plan:\n Q2hr neuro\n Cont EEG\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712422,
"text": "Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on versed drip pt gagging on ETT at first and now\n sedated so slightly withdraws and tries to reach for ETT with LUE\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\n until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n While agitated and tachycardic noted to have ~12 beat run of\n VT\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Response:\n unsure if seizure activity per EEG\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up and\n raising head off bed while LUE reached for ETT. D/W resident and versed\n drip titrated up for sedation this time not for seizure activity\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712423,
"text": "Seizure, with status epilepticus\n Assessment:\n No visibile seizure activity noted\n When not disturbed pt sleeps and does not move much\n spontaneously. Prior to intubation when stimulated pt yells out (speech\n garbled and difficult to understand) kicks with LLE, hits and pinches\n with LUE and tries to pull out NGT also tries to spit. Not following\n any commands. Right sided weakness-moves on bed. Left pupil\n surgical/cataract right pupil reactive. Does not open eyes to command.\n Once intubated on versed drip pt gagging on ETT at first and now\n sedated so slightly withdraws and tries to reach for ETT with LUE\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO vanco and IV flagyl for cdiff\n until )\n Pt receiving IV Hydralazine d/t usual antihypertensives SR\n and unable to crush\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n While agitated and tachycardic noted to have ~12 beat run of\n VT\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status)\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Response:\n unsure if seizure activity per EEG\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up and\n raising head off bed while LUE reached for ETT. D/W resident and versed\n drip titrated up for sedation this time not for seizure activity\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712566,
"text": "Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\n borderline overnoc w/ increase in Midazolam gtt to control seizures\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\n Intubated on CMV w/ FIO@ of 40% Peep 10 RR 15 x500. Copious\n oral secretions\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\n Continuous EEG per Neuro med w/ seizures per hour this\n am\n NPO w/ D5\n @75cchr. u/o borderline in the 20\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n K- level 2.8\n Action:\n Midazolam gtt increased to 8mg/hr per Neuromed. KCL repleted\n Dilantin level therapeutic w/ Albumin calculation this\n morning >20\n Fosphenytoin 150mg IV Q8hrs\n Attending at BS this morning to eval EEG and placed CT on\n hold\n Neuro checks Q2hrs\n NS bolus of 250cc for low u/o. IVG changed to NS w/ 40KCL w/\n increased rate of 100cc/hr\n Replete w/ fiber started via left NGT. Titrating to goal of\n 55cc/hr\n Response:\n Repeat Dilantin level sub-therapeutic and Fospheytion\n increased to 250mg IV Q8\n Midaz gtt continues at 8mg/hr. Pt now opening eyes\n intermittently to stimulation and continues to purposely go for ETT\n U/o remains still in 20\n Son updated by SICU\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"
},
{
"category": "Physician ",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 712490,
"text": "SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\n epilepsy. She was admitted here in due to prolonged seizures in\n the setting of low Dilantin level and infection (C.diff) and discharged\n on Dilantin and Keppra (750 mg ).\n Two days before her current admission, she had neurosurgical follow up\n for a chronic subdural hematoma, which had resolved. Therefore, she was\n advised to stop her Dilantin. The patient was then admitted to the\n medicine department two days ago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for the UTI, an EEG was performed yesterday\n (), which showed frequent electrographic seizures, originating in\n the right centro-parietal area. She was reloaded with Dilantin and\n Lorazepam was given intermittently, but she continued to have seizures\n overnight, up to 12 an hour. Clinically, she remained marginally\n responsive and rarely had events of gaze deviation to the left which\n were suggestive of seizure activity. She was transferred today to the\n ICU for frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ treatment, in\n case she fails to respond to other anticonvulsants\n Chief complaint:\n Statis epilepticus, UTI, Cdiff\n PMHx:\n PMH:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n .\n PSH:\n bilateral cataract surgery\n Current medications:\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\n Scale Order date: @ 1656\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\n DRIP INFUSION Patient must have adequate airway support prior to\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\n for K > 4 Order date: @ 1652\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\n 24 Hour Events:\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n INTUBATION - At 01:19 AM\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\n Still w//seizures/hr. Intubated in order to start versed to help\n break seizures.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:23 PM\n Vancomycin - 10:23 PM\n Metronidazole - 11:46 PM\n Infusions:\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Hydralazine - 11:46 PM\n Lorazepam (Ativan) - 04:05 AM\n Fosphenytoin - 04:05 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 35.8\nC (96.5\n HR: 91 (76 - 130) bpm\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\n RR: 16 (10 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Total In:\n 458 mL\n 440 mL\n PO:\n Tube feeding:\n IV Fluid:\n 458 mL\n 440 mL\n Blood products:\n Total out:\n 735 mL\n 175 mL\n Urine:\n 735 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n -278 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SPO2: 100%\n ABG: ///23/\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\n sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 171 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 142 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 12:42 AM\n 02:14 AM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Creatinine\n 0.8\n Glucose\n 526\n 171\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\n subtherapeutic dilantin in setting infection. Will load with dilantin\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\n subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans.\n Will discuss with primary team about either increasing or if pt is at\n baseline.\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\n lisinopril, hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\n unclear etiology.h/o Cdiff - on flagyl, PO vanco.\n Last results negative for c diff. Start TF\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI on ceftriaxone D/C. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712384,
"text": "Seizure, with status epilepticus\n Assessment:\n Pt admitted to sicu B @ 1330 from 11 with status epilepticus\n per cont EEG , no signs of sz activity noted other than EEG\n , pt lethargic & snoring, no response to verbal command, crying\n out with any nursing care, localizes to pain, mild R side weakness\n noted, pt with h/o stroke, R pupil sluggish, 2 mm, L pupil with\n cataract\n Action:\n Keppra/fosphenytoin loading doses given, pt with clotted R arm PIC\n inserted , PIC changed over wire, CXR done to confirm placement, pt\n NPO, NG tube inserted for po meds, ivf @ 75/hr, ATC iv ativan q 4 hrs,\n fosphenytoin level sent @ 1830\n Response:\n No sz activity noted, VSS, sat stable on 2 L np\n Plan:\n Neuro vs q 2 hrs, cont EEG, iv keppra/fosphenytoin as ordered, ATC iv\n ativan, ? head ct in am\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712396,
"text": "Seizure, with status epilepticus\n Assessment:\n When not disturbed pt sleeps and does not move much\n spontaneously. When stimulated pt yells out (speech garbled and\n difficult to understand) kicks with LLE, hits and pinches with LUE and\n tries to pull out NGT also tries to spit. Not following any commands.\n Right sided weakness-moves on bed. Left pupil surgical/cataract right\n pupil reactive. Does not open eyes to command.\n Fosphenytoin level still subtherapeutic at beginning of\n shift\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool (on PO flagyl for cdiff until )\n Action:\n Fosphenytoin re-bolused\n Response:\n unsure if seizure activity per EEG\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712634,
"text": "Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt at 8cc/hr\n Continuous bedside EEG\n No visible seizure activity noted\n Dilantin level 18.3, albumin 3.3\n Action:\n Midazolam gtt weaned to 2 cc/hr\n Dr. aware of Dilantin level. Fosphenytoin dose 250\n mg given.\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n Wean midaz gtt off\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 712583,
"text": "TITLE:\n 24 Hour Events: HPI:71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n : Maximized on keppra and dilantin. Versed weaned off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Metronidazole - 08:01 AM\n Ceftriaxone - 09:58 PM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 03:18 PM\n Fosphenytoin - 05:30 PM\n Other medications:\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\n Disintegrating Tab 30 mg PO/NG DAILY\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\n LeVETiracetam 1500 mg IV Q12H\n Clopidogrel 75 mg PO/NG DAILY\n Lisinopril 40 mg PO/NG DAILY\n Fosphenytoin titated to goal 20\n Midazolam 5-15 mg/hr IV DRIP INFUSION\n Gabapentin 300 mg PO/NG HS\n Potassium Chloride PO Sliding Scale\n Heparin 5000 UNIT SC TID\n Verapamil 120 mg PO Q8H\n HydrALAzine 20 mg IV Q6H\n Flowsheet Data as of 12:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.9\nC (96.7\n HR: 82 (71 - 130) bpm\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\n RR: 20 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 3,869 mL\n PO:\n TF:\n 500 mL\n IVF:\n 2,889 mL\n Blood products:\n Total out:\n 599 mL\n 0 mL\n Urine:\n 599 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,270 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 17 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/36/207/20/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 119 mEq/L\n 146 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Cr\n 0.8\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CT head : resolution of R post parietal subdural fluid\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\n posterior fossa\n EEG showed intermittent seizures consistent with diagnosis\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\n Microbiology: Bld Cx: Moraxella\n Urine Cx: E.coli (s: ceftriaxone)\n Cdiff +\n Bld Cx:P\n Ucx: Ecoli\n Bld Cx:P\n Ucx :P\n C diff Neg\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\n epiliepticus from subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\n - subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication: Son to be in pm woudl likely meeting.\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712451,
"text": "Seizure, with status epilepticus\n Assessment:\n No visibile seizure activity noted\n At beginning of shift when not disturbed pt sleeps and does\n not move much spontaneously. Prior to intubation when stimulated pt\n yells out (speech garbled and difficult to understand) kicks with LLE,\n hits and pinches with LUE and tries to pull out NGT also tries to spit.\n Not following any commands. Right sided weakness-moves on bed. Left\n pupil surgical/cataract right pupil reactive. Does not open eyes to\n command\n Fosphenytoin level still subtherapeutic despite bolus\n Remains on continuous EEG\n NGT in place with placement confirmed by xray per sicu\n resident\n +lg semiformed stool then lg liquid stool (on PO vanco and\n IV flagyl for cdiff until )\n Neuromed reported pt continues to have seizures an\n hour requesting versed drip\n Throughout shift noted to have frequent PVC\ns-incred in freq\n when Tachycardic (during agitation)\n Action:\n Fosphenytoin re-bolused x2\n Intubated for airway protection and midaz drip started\n (neuromed reports during prior admissions midaz drip has been the only\n drug to keep pt out of status). SICU resident contact pt\ns son prior\n to intubation.\n Midaz titrated up d/t nmed reporting seizure activity and\n then again for agitation\n Lytes drawn after run of VT and versed increased\n Post-intubation ABG drawn\n Response:\n During intubation HR up to 130-140 and pt then became\n hypertensive up to 180. Anesthesia pushed esmolol 20mg ivx2 with good\n effect HR down to 100 and SBP 140\ns. After about 10min s/p intubation\n HR back up to 110-120 and SBP150\ns. Verapamil SR changed to immediate\n release and dose given via NGT. Pt also noted to be waking up, becoming\n more agitated and raising head off bed while LUE reached for ETT had\n ~12 beat run of VT. D/W resident and versed drip titrated up for\n sedation this time not for seizure activity\n Current neuro exam is pt does lift head off bed while\n coughing/gaging on ett but not as much as when on lower dose versed.\n Localizes with LUE able to raise towards ETT moves LLE more then RLE on\n bed. Pupils unchanged. Still does not follow commands or open eyes. No\n visible seizure activity noted\n Lytes low (especially potassium) repleted and amt of ectopy\n decreased\n As versed drip increased SBP dropping.\n Plan:\n Q2hr neuro\n Cont EEG\n Versed drip for seizure control (as well as ETT comfort)\n Discuss sedation with SICU team on rounds. ?decrease versed\n (if no seizures) and add fent for ETT comfort d/t hypotension with\n versed increase\n"
},
{
"category": "Respiratory ",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 712455,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Airway protection during Versed drip\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments/Plan\n 71 yo F orally intubated in SICUb for airway protection during Versed\n drip initiation. Versed started for status epilepticus. Ventilating\n easily, airway pressures low. Copious oral secretions noted. No RSBI\n this am secondary to no spont. RR. See flowsheet for further data.\n Will follow.\n 05:55\n"
},
{
"category": "Respiratory ",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 712561,
"text": "Day of mechanical ventilation: 1\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Pt with continued seizure activity. No vent changes or ABG\ns. CT v MRI\n tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712551,
"text": "Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control\n Action:\n Response:\n Plan:\n Neuro q2hr\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"
},
{
"category": "Nursing",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712564,
"text": "Seizure, with status epilepticus\n Assessment:\n Found to be in status by EEG yesterday. Having \n seizures an hour on night shift. Pt intubated for airway protection\n last noc at 0100 d/t start of Midazolam gtt for seizure control. SBP\n borderline overnoc w/ increase in Midazolam gtt to control seizures\n Received pt on Midazolam at 7mg/hr. SBP in the 90s\n Bilateral eyes s/p cataracts. Right pupil 3mm and sluggish.\n Left pupil asymmetrical and non-reactive.\n Left upper extremity w/ normal strength. Moves all other\n extremities on bed. Purposeful movement for ETT w/ LUE. Hx of Right\n hemiparesis from previous stroke. Withdrawing to pain on right\n Hx a-fib in NSR 70-80s. Most cardiac meds held d/t SBP <100.\n Continuous EEG per Neuro med w/ seizures per hour this\n am\n Action:\n Response:\n Plan:\n Neuro q2hr\n Cont EEG monitoring\n WEAN off Versed starting at 2am and to off by 8am\n ? CT vs MRI on \n"
},
{
"category": "Respiratory ",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 712624,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 500x14/+5/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 66\n Comments: Maintain support until neuro picture clears.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712795,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n NGT replaced right nare\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 712440,
"text": "SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many years ago and\n epilepsy. She was admitted here in due to prolonged seizures in\n the setting of low Dilantin level and infection (C.diff) and discharged\n on Dilantin and Keppra (750 mg ).\n Two days before her current admission, she had neurosurgical follow up\n for a chronic subdural hematoma, which had resolved. Therefore, she was\n advised to stop her Dilantin. The patient was then admitted to the\n medicine department two days ago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for the UTI, an EEG was performed yesterday\n (), which showed frequent electrographic seizures, originating in\n the right centro-parietal area. She was reloaded with Dilantin and\n Lorazepam was given intermittently, but she continued to have seizures\n overnight, up to 12 an hour. Clinically, she remained marginally\n responsive and rarely had events of gaze deviation to the left which\n were suggestive of seizure activity. She was transferred today to the\n ICU for frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ treatment, in\n case she fails to respond to other anticonvulsants\n Chief complaint:\n Statis epilepticus, UTI, Cdiff\n PMHx:\n PMH:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n .\n PSH:\n bilateral cataract surgery\n Current medications:\n HydrALAzine 20 mg IV Q6H as long as pt not taking po antihypertensives\n hold if BP<110 Order date: @ 1340 1000 mL D5 1/2NS Continuous at\n 75 ml/hr for 3000 ml Order date: @ 1340 21. Insulin SC (per\n Insulin Flowsheet) Sliding Scale & Fixed Dose Order date: @\n 2206 Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Order\n date: @ 2207 5. Amlodipine 10 mg PO/NG DAILY Order date: @\n 1340 23. LeVETiracetam 500 mg IV ONCE Duration: 1 Doses Order date:\n @ 1340 6. Aspirin 81 mg PO/NG DAILY Order date: @ 1340 24.\n LeVETiracetam 250 mg IV ONCE Duration: 1 Doses Order date: @ 1356\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1340 25. LeVETiracetam 1500 mg IV Q12H Order date: @ 1451 8.\n CeftriaXONE 1 gm IV Q24H Order date: @ 1340 26. Lisinopril 40 mg\n PO/NG DAILY Order date: @ 1340 9. Clopidogrel 75 mg PO/NG DAILY\n Order date: @ 1340 27. Lorazepam 1 mg IV Q4H agitation Order\n date: @ 1454 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia\n protocol Order date: @ 1340 28. Magnesium Sulfate IV Sliding\n Scale Order date: @ 1656\n 11. Fosphenytoin 400 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 1451 29. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @\n 1340 12. Fosphenytoin 150 mg PE IV Q8H start 8hr after load. this is\n maintenance dose Order date: @ 1513 30. Midazolam 4-8 mg/hr IV\n DRIP INFUSION Patient must have adequate airway support prior to\n administration of dose. Order date: @ 0226 13. Fosphenytoin 300\n mg PE IV ONCE Duration: 1 Doses Order date: @ 31.\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @ 1158\n 14. Fosphenytoin 500 mg PE IV ONCE Duration: 1 Doses Order date: \n @ 0201 32. Potassium Chloride PO Sliding Scale Duration: 24 Hours Hold\n for K > 4 Order date: @ 1652\n 15. Gabapentin 300 mg PO/NG HS Order date: @ 1340 33. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Glucagon 1 mg IM\n Q15MIN:PRN hypoglycemia protocol Order date: @ 1340 34.\n Vancomycin Oral Liquid 125 mg PO/NG Q 12H Order date: @ 1340 17.\n Heparin 5000 UNIT SC TID Order date: @ 1340 35. Verapamil 120 mg\n PO Q8H hold sbp < 100 or HR < 60 Order date: @ 0114\n 24 Hour Events:\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n INTUBATION - At 01:19 AM\n : Found to be in status epilepticus. Transferred to SICU from for possible need airway protection. Continued EEG monitoring.\n Still w//seizures/hr. Intubated in order to start versed to help\n break seizures.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:23 PM\n Vancomycin - 10:23 PM\n Metronidazole - 11:46 PM\n Infusions:\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 PM\n Heparin Sodium (Prophylaxis) - 08:29 PM\n Hydralazine - 11:46 PM\n Lorazepam (Ativan) - 04:05 AM\n Fosphenytoin - 04:05 AM\n Other medications:\n Flowsheet Data as of 04:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 35.8\nC (96.5\n HR: 91 (76 - 130) bpm\n BP: 93/57(65) {86/53(60) - 187/91(115)} mmHg\n RR: 16 (10 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Total In:\n 458 mL\n 440 mL\n PO:\n Tube feeding:\n IV Fluid:\n 458 mL\n 440 mL\n Blood products:\n Total out:\n 735 mL\n 175 mL\n Urine:\n 735 mL\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n -278 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SPO2: 100%\n ABG: ///23/\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular), (Murmur: Systolic), (Distant heart\n sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+, 2+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Noxious\n stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 171 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 142 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 12:42 AM\n 02:14 AM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Creatinine\n 0.8\n Glucose\n 526\n 171\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk-Phos /\n T bili:118/0.5, Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 71F w/ h/o status epilepticus arrived with UTI and\n Cdiff now in status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus refractory to ativan. AMS likely due to\n subtherapeutic dilantin in setting infection. Will load with dilantin\n (13.3) and keppra. Follow levels. Ativan for seizure proph. Midaz added\n due to continued status. Aim dilantin level 15-20. Follow 24hr EEG -\n subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib. Will restart - amlodipine, verapamil,\n lisinopril, hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NPO, NGT. Follow LFT medication,\n unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI on ceftriaxone (? duration). FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Wounds:\n Imaging:\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time: 35 min\n"
},
{
"category": "Respiratory ",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 712723,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Tenacious\n Sputum source/amount: Suctioned / Small\n Comments:\n Comments: Pt extubated s/p successful weaning trial with good cuff leak\n noted. PT currently wearing 50% cool aerosol with spo2 100% RR mid to\n low 20s. Will cont to monitor for s/s fatigue.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712789,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712786,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712966,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712599,
"text": "Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt\n Continuous bedside EEG\n No visible seizure activity noted\n Action:\n Midazolam gtt weaned\n Dilantin level\n Fosphenytoin 150mg IV Q8hrs\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Midaz gtt\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712609,
"text": "Seizure, with status epilepticus\n Assessment:\n Opens eyes intermittently to voice/stimulation. Does not\n follow commands.\n Moving LUE purposefully. LLE moves on bed. Right side\n withdraws to pain.\n Remains intubated for airway protection\n Midaz gtt\n Continuous bedside EEG\n No visible seizure activity noted\n Dilantin level 18.3, albumin 3.3\n Action:\n Midazolam gtt weaned\n Dilantin level\n Dr. aware of Dilantin level. Fosphenytoin dose 250\n mg given.\n Neuro checks Q2hrs\n Response:\n No change in neuro status\n Repeat Dilantin level\n Midaz gtt\n Plan:\n Continue frequent neuro checks\n Continue follow labs- Dilantin level\n Cont EEG monitoring\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 712774,
"text": "SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Chief complaint:\n status epilepticus\n PMHx:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n Current medications:\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. HydrALAzine 15. 16. Insulin\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\n Vancomycin Oral Liquid 25. Verapamil\n 24 Hour Events:\n : extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Ceftriaxone - 09:58 PM\n Metronidazole - 07:59 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 07:07 PM\n Heparin Sodium (Prophylaxis) - 08:28 PM\n Other medications:\n Flowsheet Data as of 01:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.1\n HR: 104 (91 - 105) bpm\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\n RR: 20 (14 - 21) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,837 mL\n 15 mL\n PO:\n Tube feeding:\n 771 mL\n IV Fluid:\n 1,886 mL\n 15 mL\n Blood products:\n Total out:\n 1,235 mL\n 0 mL\n Urine:\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,602 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 413 (341 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 115 K/uL\n 8.8 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 17 mg/dL\n 116 mEq/L\n 144 mEq/L\n 29.2 %\n 5.5 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n WBC\n 9.3\n 5.5\n Hct\n 36.3\n 27.0\n 29.2\n Plt\n 174\n 115\n Creatinine\n 0.8\n 0.7\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\n with UTI and Cdiff admitted with status epiliepticus from\n subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\n keppra. Goal levels 15-20. Follow 24hr EEG\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated \n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n LENI today\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU to floor\n Lines:\n PICC Line - 02:55 PM\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 712837,
"text": "SICU\n HPI:\n 71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Chief complaint:\n status epilepticus\n PMHx:\n 1. stroke 30 years ago (? location-images not available) with residual\n right hemiparesis, dysarthria, and difficulty to express herself\n 2. Type 2 DM, insulin dependent\n 3. HLP\n 4. atrial fibrillation, not on coumadin\n 5. h/o recurrent UTI\n 6. seizure disorder, unspecified\n 7. h/o angina\n 8. PVD\n 9. chronic thrombocytopenia\n 10. anemia\n 11. depression\n 12. osteoporosis\n 13. dementia with delusional features\n 14. obesity\n 15. bilateral cataract surgery\n . prior admit for B chronic SDH and acute parafalcine SDH.\n Current medications:\n 1. 2. 3. Amlodipine 4. Aspirin 5. Bisacodyl 6. CeftriaXONE 7.\n Clopidogrel 8. Dextrose 50% 9. Fosphenytoin\n 10. Gabapentin 11. Glucagon 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. HydrALAzine 15. 16. Insulin\n 17. Lansoprazole Oral Disintegrating Tab 18. LeVETiracetam 19.\n Lisinopril 20. Magnesium Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Pneumococcal Vac Polyvalent 23. Sodium Chloride 0.9% Flush 24.\n Vancomycin Oral Liquid 25. Verapamil\n 24 Hour Events:\n : extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Ceftriaxone - 09:58 PM\n Metronidazole - 07:59 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 07:07 PM\n Heparin Sodium (Prophylaxis) - 08:28 PM\n Other medications:\n Flowsheet Data as of 01:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.2\nC (97.1\n HR: 104 (91 - 105) bpm\n BP: 140/73(80) {107/61(75) - 146/81(97)} mmHg\n RR: 20 (14 - 21) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,837 mL\n 15 mL\n PO:\n Tube feeding:\n 771 mL\n IV Fluid:\n 1,886 mL\n 15 mL\n Blood products:\n Total out:\n 1,235 mL\n 0 mL\n Urine:\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,602 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 413 (341 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 115 K/uL\n 8.8 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.5 mEq/L\n 17 mg/dL\n 116 mEq/L\n 144 mEq/L\n 29.2 %\n 5.5 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n WBC\n 9.3\n 5.5\n Hct\n 36.3\n 27.0\n 29.2\n Plt\n 174\n 115\n Creatinine\n 0.8\n 0.7\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n Other labs: PT / PTT / INR:15.4/45.5/1.3, ALT / AST:109/41, Alk-Phos /\n T bili:95/0.3, Albumin:3.3 g/dL, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: 71F w/ h/o status epilepticus arrived\n with UTI and Cdiff admitted with status epiliepticus from\n subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (18.3) and\n keppra. Goal levels 15-20. Follow 24hr EEG\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated \n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n LENI today\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication:\n Code status:FULL\n Disposition:SICU to floor\n Lines:\n PICC Line - 02:55 PM\n Total time spent: 31 min\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 712856,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\n irregularly shaped and non-reactive (surgical). Can be combative at\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels drawn prior to each dose.\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 712857,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly reactive. Left pupil is\n irregularly shaped and non-reactive (surgical). Can be combative at\n times, occasionally will spit/kick/hit etc. No seizure activity noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels drawn prior to each dose.\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-25 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 712666,
"text": "TITLE: Intensivist\n HPI:71 yo woman with HTN, AF, left hemispheric stroke many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n PICC LINE - START 02:55 PM\n INVASIVE VENTILATION - START 01:15 AM\n : Maximized on keppra and dilantin. Versed weaned off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:23 PM\n Metronidazole - 08:01 AM\n Ceftriaxone - 09:58 PM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 04:05 AM\n Heparin Sodium (Prophylaxis) - 03:18 PM\n Fosphenytoin - 05:30 PM\n Insulin SC (per Insulin Flowsheet)Sliding Scale Lansoprazole Oral\n Disintegrating Tab 30 mg PO/NG DAILY\n Amlodipine 10 mg PO/NG DAILYAspirin 81 mg PO/NG DAILY\n Bisacodyl 10 mg PO/PR DAILY:PRN constipation\n LeVETiracetam 1500 mg IV Q12H\n Clopidogrel 75 mg PO/NG DAILY\n Lisinopril 40 mg PO/NG DAILY\n Fosphenytoin titated to goal 20\n Midazolam 5-15 mg/hr IV DRIP INFUSION\n Gabapentin 300 mg PO/NG HS\n Potassium Chloride PO Sliding Scale\n Heparin 5000 UNIT SC TID\n Verapamil 120 mg PO Q8H\n HydrALAzine 20 mg IV Q6H\n Flowsheet Data as of 12:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.9\nC (96.7\n HR: 82 (71 - 130) bpm\n BP: 118/61(76) {82/50(59) - 187/91(115)} mmHg\n RR: 20 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 3,869 mL\n PO:\n TF:\n 500 mL\n IVF:\n 2,889 mL\n Blood products:\n Total out:\n 599 mL\n 0 mL\n Urine:\n 599 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,270 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 17 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/36/207/20/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 174 K/uL\n 11.4 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 119 mEq/L\n 146 mEq/L\n 36.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n WBC\n 9.3\n Hct\n 36.3\n Plt\n 174\n Cr\n 0.8\n 0.7\n TCO2\n 25\n Glucose\n 171\n 97\n Other labs: PT / PTT / INR:14.5/35.3/1.3, ALT / AST:181/97, Alk Phos /\n T Bili:118/0.5, Ca++:7.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.5 mg/dL\n Imaging: CT head : resolution of R post parietal subdural fluid\n collection. no acute ICH, Prominent extra-axial CSF spaces in the\n posterior fossa\n EEG showed intermittent seizures consistent with diagnosis\n of STATUS EPILEPTICUS; subclinical seizures 12/hr.\n Microbiology: Bld Cx: Moraxella\n Urine Cx: E.coli (s: ceftriaxone)\n Cdiff +\n Bld Cx:P\n Ucx: Ecoli\n Bld Cx:P\n Ucx :P\n C diff Neg\n Assessment and Plan\n SEIZURE, WITH STATUS EPILEPTICUS\n 71F w/ h/o status epilepticus arrived with UTI and Cdiff now in status\n epiliepticus from subtherapeutic levels vs. infection\n Neurologic: Status epilepticus Will Maxamize dilantin (13.3) and\n keppra. Goal levels 15-20. Weaned off midaz overnight. Follow 24hr EEG\n - subclinical seizures based on EEG. Neuro exam - not interactive,\n lethargic, moans\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Intubated for airway protection.\n Gastrointestinal / Abdomen: NGT begin tube feeds. Follow LFT \n medication, unclear etiology. + Cdiff - on flagyl, PO vanco.\n Nutrition: NPO. Replete electrolyttes.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl. + UTI s/p rx w/ ceftriaxone. FU repeat cx.\n Lines / Tubes / Drains: NGT, PIV, Picc\n Fluids: D51/2 NS\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Communication: Son to be in pm woudl likely meeting.\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments: LENIs today\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 31 minutes\n Patient is critically ill Sezures, Resp Failure\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712944,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\n stimuli. Reported to be patient\ns baseline. LUE/LLE with purposeful\n movement and normal strength. Positive weak cough/gag. No seizure\n activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring and for seizure activity.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712945,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring and for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712935,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 713090,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times. No seizure activity noted.\n Action:\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\n monitor levels\n next dilantin level to be drawn am, transfer to\n sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 713092,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and being treated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Continue to monitor for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of Ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete Ceftriaxone course: Last dose tonight . Follow-up\n urine cultures.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CHANGE IN MENTAL STATUS\n Code status:\n Height:\n 63 Inch\n Admission weight:\n 91.5 kg\n Daily weight:\n 91.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, Seizures\n CV-PMH: Angina, CVA\n Additional history: a-fib not on coumadin, obesity, dementia,\n cataracts, chronic SDH, recurrent UTI's, PVD, depression,anemia,\n osteoporosis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:65\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,058 mL\n 24h total out:\n 2,790 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 01:55 AM\n Potassium:\n 3.4 mEq/L\n 01:55 AM\n Chloride:\n 109 mEq/L\n 01:55 AM\n CO2:\n 24 mEq/L\n 01:55 AM\n BUN:\n 7 mg/dL\n 01:55 AM\n Creatinine:\n 0.5 mg/dL\n 01:55 AM\n Glucose:\n 145 mg/dL\n 01:55 AM\n Hematocrit:\n 27.2 %\n 01:55 AM\n Finger Stick Glucose:\n 190\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: L-finger yellow colored ring.\n Transferred from: SICU B 675\n Transferred to: 11 Room: 1121.\n Date & time of Transfer: 22:00\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712824,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Alert, unable to assess orientation fue to garbled speech.\n Follows commands inconsistently. Left side moves purposefully, right\n side withdraws to pain( right hemiparesis at baseline from prior CVA).\n Right pupil 3mm and sluggish. Left pupil asymmetrical and non-reactive.\n Agitated and combative at times, pulled out NGT.\n No seizure activity observed\n Beside continuous EEG.\n PMH Afib. Now in NSR. HR 90\n Contact precautions for hx of c.diff. Positive E.coli in\n urine\n Dilantin level 18.1. Albumin 3.1.\n Action:\n Neuro checks q 2-3\n Dilantin level drawn prior to dosing\n NGT replaced right nare confirmed by XRay by SICU resident\n TF\ns restarted\n Encouraged to cough to remove secretions\n Response:\n Neuro status unchanged.\n Plan:\n Neuro q2hr\n Dilantin level one hour before next dose\n Cont EEG monitoring\n Transfer to neuro SDU\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712937,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR. RUE/RLE withdraws only to noxious\n stimuli. Reported to be patient\ns baseline. LUE/LLE with purposeful\n movement and normal strength. Positive weak cough/gag. No seizure\n activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713089,
"text": "Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times. No seizure activity noted.\n Action:\n Continuous eeg monitoring removed. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue keppra and phosphenytoin,\n monitor levels\n next dilantin level to be drawn am, transfer to\n sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 712904,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels draw x\ns 2 today. .\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712905,
"text": "Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid, levels draw x\ns 2 today. .\n Response:\n No seizure activity noted, neuro exam unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course and follow up urine cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 713004,
"text": "24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:\n Total time spent: 32 min\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 713005,
"text": "24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:sicu\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 712979,
"text": "71 year-old- woman with HTN, AF, left hemispheric stroke 30 years ago\n and epilepsy. She was admitted on due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra. Two days before her\n current admission, she had neurosurg follow up for a chronic subdural\n hematoma, which had resolved. She was advised by PCP to stop her\n Dilantin. The patient was then admitted to the medicine department two\n days ago for altered mental status in the setting of UTI. When she\n remained unresponsive despite being afebrile and being treated with\n antibiotics for MS changes, question of UTI. An EEG was performed ,\n which showed frequent electrographic seizures, originating in the right\n centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and placed on continuous bedside EEG monitoring.\n Seizure, with status epilepticus\n Assessment:\n Opening eyes spontaneously or arouses to stimulation. Garble\n speech with frequent incomprehensible sounds. R-pupil 3mm/sluggish.\n L-pupil is cat-eye shaped/NR/surgical. RUE/RLE withdraws only to\n noxious stimuli. Reported to be patient\ns baseline. LUE/LLE with\n purposeful movement and normal strength. Positive weak cough/gag. No\n seizure activity noted.\n Action:\n Neurological exams every two hours.\n Continuous EEG monitoring.\n Keppra/Dilantin administered MD order. Last Dilantin\n level 12/12/09-19.6.\n Response:\n Neurological exam remains unchanged.\n No seizure activity noted.\n Plan:\n Continue neurological exam every 2 hours.\n Follow continuous EEG monitoring for seizure activity.\n Administer Keppra/Dilantin MD order. Follow Dilantin\n levels.\n Plan to transfer to SDU.\n"
},
{
"category": "Physician ",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 712994,
"text": "24 Hour Events: HPI: 71 yo woman with HTN, AF, left hemispheric stroke\n many\n years ago and epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and\n infection (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurgical\n follow up for a chronic subdural hematoma, which had resolved.\n Therefore, she was advised to stop her Dilantin. The patient was\n then admitted to the medicine department two days ago for altered\n mental status in the setting of UTI. When she remained unresponsive\n despite being afebrile and beingtreated with AB for the UTI, an EEG was\n performed , which showed frequent electrographic seizures,\n originating in the right centro-parietal area. She was reloaded\n with Dilantin and Lorazepam was given intermittently, but she\n continued to have seizures overnight, up to 12 an hour.\n Clinically, she remained marginally responsive and rarely had\n events of gaze deviation to the left which were suggestive of\n seizure activity. She was transferred today to the ICU for\n frequent administration of anti-epileptic agents and monitoring\n of their levels, as well as for eventual continuous BDZ\n treatment, in case she fails to respond to other anticonvulsants\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 PM\n Metronidazole - 01:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 PM\n Fosphenytoin - 04:44 AM\n Other medications:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.9\n HR: 96 (81 - 98) bpm\n BP: 143/71(88) {118/63(71) - 158/115(121)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.3 kg (admission): 91.5 kg\n Height: 63 Inch\n Total In:\n 2,101 mL\n 816 mL\n PO:\n TF:\n 891 mL\n 428 mL\n IVF:\n 790 mL\n 178 mL\n Blood products:\n Total out:\n 2,510 mL\n 910 mL\n Urine:\n 2,510 mL\n 910 mL\n NG:\n Stool:\n Drains:\n Balance:\n -409 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, decreased mental status\n Eyes / Conjunctiva: PERRL, Sclera edema\n Cardiovascular: (S1: No(t) Normal, No(t) Absent), (S2: Normal, No(t)\n Distant, No(t) Widely split ), S4, Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Rhonchorous: )\n Abdominal: No(t) Soft, Non-tender\n Skin: Not assessed\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, opens eyes to voice but does not follow\n commands\n Labs / Radiology\n 112 K/uL\n 8.7 g/dL\n 145 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 109 mEq/L\n 140 mEq/L\n 27.2 %\n 6.2 K/uL\n [image002.jpg]\n 02:14 AM\n 05:17 AM\n 01:43 PM\n 12:37 AM\n 09:33 AM\n 03:00 AM\n 01:55 AM\n WBC\n 9.3\n 5.5\n 7.0\n 6.2\n Hct\n 36.3\n 27.0\n 29.2\n 27.0\n 27.2\n Plt\n 174\n 115\n 120\n 112\n Cr\n 0.8\n 0.7\n 0.7\n 0.6\n 0.5\n TCO2\n 25\n Glucose\n 171\n 97\n 173\n 121\n 145\n Other labs: PT / PTT / INR:15.0/42.5/1.3, ALT / AST:73/35, Alk Phos / T\n Bili:83/0.2, Albumin:3.1 g/dL, Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI), SEIZURE, WITH STATUS EPILEPTICUS\n ASSESSMENT: 71F w/ h/o status epilepticus arrived with UTI and Cdiff\n admitted with status epiliepticus from subtherapeutic levels vs.\n infection\n Neurologic: Status epilepticus. No further seizures. Dilantin level at\n goal of 15-20. Continue keppra.\n Cardiovascular: HTN, afib on - amlodipine, verapamil, lisinopril,\n hydral prn. Cont , .\n Pulmonary: Extubated . Satting adequately on face mask.\n Gastrointestinal / Abdomen: NGT begin tube feeds. + Cdiff - on flagyl,\n PO vanco.\n Nutrition: Replete with fiber Full strength.\n Renal: Recurrent UTI. Foley. FU Ucx - on ceftriaxone for 7day goal.\n Hematology: h/o anemia, thrombocytopenia. On for PVD, sqh. \n Endocrine: DM. RISS\n ID: Cdiff on flagyl, negative stool x 2. UTI with ceftriaxone.\n Lines / Tubes / Drains: NGT, PIV, Picc, foley\n Fluids: KVO\n Consults: Neuro\n Billing Diagnosis: Status epilepticus, seizures\n DVT: Heparin 5000 UNIT SC TID\n Stress ulcer: PPI\n VAP bundle: N/A\n Code status:FULL\n Disposition:SICU to floor\n Disposition:\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2172-12-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 713029,
"text": "71 yo woman with HTN, AF, left hemispheric stroke 30 years ago and\n epilepsy. She was admitted here in due to\n prolonged seizures in the setting of low Dilantin level and infection\n (C.diff) and discharged on Dilantin and Keppra (750 mg\n ). Two days before her current admission, she had neurosurg lfollow\n up for a chronic subdural hematoma, which had resolved. She was advised\n by PCP to stop her Dilantin. The patient was then admitted to the\n medicine department two daysago for altered mental status in the\n setting of UTI. When she remained unresponsive despite being afebrile\n and beingtreated with AB for MS changes, ? UTI. An EEG was performed\n , which showed frequent electrographic seizures,originating in the\n right centro-parietal area (status epilepticus). She was reloaded with\n Dilantin and put on continuous EEG at bedside. \\\n Seizure, with status epilepticus\n Assessment:\n Either alert or arouses to stimulation. Speech is garbled, often makes\n incomprehensible sounds/groans. Does not follow commands. Moves left\n upper and lower extremities purposefully and with normal strength.\n Right upper and lower extremities withdraw to noxsious stimuli\n (baseline). Right pupil is 3mm and sluggishly/minimally reactive.\n Left pupil is irregularly shaped and non-reactive (surgical). Can be\n combative at times, occasionally will spit, etc. No seizure activity\n noted.\n Action:\n Continuous eeg monitoring in place. Q 2 hour neuro checks. Keppra\n , and phosphenytoin tid\n Response:\n No seizure activity noted, neuro exam remains unchanged.\n Plan:\n Continue q 2 hour neuro checks, continue eeg monitoring, continue\n keppra and phosphenytoin, monitor levels\n next dilantin level to be\n drawn am, transfer to sdu.\n Urinary tract infection (UTI)\n Assessment:\n Recurrent UTI\n Action:\n 7 day course of ceftriaxone (day 1 was )\n Response:\n Pending\n Plan:\n Complete ceftriaxone course\n last dose will be tonight, and follow\n up urine cultures.\n"
},
{
"category": "ECG",
"chartdate": "2172-12-22 00:00:00.000",
"description": "Report",
"row_id": 234723,
"text": "Sinus rhythm with ventricular premature beat. Left atrial abnormality.\nST-T wave abnormalities are non-specific. Since the previous tracing\nof sinus tachycardia is absent and further ST-T wave changes are seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-22 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1111243,
"text": " 8:09 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for intra-abd process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with change in mental status abd pain\n REASON FOR THIS EXAMINATION:\n please eval for intra-abd process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc TUE 9:03 AM\n No acute abnormalities. Diverticulosis without diverticulitis. Rectum\n distended with stool.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with change in mental status and abdominal\n pain. Evaluate for intra-abdominal process.\n\n COMPARISON: .\n\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the abdomen and\n pelvis from the lung bases to the pubic symphysis. Multiplanar reformatted\n images were obtained.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Atelectasis and nodular\n opacities in the lung bases persist unchanged from . The\n liver shows no focal lesion. The gallbladder has been removed. The spleen,\n adrenal glands, and pancreas are unremarkable. The kidneys enhance and\n excrete contrast symmetrically. There is no hydronephrosis. Subcentimeter\n hypodensities in the left kidney are too small to accurately characterize.\n\n The intra-abdominal loops of large and small bowel are normal in caliber.\n There are scattered colonic diverticula without evidence of diverticulitis.\n Note is made of a large amount of stool in the colon, especially within the\n rectum.\n\n There is no free fluid, free air, or lymphadenopathy. The aorta and iliac\n arteries are notable for severe atherosclerotic calcification. Large\n right-sided ventral hernia with post-surgical changes of the overlying\n abdominal wall is unchanged in appearance.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder is collapsed with\n Foley in place. In the left adnexa, there is either a 3.9cm exophytic fibroid\n with calcification or enlarged ovary (2:78). No free fluid or pelvic\n lymphadenopathy. The rectum is markedly distended with stool.\n\n BONE WINDOWS: No lesion worrisome for osseous metastases is identified.\n Multilevel degenerative changes are present throughout the thoracolumbar\n spine.\n\n IMPRESSION:\n 1. Massively fecal impacted rectum.\n 2. Persistent bibasilar nodular opacities and atelectasis which is again\n (Over)\n\n 8:09 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for intra-abd process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n nonspecific. Continued followup is recommended.\n 3. 3.9cm rounded structure in the left adnexa may represent an exophytic\n fibroid or enlarged ovary. Recommend pelvic ultrasound after fecal\n disimpaction.\n\n Discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1111332,
"text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r 46cm dlpicc\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with poor iv access requiring a dlpicc\n REASON FOR THIS EXAMINATION:\n s/p r 46cm dlpicc\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 4:54 PM\n PFI:\n\n Right-sided PICC line terminating in SVC, no pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 71-year-old female patient with poor IV access. Right-sided PICC\n line placed, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. Analysis is performed in direct comparison with the\n next preceding similar study obtained eight hours earlier during the same\n date. Identified now is a right-sided PICC line seen to terminate overlying\n the SVC at the level 2 cm below the carina. No pneumothorax has developed.\n As before, low inspirational volume results in vascular crowding, but there is\n no evidence of any acute infiltrate or significant pleural effusion reaching\n lateral pleural sinuses.\n\n IMPRESSION: Proper placement of PICC line. No complication.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1111333,
"text": ", P. MED 11R 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r 46cm dlpicc\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with poor iv access requiring a dlpicc\n REASON FOR THIS EXAMINATION:\n s/p r 46cm dlpicc\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n Right-sided PICC line terminating in SVC, no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-29 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1112388,
"text": " 9:57 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: NG placement\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p NGT\n REASON FOR THIS EXAMINATION:\n NG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post nasogastric tube.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n FINDINGS:\n\n Two supine radiographs of the abdomen are presented for review. The first\n 10:12 p.m. shows a nasogastric tube ending below the diaphragm with its tip\n not completely evaluated. The second radiograph taken at 10:35 p.m. does not\n show an NG tube present. The visualized bones are unremarkable. No dilated\n loops of bowel present.\n\n IMPRESSION:\n\n Initial nasogastric tube below the diaphragm, though subsequent radiograph\n shows absence of nasogastric tube.\n\n These findings were communicated to the SICU resident , M.D. at\n 11:00 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111482,
"text": " 2:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess position\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new ngt\n REASON FOR THIS EXAMINATION:\n assess position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that extends well into the body of the stomach. Continued\n low lung volumes with probable atelectatic changes at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111551,
"text": " 1:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ett location\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman intubated\n REASON FOR THIS EXAMINATION:\n assess ett location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for ETT location.\n\n COMPARISON: .\n\n FINDINGS: Newly inserted endotracheal tube, the tip of the tube projects 1 cm\n above the carina. The tube could be pulled back by 1 to 2 cm. No evidence of\n complication, notably no pneumothorax.\n\n Unchanged course of the nasogastric tube.\n\n Unchanged right PICC line. Low lung volumes with borderline size of the\n cardiac silhouette and minimal increase in diameter of the pulmonary\n vasculature, potentially indicative of mild overhydration. No focal\n parenchymal opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1111239,
"text": " 7:19 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulmonary disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with altered mental status.\n\n COMPARISON: .\n\n AP AND LATERAL VIEWS OF THE CHEST: Lung volumes are low, resulting in\n vascular crowding. However, there is no consolidation or pleural effusion.\n There is no pneumothorax. The cardiomediastinal silhouette is stable,\n demonstrating an unfolded aorta. There is no hilar or mediastinal\n enlargement, although the right hilus remains prominent. Pulmonary\n vascularity is normal.\n\n Right upper quadrant clips are consistent with cholecystectomy.\n\n IMPRESSIONS: No acute cardiopulmonary abnormality. Low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-25 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1111764,
"text": " 9:23 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SWOLLEN LEGS WHILE INTUBATED. EVAL FOR CLOT AND PE\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with swollen legs, while intubated\n REASON FOR THIS EXAMINATION:\n rule out PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old female with swollen legs. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\n superficial femoral, popliteal and tibial veins were performed. Note is made\n that the right peroneal vein could not be identified. There is normal flow,\n compression and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1111498,
"text": " 3:12 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had a right sided picc line placed 46cm and needs tip con\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new picc who needs cxry to confirm tip location.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed 46cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with new PICC.\n\n COMPARISON: Chest radiograph available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The patient is status post placement of a\n PICC terminating within the low SVC. The cardiac and mediastinal contours are\n unchanged. There is a nasogastric tube with side port located within the\n stomach and the termination point beyond the scope of this examination. There\n is no pneumothorax or pleural effusion.\n\n IMPRESSION: Status post placement of a right-sided PICC terminating within\n the low SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111893,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube position\n Admitting Diagnosis: CHANGE IN MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with status\n REASON FOR THIS EXAMINATION:\n NG tube position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: NG tube placement.\n\n One portable view. Comparison with the previous study done .\n\n There is continued evidence for mild pulmonary vascular congestion. The heart\n and mediastinal structures are unchanged. The patient has been extubated. A\n nasogastric tube remains in place, terminating well below the diaphragm.\n\n IMPRESSION: No significant change post-extubation.\n\n\n"
}
] |
124 | 112,906 | As stated above, Mr. was admitted to the ICU for blood pressure control on an esmolol drip. He remained without recurrent chest pain and he had a MRI/MRA done of his chest to further delineate his anatomy. Of note, there were two small outpouchings of contrast from the lumen of the inferior portion of the aortic arch surrounded by large thrombus component with some thickening of the aortic wall and no evidence of active bleeding or free fluid. There were additionally multiple irregularities in the aortic wall throughout the entire thoracic and abdominal aorta that was visualized. This was thought to represent an unusual appearance of a penetrating ulcer with a large thrombus component. He additionally had a cardiac catheterization to evaluate for any underlying coronary artery disease should he need operative repair. This revealed 90 percent stenosis of his right coronary artery, saphenous vein graft with patent vein grafts to the OM and patent LIMA to the LAD with diffuse disease in the distal LAD. A Heparin-coated stent was placed in the vein graft to the right coronary artery. Other findings from his catheterization revealed an 80 percent instent stenosis of the left vertebral artery and an 80 percent right brachiocephalic ostial lesion. He tolerated the procedure well and there were no bleeding or groin complications. He returned to the Intensive Care Unit for continued blood pressure monitoring and his esmolol drip was eventually weaned off. Given the patient's multiple medical problems including his severe pulmonary disease, underlying coronary artery disease, and overall debilitated condition, the decision was made to proceed with medical management as the postoperative management of this likely penetrating ulcer. He was transitioned to oral agents. His diltiazem dose was increased and Lopressor was added for additional rate control. He remained off drips for greater than 48 hours. Decision was made to send him home with close followup. Of note, his hematocrit remained stable. His creatinine remained within its baseline of around 1.4 and he was tolerating a regular diet and able to ambulate without difficulty. Of note, because of his complaint of cough, a sputum sample was sent, which grew out Pseudomonas that was , he was started on ciprofloxacin on . Follow-up chest x-ray revealed bilateral lower lobe changes concerning for pneumonia. He remained afebrile with normal white count. | Normal ascending aorta diameter. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:1. Left ventricular function.Height: (in) 69Weight (lb): 160BSA (m2): 1.88 m2BP (mm Hg): 149/46HR (bpm): 77Status: InpatientDate/Time: at 11:47Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. Mild mitral annularcalcification. TECHNIQUE: PA & lateral chest. Trivial mitralregurgitation is seen. There are unchanged interstitial changes of both lungs, most marked at the bases. The pulmonary vasculature is not engorged. The mediastinal and hilar contours are within normal limit. Diffuse emphysematous changes. The vague hyperattenuated signal within the lower aspect of the aortic arch surrounding the ulcers is of uncertain significance. Otherwise, no diagnosticinterim change.TRACING #1 no c/o chest pain. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). The left ventricular cavity size is normal. FINDINGS: Within the inferior portion of the aortic arch, there are two different small outpouchings of contrast from the lumen, the anterior one is at the level of the left subclavian and measures 6 mm, and the second one is 1 cm posterior to this one and measures 9 x 9 mm. Cardiac and mediastinal contours are stable and within normal limits. Linear atelectasis at right lung base. Limited evaluation of the upper abdomen reveals no gross abnormalities. Otherwise, no significant change in previously seen abnormalities. FINDINGS: The patient is S/P CABG with median sternotomy. IMPRESSION: Two small areas of contrast outpouching from the aortic lumen at the inferior portion of the aortic arch, surrounded by a large polylobulated thrombus extending downwards to the level of the pulmonary artery. Mild stenosis in the origin of the left carotid artery and moderate stenosis in the origin of the left subclavian artery. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to theprevious tracing of the rate has slowed. PT DENIES ANY PAIN. Low limb lead voltage. Low limb lead voltage. AM LOPRESSOR AND HYDRALIZINE HELD. CT CHEST WITHOUT AND WITH IV CONTRAST: The opacified pulmonary arterial tree does not demonstrate any filling defects indicative of pulmonary embolus to the level of the subsegmental pulmonary arteries bilaterally. There is flattening of the diaphragms secondary to emphysema. No diagnostic interim change.TRACING #2 Normal tracing as on . Suboptimal technical quality, a focalLV wall motion abnormality cannot be fully excluded. COMPARISON: CTA dated . FINDINGS: Sternal wires and mediastinal clips are again noted. His TAA volume is 173.8cc. The lung fields demonstrate diffuse emphysematous changes. Overall normal LVEF(>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Since the previous tracing of the heart rate hasdecreased. Heart size is normal. IMPRESSION: No evidence of pneumonia. The heart, pulmonary arteries and veins are unremarkable. These inferior outpouchings of contrast are surrounded by large polylobulated thrombus component, measuring 4 x 3 x 2.5 cm. L/S clear course @ bases.GI: Taking PO's well.GU: Having adequate u/o, per foley.ID: no temps.Neuro: A&Ox3. intermittent epidose to Sats 80's with wheezes recieved AlB neb and routine inhalers with improvement.cv: HR 72-82,NSR, no ectopy, A-BP 80-120 labile, BP differant R side from L side by 40 points, off ESMOLOL, recieved PO DILTIAZEM and HYDROCHLORTIASIDE, goal SBP> 100 MAPS >60. Remains on PO Dilt and HCT.Respir: O2L NP with O2 sats 97-100%, L/S clear no wheezes noted but does have occ congested sounding cough. NIRIDE off from , recieved 1 dose IV LOPRESSOR 10mg/HYDRALISINE 10mg d/t A-BP 140 w/respons, A-BP 90-130/50-60. cardiac US done--> pnd.has weak peripheral pulses.RESPwearing 2 litres nasal cannula, no c/o SOB.lungs sound clear anteriorally.sats are >95%.GI-abd is soft with positive bowel sounds. NPN MICU-B 7AM-3PMS/O: C/V: Continues on Nipride Gtt titrating to keep BP 80-100's as per A-line, @ present is on .75mcq/kq/min. Cough productive/strongcv: HR 76-91, NSR, no ectopy. NPN MICU-B 7AM-7PMS/O: C/V: Remains off of Esmolol Gtt with BP's 100-136/60, HR 70-80's SR with no ectopy noted. labs morning pendinggu/gi: foley, u/o >60cc/hr, abd soft, +BS, no BM. NPN MICU-B 7AM-7PMS/O: C/V: Remains off of Esmolol Gtt, with BP 90-128/55-68, HR-60-80's SR with no ectopy noted. Plan: manage SBP 90-100.cath on not shown aortic aneurism, but intramural trombus,that not operable by surgery,medical managment, performed PTCA to RCAgu/gi: foley,u/o >60cc/hr. Pedal pulses + by doppler, extrems warm, no edema.Resp: 2l n/p w/ 02 sat 98%, lung sound diminished throu-all fields. pain managment: c/o back pain, recieved TYLENOL w/relief.resp: NC 2L, sat96-99%, LS clear to wheezing w/respons to albut. Awaiting cath on Monday.Respir: O2 sats on 2lPN 98-100%, L/S clear to diminished @ bases. BP TITRTAED WITH NIPRIDE TO KEEP IN 80-100 RANGE VIA A-LINE. Pain Managment: c/o lower back pain, recieved po TYLENOL 650mg w/reliefresp: RR 18-24 NC 2L, sat 98-99%, LS clear, cough strong/productivecv: HR 65-85 NSR, no ectopy. Nipride currently at .7mcg/kgmin w/ SBP 100/63. No neuro deficits noted.Resp: 2L NC on, resp easy and regular, O2sat 93-97%, Lungs clear with bibasilar diminished BS. IV D5 w/KCL @ 60cc/hr, recieved routine DILT/HTZ. Abd soft, + BS.id: afebrile.social:full code,no call from family this shift.plan: monitoring SBP 90-100, wean NIPRIDE gtt transfer to the floor Heparin SQ .GU/GI: Abd round soft + BS, pt c/o of hunger and thrist/remains NPO. Full codeA/P: Continue to attempt to wean and d/c Nipride Gtt, monitor BP keep 80-100 as per A-line, is 40mm lower then L arm NBP, due to stenosis. L arm site has + pulses, also has + pedal pulses noted with doppler.Respir: Has congested cough but not productive, is on 2L NP with O2sats 95-99%, does desat with activity to 88-90%. PT IS AFEBRILE.GI: PT ON HOUSE DIET, ONLY LIQUIDS OVERNIGHT. pmicu nursing progress 7a-7preview of systemsCV-hr has been stable without ectopy noted.continues on esmolol at 80 mcgs/kg/min,this has not been changed, maintaining bp (via a-line) at ~100-120/.no c/o chest pain. | 25 | [
{
"category": "Echo",
"chartdate": "2161-12-18 00:00:00.000",
"description": "Report",
"row_id": 60860,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. S/p CABG .Evaulate aorta for evidence of pseudoaneurysm. Left ventricular function.\nHeight: (in) 69\nWeight (lb): 160\nBSA (m2): 1.88 m2\nBP (mm Hg): 149/46\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:47\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n2. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-22 00:00:00.000",
"description": "MMS SUGICAL PLANNING SERVICE",
"row_id": 847661,
"text": " 2:07 PM\n MMS SUGICAL PLANNING SERVICE Clip # \n Reason: please send images of CTA and MRA done on , to MMS, p\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with possible aortic arch pseudoaneurysm\n REASON FOR THIS EXAMINATION:\n please send images of CTA and MRA done on \n to MMS, patient in house\n ______________________________________________________________________________\n FINAL REPORT\n This report is for reference only, generated by Medical Metrx Services, For\n primary diagnosis please see CT Exam dated12/2/04\n\n , DOB: (Age 71) TAA\n Date of Service: \n Physician : \n\n\n was last scanned on and is a pre-operative TAA\n patient. His TAA volume is 173.8cc. His TAA diameter is 6.2cm.\n\n Mr. currently has the following alerts triggered in PEMS:\n His Max TAA-Diameter measurement is greater than 60.0mm. This alert has not\n been acknowledged.\n Nb: This note was automatically generated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847792,
"text": " 12:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pseudomonas on sputum culture\n\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with pseudomonas of sputum culture. Pneumonia.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The patient is S/P CABG with median sternotomy. The heart is\n normal in size. The mediastinal and hilar contours are within normal limit.\n Again note is made of patchy consolidation in bilateral lower lobes medially,\n slightly increased compared to the prior study. There is no evidence of\n congestive heart failure.\n\n IMPRESSION: Increased bilateral lower lobe patchy consolidation, representing\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-17 00:00:00.000",
"description": "MRI CHEST/MEDIASTINUM W/O & W/CONTRAST",
"row_id": 847134,
"text": " 8:35 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please evaluate aortic arch aneurysm\n Admitting Diagnosis: CHEST PAIN,R/O MI\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71m vasculopath with 3cm pseudoaneurysm on CTA\n REASON FOR THIS EXAMINATION:\n please evaluate aortic arch aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old man with suspected aneurysm on aortic CTA.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained prior to and\n after administration of IV gadolinium.\n\n Multiplanar reconstructions were obtained and viewed on a different\n workstation.\n\n COMPARISON: CTA dated .\n\n FINDINGS: Within the inferior portion of the aortic arch, there are two\n different small outpouchings of contrast from the lumen, the anterior one is\n at the level of the left subclavian and measures 6 mm, and the second one is 1\n cm posterior to this one and measures 9 x 9 mm. These inferior outpouchings\n of contrast are surrounded by large polylobulated thrombus component,\n measuring 4 x 3 x 2.5 cm. There is some thickening of the aortic wall at the\n inferior portion of the arch around this outpouching. There is no evidence of\n active bleeding, or free fluid. There are multiple irregularities in the\n aortic wall throughout the entire thoracic and visualized portions of the\n abdominal aorta.\n\n The arch vessels are patent. There is severe stenosis in the origin of the\n brachiocephalic artery. Mild stenosis in the origin of the left carotid\n artery and moderate stenosis in the origin of the left subclavian artery.\n\n The heart, pulmonary arteries and veins are unremarkable. There is no\n significant lymphadenopathy.\n\n IMPRESSION: Two small areas of contrast outpouching from the aortic lumen at\n the inferior portion of the aortic arch, surrounded by a large polylobulated\n thrombus extending downwards to the level of the pulmonary artery. This most\n likely represents an unusual appearance of a penetrating ulcer with large\n exophytic thrombus component. There is no evidence of active bleeding or\n leakage.\n\n The vague hyperattenuated signal within the lower aspect of the aortic arch\n surrounding the ulcers is of uncertain significance. Blood products cannot be\n definitely seen but small intramural hematoma cannot be excluded.\n\n (Over)\n\n 8:35 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please evaluate aortic arch aneurysm\n Admitting Diagnosis: CHEST PAIN,R/O MI\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-17 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 847008,
"text": " 1:59 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ro pe\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cp, sob. cough and elevated d-dimer with no acute process\n on cxray but chronic interstitial changes-\n REASON FOR THIS EXAMINATION:\n ro pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:50 AM\n no pe; aortic pseudoaneurysm; emphysema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 71-year-old male with chest pain, shortness of breath,\n and cough.\n\n TECHNIQUE: Multidetector CT images of the chest prior to and following the\n administration of 150 cc of Optiray. Non-ionic contrast was used due to the\n rapid bolus infusion required for the CTA technique.\n\n Multiplanar reformatted images were created.\n\n CT CHEST WITHOUT AND WITH IV CONTRAST: The opacified pulmonary arterial tree\n does not demonstrate any filling defects indicative of pulmonary embolus to\n the level of the subsegmental pulmonary arteries bilaterally. There are\n extensive atherosclerotic changes of the aorta, as well as a complex,\n predominantly thrombosed 3.3 x 2.2 cm pseudoaneurysm or penetrating ulcer of\n the aortic arch. There is no evidence of leak. The heart is normal in size.\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\n identified. The lung fields demonstrate diffuse emphysematous changes.\n Limited evaluation of the upper abdomen reveals no gross abnormalities.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. 3 cm partially thrombosed pseudoaneurysm or penetrating ulcer of the aortic\n arch 2.5 cm distal to the left SCA.\n 3. Diffuse emphysematous changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-12-22 00:00:00.000",
"description": "Report",
"row_id": 115231,
"text": "Sinus rhythm with increase in rate as compared to the previous tracing\nof . Low limb lead voltage. No diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2161-12-21 00:00:00.000",
"description": "Report",
"row_id": 115232,
"text": "Sinus rhythm. Low limb lead voltage. Technically limited study. Compared to the\nprevious tracing of the rate has slowed. Otherwise, no diagnostic\ninterim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-12-17 00:00:00.000",
"description": "Report",
"row_id": 115233,
"text": "Sinus rhythm. Since the previous tracing of the heart rate has\ndecreased. Otherwise, no significant change in previously seen abnormalities.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-12-16 00:00:00.000",
"description": "Report",
"row_id": 115234,
"text": "Sinus rhythm. Normal tracing as on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847316,
"text": " 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: CHEST PAIN,R/O MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n History of chest pain.\n\n Status post CABG. Heart size is normal. No evidence for CHF. There is\n flattening of the diaphragms secondary to emphysema. Linear atelectasis at\n right lung base. No new pulmonary consolidation or pleural effusion.\n\n IMPRESSION: Emphysema and right basilar atelectasis but no evidence for\n pneumonia or CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-12-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 846990,
"text": " 9:01 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with productive cough and cp and sob ? xray 1 week pta\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71 y/o male with cough, chest pain, and shortness of breath.\n\n TECHNIQUE: PA & lateral chest.\n\n COMPARISON: .\n\n FINDINGS: Sternal wires and mediastinal clips are again noted. Cardiac and\n mediastinal contours are stable and within normal limits. The pulmonary\n vasculature is not engorged. There are unchanged interstitial changes of both\n lungs, most marked at the bases. There are no pleural effusions. Osseous\n structures are unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-24 00:00:00.000",
"description": "Report",
"row_id": 1261811,
"text": "NURSING MICU NOTE 11P-7A\n\nPT 3, MAE, FOLLWOWS COMMANDS. PT DENIES ANY PAIN. PT C/O MILD HEARTBURN FROM DINNER. PT GIVEN 2 TUMS. PT SLEEP OUT MOST OF NIGHT. HR 80-90'S NSR. SBP 90-120'S PER NBP. AM LOPRESSOR AND HYDRALIZINE HELD. PT ALINE DAMPENED, 20POINT LOWER THAN NBP IN SAME ARM.\nPT IS CALLED OUT TO FLOOR, TELE BED. AWAITINGBED ASSIGNMENT. PT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-18 00:00:00.000",
"description": "Report",
"row_id": 1261800,
"text": "pmicu nursing progress 7p-11p addendum\n\npt was finally permitted to eat and enjoyed a .his bp began to increase however and the esmolol was titrated up gradually to a max dose of 116 mcgs/kg/min (from 80), bp was still in the 120's-130/with pt dozing. no c/o chest pain. bp then dipped to the 90's and i've started to wean esmolol back down- goal bp is 100-110/ to protect aneurysm. pt is sleeping.plan is for cardiac cath on monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-19 00:00:00.000",
"description": "Report",
"row_id": 1261801,
"text": "MICU Nursing Progress Note\n Cardiac: on esomol infusion titrating to keep SBP 100-120 however it was requiring to increase esomol infusion without effecting the SBP which was running 120-136/... requiring doses of 150mcg/kg/min. Notified Dr. , Order from Dr. to give 10 mg of IV hydralazine, quickly weaned esomol then needed to stop IVF at 3am as BP down to 70/. slowly came up to 90/ during this time pt was fully mentating, producing urine from 70-90cc/hr. double checking BP with diamapp showed art line correctly BP in the right arm. there is a 40point difference between arms, left>right. Pt was on D5NS at 75cc/hr. stopped at 2 am. then restarted at 4:30 am to help BP will stop again once BP up above 100SBP. Pt denied feeling any CP, SOB, did c/o of back pain though with futher assessment pain located at the base of his spine, reliefed with change in position.\n Respiratory: on Nasal cannula at 2 liters/min. BS diminshed at bases otherwise fine.\n GI: abd soft, + BS no stool, able to take some POS will need to be NPO again for midnight on Sunday night for cath on monday.\n GU: foley in place and draining well. urine yellow.\n ID: afribile.\n Neuro: A&O x 3, able to move in bed, on bedrest. no ambulating., clear speech. cooperative, pleasant gentleman.\n IV access: two perpheral IV;s\n Social: no contact with the family during the night.\n Plan: to monitor closely, goal is to keep SBP 100-120/ cath on monday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-18 00:00:00.000",
"description": "Report",
"row_id": 1261798,
"text": "1900-0700\n\nNeuro: Pt awake/alert/oriented, follows commands well. MAEs. equal and reactive. No neuro deficits noted.\n\nResp: 2L NC on, resp easy and regular, O2sat 93-97%, Lungs clear with bibasilar diminished BS. Denies any SOB. No exertional dsypnea noted.\n\nCV: NSR without ectopy alarms on. HR 70-80, SBP controlled 90-115, MAP 60-70. Esmolol drip titrated prn, currently infusing @ 80 mcg/kg/min. Pt denies CP. MRI completed awaiting results for aortic arch aneurysm. Pulses to ext weak acquired with doppler. A line to R radial positional. No edema noted. Skin warm/dry/intact. Heparin SQ .\n\nGU/GI: Abd round soft + BS, pt c/o of hunger and thrist/remains NPO. No N/V. Protonix IV given. Foley to BSD draining yellow clear urine.\n\nIV: PIV x2, Lt hand, LLa.\n\neview MRI results, await consult of Dr. , ? surgery. Continue Esmolol for BP control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-21 00:00:00.000",
"description": "Report",
"row_id": 1261806,
"text": "FULL CODE Contact Precautions \n\n\nNeuro: AAOx3, MAEx4 spont/command, moves self well in bed.\n\nCV: Pt had cardiac cath today, films reviewed by Drs and . They feel it's an intramural thrombu and not a pseudoanyeurysm and surgery is not required - follow medically. Pt has significant steonis in R brachial ceph artery attributing to the difference in the blood pressures in each arm. Based on central pressures during the procedure, a-line is 40mm lower than actual pressures. Nipride started to maintain SBP <120s, then surgical team rounded and want a-line SBP in 100s. Nipride currently at .7mcg/kgmin w/ SBP 100/63. Cath was done via L radial site and pressure clamp in place - to be removed at 1830. Good perfusion to L hand, 02sat monitor probe on L hand w/ good pleth. Pedal pulses + by doppler, extrems warm, no edema.\n\nResp: 2l n/p w/ 02 sat 98%, lung sound diminished throu-all fields. Congested cough, but non-productive.\n\nGI/GU: Abd soft, +BS, no BM. Taking cardiac diet. On H2B Foley cath w/ clear yellow urine.\n\nPain: No c/o discomfort.\n\nSkin: intact\n\nID: afebrile. No antibx\n\nAccess: PIV x3. R rad a-line\n\nSocial: Wife at bedside. Numerous family members have called.\n\nPlan: Nipride to maintain ABP in 100s. Clamp on L wrist to be d/c'd at 1830. Pain med prn for comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-22 00:00:00.000",
"description": "Report",
"row_id": 1261807,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED X 3 AND MAE. C/O HA AND WAS WITH TYLENOL. NO C/O CHEST PAIN.\n\nRESP: PT HAS EXTREMELY CONGESTED COUGH AND LUNG SOUNDS COARSE THROUGHOUT. PT'S O2 SAT'S WHILE AWAKE ARE IN THE HIGH 90'S BUT WILL DROP TO THE HIGH 80'S WHEN ASLEEP. NC INCREASED WHILE SLEEPING TO 4L.\nPT TAKES INHALERS SELF.\n\nCV: PT'S HR IN NSR WITHOUT ECTOPY WITH RATES IN THE 70'S TO THE 90'S. BP TITRTAED WITH NIPRIDE TO KEEP IN 80-100 RANGE VIA A-LINE. PT HAS RIGHT RADIAL ALINE WHICH IS WORKING WELL. LEFT RADIAL CATH SITE HAS DRESSING WHICH IS DRY AND INTACT. PT HAS PULSES. LEFT HAND ELEVATED ON PILLOW. PT IS AFEBRILE.\n\nGI: PT ON HOUSE DIET, ONLY LIQUIDS OVERNIGHT. ABD SOFT NONTENDER WITH POSITIVE BOWEL SOUNDS.\n\nGU: FOLEY CATH PATENT DRAINING ADEQUATE AMT'S OF PINK TINGED TO YELLOW URINE WITH OCCASIONAL CLOTS.\n\nSKIN: INTACT.\n\nSOCIAL: WIFE VISITED AND CALLED OVERNIGHT AND HAS BEEN UPDATED. PT IS FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-22 00:00:00.000",
"description": "Report",
"row_id": 1261808,
"text": "NPN MICU-B 7AM-3PM\nS/O: C/V: Continues on Nipride Gtt titrating to keep BP 80-100's as per A-line, @ present is on .75mcq/kq/min. Hydralazine increased to 50mg qd which was given @ 11am but with no effect as yet. HR- 70-80 SR with no ectopy noted. No c/'o's CP. L arm site has + pulses, also has + pedal pulses noted with doppler.\n\nRespir: Has congested cough but not productive, is on 2L NP with O2sats 95-99%, does desat with activity to 88-90%. L/S clear course @ bases.\n\nGI: Taking PO's well.\n\nGU: Having adequate u/o, per foley.\n\nID: no temps.\n\nNeuro: A&Ox3. Full code\n\nA/P: Continue to attempt to wean and d/c Nipride Gtt, monitor BP keep 80-100 as per A-line, is 40mm lower then L arm NBP, due to stenosis. Monitor I&O's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-23 00:00:00.000",
"description": "Report",
"row_id": 1261809,
"text": "micu 1900-0700 rn notes\n\nneuro: A/Ox3,open eyes spont, MAE, follows commands. pain managment: c/o back pain, recieved TYLENOL w/relief.\n\nresp: NC 2L, sat96-99%, LS clear to wheezing w/respons to albut. Cough productive/strong\n\ncv: HR 76-91, NSR, no ectopy. NIRIDE off from , recieved 1 dose IV LOPRESSOR 10mg/HYDRALISINE 10mg d/t A-BP 140 w/respons, A-BP 90-130/50-60. Given PO DILTASEM 360mg. Plan: manage SBP 90-100.\ncath on not shown aortic aneurism, but intramural trombus,that not operable by surgery,medical managment, performed PTCA to RCA\n\ngu/gi: foley,u/o >60cc/hr. Abd soft, + BS.\n\nid: afebrile.\n\nsocial:full code,no call from family this shift.\n\nplan: monitoring SBP 90-100, wean NIPRIDE gtt\n transfer to the floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-18 00:00:00.000",
"description": "Report",
"row_id": 1261799,
"text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-hr has been stable without ectopy noted.continues on esmolol at 80 mcgs/kg/min,this has not been changed, maintaining bp (via a-line) at ~100-120/.no c/o chest pain. cardiac US done--> pnd.has weak peripheral pulses.\n\nRESP_wearing 2 litres nasal cannula, no c/o SOB.lungs sound clear anteriorally.sats are >95%.\n\nGI-abd is soft with positive bowel sounds. pt is hungry! on famotidine.no stool today. has been npo for ? surgery.\n\nID-afebrile.wbc=11.3. no new cultures sent.\n\nNEURO-is alert and oriented x 3,cooperative. sleeping in naps.\n\nCOMFORT-c/o R \"tennis elbow\" pain.propped up on pillows with relief.\n\nF/E- maintainence ivf at 75/hr. has had an adequate urinary output of clear yellow urine.no peripheral edema noted.\n\nIV ACCESS-has peripheral heplocks and an a-line R wrist.\n\nSOCIAL-wife in room all day awaiting decision about possible surgery.has been updated with info as i know it.\n\na-stable.uneventful day\n\nP-will keep npo for now. awaiting cardiac to give word regarding possible surgery.continue with esmolol to keep bp <110.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-23 00:00:00.000",
"description": "Report",
"row_id": 1261810,
"text": "MICU NPN 11AM-7PM:\nPt is called out to the floor and may have his a-line d/c'd before transfer unless he goes to VICU bed where he may have the a-line transduced. See call out note for full report.\n\nNeuro: Pt denies pain. OOB to chair with minimal assist with lines/tubes. Denies pain.\n\nCV: Some BP meds held at some doses according to hold parameters. Pt began on PO lopressor 12.5mg PO BID at noon. His hydrochlorathiazide was held today as well as his 8AM and 8PM dose of hydralizine. He did get the 2PM dose of hydralizine but BP did get below 90 at times and UO dropped after this so hold parameter is 110. We are to follow his BP on his right arm.\n\nResp: Pt wanted to see if he could be off his O2 so he has spent the day on room air with O2 sats 92-95%. He does get DOE and has wheezes at times.\n\nGI: Appetite if only fair. No stool today.\n\nGU: UO dropped to 5cc/hr for two hours and pt given 500cc bolus NS at 6PM with some effect. Will follow UO closely and encourage PO's this evening. There is an order to d/c foley at midnight tonight in transfer to floor orders but this will need to be evaluated according to how well pt is urinating and if pt gets bed.\n\nPlan: Pt awaiting a bed assignment on the floor. Initially pt was to go to VICU bed but after discussion with the accepting team it was decided he could be transferred to the floor with telemetry. He is awaiting bed availability at present and will be transferred when it becomes available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-19 00:00:00.000",
"description": "Report",
"row_id": 1261802,
"text": "NPN MICU-B 7AM-7PM\nS/O: C/V: Remains off of Esmolol Gtt, with BP 90-128/55-68, HR-60-80's SR with no ectopy noted. No c/o's CP. Still a 40pt in BP difference between Left arm and R arm, with Left arm being greater. Team is aware and is going by the A-line which is in the Right arm. Has +pulses and lower extremities are warm and dry. Awaiting cath on Monday.\n\nRespir: O2 sats on 2lPN 98-100%, L/S clear to diminished @ bases. RR 20-26, no c/o's SOB.\n\nGI: Taking PO's with just mild appetite. On IFV's D5NS @ 75cc/hr. soft with +BS's.\n\nGU: U/O very adequate. No c/o's.\n\nNeuro: A&Ox3. C/O back pain this AM from lying in bed, rec'd Tylenol with relief.\n\nSocial: Family in visiting all day, very pleasant and supportive.\n\nA/P: Monitor BP maintain between 100-120/60, assess I&O's, assess c/o's CP. Prepare cath on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-20 00:00:00.000",
"description": "Report",
"row_id": 1261803,
"text": "micu 1900-0700 RN notes\n\nneuro: AOx3, open eyes spont, follows commands. PERL. pain management: c/o back pain recieved PO TYLENOL 650mg w/relief\n\nresp: NC 2L, sat 95-99%, RR 16-20, LS coarse/clear, productive cough w/secretion. sputum sent to culture. intermittent epidose to Sats 80's with wheezes recieved AlB neb and routine inhalers with improvement.\n\ncv: HR 72-82,NSR, no ectopy, A-BP 80-120 labile, BP differant R side from L side by 40 points, off ESMOLOL, recieved PO DILTIAZEM and HYDROCHLORTIASIDE, goal SBP> 100 MAPS >60. Morning labs pending\n\ngu/gi: foley, u/o>60/hr. abd soft ,+BS\n\nsocial: full code status, family visites, updates\n\nplan:cath on Monday\n surgery on Tuesday\n monitoring BP>100\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-20 00:00:00.000",
"description": "Report",
"row_id": 1261804,
"text": "NPN MICU-B 7AM-7PM\nS/O: C/V: Remains off of Esmolol Gtt with BP's 100-136/60, HR 70-80's SR with no ectopy noted. No c/o's CP. Started on IVF D5 with 20KCL @ 60cc/hr. C/O back pain due to lying in bed, relieved with Tylenol 650mg PO. Awaiting cath in the AM. Remains on PO Dilt and HCT.\n\nRespir: O2L NP with O2 sats 97-100%, L/S clear no wheezes noted but does have occ congested sounding cough. No SOB.\n\nGI: Taking PO's in small amts, to be NPO this evening for cath in the AM. Had very lrge soft brown OB neg stool.\n\nGU: U/O very good, clear yellow urine.\n\nNeuro: A&Ox3.\n\nIV lines: New # 18 angio placed in Left A/C, with 3d old #20 remains in Left wrist. A-line still in R arm.\n\nA/P: Continue to monitor BP, attempt to keep >130. Prepare for Cath. Monitor I&O's, keep NPO after MN.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-12-21 00:00:00.000",
"description": "Report",
"row_id": 1261805,
"text": "micu 1900-0700 RN notes\n\nneuro: A/Ox3, MAE,PERL. Pain Managment: c/o lower back pain, recieved po TYLENOL 650mg w/relief\n\nresp: RR 18-24 NC 2L, sat 98-99%, LS clear, cough strong/productive\n\ncv: HR 65-85 NSR, no ectopy. A-BP 80-140/50-60, (40 point discrepancy NBP L-R). Remain off ESMOLOL. IV D5 w/KCL @ 60cc/hr, recieved routine DILT/HTZ. recieved Acetylcystein 600mg @0600 for cath. labs morning pending\n\ngu/gi: foley, u/o >60cc/hr, abd soft, +BS, no BM. NPO from midnight\n\nid: afebrile, Tmax 98.9\n\nsocial: full code. Wife called/updated\n\nplan: cath in the AM, plan for surgery on \n pre/post cath ACETYLCESTEIN 600mg\n monitoring BP\n\n\n\n\n"
}
] |
31,809 | 138,978 | Patient is a 39 yo male with a h/o Lyme disease who presents with fevers, chest tightness, abdominal pain, and shortness of breath, and was found to have cardiac tamponade. . # Pericardial Effusion: Patient presented with chest tightness and shortness of breath. CXR demonstrated enlarged cardiac silhouette, and subsequent TTE showed a large pericardial effusion with right atrial collapse. Patient had a pericardialcentesis with 900 cc fluid drained. Fluid was sent for analysis and was found to have 4600 WBC. Gm stain and cultures were all negative. Labs were sent for TB, , ds-DNA, Lyme, and Babesiosis, which were all negative. Thyroid hormones were also within normal limits. The patient had two repeat ECHOs during this hospitalization, which both showed resolution of the tamponade physiology. The patient was discharged with close outpatient follow-up in the clinic. . # Fevers: Patient had persistent fevers since the end of . Serologies for Lyme, Borellia, and Histoplamosis were all negative. Patient's fevers were persistently ~ 102 F prior to admission. During this admission, the patient spiked a fever on day of admission but was afebrile 24 hours prior to discharge. He was discharged with close outpatient follow-up. | Marked diffuse adrenal enlargement. Marked diffuse adrenal enlargement. Physiologic TR.PERICARDIUM: Small to moderate pericardial effusion. Moderate pericardial effusion with enhancing pericardium. Moderate pericardial effusion with enhancing pericardium. Sustained RA diastolic collapse, c/wlow filling pressures or early tamponade.Conclusions:The left atrium is moderately dilated. Small left and tiny right pleural effusions. Small left and tiny right pleural effusions. Small left and tiny right pleural effusions. Normal ascending aorta diameter. There is atrivial/physiologic pericardial effusion. There is a small pericardial effusion. Noechocardiographic signs of tamponade.GENERAL COMMENTS: Left pleural effusion.Conclusions:Regional left ventricular wall motion is normal. There are noechocardiographic signs of tamponade.Compared with the prior study (images reviewed) of , the findings aresimilar. No AR.PERICARDIUM: Small pericardial effusion. No echocardiographic signs oftamponade.Conclusions:The left atrium is mildly dilated. There is a small to moderate sized pericardialeffusion. FINAL REPORT REASON FOR EXAM: Pericardial effusion. Prominentmoderator band/trabeculations are noted in the RV apex.AORTIC VALVE: No AR.MITRAL VALVE: Normal mitral valve leaflets. Trivialmitral regurgitation is seen. doxycyline d/c'd - ? The aortic root is mildly dilated at the sinus level. There is noventricular septal defect. Left lower lobe atelectasis or pneumonic consolidation. No tamponade.Compared with the prior study (images reviewed) of , the largepericardial effusion has nearly resolved. Enlarged cardiac silhouette has slightly decreased. Enlarged cardiac silhouette has slightly decreased. Small right and moderate left pleural effusions are unchanged. Small right and moderate left pleural effusions are unchanged. The aortic root ismildly dilated at the sinus level. Anterior to the right atrium and distalright ventricular free wall, it measures up to 0.8 cm in diameter. Pleural effusions are small on the left and tiny on the right, with adjacent atelectasis. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. FINAL REPORT REASON FOR EXAM: PERICARDIAL AND PLEURAL EFFUSIONS in followup Cardiac silhouette has slightly decreased in size. Marked adrenal hyperplasia. The left upper lung and right lung are well aerated. venous cath site with small dime sized soft hematoma. Serial evaluation 18 hrs s/p pericardiocentesis.Height: (in) 68Weight (lb): 160BSA (m2): 1.86 m2BP (mm Hg): 116/74HR (bpm): 88Status: InpatientDate/Time: at 09:00Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No PS.Physiologic PR.PERICARDIUM: Large pericardial effusion. appearing slightly dyspneic when talking.ID: TM 102po. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Small and large bowel have a normal caliber. Sinus tachycardia. effusion req. The pericardium enhances diffusely. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Contrast reaches the colon. Small right and small-to-moderate left pleural effusions are stable. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 68Weight (lb): 180BSA (m2): 1.96 m2BP (mm Hg): 112/68HR (bpm): 88Status: InpatientDate/Time: at 13:37Test: Portable TTE (Focused views)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal regional LV systolic function. Moderate to large pericardial effusion with pericardial enhancement, a finding that suggests infectious, inflammatory, or neoplastic cause. A few tiny calcified nodules are seen in the atelectatic portions of the lung at the bases. Improved left lower lobe atelectasis. Left lower lobe retrocardiac opacity likely atelectasis has worsened. Left lower lobe retrocardiac opacity likely atelectasis has worsened. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). There is sustained rightatrial collapse, consistent with low filling pressures or early tamponade.IMPRESSION: Large pericardial effusion with echocardiographic signs of earlytamponade.Cardiology consult team was present at the time of study interpretation. The aorta demonstrates a normal course and caliber. FINDINGS: CHEST: A pericardial effusion is moderate to large in size. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Normal aortic valve leaflets (3). Febrile; History of Lyme.Height: (in) 68Weight (lb): 185BSA (m2): 1.98 m2BP (mm Hg): 135/71HR (bpm): 100Status: InpatientDate/Time: at 15:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%decrease during respiration (estimated RA pressure (10-20mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. pulses palp. This is worrisome for pericardial effusion. Admitting Diagnosis: PERICARDIAL TAMPONADE Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated. SC heparin .A/P: s/p pericard. S/P pericardiocentesis.Height: (in) 68Weight (lb): 160BSA (m2): 1.86 m2BP (mm Hg): 107/80HR (bpm): 106Status: InpatientDate/Time: at 19:19Test: TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Trivial/physiologic pericardial effusion. had chest tightness and SOB, worsening- went to ED.ED CXR showing markedly enlarged silhouette. There has been interval increase in small right and moderate left pleural effusion. Right ventricular chamber size and free wall motionare normal. sat up to void. Increased bilateral pleural effusions are small on the right, moderate on the left. Increased bilateral pleural effusions are small on the right, moderate on the left. Possible PR segment depression seen in leads II and V5.Poor R wave progression across the precordium. IMPRESSION: Striking interval enlargement of the cardiac silhouette, concerning for pericardial effusion. There is mild symmetric left ventricular hypertrophy with normalcavity size and regional/global systolic function (LVEF>55%). Soft tissue attenuation infiltrates the anterior mediastinum, without evidence of mass effect. BP 110-120's/ c/o chest pain only with deep inspiration. placed on antibiotics but contin. | 16 | [
{
"category": "Radiology",
"chartdate": "2179-10-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1029840,
"text": " 12:25 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\n effusions\n REASON FOR THIS EXAMINATION:\n please assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 5:23 PM\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\n right and moderate left pleural effusions are unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: PERICARDIAL AND PLEURAL EFFUSIONS in followup\n\n Cardiac silhouette has slightly decreased in size. Improved left lower lobe\n atelectasis. Small right and small-to-moderate left pleural effusions are\n stable. No overt CHF or pneumonia.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2179-10-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1029841,
"text": ", H. 12:25 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion, recently drained, and b/l pleural\n effusions\n REASON FOR THIS EXAMINATION:\n please assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Slight improved left lower lobe consolidation likely atelectasis. Enlarged\n cardiac silhouette has slightly decreased. There is no overt CHF. Small\n right and moderate left pleural effusions are unchanged.\n\n"
},
{
"category": "Echo",
"chartdate": "2179-10-01 00:00:00.000",
"description": "Report",
"row_id": 84039,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Serial evaluation 18 hrs s/p pericardiocentesis.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 116/74\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 09:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. There is a small pericardial effusion. The effusion\nis echo dense, consistent with blood, inflammation or other cellular elements.\nThere are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2179-10-02 00:00:00.000",
"description": "Report",
"row_id": 84030,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 112/68\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 13:37\nTest: Portable TTE (Focused views)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion echo dense, c/w\nblood, inflammation or other cellular elements. Effusion is loculated.\nStranding is visualized within the pericardial space c/w organization. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is a small to moderate sized pericardial\neffusion. The effusion is echo dense, consistent with blood, inflammation or\nother cellular elements. The effusion is largest adjacent to the basal to mid\ninferolateral wall (measures 1.4 cm). Anterior to the right atrium and distal\nright ventricular free wall, it measures up to 0.8 cm in diameter. Stranding\nis visualized within the pericardial space c/w organization. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2179-09-30 00:00:00.000",
"description": "Report",
"row_id": 84031,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Febrile; History of Lyme.\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 135/71\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%\ndecrease during respiration (estimated RA pressure (10-20mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. Sustained RA diastolic collapse, c/w\nlow filling pressures or early tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and regional/global systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is a large pericardial effusion. There is sustained right\natrial collapse, consistent with low filling pressures or early tamponade.\n\nIMPRESSION: Large pericardial effusion with echocardiographic signs of early\ntamponade.\n\nCardiology consult team was present at the time of study interpretation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2179-09-30 00:00:00.000",
"description": "Report",
"row_id": 84040,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/P pericardiocentesis.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 107/80\nHR (bpm): 106\nStatus: Inpatient\nDate/Time: at 19:19\nTest: TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Emergency study performed\nby the cardiology fellow on call.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There is a\ntrivial/physiologic pericardial effusion. There are no echocardiographic signs\nof tamponade.\n\nIMPRESSION: Trivial pericardial effusion. No tamponade.\n\nCompared with the prior study (images reviewed) of , the large\npericardial effusion has nearly resolved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-09-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1029186,
"text": " 1:34 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with fever for weeks\n REASON FOR THIS EXAMINATION:\n eval for acute change\n ______________________________________________________________________________\n WET READ: 2:17 PM\n Striking increase in heart size since , w/increased retrocardiac\n opacity, concerning for pericardial effusion/\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man with fever for weeks.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: Since the prior radiograph, there has been\n a striking enlargement in heart size, with an increase in retrocardiac\n opacity. This is worrisome for pericardial effusion. There is also\n increased opacity at the left lung base, which could represent left lower\n lobe atelectasis or a pneumonic consolidation.\n\n There is no right pleural effusion. The left upper lung and right lung are\n well aerated. There is no pneumothorax. There does not appear to be hilar\n enlargement. Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Striking interval enlargement of the cardiac silhouette,\n concerning for pericardial effusion. Echocardiogram is recommended, and\n cross- sectional imaging could provide further information. Left lower lobe\n atelectasis or pneumonic consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-10-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1029622,
"text": " 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion\n REASON FOR THIS EXAMINATION:\n Please assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 3:11 PM\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\n opacity likely atelectasis has worsened. Increased bilateral pleural\n effusions are small on the right, moderate on the left.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Pericardial effusion.\n\n Comparison is made with prior study, .\n\n Increased cardiac silhouette is stable. There has been interval increase in\n small right and moderate left pleural effusion. Left lower lobe retrocardiac\n atelectasis has increased.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2179-10-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1029623,
"text": ", H. 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess interval change\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pericardial effusion\n REASON FOR THIS EXAMINATION:\n Please assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Enlarged cardiac silhouette is unchanged. Left lower lobe retrocardiac\n opacity likely atelectasis has worsened. Increased bilateral pleural\n effusions are small on the right, moderate on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-10-02 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1029668,
"text": " 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with several months of intermittant fevers, presenting with\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n please evaluate for malignancy, lymph node changes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWic SAT 8:55 PM\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\n would include infectious, inflammatory, and neoplastic etiologies.\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\n adrenal infiltration, for example secondary to tuberculosis, other\n granulomatous diseases, or rare disease such as Erdheim- disease.\n 3. Small left and tiny right pleural effusions.\n 4. Several calcified granulomata in the lung bases.\n 5. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding from adjacent pericarditis or residual thymus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male with fever and pericardial effusion.\n\n TECHNIQUE: CT images were acquired through the chest, abdomen, and pelvis\n after the administration of intravenous contrast. No priors available for\n comparison.\n\n FINDINGS:\n\n CHEST: A pericardial effusion is moderate to large in size. The pericardium\n enhances diffusely. Pleural effusions are small on the left and tiny on the\n right, with adjacent atelectasis. A few tiny calcified nodules are seen in\n the atelectatic portions of the lung at the bases. Soft tissue attenuation\n infiltrates the anterior mediastinum, without evidence of mass effect.\n Mediastinal and axillary lymph nodes are not enlarged by CT criteria. The\n aorta demonstrates a normal course and caliber. No large or central pulmonary\n emboli are demonstrated.\n\n ABDOMEN: A 7-mm low-attenuation lesion in segment VIII (image 2:46) of the\n liver is too small to further characterize. The spleen, pancreas,\n gallbladder, and kidneys demonstrate no focal lesions. The adrenal glands are\n markedly enlarged bilaterally and diffusely. Small and large bowel have a\n normal caliber. Retroperitoneal lymph nodes are not enlarged by CT criteria.\n\n PELVIS: The prostate, seminal vesicles, and urinary bladder appear within\n normal limits. Contrast reaches the colon. Pelvic and inguinal lymph nodes\n are not enlarged.\n (Over)\n\n 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MUSCULOSKELETAL: No focal osseous destructive lesions are demonstrated.\n\n IMPRESSION:\n 1. Moderate to large pericardial effusion with pericardial enhancement, a\n finding that suggests infectious, inflammatory, or neoplastic cause.\n 2. Small left and tiny right pleural effusions.\n 3. Marked adrenal hyperplasia. The differential diagnosis would include\n congenital adrenal hyperplasia, and, in the setting of the associated findings\n described above, other entities such as tuberculosis, other granulomatous\n disease, or rare entities such as Erdheim- disease.\n 4. Several tiny calcified granulomata in the lung bases, consistent with\n prior granulomatous disease such as tuberculosis.\n 5. Tiny hepatic lesions, too small to further characterize.\n 6. Stranding in the subcutaneous fat of the right groin, likely due to prior\n percutaneous vascular access.\n 7. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding, perhaps secondary to adjacent pericarditis. Residual\n thymus may also contribute.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-10-02 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1029669,
"text": ", H. 1:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for malignancy, lymph node changes.\n Admitting Diagnosis: PERICARDIAL TAMPONADE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with several months of intermittant fevers, presenting with\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n please evaluate for malignancy, lymph node changes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Moderate pericardial effusion with enhancing pericardium. Differential\n would include infectious, inflammatory, and neoplastic etiologies.\n 2. Marked diffuse adrenal enlargement. The differential diagnosis would\n include adrenal hyperplasia, for example congenital adrenal hyperplasia, or\n adrenal infiltration, for example secondary to tuberculosis, other\n granulomatous diseases, or rare disease such as Erdheim- disease.\n 3. Small left and tiny right pleural effusions.\n 4. Several calcified granulomata in the lung bases.\n 5. Soft tissue attenuation in the anterior mediastinum may represent\n inflammatory stranding from adjacent pericarditis or residual thymus.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-10-01 00:00:00.000",
"description": "Report",
"row_id": 1666632,
"text": "CCU NPN 1900-0700\nS: \" I can tell my temp is up \"\nO: 39 yo male admitted from cath lab s/p pericardiocentesis.\ndeveloped fevers, joint aches in . placed on antibiotics but contin. with fevers (hx of lyme dz)- lyme serology neg. In - fevers up to 102, neck stiffness, palps. doxycyline d/c'd - ? reaction. This week, pt. had chest tightness and SOB, worsening- went to ED.\nED CXR showing markedly enlarged silhouette. echo- showing large pericardial effusion and RA collapse. cath lab - 1L SS fluid removed.\n\nArrived to CCU ~ 1900. awake, alert. Ox3. c/o chest pain with deep inspiration.\nCV: pericardial drain mid chest- site D/I. transparent dressing intact. bag to gravity drainage. aspirated 1-4 cc seroussang fluid q4hr. ~ 75cc in bag at MN.\nHR 90's ST. no VEA. BP 110-120's/ c/o chest pain only with deep inspiration. no palps.\n\nright fem. venous cath site with small dime sized soft hematoma. pt. sat up to void. no change in site. pulses palp. no pain in area or in back.\n\nResp: LS diminished bases. sats 91-95% on RA. pt. appearing slightly dyspneic when talking.\nID: TM 102po. tylenol q6hr. BC, pericardial cultures pnd. ID consult planned.\n\nGU: voiding with urinal.\nGI: drinking water and snacking on cookies he had in bag from home.\naccess: PIV x1. SC heparin .\nA/P: s/p pericard. effusion req. drain - ID to follow. follow up on cultures, tylenol prn. follow fever curve. PPD to be placed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-10-01 00:00:00.000",
"description": "Report",
"row_id": 1666633,
"text": "CCU NURSING NOTE 0700-1900\nS/O: SEE TRANSFER SUMMARY/SEE CCU FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nCV: VSS, PERICARDIAL DRAIN W/O SIGNIFICANT DRAINAGE THROUGHOUT DAY, PULSUS PARADOX 8 THIS AM, ECHO DONE W/O SIG CHANGE, PERICARDIAL DRAIN D/C'D AT 1400, TOLERATED WELL, PT CONTINUES TO HAVE DISCOMFORT IN CHEST WHICH HAS PERSISTED SINCE PRIOR TO ADMISSION, DOES NOT FEEL HE IS NEED OF PAIN MEDICATION; TAKING TYLENOL FOR TEMPERATURES UP TO 100.4 PO; ID FOLLOWING PATIENT, NOT ON ANTIBX PRESENTLY; AWAITING LAB RESULTS ON PERICARDIAL FLUID/BLOOD/URINE. OOB TO CHAIR AFTER DRAIN PULLED, TOLERATED WELL, R FEM SHEATH SITE, DRAIN SITE D+I, PERIPH PULSES PALP BILAT; MOTHER CALLED FROM - WILL CALL PT LATER THIS EVENING, PT CALLED OUT, AWAITING BED AVAILABILITY FOR TRANSFER TO 3.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2179-10-01 00:00:00.000",
"description": "Report",
"row_id": 226648,
"text": "No significant change compared to tracing #2.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2179-09-30 00:00:00.000",
"description": "Report",
"row_id": 226649,
"text": "No significant change compared to tracing #1 except for taller R waves in\nleads V4-V6, possibly again related to lead placement.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2179-09-30 00:00:00.000",
"description": "Report",
"row_id": 226650,
"text": "Sinus tachycardia. Possible PR segment depression seen in leads II and V5.\nPoor R wave progression across the precordium. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
}
] |
43,774 | 105,720 | The patient arrived in the ED on . On primary and secondary survey, the patient was intoxicated but was otherwise hemodynamically stable and following commands with a GCS of 15. Imaging studies ultimately revealed the following injuries: Comminuted L femur fx Open right ankle fx / near amputation R lateral 2nd and 3rd rib fxs The patient's admission labs also revealed pancreatitis with a lipase of 427 and an alcohol level greater than 400. The patient was admitted to the trauma service. The orthopedic team was consulted and the patient was brought to the OR for washout and ex fix placement of the R ankle. He was started on lovenox. Ortho intended to take the patient back to the OR for ORIF of his R tib/fib fractures. However, on POD1, the patient was noted to have fevers and tachycardia. He was also diaphoretic, agitated and disoriented. He was put on CIWA protocol for alcohol withdrawal and later transferred to the ICU on because he was developing delirium tremens. While in the ICU, the patient required large amounts of valium. He was also receiving haldol and dilaudid with little effect. An NGT was used to decompress his stomach and reduce the risk of aspiration. Because of his worsening progression and increased somnolence, he was later intubated by the SICU team . He was noted to have a Hct of 21 and was therefore received 4 units of pRBCs. On , the patient was again brought to the OR for ORIF of his left femur fracture. At the same time, an IVC filter was placed by the trauma surgery service. Post-op, the patient was left intubated and transferred back to the SICU. He was noted to have fevers overnight and was therefore pancultured and started on broad-spectrum antibiotics. His sputum eventually grew out GNRs. His antibiotics were adjusted appropriately. The patient was eventually started on tube feeds. His vent was weaned and he was extubated . He continued to have altered mental status, delirium and agitation, which was controlled with Zyprexa. He was seen by physical therapy, who recommended discharge to rehab. On , ortho again took the patient to the OR for washout of the right ankle, adjustment of the ex fix, and closed reduction of the tib fib fractures. He was intubated a few hours prior to the OR for increased agitation. It was determined to keep the patient intubated post-op and obtain a head CT to assess for any potential etiology of his prolonged agitation and delirium. This was ultimately negative. The patient was then extubated and transferred to the floor. After this, the patient's mental status was noted to improve markedly. He was then transferred to the orthopedics service for continued management. On , he was confused and agitated for most of the day. He received many doses of haldol, zyprexa, valium with no avail. He tried to get OOB many times and despite mutiple restraints, he fell onto his left side suffering a small left eyebrow abrasion. Xrays were taken of his left femur. The hardware was intact, with slighly more displacement compared to the fluoroscopic images taken in the OR. He was transferred back to the SICU for more close supervision an medical management of his agitation/delirium. He became stable and oriented thereafter. In the AM of he was alert and oriented to person, time, and place. All antibiotics and IV medications were stopped prior to discharge. He is being discharged to today in stable condition, with a knee immoblizer on his left leg and an ex-fix to the right. His staples from his left leg were removed just prior to discharge. | d/c valium addiction RN recommendation HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 28. GNR on sputum and febrile -> started on Vanc/ Zosyn/ Cipro. Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. GNR on sputum and febril -> started on Vanc/ Zosyn/ Cipro. CVS: On clonidine patch. Albuterol 0.083% Neb Soln 7. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Monitor for QT prolognation (haldol and quinolone). Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @ 1316 27. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. Pain: dilaudid prn, Tylenol prn. RENAL: Foley, monitor UOP HEME: Hct monitoring,transfuse as required ENDO: RISS ID: Cefazolin 2gm IV q8hr () Other: Social work/ Addictions consult TLD: Foley, PIV.NGT,ETT IVF: thiamine, d5, folate CONSULTS: ortho, trauma BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas GLYCEMIC CONTROL: RISS PROPHYLAXIS: PPI DVT Lovenox 30 q12hr. NEURO: Recovering from ETOH w/d. NEURO: Recovering from ETOH w/d. GNR on sputum and febril -> started on Vanc/ Zosyn/ Cipro. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Pain: dilaudid prn, Tylenol prn. Monitor for QT prolognation (haldol and quinolone). Will wean sedation to attempt vent wean CVS: Tachycardic/ HTN likely secondary to withdrawal. Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 15. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. Sputum: GNR Other: Social work/ Addictions consult TLD: Foley, PIV.NGT,ETT, aline IVF: thiamine, d5, folate Wound: L femur, R ankle - watch compartments CONSULTS: ortho, trauma BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp Failure GLYCEMIC CONTROL: RISS PROPHYLAXIS: PPI DVT SQH STRESS ULCER H2B VAP BUNDLE yes COMMUNICATIONS: ICU Consent: pending CODE STATUS: full DISPOSITION: SICU Total time: 32 min Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. Restraints prn CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. CVS: Tachycardic/ HTN likely secodary to withdrawal. Endocrine: RISS. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. Intubated dt's and w/d from etoh. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 28. Will wean sedation to attempt vent wean CVS: Tachycardic/ HTN likely secondary to withdrawal. Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order date: @ 1618 15. Pain: dilaudid prn, Tylenol prn. Chief Complaint: HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and washout R ankle and IVC filter, POD 0 washout RLE. Monitor for QT prolognation (haldol and quinolone). ENDO: RISS ID: Cefazolin 2gm IV q8hr (). hospital course c/b hypertension,agitation/delirium, and tachycardia c/w EtOH withdrawal. Alcohol withdrawal with DTs, now intubated after increased somnolence. d/c valium addiction RN recommendation CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. CVS: Tachycardic/ HTN likely secondary to withdrawal. NEURO: Alcohol withdrawal/DT. CXR: left base in the retrocardiac region, likely atelectasis Microbiology: Ucx P Assessment and Plan TRAUMA, S/P ALCOHOL ABUSE with active withdrawal and disorientation NEURO: awake, alert, neuro intact, following commands, A&O x1. Will wean off prop to attempt vent wean CVS: Tachycardic/ HTN likely secodary to withdrawal. Pain: dilaudid PCA, Tylenol prn. Neuro checks Q: 1 Pain: dilaudid PCA, Tylenol prn. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal GI: Regular. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal GI: Regular. Cx w/ H.influ and Shewanella.completed course of levaquin.h/o Intubated for altered mental status from withdrawal. CVS: On clonidine patch. CVS: On clonidine patch. CVS: On clonidine patch. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. CVS: Tachycardic/ HTN likely secondary to withdrawal. HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE washout/ Ex-fix revision Chief complaint: PMHx: ETOH abuse,Varicose veins Current medications: . On SQH for prophylaxis. On SQH for prophylaxis. On SQH for prophylaxis. Leukocytosis noted . Leukocytosis noted . Leukocytosis noted . HEME: Hct 29 on . HEME: Hct 29 on . HEME: Hct 29 on . Post-op course c/b severe etoh withdrawal. ENDO: RISS. ENDO: RISS. ENDO: RISS. WBC 12.1 Pt afebrile and satting well on RA. -ATC and prn IV Haldol. -ATC and prn IV Haldol. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. Pt had been d/c'd to floor and returns to SICU code purple 12/21AM. There is a nondisplaced fracture of the left fibular head (501B:36). Views demonstrate steps related to fixation of a comminuted distal femoral fracture, side not indicated. Small Right pleural effusion and associated atelectasis. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: EX/FIX RIGHT TIBIA Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES FINAL REPORT HISTORY: ORIF FINDINGS: Multiple views from the operating suite show what appear to be external fixation devices in the tibia. | 170 | [
{
"category": "Nursing",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505291,
"text": "Trauma, s/p\n Assessment:\n Temp 100.7 to 98.8 po\n HR 90\ns nsr\n Sbp 140-150\ns when calm, hypertensive to 180\ns with stimulation such\n as suctioning\n Breath sounds clear but diminished in bases\n Suctioned for copious amounts thick yellow secretions\n Abd soft with + bowel sounds\n TF on hold for possible extubation\n Action:\n hemodynamics monitored\n suctioned q1-2 hrs for copious amounts thick yellow secretions\n suctioned for large amounts orally\n Response:\n pt remains lethargic\n arousable only when suctioned then quiets\n placed back on cpap with 10 ips/ 5 peep\n Plan:\n rest overnight\n attempt extubation in am\n resume propofol only if patient becomes agitated\n suction prn\n tube feedings resumed at 1600\n Alcohol abuse\n Assessment:\n Propofol off at 0900\n Very lethargic\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\n No visible sweats or tremors\n Action:\n CIWA scale done\n No valium given this shift\n Response:\n No evidence of DT\n Plan:\n Continue to monitor for DT\n ? d/c valium addiction RN recommendation\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506680,
"text": "TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/ h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\n RSBI 30s this AM.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation. Pt\n following commands on Precedex, but seems confused at times, will plan\n to extubate this AM. Please avoid benzos\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\n prolognation (haldol and quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\n hospitalization. s/p IVC filter.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n () x 14 day course.\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\n Wounds: Soft compartments, will monitor.\n Imaging: None planned\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Addiction Med\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n please d/c as no indication\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 32 mins\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505093,
"text": "TITLE:\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\n auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n URINE CULTURE - At 08:30 PM\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 12:34 AM\n FEVER - 102.1\nF - 09:00 PM\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Vancomycin - 07:49 PM\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\n Ciprofloxacin - 10:27 PM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:00 AM\n Metoprolol - 01:00 PM\n Hydromorphone (Dilaudid) - 03:49 PM\n Pantoprazole (Protonix) - 07:49 PM\n Heparin Sodium (Prophylaxis) - 07:49 PM\n Other medications:\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\n Heparin 5000 UNIT SC BID\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Metoprolol Tartrate 5 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Nicotine Patch 14 mg TD DAILY\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\n Pantoprazole 40 mg IV Q24H\n Cyanocobalamin 50 mcg PO/NG DAILY\n Piperacillin-Tazobactam 4.5 g IV Q8H\n Potassium Phosphate IV Sliding Scale\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Folic Acid/Multivitamin/Thiamine-1000mL NS\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Flowsheet Data as of 12:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.7\nC (99.8\n HR: 93 (82 - 101) bpm\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\n RR: 27 (18 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,921 mL\n 40 mL\n PO:\n TF:\n 277 mL\n 14 mL\n IVF:\n 2,585 mL\n 26 mL\n Blood products:\n Total out:\n 2,275 mL\n 0 mL\n Urine:\n 1,775 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 646 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 494 (466 - 605) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.46/40/155/28/5\n Ve: 12.2 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Rash: left axilla, bruising right chest\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n WBC\n 8.7\n 9.7\n Hct\n 28.7\n 26.8\n 28.1\n Plt\n 169\n 169\n Cr\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n 26\n 29\n Glucose\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n Microbiology: Ucx Negative.\n Sputum: GNR\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506815,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505149,
"text": "Trauma, s/p pedestrian struck, bilateral leg fractures and rib\n fractures\n Assessment:\n Low grade temps 100.7\n HR 80\ns, BP ~120-140\n Fluid balance MN -0500: +370cc\ns. Remains 9 liters\n positive for length of stay.\n Dopplerable pedal pulses bilat\n Left leg with knee immobilizer, ace wrap with DSD under with\n old sero-sang drg.\n Right leg with external fixator, draining yellow fluid from\n heel pin sites, dressing changed.\n Ls clear with suctioning, tan sputum\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\n Not showing signs of ETOH withdrawal, no valium given this\n shift per CIWA scale\n Dilaudid x 1 this shift in preparation for pin care and\n bathing with good effect\n Action:\n VAP protocol\n Pin care\n Repositioned q 2-3 hours\n ABX as ordered\n Tube feeds stopped in preparation for possible extubation.\n Response:\n HR and vitals acceptable\n Remains with low grade fever\n Concerning sputum\n HCT 25.3, no S+S of active bleeding.\n Plan:\n Continue to monitor respiratory status, wean to extubated if\n appropriate\n Continue to monitor for S+S of ETOH withdrawal\n Continue ABX as ordered, follow up on pending culture\n results.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505165,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Remain on minimal PSV,\n increased briefly on IPS of 10 cmh20, back down.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: on minimal propofol. ? precedex.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~54. ? elective extubation.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506816,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n : washout RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506058,
"text": "Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - Minimal response from zyprexa\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505327,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchron\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Plan to extubate in am.\n"
},
{
"category": "General",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Generic Note",
"row_id": 507540,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent after valium.\n Agitated with awake. Previosly in DT - needed excessive valium. Now\n still delirious. Need frequent re-orientation with restriants. Haldol\n PO and IV prn Ativan. ? Withdrawal from benzos. Will ask psych to\n evaluate and input in the management of patient.\n CVS: On clonidine patch. Beta blockade. HD stable.\n PULM: room air saturating well. h/o HAP likely aspiration. Cx w/ H.\n nflu and Shewanella completed course of levaquin. h/o Intubation \n for altered mental status from withdrawal.\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley. Otherwise no issues\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS with adequate glucose control. Keep < 150 Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505397,
"text": "pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 505909,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Trauma, alcohol intoxicated\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown.\n Current medications:\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\n Temporary central access (ICU) Location: Left Subclavian, Date\n inserted: Order date: @ 1336 16. IV access request:\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\n line Order date: @ 1454 17. Insulin SC (per Insulin\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\n Q24H Order date: @ 1316\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1316\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\n 1406\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n Extubated. Minimized narcotics. More awake. Agitated at night req\n restraints and zyprexa.\n Post operative day:\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\n Ciprofloxacin - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:04 PM\n Metoprolol - 12:40 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 79 (72 - 82) bpm\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\n RR: 20 (14 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: -2 (-2 - 12) mmHg\n Total In:\n 3,520 mL\n 592 mL\n PO:\n Tube feeding:\n 1,440 mL\n 309 mL\n IV Fluid:\n 2,020 mL\n 283 mL\n Blood products:\n Total out:\n 3,500 mL\n 1,280 mL\n Urine:\n 3,435 mL\n 1,280 mL\n NG:\n 65 mL\n Stool:\n Drains:\n Balance:\n 20 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Creatinine\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\n for w/drawal. Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent: 35 min\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505370,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt remain stable on PSV settings with no issues this shift.\n Pt tidal volumes, Resp rate, oxygen saturations all within normal\n range. Pt had clear lung sounds, with a strong cough. Pt is off all\n IV sedation, and is being monitored for improving mental status and\n awareness. Pt to be assessed by MD team for possible extubation.\n BEDSIDE RSBI- 76\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505911,
"text": "Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused and agitated most of night, oriented to self,\n continually tries to get out of bed, says:\nI have to go to \nI need my money\n. Hard to redirect. When told he is in the hospital\n patient looks shocked. Consistently putting legs over side rail.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Given 5 mg Olanzapine for agitation.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night, more calm after olanzapine given.\n Plan:\n Continue to monitor, reorient frequently.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505576,
"text": "pt is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n - to return to OR for procedure on RLE Tuesday ?\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505812,
"text": "Trauma, s/p\n Assessment:\n - pt more alert today, compared with yesterday\ns assessment by this\n nurse. Oriented X 1, better able to understand speech, confused,\n oriented at times, needs frequent re-orientation and re-direction\n - lungs clear, rhonchorous at times but clear with coughing\n - strong productive cough, absent gag\n - yellow drainage on pad of RLE\n - face tent 35% humidified\n Action:\n - mouth swabs to moisten oral cavity\n - encouraged coughing and deep breathing\n - OOB to chair\n - did not try pt on clear liquids at this time, uncooperative at times,\n absent gag reflex.\n - frequent pin care as needed\n Response:\n - expectorating lg amts of white secretions\n - slid pt over to stretcher chair with careful movement of legs, pt sat\n up in chair with head elevated and legs out straight at a slight angle\n for approx 2 hrs\n - tolerating TF at goal, 15cc residual\n - sm brown soft formed BM X 1\n - sats 97-100% throughout shift\n Plan:\n - continue turning/repositioning, encourage coughing, deep breathing\n - monitor respiratory status, face tent 35% for humidification of\n secretions\n - frequently re-orient pt as needed\n - to Return to OR Tuessay ? for internal fixation of R leg\n"
},
{
"category": "Nutrition",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 506045,
"text": "Subjective: patient delirious, confused, A&O x1.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 95.3 kg ( 12:00 AM)\n 28.2\n Pertinent medications: normal saline @ 55mL/hr, ABx,\n cyanocobalamin, protonix, heparin, multivitamin, folic acid, thiamine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 01:53 AM\n Glucose Finger Stick\n 120\n 10:00 PM\n BUN\n 13 mg/dL\n 01:53 AM\n Creatinine\n 0.6 mg/dL\n 01:53 AM\n Sodium\n 142 mEq/L\n 01:53 AM\n Potassium\n 3.9 mEq/L\n 01:53 AM\n Chloride\n 107 mEq/L\n 01:53 AM\n TCO2\n 26 mEq/L\n 01:53 AM\n PO2 (arterial)\n 162 mm Hg\n 02:50 AM\n PCO2 (arterial)\n 37 mm Hg\n 02:50 AM\n pH (arterial)\n 7.47 units\n 02:50 AM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:50 AM\n Calcium non-ionized\n 8.4 mg/dL\n 01:53 AM\n Phosphorus\n 3.1 mg/dL\n 01:53 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.1 mg/dL\n 01:53 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 7.1 K/uL\n 01:53 AM\n Hgb\n 9.0 g/dL\n 01:53 AM\n Hematocrit\n 27.0 %\n 01:53 AM\n Current diet order / nutrition support: Tube Feeds: Replete with fiber\n @ 60mL/hr (1440kcals, 89g protien)\\\n Diet: NPO\n GI: abd soft, bowel sounds present\n Assessment of Nutritional Status\n 50 y.o. Male ped vs auto with multiple orthopedic injuries s/p RLE\n ExFix, rib fractures, s/p L femur ORIF, right ankle external fixation\n removal + ORIF. s/p IVC filter. Patient also with alcohol withdrawal\n with DTs, initially intubated after increased somnolence, now extubated\n as of . Patient is receiving tube feeds via NGT for nutrition;\n current tube feeds do not meet nutritional needs. Recommend increasing\n goal rate to meet 100% of est. calorie and protein needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend increasing tube feed goal to 95mL/hr (2280kcals,\n 141g protein).\n Monitor tolerance with abd exam and residual checks.\n Monitor lytes and hydration.\n Following - #\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505423,
"text": "pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil move slowly.\n Hct 26 .6\n Vanco level 4.8\n Suctioned for copiius amts of thick tan\nyellow sputum.\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n On iv vanco, pipercillin and cipro.\n Response:\n Vital signs stable\n Remains off all sedation.\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505428,
"text": "HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n MULTI LUMEN - START 01:30 PM\n FEVER - 101.6\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Ciprofloxacin - 09:56 AM\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:54 PM\n Pantoprazole (Protonix) - 08:32 PM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Flowsheet Data as of 01:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.9\nC (100.3\n HR: 91 (83 - 100) bpm\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\n RR: 28 (21 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (11 - 16)mmHg\n Total In:\n 2,933 mL\n 109 mL\n PO:\n TF:\n 454 mL\n 52 mL\n IVF:\n 2,479 mL\n 57 mL\n Blood products:\n Total out:\n 2,930 mL\n 0 mL\n Urine:\n 2,930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (411 - 624) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.45/45/132/27/7\n Ve: 10.7 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: bases)\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 199 K/uL\n 8.5 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 25.3 %\n 8.0 K/uL\n [image002.jpg]\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n WBC\n 9.7\n 8.0\n Hct\n 26.8\n 28.1\n 25.3\n Plt\n 169\n 199\n Cr\n 0.7\n 0.6\n 0.6\n TCO2\n 28\n 27\n 29\n 26\n 29\n 32\n Glucose\n 87\n 104\n 121\n 128\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febrile -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\n Fiber (Full) - 04:00 PM 50 mL/hour\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Total time spent: 32 min\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505560,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments:\n Pt weaned and extubated without complications.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505562,
"text": " s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n -\n Action:\n - extubated at approx 1330\n -\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505573,
"text": " s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505574,
"text": " s/p ex-fix R tib/fib ID and ex fix R ankle ORIF L femur\n ORIF L distal femur fx and IVC filter \n OR for IVC filter and ORIF L distal femur fx Restarted SQH, postop\n hct 26.8. febrile\n pan cultured\n Trauma, s/p\n Assessment:\n - appears sedated at start of shift, slightly opening eyes to\n voice/stimulation\n - slowly waking up throughout the morning, pt wide awake\n sitting up in bed mouthing words and nodding head inconsistently,\n following simple commands\n Action:\n - extubated at approx 1330\n - coughing/deep breathing, chest pt, repositioning\n - pin care and changed dressing frequently\n Response:\n - tolerating extubation well, strong productive cough, pt will\n spit secretions, wear mask. Needs lg amt of encouragement to\n cough/deep breathe\n - difficult to understand what pt is saying, garbled,\n congested speech\n - sm-mod amt of yellow drainage from RLE pins\n Plan:\n - face tent with humidified O2\n - aggressive pulmonary toileting, coughing/deep breathing,\n chest PT\n - monitor neuro status, reoirient as needed\n - pin care as needed\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506035,
"text": "Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n Action:\n - removed restraints, constant observation, frequent\n re-orienting and re-directing\n - encouraged coughing/deep breathing\n - OOB to chair\n - zyprexa order changed to TID, given as ordered\n Response:\n - pt continues to be delirious\n - slid pt using slide board over to stretcher chair, sat\n upright with\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506310,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505809,
"text": "Trauma, s/p\n Assessment:\n - pt more alert today, compared with yesterday\ns assessment by this\n nurse. Oriented X 1, better able to understand speech, confused,\n oriented at times, needs frequent re-orientation and re-direction\n - lungs clear, rhonchorous at times but clear with coughing\n - strong productive cough, absent gag\n -\n Action:\n - mouth swabs to moisten oral cavity\n - encouraged coughing and deep breathing\n - OOB to chair\n Response:\n - expectorating lg amts of white secretions\n - slid pt over to stretcher chair with careful movement of legs, pt sat\n up in chair with head elevated and legs out straight at a slight angle\n for approx 2 hrs\n -\n Plan:\n -\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504623,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Adjust\n Min. ventilation to control pH, Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions,\n Underlying illness not resolved; Comments: Pt remains on PSV settings\n with no changes this shift. Pt remains stable as per tidal volumes,\n RR, SpO2 and airway pressures. Pt had no significant issues this\n shift. Pt to OR today and plan of care to be determined by MD team.\n BEDSIDE RSBI- 72\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506422,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, continuously\n trying to get OOB, very hard of hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Pt partially pulled out NGT. NGT found halfway in so it was\n re-inserted, chest xray done which showed it was in too far. NGT was\n drawn back. Now awaiting repeat chest xray\n - 0.5mg Ativan X 1 for agitation due to inability to give PO\n zyprexa\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n - on soft formed brown BM, used bedpan\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - follow up with repeat chest xray\n - OR today for RLE washout and internal fixation ? OR time\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505613,
"text": "Trauma, s/p\n Assessment:\n Patient is extubated and oriented x 1. Confused and believes he is in\n , constantly says he has to leave, trying to pull at lines and\n NG when unrestrained, able to redirect.\n Serous output from pin site on R leg, pin sites clean.\n L knee immobilizer in place, incision clean and dry.\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\n to touch.\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\n patient able to clear on own, sating 95-100% on 40% face tent.\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\n Action:\n Turned and repositioned for comfort,\n Pin care done q 4 hours during shift,\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\n breathe.\n Response:\n Patient continues to be confused, able to state name only.\n Plan:\n Continue to monitor, pulm. Toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505703,
"text": "24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Ciprofloxacin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:52 PM\n Metoprolol - 06:02 AM\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.4\nC (99.4\n HR: 81 (75 - 99) bpm\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\n RR: 20 (19 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 6 (0 - 14)mmHg\n Total In:\n 2,912 mL\n 844 mL\n PO:\n TF:\n 972 mL\n 388 mL\n IVF:\n 1,880 mL\n 456 mL\n Blood products:\n Total out:\n 2,950 mL\n 1,050 mL\n Urine:\n 2,920 mL\n 1,020 mL\n NG:\n 30 mL\n 30 mL\n Stool:\n Drains:\n Balance:\n -38 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/162/27/4\n Ve: 11.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: Sedated but follows commands, reluctantly\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 307 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 104 mEq/L\n 137 mEq/L\n 25.4 %\n 7.8 K/uL\n [image002.jpg]\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n Plt\n 199\n 226\n 259\n 307\n Cr\n 0.6\n 0.5\n 0.6\n TCO2\n 29\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Recovering from ETOH w/d.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, s/p resp\n failure\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n : Time spent 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506106,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve psychiatric services\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506369,
"text": "Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, very hard of\n hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - OR today for RLE washout and internal fixation\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506370,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - pt alert, oriented X , confused/agitated, continuously\n trying to get OOB, very hard of hearing\n - lungs clear, rhonchorous at times, clearing with strong\n productive cough\n Action:\n - zyprexa PO TID\n - Zyprexa IM X 1\n - Constant reorienting, redirecting, monitoring pt for high\n fall risk\n - Antibiotics given as ordered\n - Pin care and dressing changed PRN\n Response:\n - minimal response from zyprexa doses, pt continues to be\n confused/agitated\n - pt awake throughout shift, SICU and trauma teams aware\n Plan:\n - continue to monitor neuro status, frequent reorienting and\n redirecting\n - pt will require sitter when transferred to CC6 for\n agitation, confusion, high fall risk, and risk of injuring lower\n extremities\n - OR today for RLE washout and internal fixation ? OR time\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505669,
"text": "Trauma, s/p\n Assessment:\n Patient is extubated and oriented x 1. Confused and believes he is in\n , constantly says he has to leave, trying to pull at lines and\n NG when unrestrained, able to redirect.\n Serous output from pin site on R leg, pin sites clean.\n L knee immobilizer in place, incision clean and dry.\n Pedal pulses dopplerable, cap refill brisk in lower extremities, warm\n to touch.\n T max 99.2, diaphoretic, copioius amounts of thin white secretions,\n patient able to clear on own, sating 95-100% on 40% face tent.\n Continues on tubefeeds at 60 cc/hr, minimal residuals.\n Action:\n Turned and repositioned for comfort,\n Pin care done q 4 hours during shift,\n Aggressive pulmonary toilet, patient encouraged to Cough and deep\n breathe.\n Response:\n Patient continues to be confused, able to state name only.\n Plan:\n Continue to monitor, pulm. Toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505676,
"text": "24 Hour Events: HPI: 51M tranfer from Hospital intoxicated ped\n vs auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Ciprofloxacin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:52 PM\n Metoprolol - 06:02 AM\n Other medications:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.4\nC (99.4\n HR: 81 (75 - 99) bpm\n BP: 130/70(93) {102/52(70) - 142/75(100)} mmHg\n RR: 20 (19 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 6 (0 - 14)mmHg\n Total In:\n 2,912 mL\n 844 mL\n PO:\n TF:\n 972 mL\n 388 mL\n IVF:\n 1,880 mL\n 456 mL\n Blood products:\n Total out:\n 2,950 mL\n 1,050 mL\n Urine:\n 2,920 mL\n 1,020 mL\n NG:\n 30 mL\n 30 mL\n Stool:\n Drains:\n Balance:\n -38 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/162/27/4\n Ve: 11.1 L/min\n PaO2 / FiO2: 463\n Physical Examination\n General Appearance: Sedated but follows commands, reluctantly\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 307 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 104 mEq/L\n 137 mEq/L\n 25.4 %\n 7.8 K/uL\n [image002.jpg]\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n Plt\n 199\n 226\n 259\n 307\n Cr\n 0.6\n 0.5\n 0.6\n TCO2\n 29\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Recovering from ETOH w/d.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n :\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506108,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse, social work\n notified. Pts family states last name is spelt , admitting\n notified and change made in system\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n - mother and sister will be staying with friend\n locally, will be in to visit pt in the morning. Able to reach them\n if needed at number: \n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve psychiatric services.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504708,
"text": "Pt with multiple injuries and DTs\n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct monitoring,transfuse as required\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent 32 min\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 506541,
"text": "Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Pt intubated several hours pre-op for increased agitation. To OR for\n washout and maneuvering of fixation devices. CT tonight. Probable\n extubation in AM.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504675,
"text": "24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct 36 -> 26 -> 21, s/p 2u pRBC --> 25.5 --> 2u PRBC prior to\n going to OR per anesthesia request --> HCT 29.8 --> 28.7\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504682,
"text": "24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:39 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:13 PM\n Enoxaparin (Lovenox) - 08:16 PM\n Diazepam (Valium) - 07:30 AM\n Hydromorphone (Dilaudid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (70 - 86) bpm\n BP: 154/80(107) {94/52(67) - 154/80(107)} mmHg\n RR: 23 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 4,497 mL\n 1,104 mL\n PO:\n TF:\n IVF:\n 3,022 mL\n 1,104 mL\n Blood products:\n 1,475 mL\n Total out:\n 1,730 mL\n 1,210 mL\n Urine:\n 1,730 mL\n 510 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 2,767 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 384 (384 - 753) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/45/155/27/3\n Ve: 9.9 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 2+, Right ankle external fixation\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.9 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.7 %\n 8.7 K/uL\n [image002.jpg]\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n 04:13 AM\n 11:04 AM\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n WBC\n 9.3\n 6.6\n 8.3\n 8.7\n 7.5\n 8.7\n Hct\n 26.0\n 21.3\n 25.5\n 29.5\n 29.8\n 28.7\n Plt\n 152\n 153\n 164\n 141\n 154\n 169\n Cr\n 0.7\n 0.6\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n 30\n Glucose\n 124\n 83\n 97\n 104\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. ?IVC filter.\n .\n NEURO: Intubated for airway protection. Propofol gtt. Alcohol\n withdrawal. Valium CIWA prn. Significant valium requirement. Pain:\n dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Hct monitoring,transfuse as required\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr ()\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: thiamine, d5, folate\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12hr. Held this AM for surgery.\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504936,
"text": ".\n HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Post operative day:\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Pantoprazole (Protonix) - 08:02 PM\n Hydromorphone (Dilaudid) - 08:02 PM\n Diazepam (Valium) - 10:50 PM\n Metoprolol - 12:15 AM\n Other medications:\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1316 19.\n Metoprolol Tartrate 5 mg IV Q6H\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\n DAILY Order date: @ 1316\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\n Order date: @ 1316\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\n TO SEDATION Order date: @ 1316\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\n hold oral thiamine, folate and multivitamins. Order date: \n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.5\nC (101.3\n HR: 96 (72 - 101) bpm\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\n RR: 25 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 5,831 mL\n 655 mL\n PO:\n TF:\n IVF:\n 5,831 mL\n 655 mL\n Blood products:\n Total out:\n 2,520 mL\n 425 mL\n Urine:\n 1,580 mL\n 425 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 3,311 mL\n 230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 530) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI: 72\n PIP: 21 cmH2O\n Plateau: 25 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/43/120/28/3\n Ve: 14.3 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Clubbing\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n WBC\n 8.7\n 7.5\n 8.7\n 9.7\n Hct\n 29.5\n 29.8\n 28.7\n 26.8\n 28.1\n Plt\n 141\n 154\n 169\n 169\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n Glucose\n 97\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean sedation to attempt vent wean\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\n check NG tube position\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: D/CCefazolin 2gm IV q8hr (). Febrile - pan cultured. Change to\n Zosyn. Sputum: GNR\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch compartments\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\n Failure\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Total time: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504951,
"text": "HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 506775,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n :\n Respiratory Care Shift Procedures\n Comments: pt extubated to 70% cool aerosol, now on nasal cannula. Pt is\n tolerating well. Meds : alb nebs q6 prn.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504643,
"text": "HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Trauma, s/p\n Assessment:\n Remains intubated and sedated on propofol gtt.\n Diaphoretic break through during the nite\n Breath sounds rhonchous\n Pupils #2 and reacts briskly.\n Moves upper extremities on the bed.\n No movement in lower extremites\n Suctioned for thick yellow sputum.\n Hct 28.7\n Action:\n Suctioned prn\n Vap mouth care as ordered\n Npo for or today.\n On propofol gtt and infusing at 40mcg/hr.\n Iv lactatated ringers at 100cc/hr.\n Valium 10mg iv prn given\n Hydromorphone 1mg iv prn given.\n Pin care done to right foot and foot draining serous drainage.\n Type and screen specimen sent to the blood bank.\n Response:\n Patient remains intubated and sedated.\n Npo for the or today.\n Plan:\n Monitor condition closely.\n To or for femur repair\n Update cousin of patient\ns condition.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504764,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Fully sedated @ present time\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n 50 yr old male ped vs auto with\n( femur tib and bilateral rib fx.\n Patient went to OR for repair. Upon his return patient is placed on\n mechanical ventilation sedated with good ABG. CXR persitent low lung\n volume with atelectasis @ bases. BS diminished suctioned for small\n white thick secretion\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504766,
"text": "Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors,\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504770,
"text": "Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors, diaphoretic.\n Action:\n Taken to OR for internal fixation of right fib/tib fx (unable to do\n because of swelling) and repair of L femur fx.\n L knee immobilizer on and original dsg with ace bandage over it from\n OR. Sanginous drainage noted.\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\n Banana bag given,\n Pin care and incision care done on R leg .\n Response:\n Patient continues on prop and intubated on CMV.\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504776,
"text": "Trauma, s/p\n Assessment:\n Patient S/P MVA, L comminuted femur fx, R tib/fib fx, bilat. Rib fx.\n Right leg has external fixation in place, pins look pinkish, serosang\n drainage from pin sites and incision, L knee immobilizer on.\n Intubated and sedated on propofol.\n When woken up patient unable to follow commands, face very red, bites\n on tube, tremors, diaphoretic.\n Action:\n Taken to OR for internal fixation of right fib/tib fx (unable to do\n because of swelling) and repair of L femur fx. Also placement of IVC\n filter.\n L knee immobilizer on and original dsg with ace bandage over it from\n OR. Sanginous drainage noted.\n Given IV dilaudid for pain (dose increased), IV valium to tx DT\n Banana bag given,\n Pin care and incision care done on R leg .\n Response:\n Patient continues on prop and intubated on CMV. HR 80\ns-90\ns NSR, SBP\n 100-120.\n Plan:\n Continue to monitor.\n Alcohol abuse\n Assessment:\n Patient has hx of alcohol abuse (admitted to 12 beers/day) Came in to\n ED with alcohol blood level of 400). Continues to be\n sedated on prop, when woken up patient is unable to follow commands,\n face very red, bites on tube, tremors, diaphoretic.\n Action:\n Given 10 mg IV valium per CIWA scale q 1-2 hours.\n Response:\n Vital signs stable, SBP 100-120, HR 80\ns-90\ns, patient appears\n comfortable after valium given.\n Plan:\n Continue to monitor, continue with CIWA scale.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505058,
"text": "HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements lungs clear upper lobes diminished in lower lobes\n suctioned for thick tan secretions, and copious amounts of thin oral\n secretions abd soft + bowel sounds + flatus no bm Foley patent\n draining amber urine pin care done + pulses by Doppler + cap refill. T\n max 99.0 heart rate 80-90\ns sinus rhythm systolic 90-120\n over 60\n Action:\n Tube feeding replete with fiber started through NG tube patient started\n on vancomycin, cipro for VAP central line placed for access confirmed\n by x-ray. Ventilator settings changed to 10/10 then weaned to \n Response:\n Patient tolerating vent settings remains stable at this time.\n Plan:\n Continue with current plan of care provide comfort and support as\n needed notify team of any changes\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505061,
"text": "Day of mechanical ventilation: 4\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Weaned to CSV, eventually to with good ABG\ns. Possible extubation\n in AM.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504844,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 80.7\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504887,
"text": "Trauma, s/p leg fractures\n Assessment:\n Febrile to 102\n Tachycardic to low 100\ns with PVC\n Diaphoretic\n Sedated on Propofol\n Period of hypotension\n HCT and electrolytes checked\n Adequate urine output 45-100 cc\ns/hr.\n Dopplerable pulses bilateral lower extremities\n Action:\n X1 peripheral BC, U/A, C+S, and sputum samples sent\n Valium x1 given\n Dilaudid x1 given\n LR 500 cc fluid bolus for hypotension\n Magnesium and calcium repleated\n Propofol stopped for daily wakeup, patient biting on ETT, no\n other purposeful movement noted, unable to finish exam before having to\n restart sedation.\n Suctioned for copious amounts of tan sputum @ ~ 0530\n VAP protocol\n Pin care done\n Left knee remains in immobilizer with visible sero-sang\n drainage on original dressing.\n Response:\n Fluid balance for + 3 liters\n No further signs of DT\ns / tremors after valium given\n Remains febrile\n Hypotension resolved\n Plan:\n Continue to monitor for S+S of DT\n Continue to check and correct electrolyte imbalances\n Wean ventilator\n Follow up on culture results\n Follow up with ortho on plans for future surgeries\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505197,
"text": "TITLE:\n 24 Hour Events: 51M tranfer from Hospital intoxicated ped vs\n auto. B/L LE injuries including an open tib/fib on R and comminuted\n femur fracture on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable\n lesion on CT ? mass vs pna on R. VSS. Intoxicated with ETOH in 400's at\n Hospital. Denies PMHx, but intoxicated. Hypertension, change in\n MS, and tachycardia c/e etoh withdrawal requiring >10 mg valium q hr\n prompting admission to ICU.\n URINE CULTURE - At 08:30 PM\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 12:34 AM\n FEVER - 102.1\nF - 09:00 PM\n : Started on zosyn for GNR on sputum and prophylaxis s/p exfix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Vancomycin - 07:49 PM\n Piperacillin/Tazobactam (Zosyn) - 09:31 PM\n Ciprofloxacin - 10:27 PM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:00 AM\n Metoprolol - 01:00 PM\n Hydromorphone (Dilaudid) - 03:49 PM\n Pantoprazole (Protonix) - 07:49 PM\n Heparin Sodium (Prophylaxis) - 07:49 PM\n Other medications:\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain\n Heparin 5000 UNIT SC BID\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Metoprolol Tartrate 5 mg IV Q6H\n Ciprofloxacin 400 mg IV Q12H\n Nicotine Patch 14 mg TD DAILY\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON\n Pantoprazole 40 mg IV Q24H\n Cyanocobalamin 50 mcg PO/NG DAILY\n Piperacillin-Tazobactam 4.5 g IV Q8H\n Potassium Phosphate IV Sliding Scale\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Folic Acid/Multivitamin/Thiamine-1000mL NS\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Flowsheet Data as of 12:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.7\nC (99.8\n HR: 93 (82 - 101) bpm\n BP: 106/59(76) {85/50(63) - 140/76(97)} mmHg\n RR: 27 (18 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,921 mL\n 40 mL\n PO:\n TF:\n 277 mL\n 14 mL\n IVF:\n 2,585 mL\n 26 mL\n Blood products:\n Total out:\n 2,275 mL\n 0 mL\n Urine:\n 1,775 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 646 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 494 (466 - 605) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.46/40/155/28/5\n Ve: 12.2 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Rash: left axilla, bruising right chest\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n WBC\n 8.7\n 9.7\n Hct\n 28.7\n 26.8\n 28.1\n Plt\n 169\n 169\n Cr\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n 26\n 29\n Glucose\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR:R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n Microbiology: Ucx Negative.\n Sputum: GNR\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs, now intubated after increased\n somnolence. Going to OR today for L femur ORIF, right ankle external\n fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas, Resp\n Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:05 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 min\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506820,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n : washout RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n PEDESRTRIAN STRUCK, LEG FRACTURES\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 94.5 kg\n Daily weight:\n 91.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\n withdrawing from alcholol and requiring q1hr valium. heart rate\n 130-140's. very agitated and requiring constant watch. npo for or on\n monday to repair left femur.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:68\n Temperature:\n 100.7\n Arterial BP:\n S:123\n D:83\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,938 mL\n 24h total out:\n 2,265 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:30 AM\n Potassium:\n 4.4 mEq/L\n 02:30 AM\n Chloride:\n 110 mEq/L\n 02:30 AM\n CO2:\n 26 mEq/L\n 02:30 AM\n BUN:\n 12 mg/dL\n 02:30 AM\n Creatinine:\n 0.8 mg/dL\n 02:30 AM\n Glucose:\n 95 mg/dL\n 02:30 AM\n Hematocrit:\n 29.1 %\n 08:13 AM\n Finger Stick Glucose:\n 95\n 07:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: cc6\n Date & time of Transfer: 09:00 PM\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505033,
"text": "HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505041,
"text": "HPI: 51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Trauma, s/p\n Assessment:\n Patient vented and sedated when sedation lightened patient has\n purposeful movements lungs clear upper lobes diminished in lower lobes\n suctioned for thick tan secretions, and copious amounts of thin oral\n secretions abd soft + bowel sounds + flatus no bm Foley patent\n draining amber urine pin care done + pulses by Doppler + cap refill. T\n max 99.0 heart rate 80-90\ns sinus rhythm systolic 90-120\n over 60\n Action:\n Tube feeding replete with fiber started through NG tube patient started\n on vancomycin, cipro for VAP central line placed for access confirmed\n by x-ray. Ventilator settings changed to 10/10 then weaned to \n Response:\n Patient tolerating vent settings remains stable at this time.\n Plan:\n Continue with current plan of care provide comfort and support as\n needed notify team of any changes\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506589,
"text": "TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/24 h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS)\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation.\n Consider LP or further imaging for continued AMS.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: Extubate today, HAP likely aspiration. Cx w/ H.influ and\n Shewanella. Now on Levaquin (). Intubated for altered mental\n status from withdrawal. Reintubated for increasing agitation and in\n prep for OR. Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter.\n Endocrine: RISS\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC\n Wounds:\n Imaging:\n Fluids: D5NS\n Consults: Trauma surgery, Ortho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506651,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n Alcohol abuse\n Assessment:\n Propofol gtt for sedation till after head CT as above then precedex\n started and propofol transiently weaned to off, pt given dilaudid PRN\n for pain management\n Action:\n Precedex titrated up as needed\n Response:\n Pt awoke with a bang while on just precdeax\n Plan:\n Team requests pt be resedated on propofol at this time, will attempt to\n lighten again later this AM after rounds and ? extubated at that time.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 505964,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Trauma, alcohol intoxicated\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown.\n Current medications:\n Heparin 5000 UNIT SC BID Order date: @ 1316 2. IV access:\n Temporary central access (ICU) Location: Left Subclavian, Date\n inserted: Order date: @ 1336 16. IV access request:\n Peripheral Place Urgency: Routine Order date: @ 1316 3. OK to use\n line Order date: @ 1454 17. Insulin SC (per Insulin\n Flowsheet) Sliding Scale Order date: @ 2158 4. 1000 mL 1/2NS\n Continuous at 55 ml/hr Order date: @ 1625 18. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1316 5. Acetaminophen 650 mg PO\n Q4H:PRN pain, t>100 Order date: @ 1316 19. Metoprolol Tartrate 5\n mg IV Q6 Hold for HR < 60 Order date: @ 1316 6. Calcium\n Gluconate IV Sliding Scale Order date: @ 1316 20. Multivitamins\n 1 TAB PO/NG DAILY Order date: @ 1406 7. Ciprofloxacin 400 mg IV\n Q12H Order date: @ 0807 21. Nicotine Patch 14 mg TD DAILY Order\n date: @ 1316 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n Order date: @ 1406 22. Olanzapine 5 mg PO DAILY Order date:\n @ 0246 9. Cyanocobalamin 50 mcg PO/NG DAILY\n when taking PO Order date: @ 1316 23. Pantoprazole 40 mg IV\n Q24H Order date: @ 1316\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1316 24. Piperacillin-Tazobactam 4.5 g IV Q8H Order date:\n @ 0807 11. Diazepam 5-20 mg PO/NG Q6H:PRN ciwa >12 Order date:\n @ 1055 25. Potassium Phosphate IV Sliding Scale Infuse over 6\n hours Order date: @ 1316 12. FoLIC Acid 1 mg PO/NG DAILY Order\n date: @ 1406 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1316\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1316 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14.\n HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8 Order\n date: @ 1618 28. Thiamine 100 mg PO/NG DAILY Order date: @\n 1406\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n Extubated. Minimized narcotics. More awake. Agitated at night req\n restraints and zyprexa.\n Post operative day:\n HD9 POD7 POD5 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 09:04 PM\n Ciprofloxacin - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:04 PM\n Metoprolol - 12:40 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 79 (72 - 82) bpm\n BP: 142/80(95) {107/61(72) - 142/93(106)} mmHg\n RR: 20 (14 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: -2 (-2 - 12) mmHg\n Total In:\n 3,520 mL\n 592 mL\n PO:\n Tube feeding:\n 1,440 mL\n 309 mL\n IV Fluid:\n 2,020 mL\n 283 mL\n Blood products:\n Total out:\n 3,500 mL\n 1,280 mL\n Urine:\n 3,435 mL\n 1,280 mL\n NG:\n 65 mL\n Stool:\n Drains:\n Balance:\n 20 mL\n -688 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Creatinine\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n NEURO: Agitated and disoriented. C1wa scale. Dialudid for pain. Valium\n for w/drawal. Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley,, NGT, ,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506144,
"text": "24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n : agitated despite zyprexa,responded to haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\n Ciprofloxacin - 09:22 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 08:50 PM\n Haloperidol (Haldol) - 10:17 PM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 90 (76 - 96) bpm\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 9 (-2 - 16)mmHg\n Total In:\n 3,706 mL\n 210 mL\n PO:\n TF:\n 1,658 mL\n 190 mL\n IVF:\n 1,908 mL\n 20 mL\n Blood products:\n Total out:\n 4,140 mL\n 170 mL\n Urine:\n 4,140 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Agitated and disoriented.\n Started zyprexa. Restraints prn\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\n Lines:\n Multi Lumen - 01:30 PM\n Disposition:\n Total time spent:\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 506750,
"text": "Subjective:\n I will try to get OOB\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise\n Updated medical status: s/p Wash out of RLE c ext fix\n manipulation. Head CT - . Extubated this AM.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NT\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n for RLE\n\n\n\n T\n\n\n Transfer:\n T Transfer Bed to Chair\n\n\n\n T\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 83\n 112/62\n 16\n 100% 2LO2\n Activity\n Sit\n 86\n 102/60\n 24\n 95 RA\n Recovery\n Sit\n 82\n 98/50\n 20\n 100% 2LO2\n Total distance walked:\n Minutes:\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\n 1 UE support.\n Education / Communication: c RN RE Pt Status\n Pt RE Rehab Process\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\n ROM L knee 0-40 c hard end-feel\n Pain: B LE c mobility\n MS . Able to follow commands. Reported date at .\n Orientated to self and .\n HOH\n Assessment: Pt is a 51M with multiple fractures presents with continued\n limitations in mobility. Pt is functioning well below baseline and\n will require STR when medically stable.\n Anticipated Discharge: Rehab\n Plan: Progress transfers ?slideboard\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506074,
"text": "\n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from zyprexa\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n - OR tomorrow for R internal fixation ?\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506075,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from zyprexa\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa as ordered\n - OR tomorrow for R internal fixation ?\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506230,
"text": "24 Hour Events:\n ARTERIAL LINE - STOP 11:39 AM\n : agitated despite zyprexa,responded to haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:50 PM\n Ciprofloxacin - 09:22 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 08:50 PM\n Haloperidol (Haldol) - 10:17 PM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 90 (76 - 96) bpm\n BP: 147/80(91) {109/53(65) - 147/91(102)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 9 (-2 - 16)mmHg\n Total In:\n 3,706 mL\n 210 mL\n PO:\n TF:\n 1,658 mL\n 190 mL\n IVF:\n 1,908 mL\n 20 mL\n Blood products:\n Total out:\n 4,140 mL\n 170 mL\n Urine:\n 4,140 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 327 K/uL\n 9.0 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.0 %\n 7.1 K/uL\n [image002.jpg]\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n Plt\n 199\n 226\n 259\n 307\n 327\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 26\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. s/p L femur ORIF, right ankle\n external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Agitated and disoriented.\n Started zyprexa. Restraints prn Additional Haldol.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Zosyn/ Cipro for gnr (H.influenzae) in sputum and for surgical\n prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment ? OR tomorrow.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Replete with Fiber (Full) - 09:13 PM 95 mL/hour\n Lines:\n Multi Lumen - 01:30 PM\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 506649,
"text": "TSICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Current medications:\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Clonidine Patch 0.3 mg/24 h\n Cyanocobalamin\n Dexmedetomidine\n FoLIC Acid\n HYDROmorphone (Dilaudid)\n Haloperidol\n Metoprolol Tartrate\n Pantoprazole\n 24 Hour Events:\n s/p washout RLE by Ortho, Head CT normal (recent AMS). Intubated. On\n levaquin for PNA (based on sensis). On Haldol for agitation/delirium.\n RSBI 30s this AM.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 1 washout RLE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.3 mcg/Kg/hour\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 04:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.5\n T current: 38.1\nC (100.5\n HR: 95 (66 - 106) bpm\n BP: 143/86(98) {100/52(63) - 158/88(106)} mmHg\n RR: 18 (13 - 32) insp/min\n SPO2: 84%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,093 mL\n 561 mL\n PO:\n Tube feeding:\n 58 mL\n IV Fluid:\n 3,093 mL\n 503 mL\n Blood products:\n Total out:\n 2,100 mL\n 590 mL\n Urine:\n 1,950 mL\n 440 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 993 mL\n -26 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SPO2: 84%\n ABG: 7.43/40/184/26/2\n Ve: 10 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 27.2 %\n 9.6 K/uL\n [image002.jpg]\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n WBC\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n Plt\n 27\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n :Worsening left retrocardiac opacification suggests developing\n pneumonia, and new small left effusion. CXR - atelectasis at bases. low\n lung volumes.\n CXR: R SVC mid svc. ETT 6.8 cm above carina. No ptx.\n CXR: ETT 11cm above carina\n Head CT: no acute intracranial process\n Microbiology: Ucx Negative.\n Bcx Negative.\n Sputum: GNR - Haemophilus, Shewanella -> Sensitive to Levaquin\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment and Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and washout, L femur ORIF and IVC filter.\n Neurologic: Intubated on Precedex. Head CT normal. Admitted with DTs,\n still delerious when off sedation. Continue to wean sedation. Pt\n following commands on precidex, but seems confused at times, will plan\n to extubate this AM.\n Cardiovascular: On clonidine patch. Beta blockade. Monitor for QT\n prolognation (haldol and quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Wean to extubate today.\n Gastrointestinal / Abdomen: NGT feeding (hold peri-extubation).\n Nutrition: Tube feeding, Thiamine, folate, MVI.\n Renal: Foley, Adequate UO\n Hematology: Normocytic anemia. s/p 4u pRBC during entire\n hospitalization. s/p IVC filter.\n Endocrine: RISS, goal BS<150, adequate control.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n () x 14 day course.\n Lines / Tubes / Drains: Foley, PIV, NGT, left subclavian TLC.\n Wounds: Soft compartments, will monitor.\n Imaging: None planned\n Fluids: KVO\n Consults: Trauma surgery, Ortho, Addiction Med\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n Total time spent: 32 mins\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 506746,
"text": "Subjective:\n I will try to get OOB\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise\n Updated medical status: s/p Wash out of RLE c ext fix\n manipulation. Head CT - . Extubated this AM.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NT\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n for RLE\n\n\n\n T\n\n\n Transfer:\n T Transfer Bed to Chair\n\n\n\n T\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 83\n 112/62\n 16\n 100% 2LO2\n Activity\n Sit\n 86\n 102/60\n 24\n 95 RA\n Recovery\n Sit\n 82\n 98/50\n 20\n 100% 2LO2\n Total distance walked:\n Minutes:\n Balance: No LOB c above. Able to sit at EOB and in longsitting s LOB c\n 1 UE support.\n Education / Communication: c RN RE Pt Status\n Pt RE Rehab Process\n Other: Pulm: Decreased at bases. Min DOE. Strong clear cough\n ROM L knee 0-40 c hard endfeel\n Pain: B LE c mobility\n MS . Able to follow commands. Reported date at .\n Orientated to self and .\n HOH\n Assessment: Pt is a 51M with multiple fractures presents with continues\n limitations in mobility.\n Anticipated Discharge: Rehab\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Physical Therapy Initial Evaluation",
"row_id": 506755,
"text": "TITLE: Rehab Services Physical Therapy Evaluation \n Attending Physician:\n date: \n Medical Diagnosis / ICD 9: 959.9 /\n Reason of : eval and treat\n History of Present Illness / Subjective Complaint: 50 m adm from osh\n s/p ped struck by car sustaining R open ankle fx, L distal femur fx and\n 2nd and 3rd rib fractures. -LOC, +ETOH. Intubated dt's and w/d from\n etoh. OR for ORIF L femur, ex fix placement R ankle, IVC filter\n placed. Extubated . Plan for return to OR in near future for ORIF\n RLE.\n Past Medical / Surgical History: unclear\n Medications: Acetaminophen\n Pantoprazole\n Glucagon\n Cyanocobalamin\n Nicotine Patch\n Metoprolol Tartrate\n Heparin\n HYDROmorphone (Dilaudid)\n Piperacillin-Tazobactam\n Ciprofloxacin\n Clonidine Patch\n Thiamine\n FoLIC Acid\n Multivitamins\n Olanzapine\n Radiology: Five views of the right tibia and fibula and ankle show\n comminuted\n oblique fractures of the distal tibia and fibula. There is lateral and\n anterior subluxation of the distal tibia and fibula as well as foot\n relative\n to the proximal lower extremity. The talar dome is smooth. The distal\n fibula\n is slightly medially displaced, projecting over the ankle mortise.\n Limited\n views of the knee joint are unremarkable. There is no radiopaque\n foreign\n body.\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as\n above.\n Four views of the left femur reveal a comminuted fracture of the distal\n femoral diaphysis. There is posterior and slight lateral displacement\n of the\n distal femur relative to the proximal. There is no evidence of\n intra-articular extension. A faint lucency seen at the fibular head\n suggests\n a non-displaced fracture in that location as well. A small of\n bone at\n the lateral margin of the proximal tibia suggests avulsion injury.\n There is\n no radiopaque foreign body.\n Labs:\n 32.9\n 11.7\n 161\n 8.0\n Other labs:\n Activity Orders: NWB RLE, TDWB LLE, unlocked, ROM ok. oob to\n chair.\n Social / Occupational History: ? homeless.\n Living Environment: difficult to obtain history confusion\n Prior Functional Status / Activity Level: presumed I.\n Objective Test\n Arousal / Attention / Cognition / Communication: Awake, speaking\n non-sensically t/o eval. Inconsistently following commands but with\n limited attention span.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 80\n 130/82\n 16\n 97% RA\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: even coordinated breathing pattern\n Integumentary / Vascular: R LE with ex fix, large incision at joint\n line medially, healing well. L LE with brace, DSD, no drainage.\n +edema B feet. NGT, foley, central line\n Sensory Integrity: difficult to assess formally. responds to touch in\n all extremities\n Pain / Limiting Symptoms: c/o pain but then laughing as I ranged his L\n knee. otherwise no c/o pain\n Posture: received supine in bed\n Range of Motion\n Muscle Performance\n WFL x: R ankle ex fix, L knee range 0-25degrees. + guarding\n BUE >/= \n moving R LE against gravity, moves B toes, guarding with L knee/quads,\n able to slr B\n Motor Function: isolates through function. not following commands to\n formally test. ? clonus LLE\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total A to roll and slide to stretcher chair to sit\n up. RN, pt moving on his own in the bed, but not to command\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: deferred\n Education / Communication: pt ed: role of PT, importance of ROM\n case discussed with RN and MD\n Intervention: ROM L knee\n Other:\n Diagnosis:\n 1.\n Knowledge, Impaired\n 2.\n Muscle Performace, Impaired\n 3.\n Range of Motion, Impaired\n 4.\n Transfers, Impaired\n Clinical impression / Prognosis: 50 m s/p ped struck with multiple LE\n injuries presents with above associated with fracture. His current\n situation is limited by confusion and inabiliyt to follow commands\n consistently. Given his age and lack of UE involvement feel that he has\n good potential to be I at a w/c level until his WB status is progressed\n provided his mental status clears a bit. Overall he ahs good potential\n to return to functional ambulation in weeks given success of\n internal fixation, young age and lack of other apparent comorbiidiites.\n This will all depend on resolution of cognitive function. The patient\n will require inpatient rehab to maximize function although ? if\n insurance constraints will prohibit this? rec OT consult.\n Goals\n Time frame: 1 week\n 1.\n increase ROM L knee 0-65\n 2.\n follow 50% simple commands\n 3.\n sit eob iwth max a\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 4-6x/wk\n ROM L knee\n eob activity\n d/c planning\n pt ed: rom, therex\n strengthening/ exercises for LE's with coop student (therex, rom)\n consult OT\n w/c training\n time: 10:15-10:45\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506814,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt weaned and extubated this am without difficulty. Pt alert and\n orientated. At times, pt makes comments that do not make sense.\n Pleasant and cooperative. Garbled speech. Hemodynamically stable. HCT\n stable. Right LE with ex fix intact, +pedal pulses via Doppler. Left LE\n with knee brace intact, +pedal pulses. Pt coughing with thin liquids\n this am. Foley draining clear yellow urine. BM X 1 this afternoon. Pt\n complains of pain to BLE.\n Action:\n OOB to chair with PT this afternoon, tolerated sitting in chair. Speech\n and swallow evaluation this afternoon. Fluids KVO. PRN Dilaudid given\n for pain.\n Response:\n Pt remains pleasant and cooperative. Pain improved with Dilaudid. Pt\n able to have nectar thick liquids and ground solids per speech therapy.\n Plan:\n Transfer to floor this evening.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506744,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506312,
"text": "51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506321,
"text": "51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 with sitter\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506382,
"text": "24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\n w/d.\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 07:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Metoprolol - 12:37 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 93 (76 - 100) bpm\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\n RR: 13 (13 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 39 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 39 mL\n Blood products:\n Total out:\n 3,795 mL\n 215 mL\n Urine:\n 3,795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n -176 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\n agitation\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 390 K/uL\n 9.1 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 107 mEq/L\n 140 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n Plt\n 199\n 226\n 259\n \n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n TCO2\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\n s-levofloxacin,meropenem,cefipime and H.influenzae\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 506474,
"text": "24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course c/b ETOH\n w/d.\n No major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 07:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Metoprolol - 12:37 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.1\n HR: 93 (76 - 100) bpm\n BP: 128/78(89) {114/67(79) - 150/107(114)} mmHg\n RR: 13 (13 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.6 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 39 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 39 mL\n Blood products:\n Total out:\n 3,795 mL\n 215 mL\n Urine:\n 3,795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n -176 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Diaphoretic, Somnolent with sporadic episode of\n agitation\n Eyes / Conjunctiva: PERRL\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 390 K/uL\n 9.1 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 107 mEq/L\n 140 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 06:07 PM\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n Plt\n 199\n 226\n 259\n \n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n TCO2\n 29\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n NEURO: Awake but disoriented. Attempts to climb out Started zyprexa PO\n ATC on . prn IM zyprexa. Restraints prn. Prn haldol. Avoid BDZ.\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: HAP likely aspiration. Right rib fx but no ptx. Intubated\n for altered mental status from withdrawal. GNR on sputum with\n -> started on Zosyn/ Cipro. FU sputum cx. Now extubated.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. Sputum positive for SHEWANELLA SPECIES.MODERATE GROWTH\n s-levofloxacin,meropenem,cefipime and H.influenzae\n s-cefepime,CTX,zosyn,levofloxacin,gentamycin,bactrim. Pt currently on\n Zosyn/ Cipro for broad gnr coverage. Will narrow coverage.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV, NGT, left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506738,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n Trauma, s/p\n Assessment:\n Pt admitted from OR post-op washout of RLE and reconfiguration of\n exfix. Intubated and sedated on propofol gtt at 30mcgs/kg/min. Taken\n for head CT while sedated and post transferred from propofol to\n precedex gtt to allow to awaken and wean from vent. Pt Hemodynamically\n stable, pulses weakly palpable in LE\ns, dopplerable in both Poterior\n tibial and dorsalis pedis sites bilaterally. Pt initially very clamped\n in distal extremities, sepicially hands very cyanotic and cool yet\n perfusion improved as pt warmed. Hct post-op 27.9 , other labs wnl\n Tube feeds restarted via NGT as ordered.\n Action:\n Pt taken to CT, pulses monitored q 2-4 hours, post-op labs sent, pt\n monitored closely with IVF as ordered.\n Response:\n Pt with RISB of 27 this AM, weaned to CPAP 5/5, tolerating well.\n Plan:\n Plan to con\nt to lighten as tolerated and wean and extubated today\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 506313,
"text": "51M transfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0 Patient has soft limb\n restraints\n Action:\n Continue with oral zyprexa and prn haldol dc\ndl an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho called out today to CC6 if agitation is\n better\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 506554,
"text": "Chief Complaint: HD12 POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix\n right ankle ORIF left femur , now s/p ORIF L distal femur fx and\n IVC filter . S/p washout .\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n POD10 POD8 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter . S/p\n washout .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Other medications:\n Clonidine Patch\n Precedex\n Dilaudid\n Haldol\n Past medical history:\n Family / Social history:\n PMH:ETOH abuse,Varicose veins, o/w unknown.\n PSH:Ex fix/ wahout right ankle\n :Unk\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\n Flowsheet Data as of 08:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 76 (69 - 106) bpm\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\n RR: 16 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 2,689 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 2,689 mL\n Blood products:\n Total out:\n 3,795 mL\n 1,705 mL\n Urine:\n 3,795 mL\n 1,555 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress, Sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 455 K/uL\n 9.7 g/dL\n 125 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 30.2 %\n 12.3 K/uL\n [image002.jpg]\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n Plt\n 199\n 226\n 259\n \n 455\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n TCO2\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n 125\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Needs frequent re-orientation\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\n intubated.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Gastrointestinal: NGT feeding.\n Renal: Foley, monitor UOP\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Endocrine: RISS. Euthyroid\n Fluids: thiamine, d5, folate\n Electrolytes:\n Nutrition: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n General:\n ICU Care\n Nutrition:\n Comments: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 506555,
"text": "Chief Complaint: HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7 \n plate left femur and washout R ankle and IVC filter, POD 0 washout RLE.\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n POD11 s/p Ex-fix R tib/fib and ID, POD7 plate left femur and\n washout R ankle and IVC filter, POD 0 washout RLE.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Ciprofloxacin - 10:02 AM\n Levofloxacin - 01:03 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 06:00 AM\n Lorazepam (Ativan) - 07:00 AM\n Other medications:\n Clonidine Patch\n Precedex\n Dilaudid\n Haldol\n Past medical history:\n Family / Social history:\n PMH:ETOH abuse,Varicose veins, o/w unknown.\n PSH:Ex fix/ wahout right ankle\n :Unk\n +ETOH, approx 12 beers per day, denies seziures with withdrawal.\n Flowsheet Data as of 08:43 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 76 (69 - 106) bpm\n BP: 126/70(82) {100/52(63) - 158/88(106)} mmHg\n RR: 16 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.5 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 3,278 mL\n 2,689 mL\n PO:\n TF:\n 2,247 mL\n IVF:\n 850 mL\n 2,689 mL\n Blood products:\n Total out:\n 3,795 mL\n 1,705 mL\n Urine:\n 3,795 mL\n 1,555 mL\n NG:\n Stool:\n Drains:\n Balance:\n -517 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress, Sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, ex-fix RLE\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 455 K/uL\n 9.7 g/dL\n 125 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 30.2 %\n 12.3 K/uL\n [image002.jpg]\n 02:08 AM\n 02:21 AM\n 01:03 AM\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n WBC\n 8.0\n 8.0\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n Hct\n 25.3\n 25.8\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n Plt\n 199\n 226\n 259\n \n 455\n Cr\n 0.6\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n TCO2\n 32\n 29\n 28\n Glucose\n 128\n 120\n 124\n 119\n 126\n 125\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE\n Assessment And Plan: 51M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.\n Neurologic: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Needs frequent re-orientation\n with restriants. Haldol PO and IV prn. Head CT after OR. Precedex while\n intubated.\n Cardiovascular: Tachycardic/HTN likely secodary to withdrawal. On\n clonidine patch. Beta blockade. Monitor for QT prolognation (haldol and\n quinolone).\n Pulmonary: HAP likely aspiration. Cx w/ H.influ and Shewanella. Now\n on Levaquin (). Intubated for altered mental status from\n withdrawal. Reintubated for increasing agitation and in prep for OR.\n Gastrointestinal: NGT feeding.\n Renal: Foley, monitor UOP\n Hematology: Normocytic anemia. s/p 4u pRBC. s/p IVC filter. On SQH for\n prophylaxis.\n Infectious Disease: HAP. SHEWANELLA SPECIES and H.influenzae. Levaquin\n ().\n Endocrine: RISS. Euthyroid\n Fluids: thiamine, d5, folate\n Electrolytes:\n Nutrition: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n General:\n ICU Care\n Nutrition:\n Comments: Replete with fiber Full strength;\n Goal rate: 95 ml/hr\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Comments: Foley, PIV, NGT, left subclavian TLC\n Prophylaxis:\n DVT: SQ UF Heparin, IVC filter\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Bedside Swallowing Evaluation",
"row_id": 506729,
"text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 51 y/o male who initially\npresented to OSH s/p being an intoxicated pedestrian struck by a\ncar at unknown speed, ?+LOC. Patient found with open tib/fib fx,\nL distal femur fx. Patient was transferred to on \nfor further management and underwent irrigation and debridement\nof soft tissue, muscle including bone of the right distal tibia\nopen fracture and application of multiplanar external fixator to\nthe right lower extremity. Patient underwent inferior vena caval\nfilter placed by the right femoral route and open reduction,\ninternal fixation of left supracondylar femur fracture on\n. hospital course c/b hypertension,\nagitation/delirium, and tachycardia c/w EtOH withdrawal. Patient\nwas successfully extubated this am and we were consulted to\nevaluate patient's oral and pharyngeal swallowing function and\nr/o aspiration while eating and drinking. RN reported patient was\nnoted with coughing on water this am following extubation.\nPMH: unknown\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the TSICU.\nCognition, language, speech, voice: Patient was sleeping upon\narrival, easily aroused to voice, however remained fatigued and\nwas able to fall asleep instantly when not stimulated. Patient\nwas oriented to self and \" Hospital\" when asked but\nwas noted with confusion when he later asked a question about\nwhere he was and asked other nonsensical questions. Patient was\nable to follow most basic commands with max cues and models.\nSpeech was fluent and somewhat unintelligible for long\nutterances. Voice was significantly hoarse and ? close to\nbaseline.\nTeeth: poor sparse dentition remaining, no dentures\nSecretions: dry oral cavity, productive baseline cough\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual ROM, and\nbuccal tone. Mildly reduced lingual strength. Palatal elevation\nwas symmetrical. Gag deferred to maintain rapport.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp), nectar thick\nliquids via straw, bites of puree, ground solid, and a bite of \n cracker. Oral phase was remarkable for prolonged, however\nfunctional mastication of regular solid poor dentition, with\nnormal oral residue remaining. Laryngeal elevation felt adequate\nto palpation. Immediate wet vocal quality and delayed coughing\nnoted on ice chips and thin liquid trials. One delayed cough was\nnoted on regular solids followed by nectar thick liquid. No\nfurther throat clearing, coughing, or choking noted. O2 sats\nremained stable at 96%. Patient denied the sensation of PO stuck\nin his throat.\nSUMMARY / IMPRESSION:\nMr. presents with confusion and lethargy and overt s/sx of\naspiration on thin liquids as evidenced by wet vocal quality and\ndelayed coughing, consistent with symptoms usually seen\nimmediately post-extubation. Patient's mastication of regular\nsolids was prolonged poor dentition and he was noted with\ncoughing on the dry, crumbly solid when followed by nectar thick\nliquids. Recommend initiating a PO diet of nectar thick liquids\nand ground solids at this time with 1:1 supervision and only when\npatient is most awake and alert. We will return tomorrow to\nrepeat the evaluation to determine if patient's diet may be\nupgraded given more time to recover from acute extubation.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 5 out of 7.\nRECOMMENDATIONS:\n1. PO diet of nectar thick liquids and ground solids.\n2. Pills whole or crushed with puree.\n3. 1:1 supervision with POs, please give only when most awake and\nalert, seated upright in bed.\n4. Q6 oral care.\n5. We will return tomorrow to repeat the evaluation to determine\nif patient's diet may be upgraded given more time to recover from\nacute extubation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1335-1350\nTotal time: 50 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505896,
"text": "Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused and agitated most of night, oriented to self,\n continually tries to get out of bed, says:\nI have to go to \nI need my money\n. Hard to redirect. When told he is in the hospital\n patient looks shocked. Consistently putting legs over side rail.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Given 5 mg Olanzapine for agitation.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night, more calm after olanzapine given.\n Plan:\n Continue to monitor, reorient frequently.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 506616,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nutrition",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 506709,
"text": "Subjective\n on facemask\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 91.1 kg ( 03:00 AM)\n 28.2\n Pertinent medications: Dextrose 5 normal saline with KCl, IV abx, folic\n acid, Vit B12, multivitamin, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 95 mg/dL\n 02:30 AM\n Glucose Finger Stick\n 148\n 08:00 AM\n BUN\n 12 mg/dL\n 02:30 AM\n Creatinine\n 0.8 mg/dL\n 02:30 AM\n Sodium\n 142 mEq/L\n 02:30 AM\n Potassium\n 4.4 mEq/L\n 02:30 AM\n Chloride\n 110 mEq/L\n 02:30 AM\n TCO2\n 26 mEq/L\n 02:30 AM\n PO2 (arterial)\n 184 mm Hg\n 10:45 PM\n PCO2 (arterial)\n 40 mm Hg\n 10:45 PM\n pH (arterial)\n 7.43 units\n 10:45 PM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 10:45 PM\n Calcium non-ionized\n 8.2 mg/dL\n 02:30 AM\n Phosphorus\n 3.1 mg/dL\n 02:30 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.1 mg/dL\n 02:30 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 9.6 K/uL\n 02:30 AM\n Hgb\n 8.8 g/dL\n 02:30 AM\n Hematocrit\n 29.1 %\n 08:13 AM\n Current diet order / nutrition support: Replete with Fiber @ 95 ml/hr =\n 2280 kcals/ 141 g protein\n GI: soft, +bowel sounds\n Assessment of Nutritional Status\n Specifics: Patient s/p washout RLE and internal fixation on .\n Patient received tube feeding over night, held for extubation this\n morning and currently running at 50 ml/hr and plan to advance to goal\n which provides 100% of nutritional needs. SLP consulted for swallow\n eval. If patient passes SLP eval he will likely need tube feedings as\n patient is delirious and will not meet needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance to goal Replete with Fiber @ 95 ml/hr\n 2. Implement any SLP recommendations\n 3. Check chemistry 10 daily and replete prn\n 4. Will follow page with questions\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506098,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - alert, oriented X 1, delirious, confused, but oriented at\n times\n - lifting legs over side rails, sitting straight up in bed and\n trying to hold on to R ex-fix, high fall risk\n - MAE, pulses dopplerable\n - Strong, productive cough, lungs rhonchorous at times, clear\n after coughing\n - Family in to visit patient\n Action:\n - removed restraints, constant observation, frequent\n reorienting and redirecting\n - encouraged coughing/deep breathing, chest PT\n - OOB to chair\n - Pin care as needed, dressing changed X 3\n - zyprexa order changed to TID, given as ordered\n - zyprexa IM PRN given at 1730\n - family identified by patient, Identification process done by\n nurse , witnessed by this nurse\n Response:\n - pt continues to be delirious, trying to get OOB, moments of\n clarity\n - requires constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - RLE seeping yellow drainage from medial pin site\n - slid pt using slide board over to stretcher chair, sat\n upright with legs at slight angle for approx 2 hours with constant\n observation\n - Minimal response from PO zyprexa, IM zyprexa with good\n effect, pt calm and resting\n - pt able to cough up secretions, spitting up secretions,\n nurse able to oral suction secretions before pt spits at times\n Plan:\n - continue constant redirecting, reorienting and constant\n observation for high fall risk and high risk for self injury\n - continue pin care PRN, monitor drainage\n - encourage coughing/deep breathing, chest PT\n - continue Zyprexa qtc and PRN as needed\n - OR tomorrow for R internal fixation ?\n - ? transfer to floor tomorrow with distinct plan for fall\n high risk in order prior to transfer. Involve nursing services at\n"
},
{
"category": "Social Work",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 506708,
"text": "Social Work:\n Rec\nd POE on this 51 yr-old man adm s/p ped struck. Pt w/R leg fx, s/p\n ORIF and IVC filter placement. +ETOH w/BAL=275 upon admit. Pt is\n homeless by report, 1 cousin locally (please see note by \n , LICSW, for family info). Mother, sisters in , but\n none involved in his care.\n Unable to interview pt today to his being somnolent and confused.\n Also, his RN, , pt scheduled for another surgery soon. At\n this point, his needs unclear & he is unable to participate in\n interview.\n SW will follow & assess coping, address substance abuse issue and offer\n resources around latter. If pt does not need or qualify for rehab, will\n assess options & provide info re: shelters. Please page PRN.\n , LICSW\n #\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506278,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Patient alert confused agitated garbled speech this am gave 1mg haldol\n and zyprexa IM heart rate 70-80\ns sinus rhythm systolic b/p 120-140\n over 70\ns lungs diminished in bases but clear upper fields respirations\n unlabored 20\ns O2 sat 95% suctioned for thick tan secretions abd soft\n but firm + bowel sounds + flatus incision sutures intact + pp by\n Doppler external fixation intact T max 100.0\n Action:\n Continue with oral zyprexa and prn haldol an IM zyprexa\n Response:\n Patient remains stable at this time\n Plan:\n No OR in the am per ortho ? callout tomorrow if agitation is better\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 506286,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for other:\n Updated medical status: no new imaging\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 74\n 120/67\n 96% on RA\n Activity\n 86\n /\n 94% on RA\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Gait: not assessed\n Balance: not assessed\n Education / Communication: Patient lethargic, sleeping throughout tx\n session. Communicated with nsg re: status.\n Other: L knee PROM 0-30 in \n Patient stirring but not awakening with ROM\n Assessment: 57 yo M pedestrian struck with multiple fxs, making minimal\n progress in PT, today limited by lethargy and not participatory in PT\n session. Tolerated ROM to L knee, mobility not assessed. D/c plan\n remains tentative given his cognition at this time, PT to continue to\n follow to progress as able.\n Anticipated Discharge: Rehab\n Plan: continue with POC\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507596,
"text": "S/P MVA, was hit by car , s/p external fixation of right leg\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\n DT\ns from ETOH.\n Code purple called on CC6 0300 this am.\n Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixation device against side rails.\n Oriented only to himself, believes he is at a church, or outside with\n his\nbuddies\n asking for cigarettes and beer, believes he hasn\nt been\n in the hospital. Agitated and combative.\n Action:\n Security called for assistance this am, patient fighting to get out of\n restraints,\n Patient calmly reassured and reoriented frequently,\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\n initiated,\n Psych in to assess, Psych CNS ( ) in to assess (valium and\n ativan d/c\nd, will give haldol for psychosis although QT has been\n 0.40-0.47, it is normally in this range for patient)\n QTC checked twice\n during shift.\n Turned and repositioned for comfort, offered food, liquids.\n Response:\n Haldol effective, patient able to nap after given.\n Continues to be confused and wake up agitated,\n QTC < 0.50.\n Plan:\n Continue to monitor, do not give benzo\ns, treat agitation with haldol,\n check QTC frequently. Daily EKG\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507584,
"text": "S/P MVA, was hit by car , s/p external fixation of right leg\n (tib/fib fx), repair of Left femur fx, s/p IVC filter placement. S/P\n DT\ns from ETOH.\n Code purple called on CC6 0300 this am.\n Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixation device against side rails.\n Oriented only to himself, believes he is at a church, or outside with\n his\nbuddies\n asking for cigarettes and beer, believes he hasn\nt been\n in the hospital. Agitated and combative.\n Action:\n Security called for assistance this am, patient fighting to get out of\n restraints,\n Patient calmly reassured and reoriented frequently,\n SICU team in to assess, 2 mg Haldol given x 3, standing dose of Haldol\n initiated,\n Psych in to assess, Psych CNS ( ) in to assess (valium and\n ativan d/c\nd, will give haldol for psychosis although QT has been\n 0.40-0.47, it is normally in this range for patient)\n QTC checked twice\n during shift.\n Turned and repositioned for comfort, offered food, liquids.\n Response:\n Haldol effective, patient able to nap after given.\n Continues to be confused and wake up agitated,\n QTC < 0.50.\n Plan:\n Continue to monitor, do not give benzo\ns, treat agitation with haldol,\n check QTC frequently. Daily EKG\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505860,
"text": "Trauma, s/p\n Assessment:\n External fixation device in place on right leg, Left Knee immbolizer\n on,\n Pin sites slightly red and clean, draining serous fluid,\n Dopplerable pulses, legs warm, good cap refill.\n Patient is confused, oriented to self, continually tries to get out of\n bed, says:\nI have to go to \nI need my money\n. Hard to\n redirect at times. When told he is in the hospital patient looks\n shocked.\n Coughing up secretions.\n Action:\n Safety precautions in place, bed alarm on, 1:1 time, reoriented\n frequently, calmly reassured.\n Pin care done x 2,\n Turned and repositioned for comfort.\n Response:\n Patient continues to be confused and hard to redirect, tries to get\n OOB. Patient hardly slept all night.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506155,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n - remains delirious and agitated\n - oriented to person only but unable to answer any orientation\n questions and speech is mostly nonsensical\n - speech at times sounds slurred but clears when patient\n coughs and clears secretions\n - + congested cough, @ times able to clear independently but\n occasionally requiring subglottal suctioning\n - tube feeds at goal\n - right lower extremitie with insision weeping sangounous\n fluid\n - right pin site leaking serous fluid\n - + cms to bil lower extremities\n Action:\n - reoriented\n - restraints applied, 1:1 sitter at bedside, haldol given in\n addition to standing and prn Zyprexa\n - ivf changed to kvo\n - dressing applied to leaking pin site\n - primary team aware of drainage to right lower extremity\n Response:\n - minimal effect with reorientation\n - at times calmer after haldol but lasting for only short\n periods of time\n Plan:\n - continue to monitor mental status and maintain safety\n - continue on iv abx for pneumonia\n - or for internal fixation of right lower extremity later this\n week\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506271,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n \n adm to trauma unit from \n \n Irrigation debridement of soft tissue muscle and bone of R\n distal tibia, open Fixation\n - external fixation of RLE\n - to floor postop\n \n adm to sicu for severe withdrawal, given high doses valium\n \n electively intubated\n \n IVC filter via R groin for increased risk for thrmoboembolism\n - open reduction, internal fixation, L supracondylar femur\n fracture\n \n extubated\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 506525,
"text": "50M ped vs auto with multiple orthopedic injuries s/p RLE ExFix and L\n femur ORIF and s/p IVC filter. Hospital course c/b ETOH w/d.\n Trauma, s/p\n Assessment:\n Pt to go to OR today for wash out of RLE & manipulation of external\n fixation device, pt npo after MN for OR, pt with increased agitation\n last noc & pulled out NGT, 0600 dose of po zyprexa not given d/t\n pending CXR to confirm placement after NGT re-inserted, pt with minimal\n c/o pain but increased agitation noted throughout day, agitation not\n controlled by prn IM zyprexa, pt on RA with RA sat 95-97, afebrile &\n VSS\n Action:\n Ho aware of increased agitation, NGT placement ok per cxr & po ATC\n zyprexa given, psych nurse called & up to eval pt d/t\n dilerium/psychosis, 5 mg iv haldol given x 2 with minimal sedative\n effect, po ATC haldol started, pt intubated @ bedside @ 1400 prior to\n OR d/t increased agitation, propofol gtt started, post intubation cxr\n done\n Response:\n Sedated on 40 mic/kg/min propofol gtt, pt off to OR @ 1630\n Plan:\n Keep intubated post op in order to keep pt sedated for head ct this PM\n to eval mental status change, transfer to TSICU from OR, post op care,\n ? extubation tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504206,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Action:\n Ciwa scale q1hr\n Valium iv q1hr.\n Response:\n Alcohol withdrawal continues.\n Plan:\n Continue with ciwa scale\n Valium iv as ordered.\n Maintain safe environment.\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Ciwa scale q1hr\n Valium 10mg q1 hr\n Iv lactated ringers at 125cc/hr.\n Npo aftermidnoc for or today.\n Pedal pulses check q 2hrs on right and left feet.\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504871,
"text": "Trauma, s/p leg fractures\n Assessment:\n Febrile to 102\n Tachycardic to low 100\ns with PVC\n Diaphoretic\n Sedated on Propofol\n Period of hypotension\n HCT and electrolytes checked\n Adequate urine output 45-100 cc\ns/hr.\n Dopplerable pulses bilateral lower extremities\n Action:\n X1 peripheral BC, U/A, C+S, and sputum samples sent\n Valium x1 given\n Dilaudid x1 given\n Lr 500 cc fluid bolus for hypotension\n Magnesium and calcium repleated\n Propofol stopped for daily wakeup, patient biting on ETT, no other\n purposeful movement noted.\n Response:\n Fluid balance for + 3 liters\n No further signs of DT\ns / tremors after valium given\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504309,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Patient bilateral legs pulses by Doppler left leg in traction with\n pin sites right leg femur fracture with leg brace on + csm multiple\n scrapes and bruising.\n Action:\n Pin site cleaning done with\n normal saline and peroxide.\n Response:\n Patient remains stable\n Plan:\n Continue to monitor notify team of any changes provide comfort and\n support as needed\n Alcohol abuse\n Assessment:\n Patient alert and orientated X1\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-06 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504865,
"text": "24 Hour Events:\n ARTERIAL LINE - START 10:00 AM\n : OR for IVC filter and ORIF L distal femur fx. Restarted SQH.\n Postop Hct 26.8. Febrile - pan cultured.\n Post operative day:\n HD5 POD3 POD1 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left\n femur , now s/p ORIF L distal femur fx and IVC filter \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:07 PM\n Pantoprazole (Protonix) - 08:02 PM\n Hydromorphone (Dilaudid) - 08:02 PM\n Diazepam (Valium) - 10:50 PM\n Metoprolol - 12:15 AM\n Other medications:\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 1316 2. 1000 mL D5LRContinuous at 100 ml/hr Order date: @ 1316\n 14. HYDROmorphone (Dilaudid) 1-1.5 mg IV Q3H:PRN pain hold for RR< 8\n Order date: @ 1618 15. Heparin 5000 UNIT SC BID Order date:\n @ 1316 Acetaminophen 650 mg PO Q4H:PRN pain, t>100 Order date:\n @ 1316 Calcium Gluconate IV Sliding Scale Order date: @\n 1316 17. Insulin SC (per Insulin Flowsheet)Sliding Scale Order date:\n @ 1316 6. CefazoLIN 2 g IV Q8H Order date: @ 1316 18.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1316 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL Use only if\n patient is on mechanical ventilation. Order date: @ 1316 19.\n Metoprolol Tartrate 5 mg IV Q6H\n Hold for HR < 60 Order date: @ 1316 8. Clonidine Patch 0.3 mg/24\n hr 1 PTCH TD QMON Order date: @ 1316 20. Nicotine Patch 14 mg TD\n DAILY Order date: @ 1316\n 9. Cyanocobalamin 50 mcg PO/NG DAILY when taking PO Order date: \n @ 1316 21. Pantoprazole 40 mg IV Q24H Order date: @ 1316 10.\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: @\n 1316 22. Potassium Phosphate IV Sliding Scale Infuse over 6 hours\n Order date: @ 1316\n 11. Diazepam 5-20 mg IV Q1H:PRN CIWA >10 hold for sedation or rr<10\n Order date: @ 1316 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE\n TO SEDATION Order date: @ 1316\n 12. Folic Acid/Multivitamin/Thiamine-1000mL NS Continuous at 125 ml/hr\n Each Liter contains: 1mg Folic Acid, 1 amp MVI & 100mg Thiamine.\n ADMINISTER NO MORE THAN ONE AMP MULTIVITAMINS PER DAY. Discontinue or\n hold oral thiamine, folate and multivitamins. Order date: \n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.5\nC (101.3\n HR: 96 (72 - 101) bpm\n BP: 126/70(89) {90/52(65) - 154/80(107)} mmHg\n RR: 25 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 5,831 mL\n 655 mL\n PO:\n TF:\n IVF:\n 5,831 mL\n 655 mL\n Blood products:\n Total out:\n 2,520 mL\n 425 mL\n Urine:\n 1,580 mL\n 425 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 3,311 mL\n 230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 530) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI: 72\n PIP: 21 cmH2O\n Plateau: 25 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.42/43/120/28/3\n Ve: 14.3 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, Clubbing\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 169 K/uL\n 9.1 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.1 %\n 9.7 K/uL\n [image002.jpg]\n 06:45 PM\n 08:17 PM\n 08:36 PM\n 02:17 AM\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n WBC\n 8.7\n 7.5\n 8.7\n 9.7\n Hct\n 29.5\n 29.8\n 28.7\n 26.8\n 28.1\n Plt\n 141\n 154\n 169\n 169\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 30\n 28\n 27\n 29\n Glucose\n 97\n 104\n 87\n 104\n 121\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean sedation to attempt vent wean\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal.\n GI: Npo. Will use NGT feeding after surgery once decreasing NGT output.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale.\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Cefazolin 2gm IV q8hr (). Febrile - pan cultured.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Total time: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504369,
"text": "24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:00 PM\n Metoprolol - 03:59 PM\n Haloperidol (Haldol) - 05:00 PM\n Pantoprazole (Protonix) - 08:20 PM\n Enoxaparin (Lovenox) - 09:00 PM\n Hydromorphone (Dilaudid) - 09:30 PM\n Diazepam (Valium) - 12:00 AM\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 75 (73 - 144) bpm\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\n RR: 16 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,909 mL\n 30 mL\n PO:\n TF:\n IVF:\n 3,909 mL\n 30 mL\n Blood products:\n Total out:\n 2,450 mL\n 40 mL\n Urine:\n 2,450 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,459 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 602 (502 - 602) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.45/43/454/28/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 1,135\n Physical Examination\n General Appearance: No acute distress, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 102 mEq/L\n 138 mEq/L\n 26.0 %\n 9.3 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n WBC\n 8.9\n 9.3\n Hct\n 35.1\n 26.0\n Plt\n 204\n 152\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n Glucose\n 120\n 129\n 124\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments.\n Neuro:sedated with propofol\n Pain: dilaudid prn, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx.Intubated \n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n ICU Care\n Lines:\n 20 Gauge - 07:10 PM\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 503913,
"text": "Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p pedestrian struck\n Assessment:\n Pt admitted from ED overnight, pedestrian struck, not intubated, GCS\n 15. Multiple ortho injuries. Vss, O2 sats 97%. Rt leg splinted, left\n knee with immobilizer on.\n Action:\n Pulse checks/Csm, turn and reposition.\n Response:\n No changes, pt stable, good pulses, csm\n Plan:\n Cont to monitor, OR in a.m. to repair open tib/fib on rt.\n Alcohol abuse\n Assessment:\n Pt with long hx of ETOH abuse. Per pt 12 pack a day of beer. Etoh\n levels in the 400\n Action:\n Ciwa checks/valium ATC.\n Response:\n Pt doing ok, was diaphoretic and had a high ciwa scale this a.m. valium\n given.\n Plan:\n Cont to monitor, medicate prn\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504200,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505245,
"text": "Trauma, s/p\n Assessment:\n Temp 100.7 to 98.8 po\n HR 90\ns nsr\n Sbp 140-150\ns when calm, hypertensive to 180\ns with stimulation such\n as suctioning\n Breath sounds clear but diminished in bases\n Suctioned for copious amounts thick yellow secretions\n Abd soft with + bowel sounds\n TF on hold for possible extubation\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Propofol off at 0900\n Very lethargic\n Arousable to vigorous stimuli- will squeeze hands with much stimuli\n No visible sweats or tremors\n Action:\n CIWA scale done\n No valium given this shift\n Response:\n No evidence of DT\n Plan:\n Continue to monitor for DT\n ? d/c valium addiction RN recommendation\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505144,
"text": "Trauma, s/p pedestrian struck, bilateral leg fractures and rib\n fractures\n Assessment:\n Low grade temps 100.7\n HR 80\ns, BP ~120-140\n Fluid balance MN -0500: Remains positive for length of stay.\n Dopplerable pedal pulses bilat\n Left leg with knee immobilizer, ace wrap with DSD under with old\n sero-sang drg.\n Ls clear with suctioning, tan sputum\n On CPAP 40% 5 peep, 5 ps ABG: 7.45, 45, 132, 32, 7.\n Not showing signs of ETOH withdrawl, no valium given this shift per\n CIWA scale\n Action:\n VAP protocol\n Pin care\n Repositioned q 2-3 hours\n ABX as ordered\n Tube feeds stopped in preparation for possible extubation.\n Response:\n HR and vitals acceptable\n Remains with low grade fever\n Concerning sputum\n HCT 25.3, no S+S of active bleeding.\n Plan:\n Wean to extubate\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 503895,
"text": "Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 503897,
"text": "Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 503909,
"text": "Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n"
},
{
"category": "Social Work",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 504294,
"text": "Social Work:\n Consult received from team.\n Pt is sicu this pm; pt is agitated, not able to communicate clearly\n this am. He is trying to get out of bed, etc.\n According to record pt is 51 y/o man admitted from \n after sustaining injuries after being hit by a car. Pt reported to\n that he was homeless and stayed in , MA.\n Pt\ns cousin, came to hospital this pm. He states he\n was contact by orthopedic team and updated recently. Today pt is\n unable to clearly communicate relationship to cousin.\n Met w/ cousin separately. Mr. reports the following:\n Pt\ns name is spelled , not \n Pt has been living in shelters in area for many years,\n he most recently has been staying w/ a friend\n\n but family has no\n other information.\n Pt has a mother, and two sisters and \n all of whom live in . Another sister lives out of the\n country. Pt was married and divorced has two children but has had no\n contact w/ them for many years.\n Pt has had long hx of substance abuse according to cousin, primarily\n alcohol of late. Cousin believes that he has been at Highpointe in\n past for substance abuse treatment.\n Pt\ns cousin, can be reached at (cell #).\n He and his sister, left note for pt. They understand\n that we will be in touch w/ pt permission.\n Will follow.\n , licsw\n Pager \n"
},
{
"category": "Physician ",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 503827,
"text": "TITLE: Admission note/daily ICU progress note\n TSICU\n HPI:\n 50y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. B/l rib fx. No ptx. Questionable lesion on CT ? mass vs pna on R.\n VSS. Intoxicated with ETOH in 400's at Hospital. Denies PMHx,\n but intoxicated.\n Chief complaint:\n b/l LE fractures, intoxication\n PMHx:\n unk - denies\n Current medications:\n denies\n 24 Hour Events:\n admitted to TSICU\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n 1. 1000 mL LR 2. CefazoLIN 3. Diazepam 4. Famotidine 5. FoLIC Acid 6.\n Gentamicin 7. Heparin 8. Morphine Sulfate\n 9. Multivitamins 10. Thiamine\n Other medications:\n Flowsheet Data as of 03:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.3\n T current: 36.3\nC (97.3\n HR: 87 (87 - 93) bpm\n BP: 110/69(79) {110/69(79) - 120/73(84)} mmHg\n RR: 12 (9 - 14) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 420 mL\n Urine:\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -420 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: R posterior)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, patient intoxicated.\n Labs / Radiology\n [image002.jpg]\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: pending\n Assessment and Plan\n Assessment and Plan: 50y M ped vs auto with multiple orthopedic\n injuries, rib fractures. Intoxicated, unclear medical history.\n Neurologic: awake, alert, neuro intact, following commands. Denies\n seizure history with withdrawl. Valium CIWA prn.\n Cardiovascular: stable, to monitor\n Pulmonary: stable on nasal cannula. rib fx but no ptx.\n Gastrointestinal / Abdomen: NPO for OR tomorrow\n Nutrition: thiamine, folate IV\n Renal: foley, monitor UOP\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: s/p gent/zosyn/ancef. wash out in OR by ortho\n planned for am.\n Wounds: R tib/fib open fracture with dressing in place. Will be removed\n in OR.\n Imaging:\n Fluids: LR\n Consults: Ortho\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:09 AM\n 18 Gauge - 03:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504188,
"text": "TITLE:\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 01:39 AM\n Other medications:\n Enoxaparin Sodium 30 mg SC Q12H\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n CloniDINE 0.3 mg PO TID\n Cyanocobalamin 50 mcg PO/NG DAILY\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Flowsheet Data as of 02:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.8\nC (100\n HR: 150 (124 - 150) bpm\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,280 mL\n 279 mL\n PO:\n TF:\n IVF:\n 1,280 mL\n 279 mL\n Blood products:\n Total out:\n 105 mL\n 150 mL\n Urine:\n 105 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,175 mL\n 129 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\n agitated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\n dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Absent, ex fix right leg, left leg in splint\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR: left base in the retrocardiac region, likely\n atelectasis\n Microbiology: U cx P\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments.\n Neuro checks Q: 1\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal:\n ICU Care\n Nutrition:\n Comments: Npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:53 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504271,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 505353,
"text": "HPI: 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n HD7 POD5 POD3 s/p Ex-fix R tib/fib ID and ex fix right ankle\n ORIF left femur , now s/p ORIF L distal femur fx and IVC filter\n \n 24 Hour Events:\n MULTI LUMEN - START 01:30 PM\n FEVER - 101.6\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:13 AM\n Ciprofloxacin - 09:56 AM\n Vancomycin - 08:32 PM\n Piperacillin/Tazobactam (Zosyn) - 10:10 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 05:54 PM\n Pantoprazole (Protonix) - 08:32 PM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Other medications:\n Flowsheet Data as of 01:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.9\nC (100.3\n HR: 91 (83 - 100) bpm\n BP: 128/70(90) {110/61(79) - 173/87(120)} mmHg\n RR: 28 (21 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98 kg (admission): 94.5 kg\n Height: 72 Inch\n CVP: 11 (11 - 16)mmHg\n Total In:\n 2,933 mL\n 109 mL\n PO:\n TF:\n 454 mL\n 52 mL\n IVF:\n 2,479 mL\n 57 mL\n Blood products:\n Total out:\n 2,930 mL\n 0 mL\n Urine:\n 2,930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (411 - 624) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.45/45/132/27/7\n Ve: 10.7 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Bronchial: bases)\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 199 K/uL\n 8.5 g/dL\n 128 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 25.3 %\n 8.0 K/uL\n [image002.jpg]\n 01:36 PM\n 03:27 PM\n 08:16 PM\n 10:00 PM\n 01:55 AM\n 02:03 AM\n 09:24 AM\n 06:07 PM\n 02:08 AM\n 02:21 AM\n WBC\n 9.7\n 8.0\n Hct\n 26.8\n 28.1\n 25.3\n Plt\n 169\n 199\n Cr\n 0.7\n 0.6\n 0.6\n TCO2\n 28\n 27\n 29\n 26\n 29\n 32\n Glucose\n 87\n 104\n 121\n 128\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Lactic Acid:0.6 mmol/L, Ca++:7.7 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs, now\n intubated after increased somnolence. Going to OR today for L femur\n ORIF, right ankle external fixation removal + ORIF. s/p IVC filter.\n .\n NEURO: Alcohol withdrawal/DT. Intubated for airway protection. Propofol\n gtt. Valium CIWA prn w/ significant valium requirement. Pain: dilaudid\n prn, Tylenol prn. Will wean off prop to attempt vent wean\n CVS: Tachycardic/ HTN likely secodary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx. Intubated for altered mental\n status from withdrawal. GNR on sputum and febril -> started on\n Vanc/ Zosyn/ Cipro. Sputum cultures P. Wean to extubate.\n GI: NGT feeding.\n Nutrition: Thiamine, folate, MVI. Mg and K sliding scale. Replete with\n Fiber (Full) - 04:00 PM 50 mL/hour\n RENAL: Foley, monitor UOP\n HEME: s/p 4u pRBC. s/p IVC filter. On SQH for prophylaxis.\n ENDO: RISS\n ID: Vanc/Zosyn/ Cipro for gnr in sputum and for surgical prpophy\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT, aline,left subclavian\n IVF: thiamine, d5, folate\n Wound: L femur, R ankle - watch for compartment\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT SQH\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n Lines:\n Arterial Line - 10:00 AM\n Multi Lumen - 01:30 PM\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505419,
"text": "pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil move slowly.\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Remains off all sedation.\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505408,
"text": "pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Pupils #3 and reasts briskly\n Moves upper extremtites off the bed.\n Move right leg back and forth but has some difficulty moving off the\n bed due to the metal apparatus.\n Does not move left leg freely and only wiil\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-02 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 504170,
"text": "TITLE:\n Chief Complaint: Withdrawal from ETOH\n HPI:\n 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: ETOH abuse,Varicose veins, othewise unk\n PSH: Ex fix/ wahout right ankle\n Meds at home: Denies\n All: Denies\n SH: homeless history of ETOH 12 beers/ day but denies withdrawal\n seizures ( per prior notes)\n FH:unk\n Flowsheet Data as of 09:56 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.3\nC (100.9\n HR: 124 (124 - 124) bpm\n BP: 134/87(98) {134/87(98) - 134/87(98)} mmHg\n RR: 27 (27 - 27) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 729 mL\n PO:\n TF:\n IVF:\n 729 mL\n Blood products:\n Total out:\n 1,150 mL\n 30 mL\n Urine:\n 1,150 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n -421 mL\n -30 mL\n Respiratory support\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Anxious, Diaphoretic, Confused\n Eyes / Conjunctiva: injected conjunctiva\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), Tachycardic to 120-130s\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), Bilateral\n DP dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Trace, LEft leg in brace, Right ankle with ex fix in place\n bialteral feet warm with intact sensation\n Skin: Warm, flushed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x1 to self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: : CT torso: Acute right rib fractures involving the\n 2nd, 3rd and likely 12th ribs. No pneumothorax. Dependant atelectasis\n bilaterally and a more nodular right upper lobe opacity. This may be\n aspiration, though followup when clinically stable is recommended to\n document resolution and exclude underlying pulmonary nodule.\n : CT L leg: Markedly comminuted fracture or the distal femoral\n diaphysis. There is no evidence of intra-articular extension. In\n addition, there is a non-displaced fracture of the prox fibula.\n : R tib/fib films: Comminuted fractures of the distal tibia and\n fibula.\n CXR: left base in the retrocardiac region, likely atelectasis\n Microbiology: Ucx P\n Assessment and Plan\n TRAUMA, S/P\n ALCOHOL ABUSE with active withdrawal and disorientation\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn.\n Neuro checks Q: 1\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine.\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines: PIV x 2\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP: NA\n Need for restraints reviewed Y\n Comments:\n Communication: Comments: ICU consent deferred due to poor MS\n status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504251,
"text": "TITLE:\n 24 Hour Events: : Readmitted to SICU for EtOH widrawal and\n DT's. Significant valium requirements 30-60 mg/ hr for CIWA score 30s.\n s/p Ex-fix R tib/fib ID and ex fix right ankle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 01:39 AM\n Other medications:\n Enoxaparin Sodium 30 mg SC Q12H\n FoLIC Acid 1 mg IV Q24H Order date: @ 2121\n Acetaminophen 650 mg PO Q4H:PRN pain, t>100\n Insulin SC (per Insulin Flowsheet)Sliding Scale\n CloniDINE 0.3 mg PO TID\n Cyanocobalamin 50 mcg PO/NG DAILY\n Diazepam 5-20 mg IV Q1H:PRN CIWA >10\n Flowsheet Data as of 02:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.8\nC (100\n HR: 150 (124 - 150) bpm\n BP: 162/95(113) {134/82(98) - 162/95(113)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,280 mL\n 279 mL\n PO:\n TF:\n IVF:\n 1,280 mL\n 279 mL\n Blood products:\n Total out:\n 105 mL\n 150 mL\n Urine:\n 105 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,175 mL\n 129 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic, Confused and\n agitated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), LE Dp\n dopplerable\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: Absent, ex fix right leg, left leg in splint\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): x1 self, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 204 K/uL\n 11.5 g/dL\n 129\n 0.6 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 104 mEq/L\n 138 mEq/L\n 35.1 %\n 8.9 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n WBC\n 8.9\n Hct\n 35.1\n Plt\n 204\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 120\n 129\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:55/70, Alk Phos / T Bili:78/0.1, Amylase\n / Lipase:141/177, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR: left base in the retrocardiac region, likely\n atelectasis\n Microbiology: U cx P\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n 50y M ped vs auto with multiple orthopedic injuries s/p RLE ExFix, rib\n fractures. Alcohol withdrawal with DTs.\n .\n NEURO: awake, alert, neuro intact, following commands, A&O x1. Denies\n seizure history with withdrawl. Valium CIWA prn. Significant valium\n requirments. Neuro checks Q 1hr. Restrained.\n Pain: dilaudid PCA, Tylenol prn.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Start beta blockade\n PULM: stable on nasal cannula. Right rib fx but no ptx.\n GI: Npo. Thiamine, folate, MVI. Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: stable\n ENDO: RISS\n ID: s/p Rc with gent/zosyn/ancef. wash out in OR by ortho planned for\n am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.\n IVF: LR @125 mL/hr.\n thiamine, folate for protection\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal:\n ICU Care\n Nutrition:\n Comments: Npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:53 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 35\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504350,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: periods of agitation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505406,
"text": "pt he is homeless and lives in . 12 beer a day drinker/smokes\n cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Action:\n Neuro signs q2hrs\n Pin care to right leg and foot\n Suctioned prn\n Vap mouth care\n Iv 1/2ns at 55cc/hr\n Tube fdg at goal\n Response:\n Vital signs stable\n Slowly waking and following simple commands\n Hct stable at 26\n Continues to be suctioned for copius amts of thick white/yellow sputum.\n Plan:\n Monitor patient\ns condition closely.\n Provide emotional support to patient.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504335,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Trauma, s/p\n Assessment:\n Patient bilateral legs pulses by Doppler left leg in traction with\n pin sites right leg femur fracture with leg brace on + csm multiple\n scrapes and bruising.\n Action:\n Pin site cleaning done with\n normal saline and peroxide.\n Response:\n Patient remains stable\n Plan:\n Continue to monitor notify team of any changes provide comfort and\n support as needed\n Alcohol abuse\n Assessment:\n Patient alert and orientated X1 very agitated not appropriate trying\n to climb out of bed heart to 120-130\ns b/p 140\ns over 80\n Action:\n Giving valium 10-20mg IV haldol X 1 and dilaudid with little effect\n patient intubated for increased agitation and DT\ns @ 1700\n Response:\n Patient less agitated and comfortable\n Plan:\n Continue with current plan of care notify team of any changes\n Please see social service note\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504490,
"text": "Trauma, s/p\n Assessment:\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\n Patient is intubated and sedated on Propofol.\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\n am.\n Vital signs stable (HR 60-70, SBP 90\ns-100)\n When off prop patient tremulous, diaphoretic, inconsistently follow\n commands, able to move upper extremities.\n Action:\n Turned and repositioned for comfort.\n Pin care done, incisional dsg on right leg changed, moderate serosang\n drainage noted.\n Given 2 units PRBC.\n Given 1 mg Dilaudid q 4 hours for pain.\n Response:\n Patient continues to be intubated and sedated,\n Post transfusion HCT up to 25.5,\n Plan:\n Patient to go to OR for ORIF right tibia and left femur, 3 plates,\n and placement of IVC filter.\n Alcohol abuse\n Assessment:\n Last drink : Patient on CIWA scale despite being intubated and\n sedated. Moderate diaphoresis noted.\n Off sedation patient very tremulous, unable to follow commands\n consistently, agitated.\n Action:\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\n Response:\n Patient not as diaphoretic,\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504208,
"text": "Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Pt homeless, alcoholic. Per pt was ordering food from a local take out\n facility when he went to cross the street he got hit by a car.Pt\n remembers whole accident. Negative LOC per witness. Pt sent to then transferred here for further mgmt.\n Injuries include: Open tib/fib to right (per osh reports hanging by a\n thread), Lt comminuted femur fx, bilateral rib fxs\n Alcohol abuse\n Assessment:\n Patient has a long history of alcholol abuse. Patient drinks 12 beers\n /day\n Diaphoretic with heart rate 120-140\n Bp 140-150\ns syst.\n Action:\n Ciwa scale q1hr\n Valium iv q1hr.\n Response:\n Alcohol withdrawal continues.\n Ciwa scale\n Continue with valium iv .\n Plan:\n Continue with ciwa scale\n Valium iv as ordered.\n Maintain safe environment.\n Trauma, s/p\n Assessment:\n Admitted to the sicu from cc6. sitting up in the bed and attempting to\n climb oob,\n Diaphoretic and slight ly tremorous.\n Yelling out and not making any sense.\n Pulling at the bedclothes and sheets.\n Eyes open wide.\n Unable to answer where he is, unable to name month or year.\n Patient is able to state his own name.\n Heart rate up to the 130-140\n Left leg has immobilizer on . good pedal pulses.\n Right leg dsg oozing some bloody drainage. Pins and wire brackets in\n place/\n Patient moving right leg despite pins and bracket. Patient does yell\n out wnen moving leg.\n Iv lactated ringers at 125 cc/hr\n Fluid bolus x2 with lactated ringers iv given.\n Breath sounds clear\n Action:\n Ciwa scale q1hr\n Valium 10mg q1 hr\n Iv lactated ringers at 125cc/hr.\n Npo aftermidnoc for or today.\n Pedal pulses check q 2hrs on right and left feet.\n Response:\n Continues to have alcholol withdrawal\n Ciwa scale q1hr maintained.\n Valium iv q1 hr.\n Plan:\n Monitor very closely\n Continue with ciwa scale.\n To or for femur repair.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504594,
"text": "HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Trauma, s/p\n Assessment:\n Action:\n Suctioned prn\n Vap mouth care as ordered\n On propofol gtt and infusing at 40mcg/hr.\n Iv lactatated ringers at 100cc/hr.\n Valium 10mg iv prn given\n Hydromorphone 1mg iv prn given.\n Response:\n Plan:\n Monitor condition closely.\n To or for femur repair\n Update cousin of patient\ns condition.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 504438,
"text": "HPI: 51y M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n .\n 24 Hour Events: :Worsening left retrocardiac opacification suggests\n developing pneumonia, and new small left effusion\n : Intubated for airway protection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:49 AM\n Gentamicin - 07:26 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:00 PM\n Metoprolol - 03:59 PM\n Haloperidol (Haldol) - 05:00 PM\n Pantoprazole (Protonix) - 08:20 PM\n Enoxaparin (Lovenox) - 09:00 PM\n Hydromorphone (Dilaudid) - 09:30 PM\n Diazepam (Valium) - 12:00 AM\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 75 (73 - 144) bpm\n BP: 102/66(74) {94/51(61) - 150/83(97)} mmHg\n RR: 16 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,909 mL\n 30 mL\n PO:\n TF:\n IVF:\n 3,909 mL\n 30 mL\n Blood products:\n Total out:\n 2,450 mL\n 40 mL\n Urine:\n 2,450 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,459 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 602 (502 - 602) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.45/43/454/28/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 1,135\n Physical Examination\n General Appearance: No acute distress, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 152 K/uL\n 8.7 g/dL\n 124 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 102 mEq/L\n 138 mEq/L\n 26.0 %\n 9.3 K/uL\n [image002.jpg]\n 04:17 AM\n 05:00 AM\n 07:11 PM\n 04:50 AM\n 01:15 PM\n 07:42 PM\n WBC\n 8.9\n 9.3\n Hct\n 35.1\n 26.0\n Plt\n 204\n 152\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n TCO2\n 32\n 31\n Glucose\n 120\n 129\n 124\n Other labs: PT / PTT / INR:12.0/25.1/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50y M ped vs auto with multiple orthopedic\n injuries s/p RLE ExFix, rib fractures. Alcohol withdrawal with DTs.\n .\n NEURO: Sedation with propofol. Significant valium requirements for ETOH\n withdrawal. Cpap/ PS.\n CVS: Tachycardic/ HTN likely secondary to withdrawal. On clonidine\n patch. Beta blockade.\n PULM: Right rib fx but no ptx.Intubated \n GI: Npo will feed post procedure. Thiamine, folate, MVI via banana bag\n Electrolyte repletion\n RENAL: Foley, monitor UOP\n HEME: Transfuse 2 unit preoperatively for hct 21. Check post hct.\n ENDO: RISS\n ID: Wash out in OR by ortho planned for am.\n Other: Social work/ Addictions consult\n TLD: Foley, PIV.NGT,ETT\n IVF: LR @125 mL/hr.\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: PPI\n DVT Lovenox 30 q12\n STRESS ULCER H2B\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU\n ICU Care\n Lines:\n 20 Gauge - 07:10 PM\n Total time spent: 32 min Delirium Tremens\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504430,
"text": "Alcohol abuse\n Assessment:\n pt intubated and on propofol drip, pt is sedate but continues to have\n profound diaphoresis.\n Action:\n spoke with dr valium iv given. LR bolus 500 cc times one\n Response:\n decreased daphoresis with valium doses\n Plan:\n Assess for underlying symptoms of with drawal ie diphoresis,\n twitching, tremors and medicate prn. Please give medication for pain\n periodically.\n Trauma, s/p\n Assessment:\n rlower leg draining sero-sanguinous,left leg with knee brace in place\n Action:\n npo for OR ot day for repair . medicated for pain times 4 with .5 mg\n iv\n Response:\n difficult to evaluate for pain so medicate for pain periodically\n Plan:\n NPo for or today. hold enoxaprin sodium but if OR cancelled pt should\n receive doses.\n"
},
{
"category": "Nutrition",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 504474,
"text": "Subjective\n Unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 28.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 117%\n unknown\n Diagnosis: pedestrian struck, leg fractures\n PMHx: patient denies, per report drinks 12 beers/day\n Food allergies and intolerances: none noted\n Pertinent medications: Propofol drip, RISS, Pantoprazole, vitamin B12,\n Banana bag, KPhos 15mmol\n Labs:\n Value\n Date\n Glucose\n 83 mg/dL\n 04:13 AM\n Glucose Finger Stick\n 115\n 10:00 AM\n BUN\n 13 mg/dL\n 04:13 AM\n Creatinine\n 0.6 mg/dL\n 04:13 AM\n Sodium\n 137 mEq/L\n 04:13 AM\n Potassium\n 5.1 mEq/L\n 04:13 AM\n Chloride\n 105 mEq/L\n 04:13 AM\n TCO2\n 28 mEq/L\n 04:13 AM\n PO2 (arterial)\n 454 mm Hg\n 07:42 PM\n PCO2 (arterial)\n 43 mm Hg\n 07:42 PM\n pH (arterial)\n 7.45 units\n 07:42 PM\n CO2 (Calc) arterial\n 31 mEq/L\n 07:42 PM\n Calcium non-ionized\n 7.4 mg/dL\n 04:13 AM\n Phosphorus\n 4.3 mg/dL\n 04:13 AM\n Magnesium\n 2.2 mg/dL\n 04:13 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 8.3 K/uL\n 11:04 AM\n Hgb\n 8.4 g/dL\n 11:04 AM\n Hematocrit\n 25.5 %\n 11:04 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, (+) bowel sounds; OGT to low continuous suction\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NP, trauma, Etoh use PTA\n Estimated Nutritional Needs\n Calories: 2270-2455 (24-26 cal/kg)\n Protein: 113-142 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 51 YO homless male admitted to Hospital after struck by a car\n while walking intoxicated. Injuries including an open tibia/fibia on\n right and comminuted femur fracture on left; right rib fractures\n 2nd/3rd/ 12th. Questionable lesion on CT question mass versus pna on\n right. Transferred to for further management. Hypertension,\n change in MS, and tachycardia consistent with etoh withdrawal requiring\n >10 mg valium every hr prompting admission to ICU. Intubated for\n airway protection. Plan for OR today for ORIF right tibia/fibia, left\n femur. Remains NPO; propofol providing 750 calories. Questionable\n nutrition status PTA given homeless, report of Etoh use.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n NPO\n Multivitamin / Mineral supplement: continue current;\n multi-vitamin via enteral nutrition\n Tube feeding recommendations: When able begin nutrition\n support\n o Replete with Fiber @ 20ml/hr, advance as tolerated to goal of\n 65ml/hr + 15g Beneprotein = 1615 calories and 120g protein while\n propofol running\n o If propofol discontinued, can advance tube feed goal to\n 95ml/hr = 2280 calories and 141g protein\n o Check residuals, hold tube feed if greater than 200ml\n Check chemistry 10 panel daily\n o Replete lytes PRN\n BS management\n Will follow, page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504524,
"text": "Trauma, s/p\n Assessment:\n S/P Right tib/fib fx, comminuted Left femur fx, bilat. Rib f x.\n Patient is intubated and sedated on Propofol.\n Pedal pulses dopplerable bilaterally, Cap refill < 3 sec. HCT 21.3 this\n am.\n Vital signs stable (HR 60-70, SBP 90\ns-100)\n When off prop patient tremulous, diaphoretic, unable to follow\n commands, able to move upper extremities.\n Action:\n Turned and repositioned for comfort.\n Pin care done, incisional dsg on right leg changed, moderate serosang\n drainage noted.\n Given 2 units PRBC.\n Given 1 mg Dilaudid q 4 hours for pain.\n Response:\n Patient continues to be intubated and sedated,\n Post transfusion HCT up to 25.5, given 2 more units PRBC.\n Plan:\n Patient to go to OR for ORIF right tibia and left femur , 3 \n plates, and placement of IVC filter tomorrow.\n Alcohol abuse\n Assessment:\n Last drink : Patient on CIWA scale despite being intubated and\n sedated. Moderate diaphoresis noted.\n Off sedation patient very tremulous, unable to follow commands\n consistently, agitated.\n Action:\n - On CIWA scale q 1-2 hours, given valium 10 mg IV q 1-2 hours.\n Response:\n Patient not as diaphoretic,\n Plan:\n Continue to monitor.\n"
},
{
"category": "Respiratory ",
"chartdate": "2146-01-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504526,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507576,
"text": "Delirium / confusion\n Assessment:\n Patient extremely agitated this am, trying to get out of bed, banging\n right external fixationdevise against side rails.\n Oriented only to himself, believes he is at a church,\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 507449,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented. Previosly in DT - needed\n excessive valium. Now still delirious. Need frequent re-orientation\n with restriants. Haldol PO and IV prn.Ativan prn.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal. Reintubated for increasing\n agitation and in prep for OR\n GI: Regular.\n Nutrition: Thiamine, folate, MVI.\n RENAL:\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent:\n :\n :\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 507522,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\n - needed excessive valium. Now still delirious. Need frequent\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley.\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n :\n :\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 507541,
"text": "SICU\n HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Chief complaint:\n PMHx:\n ETOH abuse,Varicose veins\n Current medications:\n . Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Clonidine Patch 0.3\n mg/24 hr 8. Cyanocobalamin 9. FoLIC Acid 10. Haloperidol 11.\n Haloperidol 12. Heparin 13. Levofloxacin 14. Lorazepam 15. Metoprolol\n Tartrate 16. Multivitamins 17. Nicotine Patch 18. OxycoDONE (Immediate\n Release\n 24 Hour Events:\n agitated on floor not responding to haldol/valium/zyprexa\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 103 (103 - 103) bpm\n BP: 116/69(80) {116/69(80) - 116/69(80)} mmHg\n RR: 17 (17 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Anxious, agitated/delerius\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Skin: RLE EX fix\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n agitated and deleriuous\n Labs / Radiology\n 433 K/uL\n 8.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.1 %\n 9.6 K/uL\n [image002.jpg]\n 05:00 AM\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n WBC\n 8.1\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n Hct\n 26.6\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n Plt\n 259\n 307\n 327\n 390\n 455\n 433\n Creatinine\n 0.5\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 120\n 124\n 119\n 126\n 125\n 95\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CK-MB / Troponin\n T:/2/<0.01, ALT / AST:25/46, Alk-Phos / T bili:60/1.0, Amylase /\n Lipase:27/15, Differential-Neuts:69.0 %, Band:3.0 %, Lymph:13.0 %,\n Mono:14.0 %, Eos:0.0 %, Lactic Acid:0.6 mmol/L, Ca:8.2 mg/dL, Mg:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n TRAUMA, S/P, ALCOHOL ABUSE\n ASSESSMENT AND PLAN: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter.Code purple on\n floor.Transferred to ICU\n NEURO: Delirious, awake but disoriented and somnolent. Previosly in DT\n - needed excessive valium. Now still delirious. Need frequent\n re-orientation with restriants. Haldol PO and IV prn Ativan. ?\n withdrawl from benzos. Check CT scan head. Will ask psych to see.\n CVS: On clonidine patch. Beta blockade.\n PULM:room air.saturating well. h/oHAP likely aspiration. Cx w/\n H.influ and Shewanella.completed course of levaquin.h/o Intubated \n for altered mental status from withdrawal\n GI: Regular. Not taking pos now.\n Nutrition: Thiamine, folate, MVI.\n RENAL: Place foley.\n HEME: Hct 29 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES and H.influenzae being treated with\n levaquin.\n Other: Social work/ Addictions consult\n TLD: PIV\n IVF: KVO\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT SQH/IVC filter\n STRESS ULCER\n VAP BUNDLE yes\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n Total time spent: 35 min\n :\n :\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 10:46 ------\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 507811,
"text": "HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 507813,
"text": "HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n Demographics\n Attending MD:\n K.\n Admit diagnosis:\n PEDESRTRIAN STRUCK, LEG FRACTURES\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 94.5 kg\n Daily weight:\n 91.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Eu Critical AKA DOB \n Per pt no PMH/PSH . Per report Hep C but pt denies.\n Per pt he is homeless and lives in . 12 beer a day\n drinker/smokes cigarettes. Admitted with an alcohol level >400.\n Surgery / Procedure and date: to sicu from cc6 on 2130pm patient\n withdrawing from alchohol and requiring q1hr valium. heart rate\n 130-140's. very agitated and requiring constant watch. npo for or on\n monday to repair left femur.\n -pt back to sicu from CC6 after causing \"code purple\" d/t severe\n agitation and delerium\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:68\n Temperature:\n 97.5\n Arterial BP:\n S:123\n D:83\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,066 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:31 AM\n Potassium:\n 4.1 mEq/L\n 04:31 AM\n Chloride:\n 109 mEq/L\n 04:31 AM\n CO2:\n 24 mEq/L\n 04:31 AM\n BUN:\n 10 mg/dL\n 04:31 AM\n Creatinine:\n 0.7 mg/dL\n 04:31 AM\n Glucose:\n 111 mg/dL\n 04:31 AM\n Hematocrit:\n 30.6 %\n 04:31 AM\n Finger Stick Glucose:\n 95\n 07:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: notebook\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: CC 6\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nutrition",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 507810,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 94.5 kg\n 91.1 kg ( 03:00 AM)\n 28.2\n Pertinent medications: Dextrose 5% with 1/2 normal saline with KCl @\n 10mL/hr, Haldol, others noted\n Labs:\n Value\n Date\n Glucose\n 111 mg/dL\n 04:31 AM\n Glucose Finger Stick\n 95\n 07:00 PM\n BUN\n 10 mg/dL\n 04:31 AM\n Creatinine\n 0.7 mg/dL\n 04:31 AM\n Sodium\n 141 mEq/L\n 04:31 AM\n Potassium\n 4.1 mEq/L\n 04:31 AM\n Chloride\n 109 mEq/L\n 04:31 AM\n TCO2\n 24 mEq/L\n 04:31 AM\n PO2 (arterial)\n 184 mm Hg\n 10:45 PM\n PCO2 (arterial)\n 40 mm Hg\n 10:45 PM\n pH (arterial)\n 7.43 units\n 10:45 PM\n pH (urine)\n 6.0 units\n 08:56 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 10:45 PM\n Calcium non-ionized\n 8.8 mg/dL\n 04:31 AM\n Phosphorus\n 3.7 mg/dL\n 04:31 AM\n Ionized Calcium\n 1.11 mmol/L\n 02:21 AM\n Magnesium\n 2.4 mg/dL\n 04:31 AM\n ALT\n 25 IU/L\n 04:50 AM\n Alkaline Phosphate\n 60 IU/L\n 04:50 AM\n AST\n 46 IU/L\n 04:50 AM\n Amylase\n 27 IU/L\n 04:50 AM\n Total Bilirubin\n 1.0 mg/dL\n 04:50 AM\n WBC\n 6.7 K/uL\n 04:31 AM\n Hgb\n 10.1 g/dL\n 04:31 AM\n Hematocrit\n 30.6 %\n 04:31 AM\n Current diet order / nutrition support: Diet: Regular\n Assessment of Nutritional Status\n Patient was extubated and passed for a ground diet and nectar\n thick liquids per SLP on . Patient was re-evaluated and was\n upgraded to a regular diet. Patient was transferred to ICU o/n due to\n a code purple. Patient is now much more calm and oriented, and is\n tolerating a regular diet well RN. Will continue to follow and\n monitor po intake.\n #\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507512,
"text": "Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507514,
"text": "51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.subsequently discharged to floor on .code purple\n on -transferred to SICU.\n HD17 s/p Ex-fix R tib/fib ID and ex fix right ankle ORIF left femur\n , now s/p ORIF L distal femur fx and IVC filter 12/8, RLE\n washout/ Ex-fix revision\n Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507510,
"text": "Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -keep pt safe\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507511,
"text": "Delirium / confusion\n Assessment:\n -pt arrived from floor to sicu after causing\ncode purple\n due to\n delirium and extreme agitation\n -pt arrived with security escorts, sitting upright in bed, hollering\n out . Pt unable to answer questions appropriately and appeared to be\n having hallucinations at times\n -pt at high risk to fall as he was flipping legs over edge of bed and\n pulling at restraints\n Action:\n -pt given 1mg IV haldol without effect\n -pt subsequently given 10mg IV valium\n Response:\n -pt fell asleep after valium administration\n Plan:\n -keep pt safe\n -frequent safety checks to maintain safety\n -?consult psych to manage pt meds for better treatment of\n delirium/agitation\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 507666,
"text": "24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\n amounts of valium. Now still disoriented, requiring frequent\n re-orientation with restriants. Evaluated by psych. Will avoid BDZs for\n now.\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC.\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 507672,
"text": "Delirium / confusion\n Assessment:\n Pt with delirium, very confused when wakes up, believes he is at \n beach, constantly asking for alcohol and cigarettes.\n Action:\n Medicated with Haldol overnight.\n No Benzos given.\n Response:\n Pt able to sleep for good periods, was oriented x3 at one point, but\n now confused as to place etc. No further periods of agitation.\n Plan:\n Continue to medicate with Haldol for agitation, re-orient pt as needed.\n c/o to floor.\n"
},
{
"category": "Rehab Services",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 507740,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: trauma / 959.9\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 51 yo M admitted\n as pedestrian struck, sustained R open tibia/fibula fx and L\n comminuted supracondylar fx with several R-sided rib fractures.\n Underwent open fixation and ex. fix placement of R ankle, and L knee\n ORIF. Post-op course c/b severe etoh withdrawal.\n Past Medical / Surgical History: See initial eval\n Medications: tylenol, heparin, metoprolol, oxycodone, haloperidol\n Radiology: L knee XR- There is a comminuted fracture of the distal\n femur. There is apparent increase in the space/gap between the plate\n and the largest fragment in the distal diaphysis\n Labs:\n 30.6\n 10.1\n 474\n 6.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist, TDWB B LE's\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert and oriented,\n follows all simple commands. hard of hearing.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 76\n 132/80\n 97% on RA\n Activity\n 88\n /\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lungs cta, non-labored breathing, no cough noted.\n Integumentary / Vascular: L knee with staples intact, in place\n and locked in extension. R ex.fix in place.\n Sensory Integrity: B LE's intact to light touch\n Pain / Limiting Symptoms: c/o 8/10 L knee pain with ROM\n Posture: WNL\n Range of Motion\n Muscle Performance\n L knee ext-flex \n L ankle to neutral\n R hip/knee WNL\n B LE's at least t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: not assessed\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: not assessed, patient in 4-point restraints during eval.\n Education / Communication: Reviewed PT , positioning and use of\n brace. Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired ROM/strength\n Clinical impression / Prognosis: 51 yo M s/p B LE fractures p/w above\n impairments a/w bony surgery. He is most limited by L knee pain and\n decreased ROM at this time, as well as B weight-bearing restrictions.\n He has also had episodes of agitation and has required sedation and\n restraints. He is below his baseline level, but anticipate good rehab\n potential given his strength and level of mobility. PT to continue to\n follow daily for ROM, and mobility when appropriate.\n Goals\n Time frame: 1 week\n 1.\n Min A transfers bed-to-chair\n 2.\n Tolerate OOB >/= 3 hours/day\n 3.\n Tolerate daily LE ROM/strength, L knee ROM 0-90\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily\n transfers, ambulation, balance, endurance, education, strengthening,\n ROM\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 507741,
"text": "24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previosly in DT - requiring intubation and large\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\n BDZs for now.\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H.influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\n Off abx.\n Pt afebrile and satting well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 507750,
"text": "24 Hour Events: 50M ped vs auto with multiple orthopedic injuries s/p\n RLE ExFix and L femur ORIF and s/p IVC filter. Hospital course notable\n for ETOH w/d requiring intubation and large amounts of diazepam. Pt had\n been d/c'd to floor and returns to SICU code purple 12/21AM.\n No major events overnight. Pt's agitation improved with haldol,\n however, pt remains disoriented.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 12:39 PM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 AM\n Diazepam (Valium) - 05:13 AM\n Heparin Sodium (Prophylaxis) - 07:58 PM\n Haloperidol (Haldol) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 02:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.9\nC (98.5\n HR: 72 (70 - 116) bpm\n BP: 118/68(79) {107/60(74) - 156/85(109)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.1 kg (admission): 94.5 kg\n Height: 72 Inch\n Total In:\n 1,953 mL\n 209 mL\n PO:\n 480 mL\n 120 mL\n TF:\n IVF:\n 1,473 mL\n 89 mL\n Blood products:\n Total out:\n 1,600 mL\n 0 mL\n Urine:\n 1,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 353 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 504 K/uL\n 9.8 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 105 mEq/L\n 138 mEq/L\n 29.8 %\n 12.1 K/uL\n [image002.jpg]\n 12:59 PM\n 02:41 AM\n 02:50 AM\n 01:53 AM\n 01:50 AM\n 10:58 AM\n 10:45 PM\n 02:30 AM\n 08:13 AM\n 03:44 AM\n WBC\n 7.8\n 7.1\n 8.6\n 12.3\n 9.6\n 12.1\n Hct\n 25.4\n 27.0\n 27.7\n 30.2\n 27.2\n 29.1\n 29.8\n Plt\n 55\n 433\n 504\n Cr\n 0.6\n 0.6\n 0.8\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 28\n 27\n Glucose\n 124\n 119\n 126\n 125\n 95\n 105\n Other labs: PT / PTT / INR:12.0/26.5/1.0, CK / CKMB /\n Troponin-T:/2/<0.01, ALT / AST:25/46, Alk Phos / T Bili:60/1.0, Amylase\n / Lipase:27/15, Differential-Neuts:79.3 %, Band:3.0 %, Lymph:14.3 %,\n Mono:5.7 %, Eos:0.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, TRAUMA, S/P\n Assessment And Plan: 50M ped vs auto with multiple orthopedic injuries\n s/p RLE ExFix and L femur ORIF and s/p IVC filter. Code purple on floor\n early 12/21AM. Transferred to ICU\n NEURO: Disoriented. Previously in DT - requiring intubation and large\n amounts of valium. Now more oriented. Evaluated by psych. Will avoid\n BDZs for now per psych\ns recs and will use Haldol around the clock and\n prn for agitation. Overall, pt is doing better\n -ATC and prn IV Haldol. Daily EKGs to monitor QTC (stable at 440).\n -Nicotine patch.\n CVS: Metoprolol Tartrate 5 mg IV Q4H. Will d/c and switch to PO given\n pt's improved mental status. Daily EKGs while on haldol. QTC 459\n QTC 437.\n PULM: saturating well on RA. h/o HAP likely aspiration. Cx w/\n H.influ, Shewanella, and proteus vulgaris. Pt is on levaquin ().\n CXR in AM.\n GI: Regular diet\n Nutrition: Thiamine, folate, MVI.\n RENAL: Cr 0.8; No foley.\n HEME: Hct 29 on . HCT 29.8 on . On SQH for prophylaxis.\n ENDO: RISS. Euthyroid\n ID: HAP. SHEWANELLA SPECIES, H. influenzae, and proteus vulgaris on\n sputum cx. Levaquin started . Leukocytosis noted . WBC 12.1.\n Off abx.\n Pt afebrile and saturating well on RA. CXR in AM. Trend WBC.\n Other: Social work/ Addictions consult/Psych\n TLD: PIV\n IVF: Banana bag. Switch back to PO vitamins once pt is agreeable to\n taking pills.\n Wound: L femur, R ankle\n CONSULTS: ortho, trauma\n BILLING DIAGNOSIS: ETOH Withdrawal; Multiple ortho traumas\n DVT SQH/IVC filter\n STRESS ULCER: regular diet\n VAP BUNDLE N/A\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: SICU-floor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin, IVC filter\n Stress ulcer: regular diet\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds. Comments:\n Need to obtain ICU consent.\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20minutes\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 507777,
"text": "Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 507779,
"text": "HPI:\n 51M tranfer from Hospital intoxicated ped vs auto. B/L LE\n injuries including an open tib/fib on R and comminuted femur fracture\n on L. R rib fx 2nd/3rd/ 12th. No ptx. Questionable lesion on CT ? mass\n vs pna on R. VSS. Intoxicated with ETOH in 400's at Hospital.\n Denies PMHx, but intoxicated. Hypertension, change in MS, and\n tachycardia c/e etoh withdrawal requiring >10 mg valium q hr prompting\n admission to ICU.\n Chief complaint:\n Pedestrian struck, now HD12 POD11 s/p Ex-fix R tib/fib and ID, POD7\n plate left femur and washout R ankle and IVC filter, POD 1 washout\n RLE\n PMHx:\n ETOH abuse,Varicose veins, o/w unknown\n Delirium / confusion\n Assessment:\n S/P code purple called on at 0300, patient is now not agitated,\n alert, oriented to self and place, unsure of date. Able to follow\n commands, was not trying to get out of bed, able to use call bell for\n help.\n Action:\n Continued on standing dose of haldol (all benzo\ns d/c\nd yesterday per\n psych recommendation),\n PT in to work with patient, offered to get OOB to chair,\n Response:\n Patient continues to be calm, a little confused at times.\n Plan:\n Continue to monitor, no benzo\ns per pysch.\n Trauma, s/p\n Assessment:\n S/P internal fixation of right fibula, repair of L femur fx,\n External fixation in place, draining serous fluid from pin sites, pin\n sites look clean.\n Action:\n Pin care x 2 today,\n Dsg changed,\n PT in to work with patient.\n Response:\n Patient c/o of some pain after working with PT, given Tylenol with good\n effect.\n Plan:\n Continue to monitor.\n"
},
{
"category": "ECG",
"chartdate": "2146-01-18 00:00:00.000",
"description": "Report",
"row_id": 233207,
"text": "Sinus rhythm. Lead V2 is missing. Otherwise, tracing is within normal limits.\nCompared to the previous tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-17 00:00:00.000",
"description": "Report",
"row_id": 233208,
"text": "Baseline artifact. Normal sinus rhythm, rate 93 beats per minute. Possible left\natrial abnormality. Compared to the previous tracing of heart rate is\nfaster. QTc interval is not prolonged.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-14 00:00:00.000",
"description": "Report",
"row_id": 233209,
"text": "Sinus rhythm. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-12 00:00:00.000",
"description": "Report",
"row_id": 233210,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrate has slowed. Otherwise, there is no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-02 00:00:00.000",
"description": "Report",
"row_id": 233211,
"text": "Sinus tachycardia. Otherwise, probably normal tracing but unstable baseline in\nthe precordial leads makes assessment difficult. Since the previous tracing\nof sinus tachycardia is now present but otherwise, probably no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-01 00:00:00.000",
"description": "Report",
"row_id": 233212,
"text": "Sinus rhythm. Probably normal tracing but unstable baseline in the precordial\nleads makes assessment difficult. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-16 00:00:00.000",
"description": "LP KNEE (2 VIEWS) LEFT PORT",
"row_id": 1113015,
"text": " 1:40 PM\n KNEE (2 VIEWS) LEFT PORT Clip # \n Reason: assess for hardware movement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with fall from chair today. s/p ORIF L distal femur\n REASON FOR THIS EXAMINATION:\n assess for hardware movement\n ______________________________________________________________________________\n FINAL REPORT\n LEFT KNEE, TWO VIEWS\n\n REASON FOR EXAM: Trauma, assess for hardware displacement.\n\n Comparison is made with prior study fluoroscopic views performed in the O.R.\n on .\n\n There is a comminuted fracture of the distal femur. There is apparent\n increase in the space/gap between the plate and the largest fragment in the\n distal diaphysis.\n\n There is no dislocation. There is joint effusion. Skin staples are present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111208,
"text": " 9:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NC tube position,ETT position\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ETOH WITHDRAWL\n REASON FOR THIS EXAMINATION:\n NC tube position,ETT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube position.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube now measures approximately 3.5 cm above the carina.\n Persistent low lung volumes with atelectatic changes at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-12 00:00:00.000",
"description": "OR ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT",
"row_id": 1112510,
"text": " 6:01 PM\n ANKLE (AP, LAT & OBLIQUE) IN O.R. RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: RIGHT ANKLE EXFIXATOR ADJUSTMENT\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n WET READ: SPfc WED 6:35 PM\n Intraoperative views of the right ankle redemonstrate comminuted fractures of\n the distal tibia and fibula. See operative note for complete details.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Right ankle external fixator adjustment.\n\n COMPARISON: Right ankle intraoperative radiograph .\n\n FINDINGS: Eight intraoperative fluoroscopic images were acquired without the\n radiologist present, using a fluoro time of 43.6 seconds. The images\n demonstrate a comminuted distal tibial fracture with extension into the distal\n tibiotalar joint. There is a comminuted distal fibular fracture with minimal\n distraction of the fracture fragments. An external fixator is seen in situ.\n There is mild widening of the ankle mortise superiorly and medially. Please\n refer to the operative note for further details of surgery.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111542,
"text": " 9:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess location\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ett tube repositioned\n REASON FOR THIS EXAMINATION:\n assess location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: ETT repositioning.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the position of the\n endotracheal tube has not substantially changed. On today's examination, the\n tip of the tube projects approximately 6.5 cm above the carina. Normal course\n and position of the nasogastric tube. The pre-existing bilateral areas of\n atelectasis have decreased in extent. No newly appeared focal parenchymal\n opacities. Unchanged size and shape of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1111647,
"text": " 2:04 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx, line position\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh wothdrawal s/p new left subclavian\n REASON FOR THIS EXAMINATION:\n ptx, line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, status post new\n subclavian line.\n\n UPRIGHT AP VIEW OF THE CHEST:\n The patient is status post placement of a central venous catheter via a left\n subclavian approach, with the tip terminating within the mid SVC. An\n endotracheal tube terminates 6.8 cm above the level of the carina. The\n cardiac and mediastinal contours are unchanged in comparison to the prior\n chest radiograph from . There is no evidence of pneumothorax\n or pleural effusion.\n\n IMPRESSION: Status post placement of a new subclavian central venous catheter\n terminating within the mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112016,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with PNA and ETOH withdrawal. Extubated .\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Pneumonia, extubated, question interval change.\n\n FINDINGS: The ET tube has been removed. NG tube tip is in the stomach. Left\n subclavian line is in the SVC, unchanged. There are some patchy areas of\n volume loss in both lower lobes but no focal infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1110794,
"text": " 12:51 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck pedestrian\n\n Frontal bedside view of the chest is obtained with the patient placed on a\n trauma board. Lung volumes are low and there is bibasilar atelectasis. There\n is mild cardiomegaly, which may be related to technique. Mediastinal and\n hilar contours are unremarkable. There is no definite pneumothorax. Left rib\n fractures are visualized involving the sixth and seventh ribs and a right rib\n fracture is seen in the second rib (please see CT of the Torso for full\n fracture characterization).\n\n A frontal view of the pelvis obtained with the patient on a trauma board shows\n no fracture or dislocation. Bowel gas pattern is unremarkable. Contrast is\n seen within both ureters as well as in the urinary bladder, which contains a\n small amount of gas, presumably sequelae of previous contrast as well as Foley\n catheter placement. There is no radiopaque foreign body.\n\n IMPRESSION: Rib fractures as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1110795,
"text": " 12:57 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n ?injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 1:40 AM\n Acute right rib fractures involving the 2nd, 3rd and likely 12th ribs. No\n pneumothorax. Dependant atelectasis bilaterally and a more nodular right\n upper lobe opacity. This may be aspiration, though followup when clinically\n stable is recommended to document resolution and exclude underlying pulmonary\n nodule.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck pedestrian.\n\n TECHNIQUE: Axial CT images were acquired through the torso following the\n administration of 120 cc of intravenous Optiray contrast.\n\n COMPARISON: Radiographs from the same day.\n\n CT CHEST WITH CONTRAST: Airways are patent to subsegmental levels\n bilaterally. There is no pneumothorax. Dependent atelectasis is visualized\n bilaterally, and there is a focus in the right upper lobe of poorly marginated\n 15 x 15mm opacity, with hazy margins. The heart and great vessels are\n unremarkable. There is no mediastinal or axillary lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: The stomach, duodenum, spleen, pancreas, adrenal\n glands, gallbladder, kidneys, and liver are unremarkable. There is no free\n gas or fluid in the abdomen. Regional vascular structures are notable for\n scattered atherosclerotic calcification of the aorta in the absence of\n aneurysmal dilation.\n\n CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter and a\n small amount of gas. Dense contrast reflects the previous study. The\n prostate, seminal vesicles, rectum, colon, and appendix are unremarkable.\n There is no free gas or fluid in the pelvis. There is no pelvic or inguinal\n lymphadenopathy.\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n Note is made of bilateral spondylolysis at L5, without associated\n spondylolisthesis. Acute fractures are visualized with mild displacement on\n the right involving the second and third ribs laterally (2:19). Chronic\n fracture deformities are also visualized on the right, involving the sixth rib\n laterally. An additional acute fracture is seen posteriorly in the twelfth on\n the right. On the left, chronic fracture deformities are visualized involving\n the fifth, sixth, seventh, and eighth ribs.\n\n (Over)\n\n 12:57 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Rib fractures, appearing both chronic and with acute rib fractures seen at\n the second and third ribs on the right as well as in the twelfth rib. There\n is no pneumothorax.\n 2. Bilateral spondylolysis, without spondylolisthesis at L5.\n 3. Bilateral dependent atelectasis as well as a poorly marginated opacity in\n the right upper lobe. Considerations for the latter finding include nodule\n or, less likely aspiration. Followup is recommended to document\n resolution/progression when clinically stable.\n\n Results and recommendations were reviewed in person at the time of image\n acquisition with Dr. from surgery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "L CT LOW EXT W/O C LEFT",
"row_id": 1110797,
"text": " 1:23 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: L knee CT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n L knee CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 8:47 AM\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\n evidence of intra-articular extension. The largest distal fracture fragment\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\n proximal femur. In addition, there is a non-displaced fracture of the\n proximal fibula (500b:39). Finally, a small osseous near the lateral\n proximal tibia suggests an avulsion injury (Segond fracture) which raises\n concern for internal ligamentous injury to the knee.\n WET READ VERSION #1 SPfc SAT 1:44 AM\n Markedly comminuted fracture or the distal femoral diaphysis. There is no\n evidence of intra-articular extension. The largest distal fracture fragment\n is displaced laterally by ~3cm and posteriorly by ~2cm relative to the\n proximal femur. In addition, there is a non-displaced fracture of the\n proximal fibula (500b:39).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left femur fracture.\n\n COMPARISON: Radiograph .\n\n TECHNIQUE: MDCT axial images through the left knee were obtained without\n intravenous contrast and displayed with multiplanar reformats.\n\n FINDINGS:\n\n There is a markedly comminuted fracture through the left distal femoral\n metadiaphysis with multiple large fracture fragments. There is apex-posterior\n angulation as well as one shaft width posterior and lateral displacement of\n the distal fracture fragment. There is no intra-articular extension of the\n fracture line.\n\n There is a nondisplaced fracture of the left fibular head (501B:36). A -\n like 2.4-mm osseous fragment arises from the proximal lateral tibial epiphysis\n and may represent a Segond fracture.\n\n There is a small lipohemarthrosis as well as expected soft tissue and\n intramuscular edema. Prominent varicose veins are identified. While the\n anterior cruciate ligament is visualized, given the Segond fracture, there is\n high suspicion for ACL injury.\n\n IMPRESSION:\n\n 1. Comminuted displaced left distal femur fracture without intra-articular\n (Over)\n\n 1:23 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: L knee CT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n extension.\n\n 2. Segond fracture concerning for anterior cruciate ligament injury.\n\n 3. Fracture through the fibular head which may signify posterolateral corner\n injury. Further evaluation can be performed with MRI if indicated.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "L FEMUR (AP & LAT) LEFT",
"row_id": 1110798,
"text": " 1:35 AM\n FEMUR (AP & LAT) LEFT Clip # \n Reason: ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pedestrian versus car trauma.\n\n Four views of the left femur reveal a comminuted fracture of the distal\n femoral diaphysis. There is posterior and slight lateral displacement of the\n distal femur relative to the proximal. There is no evidence of\n intra-articular extension. A faint lucency seen at the fibular head suggests\n a non-displaced fracture in that location as well. A small of bone at\n the lateral margin of the proximal tibia suggests avulsion injury. There is\n no radiopaque foreign body.\n\n IMPRESSION: Comminuted left femoral fracture, nondisplaced proximal fibular\n fracture and possible avulsed tibial fracture fragment (Segond fracture) which\n raises concern for internal ligamentous injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111590,
"text": " 9:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh withdrawal\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Alcohol withdrawal. NG tube placement.\n\n COMPARISON: Chest radiograph from .\n\n FRONTAL VIEW OF THE CHEST AND UPPER ABDOMEN: Previous NG tube has been\n advanced into the stomach and appears to be at the antrum of the stomach.\n Endotracheal tube at the level of the clavicles is stable. EKG leads\n overlying the patient limit evaluation. Within these limitations, there is no\n evidence of pneumothorax. There is small right pleural effusion and\n associated atelectasis. Right lateral pleural thickening is secondary to prior\n rib fractures and has decreased. There is no evidence of congestive heart\n failure. Heart is not enlarged. Aortic arch is obscured by overlying EKG\n lead.\n\n IMPRESSION:\n 1. NG tube in the stomach.\n 2. Small Right pleural effusion and associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-05 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1111446,
"text": " 11:35 AM\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: TRUAMA, FX, ORIF LEFT FEMUR\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH WED 1:26 PM\n Fluoroscopic assistance provided to the surgeon in the OR.\n ______________________________________________________________________________\n FINAL REPORT\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Twelve spot views obtained. Views demonstrate steps\n related to fixation of a comminuted distal femoral fracture, side not\n indicated. Fluoro time recorded as 224 seconds on the electronic requisition.\n Correlation with real-time findings, and when appropriate, conventional\n radiographs is recommended for full assessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-05 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1111447,
"text": ", T. SICU-A 11:35 AM\n FEMUR (AP & LAT) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: TRUAMA, FX, ORIF LEFT FEMUR\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n PFI REPORT\n Fluoroscopic assistance provided to the surgeon in the OR.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-05 00:00:00.000",
"description": "O ABDOMEN, SINGLE VIEW IN O.R.",
"row_id": 1111449,
"text": " 11:36 AM\n ABDOMEN, SINGLE VIEW IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n -77 BY DIFFERENT PHYSICIAN\n : IVC FILTER INSERTION\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male status post IVC filter insertion.\n\n STUDY: Single spot radiograph in the upper lumbar spine region.\n\n FINDINGS: An IVC filter is in appropriately positioned, projecting just\n lateral to the L2 vertebral body.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112401,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, NGT placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ETOH w/d, pulled out NGT which was reinserted\n REASON FOR THIS EXAMINATION:\n interval change, NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, reinserted NG tube.\n\n COMPARISON: Chest radiographs available from .\n\n SEMI-ERECT AP VIEW OF THE CHEST: The patient is status post placement of a\n nasogastric tube, which terminates beyond the scope of the study. The side\n port is also excluded. There is a central venous catheter, via a left\n subclavian approach, which terminates at the mid SVC. The cardiac and\n mediastinal contours are unchanged since the prior examination from , . There is no pneumothorax or pleural effusion.\n\n IMPRESSION: Status post placement of a nasogastric tube, which extends to at\n least the level of the stomach, however the side port and tip are both\n excluded from the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "RO ANKLE (2 VIEWS) RIGHT IN O.R.",
"row_id": 1110831,
"text": " 8:55 AM\n ANKLE (2 VIEWS) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: EX/FIX RIGHT TIBIA\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF\n\n FINDINGS: Multiple views from the operating suite show what appear to be\n external fixation devices in the tibia. Further information can be gathered\n from the operative report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112530,
"text": " 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with continued agitation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc WED 10:16 PM\n No acute intracranial abnormality. Paranasal sinus disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Continued agitation.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial CT images were acquired through the head in the\n absence of intravenous contrast.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarction. The ventricles and sulci are normal in size\n and in configuration. Extracranial soft tissue structures reveal a small\n subcutaneous nodule overlying the occipital bone on the left as well as the\n frontal bone on the left. There is no fracture. The mastoid air cells are\n clear. The paranasal sinuses reveal circumferential mucosal thickening at the\n right frontoethmoidal recess extending into the ethmoidal air cells\n bilaterally, the sphenoid sinus as well as both maxillary sinuses.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Paranasal sinus disease.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation, but\n note that tthere is a chronic-appearing defect in the maxilla, primarily right\n of midline, but extending to the left. This has sclerotic margins, implying a\n chronic process. This may be related to dental disease with a periapical cyst\n or related to paranasal sinus inflammatory disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112476,
"text": " 2:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess ETT location\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man now intubated\n REASON FOR THIS EXAMINATION:\n assess ETT location\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for ETT location.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the patient has now been\n intubated. The tip of the endotracheal tube projects 11 cm above the carina,\n the tube could be advanced by 3-4 cm. The nasogastric tube and the left\n subclavian catheter are unchanged. Also unchanged is the appearance of the\n lung parenchyma and the size of the cardiac silhouette. No evidence of\n complications, notably no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1110958,
"text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with trauma\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-trauma, to evaluate for aspiration.\n\n FINDINGS: No previous images. The cardiac silhouette is within normal limits\n and there is no vascular congestion or pleural effusion. Suggestion of some\n increased opacification at the left base in the retrocardiac region, which\n most likely represents atelectasis. The possibility of early aspiration\n cannot be definitely excluded. If clinical symptoms persist, followup\n radiograph would be indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113227,
"text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hospital acquired PNA, ETOH w/d.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hospital acquired pneumonia. ETOH withdrawal.\n\n Comparison is made with prior study .\n\n Cardiac size is top normal. Lines and tubes have been removed. There are\n multiple opacities that are consistent with atelectasis in the lower lobes\n bilaterally and in the left upper lobe. There are no new lung abnormalities.\n There is no pleural effusion or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111191,
"text": " 6:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube placement\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with bilateral fractures of legs\n REASON FOR THIS EXAMINATION:\n et tube placement\n ______________________________________________________________________________\n WET READ: RSRc MON 7:50 PM\n Post-intubation, with ETT 6 cm above carina but below thoracic inlet.\n Worsening left retrocardiac opacification suggests developing pneumonia, and\n new small left effusion. 7:45 p .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:54 P.M., \n\n HISTORY: Bilateral leg fractures, check ET tube placement.\n\n IMPRESSION: AP chest compared to , 8:19 a.m.:\n\n Tip of the newly placed endotracheal tube is above the upper margin of the\n clavicles, more than 6 cm from the carina, 3-4 cm above standard placement.\n This may account for lower lung volumes and new bibasilar atelectasis. Low\n lung volumes in turn may explain in part increase in heart size, though\n increased caliber of mediastinal veins suggests increased intravascular\n volume. No pneumothorax. Small bilateral pleural effusions may be present.\n Despite identification to the contrary this radiograph may have been taken\n with the patient in supine position, contributing to heart size and caliber of\n mediastinal capacitance vessels.\n\n An acute fracture through the lateral aspect of the right second rib is\n slightly more displaced than it was earlier today, but there has been no\n change in the small adjacent extrapleural hematoma.\n\n Findings were discussed by teleophone with Dr at 9:30AM.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-01 00:00:00.000",
"description": "R TIB/FIB (AP & LAT) RIGHT",
"row_id": 1110799,
"text": " 1:35 AM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: ?injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p ped struck\n REASON FOR THIS EXAMINATION:\n ?injuries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck-pedestrian trauma.\n\n FINDINGS: Five views of the right tibia and fibula and ankle show comminuted\n oblique fractures of the distal tibia and fibula. There is lateral and\n anterior subluxation of the distal tibia and fibula as well as foot relative\n to the proximal lower extremity. The talar dome is smooth. The distal fibula\n is slightly medially displaced, projecting over the ankle mortise. Limited\n views of the knee joint are unremarkable. There is no radiopaque foreign\n body.\n\n IMPRESSION: Comminuted fractures of the distal tibia and fibula as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1112433,
"text": " 9:11 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement.\n Admitting Diagnosis: PEDESRTRIAN STRUCK, LEG FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with etoh w/d. pulled out his ngt, placed back in. took CXR\n this am but could not identify tip. pulled ngt back more, please repeat CXR.\n REASON FOR THIS EXAMINATION:\n NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with alcohol withdrawal, status post pulling of\n NG tube, with consequent replacement.\n\n COMPARISON: Chest radiographs available from at 5:15 a.m.\n\n SUPINE AP VIEW OF THE CHEST: The patient is status post placement of a\n nasogastric tube, which extends to at least the level of the stomach, with the\n tip excluded from the study. The side port is also excluded. A left-sided\n central venous catheter via subclavian approach terminates at the mid SVC.\n The cardiac and mediastinal contours are unchanged since prior exam. There is\n no pneumothorax or pleural effusion.\n\n IMPRESSION: Nasogastric tube extends to at least the level of the stomach,\n however the side port and tip are both excluded from the study.\n\n\n"
}
] |
11,228 | 167,826 | Shortly after arrival in the intensive care unit the patient's right internal jugular catheter was immediately exchanged for a catheter capable of accepting a Swan. The Swan was floated successfully showing mild cardiogenic shock and dehydration. Preparations were made at that time for additional inotropic support as well as CVVHD. Initial evaluation at that time by the transplant team concluded that the patient's presentation was most consistent with resolving sepsis, acute renal failure and possibly adult respiratory distress syndrome. It was felt given that the family still was quite interested in possible transplant candidacy it was felt that additional work up was necessary. Effort during the next several days thus surrounded transplant work up as well as stabilization of his multiple medical problems. Infectious disease consultation felt that the patient had multiple possible sources for sepsis and final antibiotic course regimen including Vancomycin, meropenum, caspofungin was selected. At that time HIV testing was necessary to assess patient's candidacy for transplant. Ethics consult was requested and per recommendations of that consult HIV testing was performed. At that time neurologic function was questionable at best. Patient responded to some basic commands, however, was never oriented to person, place or time. Ammonia level check shortly after arrival in the Intensive Care Unit showed ammonia to be 69. Hospital days 2 through 4 patient's pressor requirements continued to increasing including Neo-Synephrine drip which at that time was 1.25. A delicate balance had to be maintained for diuresis and dialysis needs which were maintained using CVVHD and Neo-Synephrine for blood pressure maintenance. Despite expansion of the antibiotic regimen patient's white count continued to increase peaking at 24.6 on hospital day 4. Repeated culturing and imaging failed to reveal any undiagnosed sources for this infection. By hospital day 8 or , patient's condition had continued to deteriorate. His blood pressure was refractory to additional pressors. Over the course of several family discussions including the chief resident and Dr. family began to inquire about changing the patient's status to Do Not Resuscitate, Do No Intubate. Given the patient's increasing coagulopathy, sepsis and circulatory collapse he was not longer being considered a good candidate for liver recipient and the family's request was thought to not be unreasonable. On or hospital day 10, with patient's white blood cell count at 36.1, pressor support maxed out, patient's family including his mother, the designated health care proxy, requested that he be made Do Not Resuscitate, Do Not Intubate and life support be gradually withdrawn. In accordance with their request pressors were withdrawn and ventilator settings were changed to room air. Patient expired shortly thereafter. Per the patient's family's request patient was submitted for autopsy. , MD, PHD Dictated By: MEDQUIST36 D: 14:30:54 T: 15:36:05 Job#: | Left-sided stable pleural effusion is noted. Thereis a trivial/physiologic pericardial effusion. Mild (1+) mitral regurgitation is seen. Withdraws slightly when PPF d/c'd. Stable left pleural effusion. Stable left pleural effusion. Bibasilar atelectasis and small left pleural effusion. Stable left-sided pleural effusion with left lower lobe atelectasis is seen. Thereis moderate mitral stenosis. essentially anuric. Right ventricular chamber size and free wall motion appear normal.The aortic root is mildly dilated. There isa minimally increased gradient consistent with trivial mitral stenosis. Hypo BS. Persistent right middle lobe and lower lobe atelectasis/consolidation. There is persistent right middle lobe and lower lobe atelectasis/consolidation. Small to moderate left pleural effusion with adjacent opacity at the left base consistent with atelectasis versus consolidation. FINDINGS: An endotracheal tube is in place at the level of the thoracic inlet with tip terminating 7.1 cm from the carina. There is mild cardiomegaly. TECHNIQUE: Single AP portable supine chest. TECHNIQUE: Single AP portable supine chest. There is mild pulmonary artery systolic hypertension. FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from the carina. TECHNIQUE: AP single view of the abdomen. Bilateral pleural effusions. There is bilateral upper lobe improved aeration consistent with decreasing edema. Non-specificrepolarization changes. Withdraws to sternal rub, shaking head slightly when off gtt. There is generalized subcutaneous edema noted bilaterally extending down to and below the popliteal level. Mild pulmonary edema. Since the examination dated , the right internal jugular venous access catheter has been replaced with a sheath containing a catheter, which is poorly visualized beyond the level of the right atrium. Mild PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. There is a normal portal venous wave form. The heart is upper limits of normal in size. PPF gtt for sedation and comfort. CONCLUSION: 1. There is mild prominence of the pulmonary vasculature consistent with pulmonary edema. pboots ordered.GI: Abd large soft distended. tpn infusing. tpn infusing. TPN infusing. cvvhdf tol well. D/C CRRT D/T LABILE BP'S. Hypothermic, Bair Hugger in place. +Anasarca, faintly palpable pulses bilaterally. +anasarca throughout. filter clotted x1. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT SEDATED ON PROPOFOL GTT. repeat fio2 84. wbc 30.0 on iv caspofungin and merepenum. care note - Pt. care note - Pt. Neo weaned to off. on iv reglan and iv protonix. Resp. Resp. WHEN ATTEMPTED TO SET PFR TO MAINTAIN FLUID BALANCE EVEN, PT BECAME AGAIN. reinitiated.action: suctioned prn. level done this am.cardiac: remains in nsr. ABGs WNL. CONT FLUID BOLUSES AS ORDERED. iv calicium gluconate given. CXR done.CV: Remains slightly hypothermic, Bair Hugger worn. inr 6.9 2 units of ffp given. START LEVO OR VASOPRESSIN IN LIEU OF NEO. vanco iv given. lg amt of oral secretitions. CRRT SET TO 0 PFR. Bolused and given Albumin x1. -BS. neo down to 2.5mcg.gI abd soft ngt draining lg amt of , pink drainage. and UEs. Echo done.GI: Abdomen large, +ascites. calicum gluconate iv given.response: monitor closely MD'S AND INFORMED. MD'S AND INFORMED. +pp. TFs held for high residuals, NGT to suction.GU/RENAL: Foley patent minimal amount icteric urine. on neo gtt and titrated to keep bp > 100syst. 2 ffp given. US done and abdomen tapped for small amount ascites by Dr. @ bedside, sent for cx. clotted. Nursing note:NEURO: Arouses to verbal stimulation, moves UEs. repeat 2.1 post hct 31.3, k 3.5. bp up to > 100syst. PT 2 500CC NS BOLUSES AS ORDERED WITH TRANSIENT IMPROVEMENT IN SBP. 2 units prbc given. 2 units prbc given. Continue current plan of care. Changed to PCV, ABGs acceptable. 1 liter of ns given. Begin CVVHD.ENDO: Glucose stable, given SSRI PRN.SKIN: Breakdown to coccyx noted, Tegaderm in place, no drainage. PADs 24-30. Will cont to monitor. BS coarse bil. PERRLA 3 and brisk. Scrotal area edematous with dry chapped areas, Edematous throughtout, skin tears in folds of upper thighs, cloth heel protecters on.PLAN: Start CVVH in the AM, Continue with hepatic work-up, Attempt to wean vent, Provide extra comfort. TPN INFUSING.GU: CVVHDF INFUSING OK. propofol and neo gtt maintained. tpn infusing. cvvhdf being tol. care note - Pt. care note - Pt. total tonite.action: suctioned prn. Resp. Resp. TUBE FDGS ON HOLD. TUBE FDGS ON HOLD. Noted status is DNR. PT NOW DNR. on caspofungin. abg's. FLUID BOLUS ORDERED AND GIVEN BY MD . HR- occ PVC'S. LEVEL DRAWN THIS AM. LEVO WEANED SLIGHTLY TO INPROVE HR. CREAT 1.5 AND BUN 65ACTION: SUCTIONED PRN. ABG'S GOOD.CARDIAC: REMAINS IN NSR. MD' , , AND INFORMED. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: SEDATED ON PROPOFOL GTT. TACHYCARDIC TO 130S WITH TEMP. for further workup of ESLD.Remains on current vent settings. STATUSD: VSS SEE FLOW SHEET..REMAINS ON LEVO/INSULIN/PROPOFOL GTT'S.. ABG's WNL. MD INFORMED.CV: LABILE BP. lg amt of oral secretitions. LG AMT OF ORAL SECRETITIONS. DNR. CRRT RESTARTED WITH SOME HYPOTENSION. moves head back and forth.resp: remains vented. AM ABGs WNL. focus hemodydnmicsdata: neuro: on propofol gtt. albumin 2.8.tube fdgs cont to be held. Plan to continue with vent support at this time. ABGs WNL, Plan to continue with vent support at this time. Plan to continue with mech. CMP TO BE FURTHER DISCUSSED.PLAN: CONT PER CURRENT MGMT FOR NOW. PT'S PROGNOSIS DISCUSSED. cvvhdf being tolerated. ON NEO GTT. AIR WAY IN PLACE AND REMOVED TO CLEANSE MOUTH. Bil breath sounds clear t/o. ON IV CASPOFUNGIN AND VANCOMYCIN 1GM IV GIVEN. guiac post stool. labs as ordered. LABS AS ORDERED. k 3.3-3.4 k via ccvvh fluid. on a neo gtt. ventilation at this time. PROPOFOL GTT INFUSING TO MAINTAIN QUIET. CATHETER NOT WEDGED.GI ABD SOFFT. creat 2.7 and bun 55.gI abd soft and distended. Suctioned for sml amts thick bld tinged secretions. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: UNCHANGED.RESP: NO VENT CHANGED. BP SYST 110-120. FOCUS HEMODYNMICSDATA: NEURO: PERLA # AND REACTS BRISKLY. See vent flow sheet for details. perla # and reacts briskly. Resp Care Note, Pt from MED CTR. I AND O NEGATIVE. | 46 | [
{
"category": "Echo",
"chartdate": "2193-06-19 00:00:00.000",
"description": "Report",
"row_id": 79636,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 330\nBSA (m2): 2.58 m2\nBP (mm Hg): 129/62\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 16:19\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: No AS.\n\nMITRAL VALVE: Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may\nbe significantly UNDERestimated.]\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function appears normal\n(LVEF>55%). Right ventricular chamber size and free wall motion appear normal.\nThe aortic root is mildly dilated. There is no aortic valve stenosis. There is\na minimally increased gradient consistent with trivial mitral stenosis. There\nis moderate mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is mild pulmonary artery systolic hypertension. There\nis a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873415,
"text": " 1:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT PLACEMENT\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n S/p tranfer in\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure, status post ET tube placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place at the level of the thoracic inlet\n with tip terminating 7.1 cm from the carina. There is a right internal\n jugular venous access catheter with tip terminating in the mid SVC. Left\n internal jugular venous access catheter with tip in the distal SVC near the\n SVC/RA junction. The heart is upper limits of normal in size. The\n mediastinal contours appear within normal limits. There is mild prominence of\n the pulmonary vasculature consistent with pulmonary edema. Small to moderate\n left pleural effusion with adjacent opacity at the left base consistent with\n atelectasis versus consolidation. Additional patchy opacity at the right base\n may also represent atelectasis versus consolidation or component of pulmonary\n edema. The right costophrenic angle is excluded from the radiograph. The\n osseous structures appear within normal limits.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position.\n 2. Bibasilar atelectasis and small left pleural effusion.\n 3. Mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 873557,
"text": " 12:53 AM\n PORTABLE ABDOMEN Clip # \n Reason: s/p NGT\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n REASON FOR THIS EXAMINATION:\n s/p NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of liver failure, status post NG tube placement.\n\n COMPARISON: None.\n\n PORTABLE ABDOMINAL RADIOGRAPHS: The study is somewhat limited secondary to\n motion and technique. An NG tube is seen with the tip positioned within the\n stomach. Air can be seen within the small bowel. Evaluation of the lung\n fields is limited secondary to motion. An ET tube and central venous\n catheters are seen overlying the mediastinal contour.\n\n IMPRESSION: NG tube is seen with the tip in the stomach. The remainder of\n the study is limited secondary to motion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-20 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 873595,
"text": " 10:17 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ASCITES. PLEASE MARK FOR PERITONEAL TAP\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD\n\n REASON FOR THIS EXAMINATION:\n Please mark for peritoneal tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old with endstage liver disease, assess for ascites and\n mark the spot.\n\n Using ultrasound guidance, a spot was marked in the left lower quadrant for\n paracentesis to be performed by the clinical team. The distance from the skin\n to intraperitoneal fluid is approximately 4 cm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873592,
"text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: routine\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n\n REASON FOR THIS EXAMINATION:\n routine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with liver failure and decreased O2 sats.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: There is cardiomegaly and perihilar haziness and pulmonary edema.\n These findings are consistent with CHF. There are also bilateral pleural\n effusions. There are new patchy opacities in the bilateral mid lung zones\n that could represent pneumonia or aspiration. The ET tube is in good\n position. There is an NG tube extending below the limits of the radiograph.\n\n IMPRESSION:\n 1. Cardiomegaly and findings consistent with CHF with pulmonary edema.\n 2. Bilateral pleural effusions.\n 3. New patchy opacities in bilateral mid lung zones most likely represent\n pneumonia versus aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 874331,
"text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, etc\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n REASON FOR THIS EXAMINATION:\n assess for PNA, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure with decreased oxygen sats.\n\n X-ray, chest AP portable view.\n\n COMPARISON: .\n\n The quality of the radiograph is poor due to patient body habitus.\n\n There is persistent right middle lobe and lower lobe\n atelectasis/consolidation. Stable left-sided pleural effusion with left lower\n lobe atelectasis is seen. The mediastinal and hilar contours are stable.\n\n IMPRESSION:\n 1. Persistent right middle lobe and lower lobe atelectasis/consolidation.\n 2. Stable left pleural effusion.\n 3. Stable CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-19 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 873449,
"text": " 9:08 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: Liver failure pre transplant\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD\n REASON FOR THIS EXAMINATION:\n Liver failure pre transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old with end stage liver disease pre-transplant.\n\n No prior studies.\n\n The study is technically limited due to patient body habitus and difficulties\n in positioning the patient. The liver is coarse and heterogeneous in\n architecture consistent with the history of cirrhosis. No focal mass is\n identified. The gallbladder is normal without stones or sludge. The common\n bile duct measures 3 mm. There is no intrahepatic ductal dilation. The right\n kidney measures 11.8 cm. No mass, hydronephrosis, or stone is seen in the\n right kidney. The pancreas, left kidney, and spleen were not visualized.\n There is a moderate amount of ascites seen throughout the abdomen.\n\n Pulse color Doppler imaging demonstrates normal hepatopetal flow within the\n main portal vein, which is widely patent. There is a normal portal venous\n wave form.\n\n IMPRESSION:\n\n Cirrhotic appearing liver with ascites. Patent portal vein. The study is\n technically limited.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 874132,
"text": " 1:58 PM\n PORTABLE ABDOMEN Clip # \n Reason: asses NG placement\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure\n\n REASON FOR THIS EXAMINATION:\n asses NG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISONS: Comparison is made to . Comparison is also made to\n chest radiograph performed one day earlier.\n\n TECHNIQUE: AP single view of the abdomen.\n\n FINDINGS: The images are slightly limited due to motion. Also, the images do\n not include the entire abdomen.\n\n There is interval placement of NG tube with the tip in the second portion of\n the duodenum. There is again noted left pleural effusion with associated\n atelectasis which was not completely imaged in this study.\n\n IMPRESSION: NG tube tip is located within duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873974,
"text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates?\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\n\n REASON FOR THIS EXAMINATION:\n infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with liver failure and decreased oxygen sats.\n\n COMPARISON: .\n\n There is mild cardiomegaly. There is bilateral hilar prominence. There is\n persistent right middle lobe collapse. Left-sided stable pleural effusion is\n noted. There is bilateral upper lobe improved aeration consistent with\n decreasing edema.\n\n The ET tube is 4 cm from the carina. The central venous catheter tip is in\n the SVC.\n\n IMPRESSION:\n 1. Persistent right middle lobe collapse.\n 2. Stable left pleural effusion.\n 3. Improving CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873471,
"text": " 11:36 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assexssx ETT placement\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats\n REASON FOR THIS EXAMINATION:\n Assexssx ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure and decreased O2 sat, assess ET tube placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from\n the carina. Since the examination dated , the right internal\n jugular venous access catheter has been replaced with a sheath containing a\n catheter, which is poorly visualized beyond the level of the right atrium. The\n left internal jugular venous access catheter appears in unchanged position,\n with tip located at the RA/SVC junction. The heart size and mediastinal\n contours are unchanged. There is moderate left pleural effusion and increase\n in bibasilar parenchymal opacities, probably related to atelectasis versus\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-19 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 873469,
"text": " 11:17 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILATERAL SWELLING, PLEASE ASSESS FOR DVT IN BOTH LEGS\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with leg swelling\n REASON FOR THIS EXAMINATION:\n please assess for DVT in bilaterally\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER LIMB DOPPLER VENOUS ULTRASOUND.\n\n CLINICAL DETAILS: Query lower limb DVT.\n\n FINDINGS: The right and left lower limb veins are patent and compressible\n along their length, normal phasic venous flow and increased venous return with\n calf compression on color Doppler.\n\n There is generalized subcutaneous edema noted bilaterally extending down to\n and below the popliteal level.\n\n CONCLUSION:\n 1. No right or left lower limb DVT demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-06-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 873905,
"text": " 1:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line please\n Admitting Diagnosis: ENDSTAGE RENAL DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver failure, decreased O2 sats s/p lin4e change\n\n REASON FOR THIS EXAMINATION:\n assess line please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased O2 sats. Assess line placement.\n\n CHEST PORTABLE: The endotracheal tube is 5 cm above the carina. The\n nasogastric tube tip is not seen since the abdomen is cut off the film. There\n is a right central line, which has its tip in the right atrium. The left\n central catheter has its tip in the distal SVC. There is no pneumothorax.\n Persistent and worsening pulmonary atelectasis and effusions are noted.\n\n IMPRESSION: Life support lines in good position. Increasing atelectasis and\n pulmonary infiltrates.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-06-19 00:00:00.000",
"description": "Report",
"row_id": 210023,
"text": "Normal sinus rhythm, rate 82. Borderline low voltage. Non-specific\nrepolarization changes. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-24 00:00:00.000",
"description": "Report",
"row_id": 1410229,
"text": "Nursing note:\nNEURO: Sedated on Propofol gtt, no spont. movement noted. PERRLA 3mm and brisk. Withdraws to sternal rub, shaking head slightly when off gtt. Withdraws slightly when PPF d/c'd. Does move UEs slightly when off gtt, no movement to LEs noted. Grimacing with interventions.\nRESP: Lung sounds coarse, suctioned for thick tan secretions and occ. plugs. Occ. moving mouth and biting on ETT. No vent changes made.\nCV: SR-SB, occ. PVCs. Afebrile, hypothermic at times, warm blankets on. Neo gtt to maintain SBP >100. CVP 13-17. Pt. very weepy from all open areas and total body anasarca. Dopplerable pulses.\nGI: Abdomen large, +ascites. Hypo BS. NGT to sxn for copious amounts -pink liquid. NPO otherwise. TPN infusing.\nENDO: Insulin gtt titrated to keep glucose <120.\nGU/RENAL: Foley patent small amount icteric urine, pt. essentially anuric. running to keep pt. even, clotted filter x1 and changed.\nSOCIAL: mother called and given update. Will not be in until Wednesday.\nSKIN: Breakdown to coccyx, Duoderm intact, no drainage. Scrotum w/abrasion noted to underside, cleaned w/wound cleanser and DSD applied. Heels reddened, R. heel w/small dark area noted, kept off bed. MPBs ordered. Mult. old tap and line sites weepy to UEs, covered w/surgicel and occlusive dressings.\n\nA/P: Continues w/labile SBP on Neo gtt, to keep pt even. Rising WBCs, ID following for recs. PPF gtt for sedation and comfort. Insulin gtt to keep <120.\nWorsening overall status. Continue current plan of care, awaiting some improvement in status in order to be considered for liver/kidney tx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-24 00:00:00.000",
"description": "Report",
"row_id": 1410230,
"text": "Resp Care: Pt remains intubated/sedated. BS clear @apices, sl decreased w/ few scatt rales @ bases. ABG WNL, (PaO2= 81 on FiO2=.6, and 8cm PEEP). Pt having periods of subtle discoordination w/ vent (actively exhaling @ times). Pip/plat= 36/21. No vent changes made this shift. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-25 00:00:00.000",
"description": "Report",
"row_id": 1410231,
"text": "Resp Care\nPt remains intubated on AC, no vent changes made during noc. Pt sx'd for sm tan secretions, bil breath sounds clear. ABG's WNL. Plan to continue with vent support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-25 00:00:00.000",
"description": "Report",
"row_id": 1410232,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED ON PROPOFOL GTT. WITH GTT OFF FOR SHORT PERIOD , PT WITHDREW ALL EXTREMITIES TO PAINFUL STIMULI, OPENED EYUES TO VOICE.\nRESP: SCANT SECRETIONS VIA ET SUCTION. NO VENT CHANGES. ABG STABLE.\nCV: BAIR HUGGER FOR HYPOTHERMIA. CRRT RUNNING IN ATTEMPT TO KEEP PT EVEN, BUT PT . NEO REQUIRMENT INCREASING THROUGH NOC, CURRENTLY AT MAX OF 5MCG/KG/MIN. MD'S AND INFORMED. PT 2 500CC NS BOLUSES AS ORDERED WITH TRANSIENT IMPROVEMENT IN SBP. CRRT SET TO 0 PFR. WHEN ATTEMPTED TO SET PFR TO MAINTAIN FLUID BALANCE EVEN, PT BECAME AGAIN. UNABLE TO MAINTAIN SBP 100 THIS AM, CURRENTLY 80S. MD'S AND INFORMED. TRANSPLANT TEAM TO COME AND PT. MD INFORMED OF AM LABS, HCT, INR, PLT.\nGI: LG AMTS PINK NG O/P.\nGU: ANEURIC.\nENDO: INSULIN GTT TITRATED PER RISS.\nPLAN: MAINTAIN SBP > 100. ? START LEVO OR VASOPRESSIN IN LIEU OF NEO. CONT FLUID BOLUSES AS ORDERED. ? D/C CRRT D/T LABILE BP'S. AWAIT INPUT FROM TRANSPLANT TEAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-25 00:00:00.000",
"description": "Report",
"row_id": 1410233,
"text": "Nursing note:\nNEURO: Sedated on PPF gtt, attempting to open eyes and withdraws w/UEs when off gtt briefly this am. PERRLA 4-5mm and brisk. No movement to LEs noted, no spont. movement. Moves head when less sedated.\nCV: SR-SB, no ectopy. Hypothermic, Bair Hugger in place. Neo weaned to off. SBP kept >100 w/increasing Levophed requirements, ICU and tx. teams aware. SBP to 50-70s w/turning and interventions, slow to recover. Bolused 250cc NS x1 and given 250cc 5% albumin x1 w/some improvment. CVP 9-15. +Anasarca, weepy areas to abd. and UEs. Dopplerable pulses bilaterally.\nRESP: Lung sounds coarse, suctioned for thick blood-tinged sputum. Poor PO2, Fi02 increased to 70% and TV to 700 w/some improvement in oxygenation.\nGI: Abdomen distended, +ascites. +BS, NGT to drainage for pink to bile tinged drainage in lg. amounts. TPN infusing. Insulin gtt titrated to keep glucose <120.\nGU/RENAL: Foley patent, essentially anuric. Attempting to run to keep pt. even in am, running @ PFR 0/hr as pt's pressor requirments have increased.\nSKIN: See Carevue for skin care details.\n\nA/P: Increasing Levophed requirements, labile SBP, unable to tolerate fluid removal during and turning for care. Bolused and given Albumin x1. Oxygenation poor.\n\nGenerally worsening status in this 46 year old man with ESLD/ARF, will continue current plan of care and monitor closely.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-23 00:00:00.000",
"description": "Report",
"row_id": 1410226,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB/ASSESSMENT\nPATIENT GENERALLY WORSE TODAY THAN YESTERDAY. UNABLE TO WEAN NEO, INCREASINGLY NEO DEPENDEDNT, NEEDS BETWEEN 2-3 MCG TO MAINTAIN SBP>100. PA LINE TO TLC THIS AFTERNOON, TIPS SENT FOR CULTURES.\nTRENDING LOWER PO2 AND INCREASING PIPS, HO AWARE, PEEP TO 8, WILL RECHECK GASES.\nCONTINUES WITH LARGE AMOUNTS OF NGT DRAINAGE.\n TO RUN EVEN,\nFAMILY IN, REPORT GIVEN.\nHO AND ICU TEAM AWARE OF ABOVE. WILL CONTINUE TO AGGRESSIVELY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-24 00:00:00.000",
"description": "Report",
"row_id": 1410227,
"text": "focus hemodymmics\ndata: neuro: on propofol gtt at 20mcg/kg/min. gtt off for neuro assessment. pt moves head back and forth. perla # and reacts briskly.\n\nresp: suctioned for thick tan sputum. lg amt of oral secretitions. po2 74 and fio2 increased to 60%. repeat fio2 84. wbc 30.0 on iv caspofungin and merepenum. vanco iv given. level done this am.\n\ncardiac: remains in nsr. on neo gtt and titrated to keep bp > 100syst. episode of bp dropping to the 70's. neo titrated up to 4mcg. clotted. 1 liter of ns given. 2 units prbc given. iv calicium gluconate given. inr 6.9 2 units of ffp given. vitamin k 10mg sc given. repeat 2.1 post hct 31.3, k 3.5. bp up to > 100syst. neo down to 2.5mcg.\n\ngI abd soft ngt draining lg amt of , pink drainage. on iv reglan and iv protonix. tpn infusing. total bili 40.3.\n\ngU: foley patent and no urine out. cvvhdf tol well. filter clotted x1. reinitiated.\n\naction: suctioned prn. labs as ordered. on iv neo and titrated to keep bp> 100. on iv propofol. iv insulin gtt infusing with q1 blood sugars. fio2 incresased to 60%. tpn infusing. 2 units prbc given. 2 ffp given. 10mg vit k given. cvvhdf tol ok and goal to remain even. calicum gluconate iv given.\n\nresponse: monitor closely\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-24 00:00:00.000",
"description": "Report",
"row_id": 1410228,
"text": "Resp Care\nPt remains on AC during noc, fio2 increased to 60%. Bil breath sounds clear, sx'd for mod thick tan secretions. ABGs WNL. Plan to continue vent support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-19 00:00:00.000",
"description": "Report",
"row_id": 1410209,
"text": "Nursing Note--B shift\nPlease see Carevue for complete assessment and specifics.\n\nNEURO: Opens eyes briefly to loud voice. PERRLA 3 and brisk. Occ nods and shakes head to questions asked. Follows very simple commands with BUE but needs lots of encouragement. Does not follow commands with BLE, withdraws minimally to noxious stimuli.\n\nCARDIAC: Afebrile. HR 80's NSR with occ pvc's. SBP 120-140's. +pp. pboots ordered.\n\nGI: Abd large soft distended. BS absent. Rectal tube intact draining black liquid.\n\nGU: Foley intact draining 15cc/hr of dark amber urine.\n\nRESP: Tol vent settings. Deep sxn for small amts of thick white sputum.\n\nEndo: FS 87\n\nInteg: Area on coccyx erethematous with serosang drainage, 2x2 with tegaderm, skin care rn notified. Scrotal area edematous with dry chapped areas, Edematous throughtout, skin tears in folds of upper thighs, cloth heel protecters on.\n\nPLAN: Start CVVH in the AM, Continue with hepatic work-up, Attempt to wean vent, Provide extra comfort.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-20 00:00:00.000",
"description": "Report",
"row_id": 1410212,
"text": "resp care\nPt initially on pcv but sats and volumes so pt was changed to a/c. Currently pt is on a/c 600x20 50% 5peep with peak/plat 35/24. BS coarse bil. Suct for sml amt of blood tinged sput.Pt appears mich more comfortable on a/c mode of ventilation. Will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-20 00:00:00.000",
"description": "Report",
"row_id": 1410213,
"text": "Resp. care note - Pt. remaines intubated and vente, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-19 00:00:00.000",
"description": "Report",
"row_id": 1410210,
"text": "Nursing note:\nNEURO: Arouses to verbal stimulation, moves UEs. Agitated at times, given Fentanyl for c/o's pain, begun on low dose PPF gtt. PERRLA 3mm and brisk. Does nod to ?s.\nRESP: Lung sounds coarse, dim to bases. Suctioned infrequently for blood-tinged secretions. Changed to PCV, ABGs acceptable. Biting down on ETT at times, dropping sats and TVs, bite block in place.\nCV: Hypothermic @95, warm blankets on. SR w/occ PVCs in 80s. CVP 17-24. PADs 20-26. PA catheter advanced slightly by Dr. to 51 cm. Given platelets for plt count 36, oozing from mult. line sites and mouth/gums. +anasarca throughout. Echo done.\nGI: Abdomen large, +ascites. +liquid black tarry stool, sent for cdiff and cxs. -BS. US done of liver and of LEs.\nGU: Foley patent minimal amount cloudy amber urine. ? Begin CVVHD.\nENDO: Glucose stable, given SSRI PRN.\nSKIN: Breakdown to coccyx noted, Tegaderm in place, no drainage. Leaking ascites from mult. sites.\nSOCIAL: pt's mother updated by team, will be in this evening.\n\nA/P: Hemodynamically stable pt. w/ESLD and likely hepatorenal syndrome undergoing ? tx work-up.\nContinue to monitor closely, ? CVVHD, frequent labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-20 00:00:00.000",
"description": "Report",
"row_id": 1410211,
"text": "46 year old male ESLD, sepsis, with ARF, CVVHDF started, NGT placed and Nephro started, SBP labile neo gtt started, melena stool out, sx oral and ETT for bld tinged, Plts, FFP, PRBC given,\n\nNeuro-pt grimace and biting on ett moves upper extrem weakly with draws LE, fentanly given x1 and propofol gtt increased, PERLLA\nCV-MP SR occass PVC, pt hypothermic bair hugger on, hyperdynamic, pitting anasarca, SCDS on, palp pulses neo drip started for SBP>90\nResp-LS dim at bases coarse upper lobes, bite block in due to biting, changed from PCV to AC, due to desats and decrease TV currently on AC and improved ventilation sx q3 hours for thick bld tinged\nGI-abd acites, large obese, neg BS, NGT placed by MD started, BS>200 ?need for insulin gtt, cont on D51/2 ns at 100cc/hr\nGU-anuric, foley changed, CVVHDF started and running even to negative 100cc/hr, following lytes and ABG\nHeme/monitoring HCT, plt and coags, and LFTS\n\nPlan- cont prop, PRN fentanly,CVVHDF running negativ, follow lytes, ABG, and plt, HCT, plts, coags, cont TF, monitor stool out, ?need for insulin gtt, and d/c IVF, cont ABX\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-20 00:00:00.000",
"description": "Report",
"row_id": 1410214,
"text": "Nursing note:\nNEURO: Sedated on PPF gtt, appears comfortable. Awakens to stimulation when off gtt, grimaces and bites on ETT. Does not follow commands, moving UEs, not noted to move LEs. Shaking head back and forth at times. PERRLA 3mm and brisk.\nRESP: Lung sounds coarse, suctioned for blood-tinged secretions frequently. No vent changes made, ABGs acceptable. Oozing from mouth and gums. Bite block in place. CXR done.\nCV: Remains slightly hypothermic, Bair Hugger worn. SR in 70s-80s, no ectopy. MAP >70 w/Neo gtt. +Anasarca, faintly palpable pulses bilaterally. CVP 13-18. PADs 24-30. CO/CI per Carevue, remains hyperdynamic.\nSKIN: Weeping from all open areas, all dressed w/Aquacel/Tegaderm. Duoderm intact to coccyx. Skin care RN in to see pt, will write recs. tomorrow. Recommends skin care gel to scrotal abrasion and DSD.\nGI: Abdomen large, +ascites. -BS, +dark black stool via Mushroom catheter. Stool for 3rd O&P sent. US done and abdomen tapped for small amount ascites by Dr. @ bedside, sent for cx. TFs held for high residuals, NGT to suction.\nGU/RENAL: Foley patent minimal amount icteric urine. CVVHD running -50cc/hr, clotted x1 and filter changed.\nENDO: Insulin gtt @2-6U/hr, D10 infusing as well. Glucose stable, checked hourly.\n\nA/P: ESLD/hepatorenal syndrome on CVVHD, worsening LFTs.\nNeo gtt for MAP >70, PPF gtt for sedation/comfort, frequent labs, CVVHD for 50cc/hr negative. Continue current plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-21 00:00:00.000",
"description": "Report",
"row_id": 1410215,
"text": "Neuro-prop turned off to assess neuro, pt shakes head side to side, biting on ETT and bite block noted chewing motion of mouth, does not follow commands, minimal movement of upper extrem withdraws to stimuli intermitently, does not withdraw LE, grimace, PERRLA, prop restarted for comfort and ventilation due to biting on ETT\nCV-MP SR occass PAC, doppler DP/PT, + pitting edema, anasarca, neo gtt for MAP>70, remains hyperdyanamic and requires bair hugger to maintain temp\nResp-LS grossly dim, coarse upper lobes sx for thick tan, remains on AC\nGI-TPN, Insulin gtt, neq BS, reglan and protonix for GI motility, mushroom cath with melena out,\nGU-CVVHDF running neg 50cc/hr, anuric, lytes, ABG, followed\nHeme-HCT, coags, plts, followed, and pt monitored for bleeding\nID-cont on ABX\n\nPlan-cont to run CVVHDF even, follow all labs, monitor neuro, maintain pts comfort, cont TPN, and insulin, wean neo as SBP tolerates, ?amonia, please see carvue\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-21 00:00:00.000",
"description": "Report",
"row_id": 1410216,
"text": "Resp Care\nPt remains intubated during noc, no vent changes made, ABG's WNL. Bil breath sounds, sx'd mod thick yellow secretions. Plan to continue vent support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-21 00:00:00.000",
"description": "Report",
"row_id": 1410217,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-27 00:00:00.000",
"description": "Report",
"row_id": 1410240,
"text": "STATUS\nD: ON PROPOFOL/LEVO/INSULIN GTT'S..NEURO UNCHANGED..LABILE BP..CVVH FILTER CLOTTED\nA: FAMILY HERE SPOKE WITH DR PT NOW .. NOT RESTARTED .. LEVO/INSULIN GTT'S DC'D..STARTED ON FENTANYL GTT FOR COMFORT..PT HR V FIB/FLUTTER>>ASYSTOLE..FAMILY WITH PT..DR ? POST\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-21 00:00:00.000",
"description": "Report",
"row_id": 1410218,
"text": "status\nD: REMAINS ON PROPOFOL/NEO GTT'S & ON & OFF INSULIN GTT..CVVHDF RUNNING..PLTS DROPPING..COAG'S CLIMBING..CA+ DOWN(REPLETED)\nA: NO VENT CHANGES..ADQUATE ABG'S & SAT'S..CVVHDF FILTER CHANGED X1..REPLACEMENT INCREASED TO 2L/H..FLUID REMOVAL INCREASED TO 200CC/H..PLACED ON ROTATING BARI BIG BOY BED..CONTINUES WITH LGE AMT NG DRAINAGE.. MULTIPLE AREAS OF BLISTERS & ABRASIONS OOZING LGE AMT SEROUS..MUSHROOM CATH WITH SM AMT CLEAR/BLACK FLECKED STOOL..MIN AMBER URINE\nR: CONTINUES WITH HEPATO-RENAL SYNDROME\nP: CONTINUE TO CLOSELY MONITOR Q6H LABS REPLETE AS NEEDED\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-22 00:00:00.000",
"description": "Report",
"row_id": 1410219,
"text": "Resp Care\nPt remains intubated on AC during noc, no changes made. BIl breath sounds, sx'd mod thick tan secretions. ABG's WNL. Plan to continue with mech. ventilation at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-22 00:00:00.000",
"description": "Report",
"row_id": 1410220,
"text": "FOCUS HEMODYNMICS\nDATA: NEURO: PERLA # AND REACTS BRISKLY. MOVES UPPER ARMS BUT DOES NOT FOLLOW COMMANDS. WITHDRAWS TO PAINFUL STIMULI. DID NOT MOVE LEGS ON THE BED. LEGS EDEMATOUS. PROPOFOL GTT ON AND OFF FOR NEURO ASSESSMENT.\n\nRESP: SUCTIONED FOR THICK BROWN SPUTUM. LG AMT OF ORAL SECRETITIONS. AIR WAY IN PLACE AND REMOVED TO CLEANSE MOUTH. ABG'S GOOD.\n\nCARDIAC: REMAINS IN NSR. ON NEO GTT. AT 1.25MCG/KG//MIN. GOAL OF MAP > 65. BP SYST 110-120. INR 2.5 PT 19.6 AND PTT 50.5. HCT 30 K 3.3-3.4 KCL IN CCVH FLUID. DDR PALASTRAIN NOTIFIED OF RESULTS THIS AM DURING HIS ROUNDS. CO CI 3 AND SVR 300-450. CATHETER NOT WEDGED.\n\nGI ABD SOFFT. MUSHROOM CATHETER IN PLACE AND REMOVED Q2 HRS. GUIAC POS BLACK STOOL. SKIN JAUNDICED. TUBE FDGS ON HOLD. TPN INFUSING.\n\nGU: CVVHDF INFUSING OK. I AND O NEGATIVE. CREAT 1.5 AND BUN 65\n\nACTION: SUCTIONED PRN. LABS AS ORDERED. ON IV CASPOFUNGIN AND VANCOMYCIN 1GM IV GIVEN. LEVEL DRAWN THIS AM. CVVHDF TOL WELL GOAL 200CC /HR. I AND O NEGATIVE. INSULIN GTT ON INFUSING BLOOD SUGARS Q1HRS. NEO GTT TITRATED TO KEEP MAP > 65. PROPOFOL GTT INFUSING TO MAINTAIN QUIET. TUBE FDGS ON HOLD. MUSHROOM CATHETER IN PLACE AND REMOVED TO REST RECTUM. VENODLYNES ON FAMILLY IN TO SEE PT TODAY AND UPDATE GIVEN.\n\nRSPONSE: MONITOR CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-22 00:00:00.000",
"description": "Report",
"row_id": 1410221,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-22 00:00:00.000",
"description": "Report",
"row_id": 1410222,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFICS.\nREMAINS ON , DR. , RUN TO KEEP EVEN AND TRY TO GET NEO OFF, YET IS VERY DEPENDENT ON NEO.\nRECEIVED 2 U FFP TODAY OR INR OF 2.8, UNCHANGED AFTER FFP INFUSED.\nVERY OOZY WITH TOTAL BODY ANASARCA.\nWILL START SLIDING SCALE CALCIUM DRIP PER RENAL SINCE IONIZED CA REMAINS LOW.\nDIALYASATE AND REPLACEMENT FLUIDS CHANGED DURING THIS SHIFT FOR LOWER K/CA.\nNGT CONTINUES WITH A LARGE AMOUNT OF DRAINAGE.\nTAKEN OF POPOFOL THIS AM, DID NOT FOLLOW COMMANDS, BUT MINIMAL MOVEMENT OF ALL 4 EXTREMITIES NOTED.\nTRANSPLANT TEAM AND ICU TEAM AWARE OF ABOVE AND ALL FLOW SHEET VALUES.\nFAMILY IN, VERY SUPPORTIVE,\nWILL CONTINUE WITH AGGRESSIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-23 00:00:00.000",
"description": "Report",
"row_id": 1410223,
"text": "Resp Care\nPt remains intubated on AC, no vent changes made during noc. Pt has bil breath sounds clear, sx'd for mod thick brown secretions. AM ABGs WNL. Plan to continue with vent support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-19 00:00:00.000",
"description": "Report",
"row_id": 1410208,
"text": "Resp Care Note, Pt from MED CTR. for further workup of ESLD.Remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions. HR- occ PVC'S. RSBI done on 0 peep/5 ips-10 Will cont to monitor resp status for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-26 00:00:00.000",
"description": "Report",
"row_id": 1410234,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: SEDATED ON PROPOFOL GTT. NO CHANGES.\nRESP: NO VENT CHANGES. ABG STABLE.\nCV: FEBRILE THIS EVE TO 101.7. MD' , , AND INFORMED. TACHYCARDIC TO 130S WITH TEMP. LEVO WEANED SLIGHTLY TO INPROVE HR. CRRT RESTARTED WITH SOME HYPOTENSION. FLUID BOLUS ORDERED AND GIVEN BY MD . TACHYCARDIA AND TEMPERATURE IMPROVED. LEVO GTT TITRATED TO MAINTAIN SBP >100. CRRT RUNNING WITH NO PFR.\nGI: NGT TO LCWS WITH PINK O/P, MOD AMTS. MUSHROOM CATH INTACT WITH SCANT CLEAR LIQUID O/P.\nGU: ANEURIC.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: PT WITH MULTIPLE OPEN SKIN LESIONS AT ARMS WITH LG AMTS SEROUS DRG, CLEANED WITH SOAP AND H2O, COVERED WITH AQUACEL AND TEGADERM IN ATTEMPT TO KEEP PT'S SKIN DRY. ANTIFUNGAL LOTION APPLIES TO SKIN FOLDS AT PANNUS. R HEEL BLISTER CLEARNED WITH WOUND SPRAY WITH DSD APPLIED, NO DRG, ELEVATED FROM BED. SCROTAL WOUND CLEANED WITH WOUND CLEANSER AND COVERED WITH DOUDERM GEL, ADAPTIC, AND SPFTSORB.\nSOC: FAMILY MEETING THIS EVE WITH RN, PT'S MOTHER, , RN AND MD . PT'S PROGNOSIS DISCUSSED. PT NOW DNR. CMP TO BE FURTHER DISCUSSED.\nPLAN: CONT PER CURRENT MGMT FOR NOW. DNR. EMOTIONAL SUPPORT TO FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-26 00:00:00.000",
"description": "Report",
"row_id": 1410235,
"text": "REsp Care\nPt remians intubated , no vent changes made. Bil breath sounds clear t/o. Pt sx'd for mod thick blood tinged secretions. ABGs WNL, Plan to continue with vent support at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-26 00:00:00.000",
"description": "Report",
"row_id": 1410236,
"text": "Respiratory Care Note:\n Patient remains on A/C of 20 x 700cc, 70% and 8 PEEP. BS=bilat, decreased bilat lower lobes. Suctioned for moderate amounts of thick blood tinged sputum. He is sedated on propofol. CVVH continues and he remains on levo and insulin infusions. Plan to continue with supportive care. Noted status is DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-26 00:00:00.000",
"description": "Report",
"row_id": 1410237,
"text": "STATUS\nD: VSS SEE FLOW SHEET..REMAINS ON LEVO/INSULIN/PROPOFOL GTT'S.. ESSENTIALLY UNRESPONSIVE..WILL WITHDRAW ARMS TO PAINFUL STIMULI BUT DOESN'T FOLLOW COMMANDS\nA: REMAINS ON CVVHDF..FILTER CLOTTED X1 REPLACED..MIN HUO & STOOL.. CONTINUES TO OOZE SEROUS FROM MULTIPLE AREAS ON ARMS/SCROTUM.. DR SPOKE WITH FAMILY RE CMO..MOTHER WILL SPEAK WITH PT'S CHILDREN & WILL MAKE DECISION IN AM\nR: ESSENTIALLY UNCHANGED\nP: CONTINUE WITH FULL SUPPORT..AWAITING FAMILY DECISION\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-27 00:00:00.000",
"description": "Report",
"row_id": 1410238,
"text": "Respiratory Care:\nPt has been on all noc. No vent changes. PaO2 = 67; on FiO2\nOf 70%. Will follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-27 00:00:00.000",
"description": "Report",
"row_id": 1410239,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: UNCHANGED.\nRESP: NO VENT CHANGED. PO2 DOWN TO 67. MD INFORMED.\nCV: LABILE BP. LEVO GTT TITRATED TO SBP >100. CRRT WITH NO PFR D/T OVERALL INCREASING LEVO REQUIREMENT.\nGI: PINK TO YELLOW NGT O/P. SCANT AMT LIQUID STOOL.\nGU: ANEURIC.\nSKIN: SEE FLOWSHEET.\nENDO: INSULIN GTT TITRATED TO RISS.\nSOC: MULT FAMILY MEMBERS IN TO VISIT IN EVE. REQUEST FOR PRIEST THIS AM BY SISTER.\nPLAN: CONT PER CURRENT MGMT. AWAIT FAM MTG TO DISCUSS POSSIBLE CMO. ARRANGE FOR PRIEST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-23 00:00:00.000",
"description": "Report",
"row_id": 1410224,
"text": "focus hemodydnmics\ndata: neuro: on propofol gtt. at 20mcg/kg/min. perla # and reacts briskly. moves upper extremities but does not move lower extremties. propofol off for neuro exam. moves head back and forth.\n\nresp: remains vented. suctioned for thick tan sputum with some plugs present. lg amt of oral secretitions. abg's. good. no vent changes tonite.\n\ncardiac: remains in nsr. occasional pvc. k 3.3-3.4 k via ccvvh fluid. on a neo gtt. goal to keep map 65-70/ 1unit of prbc given for hct 26 post hct 30.1. inr 2.2. pt 18.4. 2 bags of plts given tonite.\n\ngU foley patent and no urine . cvvhdf being tolerated. goal is to be even. creat 2.7 and bun 55.\n\ngI abd soft and distended. mushroom catheter in place. guiac post stool. albumin 2.8.tube fdgs cont to be held. ngt draining brown drainage. > 1000cc. total tonite.\n\naction: suctioned prn. labs as ordered. insulin gtt and blood sugars q1hr. propofol and neo gtt maintained. cvvhdf being tol. tpn infusing. on caspofungin. vanco iv held due to high level.\n\nresponse: monitor closely\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-06-23 00:00:00.000",
"description": "Report",
"row_id": 1410225,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
}
] |
22,217 | 136,274 | The patient was taken immediately to the operating room for bladder repair. There was gross blood in the abdomen. The spleen had a small tear at the capsule of the inferior pole. Spleen was initially packed and then the packing was removed, possible abrasion. A 12 cm bladder laceration was identified and sutured with Urology present. The left thigh was debrided and washed out. For further details, please see the operative report of . The patient was transferred to the Trauma SICU after the procedure for close hemodynamic monitoring. He remained stable and was extubated on hospital day three. On , the patient returned to the operating room with Orthopedics for ORIF with plate and screws to the left forearm. The pelvic fracture was deemed nonoperative. The patient progressed well after his surgery and Addiction consult was obtained, and patient was counseled on his alcohol use. The patient was cleared for home with services on . The patient was tolerating p.o. without nausea or vomiting, was passing flatus. Was able to walk using the walker and crutches with Physical Therapy, and was able to perform stairs independently. The patient was discharged home with VNA for dressing changes wet-to-dry on the left thigh and bladder bag care and teaching, and home OT for his left wrist. | There is a small amount of hemorrhage layering posteriorly in the occipital of the left lateral ventricle, which in retrospect, is not changed from the prior study. There is a tiny amount of hemorrhage layering posteriorly in the occipital of the left lateral ventricle. The surrounding osseous and soft tissue structures are within normal limits, aside from mild mucosal thickening in the sphenoid sinus. TECHNIQUE: Non-contrast head CT was obtained. There is a vertical fracture through the body of S1 extending to the left incompletely visualized. FINDINGS: There is suspicion of a small amount of subarachnoid blood along the left posterior parietal convexity surface superiorly. There is a left superior and inferior pubic ramus fracture. CONCLUSION: No definite intracranial hemorrhage. PELVIS: Single view of the pelvis is limited by overlying trauma board. CONCLUSION: Suspected small amount of subarachnoid hemorrhage with other findings as noted above. TECHNIQUE: Routine non-contrast head CT. TECHNIQUE: Non-contrast head CT scan was obtained. IMPRESSION: Angulated fracture of the distal radial shaft associated with positive ulnar variance as described above. Carpal rows are intact although there is positive ulnar variance. ADDENDUM: There is a mild degree of scalp soft tissue swelling in the left parietal vertex region of the skull. IMPRESSION: Left pubis fracture. There also is a focus of decreased attenuation in the left occipital lobe, which appears slightly more prominent than on the prior study. of c-spine irreg on OSH films REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast FINAL REPORT INDICATIONS: Question of C-spine irregularity on outside films. COMMENT: There is loss of visualization of the airway, likely due to intubation. FINDINGS: This exam is limited by the overlying trauma board. A vague irregular linear lucency overlying the portion of the upper sacrum is difficult to evaluate on this study.No prior studies for review. The heart size is stable, given differences in technique. FINDINGS: The small focus of increased attenuation overlying the left parietal region seen on the examination is not appreciated today. There is moderate mucosal thickening of the visualized portions of the left maxillary sinus. There is moderate mucosal thickening within the maxillary and ethmoid sinuses, with a minor degree of mucosal thickening in the sphenoid sinus. There is a moderate degree of soft tissue swelling within the scalp bilaterally, most notably near the vertex of the skull. IMPRESSION: 1) No evidence for subarachnoid hemorrhage. No diastasis of the sacroiliac joints. There is probable moderate thickening of the posterior superior nasopharyngeal soft tissues. vert injury on OSH films/CT REASON FOR THIS EXAMINATION: r/o fx No contraindications for IV contrast FINAL REPORT INDICATIONS: High speed MVA. MG+ REPLETED.ENDO: STABLEID: LOW GRADE TEMP - 100.3, IV ABX D/C'D .SKIN: BACK/BUTTOCKS INTACT, MIDLINE ABD.INC WNL - COVERED W/OCCLUSIVE PRIMARY DSG, D/I. wbc=7.3 from 10.2. left upper leg redressed for moderate serosanguineous drainage. SKIN PIN/WARM/DRY - HEPARIN AND PB'S FOR DVT PROPHYLAXIS.HEME: HCT 32.4(33.1)RESP: LUNG SOUNDS CLEAR, DIMINISHED AT BASES B/L. Lung sounds ess clear dim R base. SOFT TISSUE SENSITIVITY TO BE PERFORMED THIS PM UPON INCREASED ALERT STATUS.CV: HR 110 ST. BP 160/70 LOPRESSOR 5MG X 1 PULSES EASILY PALPABLE THROUGOUT.RESP: EXTUBATED LUNG SOUNDS CLEAR DIMINISHED AT BASES. R THIGH W/W->D DSG DRAINING SCANT AMT SEROUS FLUID. after a.m. care, slightly pink-tinged.heme=continues on q 6hr hcts--no change.endo=no issues.id=temp. POST EXTUBATION ABG PENDING.GI: NPO ABSENT BOWEL SOUNDS OGT D/C'D. PULSES EASILY PALPABLE THROUGHOUT.RESP: LUNG SOUNDS CLEAR DIMINISHED AT BASES. Nasal airway placed as Pt intermittantly with partial airway obstruction. DENIES N/V.GU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/ADEQUATE HOURLY VOLUME OUT. nsg note ROS: CV:OCCASIONALLY TACKY AND HYPERTENSIVE DEPENDING ON AMT OF PAIN.HE WAS STARTED ON DILAUDID PCA WHICH IS EFFECTIVE. GU:EXCELLENT UO,NO BLD NOTED.IV AT KVO GI:STARTED ON CLEAR LIQUIDS,CAN ADVANCE AS TOLERATED. CLEARANCE OF C-SPINE, DECREASE SEDATION.P: PROVIDE PAIN CONTROL, FOLLOW WND, FOLLOW TEMPS, PULM TOLIETING FREQUENTLY, SUPPORT FAMILY, ADV DIET D/C TO FLOOR. RR 16-24 AT REST.GI: ABD SOFT, APPROPRIATELY TENDER W/(+)HYPOACTIVE BS, NO RF/BM. Pt sedated on propofol, plan to cont vent support. sats cocsistently 100%.gi=orogastric tube to low wall suction. Once cleared, sedation stopped and Pt placed on CPAP/PSV. Resp Care Note:Pt cont intub sedated on mech vent as per Carevue. suctioned for thick slightly tan secretions--scant amts. PT'S UPPER LIP SWOLLEN, SLIGHTLY IMPROVED FROM PREVIOUS DAY.SOCIAL: NO FAMILY CONTACT OVER .A/P: STABLE S/P MVC, TOLERATED EXTUBATION. AP, neutral, and axillary views of the left shoulder show AC joint separation. BUN 9 CREAT .09HEME: CYCLE HCT 33.2 (33.4) CONT TO FOLLOW TREND.ID: TMAX 100.9 WBC 9 FLAGYL, KEFZOL.SKIN: ABD INCISION WITH STAPLES C/D/I MODERATE SEROUS STAINING ON PRIMARY DRESSING. Continues tachycardic and relatively hypertensive.P:Continue to answer pt's questions. BS equal bilat, slight decreased to bases. k+ to be repleted--awaiting mix from phcy.pulm=ventilated on simv 16-40%-700-5 cm peep and 5 cm pressure support. Care NotePt received intubated, sedated and vented on settings SIMV 700x 16x 40% peep 5 psv 5. also sedated with alternating doses of mso4 and dilaudid for pain.cv=monitor=st with no ectopy noted. SUCTIONED FOR MINIMUM SECRETIONS.GI: NPO OGT TO LWS WITH MINIMAL OUTPUT FAMOTIDINE ABSENT BOWEL SOUNDS.GU: URINE OUTPUT 100-200 CC CLEAR YELLOW URINE VIA FOLEY CATHETER LYTES REPLEATED. WRAPPED IN KERLEX. FAMOTIDINE DENIES NAUSEA.GU: URINE OUTPUT 100-150CC CLEAR YELLOW URINE VIA FOLEY CATH.SKIN: ABD INCISION C/D/I MINIMAL SEROUS STAINING STAPLES WELL APPROXIMATED. NT SUCTION FOR MINIMAL TNA SECRETIONS NASAL TRUMPET INTACT FOR ACCESS. npns=orally intubated and sedated.o=sedated, responds to painful stimuli only. Pt arrived to T-SICU and placed on vent with initial settings of SIMV 700x 12x 100% peep 5 and psv 5. | 23 | [
{
"category": "Radiology",
"chartdate": "2123-05-18 00:00:00.000",
"description": "CT T-SPINE W/ CONTRAST",
"row_id": 792352,
"text": " 8:19 AM\n CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High speed MVA.\n\n TECHNIQUE: Contiguous axial images with reformatted images.\n\n FINDINGS: This is a survey examination and the reformatted images are quite\n limited. No definite evidence of fracture or malalignment. If there is a\n specific issue regarding one area of the thoracic spine, a more focused\n examination is recommended. Note is made of parenchymal opacifications in the\n posterior aspect of the lungs.\n\n IMPRESSION: Limited survey examination showing no evidence of fracture or\n malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-18 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 792351,
"text": " 8:19 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? of c-spine irreg on OSH films\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Question of C-spine irregularity on outside films.\n\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\n\n FINDINGS: There is no evidence of fracture or malalignment. Disc spaces are\n preserved. Orogastric and orotracheal tubes are in place.\n\n IMPRESSION: No evidence of fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-18 00:00:00.000",
"description": "CT RECONSTRUCTION",
"row_id": 792353,
"text": " 8:19 AM\n CT RECONSTRUCTION Clip # \n Reason: r/o fx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o high mech MVC ? vert injury on OSH films/CT\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High speed MVA.\n\n TECHNIQUE: Contiguous axial images with multiplanar reformatted images.\n\n FINDINGS: There is a fracture of the transverse process of L5 on the left, a\n fracture of the inferior articular facet of L5 on the left and the superior\n articular facet of S1 on the left. There is a vertical fracture through the\n body of S1 extending to the left incompletely visualized. There is a fracture\n of the lamina of S1 as well.\n\n IMPRESSION: Fractures of L5 and S1 with features as discussed above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-19 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 792480,
"text": " 9:58 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: please evaluate for s1 type 2 fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with sacral fracture\n REASON FOR THIS EXAMINATION:\n please evaluate for s1 type 2 fracture\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS, SINGLE FILM:\n\n History of sacral fracture.\n\n No definite fracture is not identified on this film. The upper iliac crests\n are not included on the film. No diastasis of the sacroiliac joints. A vague\n irregular linear lucency overlying the portion of the upper sacrum is\n difficult to evaluate on this study.No prior studies for review.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 792602,
"text": " 11:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval interval for subarachnoid bleed\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,\n REASON FOR THIS EXAMINATION:\n please eval interval for subarachnoid bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC, evaluate for subarachnoid hemorrhage.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n COMPARISON: and .\n\n FINDINGS: The small focus of increased attenuation overlying the left\n parietal region seen on the examination is not appreciated today.\n There is a small amount of hemorrhage layering posteriorly in the occipital\n of the left lateral ventricle, which in retrospect, is not changed from\n the prior study. No other areas of hemorrhage are appreciated. There is no\n mass effect or shift of normally midline structures. There also is a focus of\n decreased attenuation in the left occipital lobe, which appears slightly more\n prominent than on the prior study. This may represent an area of developing\n encephalomalacia. The -white matter differentiation is preserved. There\n is no hydrocephalus.\n\n There is moderate mucosal thickening of the visualized portions of the left\n maxillary sinus. There is also mild mucosal thickening within the ethmoid and\n sphenoid sinuses. There may be an air fluid level in the left and right\n sphenoid air cells. No fractures are identified.\n\n IMPRESSION:\n\n 1) No evidence for subarachnoid hemorrhage. There is a tiny amount of\n hemorrhage layering posteriorly in the occipital of the left lateral\n ventricle.\n 2) Probable area of developing encephalomalacia in the left occipital lobe.\n 3) Mucosal sinus disease as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "LP HIP UNILAT MIN 2 VIEWS LEFT PORT",
"row_id": 792282,
"text": " 1:35 PM\n HIP UNILAT MIN 2 VIEWS LEFT PORT Clip # \n Reason: eval fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 year old status post motor vehicle accident.\n\n A single oblique view of the pelvis shows a fracture through the left pubic\n bone and left inferior pubic rami bone. No other fractures are seen. The hip\n joints are intact. Surgical staples are seen overlying the lower abdomen,\n vertically.\n\n IMPRESSION: Left inferior pubic rami fracture, and left pubic bone fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "LP FEMUR (AP & LAT) LEFT PORT",
"row_id": 792283,
"text": " 1:35 PM\n FEMUR (AP & LAT) LEFT PORT; KNEE (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle accident.\n\n AP and lateral views of the left femur and knee again demonstrate a fracture\n through the left pubic bone and left inferior pubic ramus bone. The left hip\n joint is intact. No fracture of the left femur or knee is seen. The knee joint\n space is intact. No knee joint effusion seen. Knee joint space is preserved.\n subcutaneous air within the soft tissues of the medial is appreciated, maybe\n be related to trauma or prior intervention.\n\n IMPRESSION: As described previously, fracture through the left inferior pubic\n ramus bone and left pubic bone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 792281,
"text": " 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries, now post-op ex-lap\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple injuries, MVC, evaluate for pneumothorax.\n\n Comparison is made to the AP chest radiograph from approximately five hours\n earlier.\n\n AP CHEST RADIOGRAPH: Again seen are an ET tube in satisfactory position\n several cm above the carina and an NG tube with tip below the diaphragm. The\n heart size is stable, given differences in technique. Again seen is a sharply\n demarcated prominence of the superior mediastinum, which is stable in\n appearance. There is slight increase in opacity in the left upper lung zone.\n No pleural effusions or pneumonic consolidations are present. No pneumothorax\n is seen. Osseous structures are unchanged.\n\n IMPRESSION: No evidence of pneumothorax. Increased opacity in left upper\n lung zone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "LP WRIST(3 + VIEWS) LEFT PORT",
"row_id": 792318,
"text": " 6:05 PM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: left radius\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n left forearm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 23 year old male status post motor vehicle collision.\n\n TECHNIQUE: AP, lateral, and oblique views of the left wrist were obtained.\n\n COMPARISON: Exam performed five hours earlier.\n\n FINDINGS: There is a comminuted fracture of the distal third of the radial\n shaft with volar angulation of the distal fracture fragment. Carpal rows are\n intact although there is positive ulnar variance.\n\n IMPRESSION: Angulated fracture of the distal radial shaft associated with\n positive ulnar variance as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 792218,
"text": " 7:54 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: MVA. Assess ET tube placement and pelvic fracture.\n\n FINDINGS: This exam is limited by the overlying trauma board.\n ET tube is several cm above the carina in good position. NG tube tip is\n within the stomach. Cardiac and mediastinal contours are unremarkable. There\n is no pulmonary vascular congestion, pleural effusion, focal infiltrate or\n pneumothorax.\n\n PELVIS: Single view of the pelvis is limited by overlying trauma board. There\n is a left superior and inferior pubic ramus fracture. No other displaced\n fractures are seen.\n\n IMPRESSION: Left pubis fracture. Tubes and lines in good position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 792222,
"text": " 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n MVC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN:\n\n HISTORY: MVA collision.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no sign of an intraparenchymal hemorrhage, mass effect or\n shift of midline structures. There is slight increased density of the falx\n cerebri and tentorium cerebelli, which in a patient of this age is probably\n within normal limits. The surrounding osseous and soft tissue structures are\n within normal limits, aside from mild mucosal thickening in the sphenoid\n sinus. There is probable moderate thickening of the posterior superior\n nasopharyngeal soft tissues. In a patient of this age, this finding could\n represent enlarged adenoids.\n\n CONCLUSION: No definite intracranial hemorrhage.\n\n ADDENDUM: There is a mild degree of scalp soft tissue swelling in the left\n parietal vertex region of the skull. Presumably this is post traumatic in\n origin.\n\n The nasogastric and endotracheal tubes are seen on the lateral scout image.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-18 00:00:00.000",
"description": "CT HEAD W/ CONTRAST",
"row_id": 792347,
"text": " 7:50 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: MVC\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with mvc\n REASON FOR THIS EXAMINATION:\n rule out any bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN:\n\n HISTORY: Motor vehicle accident. Assess for intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan was obtained.\n\n FINDINGS: There is suspicion of a small amount of subarachnoid blood along\n the left posterior parietal convexity surface superiorly. There is no other\n definite accumulation of intracranial hemorrhage identified. There is no mass\n effect or shift of normally midline structures. There is a moderate degree of\n soft tissue swelling within the scalp bilaterally, most notably near the\n vertex of the skull. There is moderate mucosal thickening within the\n maxillary and ethmoid sinuses, with a minor degree of mucosal thickening in\n the sphenoid sinus. The sinus abnormalities could represent an allergic or\n some other type of inflammatory process.\n\n CONCLUSION:\n\n Suspected small amount of subarachnoid hemorrhage with other findings as noted\n above.\n\n COMMENT: There is loss of visualization of the airway, likely due to\n intubation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "OL FEMUR (AP & LAT) IN O.R. LEFT",
"row_id": 792251,
"text": " 10:46 AM\n FEMUR (AP & LAT) IN O.R. LEFT Clip # \n Reason: H/O TRAUMA, OPEN WOUND LEFT FEMUR, ASSESS FOR FX\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: H/O trauma, open wound in left femur. Assess for skeletal\n injury.\n\n AP FILM OF LEFT FEMUR INCLUDED IN TRAUMA SERIES: Single view covers only a\n distal two-thirds of the femur where there is no conclusive evidence of the\n traumatic bony injury. A subcutaneous wound is noted in the lateral aspect\n of the mid-thigh.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-17 00:00:00.000",
"description": "LP SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT",
"row_id": 792284,
"text": " 1:35 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT; ELBOW (AP, LAT & OBLIQUE) LEFT PORTClip # \n WRIST(3 + VIEWS) LEFT PORT\n Reason: r/o fracture\n Admitting Diagnosis: EXP LAP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with MVC,mult injuries\n\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P motor vehicle accident.\n\n AP, neutral, and axillary views of the left shoulder show AC joint separation.\n No shoulder joint dislocation seen. The AC joint separation measures\n approximately 1.6 cm.\n\n Two views of the left elbow show no fracture or dislocation. A lateral view\n of the elbow is not provided, and therefore no elbow joint effusion can be\n assessed.\n\n Two views of the distal radius and ulna/wrist on the left show a comminuted\n fracture through the distal of the radial shaft, with minimal\n displacement. Note is also made of a small foreign body with the appearance\n typical for glass seen within the soft tissues adjacent to the proximal ulna.\n\n IMPRESSION: Left AC joint separation, fracture through the distal radial\n shaft, and small foreign body within the soft tissues adjacent to the proximal\n ulna.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-17 00:00:00.000",
"description": "Report",
"row_id": 1553183,
"text": "Resp. Care Note\nPt arrived in ER intubated with 8.0 ETT secured at 25cm. BS equal bilat, slight decreased to bases. Pt transported to ER CT scanner and then to OR for E. Lap. Pt arrived to T-SICU and placed on vent with initial settings of SIMV 700x 12x 100% peep 5 and psv 5. Combined acidosis on ABG so minute ventilation increased and FiO2 weaned down. Current settings SIMV 700x 18x 40% 5/5. Last ABG 7.41/37/153/24 on 50%. Pt sedated on propofol, plan to cont vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-17 00:00:00.000",
"description": "Report",
"row_id": 1553184,
"text": "TSICU ADMIT NOTE\n23 S/P MVC +ETOH PMH PEDIATRIC BURN WITH GRAFT REPAIRS.\nTRANSFERRED TO FROM OSH.\nINJURIES:\nRUPTURED BLADDER, LEFT SUPERIOR AND INFERIOR PUBIC RAMI FX (NON-DISPLACED), LEFT FOREARM FX, ?LUMBER FRACTURES, SPLENIC PERIPLEURAL TEAR, LEFT THIGH ABRASION\n\nOR: S/P EX LAP REPAIR BLADDER RUPTURE DEBRIDEMENT LEFT THIGH WOUND.\nCRYST 4000\nEBL 300\nU/O 400\n\nNEURO: INTUBATED AND SEDATED WITH PROPOFOL, MORPHINE AND DILAUDID. OPENS EYES TO PAINFUL STIMULI DOES NOT FOLLOW COMMANDS, MOVES EXTREMITIES WITH EXCEPTION OF LEFT UPPER EXTREMITITY WHICH REMAINS STABILIZED IN A SPLINT. COUGH/GAG INTACT PUPILS 3MM/BRISK. HEAD CT INDICATES NO SIGNS OF BLEED/SHIFT.\n\nCV: HR 120'S ST NO ECTOPY. BP 140/70'S. LR @ 100/HR. PULSES EASILY PALPABLE THROUGHOUT.\n\nRESP: LUNG SOUNDS CLEAR DIMINISHED AT BASES. SATS 100% SIMV 18/700 PEEP 5 PS 5 FIO2 40%. ABG INDICATE ADEQUATE V/Q CONT TO FOLLOW. SUCTIONED FOR MINIMUM SECRETIONS.\n\nGI: NPO OGT TO LWS WITH MINIMAL OUTPUT FAMOTIDINE ABSENT BOWEL SOUNDS.\n\n\nGU: URINE OUTPUT 100-200 CC CLEAR YELLOW URINE VIA FOLEY CATHETER LYTES REPLEATED. BUN 9 CREAT .09\n\nHEME: CYCLE HCT 33.2 (33.4) CONT TO FOLLOW TREND.\n\nID: TMAX 100.9 WBC 9 FLAGYL, KEFZOL.\n\nSKIN: ABD INCISION WITH STAPLES C/D/I MODERATE SEROUS STAINING ON PRIMARY DRESSING. LEFT DEBRIDEMENT WITH LARGE AMTS OF SEROUS OUTPUT. WRAPPED IN KERLEX. LEFT ARM SECURED WITH BRACE. J-COLLAR.\n\nSOCIAL: MOTHER AND GIRLFRIEND AND BEDSIDE PATIENT IS CURRENTLY UNEMPLOYED AND LIVING WITH GIRLFRIEND.\n\nA:S/P TRAUMA FOLLOWING HEMODYNAMICS, FOLLOWING RADIOLOGY REPORTS.\n\nP:ONCE RADIOLOGICALLY CLEAR CHANGE ACT STATUS FOR EXTUBATION, FOLLOW HCTS, FOLLOW SEDATION AND PAIN CONTROL, CHANGE WOUND DRESSINGS, SUPPORT FAMILY, REPLEAT LYTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-19 00:00:00.000",
"description": "Report",
"row_id": 1553190,
"text": "T/SICU NPN 2300-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT/ORIENTED/AFFECT AND QUESTIONS APPROPRIATE. OCCASIONALLY CONFUSED WHEN WAKING FROM SLEEP - REORIENTS WELL. MOVES ALL EXTREMITIES, LIFTS/HOLDS R ARM/LEG, MOVES L ARM/LEG ON BED: CAP REFILL TO ALL EXTREMITIES. GIVEN PRN DILAUDID FOR C/O EXTREMITY AND ABD PAIN W/(+) EFFECT - RESTING COMFORTABLY - SLEPT ON/OFF. C-COLLAR INTACT - AWAITING CLINICAL CLEARANCE OF NECK.\n\nCV: HR ST 110-120'S, BP 140-160'S/80-90'S. BP 130'S WHEN ASLEEP. NO ECTOPY NOTED ON TELEMETRY. PERIPHERAL PULSES EASILY PALPABLE. SKIN PIN/WARM/DRY - HEPARIN AND PB'S FOR DVT PROPHYLAXIS.\n\nHEME: HCT 32.4(33.1)\n\nRESP: LUNG SOUNDS CLEAR, DIMINISHED AT BASES B/L. O2 2L VIA NC AS WELL AS COOL NEB FACE MASK @40% FOR HUMIDITY: SATS 94-97% AT THESE SETTINGS; PT TRENDS DOWN TO 80'S ON RA. DENIES SOB, NORMAL COUGH EFFORT, NEEDS TO SUPPORT ABD FOR COUGH/DEEP BREATH EXERCISES. RR 16-24 AT REST.\n\nGI: ABD SOFT, APPROPRIATELY TENDER W/(+)HYPOACTIVE BS, NO RF/BM. NPO - IVF @KVO RATE. DENIES N/V.\n\nGU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/ADEQUATE HOURLY VOLUME OUT. MG+ REPLETED.\n\nENDO: STABLE\n\nID: LOW GRADE TEMP - 100.3, IV ABX D/C'D .\n\nSKIN: BACK/BUTTOCKS INTACT, MIDLINE ABD.INC WNL - COVERED W/OCCLUSIVE PRIMARY DSG, D/I. L ARM IN SPLINT W/(+)CSM TO FINGERS. R THIGH W/W->D DSG DRAINING SCANT AMT SEROUS FLUID. R ARM W/IV INFILTRATE - (+)EDEMA - BOTH EXTREMITIES ELEVATED ON PILLOWS. CAP REFILL THROUGHOUT. PT'S UPPER LIP SWOLLEN, SLIGHTLY IMPROVED FROM PREVIOUS DAY.\n\nSOCIAL: NO FAMILY CONTACT OVER .\n\nA/P: STABLE S/P MVC, TOLERATED EXTUBATION. LOW GRADE TEMP. CONTINUE PER CURRENT PLAN OF CARE: MONITOR SYSTEMS/LABS FOR CHANGES, REPLETE LYTES AS NEEDED. PAIN MGT - PULMONARY HYGEINE. DSG CHANGES AS ORDERED. F/U W/TEAM TO CLEAR C-SPINE AND REMOVE COLLAR. (?)SLOW DIET ADVANCE. PT LIKELY ABLE TO TRANSFER TO FLOOR IF HE REMAINS STABLE AND BED BECOMES AVAILABLE. FULL SUPPORT/COMFORT/ASSIST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-19 00:00:00.000",
"description": "Report",
"row_id": 1553191,
"text": "nsg note\n ROS:\n\n CV:OCCASIONALLY TACKY AND HYPERTENSIVE DEPENDING ON AMT OF PAIN.HE WAS STARTED ON DILAUDID PCA WHICH IS EFFECTIVE. T MAX 99.6.\n\n RESP:STRONG PROD COUGH.ON 2L NP WITH SAT 98\n\n NEURO:AWARE,SLEEPY BUT EASILY AROUSABLE.MOVING R SIDE WELL,DUE TO INJURY NOT MOVING L ARM OR LEG.\n\n GU:EXCELLENT UO,NO BLD NOTED.IV AT KVO\n\n GI:STARTED ON CLEAR LIQUIDS,CAN ADVANCE AS TOLERATED.\n\n SKIN:L THIGH W-D DSD DONE AT 1PM,MIMINAL SS DRAINAGE.\nBACK INTACT.\n\n FAMILY:MOTHER,GIRLFRIEND IN THIS PM.AWARE OF PLANS TO SEND PT TO FLOOR WHEN BED AVAILABLE.\n\n PLAN:TRANSFER TO FLOOR.OR FOR ORIF L WRIST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-18 00:00:00.000",
"description": "Report",
"row_id": 1553187,
"text": "TSICU PROGRESS NOTE\nNEURO: APTIETN IS ALERT AND ORIENTED X 3 SLIGHTLY CLOUDY WHEN FIRST AWAKE BUT REORIENTS QUICKLY. FOLLOWING ALL COMMANDS, COUGH/GAG INTACT, PUPILS 3 , , DILAUDID PRN FOR DISCOMFORT, ENIES NUMBNESS AND TINGLING THROUGHOUT. HEAD/NECK LUMBAR/THORACIC CT PERFORMED THIS AM. L5 WITH NON-OPERABLE FRACTURE. LOGROLL PRECAUTIONS DISCONTINUED. J COLLAR REMIANS INTACT. SOFT TISSUE SENSITIVITY TO BE PERFORMED THIS PM UPON INCREASED ALERT STATUS.\n\nCV: HR 110 ST. BP 160/70 LOPRESSOR 5MG X 1 PULSES EASILY PALPABLE THROUGOUT.\n\nRESP: EXTUBATED LUNG SOUNDS CLEAR DIMINISHED AT BASES. ENCOURAGE COUGH AND DEEP BREATHE. FREQUENT PULMONARY TOLIETING. NT SUCTION FOR MINIMAL TNA SECRETIONS NASAL TRUMPET INTACT FOR ACCESS. SATS 95 5 ON 40% FACE MASK. POST EXTUBATION ABG PENDING.\n\nGI: NPO ABSENT BOWEL SOUNDS OGT D/C'D. FAMOTIDINE DENIES NAUSEA.\n\nGU: URINE OUTPUT 100-150CC CLEAR YELLOW URINE VIA FOLEY CATH.\n\nSKIN: ABD INCISION C/D/I MINIMAL SEROUS STAINING STAPLES WELL APPROXIMATED. LEFT LEG INCISION W->D DRESSING WITH+ GRANULATION.\n\nID: TMAX 101.3 WBC 7 KEFZOL/FLAGYL DISCONTINUED.\n\nHEME: HCT 33.4 HEPARIN P-BOOTS.\n\nSOCIAL:GIRLFRIEND AND MOTHER IN ROOM SOCIAL WORK FOLLOWING.\n\nA: RESP STATUS POST-EXTUBATION. CLEARANCE OF C-SPINE, DECREASE SEDATION.\n\nP: PROVIDE PAIN CONTROL, FOLLOW WND, FOLLOW TEMPS, PULM TOLIETING FREQUENTLY, SUPPORT FAMILY, ADV DIET D/C TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-18 00:00:00.000",
"description": "Report",
"row_id": 1553188,
"text": "Resp. Care Note\nPt received intubated, sedated and vented on settings SIMV 700x 16x 40% peep 5 psv 5. Pt transported to CT scan of head and for spine clearance. Once cleared, sedation stopped and Pt placed on CPAP/PSV. Weaned quickly to and extubated without incident. Nasal airway placed as Pt intermittantly with partial airway obstruction. Follows commands for deep breathing and coughing. Face tent at 40%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-18 00:00:00.000",
"description": "Report",
"row_id": 1553189,
"text": "T-SICU Nsg Note\nNeuro - pt frequently asks what happened to him, wanting to hear his list of injuries. Does not remember car accident, but can repeat that was in a car accident. Follows commands, purposeful. Good strength R arm & R leg. L leg painful to move, L arm splinted, but good movement of fingers, L fingers warm cap refill. O x 3, arouses to voice when sleeping. 2mg Hydromorphone IVP for pain with sleep ensuing.\n\nCV - remains tachycardic to 130, sinus tach. BP often 150-160 sys.\n\nResp - regular, non-labored breathing. Weak cough when asked to cough, dry. O2 sats fall into 80's without supplemental O2. With face tent & cool neb at 40%, O2 sats 93-96%.\n\nGU - urine is clear yellow, no hematuria. QS u/o.\n\nGI - no bowel sounds heard. abd softly distended, abd dressing with wrinkles in dressing.\n\nL posterior thigh wound beefy red in color, scant serosanguinous drainage. No odor. About kerlix packed into wound.\n\nHct at 21:00 33.1, similar to earlier Hcts today.\n\n mother & SO, went home for night, both supportive of pt and each other.\n\nA; Pt frequently asks what happened to him - short term memory deficit? Continues tachycardic and relatively hypertensive.\n\nP:Continue to answer pt's questions. Informational support to family.\n go to OR Friday to repair L forearm fx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-18 00:00:00.000",
"description": "Report",
"row_id": 1553185,
"text": "Resp Care Note:\n\nPt cont intub sedated on mech vent as per Carevue. Lung sounds ess clear dim R base. ABGs stable. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-18 00:00:00.000",
"description": "Report",
"row_id": 1553186,
"text": "npn\ns=orally intubated and sedated.\n\no=sedated, responds to painful stimuli only. does not open eyes unless moved or suctioned. pupils equal and reactive--left pupil sometimes not in midline. no corneal reflexes noted while sedated on propofol. moves all extremities except left arm. ortho in at start of shift and clamshell splint applied. circulation and color to arm good after application. good cap. refill. propofol decreased at 0600 from 50mkm to 25 mkm in anticipation of extubation. also sedated with alternating doses of mso4 and dilaudid for pain.\n\ncv=monitor=st with no ectopy noted. sbp via right radial a-line= 140--170's. diastolic pressures remain consistently in 90's. md aware. ivf at 100cc/hr. propofol as noted above. mgso4 repleted. k+ to be repleted--awaiting mix from phcy.\n\npulm=ventilated on simv 16-40%-700-5 cm peep and 5 cm pressure support. resp. rate overnight 16--did not overbreathe vent. at all. breath sounds clear bilaterally to bases except decreased at right base. suctioned for thick slightly tan secretions--scant amts. sats cocsistently 100%.\n\ngi=orogastric tube to low wall suction. patent for green gastric contents--50cc. absent bowel sounds. abdomen soft, slightly distended. dressing to abdomen with previously marked serosanguineous staining--no increase in size throughout shift.\n\ngu=foley patent for clear yellow urine, at times with sediment. after a.m. care, slightly pink-tinged.\n\nheme=continues on q 6hr hcts--no change.\n\nendo=no issues.\n\nid=temp. remains afebrile this shift. wbc=7.3 from 10.2. left upper leg redressed for moderate serosanguineous drainage. edges clean, non-odorous. continues on antibiotics as ordered.\n\nskin=small abrasions at left shoulder and left upper chest laterally. no drainage.\n\nsocial=no family contact this shift.\n\na=continues tachycardic and hypertensive while sedated on propofol, mso4 and dilaudid. becomes agitated when disturbed.\n\np=plan to extubate today.\n"
}
] |
25,557 | 178,001 | SUMMARY 75 yo F with CAD s/p 3V CABG and critical aortic stenosis. She arrived in chest pain that was due to hypertensive emergency (arterial line pressures in excess of 330). She was gradually brought under better control. She was discharged with sBP's of 140-180 and tolerated these pressures without syncope or neurologic deficits. She was evaluated and deemed ineligible for an open AVR. She was discharged to continue optimal medical management of her hypertension, dyslipidemia, cad and AS. She will follow up with Dr. and may receive a percutaneous AVR. BY PROBLEM # Hypertension: Patient presented with hypertensive emergency & chest pain. She was grossly hypertensive in the cath lab with arterial tracings showing systolics in the 330s. She was thought to be chronically hypertensive in setting of medication non-compliance due to financial issues. While outpatient blood pressure checks have SBPs ranging from 110s-140s, she has known left subclavian steal phenomenon and as an inpatient, her cuff pressures underestimate BPs measured via A-line. In the CCU, the patient's blood pressure was initially controlled with Nitroprusside gtt before being transitioned to PO Metoprolol 75mg TID & PO Captopril 100mg TID with resulting sbp's in the 180's-200's initially. Unfortunately, the patient continued to have intermittent SBP's >200 so metoprolol was changed to carvedilol for greater control of blood pressure. She was discharged with sBP's of 140-180 and on a regimen of Carvedilol 25 and Lisinopril 40 . . # Critical AS: Patient with Valve area 0.68 cm^2. Symptomatic with peak gradient of 25 mm Hg. Has symptoms for AS triad (angina, CHF). Cardiac surgery was consulted and accepted the patient for valve replacement surgery. Given her h/o autoimmune hepatitis, she was cleared by hepatology for the procedure. However, given the degree of Aortic Calcification, she was not deemed to be a surgical candidate. Dr. will continue to follow her for percutaneous valve replacement in the spring. . # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain on admission was thought to be demand ischemia in the setting of critical AS and hypertensive emergency as pain resolved with improved bp??????s & patient with negative troponins, no new ischemic EKG changes. Her discharge medications are baby asa, pravastatin, carvedilol and lisinopril . # PUMP: Patient with evidence of acute diastolic congestive heart failure (EF 55% this admission, down from 65% in ), with elevated PCWP. Patient also with R sided PA and RA pressures on R heart cath, indicating evidence of pulmonary hypertension and right-sided heart failure, likely exacerbated in setting of L sided heart failure from critical AS. Her blood pressure was managed as above, avoiding agents that would decrease preload. . # RHYTHM: Patient with history of SVT in 2/. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. She was maintained on Metoprolol and observed on telemetry throughout her stay. . # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line higher than blood pressure cuff, consistent with a diagnosis of PVD. She was maintained on ASA & Pravastatin. . # Carotid artery disease: Patient with history of TIA in (significant R sided ICA stenosis). Carotid US this admission, uchanged from , showed 60-69% stenosis of the right internal carotid artery. Less than 40% stenosis of the left internal carotid artery. Reversed flow in the left vertebral artery, which may correspond to subclavian steal phenomenon. She was maintained on the above beta-blocker, ACE, ASA, statin regimen. . # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11. Patient reportedly on Lipitor but discontinued due to patient concern about cirrhosis and possible liver damage. Patient was prescribed Zetia, but given cost, changed to Pravastatin. . # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8. She was placed on a RISS with FS qACHS during this admission. This were discontinued as her admission hyperglycemia normalized. . # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI at . LFT's were normal during her stay and hepatology cleared patient for cardiac surgery. . # Anemia: Patient with an admission Hct of 30.9 that remained stable throughout her CCU stay. . # History of seizure: Patient was admitted for seizure in . She has been on Keppra, but self-discontinued it because of depression. No further episodes since then or during this CCU stay. **** **** **** **** **** TO BE FOLLOWED 1) Hypertension: Patient discharged on lisinopril 40 after 100 mg of Captopril TID in house. Patient tolerates high blood pressures but becomes weak or dizzy with sBP < 140 2) Medication Managment: Patient with poor compliance due to cost and other issues. The medications were selected with the intention of cost minimization. Her compliance is crucial to the natural history of her present cardiovascular disease. **** **** **** **** **** Medications on Admission: ASA 162 mg daily Cozaar 100 mg daily, Metoprolol XL 100 mg daily . Of note: has been intolerant of statins in the past, has been on Zetia 10 mg PO daily, but also stopped this due to non-compliance. Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. Discharge Disposition: Home With Service Facility: Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart failure Severe Aortic Stenosis Hypertension Hyperlipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had an episode of congestive heart failure and chest pain and was transferred from for a cardiac catherization. You did not have a heart attack. Your blood pressure has been much too high and your aortic valve is very stiff. You were seem by a cardiac surgeon here who thought that you are not a good candidate for a traditional surgical valve replacement. You may be a candidate for a valve replacement done using a cardiac catheterization technique. Dr. will see you at your next cardiologist visit to discuss this further. In the meantime, it is extremely important that you take your blood pressure medicine every day and check your blood pressure at home daily. You need to stay away from salt in your diet. Weigh yourself every morning, call Dr. if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking Cozaar and Metoprolol. 2. Start Carvedilol twice daily to keep your heart rate and blood pressure controlled. 3. Start Lisinopril twice daily to keep your blood pressure controlled. 4. continue aspirin and Pravastatin at the previous dose. Followup Instructions: Cardiology: , Phone: at 9:00am. Please call the office to confirm this appt. . Primary Care: , M. Phone: Date/time: Please keep any previously scheduled appts. | Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. Aortic stenosis/ Diastolic Heart Failure Assessment: AS- Critical AS per cardiac cath - 0.68cm2. Diastolic HF-LS CTA Bilat. Diastolic HF-LS CTA Bilat. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. - RISS with FS qACHS - check HgA1c . - RISS with FS qACHS - check HgA1c . Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. - transition nitroprusside gtt to metoprolol and losartan today, as above - Pt appears euvolemic currently. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Cath showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/ SBP 310 & elevated PA pressures w/ PCWP 29. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. Hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous sheaths remain in R fem. Response: Plan: Continue ABP management with IV Nipride gtt Aortic stenosis & CHF (Acute Diastolic) Assessment: AS: Cath showing critical AS (the aortic valve area was 0.68 cm2 with a 25mm Hg peak to peak gradient). Action: Response: Plan: Continue ABP management with IV Nipride gtt Aortic stenosis & CHF (Acute Diastolic) Assessment: AS: Cath showing critical AS (the aortic valve area was 0.68 cm2 with a 25mm Hg peak to peak gradient). | 78 | [
{
"category": "Echo",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Report",
"row_id": 84570,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Hypertension. Left ventricular function.\nHeight: (in) 61\nWeight (lb): 149\nBSA (m2): 1.67 m2\nBP (mm Hg): 208/72\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV\nchamber size.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\nannular calcification. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is severe symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. Right ventricular chamber size is normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. There are three\naortic valve leaflets. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area 0.5\ncm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. There is severe mitral annular calcification. Mild to\nmoderate (+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\nhypertrophy with normal global and regional biventricular systolic function.\nMild aortic regurgitation. Mild to moderate mitral regurgitation. Mild\npulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , aortic stenosis\nseverity and degree of LV hypertrophy have progressed. The other findings are\nsimilar.\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 398752,
"text": "Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaterally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely due to demand in setting of critical AS and increased\n afterload from her hypertensive emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\n daily\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 14:48 ------\n"
},
{
"category": "ECG",
"chartdate": "2127-12-10 00:00:00.000",
"description": "Report",
"row_id": 206933,
"text": "Sinus rhythm with A-V conduction delay. Left atrial abnormality. Right\nbundle-branch block. Left axis deviation may be due to left anterior\nfascicular block. Left ventricular hypertrophy with ST-T wave abnormalities.\nSince the previous tracing of the same date no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2127-12-10 00:00:00.000",
"description": "Report",
"row_id": 206934,
"text": "Sinus rhythm with A-V conduction delay and ventricular premature beat. Left\natrial abnormality. Right bundle-branch block. Left axis deviation may be due\nto left anterior fascicular block. Left ventricular hypertrophy with ST-T wave\nabnormalities. Clinical correlation is suggested. Since the previous tracing\nof ventricular ectopy is present. Otherwise, no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2127-12-04 00:00:00.000",
"description": "Report",
"row_id": 207170,
"text": "Sinus rhythm. The P-R interval is prolonged. Left atrial abnormality. Left\naxis deviation. Right bundle-branch block with left anterior fascicular block.\nLeft ventricular hypertrophy with associated ST-T wave changes, although\nischemia or myocardial infarction cannot be excluded. Compared to the previous\ntracing the P-R interval is longer.\n\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398138,
"text": "Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\n pain and progressive DOE as a transfer from \n for cardiac cath on now diagnosed with critical aortic\n stenosis and marked systemic hypertension.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398140,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: pending\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily and zetia 10mg daily\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will restart losartan today after nitroprusside gtt is discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and losartan today, goal\n sBP 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, consistent with a diagnosis of PVD.\n - continue ASA, Zetia\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - try to obtain carotid U/S records in AM\n - may need carotid U/S here at for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result.\n - continue Zetia 10 mg PO daily\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398146,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: my read\nno acute cardiopulmonary process\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398125,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 07:52 PM\n SHEATH - START 07:56 PM\n CARDIAC CATH - At 08:08 PM\n NASAL SWAB - At 12:00 AM\n Admitted overnight\n No event overnight\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 69 (69 - 86) bpm\n BP: 193/69(112) {177/64(102) - 281/107(176)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 512 mL\n 328 mL\n PO:\n 200 mL\n TF:\n IVF:\n 312 mL\n 328 mL\n Blood products:\n Total out:\n 1,595 mL\n 435 mL\n Urine:\n 995 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,083 mL\n -107 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n NECK: Supple, with JVP of 8cm\n CARDIAC: RR, normal S1, S2 (softer than S1 at the apex). +III/VI late\n peaking systolic crescendo-decrescendo murmur heard throughout the\n precordium radiating to the carotics. no gallops or rubs.\n LUNGS: CTAB\n ABDOMEN: BS+, Soft, ND. Mild tenderness to palpation at LUQ, no\n guarding, no rebound.\n EXTREMITIES: No c/c/e. No femoral bruits. Arterial and venous sheath\n at right groin in place (not pulled)\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Neurologic: AOx3, neuro exam grossly normal\n Labs / Radiology\n 186 K/uL\n 9.8 g/dL\n 180 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 27 mg/dL\n 104 mEq/L\n 138 mEq/L\n 28.7 %\n 4.3 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n WBC\n 7.2\n 4.3\n Hct\n 30.9\n 28.7\n Plt\n 182\n 186\n Cr\n 0.9\n 1.1\n Glucose\n 191\n 180\n Other labs:\n PT / PTT / INR:12.8/25.5/1.1,\n CK 31,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, LDH:212 IU/L,\n Ca++:8.7 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n proBNP: 2787\n MICRO: none\n CXR from today: pending\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily and zetia 10mg daily\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - will restart losartan today\n - treatment of hypertension (see below)\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s. BP\n brought down by nitroprusside gtt overnight in the CCU to SBPs 200.\n Likely chronically hypertensive in setting of medication non-compliance\n due to financial issues. Outpt blood pressure checks have SBPs ranging\n from 110s-140s, but were in the left arm with known L subclavian steal\n phenomenon. Also, cuff pressure seems to underestimate the true BPs\n that are measured via A-line.\n - transition nitroprusside gtt to metoprolol and losartan today\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Critical symptomatic AS (0.7 cm^2)\n with peak to peak gradient of 25 mm Hg. Patient also with R sided PA\n and RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - transition nitroprusside gtt to metoprolol and losartan today\n - no nitroglycerin given critical AS\n - f/u on BNP\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, consistent with a diagnosis of PVD.\n - continue ASA, Zetia\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - try to obtain carotid U/S records in AM\n - may need carotid U/S here at for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result.\n - continue Zetia 10 mg PO daily\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: cardiac healthy low salt low fat diet.\n Glycemic Control: RISS\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: pneumoboots (pt refusing SQ heparin)\n Stress ulcer: none\n VAP: n/a\n Comments: Bowel regimen with colace and senna prn\n Communication: Comments: (husband)\n status: Full code (confirmed with patient)\n Disposition: CCU for now\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398207,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Action:\n Response:\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398209,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Response:\n No CHF on CXR, adequate UOP. + 300cc at MN.\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398210,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm significantly\n lower than R arm, c/w left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable, BPs ~200 when awake. SBP 150-180s when sound asleep\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Response:\n No CHF on CXR, adequate UOP. + 300cc at MN.\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n ------ Protected Section ------\n Of note: 02 sat transiently down to 85% then quickly back up to 93%. Pt\n sound asleep. ? sleep apnea. Sat 96-98% when woken up by RN. Denies\n SOB. Pt denies any h/o sleep apnea. Placed on supplemental 2L\n NC\nContinue to monitor.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:16 ------\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398119,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398120,
"text": "Pt is a 75 yo woman with CAD s/p 3V CABG presenting with chest\n pain and progressive DOE as a transfer from \n for cardiac cath on now diagnosed with critical aortic\n stenosis and marked systemic hypertension.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no c/o h/a or dizziness. Reports\n non-compliance with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250. Bounding pedal pulses.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem a-line) of 200.\n 50 mg lopressor given in TID dosing\n Knee immobilizer to right leg to encourage patient to\n maintain straight leg and bedrest\n Patient refused sq heparin\n MD notified\n Requested SW consult to discuss financial medication issues.\n Response:\n Nipride gtt at 0.3 mcg/mcg/kg/min effective in keeping\n arterial SBP 200 while patient sleeping\n Patient non-compliant with bedrest condition, keeps\nforgetting\n restrictions, but is easily re-oriented and slept\n comfortably overnight, startles aware to light touch. (? Degree of\n dementia).\n SQ heparin d/c\nd- pneumo boots ordered & placed.\n SW consult ordered.\n Plan:\n Continue ABP management with IV Nipride gtt\n Invasive hemodynamic monitoring- goal currently SBP 200.\n Maintain safety & integrity of femoral aline and venous\n sheath\n SW consult\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Completed post-cath fluid D5\n NS at 75 cc\ns per hour for\n 450 cc\ns total.\n Monitored output in response to 40 mg IVP lasix given in lab\n Response:\n Excellent diuretic response to 40 mg IV- negative 1 liter at\n midnight.\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weight.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100 %\n (patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered.\n Hyperglycemia\n Assessment:\n Patient denies history of DM. Elevated serum glucose on CCU admission\n to 191.\n Action:\n FSBG elevated to 274 at 10 pm\n Response:\n RISS sliding scale coverage ( 8 units at 10 pm) given\n Plan:\n Continue to monitor BG levels.\n Team discussing ordering HgA1c.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398304,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398286,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:00 AM\n SHEATH - STOP 11:00 AM\n - increased captopril to 100 TID\n - used nipride to drop pressure while Aline sheeth is being pulled\n - pressure to 120's with 3 of Nipride, to 176 after decreased to 0.24,\n adjusting to goal fo 150\n - ordered dental consult and panorex\n - hepatology consult: good candidate for surgery from liver perspective\n - CTA: Contrast allergy to be managed with pre-treatment (prednisone,\n ranitidine, benadryl). CTA at 8am Sunday\n - Received Hydralazine 25 mg at 0100 for sBP > 190\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.1\n HR: 62 (56 - 76) bpm\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.2 kg (admission): 64.8 kg\n Total In:\n 506 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 266 mL\n Blood products:\n Total out:\n 1,075 mL\n 215 mL\n Urine:\n 1,075 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n -95 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///23/\n Physical Examination\n General: Well nourished, No acute distress\n Neck: supple with JVP 7cm\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\n at LUSB\n Respiratory: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\n Extremities: No LE edema\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, AAOx3\n Labs / Radiology\n 181 K/uL\n 10.3 g/dL\n 150 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 40 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.9 %\n 6.6 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n Plt\n 182\n 186\n 184\n 181\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n 150\n Other labs:\n PT / PTT / INR:12.7/25.5/1.1,\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved but still not at goal of\n 150-160.\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control for goal sBP 150-160\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR.\n - ordered dental consult and panorex\n - per hepatology consult, pt is a good candidate for surgery from liver\n perspective\n - pt will get CTA today. Pt with Contrast allergy to be managed with\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\n - avoid medications that could decrease preload, such as NTG\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA and pravastatin\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - awaiting AVR surgery\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - pt may live at BP around 200, and if BP drop lower pt may experience\n TIA and dizziness. Need to monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, zetia\n changed to pravastatin.\n - continue pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n - per hepatology, pt is a good candidate for AVR from liver stand\n point.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable during this admission.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: regular cardiac-healthy diet\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 07:54 PM\n Prophylaxis:\n DVT: pneumoboots (pt refused sc heparin)\n Stress ulcer: none\n VAP: n/a\n Comments:\n Communication: Comments: husband\n status: Full code\n Disposition: will stay in CCU for BP optimization\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 398383,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n AS- Critical AS per cardiac cath - 0.68cm2. Elevated\n R sided pressures/ PCWP/ pulm htn.\n Diastolic HF-LS CTA Bilat. SPO2 95-100% RA while awake, does\n drift to low 90s while sleeping. No edema. Denies SOB. EF 64%.\n BP as below. HR 50s-60s NSR w/ 1^st degree AV delay,\n occasional PVCs.\n Action:\n Pre-op workup underway. Carotid US/ Panorex/ Abd CT\n complete. Cleared by hepatology for pt w/ autoimmune hepatitis.\n Monitored resp/ cardiac status\n 2 L fluid restriction PO; daily wt= 68kg.\n Response:\n Volume status- even I/Os at 1700.\n Plan:\n Tentative plan for AVR Thurs . Continue to monitor.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n AORTIC STENOSIS RIGHT HEART CATH;LEFT HEART CATH\n Code status:\n Full code\n Height:\n Admission weight:\n 64.8 kg\n Daily weight:\n 68 kg\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Precautions:\n PMH: Hepatitis\n CV-PMH: CAD, Hypertension\n Additional history: cath , CABG in the past with known aortic\n stenosis (no valve surgery at time of CABG), autoimmune Hepatitis,\n hyperlipidemia, HTN, subclavian steel syndrome- SC stenosis L side. BP\n L<R.\n Surgery / Procedure and date: cath : RCA graft open, LAD open,\n Occluded OM. Aortic Stenosis with 40 mm gradient and 0.68 valve area.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:58\n Temperature:\n 98.2\n Arterial BP:\n S:196\n D:68\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 788 mL\n 24h total out:\n 625 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:06 AM\n Potassium:\n 4.8 mEq/L\n 04:06 AM\n Chloride:\n 105 mEq/L\n 04:06 AM\n CO2:\n 25 mEq/L\n 04:06 AM\n BUN:\n 47 mg/dL\n 04:06 AM\n Creatinine:\n 1.2 mg/dL\n 04:06 AM\n Glucose:\n 111 mg/dL\n 04:06 AM\n Hematocrit:\n 30.9 %\n 04:06 AM\n Finger Stick Glucose:\n 113\n 12:00 PM\n Additional pertinent labs:\n PM electrolytes/ UA, urine lytes, C&S PND.\n Lines / Tubes / Drains:\n PIV L FA; foley cath\n Valuables / Signature\n Patient valuables: Dentures: (Partial / Bridge )\n Other valuables: Cell phone\n Clothes: Sent w/ patient.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398380,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n AS- Critical AS per cardiac cath - 0.68cm2. Elevated\n R sided pressures/ PCWP/ pulm htn.\n Diastolic HF-LS CTA Bilat. SPO2 95-100% RA while awake, does\n drift to low 90s while sleeping. No edema. Denies SOB. EF 64%.\n BP as below. HR 50s-60s NSR w/ 1^st degree AV delay,\n occasional PVCs.\n Action:\n Pre-op workup underway. Carotid US/ Panorex/ Abd CT\n complete. Cleared by hepatology for pt w/ autoimmune hepatitis.\n Monitored resp/ cardiac status\n 2 L fluid restriction PO; daily wt= 68kg.\n Response:\n Volume status- even I/Os at 1700.\n Plan:\n Tentative plan for AVR Thurs . Continue to monitor.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 398381,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n AS- Critical AS per cardiac cath - 0.68cm2. Elevated\n R sided pressures/ PCWP/ pulm htn.\n Diastolic HF-LS CTA Bilat. SPO2 95-100% RA while awake, does\n drift to low 90s while sleeping. No edema. Denies SOB. EF 64%.\n BP as below. HR 50s-60s NSR w/ 1^st degree AV delay,\n occasional PVCs.\n Action:\n Pre-op workup underway. Carotid US/ Panorex/ Abd CT\n complete. Cleared by hepatology for pt w/ autoimmune hepatitis.\n Monitored resp/ cardiac status\n 2 L fluid restriction PO; daily wt= 68kg.\n Response:\n Volume status- even I/Os at 1700.\n Plan:\n Tentative plan for AVR Thurs . Continue to monitor.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n AORTIC STENOSIS RIGHT HEART CATH;LEFT HEART CATH\n Code status:\n Full code\n Height:\n Admission weight:\n 64.8 kg\n Daily weight:\n 68 kg\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Precautions:\n PMH: Hepatitis\n CV-PMH: CAD, Hypertension\n Additional history: cath , CABG in the past with known aortic\n stenosis (no valve surgery at time of CABG), autoimmune Hepatitis,\n hyperlipidemia, HTN, subclavian steel syndrome- SC stenosis L side. BP\n L<R.\n Surgery / Procedure and date: cath : RCA graft open, LAD open,\n Occluded OM. Aortic Stenosis with 40 mm gradient and 0.68 valve area.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:58\n Temperature:\n 98.2\n Arterial BP:\n S:196\n D:68\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 788 mL\n 24h total out:\n 625 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:06 AM\n Potassium:\n 4.8 mEq/L\n 04:06 AM\n Chloride:\n 105 mEq/L\n 04:06 AM\n CO2:\n 25 mEq/L\n 04:06 AM\n BUN:\n 47 mg/dL\n 04:06 AM\n Creatinine:\n 1.2 mg/dL\n 04:06 AM\n Glucose:\n 111 mg/dL\n 04:06 AM\n Hematocrit:\n 30.9 %\n 04:06 AM\n Finger Stick Glucose:\n 113\n 12:00 PM\n Additional pertinent labs:\n PM electrolytes/ UA, urine lytes, C&S PND.\n Lines / Tubes / Drains:\n PIV L FA; foley cath\n Valuables / Signature\n Patient valuables: Dentures: (Partial / Bridge )\n Other valuables: Cell phone\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398109,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398265,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398274,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from Hosp for cardiac cath on . Cath showed\n critical AS w/ aortic valve area 0.68cm, marked systemic HTN w/ SBP 310\n & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/ Nipride gtt--\n DCd -- converted to PO antihypertensives. Diuresed w/ lasix in cath\n lab. R fem venous and art sheaths DCd . OF NOTE: L subclavian steel-\n significant difference in arm BPs, L<R. Non-compliant w/ cardiac meds\n financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n Pre-contrast prophylactic meds for CT given as ordered\n (allergy to Shellfish/iodine), Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CF management-2L Fluid restruction, low Na+ diet, daily wts,\n strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398275,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\n minimal assist. No c/o dizziness. Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\n for CT given as ordered, Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"
},
{
"category": "General",
"chartdate": "2127-12-04 00:00:00.000",
"description": "Generic Note",
"row_id": 398095,
"text": "TITLE: Cardiology fellow CCU admit note\n 75 yo woman with CAD s/p CABG in , autoimmune hepatitis, now with\n severe aortic stenosis ( 0.7 cm2) and SEVERE HTN with systolic BPs\n in the 280s and LV systolic pressures in the 320s. Admitted to CCU for\n invasive BP monitoring, intravenous antihypertensives and diuresis.\n Start with nitroprusside with goal SBP of 200 mm Hg. Would also\n administer 10 mg IV furosemide at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 398101,
"text": "Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaerally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n .\n Cardiac cath: :\n Aortic valve area: 0.68 cm^2 and 25 mm Hg peak to peak gradient\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low na, cardiac, diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 398102,
"text": "Chief Complaint: chest pain, SOB\n HPI:\n Mrs. is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM,\n SVG->RCA) in , HTN, HLD, AS and cirrhosis autoimmune hepatitis\n who presented to an OSH on with acute onset chest pain and\n progressive DOE, and was transferred to today for cardiac\n catherization.\n .\n Patient reports progressive worsening of DOE since her CABG in .\n Her DOE has subacutely worsened over the past 3 months-- walking up 3\n stairs and around house results in DOE. No orthopnea, PND, syncope, no\n . Her symptoms have progressed to the point where she rarely leaves\n her house anymore. Denies any associated chest pain prior to this\n symptoms except on Monday at midnight, when she had sudden onset\n SSCP radiating to L arm at rest, associated with feeling 'warm'. Denies\n n/v. No SOB at time due to being at rest. Anginal equivalent is\n atypical fleeting pain in all areas of her chest, states this\n particular pain was more severe in nature. Chest pain lasted for 4\n hours, subsided without intervention. She called her cardiologist's\n office in the morning and was advised by her cardiologist to go to the\n ED for immediate evaluation. Poorly compliant with blood pressure\n medications due to medications prices (ie has been taking some meds\n daily in order to make them last).\n .\n She presented to Hospital for these symptoms on . There,\n cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8.\n She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch\n nitroglycerine paste, lovenox 80 mg SQ , and transferred to \n for cardiac cath on .\n .\n In the cath lab, patient was noted to have severe AS (valve area of\n 0.7) and arterial tracing with systolic blood pressures in the 320s.\n Cardiac cath showed patent grafts unchanged from cath. She was\n started on a nitroglycerin gtt and transferred to the CCU. In the CCU,\n patient denies chest pain. Her nitroglycerin gtt was weaned, and she\n was started on a nitroprusside gtt with good control of her SBPs in the\n 200s.\n .\n On review of systems, s/he denies any prior history of deep venous\n thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. S/he denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Patient admitted from: Transfer from other hospital\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroprusside - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ASA 162 mg daily\n Cozaar 100 mg daily,\n Metoprolol XL 100 mg daily\n .\n Of note: has been intolerant of statins in the past, has been on Zetia\n 10 mg PO daily, but also stopped this due to non-compliance.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n Cardiac Catheterization performed for symptoms of unstable\n angina\n PTCA to mid LAD\n Coronary Artery Bypass Graft x 3 (Saphenous vein graft\n -> Left anterior descending, Saphenous vein graft -> Obtuse\n marginal, saphenous vein graft-> right coronary artery). A LIMA was\n not used due to retrograde L vertebral flow and concern of future left\n subclavian artery steal.\n : Cardiac Cath (performed in setting of chest pain, SVT):\n patent grafts, SVG-> OM1 occluded. No significant change in graft\n patency otherwise.\n .\n 3. OTHER PAST MEDICAL HISTORY:\n Hypertension\n Autoimmune Hepatitis with cirrhosis (Child's Class A)\n Anemia\n Aortic stenosis\n TIA (significant R sided ICA stenosis)\n Peripheral Vascular Disease\n Seizure in (oral numbness, followed by R hand/R leg numbness and\n weakness. has been on Keppra, but was self-discontinued by patient due\n to symptoms of depression).\n Carotid artery disease\n L sided subclavian steal\n h/o SVT in \n s/p appendectomy\n (+) FHx CAD: 5 brothers and sisters all with CAD\n in 60's\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired, married lives with husband and 2 adult children. used\n to work at for 20 years. denies tobacco or ETOH use\n Review of systems:\n Flowsheet Data as of 12:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 75 (75 - 86) bpm\n BP: 192/71(112) {192/71(112) - 281/107(176)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.8 kg (admission): 64.8 kg\n Total In:\n 312 mL\n 30 mL\n PO:\n TF:\n IVF:\n 312 mL\n 30 mL\n Blood products:\n Total out:\n 1,595 mL\n 0 mL\n Urine:\n 995 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,283 mL\n 30 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T= 98 BP= 259/200 (aline) HR= 85 RR= 16 O2 sat= 97% on RA\n GENERAL: elderly, pleasant F in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm at 45' angle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2 (softer than S1 at the apex). +III/VI late peaking\n systolic crescendo-decrescendo murmur heard throughout the precordium\n radiating to the carotics. no gallops or rubs.\n Carotids: III/VI decresencdo murmer radiating to both carotids\n bilaterally, louder R > L.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, mild crackles at bases.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 2+ PT 2+\n Left: DP 2+ PT 2+\n Labs / Radiology\n 182 K/uL\n 10.2 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 21 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 30.9 %\n 7.2 K/uL\n [image002.jpg]\n \n 2:33 A1/7/ 08:37 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.2\n Hct\n 30.9\n Plt\n 182\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:12.9/29.2/1.1, ALT / AST:14/18, Alk Phos / T\n Bili:69/0.5, LDH:212 IU/L, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.2\n mg/dL\n Fluid analysis / Other labs: ETT: () - normal symptomatic\n response to adenosie, no significant arythmias, nuclear images neg for\n ischemia with LVEF of > 60%.\n .\n CARDIAC CATH:\n :\n 1. Selective coronary angioigraphy of this right-dominant system\n demonstrated stable multivessel CAD. The LMCA had a 40% ostial senosis.\n The LAD had 50% proximal stenosis. The LCX was free from significant\n disease. The RCA had 90% ostial stenosis and moderate mid vessel\n disease.\n 2. Conduit graft angiography revealed patent SVG-LAD and SVG-RCA and\n occluded SVG-OM.\n 3. Left ventriculography was deferred due to known dilated ascending\n aorta and complex > 4 mm aortic plaque per previous TEE.\n 4. Limited hemodynamic assessment revealed severe systemic arterial\n hypertension (190/70 mmHg, right arm).\n .\n :\n Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to\n peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)\n .\n Coronary angiography: right dominant\n LMCA: non selective injection. No apparent stenosis\n LAD: 100% proximal occlusion\n LCX: Patent to tortuous OMB\n SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA\n SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40%\n SVG-OMB: occluded\n .\n There was marked systemic hypertension (up to 310mmHg) and a pressure\n difference from the left arm to the right arm consistent with\n subclavian stenosis.\n .\n Assessment and Recommendation:\n 1. three vessel coronary artery disease\n 2. Patent SVG to the LAD; Patent SVG to the RCA\n 3. Occluded SVG to the OMB\n 4. Severe systemic hypertension\n 5. Critical aortic stenosis\n 6. CCU for IV nipride and BP control\n 7. Aortic valve replacement surgery\n .\n FINAL DIAGNOSIS:\n 1. Two vessel and moderate left main coronary artery disease, unchanged\n from prior angiogram.\n 2. Patent SVG-RCA and SVG-LAD with occluded SVG-OM.\n 3. Severe hypertension.\n Hospital Records:\n Lipid panel:\n - HDL 11, Trigs: 242, Total chol: 193, LDLcalc: 134\n LFTs: ALT 17, TP 7.7 albumin: 3.7 AP: 60 Bili: 0.8, Dbili: 0.1\n Ferritin: 73 TSH: 3.0\n Imaging: : (TEE) -\n Prebypass: No atrial septal defect is seen by 2D or color Doppler.\n There is moderate symmetric left ventricular hypertrophy. Right\n ventricular chamber size and free wall motion are normal. There are\n complex (>4mm) atheroma in the ascending aorta. Epiaortic scanning was\n done to confirm no atheroma at cannulation or cross-clamp location.\n There are simple atheroma in the descending thoracic aorta. The aortic\n valve leaflets are moderately thickened with relative immobility of the\n non coronary cusp. There is moderate aortic valve stenosis (1.1-1.2 cm2\n by continuity equation and 1.1cm2 by planimetry)). Mean AV gradient is\n 14mm Hg. Trace aortic regurgitation is seen. Mild (1+) mitral\n regurgitation is seen. There is severe MAC. There is no pericardial\n effusion.\n .\n Postbypass: - Normal LV systolic function, Normal RV systolic\n function.. Mild MR (unchanged). Aortic contours unchanged. Study is\n otherwise unchanged from prebypass.\n .\n TTE: () per PCP : concentric LVH, post-operative septal\n motion abnormality, LVEF 64%, mild aortic stenosis, aortiva valve area\n 0.9 cm^2, 2+ AI, calcified mitral annulus, 2+ MR, left atrial\n enlargenemnt, 1+ TR, RV systolic pressures of 28 mm Hg, 1+ PI.\n .\n ECG: EKG: Rate 78, regular sinus rhythm, left axis deviation. Prolonged\n PR interval (254ms), consistent with 1st degree AV block (prolonged AV\n conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent\n with RBBB. Given LAD, this is indicative of bifascicular block with\n RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline\n left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL,\n V1-V3. No significant ST changes.\n Assessment and Plan\n ASSESSMENT AND PLAN: Pt is a 75 yo F with CAD s/p 3V CABG presenting\n with chest pain and progressive DOE, diagnosed with critical aortic\n stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely due to demand in setting of critical AS and increased\n afterload from her hypertensive emergency.\n - continue ASA 325 mg PO daily, zetia\n - start short acting metoprolol 50 mg PO TID, goal HR 55-60\n - hold losartan for now\n - treatment of hypertension (see below)\n .\n # PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Hypertension: Hypertensive emergency. Patient grossly hypertensive in\n the cath lab with arterial tracings showing systolics in the 330s.\n Currently better controlled on nitroprusside gtt in the CCU with SBPs\n in the 220s. Likely chronically hypertensive in setting of medication\n non-compliance due to financial issues. Outpt blood pressure checks\n have SBPs ranging from 110s-140s, but were in the left arm, indicating\n evidence of patient's known L subclavian steal phenomenon.\n - continue nitroprusside gtt goal SBP 200\n - continue BB\n - has arterial sheath in place for A-line tracings\n - holding for now\n - SW consult for med compliance\n - consider renal U/S to assess for artery stenosis.\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - needs eval for AVR\n - avoid medications that could decrease preload\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - check HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at .\n - trend LFTS\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis)\n - try to obtain carotid U/S records in AM\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage.\n - continue Zetia 10 mg PO daily\n .\n # Peripheral Vascular Disease: Patient with possible vascular dementia\n given hx of PVD and TIAs. A-line higher than blood pressure\n cuff, indicating evidence of PVD.\n - continue ASA, Zetia\n .\n # History of seizure: Patient was admitted for seizure in (has\n been on Keppra, but was self-discontinued by patient). No further\n episodes since then. Will continue to monitor.\n .\n ICU Care\n Nutrition: low sodium, cardiac, diabetic diet fluid restrict < 2 L\n daily\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398179,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by .\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398367,
"text": "Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398368,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398369,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx. Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Improving\n Plan:\n Monitor area closely- prevent further breakdown\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398370,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Pre-op workup underway. Carotid US complete. Panorex\n complete.\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s- 200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP 170s-180s/60s after antihypertensives.\n Plan:\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx. Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Improving\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20ml/hr.\n Action:\n IVF 100ml/hr x 1000.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398376,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n Action:\n Pre-op workup underway. Carotid US complete. Panorex\n complete.\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398377,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n AS- Critical AS per cardiac cath - 0.68cm2. Elevated\n filling pressures.\n Diastolic HF-LS CTA Bilat. SPO2 95-100% RA while awake, does\n drift to low 90s while sleeping. No edema. Denies SOB.\n BP as below. HR 50s-60s NSR w/ 1^st degree AV delay,\n occasional PVCs.\n Action:\n Pre-op workup underway. Carotid US/ Panorex/ Abd CT\n complete.\n Monitored resp/ cardiac status\n 2 L fluid restriction PO; daily wt= ____.\n Response:\n Volume status- even I/Os at 1700.\n Plan:\n Tentative plan for AVR Thurs . Continue to monitor.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398378,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following.\n Aortic stenosis/ Diastolic Heart Failure\n Assessment:\n AS- Critical AS per cardiac cath - 0.68cm2. Elevated\n filling pressures.\n Diastolic HF-LS CTA Bilat. SPO2 95-100% RA while awake, does\n drift to low 90s while sleeping. No edema. Denies SOB.\n BP as below. HR 50s-60s NSR w/ 1^st degree AV delay,\n occasional PVCs.\n Action:\n Pre-op workup underway. Carotid US/ Panorex/ Abd CT\n complete. Cleared by hepatology for pt w/ autoimmune hepatitis.\n Monitored resp/ cardiac status\n 2 L fluid restriction PO; daily wt= 68kg.\n Response:\n Volume status- even I/Os at 1700.\n Plan:\n Tentative plan for AVR Thurs . Continue to monitor.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n **Known subclavian stenosis L arm** . All BPs R ARM.\n Non-compliant w/ BP meds at home r/t cost\n This AM manual BP R arm 205/60s, Manual BP L arm 100/ 60s.\n Thigh cuff automatic: 213/ 72\n Goal SBP 150s-200. Team to be notified if SBP<150 given\n severe AS and preload dependence.\n Action:\n Captopril 100mg TID- 1600 captopril held r/t SBP<150\n Lopressor changed to coreg 25mg \n SW following for Rx cost issues. CCU team changing meds to\n less expensive variety.\n Response:\n BP as low as 120s-140s/60s manually after antihypertensives. Team\n alerted. Pt mentating. No interventions ordered at this time.\n Plan:\n Continue to closely monitor blood pressure. Goal SBP 150-200s. Alert\n team if pt outside of BP parameters or becomes symptomatic.\n Impaired Skin Integrity\n Assessment:\n small area of cracked skin note @ gluteal fold/coccyx.\n Mepilex placed \n Lower back w/ purplish-red dots in the shape of an\n Action:\n Pt turning self independently in bed. OOB x several today.\n Mepliex dsg removed at 1700. Area intact, slightly pink,\n +blanching. Barrier cream applied.\n Response:\n Improving skin impairments. No new breakdown.\n Plan:\n Monitor area closely- prevent further breakdown\n Chronic Renal Impairment\n Assessment:\n BUN 47/ Creat 1.2. UOP ~20-50 ml/hr.\n Action:\n IVF 100ml/hr x 1000. Urine lytes/ UA/ C&S sent.\n Response:\n Stable UOP. PM BUN/Creat PND.\n Plan:\n Continue to monitor.\n"
},
{
"category": "Social Work",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 398174,
"text": "Social Work:\n Consult rec\nd from nsg staff to assist pt w/ medication needs.\n Met w/ pt this pm in CCU.\n Pt is 75 y/o married woman, lives w/ husband and two adult sons in own\n home in . Pt has significant hx of CAD and s/p CABG; she is\n treated in /. Pt states that she has not filled\n prescriptions (esp for Cozaar) recently as she couldn\nt afford meds/co\n pays. Pt states that co pays have increased from $35.00 a month to\n $70.00 a month. Pt states that she lives on limited income. She has\n not wanted to tell PCP or cardiologist that she can\nt afford meds.\n Pt and husband receive and husband receives pension. Pt has two\n sons, 50 and 55y/o who are living at home as well and not working\n regularly.\n Contact Community Resource Specialist, who can assist\n pt/family to apply for prescription assistance programs. Gave pt Ms.\n \ns contact info () for husband to get application.\n Will f/u as needed.\n , licsw\n Pager \n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398175,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398176,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398177,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398178,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by .\n Response:\n Plan:\n Hyperglycemic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398181,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID.\n Response:\n SBP <200- Nipride gtt weaned and D?C\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398258,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs persistently > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP mamangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398264,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given\n Response:\n SBP 180-190s. OOB to BSC w/ minimal assist. No c/o dizziness.\n Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~ 150-160s.\n Aortic stenosis\n Assessment:\n Pre-op AVR w/u/tests\n Action:\n Pre-contrast prophylactic meds for CT given as ordered,\n Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n Resume diet after CT\n Needs Panorex and carotids check\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Emotional support provided\n Get OOB, ^ activity\n as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398340,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 75mg TID given as ordered\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. No\n dizziness/lightheadedness\n Plan:\n Continue BP manangement, goal SBP ~150-160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills, I\nve taken 25 pills today\n. Slept well overnight,\n startles when woken up by RN for nsg interventions.\nJust leave me\n alone\n. Emotional support provided\n Get OOB, ^ activity as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398341,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs ~200\n Action:\n Captopril 100mg TID and Lopressor 75mg TID given as ordered\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. No\n dizziness/lightheadedness\n Plan:\n Continue BP manangement, goal SBP ~150-160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills, I\nve taken 25 pills today\n. Slept well overnight,\n startles when woken up by RN for nsg interventions.\nJust leave me\n alone\n. Emotional support provided\n Get OOB, ^ activity as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398346,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\n of the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - no CTsurg recs\n - BP great, in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398348,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - got CTA, prelim read: Extensive atherosclerotic disease with ectasia\n of the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - no CTsurg recs\n - BP great, in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt may be slightly dry today given small rise in Cr. Continue to\n observe, but very conservative fluid management.\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398349,
"text": "Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt may be slightly dry today given small rise in Cr. Continue to\n observe, but very conservative fluid management.\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398352,
"text": "Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398354,
"text": "Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398357,
"text": "Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398358,
"text": "Chief Complaint:\n 24 Hour Events:\n - CTA, prelim read: Extensive atherosclerotic disease with ectasia of\n the ascending aorta\n - Metoprolol increased from 50mg TID to 75mg TID, kept Captopril at\n 100mg TID\n - SBP in the 160s. Patient was asymptomatic all day.\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36\nC (96.8\n HR: 68 (58 - 83) bpm\n BP: 209/63(101) {142/32(51) - 225/110(128)} mmHg\n RR: 18 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68 kg (admission): 64.8 kg\n Total In:\n 930 mL\n PO:\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,130 mL\n 265 mL\n Urine:\n 1,130 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished woman, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, AT, oropharynx clear\n Cardiovascular: (S1: Normal), (S2: Normal), IV/VI high-pitched & late\n peaking systolic murmur loudest at RUSB radiating to carotids\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Clear to auscultation\n bilaterally\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 216 K/uL\n 10.0 g/dL\n 111 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 47 mg/dL\n 105 mEq/L\n 139 mEq/L\n 30.9 %\n 11.0 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n 04:06 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n 11.0\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n 30.9\n Plt\n 182\n 186\n 184\n 181\n 216\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n 1.2\n Glucose\n 191\n 180\n 108\n 150\n 111\n Other labs: PT / PTT / INR:12.6/25.9/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:9.0 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75 yo F with CAD s/p 3V CABG and critical aortic stenosis awaiting AVR\n later this week.\n .\n # Hypertension: Patient presented with hypertensive emergency & chest\n pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved to sbp\ns in 160\ns yesterday\n with increased Metoprolol 75mg TID & Captopril 100mg TID.\n - Continue Metoprolol Tartrate 75 mg PO TID (goal HR 55-60)\n - Continue Captopril 100mg TID (goal sbp\ns 150-170\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR. Cleared by hepatology for AVR. CTA\n preliminary read demonstrated extensive atherosclerotic disease with\n ectasia of the ascending aorta.\n - Panorex scheduled for today, will then need dental re-consult\n - F/U final CTA read.\n - Cr elevation after dye-load yesterday. F/U Urine electrolytes &\n conservative fluid management PRN.\n - Avoid medications that decrease preload\n .\n # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain\n on admission likely demand ischemia in setting of critical AS and\n hypertensive emergency as pain resolved with improved bp\ns & patient\n with negative troponins, no new ischemic EKG changes.\n - continue ASA and Pravastatin\n - continue Metoprolol 75 mg PO TID\n - continue Captopril 100mg TID\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - No nitroglycerin given critical AS\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue Metoprolol Tartrate 75mg PO TID\n - Telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and Pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - If BP drop lower than sbp\ns of 150\ns-170\ns, pt may experience TIA and\n dizziness. Will monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was prescribed\n Zetia, but given cost, changed to Pravastatin.\n - continue Pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - Trend LFT\n - Per hepatology, pt is a good candidate for AVR.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable since admission.\n - Trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: Low sodium/Cardiac/Diabetic/2L fluid restriction\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: none\n VAP: N/A\n Communication: Patient & husband, \n status: Full code\n Disposition: pending cardiac surgery later this week\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Will target BP of 150 mm/Hg. Surgery Wed or Friday.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:18 ------\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398243,
"text": "is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n Impaired Skin Integrity\n Assessment:\n Gluteal fold/coccyx\n Action:\n Mepilex intact in place pt repositioned several times\n Response:\n Unchanged\n Plan:\n Continue to turn side to side , change positions frequently\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP 130-220, critical AS per cardiac cath\n Action:\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\n pulses dopplerable\n Response:\n Sbp 190\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\n hypotension that she felt sick nausea dizzy once when bp went as low as\n 130sbp and another when pt tried to get oob to use commode pt s bp\n dropped to 160\ns and pt had to quickly get back into bed r/t feeling so\n bad once n bed c legs elevated pt felt better she received zofran for\n nausea, right fem arterial and venous sheaths removed no bleeding at\n site no hematoma\n Plan:\n Monitor hemodynamics closely, po meds will need to be increased as\n needed and tolerated, niprid gtt dc\nd , goal is to decrease bp very\n slowly\n .\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398244,
"text": "is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n Impaired Skin Integrity\n Assessment:\n Gluteal fold/coccyx skin tear\n Action:\n Mepilex intact in place pt repositioned several times\n Response:\n Unchanged\n Plan:\n Continue to turn side to side , change positions frequently\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP 130-220, critical AS per cardiac cath\n Action:\n Lopressor 50mg tid captopril 100mg tid, nipride gtt off and on during ,\n pulses dopplerable\n Response:\n Sbp 190\ns, nipride off, U/O 30-40cc/hr, pt had two episode of\n hypotension that she felt sick nausea dizzy once when bp went as low as\n 130sbp and another when pt tried to get oob to use commode pt s bp\n dropped to 160\ns and pt had to quickly get back into bed r/t feeling so\n bad. once n bed c legs elevated pt felt better she received zofran for\n nausea, right fem arterial and venous sheaths removed no bleeding at\n site no hematoma\n Plan:\n Monitor hemodynamics closely, po meds will need to be increased as\n needed and tolerated, niprid gtt dc\nd , goal is to decrease bp very\n slowly\n .\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398344,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs ~200\n Action:\n Captopril 100mg TID and Lopressor 75mg TID given as ordered\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. No\n dizziness/lightheadedness\n Plan:\n Continue BP manangement, goal SBP ~150-160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB\n Action:\n . Pre-op AVR w/u in progress\n Response:\n Stable overnight\n Plan:\n Needs Panorex and carotids check\n CHF management--2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx. Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Improving\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: freq\n BP checks and not being able to go to the bathroom in room or shower.\n Stated,\n I am not taking anymore pills, I\nve taken 25 pills today\n Slept well overnight, startles when woken up by RN for nsg\n interventions.\nJust leave me alone\n. Emotional support provided\n Get\n OOB, ^ activity as tolerated. ? DC foley\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398325,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n HTN persist this am- SBP 199-224\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered-\n Response:\n SBP trended down late morning thru afternoon- Lopressor dose increased\n to 75mg TID- OOB to chair w/ no orthostatic c/o.\n Plan:\n Con\nt present management\n goal SBP 160\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted & pre-op workup started\n for AVR- lung sounds clear.\n Action:\n Chest CT done as ordered without incident- attempted panorex films,\n however Xray machine was down so unable to obtain- remedicated w/\n benadryl and ranitidine upon return to CCU- SBP 163-180 w/ MAPs 77-88\n this afternoon- diet resumed.\n Response:\n Stable- taking Po well.\n Plan:\n Panorex & carotids studies tomorrow\n Impaired Skin Integrity\n Assessment:\n Small area of crack skin (? Skin tear) @ gluteal fold/coccyx- mepilex\n placed \n Action:\n Patient turns independently in bed- encouraged to keep off back-\n OOB-chair.\n Response:\n No c/o discomfort- skin site checked under mepilex -> improvement\n noted.\n Plan:\n Monitor area closely- con\nt skin care.\n Hyperglycemia\n Assessment:\n Blood sugar elevated on admission- glucose range 141- 218 today.\n Action:\n Insulin given as per sliding scale.\n Response:\n Stable.\n Plan:\n Con\nt q6hr fingersticks and Rx as per SS.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398241,
"text": "Impaired Skin Integrity\n Assessment:\n gluteal\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\n tomorrow.\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Con\nt to monitor closely.\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- area open to air.\n Response:\n Unchanged.\n Plan:\n Monitor area closely- con\nt freq repositioning & back care.\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398223,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n AORTIC STENOSIS\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398224,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n TTE\n The left atrium is moderately dilated. There is severe symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Regional left ventricular wall motion is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. Right ventricular chamber\n size is normal. The diameters of aorta at the sinus, ascending and arch\n levels are normal. There are three aortic valve leaflets. The aortic\n valve leaflets are severely thickened/deformed. There is critical\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\n regurgitation is seen. The mitral valve leaflets are moderately\n thickened. There is severe mitral annular calcification. Mild to\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\n hypertrophy with normal global and regional biventricular systolic\n function. Mild aortic regurgitation. Mild to moderate mitral\n regurgitation. Mild pulmonary hypertension.\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398229,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - According to PCP, previously on statin & ACE, problems with\n compliance & minor side effects, but no major contraindications\n - Started on Pravastatin 20mg\n - Started on Captopril 6.25mg TID, raised to 25mg TID over the day\n - Nitroprusside stopped\n - HgbA1c 5.8%\n - : Albumin, Type and Screen. Carotid ultrasound and bilateral LE\n vein mapping, Echo, Chest CT without contrast to evaluate Ascending\n Aorta size and calcification\n - TTE demonstrated EF>55%, aortic stenosis 0.05cm2 (estimate) and a\n greater degree of LV hypertrophy have progressed compared to prior\n - CXR demonstrate that lungs are w/out no pleural effusions or acute\n skeletal findings\n - seen by SW, attempting medication assistance\n - Will need Dental/Panorex consult in AM\n - Will need Hepatology consult with Dr. in AM to clear for\n surgery\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: uncomfortable\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.2\nC (97.1\n HR: 69 (61 - 79) bpm\n BP: 200/63(111) {171/52(95) - 216/77(128)} mmHg\n RR: 21 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 64.8 kg\n Total In:\n 1,521 mL\n 77 mL\n PO:\n 840 mL\n TF:\n IVF:\n 681 mL\n 77 mL\n Blood products:\n Total out:\n 1,185 mL\n 420 mL\n Urine:\n 1,185 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 336 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, EOMI\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Harsh,\n Crescendo, all fields of precordium/ worst at LUSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): AAOx3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 106 mEq/L\n 137 mEq/L\n 30.8 %\n 9.4 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n WBC\n 7.2\n 4.3\n 9.4\n Hct\n 30.9\n 28.7\n 30.8\n Plt\n 182\n 186\n 184\n Cr\n 0.9\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n Other labs: PT / PTT / INR:12.5/26.2/1.1, CK / CKMB / Troponin-T:31//,\n ALT / AST:14/18, Alk Phos / T Bili:69/0.5, Albumin:4.2 g/dL, LDH:212\n IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n TTE\n The left atrium is moderately dilated. There is severe symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Regional left ventricular wall motion is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). Right ventricular\n chamber size and free wall motion are normal. Right ventricular chamber\n size is normal. The diameters of aorta at the sinus, ascending and arch\n levels are normal. There are three aortic valve leaflets. The aortic\n valve leaflets are severely thickened/deformed. There is critical\n aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic\n regurgitation is seen. The mitral valve leaflets are moderately\n thickened. There is severe mitral annular calcification. Mild to\n moderate (+) mitral regurgitation is seen. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular\n hypertrophy with normal global and regional biventricular systolic\n function. Mild aortic regurgitation. Mild to moderate mitral\n regurgitation. Mild pulmonary hypertension.\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA 325 mg PO daily\n - start pravastatin today\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - will start ACEI today while nitroprusside gtt is down-titrated and\n discontinued\n - treatment of hypertension (see below)\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP was around 200 overnight on\n nitroprusside gtt.\n - transition nitroprusside gtt to metoprolol and ACEI today, goal sBP\n 150 today.\n - has arterial sheath in place for A-line tracings\n - SW consult for med compliance\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF).\n - f/u CSurg eval for AVR\n - avoid medications that could decrease preload, such as NTG\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. BNP elevated at 2787, consistent with\n heart failure.\n - transition nitroprusside gtt to metoprolol and losartan today, as\n above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - f/u Csurg recs on AVR\n - f/u on CXR and TTE today\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA\n - will start pravastatin today\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis).\n - may need carotid U/S here for pre-op eval\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, would\n change to pravastatin.\n - start pravastatin today\n .\n # Hyperglycemia: BS 191 on admission. Patient without history of\n diabetes.\n - RISS with FS qACHS\n - f/u HgA1c\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:52 PM\n 20 Gauge - 07:54 PM\n Sheath - 07:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Will further lower blood pressure parenterally for sheath pull. Will\n image thorax per request of interventional cardiology and CT surgery.\n Increase dose of ACE.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398240,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398312,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n HTN persist this am- SBP 199-224\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered-\n Response:\n SBP trended down late morning thru afternoon- Lopressor dose increased\n to 75mg TID- OOB to chair w/ no orthostatic c/o.\n Plan:\n Con\nt present management\n goal SBP 160\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted & pre-op workup started\n for AVR- lung sounds clear.\n Action:\n Chest CT done as ordered without incident- attempted panorex films,\n however Xray machine was down so unable to obtain- remedicated w/\n benadryl and ranitidine upon return to CCU- SBP 163-180 w/ MAPs 77-88\n this afternoon- diet resumed.\n Response:\n Stable- taking Po well.\n Plan:\n Panorex & carotids studies tomorrow\n Impaired Skin Integrity\n Assessment:\n Small area of crack skin (? Skin tear) @ gluteal fold/coccyx- meilex\n placed \n Action:\n Patient turns independently in bed- encouraged to keep off back-\n OOB-chair.\n Response:\n No c/o discomfort- unchanged.\n Plan:\n Monitor area closely- con\nt skin care.\n Hyperglycemia\n Assessment:\n Blood sugar elevated on admission- glucose range 141-150 today.\n Action:\n No insulin given as per sliding scale.\n Response:\n Stable.\n Plan:\n Con\nt q6hr fingersticks and Rx as per SS if necessary.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398115,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference noted Left arm < Right arm; consistent with left subclavian\n stenosis.\n Patient asymptomatic with no h/a or dizziness. Reports non-compliance\n with cardiac meds financial restrictions.\n Received patient on nitroglycerin gtt at 2 mcg/kg/min with femoral\n aline SBP > 250.\n Action:\n Nitroglycerin d/c\nd- initiated low-dose Nipride gtt with\n goal SBP (by fem aline) of 200.\n Requested SW consult to discuss financial medication issues.\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Caution with meds that reduce pre-load (ie NTG).\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weights\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398112,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n PUMP: Acute diastolic congestive heart failure (EF 64% in 3/.)\n Critical symptomatic AS (0.7 cm^2) with peak to peak gradient of 25 mm\n Hg. Patient also with R sided PA and RA pressures on R heart cath,\n indicating evidence of pulmonary hypertension, likely exacerbated in\n setting of L sided heart failure. Receive 40 mg IV lasix in cath lab\n with good urine output of -1 L. EF 64% in 3/.\n - daily weights, fluid restriction < 2 L daily, strict Is and Os, salt\n restricted diet\n - continue nitroprusside gtt\n - if chest pain, start enalaprilat or esmolol gtt\n - diurese gently with lasix 10 mg IV given preload dependence, I/O goal\n -1 L overnight\n - no nitroglycerin\n - continue BB\n - holding for now\n - check BNP\n - contact for aortic valve replacement evaluation\n - CXR, TTE in AM\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398110,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Cath showing unchanged 3 VD native LAD 100 %.(patent SVG to LAD &\n patent SVG to RCA) (Occluded SVG to OM, diffuse mid-LAD <40%).\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398111,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis\n Assessment:\n Cath showing critical AS (the aortic valve area was 0.68 cm2 with a\n 25mm Hg peak to peak gradient).\n Action:\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16)\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398114,
"text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Cath showing\nmarked systemic HTN\n (up to 310 mmHG). NIBP\n difference Left arm < Right arm consistent with subclavian stenosis.\n Action:\n Response:\n Plan:\n Continue ABP management with IV Nipride gtt\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n AS: Cath showing critical AS (the aortic valve area was\n 0.68 cm2 with a 25mm Hg peak to peak gradient). Audible murmur.\n CHF: PA pressures were: (51/34, mean 42); PCWP were: (mean\n 29, RA mean 16)- EF 64 % . Trace pedal edema noted. Lung\n clear/slightly diminished bilateral bases.\n Received 40 mg IVP lasix in cath lab prior to transfer.\n Action:\n 2 liter fluid restrictions; goal 1 liter negative overnight.\n Response:\n Plan:\n CSurg consult for aortic valve replacement surgery\n Ordered for Cxray and TTE in am\n Maintain 2 liter fluid restriction, low-salt diet, daily\n weights\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Known CAD s/p CABG. Cath showing unchanged 3 VD native LAD 100\n %.(patent SVG to LAD & patent SVG to RCA) (Occluded SVG to OM, diffuse\n mid-LAD <40%). No evidence ACS for this admission. CP free.\n Hypertensive w. management as above. HR 80\ns, SR, no ectopy noted.\n Action:\n Lopressor 50 mg po given in TID dosing.\n Monitored for c/o CP.\n Response:\n Lopressor effective in decreasing HR to 60\n Remains CP free overnight.\n Plan:\n Monitor for c/o CP or discomfort. Medical management with lopressor,\n asa and zetia as ordered. Diovan held.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398195,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68 cm2 w/ a 25mm Hg peak to\n peak gradient & marked systemic HTN w/ SBP 310 & elevated PA pressures\n w/ PCWP 29. BPs intially tx\nd w/ Nipride gtt, DCd . Diuresed w/\n lasix in cath lab. Echo showed EF >55%.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\n left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Action:\n Response:\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT.\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398196,
"text": "75 F w/ CAD s/p 3V CABG p/w CP & progressive DOE as a transfer\n from for cardiac cath on . Cath\n showed critical AS w/ aortic valve area 0.68, marked systemic HTN w/\n SBP 310 & elevated PA pressures w/ PCWP 29. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs via R fem art line ~200. NIBP difference noted L arm < R arm, c/w\n left subclavian stenosis.\n Pt asymptomatic w/ no c/o h/a or dizziness. Non-compliant w/ cardiac\n meds financial restrictions\ns/w consulted and following\n Action:\n 50 mg lopressor given in TID dosing\n Captopril 25mg TID\n Response:\n Stable\n Plan:\n Continue BP management w/ current med regimen\ngoal SBP 200\n ? DC F fem venous and art sheaths\n Aortic stenosis & CHF (Acute Diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB.\n Action:\n Response:\n No CHF on CXR, adequate UOP. 30-40cc/hr- I&O equal\n Plan:\n C- pre-ops\nwill need carotid u/s (h/o R ICA stenosis),\n dental panorex, chest CT. ? surgery mid-week\n CHF management\n2L fluid restriction, low-salt diet, daily\n weights, strict I&Os.\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG at 22:00 119\n Action/Response:\n FS QID, stable\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- Mepilex placed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown, con\nt freq\n repositioning & back care as pt mobility is impaired while bedridden\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398276,
"text": "75 F w/ CAD, PVD, TIA in (significant R sided ICA stenosis),\n s/p 3V CABG p/w CP & progressive DOE as a transfer from Hosp for cardiac cath on . Cath showed critical AS w/\n aortic valve area 0.68cm, marked systemic HTN w/ SBP 310 & elevated PA\n pressures w/ PCWP 29. Cardiac enzymes Neg. BPs intially tx\nd w/\n Nipride gtt-- DCd -- converted to PO antihypertensives. Diuresed w/\n lasix in cath lab. R fem venous and art sheaths DCd . OF NOTE: L\n subclavian steel- significant difference in arm BPs, L<R. Non-compliant\n w/ cardiac meds financial restrictions\ns/w consulted and following\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBPs > 200\n Action:\n Captopril 100mg TID and Lopressor 50mg TID given as ordered\n Additional 1 time dose 25mg PO hydral given @ 01:00\n Response:\n SBP 180-190s. HR 55-70s Sr/1^st degree AV delay/BBB. OOB to BSC w/\n minimal assist. No c/o dizziness. Orthostatics neg.\n Plan:\n Continue BP manangement, goal SBP ~160s.\n Aortic stenosis & CHF (Acute diastolic)\n Assessment:\n Critical AS per cardiac cath- consulted . Echo showed EF\n >55%. LS clear. No SOB. Pre-op AVR w/u in progress\n Action:\n allergy to Shellfish/iodine-- Pre-contrast prophylactic meds\n for CT given as ordered, Prednisone, benedryl and ranitidine\n NPO for CT per techs\n Response:\n Stable overnight\n Plan:\n CT scheduled for 8am. Resume diet after CT\n Needs Panorex and carotids check\n CHF management-2L Fluid restruction, low Na+ diet, daily\n wts, strict I&Os\n Hyperglycemic\n Assessment:\n No h/o diabetes, FSBG elevated on admit. FS 172 @ 22:00.\n Action/Response:\n Covered w/ RISS\n Plan:\n Con\nt to check FS q6hrs, treat as indicated per SS (of\n note: pt on prednisone)\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length, Mepilex placed \n Action:\n Pt turning self independently in bed\n Response:\n Unchanged\n Plan:\n Monitor area closely- prevent further breakdown\n NEURO: A&Ox3. Anxious r/t being in ICU. Expressed frustrations re: not\n being able to go to the bathroom in room or shower. Stated,\n I am not\n taking anymore pills\n. Slept well overnight, startles when woken up by\n RN for nsg interventions.\nJust leave me alone\n. Emotional support\n provided\n Get OOB, ^ activity as tolerated.\n RESP: +Sleep apnea w/ sats transiently dropping to 81%. Supplemental 02\n placed but pt taking off. Pt encouraged to keep on for the night.\n continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398186,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n"
},
{
"category": "Nursing",
"chartdate": "2127-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 398190,
"text": "Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n SBP >200 this am on Nipride gtt @ .3mcq/kg/min- arterial & venous\n sheaths remain in R fem.\n Action:\n Lopressor 50mg given as ordered and patient started on captopril 6.25mg\n TID- R fem site without oozing or hematoma- (-) distal pulses.\n Response:\n SBP <200- Nipride gtt weaned and D/C\nd- captopril increased to 12.5mg\n TID\n Plan:\n Monitor hemodynamics closely- ? increase lopressor- ? D/C sheaths\n tomorrow.\n Aortic stenosis\n Assessment:\n Critical AS per cardiac cath- consulted.\n Action:\n CXR done- echo done- seen by this evening- ? surgery mid week-\n pre-op orders started.\n Response:\n No CHF per CXR- U/O 30-40cc/hr- I&O equal today.\n Plan:\n Con\nt to monitor closely.\n Hyperglycemic\n Assessment:\n Glucose range 123-180\n Action:\n Insulin given as per sliding scale.\n Response:\n Better glucose control.\n Plan:\n Con\nt fingersticks q6hrs and follow sliding scale.\n Impaired Skin Integrity\n Assessment:\n small area of crack skin note @ gluteal fold/coccyx- appox 4cm in\n length.\n Action:\n Repositioned q2hrs off back- freq back care- area open to air.\n Response:\n Unchanged.\n Plan:\n Monitor area closely- con\nt freq repositioning & back care.\n"
},
{
"category": "Physician ",
"chartdate": "2127-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 398280,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 11:00 AM\n SHEATH - STOP 11:00 AM\n - increased captopril to 100 TID\n - used nipride to drop pressure while Aline sheeth is being pulled\n - pressure to 120's with 3 of Nipride, to 176 after decreased to 0.24,\n adjusting to goal fo 150\n - ordered dental consult and panorex\n - hepatology consult: good candidate for surgery from liver perspective\n - CTA: Contrast allergy to be managed with pre-treatment (prednisone,\n ranitidine, benadryl). CTA at 8am Sunday\n - Received Hydralazine 25 mg at 0100 for sBP > 190\n Allergies:\n Sulfa (Sulfonamides)\n Anaphylaxis;\n Shellfish\n Anaphylaxis;\n Iodine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.1\n HR: 62 (56 - 76) bpm\n BP: 205/67(103) {130/51(79) - 208/118(139)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.2 kg (admission): 64.8 kg\n Total In:\n 506 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 266 mL\n Blood products:\n Total out:\n 1,075 mL\n 215 mL\n Urine:\n 1,075 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n -95 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///23/\n Physical Examination\n General: Well nourished, No acute distress\n Neck: supple with JVP 7cm\n Cardiovascular: normal S1, S2, regular rhythm, Harsh,\n Crescendo-decrescendo systolic murmur all fields of precordium/ worst\n at LUSB\n Respiratory: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended\n Extremities: No LE edema\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present), The\n DP pulses are biphasic and easily extinguished with soft compression\n Musculoskeletal: Right leg immobilized, Left Leg in SCD\n Skin: Not assessed\n Neurologic: Attentive, AAOx3\n Labs / Radiology\n 181 K/uL\n 10.3 g/dL\n 150 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 40 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.9 %\n 6.6 K/uL\n [image002.jpg]\n 08:37 PM\n 04:29 AM\n 03:56 AM\n 04:00 AM\n WBC\n 7.2\n 4.3\n 9.4\n 6.6\n Hct\n 30.9\n 28.7\n 30.8\n 30.9\n Plt\n 182\n 186\n 184\n 181\n Cr\n 0.9\n 1.1\n 1.1\n 1.1\n Glucose\n 191\n 180\n 108\n 150\n Other labs:\n PT / PTT / INR:12.7/25.5/1.1,\n Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n Pt is a 75 yo F with CAD s/p 3V CABG and critical aortic stenosis.\n .\n # Hypertension: Patient presented with hypertensive emergency with\n chest pain. Patient grossly hypertensive in the cath lab with arterial\n tracings showing systolics in the 330s. BP brought down by\n nitroprusside gtt overnight in the CCU to SBPs 200. Likely chronically\n hypertensive in setting of medication non-compliance due to financial\n issues. Outpt blood pressure checks have SBPs ranging from 110s-140s,\n but were in the left arm with known L subclavian steal phenomenon.\n Also, cuff pressure seems to underestimate the true BPs that are\n measured via A-line. Patient\ns BP improved but still not at goal of\n 150-160.\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control for goal sBP 150-160\n .\n # Critical AS: Valve area 0.68 cm^2. Symptomatic with peak gradient of\n 25 mm Hg. Has symptoms for AS triad (angina, CHF). Pt is getting\n pre-op studies for planned AVR.\n - ordered dental consult and panorex\n - per hepatology consult, pt is a good candidate for surgery from liver\n perspective\n - pt will get CTA today. Pt with Contrast allergy to be managed with\n pre-treatment (prednisone, ranitidine, benadryl). CTA at 8am today\n - avoid medications that could decrease preload, such as NTG\n .\n # CORONARIES: Patient with known CAD s/p CABG. However, no evidence of\n ACS (negative troponins, no new ischemic EKG changes). Patient's chest\n pain likely demand ischemia in setting of critical AS and hypertensive\n emergency.\n - continue ASA and pravastatin\n - continue short acting metoprolol 50 mg PO TID, can uptitrate today to\n 75mg TID with goal HR 55-60\n - continue captopril 100mg TID\n - may need to add another for BP control\n .\n # PUMP: Patient with evidence of diastolic congestive heart failure (EF\n 64% in ), with elevated PCWP. Patient also with R sided PA and\n RA pressures on R heart cath, indicating evidence of pulmonary\n hypertension and right-sided heart failure, likely exacerbated in\n setting of L sided heart failure. BNP elevated at 2787, consistent\n with heart failure.\n - manage BP as above\n - Pt appears euvolemic currently. Keep I/O even today\n - no nitroglycerin given critical AS\n - awaiting AVR surgery\n .\n # RHYTHM: Patient with history of SVT in 2/. Currently in sinus\n rhythm with prolonged PR and RBBB/left anterior fascicular block on\n EKG. Currently HR around 60.\n - continue BB\n - telemetry\n .\n # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line\n higher than blood pressure cuff, consistent with a diagnosis of\n PVD.\n - continue ASA and pravastatin\n .\n # Carotid artery disease: Patient with history of TIA in \n (significant R sided ICA stenosis). Carotid US from showed\n 60-69% stenosis of the right internal carotid artery. Less than 40%\n stenosis of the left internal carotid artery. Reversed flow in the left\n vertebral artery, which may correspond to subclavian steal phenomenon.\n - pt may live at BP around 200, and if BP drop lower pt may experience\n TIA and dizziness. Need to monitor for sx.\n .\n # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11.\n Patient reportedly on Lipitor but discontinued due to patient concern\n about cirrhosis and possible liver damage. Patient was put on zetia as\n a result. Zetia is very expensive; given her economic situation, zetia\n changed to pravastatin.\n - continue pravastatin\n .\n # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8.\n - RISS with FS qACHS\n .\n # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI\n at . LFT normal.\n - trend LFT\n - per hepatology, pt is a good candidate for AVR from liver stand\n point.\n .\n # Anemia: baseline hct 25. Admission hct 30.9. Ferritin checked at OSH\n was 73. Hct stable during this admission.\n - trend Hct\n .\n # History of seizure: Patient was admitted for seizure in . She\n has been on Keppra, but self-discontinued it because of depression. No\n further episodes since then. Will continue to monitor.\n ICU Care\n Nutrition: regular cardiac-healthy diet\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 07:54 PM\n Prophylaxis:\n DVT: pneumoboots (pt refused sc heparin)\n Stress ulcer: none\n VAP: n/a\n Comments:\n Communication: Comments: husband\n status: Full code\n Disposition: will stay in CCU for BP optimization\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-08 00:00:00.000",
"description": "R VENOUS DUP EXT UNI (MAP/DVT) RIGHT",
"row_id": 1116006,
"text": ", M. 11:45 AM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring valve replacement surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PFI REPORT\n Patent right greater and lesser saphenous veins with diameters described\n below.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-08 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1116007,
"text": " 11:45 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:24 PM\n PFI:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\n subclavian steal.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with critical AS requiring surgery. Pre-op.\n\n TECHNIQUE: Evaluation of the bilateral extracranial carotid arteries as well\n as vertebral arteries was performed with B-mode, color and spectral Doppler\n ultrasound.\n\n FINDINGS: A mild amount of plaque was seen in the bilateral internal carotid\n arteries, with B-mode ultrasound.\n\n On the right side peak systolic velocities were 187 cm/sec for the internal\n carotid artery and 69 cm/sec for the common carotid artery. The right ICA/CCA\n ratio was 2.7.\n\n On the left side peak systolic velocities were 98 cm/sec for the ICA and 68\n cm/sec for the CCA. The left ICA/CCA ratio was 1.44.\n\n The right vertebral artery presented antegrade flow. The left vertebral\n artery presented with retrograde flow, suggestive of left subclavian steal.\n\n COMPARISON: No change when compared to the carotid duplex scan obtained in\n .\n\n IMPRESSION:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Reverse flow in the left vertebral artery, which may correspond to\n subclavian steal phenomenon.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-08 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1116008,
"text": ", M. 11:45 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. 60-69% stenosis of the right internal carotid artery.\n 2. Less than 40% stenosis of the left internal carotid artery.\n 3. Retrograde flow seen in the left vertebral artery suggestive of left\n subclavian steal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-08 00:00:00.000",
"description": "R VENOUS DUP EXT UNI (MAP/DVT) RIGHT",
"row_id": 1116005,
"text": " 11:45 AM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: pre-op\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS requiring valve replacement surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SFyb MON 7:18 PM\n Patent right greater and lesser saphenous veins with diameters described\n below.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with critical AS requiring valve replacement\n surgery. Venous mapping was requested.\n\n The right greater saphenous vein is patent and compressible with diameters\n ranging between 0.25 and 0.31 cm. The right lesser saphenous vein is patent\n and compressible with diameters ranging between 0.21 and 0.29 cm. The left\n greater saphenous vein was not visualized due to previous harvesting.\n\n COMPARISON: None available.\n\n IMPRESSION: Patent right greater and lesser saphenous veins, with diameters\n described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115565,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary congestion, consolidation\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD, critical AS, elevated PCWP\n REASON FOR THIS EXAMINATION:\n pulmonary congestion, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Pulmonary congestion.\n\n FINDINGS: Cardiac silhouette remains enlarged, and there is unchanged\n tortuosity and calcification of the thoracic aorta. Lungs are grossly clear,\n and there are no pleural effusions or acute skeletal findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-12-07 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1115847,
"text": " 9:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with aortic stenosis\n REASON FOR THIS EXAMINATION:\n please evaluate from axillary arteries to common femoral. This is a pre-op\n exam. Please conduct study at 0800 so that her pretreatment schedule is correct\n CONTRAINDICATIONS for IV CONTRAST:\n allergy: Preteated !\n ______________________________________________________________________________\n WET READ: SPfc 11:26 AM\n Extensive atherosclerotic disease with ectasia of the ascending aorta, similar\n to that seen in . Otherwise, incidental note is made of a nodule in the\n left lower lobe of the lungs, appearing slightly larger since . This\n could be followed with a dedicated high-res Chest ct in ~3months\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation in a patient with aortic stenosis.\n\n TECHNIQUE: Axial CT images were acquired through the torso prior to and\n thereafter following the administration of 100 cc of intravenous Optiray 350\n contrast. Coronal and sagittal reformatted images were also reviewed.\n\n CT CHEST WITH AND WITHOUT CONTRAST: The airways are patent to segmental\n levels bilaterally. Heterogeneous attenuation throughout the lungs is likely\n related to air-trapping. There is a small amount of dependent atelectasis\n bilaterally. A nodular opacity posterolaterally in the left lower lobe is 13\n x 9 mm. This correlates to a small nodular opacity, which was described on a\n CT from , and has now grown minimally in size. There is no\n axillary lymphadenopathy. A hypodense pretracheal node is borderline in size,\n measuring 10mm in shortest diameter.\n\n The heart and great vessels are notable for coronary arterial calcification as\n well as aortic valvular calcification. In addition, calcification is\n visualized along the length of the aorta, which is ectatic, unchanged from the\n previous studies, measuring approximately 37 x 38 mm in the ascending aorta.\n Dense calcification is also prominent at the origin of the left subclavian\n artery. The main as well as right pulmonary arteries are prominent in size\n measuring ~29 mm, suggesting pulmonary hypertension. Note is made of\n cardiomegaly, in particular with left atrium appears enlarged.\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: The stomach, duodenum, spleen,\n pancreas, adrenal glands, right kidney, and gallbladder are unremarkable. The\n left kidney contains an 18x18mm hypodensity which is hypodense (~27H.U.) and\n does not enhance, though is new or enlarged. The liver is notable for three\n hypodensities, two in the right lobe and one in the left, all of which are too\n small to characterize though appear unchanged from . There is no free gas\n or free fluid in the abdomen. There is no retroperitoneal or mesenteric\n lymphadenopathy.\n (Over)\n\n 9:38 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: AORTIC STENOSIS, PLEASE EVALUATE FROM AXILLARY ARTERIES TO COMMON FEMORALS PRE OP\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT HEART CATH;LEFT HEART CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Vascular structures are notable for extensive atherosclerotic calcification\n along the length of the aorta in the absence of aneurysmal dilation.\n Calcification is noted at the origin of the renal arteries bilaterally as well\n as at the origin of the superior mesenteric artery. The celiac trunk is\n notable for a separate origin of the left gastric artery.\n\n CT PELVIS WITH AND WITHOUT CONTRAST: The urinary bladder contains a small\n amount of gas and a Foley catheter. The uterus, right adnexa, and rectum are\n unremarkable. The colon reveals diverticulosis. A punctate calcification in\n the left adnexa is unchanged. There is no free gas or fluid in the pelvis,\n and there is no pelvic sidewall or inguinal lymphadenopathy. Regional\n vascular structures opacify normally. Note is made of scattered injection\n granulomas in the right buttocks region.\n\n OSSEOUS FINDINGS: The patient is status post median sternotomy. There is a\n wedge compression deformity in the mid thoracic spine at the T5 vertebral\n body, which is unchanged since . There is a grade 1 anterolisthesis of L4\n over L5. Degenerative disc disease at that same level with endplate sclerosis\n has progressed since .\n\n IMPRESSION:\n 1. Extensive atherosclerotic disease as well as ectatic dilation of the\n ascending aorta, similar to that seen in .\n 2. Left lower lobe pulmonary nodular opacity, appearing minimally enlarged\n from . Given the size of this lesion, followup with a PET study or\n dedicated CT of the chest within three months, is recommended.\n 3. Diverticulosis\n 4. Left renal hypodensity. While this is likely a cyst, it is new/enlarged\n from the previous study and could be correlated to U/S for further\n characterization.\n 3. Stable hepatic hypodensities too small to characterize but likely cysts.\n 4. Wedge compression deformity in the mid thoracic spine and degenerative\n changes in the remainder of the spine as cataloged above.\n\n"
}
] |
63,552 | 160,230 | 77 yo female with PMH tracheostomy respiratory failure, subglottic stenosis, Parkinson's and SLE who is s/p rigid bronchoscopy on for removal of granulation tissue who required ICU admission for observation due to tachypnea post extubation. Bronch revealed mild TBM and recidual tracehal stenosis. She has a tegaderm covering her stomal opening, which will stay in place for now. She had normal oxygen saturations throughout her ICU stay. A CT airway was done to evaluate for tracheal stenosis, which showed tracheal and subglottic stenosis as noted above. In terms of Atrial Fibrillation, Currently in sinus rhythm. Maintained on metoprolol. INR was 1.3 on . Warfarin was being held pre-procedure and was restarted on . Healthcare proxy : , (daughter) | Focal minimal collection of air is present adjacent to the upper right mediastinum, 4:58, approximately 7 mm in diameter, most likely representing loculated pneumothorax. Small amount of pericardial effusion. There is small amount of pericardial effusion. There is small amount of pericardial effusion. Since theprevious tracing of atrial flutter is now absent. Note is made that the dynamic expiration was suboptimal and does not really represent the expiratory images. FINDINGS: Thin-section images demonstrate the minimal diameter of the airway being 9.5 x 7 mm with a cross-sectional area at this location of 70 mm2 at the level of the thoracic inlet. Sinus bradycardia with probable sinus arrhythmia and a possible non-conductedatrial premature beat. The mid and distal portions of the trachea are well expanded with minimal secretions noted. Focal area of narrowing of the trachea just at the level of the thoracic inlet to be 9 x 7 mm in diameter, 71 mm2, with no significant change during dynamic expiration. The rest of the trachea is unremarkable. Cardiomegaly, moderate. Airways are patent till the level of subsegmental bronchi bilaterally. Areas of ground-glass opacity in the lungs are concerning for infection/aspiration. The imaged portion of the upper abdomen reveals no abnormality . Local collection in the area adjacent to the right upper mediastinum that might represent local pneumothorax. The descending thoracic aorta is mildly enlarged as well, ranging up to 3.2 cm as opposite to maximum of 2.5 cm. Within the limitations of this non-enhanced study, no mediastinal, hilar or axillary lymphadenopathy was present. The aorta is up to 4 mm, borderline. Bibasilar atelectasis is present. In left upper quadrant of the abdomen, there is a 9 mm rounded lesion that most likely represents a splenule given the presence of a similar one adjacent to the spleen and the proximity to spleen. No IV contrast is administered. COMPARISON: Chest radiograph from and . Lateral precordial lead T wave changes are suggestedbut unstable baseline in those leads makes assessemnt difficult. IMPRESSION: 1. TECHNIQUE: MDCT of the chest was obtained from the level of the lower neck to the level of upper abdomen during end inspiration as well as dynamic expiration. Dynamic imaging did not demonstrate significant collapsibility of the airways and in particular, there was no appreciably change in the size of the airway at that specific location (65 mm2). Those areas are highly worrisome for infectious process. Axial images reviewed in conjunction with multiple coronal, sagittal, and 3D volume-rendering reformats. The evaluation of the lung parenchyma demonstrates ground-glass opacity (Over) 9:46 AM CT TRACHEA W/O C W/3D REND Clip # Reason: pls perform airway CT. we are interested in assessing trache Admitting Diagnosis: TRACHEOBRONCHOMALACIA\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT FINAL REPORT (Cont) involving the right upper lung with diffuse and more focal components as well as right middle lobe and to a lesser extent right lower lobe. 4. No evidence of fluid accumulation next to this area is noted. 3. The main pulmonary artery is enlarged up to 3.5 cm. Aspiration would be another possibility. There are no bone lesions worrisome for infection or neoplasm within the limitations of this study technique. The heart is enlarged. REASON FOR THIS EXAMINATION: pls perform airway CT. we are interested in assessing tracheal stenosis No contraindications for IV contrast FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy with tracheal stenosis, now with trachea decannulated. 2. No evidence of fluid collection in the area demonstrated to suggest infectious origin of this finding. | 2 | [
{
"category": "Radiology",
"chartdate": "2137-12-10 00:00:00.000",
"description": "CT TRACHEA W/O C W/3D REND",
"row_id": 1168988,
"text": " 9:46 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: pls perform airway CT. we are interested in assessing trache\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with h/o resp failure, s/p trach, tracheal stenosis, now with\n trach decannulated.\n REASON FOR THIS EXAMINATION:\n pls perform airway CT. we are interested in assessing tracheal stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy with\n tracheal stenosis, now with trachea decannulated.\n\n COMPARISON: Chest radiograph from and .\n\n TECHNIQUE: MDCT of the chest was obtained from the level of the lower neck to\n the level of upper abdomen during end inspiration as well as dynamic\n expiration. No IV contrast is administered. Axial images reviewed in\n conjunction with multiple coronal, sagittal, and 3D volume-rendering\n reformats.\n\n Note is made that the dynamic expiration was suboptimal and does not really\n represent the expiratory images.\n\n FINDINGS:\n\n Thin-section images demonstrate the minimal diameter of the airway being 9.5 x\n 7 mm with a cross-sectional area at this location of 70 mm2 at the level of\n the thoracic inlet. Dynamic imaging did not demonstrate significant\n collapsibility of the airways and in particular, there was no appreciably\n change in the size of the airway at that specific location (65 mm2).\n\n The mid and distal portions of the trachea are well expanded with minimal\n secretions noted. Airways are patent till the level of subsegmental bronchi\n bilaterally. Within the limitations of this non-enhanced study, no\n mediastinal, hilar or axillary lymphadenopathy was present. There is small\n amount of pericardial effusion. The main pulmonary artery is enlarged up to\n 3.5 cm. The aorta is up to 4 mm, borderline. The heart is enlarged. There\n is small amount of pericardial effusion.\n\n The descending thoracic aorta is mildly enlarged as well, ranging up to 3.2 cm\n as opposite to maximum of 2.5 cm.\n\n The imaged portion of the upper abdomen reveals no abnormality .\n\n In left upper quadrant of the abdomen, there is a 9 mm rounded lesion that\n most likely represents a splenule given the presence of a similar one adjacent\n to the spleen and the proximity to spleen.\n\n The evaluation of the lung parenchyma demonstrates ground-glass opacity\n (Over)\n\n 9:46 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: pls perform airway CT. we are interested in assessing trache\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA\\BRONCHOSCOPY RIGID W/ STOMA REVISION T TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n involving the right upper lung with diffuse and more focal components as well\n as right middle lobe and to a lesser extent right lower lobe. Those areas are\n highly worrisome for infectious process. Aspiration would be another\n possibility.\n\n Focal minimal collection of air is present adjacent to the upper right\n mediastinum, 4:58, approximately 7 mm in diameter, most likely representing\n loculated pneumothorax. No evidence of fluid accumulation next to this area\n is noted.\n\n Bibasilar atelectasis is present.\n\n There are no bone lesions worrisome for infection or neoplasm within the\n limitations of this study technique.\n\n IMPRESSION:\n 1. Focal area of narrowing of the trachea just at the level of the thoracic\n inlet to be 9 x 7 mm in diameter, 71 mm2, with no significant change during\n dynamic expiration. The rest of the trachea is unremarkable.\n 2. Local collection in the area adjacent to the right upper mediastinum that\n might represent local pneumothorax. No evidence of fluid collection in the\n area demonstrated to suggest infectious origin of this finding.\n 3. Areas of ground-glass opacity in the lungs are concerning for\n infection/aspiration.\n 4. Cardiomegaly, moderate. Small amount of pericardial effusion.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-12-09 00:00:00.000",
"description": "Report",
"row_id": 281325,
"text": "Sinus bradycardia with probable sinus arrhythmia and a possible non-conducted\natrial premature beat. Lateral precordial lead T wave changes are suggested\nbut unstable baseline in those leads makes assessemnt difficult. Since the\nprevious tracing of atrial flutter is now absent.\n\n"
}
] |
22,734 | 184,944 | 1. Cardiovascular/respiratory: The patient's respiratory distress accelerated after admission to the Neonatal Intensive Care Unit. She progressed from CPAP to requiring intubation and treatment with Surfactant. She received two doses of surfactant. She was extubated to CPAP by the second hospital day. She uses nasal cannula oxygen by the third day and weaned to room air by the ninth hospital day. Apnea and bradycardia has not been a prominent part of her hospital course. She has not required treatment with Methylxanthine. Murmur consistent with PPS was noted at approximately day 15 of life. 2. Fluid, electrolytes and nutrition: The patient was maintained NPO on intravenous fluids through the second hospital day. At that point feedings were started and progressed easily. She is currently receiving 24 calorie formula at a volume of 150 cc per kilogram per day. The weight at the time of this dictation on is 2150 grams. Discharge weight is 2150grams. 3. Hematologic: The patient's hematocrit on admission was 40.4. A repeat on was 33.6 with a reticulocyte count of 1.4%. 4. Infectious disease: The patient was treated with antibiotics for 48 hour rule out with antibiotics. CBC on admission showed a white blood cell count of 11.1 with 32 polys and 0 bands. Blood culture remained negative and the patient was clinically stable after the discontinuation of antibiotics. 5. Gastrointestinal: The patient's maximum bilirubin was 8.9 on the fourth hospital day. She was treated with phototherapy, which was discontinued by the sixth hospital day. 6. Neurological: The patient manifested normal neurological examination throughout her hospital stay. Head ultrasound on was within normal limits. 7. Routine health care maintenance: The patient passed a hearing screen. Car seat test is passed. Hepatitis B vaccine was administered on . 8. Immunization recommendations: Synagis RSV prophylaxis should be considered from through for infants who meet any of the following three criteria, one born at less then 32 weeks, two born between 32 and 35 weeks with two of the three of the following, day care during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or three with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other care givers should be considered for immunization against influenza to protect the infant. Follow up appointment with primary care pediatrician is to be arranged within two days following discharge by the parents. Ferrous sulfate supplementation. , M.D. Dictated By: MEDQUIST36 D: 09:28 T: 09:30 JOB#: | Continue to monitorFEN status.DEV: Temps stable, swaddled in OAC. Respiratory O: Pt. Abdexam benign. A: Stable in RA P: Continue to support.#3 FEN S/O: TF 150cc/k/d. noincreased wob noted. A: StableP: Continue to support.#3 FEN S/O: TF 150cc/k/d. mild SC retractions. Mild sc rtxns. Abd soft, +BS. mild subcostal retractions. P: Continue to support.#4 DEV S/O: Infant in OAC, maintaining temps. Comfortab;e appeatring.Wt 2150 up 45. Abdomen benign,voiding and stooling. due this wk. Cl and = BS. A: Pt. A: Pt. Lungs clear, subcostalretractions. Abdomen bneign. A: Stable. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. NeonatologyDoing well. NeonatologyDOing well. Abdomen benign. minimal aspirates. 2 Resp. P: Cont to mtr#3 FENs/o: TF 150cc/k/d-- remains on BM26/PE26. Lungs CTA, =. Cont to moitor. REmains in RA. A: Stable P: Encourage po feeds.#4 DEV S/O: Maintaining temps in OAC. Swaddled w/iboundaries. infant abd exam benign. Resp O/A Rec'dinf in RA. Abd exam benign.Voiding and stooling. Cor nl s1s2 murmur as before. DEV O/A remains in an OAC cobedding with hertwin. Temp stable. Continue to monitorFEN status.DEV: Temps stable, swaddled in OAC. Resp O/A Rec'd inf in RA. Neuro non-focal and age aprpopriate.COntinue current monitoring and nurtitional regimen Skin w/o leisons. DEV O/A remains in an OAC with stable temp. Alt po/pg.Skin w/o leisons. mild subcostal retractions. Inf remains in RA. Inf remains in RA. Settles with paci. MildIC/SC rtx. Infant calmseasily w/ wrapping and pacifier when offered.A: AGAP: Cont dev. neuro non-focal and age appropriate. Remains in R air, BBS clear, equal, mild subcostal/intercostal retractions present, no spells thus far thisshift. Infant remains in RA. A; Feeds tolertaed. BBS clear/=, RR 30-70's, mild transient SCretractions. Settles best onabd. G/D: Temp. Bld cx neg to date. A: stable under single P: COnt. NPN 7p-7aSepsis: Bld cx neg to date. Issueresolved.Resp: Infant remains on Nc 02. fi02 100%. Nested insheepksin with boundries in place. No edema.Stable 02 sat with min 02 requirement.Cont to monitor. A: stable P:Cont. Max aspirate 1.2cc. IVF ofpnd10w via piv. Temps stable in OAC. Occbrief 02 sat drifts, self resolving. Cont to advance feeds as tol.Dev: Temp stable in servo isolette. Am lytespending. Mild ic/sc retractions. Bs+. Bs +. Ic/Sc retractions noted. Respiratory Care NotePt off CPAP today. A: stable in 02, no spellsovernight P: COnt. A;requiredsupplemental o2 to maintain sats P; cont to wean o2 astolerated.#3. to monitor.3infant remains on TF min. stable in servo mode isoeltte. Med spit x 1. 48 Ro/o complete. benign, voiindg/no stool.PN/lipids infusing at 80cc/k, DS stable.A: toleratingadvancement of feeds P: COnt. Settles well inbetween cares. Isolette weaned astolerated. G/D: Temps stable swaddled in off-isolette. Abd exam benign. MildIC/SCR noted. Amlytes stable. Mild rtxns. Started on amp and gent. P- Cont toassess for Resp needs.#3-O/A- TF=140cc/kg/d of BM/PE20 via NGT. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. BBS clear and =. Active, alert in an isolette, AFOF, sutures opposed, good tone. Bili this am=7.0, 0.2. Neonatology-NNP Physical ExamInfant remains in RA. 2. remains in RA, color pink, sl jaundice, RR 30-60,BBS clear, equal, sc retractions, no spells.3. Tolerating NGT feedings well; abd exambenign, no spits, min asp, and AG stable. Voiding qs and nostool noted thus far. AGA. AGA. NPNOte;#2.Remains in R air, BBS clear, equal, mild subcostal /intercostal retractions present, no spells thus far thisshift. Tol well. LS = and clear, no murmur noted, VSS, D/S:72. NPN Days#1 Pt cont on ampi and gent. LS course bilat. CBG (0200): 7.35/ 47/ 46/ 27/ 0. Cl and = BS. one spell this shift. FiO221%. Ext. Pt weaned throughout the am and cbg drawn7.32/56/29/30/0. HUSscheduled for thurs. Currently pt. Cl and = BS> RR40-70s. Pt. Pt. Pt. Pt. Pt. Pt. Pt. nospells so far this shift. was treated with 6.2cc's of Survanta at 2145 and 0400. Br. Lungs CTA, cl and = bilat. d-stick 87. aga. aga. 2+FP. 2+FP. mildsubcostal retractions. updates given. Abd soft, +BS. Tol well. Tol well. +NG. Remains on Amp & Gent.G&D: CGA=32 wk. BCpending. asking appropques. BP 68/35, 46. TF 150 cc/k/day BM26/PE26 po/pg. TF 150 cc/k/day BM/PE26 po/pg. Pt NPO. sucks onpacifier. sucks onpacifier. Mild sc rtxns. Mild sc rtxns. IC SC retrac. NPO. stable girths.gavage fed this shift. Con to monitor. On Ferinsol.DEV: Temps stable in OAC. A: small O2 needpersists P;Follow#3 TF's presently at 95cc/k. LSclear and equal. Ls clr/=.Mild ic/sc retractions. Stable temp in heated isolette. Abd benign. Bili today 11.5/0.2. LS clear/=. Will check bilitonight. AFOF, Caput over occiput. Cont to advance feeds as tol.Dev: Temp stable in servo isolette. BBS clear and =. Remains in R air, BBS clear, equal, mild subcostalretractions present, no spells thus far this shift. Belly benign. snds clear, = bilat.A: Stable in RA w/o spells.P: Cont to monitor for desats or bradys.#3 F/N: Infant continues on 150cc/kg/d PE26/BM 26 w/ promod,47cc q 4 hrs. RRR, without murmur, pulses 2+ and symmetrical. PE26 with PM (45cc Q4hr) PO/PG. Dstick 86.Abd soft. Minimal aspirates. Alt po/pgfeeds. IVf of pnd10w with IL via piv. Mod jaundice under single phototherapy. Mildretractions present. Active bs. Am bili 6.1/.3-downfrom 8.4/.3. A; ,involved.P; cont dev support. Tol feeds gavagedover 1hr20min. P- Cont toassess for Resp needs.#3-O/A- TF=110cc/kg/d of BM/PE20 via NGT. to monitor resp. Infant remainson NCO2. Abd exam benign. Abd exam benign. LSclear and equal. abd benign. P: Cont. P: Cont. P: Cont. wt. MildIC/SCR. Voiding qs and nostool noted thus far. AGA. Temp stable inheated isolette. NPNOte;#2.Remains in R air, BBs clear, equal, mild subcostalretarctions present, no spells, occassional sat drifts tomid 80's noted, QSR. Mild IC/SCretractions. lsc=. Transferred toopen crib, temp stable. mild sc/icretractions. Neonatology-NNP Physical ExamInfant remains in RA. Tolerating feedings well; abd exambenign, min asp, AG stable, and one spit. P- Cont to assess for Respneeds.#3-O/A- TF=150cc/kg/d of BM/PE24 via NGT. Will continue with current plan of care.Dev: Temp stable in low air isolette while swaddled. minimal aspirates.#4 g&dpt in oac with stable temps. | 122 | [
{
"category": "Radiology",
"chartdate": "2152-02-10 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 816466,
"text": " 7:04 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: TWIN INFANT BORN AT 32 3/7 WEEKS GESTATION, R/O IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 32 week twin\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with 32 and 3/7th weeks. Twin. R/O intraventricular\n hemorrhage.\n\n FINDINGS: The sulci and gyri of the cerebrum and cerebellum have an appearance\n consistent with the patient's prematurity. An extra-axial fluid collection is\n not seen. The ventricular system size is normal. There is no evidence of a\n subarachnoid or an intraventricular hemorrhage.\n\n IMPRESSION: Premature appearing brain. No bleed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-02-07 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 816205,
"text": " 10:14 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: check placement of ett\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with surfactant deficiency\n REASON FOR THIS EXAMINATION:\n check placement of ett\n ______________________________________________________________________________\n FINAL REPORT\n This is a child with prematurity.\n\n The exam is grossly underexposed and should be repeated at no cost to the\n patient. I can ascertain that the ETT is just at the carina. There is probably\n hyaline membrane disease present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-02-10 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 816500,
"text": " 11:18 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: 3 day old ex-32 week with worse resp distress\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress\n REASON FOR THIS EXAMINATION:\n 3 day old ex-32 week with worse resp distress\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Infant with respiratory distress.\n\n Single frontal radiographs compared to the only prior demonstrates diffuse\n ground-glass opacities bilaterally with a more focal opacity in the right\n lower lobe and right middle lobe. The enteric catheter tip overlies the\n stomach. Findings are most consistent with RDS and right middle and lower\n lobe subsegmental atelectasis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-01 00:00:00.000",
"description": "Report",
"row_id": 1987264,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats thus far this shift.\nlung sounds clear and equal. mild subcostal retractions. no\nincreased wob noted. Rr 50-60's. sats remain in the high\n90%.\n\n3: fen\ncurrent weight 2040gms up 30gms. total fluids remain at\n150cc/kilo/day of pe/bm26 with prom. tolerating feeds well.\none small spit. minimal aspirates. abd soft with no loops.\nvoiding, no stool thus far this shift.stable girths. infant\ntaking full volumes po's at first two cares. will attempt to\npo if and rooting with next care. continue to\nencourage po feedings.\n\n4: dev\ntemps stable in an open crib. and active with cares.\nsleeps well inbetween. waking prior to care time. sucks\nvigorously on pacifier. brings hands to face. aga. continue\nto monitor for developmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-01 00:00:00.000",
"description": "Report",
"row_id": 1987265,
"text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing.\n\nWt 2040 up 30. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Still requiring some gavage. Small amounts of non-bilious spits.\n\nTemp stable in open crib.\n\nHct 33.6 Retic 1.4.\n\nContinue current monitoring and nutritional managfement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-01 00:00:00.000",
"description": "Report",
"row_id": 1987266,
"text": "Neonatology - NP Physical Exam\nAwake and alertt with cares, temp stable in o-pen crib. BS clear and equal with mild subcostal retractions, color pink. RRR with soft murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-01 00:00:00.000",
"description": "Report",
"row_id": 1987267,
"text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 23.\nWT: 2040 g (+30)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 30.5 cm (~10th to 25th %ile); last: 30 cm\nLN: 44 cm (~10th to 25th %ile); last: 43 cm\nMeds include Fe\n due this wk\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant attempts po's w/ every feed; takes ~ to full volume po. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. due this wk. Learning po feeding skills. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for all parameters. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-01 00:00:00.000",
"description": "Report",
"row_id": 1987268,
"text": "NPN\n\n\n#2 Resp: infant remains in RA with sats >93%. RR 30-50's,\nBBS clear/=. mild SC retractions. no desats or brady's. cont\nto monitor resp status.\n\n#3 Fluids: infant TF remain 150cc/kg/d PE26+PM. Receiving\nPO/NG feeds 51cc Q4h. Infant took partial feed PO this AM\nand remainder gavaged. Took full volume for 1330 feeding.\nTaking PO's well with good coordination. abd soft, +BS,\nvoiding, stools heme negative. small spit. cont to offer PO\nfeedings when infant eager and interested.\n\n#4 G&D: infant bundled in OC with stable temps. Awake, \nand active, wakes for feedings. cont to provide\ndevelopmental support.\n\n#5 : called this afternoon to say that he will be\nin for 2130 feeding. cont to provide updates and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-02 00:00:00.000",
"description": "Report",
"row_id": 1987269,
"text": "NPN 1900-0700\n\n\n#2 RESP S/O: Infant in RA. Lungs clear, subcostal\nretractions. RR 30-70's, O2 sats >95%. No spells or\ndrifting. A: Stable in RA P: Continue to support.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get pe26 with promod,\n51cc q4h po/pg. Infant bottled 47ccx2 tonight so far.\nAbdomen is benign, voiding and stooling. No spits, min\naspirates. A: Tolerating feeds. P: Continue to support.\n\n#4 DEV S/O: Infant in OAC, maintaining temps. and\nactive. Waking before feeds. A: AGA P: Continue to support.\n\n#5 S/O: in tonight. Held infant and bottled her.\nAsked appropriate questions. A: Involved P: Continue to\nsupport and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-02 00:00:00.000",
"description": "Report",
"row_id": 1987270,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-60's, no increase work of breathing noted. LS clear/=.\nNo A&B's or de-sats noted this shift thus far. A: Pt. is\nstable in RA. P: Continue to monitor respiratory status.\nMonitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM26 w/PM or PE 26 w/PM =53cc\nQ 4hrs. She has taken all PO's this shift thus far ~55cc Q\nfeed. Pt. tires out a bit toward the end. Abdomen is soft,\npink, +BS, no loops/spits noted. Abdominal girth is 25cm.\nShe is voiding/ stool x1. A: Pt. is tolerating current\nnutritional plan. P: Continue w/ current feeding plan.\nMonitor for s/s of intolerance. Encourage PO feeds.\n\n#4. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. O: Mom in to visit this afternoon for cares.\nShe was udpated at bedside on pt's current status and daily\nplan of care. Mom is active and involved in cares. A:\nFamily is and involved. P: Continue to udpate,\nsupport and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-03 00:00:00.000",
"description": "Report",
"row_id": 1987271,
"text": "NPN 1900-0700\n\n\n#2 RESP S/O: Infant in RA, lungs clear with subcostal\nretractions. RR 40-70's, O2 sats >95%. No spells. A: Stable\nP: Continue to support.\n\n#3 FEN S/O: TF 150cc/k/d. To get pe26, with promod, 53cc\nq4h. Infant bottled 60ccx2 so far tonight. Abdomen benign,\nvoiding and stooling. Getting desitin to bottom. No spits,\nmin aspirates. Nutrition tonight Ca , Phos 7.5, Alk\nPhos 277. A: Stable P: Encourage po feeds.\n\n#4 DEV S/O: Maintaining temps in OAC. and active with\ncares. Waking for some feeds. A: AGA P: Continue to support.\n\n#5 S/O: No contact.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-03 00:00:00.000",
"description": "Report",
"row_id": 1987272,
"text": "Neonatology\nDoing well. RA. No spells. Comfortab;e appeatring.\n\nWt 2150 up 45. All po overnight. Seems much improved with bottling. Abdomen benign. Will dcerease cals to 24 and change from preemie formula.\n\nTemp stable\n\nWill need HBV.\n\nLeft message for mother re potential for dc in coming days.\n\nDC summary dictated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-21 00:00:00.000",
"description": "Report",
"row_id": 1987229,
"text": "#2 RESP\ns/o: BS clear and equal. Comfortable wob. Color pink. No\nspells. A: Stable. P: Cont to mtr\n#3 FEN\ns/o: TF 150cc/k/d-- remains on BM26/PE26. Void/stool qs. Abd\nexam benign. Wt up 30 gms to 1755gms tonight A: Gaining on\n26 cal formula. P: cont to mtr tolerance and daily wt\n#4 DEV\ns/o: Temp stable in open crib- with cares. Tone good.\nAwake yet little interest at breast or with po offered. A:\nDev AGA for CGA- 34-3/7 wks. P: cont dev supp cares\n#5 \ns/o: Both in tonight- actively participating in\ncares. A: Invested family P: cont dev supportive cares\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-22 00:00:00.000",
"description": "Report",
"row_id": 1987230,
"text": "2 Resp.\n Infant stable in room air, mild retractions, sats over 92\nmost of the time, 0 spells tonight. Continue to monitor and\nrecord any changes.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\ninfant tolerating feeds well by gavage, bottlee part of feed\nX1 did fair.Voiding, 0 stool. Wt. up 30gms to 1.755.\nContinue present plans.\n5 \n No contact from so far tonight, plan to keep\nfamily updated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-22 00:00:00.000",
"description": "Report",
"row_id": 1987231,
"text": "Neonatology Attending Note\nExam:\nUnchanged form previously. Resting comfortably in no distress. Pink. AFSF. Lungs CTA, =. CV RRR, soft murmur. Abd soft, +BS. Ext warm, pink and well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-22 00:00:00.000",
"description": "Report",
"row_id": 1987232,
"text": "Neonatology Attending Note\nDay 15\nCGA 34 4\n\nRA. Cl and = BS. Mild sc rtxns. RR30-60s. 2 A&Bs past 24 hours. TF 150 -160s. BP 56/44. H/o PPS murmur.\n\nWt 1755, up 30 gms. TF 150 cc/k/day BM/PE26 po/pg. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with aop and immature feeding skills. Cont to moitor. Will add promod supplementation to her feedings. No other changes to current medical plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-27 00:00:00.000",
"description": "Report",
"row_id": 1987253,
"text": "1900-0730 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-98%. RR=20-70's.\nBreath sounds clear and equal, mild SCR noted. No bradys, no\ndesats so far this shift. Will continue to monitor resp\nstatus.\n\nFEN: Weight tonight=1.930kg (+50 grams). TF=150cc/kg/d of\nPE26/BM26 with promod alternating PO/PG q4hr. Infant bottled\n24cc at 2130, remainder gavaged. Abdomen pink, soft, round,\n+BS. no loops, AG=25-26cm. Small spit x1, minimal aspirates.\nVoiding and stooling (guiac negative). Continue to monitor\nFEN status.\n\nDEV: Temps stable, swaddled in OAC. Active and with\ncares, sleeps well in between. Brings hands to face, sucks\non pacifier for comfort. MAE. Continue to support DEV.\n\n: No contact with so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-27 00:00:00.000",
"description": "Report",
"row_id": 1987254,
"text": "Neonatology Attending\n\nDay 20\n\nRemains in RA. RR 40-60s. Sats > 93%. Clear breath sounds. No bradycardia. HR 130-140s. BP mean 48. Weight gms (+50). On PE/BM 26 with Promod. Learning to bottle. Tolerating gavage feeds. Stable temperature.\n\nImproved feeding but not ready to ad lib feed. Will continue to encourage po feeding. Adequate breathing control. Monitoring closely.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-27 00:00:00.000",
"description": "Report",
"row_id": 1987255,
"text": "NEonatology-NNP PROgress Note\n\nPE: remains in her open crib, nested, in room iar, bbs cl=, rrr s1s2no murmur,abd soft, notender, V&S, afso, active with feedings, gavage tube in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-27 00:00:00.000",
"description": "Report",
"row_id": 1987256,
"text": "NEonatology-NNP PROgress Note\nsoft murmur audib,e pulses 2+=, well perfused\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-28 00:00:00.000",
"description": "Report",
"row_id": 1987259,
"text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing.\n\nWt 1270 up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Alt po/pg.\n\nSkin w/o leisons. Abdomen benign. Cor nl s1s2 murmur as before. neuro non-focal and age appropriate. Moving all 4 ext well.\n\nCOntinue current monitoring and nutritional rx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-22 00:00:00.000",
"description": "Report",
"row_id": 1987233,
"text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'dinf in RA. Inf remains in RA. No\ndesats, no spells thus far. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of PE26w/PM. Inf PO fed full\nvol 1X thus far. Tol feeds well, 1X sm spit, min asp thus\nfar. Belly soft, no loops. Inf voiding, no stool thus far.\n P cont to offer PO feeds as tol.\n4. DEV O/A remains in an OAC cobedding with her\ntwin. Temp stable. A/A with cares. P cont to assess dev\nneeds.\n5. O/A No contact thus far. P support, eudcate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987234,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nRR 30-50's. continue to monitor for resp changes.\n\n3: fluids\ncurrent weight 1790gms up 35. total fluids remain a\nt150cc/kilo/day of pe 26 with prom. tolerating feeds well.\nattempted po feed x'2. infant took 20 and 25cc with\nremainder gavaged. infant abd exam benign. no loops. stable\ngirths. voiding, no stool thus far. no spits.minimal\naspirates. continue to encourage po feeds.\n\n4: dev\ntemps stable in an open crib. co-bedded with sister. \nand active with cares. sleeps well inbetween. sucks on\npacifier. brings hands to face. aga. monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-24 00:00:00.000",
"description": "Report",
"row_id": 1987240,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats thus far this shift.\nRR 40-70's. sats > 94%. Lung sounds clear and equal. mild\nsubcostal retractions. no increased wob noted. continue to\nmonitor for changes in resp status.\n\n3: fluids\ncurrent weight 1815gms up 25gms. total fluids remain at\n150cc/kilo/day of pe 26 with prom. tolerating feeds well.\nalt po/pg feeds. infant took 30cc's po at 0130. abd exam\nbenign. no spits.minimal aspirates. stable girths. voiding,\nno stool thus far this shift. continues on iron.\n\n4: dev\ntemps stable in an open crib. co-bedded with sister. \nand active with cares. sucks vigorously on pacifier. brings\nhands to face. waking at times prior to cares. aga. continue\nto monitor for developmental milestones.\n\n5: \nmom and in following cpr for very quick visit. \nand intact family. continue to support needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-24 00:00:00.000",
"description": "Report",
"row_id": 1987241,
"text": "progress note\nd17 corrected 34 wks\nRA no spells\nlast spell on 22nd\n1815g (up 25)\ntf 150 pe26/PM\nocc spits gets feeds over 1 hour\nalt po/pg\n\nexam:\nafof\nsoft flow murmur\nnl s1/s2\nbs clr\nabd: soft, non distended\n\na/p:\nprematurity\npremature feeding pattern\npassed hearing\ncont to encourage PO\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-24 00:00:00.000",
"description": "Report",
"row_id": 1987242,
"text": "progress note\nNeonatology Attending\n\nGrowing preterm infant learning how to po feed. Reviewed and agree with medical plan as outlined by Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-27 00:00:00.000",
"description": "Report",
"row_id": 1987257,
"text": "NPN 1500\n\n\n#2 Resp: Infant stable in RA w/ O2sats 98-100%. No drifts or\nspells. RR 40-70, br. snds clear and equal.\nA: Stable in Ra.\nP: Cont to monitor for spells.\n#3 F/N: Infant remains on 26 cal PE/BM w/ promod. Bottled\n40cc X1 this AM. Tolerates gavage w/ occasional small spit.\nAbd soft, bowel snds active. Voiding and stooling.\nA: Learning to po, still requires gavage.\nP: Cont to offer po's X2 per shift.\n#4 Dev.: Infant awake and w/ cares. Swaddled w/i\nboundaries. Extremities flexed to midline. Infant calms\neasily w/ wrapping and pacifier when offered.\nA: AGA\nP: Cont dev. supports.\n#5 : No contact thus far on shift. Mother here\nyesterday at 5pm, br. fed infant. Infant latched on well but\nmother states her milk supply is low and always has been.\nShe is unsure if she will try to increase her supply at this\npoint. Mother handled well.\nA: Invested and involved family.\nP: Cont parent support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-28 00:00:00.000",
"description": "Report",
"row_id": 1987258,
"text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats 95-100%. RR=20-70's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nFEN: Weight tonight=1.970kg (+40 grams). TF=150cc/kg/d of\nPE26/BM26 with promod PO/PG q4hr. Infant bottled 46cc at\n2130 and 28cc at 0130, remainder gavaged. Abdomen pink,\nsoft, round, +BS, no loops, AG=26cm. No spits, no aspirates.\nVoiding and stooling (guiac negative). Continue to monitor\nFEN status.\n\nDEV: Temps stable, swaddled in OAC. Active and with\ncares, sleeps well in between. Brings hands to face, MAE.\nContinue to support DEV.\n\n: in for the 2130 care. Involved and .\nUpdated on patient's status/current plan of care by RN.\nContinue to support family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-28 00:00:00.000",
"description": "Report",
"row_id": 1987260,
"text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\ndrifts, no spells thus far. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of BM or PE26w/PM. Alt PO/PG\nfeeding this shift. Tol feeds well, no spits thus far, min\nasp thus far. Belly soft, no loops. Inf voiding, no stool\nthus far. P cont to offer PO feeds as tol.\n4. DEV O/A remains in an OAC with stable temp. A/A\nw/cares. Sleeping well between cares. Not waking for feeds\nthis shift. P cont to assess dev needs.\n5. O/A Mom called for updates. P support,\neducate. plan to visit later today.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-29 00:00:00.000",
"description": "Report",
"row_id": 1987261,
"text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, no spells thus far this\nshift. no sat drifts noted, soft murmur noted.A;stable in R\nair. P; cont to monitor.\n\n#3. TF=150cc/kg/day, PE26 with promod, po/pg fed\ntolertaed,po fed full volume x1, BS+, no loops, voided,\nstooled, guaic negative. A; Feeds tolertaed. P; cont current\nfeeding plan.\n\n#4. , active with care, temp stable in a open crib,\nswaddled with blanket, MAE.bath given. A; AGA P; cont dev\nsupport.\n\n#5. Mom called for a update, asking app questions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-29 00:00:00.000",
"description": "Report",
"row_id": 1987262,
"text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing. Soft murmur c/w PPS heard./ Comfortable apeparing on my exam.\n\nWt up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Good weight gain over time.. Abdomen benign.Alternating po/pg.\n\nActive . Skin w/o leisons. Moving all ext. Neuro non-focal and age aprpopriate.\n\nCOntinue current monitoring and nurtitional regimen\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-29 00:00:00.000",
"description": "Report",
"row_id": 1987263,
"text": "NPN\n\n\n#2 Resp: infant remains in RA with sats >95, no desats or\ndrifts. BBS clear/=, RR 30-70's, mild transient SC\nretractions. cont to monitor resp status\n\n#3 Fluids: infant TF remain @150cc/kg/d P26+PM/Br26+PM =50cc\nQ4h. infant alternating PO/NG feeds. Took full volume bottle\nwith Mom this afternoon. abd soft, +BS, voiding, stools dark\nbrown, heme negative. girth stable 25-26cm. X1 small spit.\ncont to monitor feeding tolerance.\n\n#4 G&D: infant bundled in OC, temps stable, awake and ,\nwaking for feeds. PO feeding with good coordination. AGA 35\nweeker. cont to provide developmental support.\n\n#5 : Mom in this afternoon. Met with Lactation to\ndiscuss feeding plans. Updated on infant status and\ndiscussed discharge teaching. Mom states although she has\ntwin#1 at home she is happy to review d/c instructions. cont\nto provide updates and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-24 00:00:00.000",
"description": "Report",
"row_id": 1987243,
"text": "Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. No bradys so far this shift. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=150cc/kg/d of BM/PE26w/ProMod. Alt po/pg feeds.\n Taking less than of feeds by bottle. Abd exam benign.\nVoiding and stooling. Tol feeds. P- Cont to assess for\nFEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nopen crib. P- Cont to assess for G&D needs.\n#5-O/A- in to visit with updates given. held\nand bottled infant. P- Cont to enc parental calls and\nvisits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-25 00:00:00.000",
"description": "Report",
"row_id": 1987244,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 90-97%. RR 30-80's. Mild\nIC/SC rtx. LS clear and equal. TB sxn'd X1 for sm amt of\npale yellow nasal secretions. No spells.\n\nFEN: wt=1855g (up 40g). TF=150cc/kg/d of BM/PE26 with\npromod. Equals 46cc q4hrs, alt PO/PG. Gavaged over 45min.\nTolerating well. Bottled 45cc at 0130. Abdomen soft, +BS, no\nloops, sm spit X1, voiding and stooling. On Fe.\n\nDEV: Temps stable, swaddled with hat in open crib. Cobedding\nwith twin. and active with cares. Sleeps well between.\nWakes ~1hr prior to feeds. Settles with paci.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-25 00:00:00.000",
"description": "Report",
"row_id": 1987245,
"text": "progress note\nNeonatology Attending\n\nGrowing preterm infant with immature feeding skills. No change to current medical plan.\n\nReviewed and agree with medical plan as outlined by Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-25 00:00:00.000",
"description": "Report",
"row_id": 1987246,
"text": "progress note\nd 18 corrected 35 wks\nra\nno spells\n\n1855g (up 40)\npe 26 / pm\npo/pg\n\nexam: afof\nsoft PPS murmur\nbs clr\nabd: soft, no mass\nnl s/1/s2\n\na/p:\nprematurity\npremature feeding pattern\npassed hearing\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-03 00:00:00.000",
"description": "Report",
"row_id": 1987273,
"text": "PCA 0700-1500\n\n\n2\ninfant remains in RA, RR 30-70, O2 sats 96-100%, lung sounds\ncl=, mild sc retractions, no desats. P:cont. to monitor.\n\n3\ninfant remains on TF min. 150cc/kg/d, formula was switched\nfrom PE26 with promod to E24=53cc q4h. infant taking all PO\nfeeds, bottling full volume with good coordination, infant\ntires out toward end of feed. abd. soft, bs+, no loops, ag\nstable 27-27.5cm, small spit X1, voiding qs, no stool thus\nfar. P:cont. to support nutritional needs.\n\n4\ninfant remains swaddled in OAC, temp. stable, occ. wakes for\nfeeds, a/a with cares, settles well in between, fontanelles\nsoft/flat, brings hands to face for comfort. P:cont. \nsupport dev. needs.\n\n5\n called to let us know he would be in for the 1730 care.\nP:cont. to update on infant's progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-03 00:00:00.000",
"description": "Report",
"row_id": 1987274,
"text": "Nursing NICU Note Addendum\n\n\nI have read the above note written by PCA and\nagree with the information as stated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-04 00:00:00.000",
"description": "Report",
"row_id": 1987275,
"text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal\nretractions still present,no spells thus far this shift.\nA;stable in R air.P; cont to monitor.\n\n#3. Todays weight=2150, no change, TF= 150cc/ kg /day ,\nEnfamil 24 cal, po fed tolerated, gets tired towards the end\nof po feeds.BS+, no loops, voided, stooled, guaic negative.\nA; Feeds tolertaed.P; cont current feeding plan.\n\n#4. , active with care, temp stable in a open crib,bath\ngiven, swaddled with blanket, MAE. Hep B vaccine given. A;\nAGA P; cont dev support.\n\n#5. No contacts from thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-04 00:00:00.000",
"description": "Report",
"row_id": 1987276,
"text": "Newborn Med Attending\n\nDOL#26. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT=2150, no change, on ~150 cc/kg/d BM24 or E24, PO. Passed hearing.\nA/P: Growing infant on full feeds. Tentative D/C home today or in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-03-04 00:00:00.000",
"description": "Report",
"row_id": 1987277,
"text": "Nursing Discharge Note\nPt d/c'd to home with at 1845 as ordered by MD. VSS. In RA. No spells. Soft murmur. TF=min 150cc/kg/d of BM24/E24 (53cc Q4hr). Pt bottlefed Q4hr, taking 55-70cc PO at each feeding. Med spit x 1. Abdomen benign. Voiding, stools x 3. On Ferinsol, demonstrated administration to who verbalized understanding. Temps stable in OAC. /active. AGA. Passed car seat test today. D/C teaching reviewed with both who verbalized understanding. Appropriate documentation signed, see chart for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987171,
"text": "NPN 7p-7a\n\n\nSepsis: Infant conts amp and gent. Bld cx neg to date. Cont\nto monitor for signs and symptoms of sepsis.\n\nResp: Infant conts on nasal prong cpap 6cm. Fio2 23-25%. RR\n30-50's. Ls clr/=. Ic/Sc retractions noted. No spells or\ndesats so far this shift. Cont to wean 02 as tol.\n\nFen: Wt tonoc 1.480kg (-60gms). Conts on tf 100cc/kg. IVF of\npnd10w via piv. Enteral feeds started at 20cc/kg of pe 20.\nTol feeds well thus far. Abd soft round. Bs +. No spits\nminimal aspirates. Mec stool x1. Voiding with each diaper\nchange. Cont to monitor toleration of feeds.\n\nDev: Temp stable transferred to servo isolette. Alert and\nactive with cares. Sleeps well between. Occasionally sucks\non pacifier. Nested in sheepskin with boundries in place.\nCont to support developmental milestones.\n\nParents: MOm and in this evening with grandfather.\n at bedside. Mom did diaper and temp as well as held\ninfant. still not feeling well. Asking appropriate\nquestions. Cont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987172,
"text": "Neonatology Attending Progress\nNow day of life 2.\nBaby remains on CPAP of 6 and in RA-24% FIO2.\nRR - 30-50s.\nNo apnea and bradycardia.\nHR - 110-120 77/46 62\n\nWt. 1480gm down 60gm on 100cc/kg/d of TF - PN/IL 80cc/kg/d enteral feedings of PE/MM 20cc/kg/d.\nUO 4.1cc/kg/hr, passing mec.\n\nBili 5.2/0.1\n\nAssessment/plan:\nVery nice progress for this 32 week gestation twin.\nWill give trial off CPAP today.\nFeeding advancement to continue slowly - FT up to 120cc/kg/d.\nFU bili tomorrow.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987173,
"text": "Clinical Nutrition\nO:\n32 wk gestational age BG, AGA, now on DOL 2.\nBirth wt: 1540 g (~25th to 50th %ile); current wt: 1480 g (-60)(down ~4% from birth wt)\nHC:: 29.5 cm (~25th to 50th %ile)\nLN: 42 cm (~25th to 50th %ile)\nLabs noted\nNutrition: 120 cc/kg/day TF. Feeds started on DOL 1; currently @ 20 cc/kg/day PE/BM 20,advancing 10 cc/kg/. PN started on DOL 1; lipids being added today. Remainder of fluids as PN via PIV; projected intake for next 24 hrs from PN ~54 kcal/kg/day, ~2.5 g pro/kg/day, and ~1.6 g fat/kg/day. From EN: ~20 kcal/kg/day, ~0.3 to 0.6 g pro/kg/day, and ~1.0 g 1.1 g fat/kg/day. Glucose infusion rate from PN ~5.7 mg/kg/min.\nGI: Abdomen soft and round; overall benign.\n\nA/Goals:\nTolerating feeds without GI problems; advancing cautiously and monitoring closely for tolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for feeds is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Expect PN to be supplemental only to feeds, and to taper as EN advances. Further increases in feeds as per growth and tolerance. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987174,
"text": "Respiratory Care Note\nPt off CPAP today. Placed in 50-100cc nasal cannula. BS clear. RR 30-50's. No bradys noted off CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987175,
"text": "Neonatology-NNP Physical Exam\n\nInfant is currently in NC. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended iwth active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987176,
"text": "NPN 7am-7pm\n\n\n1. VSS as charted on flow sheet. Afebrile. Blood cultures\nneg at this time Awaiting 48 hour rule out. Pink, no apnea\nor bradycardia. Cont on antibiotoc therapy.\nStable. No signs or symptoms of infection.\nCheck 48 hour blood culture results tonight.\nCont to monitor.\n2. Received on CPAP6, RA. Weaned to prong nasal cannula at\n1145 and remains at this time in 100%Fi02 at 50cc. Tol well\nwith 02 sats >93%. No apnea or bradycardia this shift. Occ\nbrief 02 sat drifts, self resolving. BBS clear and equal. No\nmurmur. No edema.\nStable 02 sat with min 02 requirement.\nCont to monitor. Wean 02 as tol.\n3.TF currently at 120cc/kg/day. Increased at 1730 feeding.\nCurrently taking 90cc/kg/day via PIV D10W with NaCl and KCl\nadded. Enteral feeds at 30cc/kg/day.PE20/BM20.Currently no\nbreast milk available. Mom is pumping q 3 hours. Abd soft\nactive bowel sounds. A/G 21-21.5cm Voiding qs See flow\nsheet. Mec stool x1.\nAdvancing on ent feeds. Weaning IV.\nCont as planned. Advance 10cc/kg . Next advance due at\n0530.\n4. In Servo isolette maintaining temp, Nested with boundries\nand sheepshin. Sucks on pacifier with feeds. Infant noted to\nbe irritable at times difficult to calm. Settles best on\nabd. Parents in at various times today and held infant. Mom\ndischarged this afternoon. Staying at a hotel in \nwith husband.\nCOnt stress precautions.\n5. Parents involved with infant care. Asking appropriate\nquestions. Had family meeting with team today. Verbalized\nunderstanding of criteria for discharge and plan of care.\nInvolved parents.\nCont to support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-10 00:00:00.000",
"description": "Report",
"row_id": 1987177,
"text": "NPN 7p-7a\n\n\nSepsis: Bld cx neg to date. 48 Ro/o complete. Issue\nresolved.\n\nResp: Infant remains on Nc 02. fi02 100%. 25-50cc flow. RR\n40-60's. Mild ic/sc retractions. No spells or desats so far\nthis shift. Ls clr/=. Cont to wean 02 as tol.\n\nFen: Wt tonoc 1.445kg (-35gms). Conts on tf 120cc/kg. IVF of\npnd10w with il infusing at 90cc/kg via piv. Enteral feeds at\n30cc/kg of pe20. Increasing 10cc/kg at 05 & 1730. Tol\nfeeds well. Max aspirate 1.2cc. Abd soft. Bs+. No stool thus\nfar. Voiding with each diaper change. Ag stable. Am lytes\npending. Dstick 92. Cont to advance feeds as tol.\n\nDev: Temp stable in servo isolette. Alert and active with\ncares. Irritable at times. Likes pacifier. Nested in\nsheepksin with boundries in place. Cont to support\ndevelopmental milestones.\n\n: No contact from so far this shift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-10 00:00:00.000",
"description": "Report",
"row_id": 1987178,
"text": "Neonatology Attending Progress Note\nNow day of life 3 for this 32 week gestation twin.\nIN 25cc of nasal cannula O2 - RR - 40-60s. Noted to have increased work of breathing today.\nHR 120-130s 66/36 48\n\nWt. 1445 down 35gm on 140cc/kg/d of TF - feedings up to 30cc/kg/d of MM, 110cc/kg/d of PN/IL.\nFeedings overall well tolerated - 3 cc aspirates noted.\nNormal urine and stool/mec output.\n\nLytes 140 4.7 107 22\nBili 11.5/0.2\n\nHUS - unremarkable - no IVH\n\nSocial - family meeting yesterday to review course. Awaiting further word on father's hepatitis diagnosis.\n\nAssessment/plan:\nMild worsening of respiratory status today - will evaluate with CXR.\nFeedings to be advanced gradually as tolerated.\nDouble phototherapy with FU bili tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-10 00:00:00.000",
"description": "Report",
"row_id": 1987179,
"text": "0700- NPN\n\n1 Infant with Potential Sepsis\n\nRESP: Remains in nasal cannula 25cc flow, 100% fi02. Flow\nrate increased to 75cc x1 when infant was positioned in\nsupine position (see flowsheet). LS clear/=; nares suctioned\nx1 for mod amt yellow/blood-tinged secretions. RR 40s-60s,\nmild SC/IC retractions present. No spells.\n\nFEN: TF 140cc/kg/d. IVFs PND10w and IL infusing via PIV at\n100cc/kg/d at this time. Feedings currently at 40cc/kg/d\nPE20, given via gavage q4hrs over 20min, TW. Plan to\nincrease feedings 10cc/kg/d as tolerated. No spits, max\nasp 3cc (nonbilious, partially digested formula). Abdomen\nsoft, round, no loops, active BS. Voiding (UO 3.8cc/kg/hr)\nand mec stooling. Dstick 105.\n\nDEV: Temps stable, nested with sheepskin in servo control\nisolette. MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping between cares. Brings hands to face,\nsucks on pacifier for comfort. AGA.\n\nPARENTING: visiting throughout the day, updated by\nRN. Assisting with cares, asking appropriate questions. Mom\nkangaroo'd this twin for about 1.5hrs today. loving\nand invested.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-11 00:00:00.000",
"description": "Report",
"row_id": 1987184,
"text": "NPNOte\n\n\n#2. remains on nasal cannula 100% 25cc to maintain sats\n>87-94%, BBS clear, equal, mild subcostal/intercostal\nretractions present, no spells thus far this shift, sat\ndrifts noted following shallow respiration. A;required\nsupplemental o2 to maintain sats P; cont to wean o2 as\ntolerated.\n\n#3. Tf=150cc/kg/day, Parentral at 90cc//kg/day,infusing\nPND10 with lipids at PIV, enteral at 60cc/kg/day,PE20 pg fed\ntolerated, BS+, no loops, voided, stooled,D'stix 97. A;\nFeeds tolerated. P; cont to advance feeds 10cc/kg, at\n1.30+1.30.\n\n#4. Alert, active with care, temp stable in a servo control\nisolette, nested in sheepskin, mae. loves pacifier.A; AGA P;\ncont dev support.\n\n#5. visited, asking app questions, states that\nhis lab result status is pending (type of Hep disease)\n wore gown and held the baby, A; P; cont\nparental support and teaching.\n\n#6. MIldly jaundiced, under single phototherapy.A; mildly\njaundiced. p; cont phototherapy as ordered, Bili on Sunday.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-11 00:00:00.000",
"description": "Report",
"row_id": 1987185,
"text": "Neonatology NP Exam Note\nInfant examined, care discussed with team.\nPlease refer to Dr note for detailed evaluation and plan.\n\nPhysical Exam:\nINfant netsled in isolette, under phototherapy. AFOF, eyes clear, nares clean ng in place, MMMP.\nChest is clear, comfortable resp pattern.\nCV: RRR, no murmur, pulses+2=.\nAbd: soft, active BS. Cord dry, NTND.\nGU: immature female genitalia.\nExt: lean. , \nNeuro: active, easliy consoles, primitive reflexes intact and symmetric.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-12 00:00:00.000",
"description": "Report",
"row_id": 1987186,
"text": "NICU NPN\n\n\n2. RESP: Infant remains in 02 via NC 100%, 25-50cc\nthroughout night. Lungs clear/=, breathing comfortable with\nbaseline mild SC/IC retractions. A: stable in 02, no spells\novernight P: COnt. to support and wean as tolerated.\n\n3. Fluids: Infant remains on TF of 150cc/k/d, advancing on\nenteral feeds 10cc/k/d curretnly at 70cc/k of BM/Pe20 taking\n18c q4hours via gavage over 30 min. Infant tolerating well,\nminimal asp, no spits. Abd. benign, voiindg/no stool.\nPN/lipids infusing at 80cc/k, DS stable.A: tolerating\nadvancement of feeds P: COnt. to support current feeding\nplan.\n\n4. G/D: Temp. stable in servo mode isoeltte. Infant\nturned and repositioned q4hours w/ cares, sleeping well\nbetween. A: stable P:Cont. to support G/D.\n\n5. : No contact thus far in shift.\n\n6. BILi: Infant remains under single phototherapy with eye\n on aat. REpeat bili will be checked tomorrow am2/15\nas ordered. A: stable under single P: COnt. to monitor\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-12 00:00:00.000",
"description": "Report",
"row_id": 1987187,
"text": "Neonatology Attending\n\nDOL 5 CGA 33 1/7 weeks\n\nStable in NCO2 25-50 cc. R 50s-60s. No A/B.\n\nN murmur. BP 69/38 mean 51\n\nOn 150 cc/kg/d with PE/BM 20 at 70 cc/kg and PN10/IL at 80 cc/kg. Tolerating feeds and advancing 10 cc/kg q 12. Voiding. Stooling. Wt 1405 grams (down 35).\n\nOn single phototherapy.\n\n visiting and up to date. Father being worked up for hepatitis. Family plans to return to after discharge.\n\nA: Stable. Resolving RDS with small O2 requirement. No spells. Tolerating feed advance. Hyperbili on phototherapy.\n\nP: Monitor\n Wean O2 as tolerated\n Advance feeds\n One more day of PN\n Follow bili\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-14 00:00:00.000",
"description": "Report",
"row_id": 1987193,
"text": "NPN 7p-7a\n\n\n#2 In 13cc of O2 via NC. O2 sats 97-100%. RR's ^ 80's at\ntimes. BBS clear and =. No bradys or desats. A: small O2\nrequirement P: Follow resp status\n\n#3 Feeds ^ by 15cc/k to 125cc/k. Receiving 32cc of PE20 q\n4hrs on a pump over 40 mins. No spits or aspirates.\nAbdominal exam unremarkable. Voiding, passing meconium. Am\nlytes stable. DS 87. A: tolerating feeds P: Follow weight\nand tolerance to feeds\n\n#4 Swaddled on sheepskin in air isolette. Isolette weaned as\ntolerated. Pleasantly alert with cares. Sleeps with ease. A:\nAGA P: support developmental needs\n\n#5 No parental contact.\n\n#6 Am rebound bili 7.0/.2. Lights cont. off. Passing stool.\nWorking up on feeds.P: Cont to follow bili level as\nordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-14 00:00:00.000",
"description": "Report",
"row_id": 1987194,
"text": "Neonatology Attending Note\nDay 7\nCGA 33 3\n\nNC 100%, 13-25cc. RR30-80s, int tachypneic. No A&Bs. Mild rtxns. No murmur. HR 110-140s.\n\nBili 7.0/0.2 (rebound).\n\nWt 1485, down 15. TF 125 cc/k/day PE/BM20, increasing 15/k/day for a goal of 150 cc/k/day. Tol well. Nl voiding and stooling.\n137/4.6/104/26\n\nIn low heated isolette.\n\nA/P:\nresolving RDS, wean O2 as tol\ncont feeding advance\ntransition to open crib\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-14 00:00:00.000",
"description": "Report",
"row_id": 1987195,
"text": "Social Work:\nMet briefly with . See note in sibling's chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-14 00:00:00.000",
"description": "Report",
"row_id": 1987196,
"text": "Nursing Progress Note\n\n\n#2-O/A- Received infant on NCO2 100% 25cc flow. Infant\nremains on NCO2. No resp distress. No Bradys. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=140cc/kg/d of BM/PE20 via NGT. Will advance to\nTF=150 at 1am. Abd exam benign. Voiding and, no stool so\nfar this shift. Tol feeds. P- Cont to assess for FEN\nneeds.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in low\nheated isolette. Sucks on pacifier. P- Cont to assess for\nG&D needs.\n#5-O/A- in to visit with updates given. held\ninfant with gown and gloves. interaction. P- Cont\nto enc parental calls and visits.\n#6-O/A- Remains off photo. Bili this am=7.0, 0.2. P-\nCont to assess for Hyperbilirubimemia.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-14 00:00:00.000",
"description": "Report",
"row_id": 1987197,
"text": "Neonatology-NNP PRogress Note\n remains in her isolette, nested in room air, bbs cl =, rrr s1s2no murmur, abd soft, nontender V&S, afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-15 00:00:00.000",
"description": "Report",
"row_id": 1987198,
"text": "NPN 1900-0700\n\n6 Bili:\n\n1. Resp: Received infant in NC O2 100% requiring 25 cc flow.\nInfant has been in RA since 2130 maintaining her O2 sats\ngreater than 92%. Lung sounds clear/=. RR 40-70's. Mild\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\nresp. status.\n\n2. FEN: Weight is 1520 gms up 35 gms. TF remain at 150\ncc/kg/day of BM/PE20. Tolerating NGT feedings well; abd\nexam benign, no spits, min asp, AG stable. Voiding qs and\nno stool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in weaning air-controlled\nisolette. Alert and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n4. : No contact thus far this shift.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili:; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-16 00:00:00.000",
"description": "Report",
"row_id": 1987205,
"text": "Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 9.\nWt: 1540 g (+20)(birth wt 1540 g.) Infant has just reachieved birth wt. Average wt gain over past wk ~6 g/kg/day.\nHC: n/a\nLN: n/a\nLabs not due yet.\nNutrition: 150 cc/kg/day BM/PE 24, all pg over 80 min feeds due to spits. Feeds just increased today; projected intake for next 24 hrs ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.\nGI: Abdomen benign. Spits w/ q feed overnight.\n\nA/Goals:\nTolerating feeds but w/ frequent large to mod. spits requiring extended gavage times; will monitor spits on longer feeding times. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins except Fe, which will be started tomorrow if infant's spits resolve. Growth should improve now that feeds have reached initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-16 00:00:00.000",
"description": "Report",
"row_id": 1987206,
"text": "2. remains in RA, color pink, sl jaundice, RR 30-60,\nBBS clear, equal, sc retractions, no spells.\n3. TF 150cc/k/d PE24 39cc q4h pg, abd soft, no loops,\npositive bowel sounds, minimal aspirates, very sm spit x1,\nvoiding and passing guiac neg stool.\n4. temp warm this am, isolette weaned to off, swaddled,\nactive with cares, sucking on pacifier.\n5. here for 1300 cares, held , Mom held\n. Continue to offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-17 00:00:00.000",
"description": "Report",
"row_id": 1987207,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 96%. Lung sounds clear/=. RR 40-70's. M\nIC/SCR noted. No A's or B's noted. P: Cont. to monitor\nresp. status.\n\n2. FEN: Weight is 1565 gms up 25 gms. TF remain at 150\ncc/kg/day of PE24. Tolerating NGT feedings well; abd exam\nbenign, no spits, min asp, and AG stable. Voiding qs and no\nstool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in off-isolette. Alert and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support nutritional\nneeds.\n\n4. : No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-17 00:00:00.000",
"description": "Report",
"row_id": 1987208,
"text": "progress note\nd10 corrected 33 wks\nra\n\n1565g (up 25)\ntf 150 bm/pe24\ngavage\nmin asp\n\nexam: nnp\n\na/p:\npreamturity\npremature feeding pattern\nstart Fe today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-17 00:00:00.000",
"description": "Report",
"row_id": 1987209,
"text": "progress note\nAddendum - Neonatology Attending\nInfant with feeding immaturity. Course over the past 24 hours reviewed with team. I agree with Dr. assessment. Continue to await maturation of oral feeding skills and optimize nutritional intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-17 00:00:00.000",
"description": "Report",
"row_id": 1987210,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-19 00:00:00.000",
"description": "Report",
"row_id": 1987217,
"text": "NICU NPN 1900-0700\n\n\nRESP O: LUNGS ARE CLEAR, O2 SATS 94-100% IN ROOM AIR. NO\nBRADYS THIS SHIFT.\n\nFEN O: GAINING WEIGHT, AND TOLERATING PO.PG FEEDS OF PE26\nWELL. ABDOMINAL EXAM BENIGN, VOIDING AND STOOLING, NO SPITS,\nAND MIN NGT ASPIRATES, AG STABLE.\n\nDEV O: TEMPS ARE STABLE SWADDLED IN CRIB. BABY IS AND\nACTIVE WITH CARES, SLEEPS WELL IN BETWEEN CARES. FONTANELLS\nARE SOFT AND FLAT.\n\nPARENTING O: NO CONTACT OVERNIGHT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-19 00:00:00.000",
"description": "Report",
"row_id": 1987218,
"text": "DOL 12 for this 34 week infant in RA with immature feeding skills. 1630 up 40 gms on TF of 150 cc/kg/d. Doing well\n\nRRR no m\nClear BS\nSoft abdomen + BS\n+ 2 pulses\n\nA/P: Well appearing infnat with no new medical changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987224,
"text": "NPNOte;\n\n\n#2.Remains in R air, BBS clear, equal, mild subcostal /\nintercostal retractions present, no spells thus far this\nshift. A; stable in R air. P; cont to monitor.\n\n#3. TF=150cc/kg/day,On PE26/BM26, pg fed over 1hr 30mts,\ntolerated, BS+, no loops, voided, no stool thus far this\nshift. A;Feeds tolerated.P; cont current feeding plan.\n\n#4. , active with care, temp stbale in a crib,\nco-bedding with sibling, swaddled, mae.A; AGA P;cont dev\nsupport.\n\n#5. will be in later this pm. A; . P;\ncont update and teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987225,
"text": "NPNOte;\n visited, asking app questions, wore glove and gown, po fed then held . spell x1 thus far this shift QSR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-07 00:00:00.000",
"description": "Report",
"row_id": 1987159,
"text": "NICU Nursing Admission Note:\nInfant admitted from L&D to NICU warmer due to prematurity, respiratory distress, and sepsis work-up. Infat active and alert with eyes open, occasional grunting noted. Sao2's drifted initially to 80's, resolved with BBO2. When BBO2 removed, would con't to drift to 70's and started retracting-> placed on CPAP. LS = and clear, no murmur noted, VSS, D/S:72. CBC w/diff sent, blood culture pending. PIV started at 80cc/k/d of D10W. Started on amp and gent. Voided in DR. in to bedside to visit and was updated (though CPAP will be new to him). Infant presently resting comfortably in 30%, CPAP 6, with Sao2's mid-high 90's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-07 00:00:00.000",
"description": "Report",
"row_id": 1987160,
"text": "Neonatology NP Procedure Note\nEndotracheal Intubation\nPremedicated with 3 mcg. of fentanyl\nIndication: need for surfactant administration\n3.0 ETT passed oraly through cords under direct layngoscopy. Tube secured with 8 at upper lip. Equal breath sounds and good chest wall movement present. Infant tolerated procedure well. No compliations.\nCXR pending to confirm placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-07 00:00:00.000",
"description": "Report",
"row_id": 1987161,
"text": "Neonatology Attending Admission Note\n\nDelivering Ob - Dr. primary MD - Dr. \n\nBaby is a 32 week gestation female twin #2 delivered at 17:30.\n\nPregnancy: Mother is 35 old G1 P0-1.\nMedical history is remarkable for maternal polycystic ovary disease. Pregnancy was conceived with IVF/ICSI and was a triplet pregnancy reduced to twins.\nPNS: A pos, Ab neg, HBSAg neg, RPR NR, GBS unkown.\n\nPregnacy was complicated at 28 weeks with maternal preterm labor, cervical shortening, diarrhea and a left shifted cbc on arrival back from living in . She was treated with MGSO4, antibiotics, betamethasone and then nifedipine. She also developed cholestasis of pregnancy and was treated with Actigall.\n\nCultures of stool, urine were negative. Mother was hospitalized for one month until . Father also reportedly has hepatitis? Further history pending.\nToday at 13:00 she developed PROM with preterm labor.\n\nMother was treated with ampicillin prior to delivery.\nDelivery was vaginal for both twins. This twin had vacuum assistance because of decelerations. The baby emerged with no respirator effort or tone. She responded well to bag and mask ventilation after bulb suctioning. She was bagged for approximately 1 minute and then developed a good spontaneous cry and respiratory effort. Apgars 3, 8.\n\nSocial - Both parents work for the State Department in .\n\nPE - Wt. 1540gm(40%) Lt 42cm(40%) HC 29.5cm(40%)\nVS - T 97.9 HR 140 RR 36 BP 57/30 41\nHEENT - AF soft and flat, prominent caput post vacuum, eyes PERL, normal red reflexes\nPalate intact\nResp - lungs equal, decreased air entry in bases, retractions noted after being in NICU for several minutes - improved somewhat on CPAP\nCVS - S1 S2 normal intensity, no murmur, perfusion fair, pulses normal\nAbd - soft, no organomegaly\nGU - normal AGA female\nHips stable.\nNeuro - tone wnl for GA, symmetrical exam\n\nWork of breathing and persistant grunting noted - baby intubated and treated with surfactant.\n\nAssessment/plan:\n32 week gestation female twin with clinical picture consistent with surfactant deficiency/RDS.\nBaby has responded well to intubation and surfactant treatment.\nWill wean vent support as tolerated.\nParents updated at bedside.\nIV antibiotics initiated - at risk for sepsis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-07 00:00:00.000",
"description": "Report",
"row_id": 1987162,
"text": "nursing\n\n\n#2O: baby Girl received in 28% O2 via prong CPAP 6.\n Intubated with 3.0ETT for increased work of breathing and\nhas received 11 dose of Survanta. Vent settings 24/5 x 20\nin 25% O2. Br. sounds are clear but diminshed and does have\nretractions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987163,
"text": "Respiratory Care Note\nPt. is 32 wker twin #2. Pt. was placed on 6cmH2O of nasal prong CPAP at change of shift. Pt. was requiring 30% FIO2, increased wob. Decision made to intubate and and give surfactant therapy. Pt. was intubated with a 3.0 ett taped at 8.0--gd.position per cxr. Pt. was treated with 6.2cc's of Survanta at 2145 and 0400. Pt. started out on IMV 24/5 R 20. Currently pt. is on 20/5 R 20 and 21%. Last cap gas was on 22/5 R 20 -->7.35/47. Pt. desatted with the surfactant and required hand-bagging. Plan is to obtain another cap gas and continue to wean as tolerated. Pt. improved since being intubated and given Survanta---21%, decreasd wob. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987164,
"text": "NPN:\n\nRESP: Vent - 24/5 x 20 -> -> 20/5 x 18, 21% 02; last setting change at 0530. CBG (0200): 7.35/ 47/ 46/ 27/ 0. Survanta (dose #2) given at 0400. Sx;d q 4 h for small amt cloudy secretions. BBS =/sl coarse. RR=40-60 with SC retraction. No desats, no A&Bs thus far tonight.\n\nCV: No murmur. HR=116-140. BP means 36-43; BP=66/30 (36). Color pink w/good perfusion.\n\nFEN: Birth wt=1540g. NPO. TF=80cc/kg/d; D-10-W. Dx=117. Abd soft, rounded, hypoactive bs; soft loops noted early in shift, but none at present. Bili & Elec to be done ~ 1700.\n\nID: Blood cx pending. Remains on Amp & Gent.\n\nG&D: CGA=32 wk. Temp stable on warmer w/servo control. Active and alert. Sl fussy w/cares; settles w/containment. Nested in sheepskin and resting well.\n\nSOCIAL: Mother in to visit x 1. Loving and appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-19 00:00:00.000",
"description": "Report",
"row_id": 1987219,
"text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, no desats noted thus far\nthis shift. A;no spells. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, PE26/MBM26, po/pg fed tolerated,po fed\n~10cc x1, BS+, no loops, voided, stooled, guaic negative. A;\nfeeds tolerated. P; cont current feeding plan.\n\n#4., active with care, temp stable in a open crib,\nco-bedding with sibling. A; AGA P; cont dev support.\n\n#5. No contacts from thus far this shift. \nare planning to visit this evening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987220,
"text": "npn 1900-0700\ndev: infant with healing scab on scalp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987221,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells thus far this shift. no dsats. Rr\n40-70's. Lung sounds clear and equal. mild subcostal\nretractions. no increased wob noted. continue to monitor for\nchanges in resp status.\n\n3: fen\ncurrent weight 1965gms up 55gms. total fluids remain at\n150cc/kilo/day of bm/pe 26. tolerating feeds well. one\nmedium spits. max aspirate 2cc's. voiding, no stool thus\nfar this shift. abd soft with no loops. stable girths.\ngavage fed this shift. infant not showing interest in\nbottling.\n\n4: dev\ntemps stable in an open crib. Infant had a low temp of 97.3\naxillary and 97.5 rectally at 0130 following a spit. infant\nplaced under warming lights. temp increased to 98.1.\nco-bedded with sister. and active with cares. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987222,
"text": "Neonatology Attending Note\nExam Note:\nInfant resting comfortably in open crib, co-bedding with twin. AFSF. +NG. Lungs CTA, cl and = bilat. CV RRR, 1/6 SEM heard over axilla and back - c/w PPS. 2+FP. Abd soft, +BS. Ext. warm, pink and well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-20 00:00:00.000",
"description": "Report",
"row_id": 1987223,
"text": "Neonatology Attending Note\nDay 13\nCGA 34 2\n\nRA. Cl and = BS> RR40-70s. Mild sc rtxns. No A&Bs. HR 130-160s. No murmur. BP 72/36, 49.\n\nWt 1685, up 55 gms. TF 150 cc/k/day BM26/PE26 po/pg. Tol well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\n - CVR monitoring\n - no change to nutritional plan\n - check bili in am for persistent jaundice\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-21 00:00:00.000",
"description": "Report",
"row_id": 1987226,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. one spell this shift. see flow sheet for\nfurther info. RR 30-60's. Lung sounds clear and equal. mild\nsubcostal retractions. no increased wob noted. no dsats.\ncontinue to monitor for changes.\n\n3: fluids:\ncurrent weight 2030gms up 60gms. total fluids remain at\n150cc/kilo/day of pe/bm 26 cals. tolerating feeds well.\nno spits. feeds ran over 1.5 hours for hx of spits. minimal\naspirates. voiding, no stool thus far this shift. stable\ngirths. attempted to po x's 1. infant not showing interest\nin bottling. infant taking only 5cc's.\n\n4: dev\ntemps stable co-bedded with sister. and active with\ncares. sleeps well inbetween. 14 day pku drawn. sucks on\npacifier. brings hands to face. aga. continue to monitor for\ndevelopmental milestones.\n\n5: \nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-21 00:00:00.000",
"description": "Report",
"row_id": 1987227,
"text": "Neonatology Attending Note\nDay 14\n\nRA. Cl and = BS. RR40-70s. 2 A&B past 24 hrs. Mild sc rtxns. +soft murmur. HR 130-150s. BP 68/35, 46. BP 68/35, 46.\n\nBili 5.2/0.2\n\nWt 1725, up 40 gms. TF 150 cc/k/day BM/PE26 po/pg. Tol well. Nl voiding and stooling (g-).\n\nIn open crib, co-bedding with twin.\n\nExam:\nResting comfortably in open crib. Pink. No distress.\nAFSF.\nLungs CTA, =.\nCV 1-2 SEM at LSB heard also over axilla and back. 2+FP. Pink and well perfused.\nAbd soft, +BS.\nExt warm, pink and well perfused.\n\nA/P:\n - Growing preterm infant with immature cardioresp control and po feeding skills. Con to monitor. No changes to current medical plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-21 00:00:00.000",
"description": "Report",
"row_id": 1987228,
"text": "NPNOte;\n\n\n#2. Remains in Ra ir, BBS clear, equaql, mild subcostal\nretractions present, no spells thus far this shift. A;\nstable in R air. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, Pe26 pg fed tolerated, H/O spits, no\nspits thus far, feeds given over 1hr 30mts,BS+,no loops,\nvoided, no stool thus far this shift. A; Feeds tolerated. p;\ncont current feeding plan.\n\n#4. ,a ctive with acre, temp stable in a open crib,\nco-bedding with sibling, MAE. A; AGA P; cont dev support.\n\n#5. will be visiting this pm.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987235,
"text": "Neonatology Attending\nAddendum - Physical Examination\nwell-appearing infant in no distress\nHEENT AFSF\nCHEST no retractionbs; good bs bialt; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM LSB without radiation\nCNS active, resp to stim; tone AGA\nINTEG normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987236,
"text": "Neonatology Attending\nDOL 16 / CGA 34-5/7 weeks\n\n is in room air with no distress and no bradycardias since .\n\nPPS murmur persists. BP 62/30 (41).\n\nWt 1790 (+35) on TFI 150 cc/kg/day BM26/PE26PM, tolerating well. Bottling up to volume. Abdomen benign. On iron. Voiding and stooling normally.\n\nA&P\n32-3/7 week GA infant with resolving respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Follow murmur clinically\n-No other changes in management\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987237,
"text": "CAse Management Note\nReferral called today to VNA in preparation for eventual d'c. is main # and fax is . Will need name of hotel/phone #/room #/address for VNA. Also need name/phone # of Pedi for twins. Will assess w/team if EIP is needed here in USA vs as family expects to relocate back there at some point. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987165,
"text": "Neonatology Attending Progress Note\n\nNow day one of life for this 32 week gestation infant with RDS.\nOn vent support of 18 20/5 and RA currently.\nBaby treated with 2 doses of surfactant with nice improvement.\nLast CBG - 7.35/47 prior to wean.\n\nHR 112-140s MAP 36-43 - BP 66/30 36\n\nWt. 1540 BW\nNPO on 80cc/kg/d of IV fluids.\nBS 117\nUO 3.3cc/kg/hr overnight.\n\nID - wbc 11,100 32P 0B 52L plat 264 Hct 40.4%\nOn amp and gent.\n\nAssessment/plan: Preterm infant with nice response to surfactant.\nWill wean vent support and hopefully be able to go to CPAP later today.\nPN to be initiated today.\nWill follow lytes - bili later today.\nWill set up family meeting prior to mother's discharge to home.\nHUS to be scheduled for Thursday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987166,
"text": "Social Work:\n\nParents of these twins have been known to me from mom's 6s antepartum admission. Please see note in sister's chart for complete social work note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987167,
"text": "NPN Days\n\n\n#1 Pt cont on ampi and gent. no s/s of infection. BC\npending. P- Will cont to monitor for sepsis.\n#2 Pt received intubated 20/5 with a rate of 18. FiO2\n21%. Pt weaned throughout the am and cbg drawn\n7.32/56/29/30/0. Pt extubated @ 1400 to CPAP. Pt currently\non CPAP 6. FiO2 21%. LS course bilat. IC SC retrac. no\nspells so far this shift. sx for mod cloudy secr from ETT.\nand sm clear from mouth. P- Will cont to monitor resp\nstatus.\n#3 FEN- TF=80cc/kg/d to be increased to 100cc/kg/d after\nlabs this pm. Pt NPO. IV fluids D10W infuising through PIV.\nabd benign voiding and stooling mec. d-stick 87. P- Will\ndraw lytes and bili @ 1700 and cont to monitor FEN.\n#4 G&D- Temp stable on servo warmer. alert and active with\ncares. irritable at times. sucking on pacifier. HUS\nscheduled for thurs. P- Will cont to monitor G&D.\n#5 Parents- Parents visiting throughout the shift. helping\nwith cares. loving and caring. updates given. asking approp\nques. P- Will cont to encourage parental visits and calls.\nSee flowhseet for further details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987168,
"text": "Neonatology NP Exam Note\nInfant eaxmined, care discussed with team.\nPlease refer to Dr note for detailed evaluation and plan.\n\nPhyical exam:\nInfant nested on open warmer, orally intubated. AFOF, Caput over occiput. Sutures overriding.\nChest is clear, equal BS. Good air exchange.\nRRR, nl S1, split S2. Pulses plus 2 and equal.\nAbd: active BS, cord dry.\nGU: immature female genitalia.\nExt: MAE, WWP\nNeuro: equal grasps, symmetric moro\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-08 00:00:00.000",
"description": "Report",
"row_id": 1987169,
"text": "Respiratory Care\nPt recieved on SIMV rate of 18, pressures of 20/5 with the fio2 21%. Pt weaned down on PIP from 20 to 18, pt also weaned down on ventilator rate from 18 to 14. Blood gas results obtained with good results. Pt extubated and place on nasal prong CPAP. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-09 00:00:00.000",
"description": "Report",
"row_id": 1987170,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 23-25%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. RR 30-50's stable on Prong CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987238,
"text": "Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 16.\nWT: 1790 g (+35)(~10th to 25th %ile); birth wt: 1540 g. Average wt gain over past wk ~20 g/kg/day.\nHC: 30 cm (~10th to 25th %ile); last: 29.5 cm at birth\nLN: 43 cm (~25th %ile); last: 42 cm at birth\nLabs not due yet.\nMeds include Fe\nNutrition: 150 cc/kg/day BM/PE 26 w/ promod, po/pg. Infant takes ~ to full volume w/ po feeds. Average of past 3 day intake ~150 cc/kg/day, providing ~130 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\nGI: Abdomen benign; one small spit\n\nA/Goals:\nTolerating feeds without GI problems except occasional small spit. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. Average HC and LN gains over past 2 wks not meeting recommended ~0.5 to 1 cm/wk for HC gain or ~1 cm/wk for LN gain; expect improvement now that feeds have surpassed initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-23 00:00:00.000",
"description": "Report",
"row_id": 1987239,
"text": "0700- NPN\n\n\nRESP: In RA with RR 30's-60's. LS clear/=. No\nretractions. No A/B spells or desats.\n\nFEN: TF=150cc/kg/d. PE26 with PM (45cc Q4hr) PO/PG. Pt\nbottlefed x 2, taking 22-42cc at each feed. Small and\nmedium spits. Minimal aspirates. Abdomen benign. Voiding,\nsmall stool x 1. On Ferinsol.\n\nDEV: Temps stable in OAC. /active with cares. Sleeps\nbetween cares, waking early for feeds. Sucks pacifier and\nbrings hands to face for comfort. Fontanels soft/flat.\nAGA.\n\nPARENTING: Both in to visit this shift, updated by\nthis RN, asking appropriate questions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-25 00:00:00.000",
"description": "Report",
"row_id": 1987247,
"text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal\nretractions present, no spells thus far this shift. A;\nstable in R air. P; cont to monitor.\n\n#3. Tf=150cc/kg/day, PE26 with promod, po/pg fed, tolertaed,\nBS+, no loops, voided, stooled. A; Feeds tolerated. P; cont\ncurrent feeding plan.\n\n#4. , active with care, temp stable in a open crib,\nswaddled with blanket, MAE. co-bedding with sibling,A; AGA\nP; cont dev support.\n\n#5. visited, asking app questions. will be\ndischarged home today after car seat screening.A; \n P; cont update and teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-25 00:00:00.000",
"description": "Report",
"row_id": 1987248,
"text": "Social Work:\nMet with . See note in sibling's chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-26 00:00:00.000",
"description": "Report",
"row_id": 1987249,
"text": "NPN NOCS\n\n\n2. Remians in RA. LS clear. O2 sats 91-100%. No drifts, no\nspells. Stable.\n\n3. Wt up 25gms. TF at 150cc/kg of BM/PE26 with PM. Alt po/pg\nfeeds. Gavaged over 50min. Small spits. Abd benign. Voiding,\nno stool. Continue to work on po feed skills.\n\n4. Temp stable in open crib. and active with cares.\nSwaddled. AGA.\n\n5. No contact from thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-26 00:00:00.000",
"description": "Report",
"row_id": 1987250,
"text": "Neonatology Attending Progress Note\n\nNow day of life 19, CA 1/7 weeks.\nIn RA - O2 sast >95%\nRR 30-60s.\nHR 130-150s BP 66/36 46\n\n\nWt. 1880 up 25gm on 150cc/kg/d of PE or MM26 with Promod\nFeedings well tolerated overall.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress overall.\nWill continue with current management.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-11 00:00:00.000",
"description": "Report",
"row_id": 1987182,
"text": "NPN 7p-7a\n\n6 Bili:\n\nResp: Infant remains in NC 02 100% 25-50cc flow. Ls clr/=.\nMild ic/sc retractions. RR 50-60's. No spells or desats so\nfar this shift. Cont to wean 02 as tol.\n\nFEn: Infant's wt tonoc 1.440kg (-5gms). Conts on tf 140cc/kg\nEnteral feeds at 50cc/kg of pe 20. Increasing 10cc/kg at\n0130&1330. IVf of pnd10w with IL via piv. Tol feeds well\ngavaged over 20 mins. No spits minimal aspirates. Dstick 86.\nAbd soft. Active bs. No stool thus far. Voiding with each\ndiaper change. Cont to advance feeds as tol.\n\nDev: Temp stable in servo isolette. Nested in sheepskin with\nboundries in place. Likes pacifier. Irritable at times.\nLikes prone postion. Cont to support developmental\nmilestones.\n\n: No contact from so far this shift.\n\nBili: Infant conts under double phototx. AM bili pending.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili:; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-11 00:00:00.000",
"description": "Report",
"row_id": 1987183,
"text": "Neonatology Attending Progress Note\n\nNow day of life 4.\nOn 100% 25-50cc of O2 RR 50-80s\nNo apnea and bradycardia.\nHR 120-140, BP 69/38 51\n\nBili 8.9/0.3\n\nWt. 1440gm down 5gm on 140cc/kg/d - 90ml/kg/d of PN/IL - feedings up to 50cc/kg/d of MM or PE - gavage feedings well tolerated so far - occasional non-bilious aspirates noted.\nDS 86\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management with gradual increase of feedings as tolerated.\nMonitoring for apnea/bradycardia.\nAwaiting further word on father's diagnosis of hepatitis.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-12 00:00:00.000",
"description": "Report",
"row_id": 1987188,
"text": "Neonatology-NNP PRogress Note\\\n\nPE: in her isolette, in room air, (recently out of nc) bbs cl=, rrr s1s 2no murmur,abd soft, nontender, cord drying, V&S, nested, peripheral iv and gavage tube in\n\nUpdated at bedside\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-12 00:00:00.000",
"description": "Report",
"row_id": 1987189,
"text": "NPN DAYS\n\n\nRespiratory: Remains on NC 13cc Fio2 100%. Trialed in room\nair x2 hours and failed r/t frequent drifts of sats. LS\nclear and equal. IC/SC retractions. No spells. No caffeine.\nWill continue to monitor.\n\nFluids: TF 150cc/kg/day. 80cc/kg/day PE20/BM20. 70cc/kg/day\nPND10 via PIV in right leg. Increasing feeds by 10cc/kg/.\nTolerating feeds. Belly benign. No spits. Urine output\n3.6cc/kg/day. No stool. D/S 103. Will continue to increase\nfeeds as tolerated.\n\nDevelopment: Temp stable in servo isolette. Awake and alert\nwith cares. Sleeps well between cares. Likes her pacifier.\nWill continue to support developmental needs.\n\n: in for 1pm cares, held baby. Asking\nlots of questions. Will continue to provide teaching and\nsupport.\n\nBili: Remains under single phototherapy. Will check bili\ntonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-26 00:00:00.000",
"description": "Report",
"row_id": 1987251,
"text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes, Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-26 00:00:00.000",
"description": "Report",
"row_id": 1987252,
"text": "NPN 1500\n\n\n#2 Resp: Infant remains in RA, no desats or brady spells. RR\n40-70. Br. snds clear, = bilat.\nA: Stable in RA w/o spells.\nP: Cont to monitor for desats or bradys.\n#3 F/N: Infant continues on 150cc/kg/d PE26/BM 26 w/ promod,\n47cc q 4 hrs. Infant bottled well 25cc @ 0930 this AM. Abd\nbenign, voiding well, no stool today. Tolerates gavage feed\nw/o spits.\nA: Tol. feeds, learning to po/breast feed.\nP: Cont to monitor for s/s of feeding intolerance.\n#4 Dev.: Infant maintaining temp well in an open crib. Awake\nand w/ cares. Swaddled and positioned prone.\nA: AGA\nP: Cont dev. supports.\n#5 : No contact thus far on shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-10 00:00:00.000",
"description": "Report",
"row_id": 1987180,
"text": "Neonatology - NNP PRogress Note\n\n is active with good tone. AFOF. Head ultrasound today normal. She is pink, well perfused, no murmur auscultated. She remains in NCO2 25-75ccs/100%. Moderate retractions, breath sounds diminished on left side. CXR today clear.Total fluids @ 140cc/kg/day. PN/IL infusing via PIV. She is tolerating advancing feeds. Abd soft, active bowel sounds, no loops. Voding and stooling. Mod jaundice under single phototherapy. Bili today 11.5/0.2. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-10 00:00:00.000",
"description": "Report",
"row_id": 1987181,
"text": "Rehab/OT\n\nMet at the bedside. Discussed the role of OT, infant stress signals, and ways to maximize infant comfort. Posted care plan at the bedside. Please refer to care plan for recommendations. OT to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-13 00:00:00.000",
"description": "Report",
"row_id": 1987190,
"text": "NPN 7p-7a\n\n\n#1 Remains in 13cc of 100% O2 via NC. BBS clear and =. Mild\nretractions present. No bradys or desats. A: small O2 need\npersists P;Follow\n\n#3 TF's presently at 95cc/k. IV leaking ~ 0045. NNP\nRivers advance feeds 15cc/k and leave IV out. Receiving\n24cc of PE20 Q 4hrs on a pump over 30 mins. No spits or\naspirates. Abdominal exam unremarkable. Voiding. No stool\npassed overnoc yet. A: tolerating feeds P: Advance feeds\n15cc/k and follow weight\n\n#4 Isolette weaned x 1 for warm temp. Fiesty with cares.\nNested on sheepskin with boundaries in place. Sleeps fairly\nwell. A: AGA P: Support developmental needs\n\n#5 No contact.\n\n#6 Remains under single phototherapy. Am bili 6.1/.3-down\nfrom 8.4/.3. Working up on feeds. No stool. A: bili\ndecreasing P: f/u with team\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-13 00:00:00.000",
"description": "Report",
"row_id": 1987191,
"text": "Atttending Note\nDay of life 6 CGA 33 \nnasal cannula 13-25 cc RR 50-60 mild retractions\nlungs clear\nno murmur 120-140 71/36 mean 55\nbili 6.1/0.3 still on single phototherapy\n1500 up 95 grams on 95 cc/kg/day of enteral adv 15 cc/kg/day\nBM 20 PE 20\nservocontrolled isolette\n\nimp-needs to wean from nasal cannula\nas tolerated\nwill discontinue photo and recheck rebound in am\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-13 00:00:00.000",
"description": "Report",
"row_id": 1987192,
"text": "Nursing Progress Note\n\n\n#2-O/A- Recieved infant on NCO2 100% 25cc. Infant remains\non NCO2. No resp distress. No A's or B's. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=110cc/kg/d of BM/PE20 via NGT. Abd exam benign.\n Voiding, no stool so far this shift. Tol feeds. P- Cont\nto assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nheated isolette. Sucks on pacifier. P- Cont to assess for\nG&D needs.\n#5-O/A- in to visit with updates given. Mom held\n. interaction. P- Cont to enc parental calls\nand visits.\n#6-O/A- Photo d/c this am for bili= 6.1, 0.3. Plans to\ncheck bili in am. P- Cont to assess for\nHyperbilirubinemia.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-15 00:00:00.000",
"description": "Report",
"row_id": 1987199,
"text": "progress note\nAgree with note by Dr. .\nDay of life 8 CGA 33 week\ntransition from nasal cannula to room air last night\nno spells\nweight 1520 gram up 35\non 150 cc/kg/day of PE/BM 20 cal/oz\npo/pg\n\nImp-overall making good progress\nwill increase to 24 cal/oz and\ncontinue to encourage po feeds\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-15 00:00:00.000",
"description": "Report",
"row_id": 1987200,
"text": "progress note\nd8 corrected 33 wks\nnc to RA last night - ok\nno spells\n\n57/33 (38)\n1520g (up 35)\ntf 150 pe/ bm 20 gavage\n\n\nexam:\nafof\nbs clr\nno murmur\nabd soft\nwell perfused\npink\nslightly jaundice\n\na/p:\nprematurity\npremature feeding pattern\ninc to 24 cal\nfollow juandice - resolving\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-15 00:00:00.000",
"description": "Report",
"row_id": 1987201,
"text": "NPN DAYS\n\n\nRespiratory: Remains in room air with O2 sats 96-100%. LS\nclear and equal. No desats or spells. Mild IC/SC\nretractions. Continue to monitor closely.\n\nFluids: TF 150cc/kg/day PE22/BM22, gavaging feeds over\n50mins. Belly benign. Spit x2. Voiding and stooling. Minimal\naspirates. Will continue with current plan of care.\n\nDev: Temp stable in low air isolette while swaddled. Awake\nand alert with cares. Kangaroo'd with mom for an hour and\ntolerated well. Will conitnue to support developmental\nneeds.\n\n: in to visit. Mom participated in cares and\nkangaroo'd. Will continue to provide support and teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-16 00:00:00.000",
"description": "Report",
"row_id": 1987202,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 95%. Lung sounds clear/=. RR 30-60's. Mild\nIC/SCR. Infant had one desat to 70 with spit. No bradys\nnoted. P: Cont. to monitor resp. status.\n\n2. FEN: Weight is 1540 gms up 20 gms. TF remain at 150\ncc/kg/day of BM/PE22. Tolerating feedings well; abd exam\nbenign, min asp, AG stable, and one spit. Voiding qs and no\nstool noted thus far. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in air-controlled isolette.\nAlert and active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. ; No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-16 00:00:00.000",
"description": "Report",
"row_id": 1987203,
"text": "progress note\nd9 corrected 33 wks\nra 30-60's\none desat to 70 with spit.\n\n1540g (up 20)\ntf 150 pe22 - 3 spits - increased feeding time over 1 hr\n\nexam:\nafof\nno murmur\nbs clr\nabd soft\nwell perfused\n\na/p:\nprematurity\npremature feeding pattern\nfeeding over 1 hour 20 mins\ninc 24 cals.\nstart fe tommorrow (.15cc qd)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-16 00:00:00.000",
"description": "Report",
"row_id": 1987204,
"text": "progress note\nAgree with Dr. \n of life 9 CGA 33 \nstable in room air RR 30-60\none dat with feeds\nweight 1540 gram up 20 on\n150 cc/kg/day of BM/PE 22\nvoiding and stooling\n\nImp-overall making progress\nstill have a lot of spits\nwill increase feeding time and\nconsider decreasing total fluid\nwhile at the same time increasing\ncalories.\n\ntoday will increase to 24 cal/oz\nand increase feeds to over 1 hour 20 min\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-17 00:00:00.000",
"description": "Report",
"row_id": 1987211,
"text": "Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. No bradys. P- Cont to assess for Resp\nneeds.\n#3-O/A- TF=150cc/kg/d of BM/PE24 via NGT. Abd exam benign.\n Voiding, trace stool so far this shift. Tol feeds gavaged\nover 1hr20min. Started on FeSO4. P- Cont to assess for\nFEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Transferred to\nopen crib, temp stable. Sucks on pacifier. P- Cont to\nassess for G&D needs.\n#5-O/A- called, they plan to visit at 1700. P-\nCont to enc parental calls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-18 00:00:00.000",
"description": "Report",
"row_id": 1987212,
"text": "npn 1900-0700\n\n\n#2 resp\npt continues in r/a with sats >97%. lsc=. mild sc/ic\nretractions. rr 40-50's. occational drift mid 80's-low\n90's that qsr. no spells thus far this shift.\n#3 fen\ntf 150cc/kg of pe24/bm24 gavaged q4hours. wt. 1.590kg\n(+25gms). abd benign. voiding and stooling qdiaper change\ngreen yellow stools guiac neg. lg fissure noted 6pm,\ndesitin applied with each diaper change. spitting with each\nfeeding small to lg amts. gavage time increased to 1hour and\n40 minutes due to spits. minimal aspirates.\n#4 g&d\npt in oac with stable temps. alert and active with cares.\nmaew. fontanelles soft and flat. sucking on binki.\n#5 parenting\nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-18 00:00:00.000",
"description": "Report",
"row_id": 1987213,
"text": "pregress note\nAgree with note by Dr. \n of life 11 CGA 34 0/7 weeks\nstable in room air RR 40-50\nweight 1590 up 25 grams on 150 cc/kg/day\nof BM/PE 24 cal/oz pg\nvoiding and stooling\non iron\n\nImp-overall doing well.\nwill continue to encourage po feeds\nWill advance to 26 cal/oz\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-18 00:00:00.000",
"description": "Report",
"row_id": 1987214,
"text": "pregress note\nd11 corrected 33 wks\nRA 40-50's\n\n1590g (up 25)\ntf 150 bm24/pe24\nmod spits\n\nexam: NNP\n\na/p:\nprematurity\npremature feeding pattern\ninc. to 26 cals\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-18 00:00:00.000",
"description": "Report",
"row_id": 1987215,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-02-18 00:00:00.000",
"description": "Report",
"row_id": 1987216,
"text": "NPNOte;\n\n\n#2.Remains in R air, BBs clear, equal, mild subcostal\nretarctions present, no spells, occassional sat drifts to\nmid 80's noted, QSR. A; No spells P; cont to monitor.\n\n#3. On Tf=150cc/kg/day, MBM26/PE26, po/pg fed , tolerated.\ncal increased today,BS+, no loops, voided, stooled.guaic\nnegative, A; Feeds tolerated. P; cont current feeding plan.\n\n#4. alert,a ctive with care, temp stable open crib,\nco-bedding with sibling.mae. A; AGA P; cont dev support.\n\n#5. visited, held the baby. A; ,\ninvolved.P; cont dev support.\n\n\n"
}
] |